You are on page 1of 6

Seminars in Fetal & Neonatal Medicine (2008) 13, 362e367

available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/siny

Intrauterine resuscitation during labor:


Should maternal oxygen administration
be a first-line measure?
Kathleen Rice Simpson*

Labor and Delivery, St. John’s Mercy Medical Center, St. Louis, MO, USA

KEYWORDS Summary Intrauterine resuscitation techniques are often used during labor when the fetal
Intrauterine heart rate pattern is nonreassuring. These techniques have not been well studied; common
resuscitation; practices are based on classic studies many years old. Models of intrauterine resuscitation
Maternal oxygen using one (or more) technique as a first-line intervention and adding others in a specific series
administration; or clinical algorithm based on fetal response have not been tested. Maternal oxygen therapy is
Nonreassuring fetal often used; however, recent evidence suggests potential risks to the mother and fetus or
heart rate pattern; newborn. Even small increases in maternal and fetal pO2 as a result of maternal oxygen admin-
Oxygen free radicals istration can produce oxygen free radical activity in mothers and fetuses. The potential long-
term effects are unknown. Caution should be exercised when considering maternal oxygen
administration as a first-line intrauterine resuscitation measure until more data are available,
reserving its use after other measures have been unsuccessful in resolving the nonreassuring
fetal heart rate pattern.
ª 2008 Elsevier Ltd. All rights reserved.

Introduction knowledge exist are discussed, and suggestions for future


research are provided.
When the fetal heart rate (FHR) pattern is nonreassuring
during labor, clinicians initiate a series of interventions to Assessing fetal status during labor
promote fetal well-being. These interventions are often
collectively referred to as intrauterine resuscitation. The The decision to intervene using intrauterine resuscitation
goals and associated interventions are listed in Table 1. The techniques is based on the interpretation of data regarding
purpose of this paper is to provide a brief overview of fetal status. Electronic fetal monitoring (EFM) is the most
commonly used intrauterine resuscitation techniques dur- common method of assessing fetal status during labor.
ing labor and a more in-depth discussion regarding one Although data from EFM can be helpful in determining
technique specifically: maternal oxygen administration. whether the fetus is tolerating the physiologic stress of
Areas of clinical practice in which significant gaps in labor, it has significant limitations. EFM is an indirect
measure of fetal oxygenation and, as such, might not
* Tel.: þ1 314 251 6087; fax: þ1 314 721 9806. always provide the most accurate indication of fetal status.
E-mail address: krsimpson@prodigy.net Clinicians in other specialties base patient-care decisions

1744-165X/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.siny.2008.04.016
Intrauterine resuscitation during labor 363

Table 1 Intrauterine resuscitation


Goal Techniques and methods
Promote fetal Lateral maternal positioning (either left or right)
oxygenation Discontinuation of intravenous oxytocin, removal of dinoprostone vaginal insert (Cervidil) or
withholding the next dose of misoprostol (Cytotec)
Modification of maternal pushing efforts during second stage labor (pushing with every other or every
third contraction, or temporary discontinuation of pushing)
Intravenous fluid bolus of at least 500 mL of lactated Ringer’s solution, if appropriate based on
maternal condition
Oxygen administration at 10 L/min via nonrebreather facemask may be considered if above
interventions do not resolve nonreassuring FHR pattern; discontinue as soon as possible based
on the fetal response
Reduce uterine Lateral maternal positioning (either left or right)
activity Discontinuation of intravenous oxytocin, removal of dinoprostone vaginal insert (Cervidil) or
withholding the next dose of misoprostol (Cytotec)
Intravenous fluid bolus of at least 500 mL of lactated Ringer’s solution, if appropriate based on
maternal condition
Administering terbutaline 0.25 mg subcutaneously may be considered if above interventions do not
resolve excessive uterine activity
Alleviate umbilical Maternal repositioning based on fetal response
cord compression Amnioinfusion (during first-stage labor)
Modification of maternal pushing efforts during second stage labor (pushing with every other or every
third contraction, or temporary discontinuation of pushing)
Correct maternal Lateral maternal positioning (either left or right)
hypotension Intravenous fluid bolus of at least 500 mL of lactated Ringer’s solution
Administering ephedrine 5 mg to 10 mg intravenous push may be considered if above interventions do
not resolve maternal hypotension

