Objective To investigate management and outcomes of incidences of shoulder dystocia in the 12 years following the introduction of an obstetric emergencies training programme.Design Interrupted time-series study comparing management and neonatal outcome of births complicated by shoulder dystocia over three 4-year periods: (i) Pre-training (1996-99) Method A bi-monthly multi-professional 1-day intrapartum emergencies training course, that included a 30-minute practical session on shoulder dystocia management, commenced in 2000.Main Outcomes Neonatal morbidity (brachial plexus injury, humeral fracture, clavicular fracture, 5-minute Apgar score <7) and documented management of shoulder dystocia (resolution manoeuvres performed, traction applied, head-to-body delivery interval).Results Compliance with national guidance improved with continued training. At least one recognised resolution manoeuvre was used in 99.8% (561/562) of cases of shoulder dystocia in the late training period, demonstrating a continued improvement from 46.3% (150/324, P < 0.001) pre-training, and 92% (241/262, P < 0.001) in the early training period. In parallel there was reduction in the brachial plexus injury at birth (24/324 [7.4%, P < 0.01], pre-training, 6/262 [2.3%] early training, and 7/562 [1.3%] late training.Conclusions There are significant benefits to long-term, embedded training programmes with improvements in both management and outcomes. A decade after the introduction of training there were no cases of brachial plexus injury lasting over 12 months in 562 cases of shoulder dystocia.

Objective:To investigate the association of brief (0–5 minutes) and prolonged (>5 minutes) low Apgar scores (<7) in non-encephalopathic infants with educational achievement at age 15–16 and intelligence quotients (IQs) at age 18.Design:Population-based record-linkage cohort study of 176 524 male infants born throughout Sweden between 1973 and 1976.Patients and methods:Data from the Medical Birth Register were linked to Population and Housing Censuses, conscription medical records (IQ), and school registers (summary school grade). Infants were classified according to the time for their Apgar score to reach 7 or above. Premature infants and those with encephalopathy were excluded.Results:Infants with brief (OR = 1.14 (1.03–1.27)) or prolonged (OR = 1.35 (1.07–1.69)) low Apgar scores were more likely to have a low IQ score. There was an increased risk of a low IQ score (p = 0.003) the longer it took the infant to achieve a normal Apgar score. There was no association between brief (OR = 0.96 (0.87–1.06)) or prolonged (OR = 1.01 (0.81–1.26)) low Apgar scores and a low summary school grade at age 15–16, or evidence for a trend in the risk of a low school grade (p = 0.61). The estimated proportion with an IQ score below 81 due to transiently low Apgar scores was only 0.7%.Conclusions:Infants in poor condition at birth have increased risk of poor functioning in cognitive tests in later life. This supports the idea of a “continuum of reproductive casualty”, although the small individual effect suggests that these mild degrees of fetal compromise are not of clinical importance.

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SummaryBackgroundMild cerebral injury might cause subtle defects in cognitive function that are only detectable as the child grows older. Our aim was to determine whether infants receiving resuscitation after birth, but with no symptoms of encephalopathy, have reduced intelligence quotient (IQ) scores in childhood.MethodsThree groups of infants were selected from the Avon Longitudinal Study of Parents and Children: infants who were resuscitated at birth but were asymptomatic for encephalopathy and had no further neonatal care (n=815), those who were resuscitated and had neonatal care for symptoms of encephalopathy (n=58), and the reference group who were not resuscitated, were asymptomatic for encephalopathy, and had no further neonatal care (n=10 609). Cognitive function was assessed at a mean age of 8·6 years (SD 0·33); a low IQ score was defined as less than 80. IQ scores were obtained for 5953 children with a shortened version of the Weschler intelligence scale for children (WISC-III), the remaining 5529 were non-responders. All children did not complete all parts of the test, and therefore multiplied IQ values comparable to the full-scale test were only available for 5887 children. Results were adjusted for clinical and social covariates. Chained equations were used to impute missing values of covariates.FindingsIn the main analysis at 8 years of age (n=5887), increased risk of a low IQ score was recorded in both resuscitated infants asymptomatic for encephalopathy (odds ratio 1·65 [95% CI 1·13–2·43]) and those with symptoms of encephalopathy (6·22 [1·57–24·65]). However, the population of asymptomatic infants was larger than that of infants with encephalopathy, and therefore the population attributable risk fraction for an IQ score that might be attributable to the need for resuscitation at birth was 3·4% (95% CI 0·5–6·3) for asymptomatic infants and 1·2% (0·2–2·2) for those who developed encephalopathy.InterpretationInfants who were resuscitated had increased risk of a low IQ score, even if they remained healthy during the neonatal period. Resuscitated infants asymptomatic for encephalopathy might result in a larger proportion of adults with low IQs than do those who develop neurological symptoms consistent with encephalopathy.FundingWellcome Trust.

