Intrapartum Problems

  • Adrian K. CharlesEmail author


Every year, it is estimated that there are approaching 3 million stillbirths, of which 1.2 million are intrapartum. These numbers predominantly reflect the developing world: 98 % of these stillbirths occur in the developing world with perinatal mortality rates of up to 150 per 1,000 registered births—45 % of these are intrapartum. In the developed world, the rate of hypoxic perinatal death is around 2.5 % of the overall perinatal mortality. It is important to recognize that the mortality rate only reflects the tip of the intrapartum morbidity. It is considered that each year, around 7 million years worth of disability is due to intrapartum events. It therefore is important to understand the factors in these deaths and reduce not only the intrapartum stillbirth rate but also the considerable morbidity associated with this.


Intrapartum stillbirth Intrapartum asphyxia Fetal hypoxemia Hypoxia Acidosis Brain cooling Maternal disorders Placenta Umbilical cord Myocytolysis Meconium Fetal conditions Cerebral palsy Third-trimester stillbirths Neonatal encephalopathy Birth trauma 


  1. 1.
    Goldenberg RL, McClure EM, Bhutta ZA, Belizan JM, Reddy UM, Rubens CE, et al. Stillbirths: the vision for 2020. Lancet. 2011;377:1798–805.CrossRefGoogle Scholar
  2. 2.
    Martinez-Biarge M, Diez-Sebastian J, Wusthoff CJ, Mercuri E, Cowan FM. Antepartum and intrapartum factors preceding neonatal hypoxic-ischemic encephalopathy. Pediatrics. 2013;132:e952–9.CrossRefGoogle Scholar
  3. 3.
    Flenady V, Middleton P, Smith GC, Duke W, Erwich JJ, Khong TY, et al. Stillbirths: the way forward in high-income countries. Lancet. 2011;377:1703–17.CrossRefGoogle Scholar
  4. 4.
    Bhutta ZA, Yakoob MY, Lawn JE, Rizvi A, Friberg IK, Weissman E, et al. Stillbirths: what difference can we make and at what cost? Lancet. 2011;377:1523–38.CrossRefGoogle Scholar
  5. 5.
    Li Z, Zeki R, Hilder L, Sullivan EA. Australia’s mothers and babies 2011. Canberra: AIHW; 2013.Google Scholar
  6. 6.
    Donn SM, Chiswick ML, Fanaroff JM. Medico-legal implications of hypoxic-ischemic birth injury. Semin Fetal Neonatal Med. 2014;19:317–21.CrossRefGoogle Scholar
  7. 7.
    Butler NR, Bonham D. Perinatal mortality: the first report of the 1958 British perinatal mortality survey. Edinburgh: E. & S. Livingstone; 1963.Google Scholar
  8. 8.
    Office for National Statistics. Statistical bulletin: infant and perinatal mortality in England and Wales by social and biological factors. 2011.
  9. 9.
    CMACE. Centre for maternal and child enquiries (CMACE) perinatal mortality 2009: United Kingdom. London: CMACE; 2011. Scholar
  10. 10.
    Darmstadt GL, Yakoob MY, Haws RA, Menezes EV, Soomro T, Bhutta ZA. Reducing stillbirths: interventions during labour. BMC Pregnancy Childbirth. 2009;9:S6.CrossRefGoogle Scholar
  11. 11.
    Anonymous. RCOG/B10/11/7 the sub-committee on fetal and perinatal pathology’s papers relating to the report of the working party: Joint Working Party of the Royal College of Obstetricians and Gynaecologists and the Royal College of Pathologists. Report on fetal and perinatal. London: Royal College of Pathologists, 1988.Google Scholar
  12. 12.
