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\begin{document}

\title{Fetal heart rate patterns in cerebral palsy associated with umbilical
cord troubles: Nationwide cohort study}



\author[1]{Satoru Takeda}%
\author[2]{JUNICHI HASEGAWA}%
\author[3]{Masahiro Nakao}%
\author[4]{Tomoaki Ikeda}%
\author[5]{Satoshi Toyokawa}%
\author[3]{Emi Jojima}%
\author[6]{Shoji Satoh}%
\author[7]{Kiyotake Ichizuka}%
\author[3]{Nanako Tamiya}%
\author[8]{Akihito Nakai}%
\author[9]{Keiya Fujimori}%
\author[10]{Tsugio Maeda}%
\author[11]{Hideaki Suzuki}%
\author[3]{Mitsutoshi Iwashita}%
\author[3]{Tsuyomu Ikenoue}%
\affil[1]{Juntendo University}%
\affil[2]{St. Marianna University School of Medicine}%
\affil[3]{Affiliation not available}%
\affil[4]{Mie University Graduate School of Medicine Faculty of Medicine}%
\affil[5]{The University of Tokyo}%
\affil[6]{Oita Prefectural Hospital}%
\affil[7]{Showa University Northern Yokohama Hospital}%
\affil[8]{Nippon Medical School}%
\affil[9]{Fukushima Medical University}%
\affil[10]{Maeda Clinic}%
\affil[11]{Japan Council for Quality Health Care}%


\vspace{-1em}



  
  \date{May 24, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Objective: To clarify the fetal heart rate (FHR) pattern evolution and
estimate the timing of brain injury in infants with cerebral palsy (CP)
according to each of the umbilical cord (UC) troubles. Design:
Longitudinal cohort study using the nationwide registry. Setting:
Children with CP who were approved for disability support by the Japan
Obstetric Compensation System for CP. Population: 126 infants with
severe CP caused by UC troubles with a birth weight of ?2000 g and ?33
weeks of gestational age. Methods: Observers classified the intrapartum
FHR strips into five groups: (1) the persistent bradycardia (P-Brady);
(2) the persistently non-reassuring (P-NR); (3) Hon's pattern; (4) the
reassuring-prolonged deceleration (R-PD); and (5) the persistently
reassuring (P-R). Main outcome measures: Timing and type of evolution
patterns of abnormal FHR stratified by various UC troubles. Results: Of
126 cases, 32 were associated with umbilical cord prolapse, and 94 were
with other UC morphological abnormalities. Overall, nearly half of the
eligible cases had intrapartum onset with R-PD (43\%). Meanwhile, around
half of those associated with UC morphological abnormalities had an
antenatal onset. In the intrapartum setting, most of the FHR
deteriorations occurred during the first stage of labor, and there was a
high incidence of Hon's pattern in the case with velamentous insertion
and multiple entanglements. Conclusion: Infants with severe CP
associated with the UC troubles were characterized as sudden onset
during the first stage of labor. Around half of those due to the UC
morphological abnormalities were presumed to have an antenatal onset.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Although intrapartum hypoxia-ischemia is associated with cerebral palsy
(CP), many CP cases' etiology remains unknown.\textsuperscript{1}A
systematic review found that CP associated with intrapartum
hypoxia-ischemia accounted for 14.5\% of CP in developed countries, and
the incidence of CP has persisted over the past 30
years.\textsuperscript{1} Placental and umbilical cord abnormalities are
likely to induce fetal hypoxia, and the association between CP
development and these abnormalities has been previously
reported.\textsuperscript{2-4}

The pathology of umbilical cord abnormality might be associated with its
vulnerability to the external force during uterine contraction,
resulting in acute intrapartum hypoxia-ischemia. However, the pattern
and extent of deterioration in umbilical blood flow might vary depending
on the type of umbilical cord abnormalities. A recently published
nationwide study showed that the umbilical cord troubles were
responsible for one-fourth of CP in term or near-term
infants.\textsuperscript{5} This study also classified each CP case into
five fetal heart rate (FHR) pattern categories. The FHR pattern
evolution suggests the timing of fetal brain injury, which is expected
to be critical considerations for the provision of safe delivery.
Therefore, we focused on these notable features in elucidating CP
associated with the umbilical cord troubles. We hypothesized that the
FHR pattern evolution provides clues to prevent cord-related brain
damage. The objective was to identify the FHR patterns in patients with
CP associated with cord problems.

