An Apgar score of 0 to 3 at 5 minutes is associated with an increased risk of cerebral palsy in full-term infants, but this increase is only from 0.3% to 1%. Scores of 4 through 6 are intermediate and are not markers of high levels of risk of later neurologic dysfunction. Such scores are affected by physiologic immaturity, medication, the presence of congenital malformations and other factors. Because Apgar scores at 1 and 5 minutes correlate poorly with either cause or outcome, the scores alone should not be considered evidence of or a consequence of substantial asphyxia. Therefore, a low 5-minute Apgar score alone does not demonstrate that later development of cerebral palsy was caused by perinatal asphyxia.
Correlation of the Apgar score with future neurologic outcome increases when the score remains 0 to 3 at 10, 15 and 20 minutes but still does not indicate the cause of future disability. The term asphyxia in a clinical context should be reserved to describe a combination of damaging acidemia, hypoxia and metabolic acidosis. A neonate who has had asphyxia proximate to delivery that is severe enough to result in acute neurologic injury should demonstrate all of the following:
- Profound metabolic or mixed acidemia (pH less than 7.00) on an umbilical cord arterial blood sample, if obtained
- An Apgar score of 0 to 3 for longer than 5 minutes
- Neonatal neurologic manifestations, e.g., seizures, coma, or hypotonia; and
- Multisystem organ dysfunction, e.g., cardiovascular, gastrointestinal, hematologic, pulmonary or renal system.
The Apgar score alone cannot establish hypoxia as the cause of cerebral palsy. A full-term infant with an Apgar score of 0 to 3 at 5 minutes whose 10-minute score improved to 4 or higher has a 99% chance of not having cerebral palsy at 7 years of age. Conversely, 75% of children with cerebral palsy had normal Apgar scores at birth.
Cerebral palsy is the only neurologic deficit clearly linked to perinatal asphyxia. Although mental retardation and epilepsy may accompany cerebral palsy, there is no evidence that they are caused by perinatal asphyxia unless cerebral palsy is also present, and even then a relationship is in doubt.
- American Academy of Pediatrics policy statement,
Volume 98, Numer 1, July 1996
Routine procedures need study. Only about 10% of routine obstetrical procedures have been studied adequately, but there is a similar lack of research on routine procedures performed on the baby after birth. Most of these procedures have not been assessed scientifically. A case in point is the Apgar score; although it has been used religiously for over 25 years, several studies have shown it to be of limited value in identifying infants at risk of developing neurological handicap. The appropriateness of the Apgar score should be reexamined in the light of more recent knowledge about the causes of birth asphyxiation and the feasibility of the method in some cultures and settings. A modified score, based only on respiration and heart rate, may well be more useful.
- Marsden Wagner, MD,
in Pursuing the Birth Machine,
ACE Graphics, 1994
Think About It
Just as meat for the supermarket must be inspected, stamped "USDA APPROVED" and placed in a plastic wrapper that makes it look like it did not come from a cow, so must society's new product, the baby, be inspected and rated (and wrapped and placed in a plastic box). If the rating is high, the institution and through it, society, can then claim the credit for a job well done. If there are defects, they can be used as reinforcers of the standard cultural view of nature as dangerous, untrustworty and inferior to culture, and of the inherent defectiveness of the female birth machine. The Apgar score is but the first in a long series of ratings that society will give its new member; scoring the baby at birth sets up the mother to respect and rely on society's rating system to judge her baby by for the rest of its life.
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Midwifery Today's Online Forums: Vitamin K
Following a midwife-attended birth I asked the parents if they wanted their baby to have eye ointment and/or vitamin K. They declined the eye ointment but said they would like the baby to have vit. K. Their midwife replied "Good, because I was going to strongly recommend it in this case." Her reasoning was that the baby was born OP. I've never heard of this as a reason to give the injection -- has anyone else?
To share your thoughts and experience, go to Midwifery Today's Forums.
Question of the Week: VBAC with Extended Scar
Q: Does anyone have information about or experience with successful VBACs with an extended uterine scar (8 in. vs. 4 in.)? A woman is interested in homebirth who was attempting an unassisted homebirth with her last baby. Upon SROM she found a foot presenting. She and her husband went to the hospital and the doctor on call did a c-section but had to extend the incision to get the baby out. He assured and reassured her that she had a perfectly good chance of delivering vaginally next time, given she has a care provider. I am now sending her to my backup physician for consultation (who happens to be the physician who did her c-section). I have not officially accepted her into my care yet. I am waiting to see what my backup physician says and gather more concrete info.
