title: How often is a low Apgar score the result of substandard care during labour?
abstract: OBJECTIVE
  To increase our knowledge of the occurrence of substandard care during labour.
  
  
  METHODS
  A population-based case-control study.
  
  
  METHODS
  Stockholm County.
  
  
  METHODS
  Infants born in the period 2004-2006 in Stockholm County.
  
  
  METHODS
  Cases and controls were identified from the Swedish Medical Birth Register, had a gestational age of +/-33 complete weeks, had planned for a vaginal delivery, and had a normal cardiotocographic (CTG) recording on admission. We compared 313 infants with an Apgar score of < 7 at 5 minutes of age with 313 randomly selected controls with a full Apgar score, matched for year of birth.
  
  
  METHODS
  Substandard care during labour.
  
  
  RESULTS
  We found that 62% of cases and 36% of controls were subject to some form of substandard care during labour. In half of the cases and in 12% of the controls, CTG was abnormal for > or = 45 minutes before birth. Fetal blood sampling was not performed in 79% of both cases and controls, when indicated.Oxytocin was provided without signs of uterine inertia in 20% of both cases and controls. Uterine contractions were hyperstimulated by oxytocin in 29% of cases and in 9% of controls, and the dose of oxytocin was increased despite abnormal CTG in 19% and 6% of cases and controls, respectively. Assuming that substandard care is a risk factor for low Apgar score, we estimate that up to 42% of the cases could be prevented by avoiding substandard care.
  
  
  CONCLUSIONS
  There was substandard care during labour of two thirds of infants with a low Apgar score. The main reasons for substandard care were related to misinterpretation of CTG, not acting on an abnormal CTG in a timely fashion and incautious use of oxytocin.
authors.affiliation: Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, Stockholm, Sweden. sophie.berglund@sodersjukhuset.se
authors.forename: S
authors.initials: S
authors.lastname: Berglund
authors.forename: H
authors.initials: H
authors.lastname: Pettersson
authors.forename: S
authors.initials: S
authors.lastname: Cnattingius
authors.forename: C
authors.initials: C
authors.lastname: Grunewald
mesh_terms: D000328:Adult; D001034:Apgar Score; D001724:Birth Weight; D015148:Cardiotocography; D016022:Case-Control Studies; D005260:Female; D005865:Gestational Age; D006801:Humans; D007231:Infant, Newborn; D007743:Labor, Obstetric; D008297:Male; D010120:Oxytocics; D010121:Oxytocin; D011247:Pregnancy; D011295:Prenatal Care / Q000592:standards*; D012307:Risk Factors; D055815:Young Adult
chemical_list: D010120:Oxytocics; D010121:Oxytocin