\textbf{Methods}

We performed a longitudinal cohort study using the nationwide registry.
Details about our registry were summarized in our previous
report.\textsuperscript{4} In brief, the subjects included children with
CP who were approved for disability support by the age of 5 after a
review of the Operating Organization of the Japan Obstetric Compensation
System for Cerebral Palsy (JOCSC). The JOCSC covers more than 99\% of
delivery institutions throughout Japan.

Patients eligible for inclusion in the present study were children born
from January 2009 to July 2014, with a birth weight of [?]2000 g,
gestational age of [?]33 weeks, and disability due to CP independent of
congenital causes or factors during the neonatal period or later. We
defined severe CP as the first- or second-degree of disability according
to the definitions in the Act on Welfare of Physically Disabled
Persons,\textsuperscript{4} which are equivalent to level 3 to 5 of the
Gross Motor Function Classification System-Expanded and
Revised.\textsuperscript{6} Multiple pregnancies and cases with poor FHR
tracings were excluded from the present study. Among the eligible
patients, those associated with umbilical cord troubles were retrieved
from reports of the Operating Organization of the JOCSC.

In each case, the FHR strips were obtained and retrospectively analyzed
by four authors (J.H., M.N., T.I., and E.J.). The FHR class was
determined after careful discussions. The National Institute of Child
Health and Human Development guidelines\textsuperscript{7,8} were
applied when interpreting the FHR patterns. We categorized all the FHR
patterns into the following five groups based on the guidelines between
the time of admission and delivery, as advocated by Phelan et
al.\textsuperscript{9}

When an abnormal FHR pattern was observed on admission for delivery or
at labor onset, we defined the following two groups. (i) The Persistent
bradycardia (P-Brady) group consists of fetuses with severe bradycardia
(\textless{}80 beats/min) or absent variability with persistent severe
decelerations on admission. (ii) The persistently non-reassuring (P-NR)
group comprises fetuses with late or variable decelerations or decreased
variability without bradycardia on admission test, which persisted until
delivery.

In contrast, when the admission test showed a reassuring pattern
(moderate variability on a normal baseline rate without late or variable
decelerations), the following three groups were defined. (iii) Hon's
pattern (Hon) group comprises fetuses with a reassuring FHR pattern on
admission and subsequent recurrent severe decelerations with or without
an increased baseline rate and decreased variability. Finally, prolonged
deceleration (PD) or terminal bradycardia was observed before delivery.
(iv) A reassuring-PD (R-PD) group consists of the fetuses with a
reassuring FHR pattern on admission; however, an abrupt change to severe
PD or bradycardia occurred before delivery. (v) A persistently
reassuring group indicates fetuses with a reassuring FHR that remains
within ordinary throughout the entire course (Figure 1).

Umbilical cord troubles analyzed in the present study included umbilical
cord prolapse, marginal/velamentous cord insertion, multiple cord
entanglement, a true knot, umbilical cord constriction, hyper-coiled
cord, hypo-coiled cord, and a single umbilical artery. We assessed
frequencies of the FHR evolution patterns in patients with CP associated
with umbilical cord troubles.

Definitions

The evidence of the umbilical cord troubles in the present study was
obtained from medical records in the individual facilities. And
definitions were used regarding the Glossary of Obstetrics and
Gynecology published by the Japan Society of Obstetrics and
Gynecology.\textsuperscript{10}

\emph{Velamentous and marginal cord insertion:} Velamentous or marginal
cord insertion is characterized by membranous umbilical vessels at the
placental insertion site. In velamentous insertion, the umbilical
vessels diverge, surrounded by fetal membranes with no Wharton's jelly
at the placental end of the cord. Marginal insertion is the umbilical
cord located just at the edge of the placenta.

