Intrapartum Mortality Research Articles

Timing of dietary zinc additions during gestation for improved piglet survival.

The objectives of this study were to determine a practical approach to feeding elevated dietary zinc (Zn) to gestating sows in a commercial setting and to confirm preweaning mortality could be reduced by feeding high Zn to sows during different periods of gestation. The study was conducted at a commercial sow farm in the upper Midwest. Mixed parity sows (n = 267) over three consecutive weekly farrowing groups (sows farrowing within 1wk) were assigned randomly to one of the three dietary treatments within parity. Treatments consisted of: (1) control sows fed a corn-soybean meal diet containing 206mg/kg total supplemental Zn supplied by zinc hydroxychloride; (2) breed-to-farrow: as control + 147mg/kg supplemental Zn as ZnSO4 (353mg/kg total supplemental Zn) fed from 5 d after breeding to farrowing; and (3) day 110-to-farrow: as control fed from breeding to farrowing + 4,079mg/kg supplemental Zn as ZnSO4 (4,285mg/kg total supplemental Zn) starting day 110 of gestation until farrowing. At farrowing, individual piglets were weighed and identified within 12h of birth. Data were analyzed using PROC GLIMMIX of SAS and the model considered the fixed effect of dietary treatment and random effect of farrowing group. Dietary treatments did not affect number of total pigs born per litter. For breed-to-farrow sows, there was an increase in the percentage of pigs born alive compared to sows fed the control and day 110-to-farrow treatments (P < 0.001). The number of stillborn pigs expressed as a percentage of total litter size at birth decreased for breed-to-farrow sows (P < 0.001) compared with control or day 110-to-farrow sows. Mortality of low birth weight piglets from birth to weaning did not differ among dietary treatments (P = 0.305); however, a trend for decreasing post-natal mortality (P = 0.068) of normal birth weight pigs was observed for pigs born to sows fed elevated Zn 5 d before farrowing. In conclusion, feeding elevated Zn to sows throughout gestation increased the proportion of pigs born alive suggesting that elevated gestational Zn intake makes piglets more robust to endure the stresses of farrowing and decreases intrapartum mortality. Under the conditions of this study, elevated Zn intake of sows did not influence piglet post-natal survival. However, feeding high zinc throughout gestation may decrease piglet mortality during the parturition process.

Immediate and longer-term impacts of fetal surveillance education on workforce knowledge and cognitive skills.

Background: Following the development of the Royal Australian College of Obstetricians and Gynaecologists Intrapartum Fetal Surveillance Guideline in 2003, an education program was developed to support guideline implementation and clinical practice. It was intended that improved clinician knowledge, particularly of cardiotocography, would reduce rates of intrapartum fetal morbidity and mortality. The program contains a multiple-choice assessment, designed to assess fetal surveillance knowledge and the application of that knowledge. We used the results of this assessment over time to evaluate the impact of the education program on clinicians' fetal surveillance knowledge and interpretive skills, in the immediate and longer-term. Methods: We undertook a retrospective analysis of the assessment results for all participants in the Fetal Surveillance Education Program, between 2004 and 2018. Classical Test Theory and Rasch Item Response Theory analysis were used to evaluate the statistical reliability and quality of the assessment, and the measurement invariance or stability of the assessments over time. Clinicians' assessment scores were then reviewed by craft group and previous exposure to the program. Results: The results from 64,430, broadly similar assessments, showed that participation in the education program was associated with an immediate improvement in clinician performance in the assessment. Performance improvement was sustained for up to 18 months following participation in the program and recurrent participation was associated with progressive improvements. These trends were observed for all craft groups (consultant obstetricians, doctors in training, general practitioners, midwives, student midwives). Conclusions: These findings suggest that the Fetal Surveillance Education Program has improved clinician knowledge and the associated cognitive skills over time. The stable difficulty of the assessment tool means any improvement in clinician's results, with ongoing exposure to the program, can be reliably assessed and demonstrated. Importantly this holds true for all craft groups involved in intrapartum care and the interpretation of cardiotocography.