Send your responses to:
Question of the Week Responses: Muscular Dystrophy
Q: A woman with muscular dystrophy is planning to get pregnant for the first time. She leads an active lifestyle. She attributes her good health to her daily swimming routine, which she plans to continue if she gets pregnant. An obstetrician has told her she will definitely have to have a cesarean section. She would like to have a waterbirth, preferably at home, but we really don't know how the pregnancy will affect her physical fitness and capabilities. We would love to know of other women's and midwives' experiences.
A: A woman who came to me for care had been diagnosed with multiple sclerosis over 10 years ago, and she had a daughter who was around 4 years old. I hadn't known her during her pregnancy, but she shared some of the story. It was an incredibly empowering and healing experience. I don't believe she had particular complications during pregnancy, though like many pregnant women, she chose to rest more and worked at her job less. She gave birth in a hospital but totally naturally. Her support people at the hospital encouraged her to simply trust her body and allow herself to experience how powerful her body could be. And she did! I believe they may have partially used gravity to help in the second stage, with her hanging her arms over the shoulders of two support people. I don't know if other measures were used. Four years later, she still completely glowed upon sharing the story, and has a very healthy, strong, vibrant, spunky daughter. The woman's health, including her MS, appeared to be unaffected by the pregnancy and birth.
A: I am a 33-year-old mom with cerebral palsy from birth. When I got pregnant for the first time, I decided to try a homebirth because I knew if doctors saw me coming, they would certainly talk me into a section as a "necessity." I needed the chance to try with people who believed I could. That birth was miraculous, with no problems at all. Four years later I birthed a 10-pound baby boy in my living room with much praise and shouting! I've decided the next one needs to be a waterbirth!
Give the lady a well-educated, well-supported chance to birth in all the glory her body was created to birth. Feel free to ask me more specifics about my births, should you need them.
A: I'm getting sick of all of the lame excuses for cesareans. Here are some recent examples from my practice:
- Harrington rod (she was 7 cm when this one was called)
- previous extensive laceration
- interstitial lung disease
- active hepatitis C
- previous intrauterine fetal death
- childhood repair of VSD (some minor findings on echocardiogram)
Our VBAC rate last year was about zero thanks to the recent VBAC article that came out (was it NEJM or JAMA?) that made the papers, although it was not new information. Uterine rupture is most often due to meddlesome obstetrics with prostaglandins for induction or nonjudicious use of Pitocin.
Basically if anything seems weird or out of the ordinary, the maternal fetal medicine specialists in my area and the OBs are all too happy to jump onto the cesarean bandwagon. It's quick, easy, pays more, it's scheduled, and all of the other conveniences that make natural childbirth a little too unpredictable for some people. Folks, the tide is moving toward elective cesarean on demand, and it's time to get more politically active about stopping it!
Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!
I am proud to announce that I attended my first homebirth (high time, at 57 years old). What do you bring to the home -- oxygen? vacuum machine? laryngoscope and tubes?
What would you tell a young woman who gave birth fast and easy twice but bled during her second labour while at home? She gave birth normally and everything else went smoothly after that except for the rush to the clinic and from the staff as she nearly gave birth in the car! Would you take any special step for her?
- Francoise Bardes,
Paxil [Issue 4:13] is the only SSRI that has actually been researched on pregnant women. Although I have not read the study, the drug reps say it is safe. Michael Hale lists it as a category "B" drug during pregnancy ("Medications in Mother's Milk"). We have a large practice and usually have 3 or 4 women on some form of SSRI. We have had no problems from Effexor, Paxil, Zoloft. The newer drugs are listed by Hale as category "B" drugs.
It is important to recognize why women are on Paxil. If they are depressed and go off it, they may have significant problems during their pregnancies. Our experience shows these women to have more problems sleeping, more problems with pregnancy discomforts generally, often having heart palpitations or anxiety attacks, and at a much higher risk for postpartum depression. If women are on Paxil for anxiety reduction, then taking them off often leads to high blood pressure, sleep disorders, crying spells and other pregnancy problems. We now suggest that women do not go off their SSRIs so long as they are "new generation." We have had fewer problems with women doing this than with women going off them. The babies have all been fine. There has been no noticeable differences in births or birth outcomes.