\emph{Multiple umbilical cord entanglements:} Umbilical cord
entanglement is defined when one or more loops of the umbilical cord are
encircled around any part of the fetus. In the present study, we
included cases with two or more entanglements.

\emph{Umbilical cord constriction/thin cord:} Diagnosis of umbilical
cord constriction is made when the umbilical cord has one or more narrow
parts by macroscopic evaluation, including umbilical ring constriction,
constriction in the free loop, and thin umbilical cord without Wharton's
jelly.

\emph{True knot:} A true knot of the umbilical cord is formed when the
fetus passes through a loop of the umbilical cord while being active in
the uterus.

\emph{Abnormal umbilical coiling:} The umbilical coiling index is
calculated by dividing the total number of coils by the cord's length in
centimeters. Hyper- and hypo-coiled cord after delivery are defined with
umbilical coiling indices of [?]0.3 coils/cm (\textgreater{}90\%
percentile) and \textless{}0.1 coils/cm (\textless{}10\%
percentile).\textsuperscript{11}

\emph{Single umbilical artery:} Diagnosis of a single umbilical artery
is made macro- or microscopically when one umbilical artery is absent or
obstructed.

\emph{Umbilical cord prolapse:} The umbilical cord prolapse is diagnosed
clinically when the umbilical cord's free loop protrudes into or outside
the vagina.

Statistical analysis

All analyses were conducted using Stata version 16.0 (STATA Corporation,
College Station, TX). Continuous or integer variables were reported as
mean \selectlanguage{ngerman}± standard deviation or median and range, respectively. Categorical
variables were reported as frequencies.

Ethical statement

All procedures performed in studies involving human participants were in
accordance with the ethical standards of the institutional and/or
national research committee and with the 1964 Helsinki declaration and
its later amendments or comparable ethical standards. The study protocol
was approved by the Institutional Review Boards of the JOCSC (No. 26-01,
Aug. 5, 2014). Informed consent was obtained from patients. Although the
analysis was retrospective, data for the anonymized JOCSC database were
collected in a normal clinical setting, and the confidentiality of the
patients involved was protected. All patients' records/information was
anonymized and de-identified prior to analysis.



\textbf{Results}

The study flow diagram was demonstrated in Figure 2. Among 1017 cases of
CP from the JOCSC database, 131 were considered to be associated with
umbilical cord troubles in singleton pregnancies. Five cases were
excluded because of uninterpretable or missing FHR data, and 126 cases
were analyzed.

The characteristics of our study cohort were shown in Table 1. 24.6\%
were complicated with preterm premature rupture of membranes, the
trans-cervical balloon catheter was used for cervical ripening in
17.5\%, and most cases were delivered by the emergency cesarean section
(63.5\%). More than half in the umbilical cord arterial pH was no less
than 7.0 (57.8\%). However, the Apgar scores were lower than normal in
most CP cases (Apgar score \textless{}7: at 1 min, 96.8\%; at 5 min,
83.9\%, respectively)

The FHR classifications and those stratified by the umbilical cord
troubles are shown in Figures 3 and 4. Overall, nearly half of CP caused
by umbilical cord troubles occurred with a sudden evolution pattern
during delivery (R-PD, 43\%). On the contrary, approximately one-third
of those showed abnormal FHR patterns on admission (P-Brady and P-NR,
33\%). The FHR class analysis divided by umbilical cord prolapse and the
other morphological abnormalities showed that nearly 90\% of CP due to
umbilical cord prolapse developed FHR deterioration during labor,
particularly with R-PD. Meanwhile, approximately 40\% of those
associated with cord morphological abnormalities had already shown
abnormal FHR patterns on admission, mostly persistently non-reassuring
patterns.