on multiple physiologic parameters, whereas the obstetri- Therefore, a diagnosis of nonreassuring fetal status can
cian, midwife, and labor nurse are limited to the assess- be consistent with birth of a vigorous baby.5
ment of the heart rate pattern of a patient who is unseen.
These inherent challenges of EFM make interpretation and Intrauterine resuscitation
decision making less than precise.
Approximately 30% of fetuses will demonstrate a nonreas- Choice of intervention(s) when fetal compromise is
suring FHR pattern at some time during labor1; however, in suspected is based on the individual clinical situation and
many of these cases, the fetus remains well oxygenated. specific characteristics of the nonreassuring FHR pattern.
EFM sensitivity (the ability to detect a healthy fetus when it The clinical context in which the nonreassuring FHR pattern
is indeed healthy) is high, whereas specificity (the ability to occurs and success in resolving the pattern serve as the
detect a compromised fetus when it is compromised and not basis for the clinician’s judgment in selecting which initial
include healthy fetuses in the criteria) is low.2 and subsequent methods might work best. No standardized
Further confounding factors include a lack of consensus or systematic approach to intrauterine resuscitation is
among clinicians regarding characteristics of FHR patterns found in the literature or offered by the American College
that indicate fetal compromise as well as a lack of universal of Obstetricians and Gynecologists or the Association of
adoption of standardized definitions to describe FHR Women’s Health, Obstetric and Neonatal Nurses; however,
patterns. Findings from the Joint Commission3 analysis of some techniques are commonly used for specific non-
sentinel event data related to perinatal harm during labor reassuring FHR patterns. For example, interventions for
and birth emphasized the role of accurate communication a woman experiencing a hypotensive episode following
in promoting patient safety. As a result of these data, the a medication dose for regional anesthesia with an accom-
Joint Commission recommended use of standard definitions panying FHR demonstrating recurrent late decelerations
to describe FHR patterns and interdisciplinary education to and moderate variability could include repositioning, an
enhance the likelihood that all members of the perinatal intravenous (IV) fluid bolus, and, if no resolution, ephed-
team would be speaking and understanding the same rine. Recurrent variable decelerations during the first stage
language when communicating FHR data.3 Although stan- of labor can be treated with repositioning, and, if no
dardized definitions were offered by the National Institute resolution, an amnioinfusion. During the second stage of
of Child Health and Human Development (NICHD) Research labor, the same FHR pattern could be treated with
Planning Workshop in 1997,4 all clinicians and institutions repositioning and modification of instructions to the woman
have not incorporated them into clinical practice. The regarding her pushing efforts. The key issues are timely
terms reassuring and nonreassuring are often used to identification and minimization or elimination of the
convey the clinician’s interpretation of the FHR pattern factors thought to be causing physiologic stress to the fetus
and to acknowledge the inherent imprecision of EFM. as suggested by the nonreassuring FHR pattern.
364 K.R. Simpson