    Ernst LM. A pathologist’s perspective on the perinatal autopsy. Semin Perinatol. 2015;39:55–63.CrossRefGoogle Scholar
  13. 13.
    Reed RC. Iatrogenic injury and unexpected hospital death in the newborn. Semin Perinatol. 2015;39:64–9.CrossRefGoogle Scholar
  14. 14.
    Perinatal Mortality Special Interest Group of the Perinatal Society of Australia and New Zealand. Alliance P-SSaND. PSANZ clinical practice guideline for perinatal mortality.
  15. 15.
    Herrera-Marschitz M, Neira-Pena T, Rojas-Mancilla E, Espina-Marchant P, Esmar D, Perez R, et al. Perinatal asphyxia: CNS development and deficits with delayed onset. Front Neurosci. 2014;8:47.CrossRefGoogle Scholar
  16. 16.
    Salmaso N, Jablonska B, Scafidi J, Vaccarino FM, Gallo V. Neurobiology of premature brain injury. Nat Neurosci. 2014;17:341–6.CrossRefGoogle Scholar
  17. 17.
    Azzopardi D, Strohm B, Marlow N, Brocklehurst P, Deierl A, Eddama O, et al. Effects of hypothermia for perinatal asphyxia on childhood outcomes. N Engl J Med. 2014;371:140–9.CrossRefGoogle Scholar
  18. 18.
    Jacobs SE, Berg M, Hunt R, Tarnow-Mordi WO, Inder TE, Davis PG. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database Syst Rev. 2013;1, CD003311.Google Scholar
  19. 19.
    Low JA. Intrapartum fetal asphyxia: definition, diagnosis, and classification. Am J Obstet Gynecol. 1997;176:957–9.CrossRefGoogle Scholar
  20. 20.
    Rees S, Harding R, Walker D. The biological basis of injury and neuroprotection in the fetal and neonatal brain. Int J Dev Neurosci. 2011;29:551–63.CrossRefGoogle Scholar
  21. 21.
    Storme L, Aubry E, Rakza T, Houeijeh A, Debarge V, Tourneux P, et al. Pathophysiology of persistent pulmonary hypertension of the newborn: impact of the perinatal environment. Arch Cardiovasc Dis. 2013;106:169–77.CrossRefGoogle Scholar
  22. 22.
    Higgins M, McAuliffe FM, Mooney EE. Clinical associations with a placental diagnosis of delayed villous maturation: a retrospective study. Pediatr Dev Pathol. 2011;14:273–9.CrossRefGoogle Scholar
  23. 23.
    Baergen RN. Cord abnormalities, structural lesions, and cord “accidents”. Semin Diagn Pathol. 2007;24:23–32.CrossRefGoogle Scholar
  24. 24.
    Chan JS, Baergen RN. Gross umbilical cord complications are associated with placental lesions of circulatory stasis and fetal hypoxia. Pediatr Dev Pathol. 2012;15:487–94.CrossRefGoogle Scholar
  25. 25.
    Khong TY. Evidence-based pathology: umbilical cord coiling. Pathology. 2010;42:618–22.CrossRefGoogle Scholar
  26. 26.
    Baergen RN, Malicki D, Behling C, Benirschke K. Morbidity, mortality, and placental pathology in excessively long umbilical cords: retrospective study. Pediatr Dev Pathol. 2001;4:144–53.CrossRefGoogle Scholar
  27. 27.
    Gonzalez-Quintero VH, Tolaymat L, Muller AC, Izquierdo L, O’Sullivan MJ, Martin D. Outcomes of pregnancies with sonographically detected nuchal cords remote from delivery. J Ultrasound Med. 2004;23:43–7.CrossRefGoogle Scholar
  28. 28.
    Larson JD, Rayburn WF, Crosby S, Thurnau GR. Multiple nuchal cord entanglements and intrapartum complications. Am J Obstet Gynecol. 1995;173:1228–31.CrossRefGoogle Scholar
  29. 29.
    Anonymous. Confidential enquiry into stillbirths and deaths in infancy: 7th annual report Maternal and Child Health Research Consortium. 2000.Google Scholar
  30. 30.