Timing and type of evolution patterns of abnormal FHR stratified by
umbilical cord troubles are demonstrated in Table 2. In cases of various
umbilical cord abnormalities, such as velamentous insertion, true knots,
constriction, and hyper-coiled cords, around half of the patients
already had FHR alterations at the time of admission. In terms of the
intrapartum onset, most FHR deteriorations occurred during the first
stage of labor in all types of cord troubles. Furthermore, most patients
complicated with velamentous insertion and multiple entanglements
developed CP with Hon's pattern.

\textbf{Discussion}

Main findings

This study demonstrated that severe CP associated with the umbilical
cord troubles were characterized as sudden onset during labor.
Meanwhile, around half of those due to cord morphological abnormalities
developed with an antenatal onset. Furthermore, most FHR deteriorations
occurred during the first stage of labor, and there was a high incidence
of Hon's pattern in the case with velamentous insertion and multiple
entanglements.

Strengths and limitations

The strength of this nationwide analysis highlighted the features of FHR
evolution patterns in infants with severe CP associated with umbilical
cord troubles. We also identified some factors that have the potential
of preventing CP based on FHR pattern analysis.

Despite these strengths, the current research also has several
limitations. First, this is a retrospective observational study without
a control group. Furthermore, we collected only severe CP cases with a
birth weight of \selectlanguage{english}[?]2000 g and at the gestational age of \selectlanguage{english}[?]33 weeks, and we
analyzed only available data. Therefore, the present study may have a
collection bias. Second, we were not able to infer the associations
among CP, umbilical cord abnormalities, fetal growth restriction, and
pathological findings of the placenta that were not sufficiently
available in this cohort.

We need further analysis, including milder forms of CP cases, to
generalize our result. Furthermore, larger case-control studies and
prospective cohort studies will be needed to determine whether each
umbilical cord trouble itself is associated with the specific FHR
pattern.

Interpretation

Concurring with the previous report,\textsuperscript{5} severe CP caused
by umbilical cord troubles, especially cord prolapse, was characterized
by a sudden onset (R-PD) in the intrapartum. It is not surprising, given
these configurations of the umbilical cord lead to vulnerability to
compression or torsion during uterine
contractions.\textsuperscript{12,13} In contrast, we identified a high
incidence of CP associated with cord morphological abnormalities
developed in an antenatal period, mostly P-NR accounted for 36\%. The
hyper-coiled cord is reported to be more prone to torsion rather than
compression or stretching.\textsuperscript{14,15} Furthermore, several
histological studies showed the association between umbilical cord
abnormalities and placental circulatory stasis or
thrombosis.\textsuperscript{2,16,17} Such a cumulative effect on
fetoplacental blood flow may result in antenatal etiology of brain
injury.

We identified that most FHR deteriorations occurred during the first
stage of labor and a high incidence of Hon's pattern in the case with
umbilical cord structural lesions such as velamentous insertion and
multiple entanglements. Several retrospective studies showed the
association of variable decelerations during the first stage of labor
with umbilical cord abnormalities such as velamentous cord insertion and
hyper-coiled cord.\textsuperscript{18,19} Moreover, a prospective study
showed that morphological abnormalities developed in the earlier
gestation were likely to coexist with placental abnormalities that
affect the fetoplacental perfusion during labor.\textsuperscript{20}Such
cumulative distress described above might also arise during repetitive
uterine contractions and could develop Hon's pattern. As this pattern
evolves over several hours, we may be able to intervene and correct the
FHR pattern before severe hypoxia occurs. Therefore, morphological
abnormalities of the umbilical cord have the potential of predicting
such FHR alterations, and ultrasound screening for them antenatally is
crucial to predispose labor and delivery care providers to greater focus
on Hon's FHR progression.