Although a nonreassuring FHR pattern might be idio- administer oxygen whereas others do so routinely for
pathic, in some cases, the physiologic stress imposed on the prolonged periods during labor, in some cases concurrent
fetus is iatrogenic. Examples of iatrogenic stress include with oxytocin while the FHR remains nonreassuring and in
oxytocin-induced uterine hyperstimulation, supine or li- other cases long after the nonreassuring FHR pattern has
thotomy maternal positioning, regional anesthesia, and resolved. The most common delivery method is 10 L/min
clinician-coached maternal pushing efforts during second administered via a nonrebreather mask, which results in
stage labor. Attention to clinical conditions with the an FiO2 of 80% to 100%.7,8 Other devices are less efficient
potential for fetal compromise and prompt treatment are (nasal cannula at 10 L/min: FiO2 31%, simple facemask at
indicated to promote fetal wellbeing. 10 L/min: FiO2 27% to 40%).2
Recent evidence suggests that fetal deterioration A search of the electronic databases Medline, the
evolves over time within an approximate 1-hour time Cumulative Index to Nursing and Allied Health Literature
frame.6 Thus, barring any acute adverse clinical event (CINAHL), and the Cochrane Database of Systematic
such as placental abruption, uterine rupture, or prolapsed Reviews from 1966 to January 2008 using the key words or
umbilical cord, generally there is enough time to rescue phrases ‘maternal oxygen administration/therapy’, ‘intra-
a fetus whose wellbeing is in question based on the FHR uterine resuscitation’, ‘in-utero resuscitation’, ‘treatment
pattern. In the context of adequate staffing and with a fetal for fetal distress’, and ‘nonreassuring FHR patterns’
assessment frequency of every 15 to 30 minutes based on revealed numerous studies regarding the effects of mater-
risk status, it is reasonable to expect that a nonreassuring nal oxygen therapy on the fetus during the antepartum and
FHR pattern during labor will be identified and treated in intrapartum periods. Additional studies not identified in the
a timely manner before fetal harm occurs. electronic database search were located in the reference
Despite routine use, intrauterine resuscitation techniques lists of articles reviewed.
have not been well studied; common practices are based in During the antepartum period, three studies considered
part on classic studies many years old. Models of intrauterine the effects of maternal oxygen administration on fetuses
resuscitation using one or more techniques as first-line in- with suspected intrauterine growth restriction,10e12 and
terventions and adding others in a specific series or clinical one study was conducted using healthy fetuses.13 Labor
algorithm based on the fetal response have not been tested. was the clinical setting of 13 studies in which mothers
Yet many clinicians use a step-wise method when intervening were given oxygen.7,8,14e24 However, only six of those
during a nonreassuring FHR pattern. Theoretically, the in- studies7,15,16,18,19,24 included fetuses with nonreassuring
terventions listed in Table 1 are selected on a continuum be- FHR patterns. The number of patients with nonreassuring
ginning with the least invasive and moving forward until FHR patterns in each of those studies was quite small;
there is resolution of the nonreassuring FHR pattern or plans ranging from 1 to 35; up to a total of 98 when combining
are underway for expeditious birth. Therefore, lateral posi- all six studies. Some of the studies did not specifically
tioning is often the first intervention, followed by discontinu- mention whether subjects had a nonreassuring FHR pat-
ation of oxytocin (if infusing), modification of maternal tern, instead noting that the mothers had maternal com-
pushing efforts, and/or an IV fluid bolus; while medications plications such as diabetes or preeclampsia that could
such as oxygen, terbutaline, or ephedrine and procedures increase the risk of fetal compromise. None used random-
such as amnioinfusion are used if the pattern does not resolve ization as a design method. Various amounts of oxygen
with first-line measures. A review of the evidence for each of ranging from 27% to 100% FiO2 were administered. An ad-
these intrauterine resuscitation techniques has been pub- ditional 16 studies were conducted to evaluate the poten-
lished elsewhere.2 tial benefits of routinely giving the mother oxygen to
Recently, several studies have provided more evidence hyperoxygenate the fetus immediately prior to cesarean
concerning common intrauterine resuscitation techniques. birth25e40 with FiO2 levels ranging from 28% to 100%; in
Maternal oxygen administration at 10 L/min administered some studies, comparison groups receiving 21% FiO2
via a nonrebreather facemask may be useful in improving (room air) were used.
fetal oxygen status when the FHR is nonreassuring during Results of all of the studies indicated that maternal
labor.7 Individually, maternal oxygen administration, an IV oxygen administration increases fetal oxygenation regard-
fluid bolus of 500 mL of lactated Ringer’s solution, and less of the method used to measure fetal oxygen status,
lateral positioning have been shown to increase fetal oxy- including FHR patterns, fetal scalp blood sampling, trans-
gen saturation (FSpO2) during labor.8 Reduction of uterine cutaneous oxygen saturation, near-infrared spectroscopy,
activity can be accomplished by maternal repositioning, fetal oxygen saturation (FSpO2), and umbilical blood
an IV fluid bolus of at least 500 mL of lactated Ringer’s sampling. However, although these results might be en-
solution, and discontinuation of oxytocin.9 When used con- couraging in suggesting therapeutic effects of maternal
currently, these three interventions have been found to be oxygen administration for the fetus, this body of evidence
more successful in resolving oxytocin-induced uterine suffers from lack of inclusion of fetuses with nonreassur-
hyperstimulation when compared to discontinuing oxytocin ing FHR patterns in most studies, small sample size, and
alone or with an IV fluid bolus.9 lack of randomly selected comparison groups who did
not receive oxygen except for the studies concerning rou-
Maternal oxygen administration as an tine oxygen use immediately prior to cesarean birth. Con-
intrauterine resuscitation technique ducting a randomized controlled trial allocating patients
with a nonreassuring FHR pattern during labor to a group
Use of maternal oxygen therapy as an intrauterine re- in which oxygen was withheld as an intervention would
suscitation technique varies widely. Some clinicians rarely likely be difficult.
Intrauterine resuscitation during labor 365