Alternately, in the women who have stopped taking them, we have noticed a higher rate of postpartum depression, fear and epidurals. Fear, anxiety and depression seem to have an impact on pregnancy, birth and postpartum.
- Jennesse Oakhurst
Maple Ridge, BC
I am a rather new labor/delivery RN working in a conservative metropolitan hospital. Every day I go home feeling angry and defeated, not necessarily by the families I work with, but because of the environment I am trying to practice in. Are there any chat rooms or groups out there amongst hospital-based RNs that I could get involved in for support?
[Editor's note: Start with Midwifery Today's Forums. You are sure to find lots of support there.]
Lately I've had very little time for mothering mothers, which is what I had planned to spend most of my time doing when I became a midwife. There was a problem getting reimbursement because I lost my malpractice coverage, which wasn't my fault, and I'm lucky because I did get another policy eventually. Then there was a problem being reimbursed because of something my backup doctor said, so I had to make other arrangements for backup. Now I'm being audited for CEUs, and they want them for two overlapping years in two licensing periods. Does this make sense? I have the CEUs, but as a nurse for many years I'm well aware that many folks wait till the last minute to get all their CEUs, and if I'd done that I'd be in violation of this audit. When I called to clarify this I was told no one else had raised the question! I feel I'm being picked on, and some of the hoops I've had to jump through are not quite right.
Could you please tell me what a nocebo is [Issue 4:14]?
Editor: "Nocebo" comes from Latin, meaning "I will harm," as opposed to "placebo." which means "I will please." Nocebo in the field of birth is the harmful effect/s of negative expectations as especially manifested in technology-ridden birth.
The study of breastfeeding mothers and the effects of pacifier use [Issue 4:14] should also include weight measurement and growth chart (long-term) for the two different groups to be able to make any conclusion. I have found the study as it is presented to be incomplete. Our goal is to increase breastfeeding with lots of support and minimal intervention. The main goal must be that we help our babies reach their maximum potential by feeding them on demand. I do not believe that we should offer them pacifier to control the frequency and duration of breastfeeding.
- Irma R.M.
[Editor's note: The brief was included to explain how pacifier use interferes with breastfeeding. We absolutely did not intend to present it as an alternative to breastfeeding! Midwifery Today always has been a strong and outspoken advocate of breastfeeding on demand.
Our news items are necessarily brief because E-News is severely limited in length. We include as much source information as we can so readers may research the article themselves.]
Re: scar tissue on the cervix from cryosurgery, conization or LEEP [Issue 4:12]. I just had my first client with previous cryosurgery, a 32-year-old primip who went 1-2 weeks overdue (unsure of her dates). In the last month of her pregnancy I instructed her to deposit 3 500-mg capsules of evening primrose oil in her vagina every night before bed. She had mild menstrual-type cramping on and off for the last month, especially the first night she used the EPO. When she didn't go into labor at term, I checked her cervix and she was 100% effaced, head at 0 station, but I couldn't find an os. I checked to make sure the cervix wasn't too posterior for me to feel, but it wasn't there. The only thing I felt was a hard knot, which I surmised was the cryosurgery scar tissue where I thought her cervix was (lateral, it turned out). When I removed my gloved hand, the glove was covered in bloody show, so I knew I was in contact with her cervix.
About five days later she went into labor, and I went to her home to check her. I felt the same thing I had noticed at my office five days before, so I told her I was going to try to dilate her cervix. It was extremely painful, but I dug at the hard knot and I felt a little hole start. I put two fingers in the cervix and manually opened it to 3 cm. An hour later she was 7 cm and I never had to stretch it again. She proceeded to have a very efficient labor, birthing an 8-pound baby boy.
- Dotti Kirkpatrick, RM
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The International School of Traditional Midwifery in Ashland, Oregon is accepting enrollment for 2002 classes that start in May. For information call 541-488-8273, or go to http://www.globalmidwives.org
Hands of Light - Summer Intensives on the Southern Maine Seacoast: Postpartum Doula June 12-15, Do I want to Be A Midwife? June 17-21 and Advanced Medical Skills Training June 24-28 - Elizabeth Mazanec 978-343-7384, www.holcenter.com
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