Intrauterine Asphyxia: Clinical Implications for Providers of Intrapartum Care

Jenifer Fahey, CNM, MSN, MPH; Tekoa L. King, CNM, MPH

Disclosures

J Midwifery Womens Health. 2005;50(6):498-506. 

In This Article

Abstract and Introduction

Advances in science and technology have allowed researchers to gain a better understanding of the pathophysiology leading to long-term neurologic damage in newborns. Intrapartum events are now known to be an infrequent cause of adverse neurologic outcome. Clinicians caring for women during labor must have an understanding of the pathophysiology of intrauterine asphyxia as well as an awareness of the capabilities and limitations of available intrapartum fetal assessment tools to diagnose intrauterine fetal asphyxia or predict neurologic outcome. This article reviews the physiology of acid-base balance and fetal gas exchange as well as the current scientific understanding of the role of intrauterine asphyxia in the pathophysiology of neonatal encephalopathy and cerebral palsy. Recommendations for care and documentation are included.

Cases involving neurologic injuries account for some of the largest payments for claims against providers of obstetric care, with some awards reaching higher than 40 million dollars per case.[1] Similarly, costs related to these cases absorb 60% of malpractice premiums.[2] A growing body of evidence, however, confirms findings by researchers in the 1980s that intrapartum events are an infrequent cause of adverse neurologic outcome.[3,4,5,6] Despite these findings, the perception that events during labor and delivery are the primary cause of cerebral palsy and other neurologic dysfunction persists. Clinicians have inadvertently fueled this misperception by failing to use consistent criteria and physiologically accurate definitions to describe fetal oxygenation during labor and birth.

Clinicians must have an accurate definition of intrauterine asphyxia to help guide intrapartum fetal surveillance and labor management and to avoid perpetuating the notion that intrapartum asphyxia is a common event and a common cause of long-term neurologic dysfunction. To achieve this, it is necessary first to have an understanding of fetal respiratory physiology, hypoxemia in the fetus, and the role of hypoxemia in the pathogenesis of neurologic damage. In addition, clinicians must understand the abilities and limitations of current intrapartum surveillance techniques used to predict asphyxia and newborn tests used to diagnose asphyxia.

This article reviews the physiology of acid-base balance and fetal gas exchange as well as current understanding of the role of intrauterine asphyxia in the pathophysiology of neonatal encephalopathy and cerebral palsy. The efficacy of intrapartum assessment modalities, such as fetal heart rate monitoring, fetal scalp stimulation, fetal scalp blood sampling, and cord gases in the identification of intrauterine asphyxia are discussed, and recommendations for clinical practice and documentation are outlined.

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