Decrease in perinatal mortality after closure of obstetric services in a community hospital in Amsterdam, the Netherlands. A retrospective cohort study

ObjectiveTo assess differences in adverse maternal and neonatal outcomes before and after closure of a secondary obstetric care unit of a community hospital in an urban district. Study DesignRetrospective cohort study using aggregated data from National Perinatal Registry of the Netherlands (PERINED) in the very urban region of Amsterdam, consisting of data of five secondary and two tertiary hospitals. We assessed maternal and neonatal outcomes in singleton hospital births between 24+0 weeks of gestational age (GA) up to 42+6 weeks. Data of 78.613 births were stratified in two groups: before closure (years 2012–2015) and after closure (2016–2019). ResultsPerinatal mortality decreased significantly from 0.84 % to 0.63 % (p = 0.0009). The adjusted odds ratio (aOR) of the closure on perinatal mortality was 0.73 (95 % CI 0.62–0.87). Both antepartum death (0.46 % vs 0.36 %, p = 0.02) and early neonatal death (0.38 % vs 0.28 %, p = 0.015) declined after closure of the hospital. The number of preterm births decreased significantly (8.7 % vs 8.1 %, p=<0.007) as well as number of neonates with congenital abnormalities (3.2 % vs2.2 %, p=<0.0001). APGAR < 7 after 5 min increased (2.3 % vs 2.5 %, p = 0.04). There was no significant difference in SGA or NICU admission. Postpartum hemorrhage increased significantly from 7.7 % to 8.2 % (p=<0.003). Perinatal mortality from 32 weeks onwards was not significantly different after closure 0.29 % to 0.27 %. ConclusionsAfter closure of an obstetric unit in a community hospital in Amsterdam, there was a significant decrease in perinatal, intrapartum and early neonatal mortality in neonates born from 24+0 onwards. The mortality decrease coincides with a reduction of preterm deliveries. The increasing trend in asphyxia and postpartum hemorrhage is of concern.. Centralization of care and increasing birth volume per hospital may lead to improvement of quality of care. A broad integrated, multidisciplinary maternity healthcare system linked with the social domain can achieve health gains in maternity care for all women.

Detection of Suspicious Cardiotocographic Recordings by Means of a Machine Learning Classifier.

Cardiotocography (CTG) is one of the fundamental prenatal diagnostic methods for both antepartum and intrapartum fetal surveillance. Although it has allowed a significant reduction in intrapartum and neonatal mortality and morbidity, its diagnostic accuracy is, however, still far from being fully satisfactory. In particular, the identification of uncertain and suspicious CTG traces remains a challenging task for gynecologists. The introduction of computerized analysis systems has enabled more objective evaluations, possibly leading to more accurate diagnoses. In this work, the problem of classifying suspicious CTG recordings was addressed through a machine learning approach. A machine-based labeling was proposed, and a binary classification was carried out using a support vector machine (SVM) classifier to distinguish between suspicious and normal CTG traces. The best classification metrics showed accuracy, sensitivity, and specificity values of 92%, 92%, and 90%, respectively. The main results were compared both with results obtained by considering a more unbalanced dataset and with relevant literature studies in the field. The use of the SVM proved to be promising in the field of CTG classification. However, appropriate feature selection and dataset balancing are crucial to achieve satisfactory performance of the classifier.

Time trends in caesarean section rates and associations with perinatal and neonatal health: a population-based cohort study of 1 153 789 births in Norway

ObjectivesTo study caesarean section (CS) rates and associations with perinatal and neonatal health in Norway during 1999–2018.DesignPopulation-based cohort study.SettingMedical Birth Registry of Norway.Participants1 153 789 births and 1 174 066...

Effect of the Helping Babies Breathe Program on Newborn Outcomes: Systematic Review and Meta-Analysis.