Potential risks a causal role or is merely a consequence of the physiologic


All studies that evaluated the effects of maternal oxygen sequelae associated with hypoxia and asphyxia remains
therapy on fetal acidebase status found no adverse effects, undetermined.42,45,50
except for one. In the sole study with contradictory re- Oxygen transfer from mother to fetus via passive
sults,23 a major confounding variable was the length of the diffusion as well as placental equilibrium prevent fetal
second stage of labor. One group of women in second stage hyperoxia as a result of maternal oxygen therapy43; yet
labor received oxygen (n Z 41); their umbilical artery pH even small increases in maternal and fetal pO2 caused by
was compared with that of a control group who did not re- maternal oxygen administration can produce oxygen free
ceive oxygen (n Z 44). There was no difference between radical activity in mothers and their fetuses.32 The poten-
groups based on umbilical artery pH. However, in a subgroup tial long-term effects on the mother and fetus or newborn
analysis, in women with a second stage of labor lasting more are unknown. There has been only one human study involv-
than 10 minutes, there were more cases of fetuses with ing the measurement of byproducts of oxygen free radical
lower umbilical artery pH as compared to fetuses of women activity in mothers and fetuses after mothers at term
with shorter second-stage labor duration. Unlike the group were given oxygen prior to birth.32 In this study, 22 women
that received oxygen, the control group was compared and were randomized to receive oxygen at 60% FiO2 before
analyzed in total rather than by dividing the controls into cesarean birth (mean oxygen exposure 53 minutes, range
two separate groups based on the length of second-stage la- 33e150 minutes); a control group of 22 women who did
bor. In this small subset of patients in whom the acidebase not receive oxygen was used for comparison. Levels of
status was found to be potentially adversely affected, the byproducts of oxygen free radical activity in the mothers
differences were so slight that they were not clinically sig- were noted within 10 minutes of maternal oxygen adminis-
nificant [pH 7.285 control group no oxygen (n Z 44), pH tration, peaked at 30 minutes, and continued to be de-
7.312 group with oxygen and second-stage labor <10 min- tected at abnormally high ranges throughout the 60
utes (n Z 11), pH 7.237 group with oxygen and second-stage minutes of monitoring. Levels of oxygen free radical activ-
labor >10 minutes (n Z 29)], although they were statisti- ity significantly higher than the control group who did not
cally significant.23 Nevertheless, many clinicians inter- receive oxygen were also noted in the umbilical arterial
preted these results as suggesting that maternal oxygen and venous cord blood at the birth of fetuses whose
therapy can lead to fetal acidemia and therefore should mothers received oxygen.32 There is evidence that some
not be used as an intrauterine resuscitation technique. byproducts of oxygen free radical activity cross the pla-
There is scant evidence about when and how long centa while others do not.51
maternal oxygen therapy should be initiated or continued, However, withholding oxygen to mothers when the FHR
and its effects on the mother and fetus. Both hypoxia and pattern is nonreassuring to prevent the possible adverse
hyperoxia can result in the production of oxygen free effects of oxygen free radicals is not recommended
radicals, which can cause oxidative stress and subsequent because fetal hypoxia and acidemia (umbilical artery
adverse effects such as damage to cell membranes, cell pH < 7.15, base excess  8) during labor have also been
structures, cellular lipoproteins, and deoxyribonucleic acid shown to cause abnormally elevated levels of byproducts
(DNA) (see Chapter 1).41 When oxygen is reintroduced after of oxygen free radical activity.52 Some FHR patterns, such
a period of hypoxia, the effects are more pronounced and as recurrent late or variable decelerations or ‘substantial’
are thought to be the pathogenesis of reperfusion injuries bradycardia, with absent FHR variability are likely predic-
in the newborn.41e44 Neuronal membranes in the fetal tive of current or impending fetal hypoxemia, acidemia,
and newborn brain are rich in polyunsaturated fatty acids or asphyxia.4 Clinical interventions to avoid the potential
and have a relative deficiency of several important antiox- adverse effects of progressive fetal hypoxemia and acide-
idant enzymes; thus, the brain of the fetus and newborn is mia are warranted.53 Maternal oxygen administration may
particularly vulnerable to oxidative stress.42,44 Antioxidants be therapeutic in this context.
are normal physiologic defense mechanisms that delay or
prevent oxidative stress and the formation of free radicals
or damaging byproducts; however, these defenses are lim- Clinical application of current evidence
ited in newborns (especially preterm babies) because of
their lowered levels of intracellular antioxidant enzymes Maternal oxygen administration may be beneficial to the
and the relative immaturity of other defense systems.45,46 fetus when the FHR pattern suggests fetal compromise;
Recent changes in the recommendations for neonatal however, there may also be potential risks. Clinicians should
resuscitation47 were prompted in part by data regarding the reconsider administering maternal oxygen as a first-line
potential adverse effects of hyperoxia on newborn babies intrauterine resuscitation measure and reserve for clinical
during resuscitation at birth and during the first few hours situations in which the FHR does not respond to other
of life.41,48,49 Room air (21% FiO2) is now considered an techniques. Thus, maternal repositioning, discontinuing oxy-
acceptable alternative to 100% oxygen for neonatal resusci- tocin (if infusing), and an IV fluid bolus (if appropriate for this
tation in selected clinical situations. If the baby is preterm, patient) could be first options. Because moderate variability
titration of FiO2 to the resultant oxygen saturation of the is strongly associated with an umbilical artery pH of >7.15 or
baby is recommended when oxygen is used for neonatal an Apgar score of 7 or higher at 5 minutes of life,6 it seems
resuscitation. These techniques can minimize damage to reasonable to avoid the use of maternal oxygen in the pres-
the baby from the oxidative stress produced by high levels ence of moderate variability, even with FHR decelerations.
of oxygen and associated oxygen free radical activity and Maternal oxygen administration can be initiated as
its byproducts.47 However, whether oxidative stress has a second-line measure, but it should be discontinued as
366 K.R. Simpson