On the other hand, the prevention of CP in cases with R-PD might be
difficult. A previous nationwide study on the prognosis of infants with
umbilical cord prolapse found that the interval from the diagnosis of
prolapse to delivery was significantly longer in infants with a poor
outcome than those with intact survival (median, 30 vs. 24
minutes).\textsuperscript{21} We would not reduce such CP cases unless
obstetric facilities throughout the country can provide immediate
cesarean delivery within 15 minutes. However, half of the deliveries are
managed in a private clinic where the emergency cesarean section is not
available.

Although electronic fetal monitoring (EFM) has not yet been shown to be
a good predictor of fetal asphyxia,\textsuperscript{22,23} previous
studies suggested that optimal intrapartum care could offer a preventive
opportunity of labor asphyxia in cases with normal admission FHR
tracings.\textsuperscript{24,25} Furthermore, a retrospective study
suggested the combination of EFM with clinical risk factors performed
better for screening CP than EFM alone.\textsuperscript{26} As a risk
screening of umbilical cord troubles before labor management, ultrasound
screening, triage of pregnant women according to risks of emergency
cesarean section, and appropriate intrapartum management of FHR combined
with evolution patterns are recommended.\textsuperscript{5,27,28} In
case these factors are recognized, the parturients should be placed
under continuous observation of FHR with preparing an emergency cesarean
section for early intervention to abnormal FHR that may cause fetal
brain damage.

Conclusion

Infants with severe CP associated with the umbilical cord troubles were
characterized as sudden onset during the first stage of labor. Around
half of those due to cord morphological abnormalities were presumed to
have an antenatal onset. Prenatal ultrasound screening and meticulous
FHR monitoring during the first stage of labor are crucial for early
intervention. Focusing on Hon's pattern may help prevent CP in case
velamentous insertion and multiple entanglements exist.



\textbf{Acknowledgments}

The authors are grateful to the following staff members for their great
support in data collection: Yuri Asano,~Mio Sano, Natsumi Tsuchiya,
Miyuki Takeuchi, Sana Ohno, Nozomi Kobayashi, Asami Nagatani, Hitomi
Yuasa, and Saori Ikeda, who are the members of the Recurrence Prevention
Committee, Japan Obstetric Compensation System for Cerebral Palsy,
Public Interest Incorporated Foundation Japan Council for Quality Health
Care.

\textbf{Conflict of interest:} We declare no competing interests.

\textbf{Author contributions statement:} JH, NM, TI, and TI conceived
the study. JH wrote the initial protocol, analyzed the data, and wrote
the first draft of the manuscript. All authors collected data and
analyzed cases of CP. JH, MN, TI, and EJ coordinated the study and JH,
MN, TI, and EJ produced the database. Statistical analyses were
performed by ST and NT. All authors contributed to writing the
manuscript. TI, SS, KI, ST, AN, KF, TM, ST, HS, MI and TI are the
guarantors for the study. All authors had full access to all of the data
in the study and take responsibility for the integrity of the data and
the accuracy of the data analysis. The lead author affirms that this
manuscript is an honest, accurate, and transparent account of the study
being reported; that no important aspects of the study have been
omitted; and that any discrepancies from the study as planned have been
explained.

\textbf{Funding:} None.

\textbf{Details of ethics approval:} Alll procedures performed in
studies involving human participants were in accordance with the ethical
standards of the institutional and/or national research committee and
with the 1964 Helsinki declaration and its later amendments or
comparable ethical standards. The study protocol was approved by the
Institutional Review Boards (IRBs) of the JOCSC (No.26-01, Aug. 5th
2014).

\textbf{Data sharing:} No additional data is available.