Background and objectives: In low- and middle-income countries, the leading cause of neonatal mortality is perinatal asphyxia. Training in neonatal resuscitation has been shown to decrease this cause of mortality. The program "Helping Babies Breathe" (HBB) is a program to teach basic neonatal resuscitation focused on countries and areas with limited economic resources. The aim of the study was to determine the effect of the implementation of the HBB program on newborn outcomes: mortality and morbidity. Material and Methods: A systematic review was carried out on observational studies and clinical trials that reported the effect of the implementation in low- and middle-income countries of the HBB program on neonatal mortality and morbidity. We carried out a meta-analysis of the extracted data. Random-effect models were used to evaluate heterogeneity, using the Cochrane Q and I2 tests, and stratified analyses were performed by age and type of outcome to determine the sources of heterogeneity. Results: Eleven studies were identified. The implementation of the program includes educational strategies focused on the training of doctors, nurses, midwives, and students of health professions. The poled results showed a decrease in overall mortality (OR 0.67; 95% CI 0.57, 0.80), intrapartum stillbirth mortality (OR 0.62; 95% CI 0.51, 0.75), and first-day mortality (OR 0.70; 95% IC 0.64, 0.77). High heterogeneity was found, which was partly explained by differences in the gestational age of the participants. Conclusions: The implementation of the program HBB in low- and medium-income countries has a significant impact on reducing early neonatal mortality.

Аналіз перебігу гестаційного періоду та перинатальних наслідків у жінок після оперативного лікування шийки матки

Мета дослідження – порівняльний аналіз перебігу вагітності та пологів у жінок після застосування різних органозберігаючих хірургічних методів лікування патології шийки матки. Матеріали та методи. Обстежено 250 жінок репродуктивного віку, які до вагітності перенесли ексцизію або аблативні методи лікування шийки матки. У залежності від проведеного хірургічного методу лікування патології шийки матки всіх обстежених жінок було розподілено на 5 груп. Обстеження включало загально-клінічні методи дослідження відповідно до наказів МОЗ України №417 «Про організацію амбулаторної акушерсько-гінекологічної допомоги в Україні» від 15.07.2011р. та №676 «Про затвердження клінічних протоколів з акушерської та гінекологічної допомоги» від 31.12.2004р. Результати. Найчастішими ускладненнями вагітності у пацієнток із оперованою шийкою матки були: загроза переривання вагітності, загроза передчасних пологів, анемія, низька плацентація, плацентарна дисфункція, маловоддя. Серед ускладнень пологів у жінок, які до вагітності перенесли ексцизію чи аблативні методи лікування патології шийки матки переважали аномалії пологової діяльності, передчасний розрив плодових оболонок, дистрес плода, розриви шийки матки та промежини. Серед ускладнень післяпологового періоду спостерігалися поодинокі випадки субінволюції матки, лохіометри, метроендометрита, лактостазу. Серед новонароджених дітей випадків інтранатальної та ранньої неонатальної смертності зафіксовано не було. Висновки. Враховуючи високу частоту гестаційних та післяпологових ускладнень у жінок після хірургічного лікування шийки матки необхідно вибирати максимально щадні методи. Найменша частота ускладнень під час вагітності, пологів та в післяпологовому періоді спостерігалася у жінок після оперативного втручання на шийці матки методом лазерної вапоризації та радіохвильової терапії.

Maternal caffeine administration to ewes does not affect perinatal lamb survival

Perinatal mortality of lambs is the major source of reproductive loss in extensive sheep production systems. Treatment with caffeine has reduced intra-partum mortality and/or improved metabolic indicators in other species following hypoxia. This study was conducted to evaluate the efficacy of caffeine for improving perinatal lamb survival. Experiment 1 comprised group-fed Merino ewes grazing pasture and offered 1.8 g/day (estimated 20 mg/kg live weight) caffeine throughout a 4-week lambing period, and a control without caffeine. The survival of lambs to marking (vaccinated, tail docked, males castrated) age in the caffeine treatment group (0.81) did not differ (P = 0.199) from that of control lambs (0.73; total born n = 877). Experiment 2 comprised Merino ewes lambing from three successive weekly joining groups. Treated ewes were drenched with an aqueous caffeine solution at a dose rate of 10 mg/kg live weight from the day before anticipated lambing, until the individual lambed. Control ewes were drenched with water. The proportion of lambs born dead (0.07) and the survival of lambs to marking age (caffeine 0.61; control 0.62) were similar between treatment groups (total born n = 1158). In both experiments, ewe mortality and the weight of lambs at marking were not altered by caffeine treatments. The results from this large-scale field study indicate caffeine is not an effective therapeutic agent to increase either intra-partum or perinatal survival, or lamb growth rates.