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Purpose To identify if there is an association between foetal haemoglobin (HbF) concentration and retinopathy of prematurity (ROP) in very preterm infants. Patients and methods Prospective cohort study. Infants born o32 weeks' gestational age or o1501 g in two tertiary neonatal units between January 2012 and May 2013 (n = 42) were enrolled. HbF and adult haemoglobin (HbA) concentrations were measured using high-pressure liquid chromatography from blood samples sent as part of routine neonatal care once routinely requested laboratory tests had been performed. Clinical data were obtained from case notes. We calculated odds ratios (ORs) (95% confidence intervals (CIs)) to quantify the relationship between initial and mean %HbF with ROP severity (none, stages 1-3). Results A total of 42 infants were recruited: mean gestation 28.0 weeks (SD 1.91); mean birth weight 1042 g (SD 264). Six infants died before ROP screening; 14/36 developed ROP (39%); and 22/36 (61%) did not. Infants who developed ROP had similar initial %HbF (83.3 vs 92.3%, P = 0.06), but significantly lower mean %HbF (61.75 vs 91.9%, P = 0.0001) during their inpatient stay than those who did not develop ROP. In ordinal logistic regression models adjusted for birth weight, gestation and transfusion volume, mean post-natal %HbF was negatively associated with ROP severity: adjusted OR 0.94 (0.90-0.99), while initial %HbF at birth was not: adjusted OR 1.05 (0.97-1.16). Conclusion Replacing HbF by HbA during transfusion may promote ROP development by rapidly increasing oxygen availability to the retina. Conversely, maintaining a higher %HbF may be a protective factor against ROP.

ABBREVIATION ALSPAC Avon Longitudinal Study of Parents and ChildrenAIM To investigate whether infants born late preterm have poorer cognitive outcomes than termborn infants.METHOD A cohort study based on the Avon Longitudinal Study of Parents and Children. Cognitive measures were assessed between the ages of 8 and 11 years. Exposure groups were defined as moderate ⁄ late preterm (32-36 weeks' gestation) or term (37-42wk). Regression models were used to investigate the association between gestational age and IQ.RESULTS Seven hundred and forty-one infants (5.4% of total eligible population; 422 males, 319females; mean (SD) birthweight 2495g [489]) were born between 32 and 36 weeks' gestation. The analysis was based on 6957 infants with IQ data at age 11 (50% of eligible infants). In the adjusted model, children born moderately and late preterm had similar IQ scores to peers born at term (mean difference [95% confidence interval] )0.18 [)1.88 to 1.52]). However, the preterm infants had a higher risk of having special educational needs at school (odds ratio 1.56 [1.18-2.07]).INTERPRETATION Despite an increased risk of special educational needs, there is little evidence of a reduction in IQ, memory, or attention measures at school age in children born between 32 and 36 weeks' gestation. Although interpretation is limited by the amount of missing data, further work is needed to identify why these infants have increased educational needs.The long-term effects of preterm birth are well documented in infants born before 32 weeks' corrected gestation. 1 Extreme preterm birth is associated with increased risks of cerebral palsy, 2 impairments in executive functioning, 3 as well as reduction in more global measures of cognition, 1 resulting in poorer educational achievement. 4 However, the long-term outcome of infants born only moderately preterm is less clear. Previous studies have suggested increased rates of educational difficulties in infants born before 37 weeks' gestation [5][6][7] and there is some evidence that measures of cognition may also be worse 8 . At present these infants receive little specific educational input or formal neurodevelopmental follow-up, unlike infants born at earlier gestations, and represent a much larger population than those born at earlier gestations.5 Recently the definitions of moderate (32-33 weeks' gestation) and late (34-36wk) preterm birth have been used to identify this group of infants.The aim of the present study was to investigate whether infants born at moderate and late preterm gestations (32-36wk) have poorer cognitive, memory, attention, or school outcomes in childhood than those born at term. METHODThis study is based on the Avon Longitudinal Study of Parents and Children (ALSPAC), an ongoing longitudinal study containing data on over 14 000 infants. 9 The cohort includes children born in the Bristol area of the UK, from April 1991 to December 1992. Further information about the study can be found on the ALSPAC website (http://www.alspac.bristol. ac.uk).Data on gestational a...

BackgroundProgressive ventricular dilatation after intraventricular haemorrhage (IVH) in preterm infants has a very high risk of severe disability and death. Drainage, irrigation and fibrinolytic therapy (DRIFT), in a randomised controlled trial (RCT), reduced severe cognitive impairment at 2 years.ObjectiveTo assess if the cognitive advantage of DRIFT seen at 2 years persisted until school age.ParticipantsThe RCT conducted in four centres recruited 77 preterm infants with IVH and progressive ventricular enlargement over specified measurements. Follow-up was at 10 years of age.InterventionIntraventricular injection of a fibrinolytic followed by continuous lavage, until the drainage was clear, and standard care consisting of control of expansion by lumbar punctures and if expansion persisted via a ventricular access device.Primary outcomeCognitive quotient (CQ), derived from the British Ability Scales and Bayley III Scales, and survival without severe cognitive disability.ResultsOf the 77 children randomised, 12 died, 2 could not be traced, 10 did not respond and 1 declined at 10-year follow-up. 28 in the DRIFT group and 24 in the standard treatment group were assessed by examiners blinded to the intervention. The mean CQ score was 69.3 (SD=30.1) in the DRIFT group and 53.7 (SD=35.7) in the standard treatment group (unadjusted p=0.1; adjusted p=0.01, after adjustment for the prespecified variables sex, birth weight and IVH grade). Survival without severe cognitive disability was 66% in the DRIFT group and 35% in the standard treatment group (unadjusted p=0.019; adjusted p=0.003).ConclusionDRIFT is the first intervention for posthaemorrhagic ventricular dilatation to objectively demonstrate sustained cognitive improvement.Trial registration numberISRCTN80286058.