    Baburamani AA, Ek CJ, Walker DW, Castillo-Melendez M. Vulnerability of the developing brain to hypoxic-ischemic damage: contribution of the cerebral vasculature to injury and repair? Front Physiol. 2012;3:424.CrossRefGoogle Scholar
  31. 31.
    Jacques SM, Kupsky WJ, Giorgadze T, Qureshi F. Fetal central nervous system injury in third trimester stillbirth: a clinicopathologic study of 63 cases. Pediatr Dev Pathol. 2012;15:375–84.CrossRefGoogle Scholar
  32. 32.
    Squier W. Acquired damage to the developing brain: timing and causation 1 ed. Hodder Arnold Publication, London. CRC Press; 2002 p. 227.Google Scholar
  33. 33.
    Li Y, Gonzalez P, Zhang L. Fetal stress and programming of hypoxic/ischemic-sensitive phenotype in the neonatal brain: mechanisms and possible interventions. Prog Neurobiol. 2012;98:145–65.CrossRefGoogle Scholar
  34. 34.
    Perlman JM. Intrapartum hypoxic-ischemic cerebral injury and subsequent cerebral palsy: medicolegal issues. Pediatrics. 1997;99:851–9.CrossRefGoogle Scholar
  35. 35.
    Salonen IS, Uusitalo R. Birth injuries: incidence and predisposing factors. Z Kinderchir. 1990;45:133–5.CrossRefGoogle Scholar
  36. 36.
    Oral E, Cagdas A, Gezer A, Kaleli S, Aydinli K, Ocer F. Perinatal and maternal outcomes of fetal macrosomia. Eur J Obstet Gynecol Reprod Biol. 2001;99:167–71.CrossRefGoogle Scholar
  37. 37.
    Raio L, Ghezzi F, Di Naro E, Buttarelli M, Franchi M, Durig P, et al. Perinatal outcome of fetuses with a birth weight greater than 4500 g: an analysis of 3356 cases. Eur J Obstet Gynecol Reprod Biol. 2003;109:160–5.CrossRefGoogle Scholar
  38. 38.
    O’Mahony F, Settatree R, Platt C, Johanson R. Review of singleton fetal and neonatal deaths associated with cranial trauma and cephalic delivery during a national intrapartum-related confidential enquiry. BJOG. 2005;112:619–26.CrossRefGoogle Scholar
  39. 39.
    Incerti M, Locatelli A, Consonni S, Bono F, Leone BE, Ghidini A. Can placental histology establish the timing of meconium passage during labor? Acta Obstet Gynecol Scand. 2011;90:863–8.CrossRefGoogle Scholar
  40. 40.
    Kilani RA, Wetmore J. Neonatal subgaleal hematoma: presentation and outcome – radiological findings and factors associated with mortality. Am J Perinatol. 2006;23:41–8.CrossRefGoogle Scholar
  41. 41.
    Amar AP, Aryan HE, Meltzer HS, Levy ML. Neonatal subgaleal hematoma causing brain compression: report of two cases and review of the literature. Neurosurgery. 2003;52:1470–4; discussion 1474.CrossRefGoogle Scholar
  42. 42.
    Chadwick LM, Pemberton PJ, Kurinczuk JJ. Neonatal subgaleal haematoma: associated risk factors, complications and outcome. J Paediatr Child Health. 1996;32:228–32.CrossRefGoogle Scholar
  43. 43.
    Gebremariam A. Subgaleal haemorrhage: risk factors and neurological and developmental outcome in survivors. Ann Trop Paediatr. 1999;19:45–50.CrossRefGoogle Scholar
  44. 44.
    Boo NY, Foong KW, Mahdy ZA, Yong SC, Jaafar R. Risk factors associated with subaponeurotic haemorrhage in full-term infants exposed to vacuum extraction. BJOG. 2005;112:1516–21.CrossRefGoogle Scholar
  45. 45.
    Rupp W, Ropohl D, Bohnert M. Differential diagnosis of traumatic skull findings in infants: residues after vacuum extraction. Arch Kriminol. 2005;215:70–6.PubMedGoogle Scholar