soon as possible when the FHR pattern shows improvement. References


When oxygen is chosen for intrauterine resuscitation, there
is the assumption that other sources of potential fetal 1. Garite TJ, Dildy GA, McNamara H, et al. A multicenter con-
physiologic stress have been minimized; thus, IV oxytocin trolled trial of fetal pulse oximetry in the intrapartum man-
for labor induction or augmentation should not be infusing agement of nonreassuring fetal heart rate patterns. Am J
concurrently with maternal oxygen administration. In cases Obstet Gynecol 2000;183:1049e58.
of sudden acute fetal deterioration (such as that caused by *2. Simpson KR. Intrauterine resuscitation during labor: review of
placental abruption, uterine rupture, or prolapsed umbili- current methods and supportive evidence. J Midwifery
cal cord), maternal oxygen administration could be Womens Health 2007;52:229e37.
3. Joint Commission on Accreditation of Healthcare Organiza-
included in the first series of interventions initiated, even
tions. Preventing Infant Death and Injury During Delivery
if clinical conditions are such that the maternalefetal 2004 [Sentinel Event Alert No. 30.]. Oak Brook, IL: Joint Com-
exchange is compromised by umbilical cord compression mission on Accreditation of Healthcare Organizations; 2004.
or partial placental abruption. 4. National Institute of Child Health and Human Development
Research Planning Workshop. Electronic fetal heart rate
Summary monitoring: research guidelines for interpretation. Am J
Obstet Gynecol 1997;177:1385e90.
5. American College of Obstetricians and Gynecologists. Inap-
Although there is evidence that maternal oxygen adminis- propriate use of the terms fetal distress and birth asphyxia
tration can increase fetal oxygen levels, little is known [Committee Opinion No. 326]. Washington, DC: American
regarding the potential risks. However, the evidence, albeit College of Obstetricians and Gynecologists; 2005.
limited, regarding the potential effects of associated 6. Parer JT, King T, Flanders S, Fox M, Kilpatrick SJ. Fetal acid-
oxygen free radical activity should cause clinicians to emia and electronic fetal heart rate patterns: is there evi-
exercise caution when considering maternal oxygen admin- dence of an association? J Matern Fetal Neonatal Med 2006;
istration as a first-line intrauterine resuscitation measure 19:289e94.
until more data are available. Unfortunately, no data exist *7. Haydon ML, Gorenberg DM, Nageotte MP, et al. The effect of
maternal oxygen administration on fetal pulse oximetry during
regarding a reasonable interval to wait before initiating
labor in fetuses with nonreassuring fetal heart rate patterns.
oxygen therapy during a nonreassuring FHR pattern or the Am J Obstet Gynecol 2006;195:735e8.
optimal duration of oxygen therapy once initiated. Many *8. Simpson KR, James DC. Efficacy of intrauterine resuscitation
more data are needed regarding the short-term and long- techniques in improving fetal oxygen status during labor.