Admission Cardiotocography as a Predictor of Low Apgar Score: An Observational, Cross-Sectional Study.

Background and objectiveCardiotocography (CTG) has been used more frequently in recent decades to reduce intrapartum fetal mortality rates. The purpose of this study was to determine whether pathological or non-reactive CTG could predict a low Apgar (Appearance, Pulse, Grimace, Activity, and Respiration) score. An abnormal trace would indicate a distressed fetus, whereas a normal trace would indicate a well-oxygenated fetus.MethodsThis study included a total of 470 women with a gestational period of more than 37 weeks. Based on the results of their CTGs, they were divided into three groups. An emergency cesarean section (CS) was performed if there was any sign of fetal distress on CTG. The Apgar scoring for newborns was recorded in the proforma following delivery.ResultsThe study was carried out at two major tertiary-care hospitals in Pakistan. A reactive CTG was found in more than one-third (39.36%) of the 470 patients. An Apgar score above 8 was obtained by 34.26% of the newborns, while an Apgar score below 8 was obtained by more than half (63.40%). Only 2.34% of newborns had an Apgar score below 6. A third (30.64%) of the patients had grade-1 meconium-stained liquor (MSL), 24.89% had grade-2 MSL, 19.79% had grade-3 MSL, and 24.68% had no MSL. One-third (32.34%) of the neonates were admitted to the neonatal intensive care unit (NICU) shortly after birth. When CTG was pathological or non-reactive, the odds of securing a higher Apgar score decreased by 70.45% (OR: 0.30; 95% CI: 0.20-0.44; p<0.001).ConclusionThe main conclusion drawn from this study's findings is that a pathological CTG is an indicator of a low Apgar score.

Health care workers\u2019 experiences of managing foetal distress and birth asphyxia at health facilities in Northern Uganda

BackgroundBirth asphyxia is one of the leading causes of intrapartum stillbirth and neonatal mortality worldwide. We sought to explore the experiences of health care workers in managing foetal distress and birth asphyxia to gain an understanding of the challenges in a low-income setting.MethodsWe conducted in-depth interviews with 12 midwives and 4 doctors working in maternity units from different health facilities in Northern Uganda in 2018. We used a semi-structured interview guide which included questions related to; health care workers’ experiences of maternity care, care for foetal distress and birth asphyxia, views on possible preventive actions and perspectives of the community. Audio recorded interviews were transcribed verbatim and analysed using inductive content analysis.ResultsFour categories emerged: (i) Understanding of and actions for foetal distress and birth asphyxia including knowledge, misconception and interventions; (ii) Challenges of managing foetal distress and birth asphyxia such as complexities of the referral system, refusal of referral, lack of equipment, and human resource problems, (iii) Expectations and blame from the community, and finally (iv) Health care worker’ insights into prevention of foetal distress and birth asphyxia.ConclusionHealth care workers described management of foetal distress and birth asphyxia as complex and challenging. Thus, guidelines to manage foetal distress and birth asphyxia that are specifically tailored to the different levels of health facilities to ensure high quality of care and reduction of need for referral are called for. Innovative ways to operationalise transportation for referral and community dialogues could lead to improved birth experiences and outcomes.

