Intra-ventricular hemorrhage and method of delivery of very low birth weight infants

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Abstract
Infants (152) with birthweight .ltoreq. 1500 g admitted consecutively to a tertiary NICU [neonatal intensive care unit] are reported. Autopsy was done in all 29 infants who died, IVH [intraventricular hemorrhage] was present in 13. Ultrasound scanning through the anterior fontanelle was done in 113 survivors; IVH was found in 42. Infants (98) were delivered by cesarian section and IVH was less frequent in these infants: 28/91 compared to 27/51 in the infants delivered per vaginam. (Odds ratio = 0.58, P < 0.05). Gestational age was higher (30.5 .+-. 2.5 wk) in the infants delivered by cesarean section than in the infants delivered per vaginam (28.5 .+-. 2.4 wk). After correction for difference in gestational age the trend consistently showed reduced incidence of IVH after cesarian section (odds ratio = 0.85) but the difference did no longer achieve statistical significance. Information on neonatal asphyxia, intermittent positive pressure ventilation, acidosis, hypercarbia and rapid change of weight during the first 96 h of life was collected from clinical records. A multiple regression analysis showed increased risk of IVH with low gestational age and with use of intermittent positive pressure ventilation. The effect of cesarian section was only sub-significant (0.1 > P > 0.05: 1-tailed t-test). The results of 7 previous reports on the association between method of delivery and IVH are reviewed (Tab. IV); in all but 1 the risk of IVH was reduced after cesarian section although in no case the difference did reach statistical significance. The problem of achieving comparability between groups of infants delivered by cesarian section and per vaginam are discussed as a controlled randomized study can be considered as impractical. The recent reports of very early occurrence of IVH in a majority of cases points at stress during delivery to be an important causal factor. This is further suggested by the proposed pathogenesis of IVH involving changes of blood-gases, blood pressure and of loss of autoregulation of cerebral blood flow. Apparently, the available evidence indicates liberal use of cesarian section for the delivery of the very low birth weight infant regardless of fetal presentation.