  46. 46.
    Whitby EH, Griffiths PD, Rutter S, Smith MF, Sprigg A, Ohadike P, et al. Frequency and natural history of subdural haemorrhages in babies and relation to obstetric factors. Lancet. 2004;363:846–51.CrossRefGoogle Scholar
  47. 47.
    Scheimberg I, Cohen MC, Zapata Vazquez RE, Dilly S, Adnani MA, Turner K, et al. Nontraumatic intradural and subdural hemorrhage and hypoxic ischemic encephalopathy in fetuses, infants, and children up to three years of age: analysis of two audits of 636 cases from two referral centers in the United Kingdom. Pediatr Dev Pathol. 2013;16:149–59.CrossRefGoogle Scholar
  48. 48.
    RCPath. Report of a meeting on the pathology of traumatic head injury in children.
  49. 49.
    Service TCP. Non accidental head injury cases (NAHI, formerly referred to as Shaken Baby Syndrome [SBS]) – prosecution approach.
  50. 50.
    Heise RH, Srivatsa PJ, Karsell PR. Spontaneous intrauterine linear skull fracture: a rare complication of spontaneous vaginal delivery. Obstet Gynecol. 1996;87:851–4.PubMedGoogle Scholar
  51. 51.
    Dupuis O, Silveira R, Dupont C, Mottolese C, Kahn P, Dittmar A, et al. Comparison of “instrument-associated” and “spontaneous” obstetric depressed skull fractures in a cohort of 68 neonates. Am J Obstet Gynecol. 2005;192:165–70.CrossRefGoogle Scholar
  52. 52.
    Wigglesworth JS, Husemeyer RP. Intracranial birth trauma in vaginal breech delivery: the continued importance of injury to the occipital bone. Br J Obstet Gynaecol. 1977;84:684–91.CrossRefGoogle Scholar
  53. 53.
    Hauck AJ, Bambara JF, Edwards WD. Embolism of brain tissue to the lung in a neonate. Report of a case and review of the literature. Arch Pathol Lab Med. 1990;114:217–8.PubMedGoogle Scholar
  54. 54.
    Baergen RN, Castillo MM, Mario-Singh B, Stehly AJ, Benirschke K. Embolism of fetal brain tissue to the lungs and the placenta. Pediatr Pathol Lab Med. 1997;17:159–67.CrossRefGoogle Scholar
  55. 55.
    Chan YE, Stewart KA, Rowlands S. Intrapartum fetal death caused by embolisation of cerebral tissue to the heart and the lung. Aust N Z J Obstet Gynaecol. 2003;43:246–8.CrossRefGoogle Scholar
  56. 56.
    Drut R. Embolism of fetal brain tissue to the lungs. Pediatr Pathol Lab Med. 1997;17:987.Google Scholar
  57. 57.
    Ruggieri M, Smarason AK, Pike M. Spinal cord insults in the prenatal, perinatal, and neonatal periods. Dev Med Child Neurol. 1999;41:​311–7.CrossRefGoogle Scholar
  58. 58.
    Ebinger F, Boor R, Bruhl K, Reitter B. Cervical spinal cord atrophy in the atraumatically born neonate: one form of prenatal or perinatal ischaemic insult? Neuropediatrics. 2003;34:45–51.CrossRefGoogle Scholar
  59. 59.
    MacKinnon JA, Perlman M, Kirpalani H, Rehan V, Sauve R, Kovacs L. Spinal cord injury at birth: diagnostic and prognostic data in twenty-two patients. J Pediatr. 1993;122:431–7.CrossRefGoogle Scholar
  60. 60.
    Chang KT. Examination of the placenta: medico-legal implications. Semin Fetal Neonatal Med. 2014;19:279–84.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing 2015

Authors and Affiliations

  1. 1.Department of PathologySidra Medical and Research Center and Weill Cornell Medical College in QatarDohaQatar

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