term effects of maternal oxygen therapy on the mother, Obstet Gynecol 2005;105:1362e8.
fetus, and newborn. 9. Simpson KR, James DC. Effects of oxytocin-induced uterine
hyperstimulation on fetal oxygen status and fetal heart rate
patterns during labor. Am J Obstet Gynecol 2008 March 13;
198: [Epub ahead of print], in press.
10. Bartnicki J, Saling E. Influence of maternal oxygen administra-
Practice points tion on the computer-analysed fetal heart rate patterns in
small-for-gestational-age fetuses. Gynecol Obstet Invest
 Consider maternal oxygen administration as a sec- 1994;37:172e5.
ond-line intrauterine resuscitation measure if 11. Nicolaides KH, Campbell S, Bradley RJ, Bilardo CM,
other methods have not resulted in the resolution Soothill PW, Gibb D. Maternal oxygen therapy for intrauterine
growth retardation. Lancet 1987;1:942e5.
of the nonreassuring FHR pattern.
12. Kyank HR, Seidenschnur G. Intrauterine growth retardatione
 Avoid the use of maternal oxygen therapy if the CTG findings in pre-partum oxygen respiration and transcutax-
FHR pattern demonstrates moderate variability. neous nerve stimulation [in German]. Zentralbl Gynakol 1988;
 In general, oxytocin should be discontinued before 110:1407e15.
maternal oxygen therapy is initiated. 13. Simchen MJ, Tesler J, Azami T, et al. Effects of maternal hyper-
 Although maternal oxygen therapy can increase oxia with and without normocapnia in uteroplacental and fetal
fetal oxygen levels, there are limited data regard- Doppler studies. Ultrasound Obstet Gynecol 2005;26:495e9.
ing its risks to the mother, fetus, and newborn. 14. Aldrich CJ, Wyatt JS, Spencer JA, Reynolds EO, Delpy DT. The
effect of maternal oxygen administration on human fetal ce-
rebral oxygenation measured during labour by near infrared
spectroscopy. Br J Obstet Gynaecol 1994;101:509e13.
15. Althabe Jr O, Schwarcz RL, Pose SV, Escarcena L, Caldeyro-
Research agenda Barcia R. Effects on fetal heart rate and fetal pO2 of oxygen
administration to the mother. Am J Obstet Gynecol 1967;98:
 Clinical algorithms for intrauterine resuscitation 858e70.
using a step-wise approach. 16. Bartnicki J, Langner K, Harnack H, Meyenburg M. The influ-
 Types of FHR patterns during labor that warrant ence of oxygen administration to the mother during labor on
maternal oxygen administration. the fetal transcutaneously measured carbon-dioxide partial
 Duration of maternal oxygen administration once pressure. J Perinat Med 1990;18:397e402.
initiated. 17. Dildy GA, Clark SL, Loucks CA. Effects of maternal inhalation
of 40% oxygen on fetal oxygen saturation. Am J Obstet Gyne-
 Short-term and long-term risks to the mother, fetus
col 1995;172:1939e43.
and newborn from maternal oxygen administration 18. Gare DJ, Shime J, Paul WM, Hoskins M. Oxygen administration
during labor for intrauterine resuscitation. during labor. Am J Obstet Gynecol 1969;105:954e61.
Intrauterine resuscitation during labor 367

