Using malpractice claims to identify risk factors for neurological impairment among infants following non-reassuring fetal heart rate patterns during labour.
OBJECTIVE
We sought to use a novel case-selection methodology to identify antenatal or intrapartum risk factors associated with neonatal neurological impairment following non-reassuring fetal heart rate patterns during labour.


METHODS
We used a retrospective case-control design with bivariate and multivariate conditional logistic regression. Cases were births in which electronic fetal monitoring (EFM) showed non-reassuring patterns and the infant had neurological disability. Controls were births in which EFM was non-reassuring but the infant was born healthy. We identified 36 cases from among malpractice claims filed with a liability insurer in Massachusetts between 1985 and 2001 and randomly selected 70 controls, matching them to cases by hospital, birth date and gestational age.


RESULTS
More cases had maternal antenatal vaginal bleeding (P = 0.004), a prolonged latent phase or protracted dilation during the first stage of labour (P = 0.03), and protracted descent or prolonged second stage (P = 0.01). More cases also had minimal variability on EFM on admission (P = 0.02) and during the second stage (P = 0.02). Multivariate analysis highlighted three significant predictors of neurological injury following complicated labour: antenatal vaginal bleeding (OR = 27.1), prolonged latent phase or protracted dilation in the first stage (OR = 4.0) and EFM showing minimal variability in the first stage (OR = 4.3).


CONCLUSIONS
These promising initial findings suggest that future research into outcomes from complicated labour with non-reassuring heart rate patterns should focus on maternal history of vaginal bleeding, slow labour and minimal variability on EFM.
Kesselheim
Aaron S
AS
Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA02120, USA. akesselheim@partners.org
November
Martin T
MT
Lifford
Karen L
KL
McElrath
Thomas F
TF
Puopolo
Ann L
AL
Orav
E John
EJ
Studdert
David M
DM
D000293:Adolescent; D000328:Adult; D005260:Female; D005323:Fetal Monitoring / Q000379:methods; D006340:Heart Rate, Fetal / Q000502:physiology*; D006801:Humans; D007231:Infant, Newborn; D007345:Insurance Claim Review; D008318:Malpractice; D008404:Massachusetts; D009422:Nervous System Diseases / Q000209:etiology*; D011247:Pregnancy; D011248:Pregnancy Complications; D012189:Retrospective Studies; D012307:Risk Factors; D055815:Young Adult