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\par\null

\textbf{Table 1. Maternal and neonatal background of the study cohort}\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\begin{minipage}[b]{0.32\columnwidth}\raggedright\strut
Variables\strut
\end{minipage} & \begin{minipage}[b]{0.32\columnwidth}\raggedright\strut
Variables\strut
\end{minipage} & \begin{minipage}[b]{0.32\columnwidth}\raggedright\strut
\selectlanguage{ngerman}\textbf{Mean ± SD} \textbf{or median (range)} \textbf{or n (\%)}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Maternal characteristics\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Maternal characteristics\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Age -- mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
31.6 \selectlanguage{ngerman}± 5.4\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Height (cm) -- mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
157.4 \selectlanguage{ngerman}± 5.8\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Weight at the beginning of pregnancy (kg) -- mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
52.5 \selectlanguage{ngerman}± 7.8\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
BMI (kg/m\textsuperscript{2}) -- mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
21.2 \selectlanguage{ngerman}± 2.9\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Weight at delivery (kg) -- mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
62.6 \selectlanguage{ngerman}± 8.2\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Weight gain (kg) -- mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
10.2 \selectlanguage{ngerman}± 3.9\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Parity -- median (range)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
0 (0--4)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\emph{In vitro} fertilization -- n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
6 (4.6\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Delivery profiles\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Delivery profiles\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Premature rupture of membranes -- n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
22 (17.5\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Use of a cervical balloon catheter -- n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
22 (17.5\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Augmentation -- n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
45 (35.7\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Uterine fundal pressure -- n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
27 (21.4\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\emph{Mode}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\emph{Mode}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Normal spontaneous -- n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
24 (19.0\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Instrumental -- n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
22 (17.5\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Elective CS -- n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
0 (0.0\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Emergency CS -- n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
80 (63.5\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\emph{Delivery at}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\emph{Delivery at}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Hospital -- n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
74 (56.4\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Clinic -- n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
51 (38.9\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Midwifery home -- n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
1 (0.8\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\emph{Maternal transport after the onset of labor} -- n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\emph{Maternal transport after the onset of labor} -- n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
9 (7.1\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Neonatal outcomes\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Neonatal outcomes\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Gestational weeks -- mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
38.6 \selectlanguage{ngerman}± 1.9\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Birth weight (g) -- mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
2861 \selectlanguage{ngerman}± 449\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Birth weight (SD) -- mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
-0.31 \selectlanguage{ngerman}± 0.99\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Male -- n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
69 (54.8\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Apgar score at 1 min -- median (range)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
1(0--10)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
[?]7 -- n/total (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
4/126 (3.2\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
4--6 -- n/total (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
22/126 (17.5\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
[?]3 -- n/total (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
100/126 (79.4\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Apgar score at 5 min -- median (range)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
3 (0--10)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
[?]7 -- n/total (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
20/124 (16.1\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
4--6 -- n/total (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
40/124 (31.7\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
[?]3 -- n/total (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
64/124 (50.8\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Umbilical artery pH -- mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
7.04 \selectlanguage{ngerman}± 0.22\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textgreater{}7.20 -- n/total (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
24/83 (28.9\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
7.00--7.20 -- n/total (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
24/83 (28.9\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textless{}7.00 -- n/total (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
35/83 (42.2\%)\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

SD, standard deviation; BMI, body mass index; CS, cesarean section.