19. Khazin AF, Hon EH, Hehre FW. Effects of maternal hyperoxia 36. Parpaglioni R, Capogna G, Celleno D, Fusco P. Intraoperative
on the fetus. I. Oxygen tension. Am J Obstet Gynecol 1971; fetal oxygen saturation during Caesarean section: general
109:628e37. anaesthesia using sevoflurane with either 100% oxygen or 50%
20. McNamara H, Johnson N, Lilford R. The effect on fetal arteri- nitrous oxide in oxygen. Eur J Anaesthesiol 2002;19:115e8.
olar oxygen saturation resulting from giving oxygen to the 37. Piggott SE, Bogod DG, Rosen M, Rees GA, Harmer M. Isoflurane
mother measured by pulse oximetry. Br J Obstet Gynaecol with either 100% oxygen or 50% nitrous oxide in oxygen for
1993;100:446e9. caesarean section. Br J Anaesth 1990;65:325e9.
21. Newman W, McKinnon L, Phillips L, Paterson P, Wood C. Oxy- 38. Robertson A, Fothergill RJ, Hall RA, Bond RA. Effects of anaes-
gen transfer from mother to fetus during labor. Am J Obstet thesia with a high oxygen concentration on the acid-base
Gynecol 1967;99:61e70. state of babies delivered at elective Caesarean section.
22. Roztocil A, Miklica J, Ventruba P, Kucera M, Kachlı́k P. Effect S Afr Med J 1974;48:2309e13.
of maternal O2 inhalation on oxygen saturation in the parturi- 39. Rorke MJ, Davey DA, Du Toit HJ. Foetal oxygenation during
ent (SpO2) and the fetus (FSpO2). Ceska Gynekol 2000;65: caesarean section. Anaesthesia 1968;23:585e96.
393e7 [in Czech]. 40. Young DC, Popat R, Luther ER, Scott KE, Writer WD. Influence
23. Thorp JA, Trobough T, Evans R, Hedrick J, Yeast JD. The effect of of maternal oxygen administration on the term fetus before
maternal oxygen administration during the second stage of labor labor. Am J Obstet Gynecol 1980;136:321e4.
on umbilical cord blood gas values: a randomized controlled pro- *41. Klinger G, Beyene J, Shah P, Perlman M. Do hyperoxaemia
spective trial. Am J Obstet Gynecol 1995;172:465e74. and hypocapnia add to the risk of brain injury after intrapar-
24. Willcourt RJ, King JC, Queenan JT. Maternal oxygenation tum asphyxia? Arch Dis Child Fetal Neonatal Ed 2005;90:
administration and the fetal transcutaneous PO2. Am J Obstet F49e52.
Gynecol 1983;146:714e5. 42. Blomgren K, Hagberg H. Free radicals, mitochondria, and
25. Backe SK, Kocarev M, Wilson RC, Lyons G. Effect of maternal hypoxia-ischemia in the developing brain. Free Radic Biol
facial oxygen on neonatal behavioural scores during elective Med 2006;40:388e97.
Caesarean section with spinal anaesthesia. Eur J Anaesthesiol *43. Khaw KS, Ngan Kee WD. Fetal effects of maternal supplemen-
2007;24:66e70. tary oxygen during Caesarean section. Curr Opin Anaesthesiol
26. Cogliano MS, Graham AC, Clark VA. Supplementary oxygen 2004;17:309e13.
administration for elective Caesarean section under spinal 44. Perlman JM. Pathogenesis of hypoxic-ischemic brain injury.
anaesthesia. Anaesthesia 2002;57:66e9. J Perinatol 2007;27:S39e46.
27. Crosby ET, Halpern SH. Supplemental maternal oxygen ther- 45. Buonocore G, Perrone S, Bracci R. Free radicals and brain
apy during caesarean section under epidural anaesthesia: damage in the newborn. Biol Neonate 2001;79:180e6.
a comparison of nasal prongs and facemask. Can J Anaesth 46. Haynes RL, Baud O, Li J, Kinney HC, Volpe JJ, Folkerth DR.
1992;39:313e6. Oxidative and nitrative injury in periventricular leukomalacia:
28. Fox GS, Houle GL. Acid-base studies in elective caesarean a review. Brain Pathol 2005;15:225e33.
sections during epidural and general anaesthesia. Can 47. American Academy of Pediatrics & American Heart Associa-
Anaesth Soc J 1971;18:60e71. tion. Textbook of neonatal resuscitation. 5th ed. Chicago,
29. Haruta M, Funato T, Sumida T, Shinkai T. The influence of IL: American Academy of Pediatrics & American Heart Associ-
maternal oxygen inhalation for 30 to 60 minutes on fetal ation; 2006.
oxygenation [in Japanese]. Nippon Sanka Fujinka Gakkai Zas- *48. Vento M, Asensi M, Sastre J, Garcı́a-Sala F, Pallardó FV, Viña J.
shi 1984;36:1921e9. Resuscitation with room air instead of 100% oxygen prevents
30. Jozwik M, Sledziewski A, Klubowicz Z, Zak J, Sajewska G, oxidative stress in moderately asphyxiated term neonates.
Pietrzycki B. Use of oxygen therapy during labour and acid- Pediatrics 2001;107:642e7.
base status in the newborn [in Polish]. Med Wieku Rozwoj *49. Vento M, Asensi M, Sastre J, Lloret A, Garcı́a-Sala F, Viña J.
2000;4:403e11. Oxidative stress in asphyxiated term infants resuscitated
31. Khaw KS, Ngan Kee WD, Lee A, et al. Supplementary oxygen with 100% oxygen. J Pediatr 2003;142:240e6. Erratum in:
for elective Caesarean section under spinal anaesthesia: use- J Pediatr 2003;142:616.
ful in prolonged uterine incision-to-delivery interval? Br J *50. Higgins RD, Bancalari E, Willinger M, Raju TN. Executive
Anaesth 2004;92:518e22. summary of the workshop on oxygen in neonatal therapies:
*32. Khaw KS, Wang CC, Ngan Kee WD, Pang CP, Rogers MS. Effects of controversies and opportunities for research. Pediatrics
high inspired oxygen fraction during elective caesarean section 2007;119:790e6.
under spinal anaesthesia on maternal and fetal oxygenation and 51. Rogers MS, Mongelli M, Tsang KH, Wang CC. Fetal and mater-
lipid peroxidation. Br J Anaesth 2002;88:18e23. nal levels of lipid peroxides in term pregnancies. Acta Obstet
33. Lawes EG, Newman B, Campbell MJ, Irwin M, Dolenska S, Gynecol Scand 1999;78:120e4.
Thomas TA. Maternal inspired oxygen concentration and neo- *52. Rogers MS, Wang W, Mongelli M, Pang CP, Duley JA, Chang AM.
natal status for caesarean section under general anaesthesia. Lipid peroxidation in cord blood at birth: a marker of fetal
Comparison of effects of 33% or 50% oxygen in nitrous oxide. hypoxia during labour. Gynecol Obstet Invest 1997;44:229e33.
Br J Anaesth 1988;61:250e4. 53. American College of Obstetricians and Gynecologists and
34. Marx GF, Mateo CV. Effects of different oxygen concentrations American Academy of Pediatrics. Neonatal encephalopathy
during general anaesthesia for elective caesarean section. and cerebral palsy: defining the pathogenesis and
Can Anaesth Soc J 1971;18:587e93. pathophysiology. Washington, DC: American College of
35. Ngan Kee WD, Khaw KS, Ma KC, Wong AS, Lee BB. Random- Obstetricians and Gynecologists and American Academy
ized, double-blind comparison of different inspired oxygen of Pediatrics; 2003.
fractions during general anaesthesia for Caesarean section.
Br J Anaesth 2002;89:556e61. *The most important references are indicated with an asterisks.

You might also like