\textbf{Table 2. Timing and type of evolution patterns of abnormal fetal
heart rate stratified by umbilical cord troubles}\selectlanguage{english}
\begin{longtable}[]{@{}llllllllll@{}}
\toprule
\begin{minipage}[b]{0.10\columnwidth}\raggedright\strut
Umbilical cord troubles\strut
\end{minipage} & \begin{minipage}[b]{0.10\columnwidth}\raggedright\strut
Abnormal FHR on admission\strut
\end{minipage} & \begin{minipage}[b]{0.10\columnwidth}\raggedright\strut
Abnormal FHR on admission\strut
\end{minipage} & \begin{minipage}[b]{0.10\columnwidth}\raggedright\strut
Abnormal FHR on admission\strut
\end{minipage} & \begin{minipage}[b]{0.10\columnwidth}\raggedright\strut
Abnormal FHR during labor\strut
\end{minipage} & \begin{minipage}[b]{0.10\columnwidth}\raggedright\strut
Abnormal FHR during labor\strut
\end{minipage} & \begin{minipage}[b]{0.10\columnwidth}\raggedright\strut
Abnormal FHR during labor\strut
\end{minipage} & \begin{minipage}[b]{0.10\columnwidth}\raggedright\strut
Abnormal FHR during labor\strut
\end{minipage} & \begin{minipage}[b]{0.10\columnwidth}\raggedright\strut
Abnormal FHR during labor\strut
\end{minipage} & \begin{minipage}[b]{0.10\columnwidth}\raggedright\strut
Persistently reassuring throughout labor (P-R)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{P-Brady}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{P-NR}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
1st stage\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2nd stage\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{Hon}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{R-PD}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Umbilical cord prolapse (n = 32)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{4 (13\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
0\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{28 (88\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
96\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
4\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
21\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
79\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{0 (0\%)}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Marginal insertion (n = 33)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{10 (30\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
20\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
80\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{21 (64\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
95\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
5\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
33\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
67\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{2 (6\%)}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Velamentous insertion (n = 10)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{4 (40\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
0\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{4 (40\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
75\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
25\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
75\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
25\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{2 (20\%)}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Multiple cord entanglements (n = 28)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{10 (36\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
20\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
80\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{13 (46\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
69\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
31\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
54\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
46\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{5 (18\%)}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
True knots (n = 5)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{3 (60\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
0\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{1 (20\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
0\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
0\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{1 (20\%)}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Cord constriction (n = 18)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{7 (39\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
29\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
71\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{10 (56\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
0\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
20\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
80\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{1 (6\%)}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Hyper-coiled cord (n = 20)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{14 (70\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
0\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{6 (30\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
83\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
17\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
0\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{0 (0\%)}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Hypo-coiled cord (n = 3)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{1 (33\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
0\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{2 (67\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
0\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
0\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{0 (0\%)}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Single umbilical artery (n = 7)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{2 (29\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
0\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{4 (57\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
0\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
0\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textbf{1 (14\%)}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

P-Brady, persistent bradycardia; P-NR, persistently non-reassuring;
R-PD, reassuring-prolonged deceleration; P-R, persistently reassuring

\textbf{Figure legends}

\textbf{Figure 1:} Study flow diagram

JOCSC, Japan Obstetric Compensation System for cerebral palsy; CP,
cerebral palsy; FHR, fetal heart rate

\textbf{Figure 2:} Fetal heart rate evolution patterns and the estimated
timing of brain injury (adapted from Parer JT, King TL, Ikeda T.
Electronic fetal heart rate monitoring: the 5-tier system
3\textsuperscript{rd} ed, Burlington, MA: Jones \& Barlett Learning,
2018.)

P-Brady, severe bradycardia (\textless{}80 beats/min) or absent
variability with persistent severe decelerations on admission; P-NR:
recurrent decelerations or a decreased variability without severe
bradycardia on admission and persisted until delivery; Hon, reassuring
on admission and deteriorate gradually followed by a decline in baseline
fetal heart rate; R-PD, reassuring on admission and an abrupt change to
severe prolonged deceleration or bradycardia occurred before delivery;
P-R, reassuring on admission and remained within ordinary pattern during
the entire course.

P-Brady, persistent bradycardia; P-NR, persistently non-reassuring;
R-PD, reassuring-prolonged deceleration; P-R, persistently reassuring

\textbf{Figure 3:} Analysis of fetal heart rate evolution patterns

P-Brady, persistent bradycardia; P-NR, persistently non-reassuring;
R-PD, reassuring-prolonged deceleration; P-R, persistently reassuring

\textbf{Figure 4:} Analysis of fetal heart rate evolution patterns
stratified by umbilical cord troubles

P-Brady, persistent bradycardia; P-NR, persistently non-reassuring;
R-PD, reassuring-prolonged deceleration; P-R, persistently reassuring\selectlanguage{english}
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