Perinatal outcome after planned vaginal delivery in monochorionic compared with dichorionic twin pregnancy

To assess, according to chorionicity, the perinatal outcome of twin pregnancy in which vaginal delivery is planned. JUMODA (JUmeaux MODe d'Accouchement) was a national prospective population-based cohort study of twin pregnancies, delivered in 176 maternity units in France, from February 2014 to March 2015. In this planned secondary analysis, we assessed, according to chorionicity, the perinatal outcome of twin pregnancies, in which vaginal delivery was planned, that delivered at or after 32 weeks of gestation with the first twin in cephalic presentation. In order to select a population with well-recognized indications for planned vaginal delivery, we applied the same exclusion criteria as those in the Twin Birth Study, an international randomized trial. Monochorionic twin pregnancies with twin-to-twin transfusion syndrome or twin anemia-polycythemia sequence were defined as complicated and were excluded. The primary outcome was a composite of intrapartum mortality and neonatal morbidity and mortality. Multivariable logistic regression models were used to control for potential confounders. Subgroup analyses were conducted according to birth order (first or second twin) and gestational age at delivery (< 37 or ≥ 37 weeks of gestation). Among 3873 twin pregnancies, in which vaginal delivery was planned, that delivered at ≥ 32 weeks' gestation with the first twin in cephalic presentation, meeting the inclusion criteria of the Twin Birth Study, 729 (18.8%) were uncomplicated monochorionic twin pregnancies and 3144 (81.2%) were dichorionic twin pregnancies. The rate of composite intrapartum mortality and neonatal morbidity and mortality did not differ between uncomplicated monochorionic (27/1458 (1.9%)) and dichorionic (107/6288 (1.7%)) twin pregnancies when adjusting for conception by assisted reproductive technologies (adjusted relative risk, 1.07 (95% CI, 0.66-1.75)). No significant difference in the primary outcome was found between the groups on subgroup analyses according to birth order and gestational age at delivery. When vaginal delivery is planned, and delivery occurs at ≥ 32 weeks of gestation with the first twin in cephalic presentation, uncomplicated monochorionic twin pregnancy is not associated with a higher rate of composite intrapartum mortality and neonatal morbidity and mortality compared with dichorionic twin pregnancy. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Role of Admission test in predicting foetal outcome in low and high risk pregnancies

Introduction: Unfortunately, risk assessment profiles used at present are insufficient. Intrapartum mortality and morbidity are not uncommon in the low risk pregnancies also. FHR and fetal acidosis can occur with the same frequency as in a High risk group. Hence, there is a need for a simple, effective screening test to identify the pregnancies requiring continuous EFM. Materials and Methods: This study is a prospective study comprising of 200 singleton pregnancies with cephalic presentation in early labour admitted to the labour room. Following Admission, the Admission test was done and the results were classified based on the three tier Heart interpretation system recommended by the 2008 NICHD Workshop on EFM as Reassuring, Nonreassuring and Ominous. The patients were then followed up and the mode of delivery and the different variables of perinatal outcome noted and correlated with the Admission test results. Results: The Low risk group had 88% Reassuring, 8% Nonreassuring and 4% Ominous Admission Test patterns. The High risk group had 80% Reassuring, 11% Nonreassuring and 9% Ominous Admission Test patterns. The study showed that operative deliveries were more significantly associated with Non reassuring and Ominous Admission test patterns especially in the High risk group. Admission test showed Sensitivity of 60%, Specificity of 90.86%, PPV 48.39% and NPV of 94.08%. Conclusion: Admission test can be used as an important non-invasive method to diagnose fetal compromise present at the time of admission in both high as well as low risk patients in labour. Keywords: Admission test, Low and high risk pregnancies, Fetal distress, NICU admission.

The cost-effectiveness of a program to reduce intrapartum and neonatal mortality in a referral hospital in Ghana.

To evaluate the cost-effectiveness of a program intended to reduce intrapartum and neonatal mortality in Accra, Ghana. Quasi-experimental, time-sequence intervention, retrospective cost-effectiveness analysis. A program integrating leadership development, clinical skills and quality improvement training was piloted at the Greater Accra Regional Hospital from 2013 to 2016. The number of intrapartum and neonatal deaths prevented were estimated using the hospital's 2012 stillbirth and neonatal mortality rates as a steady-state assumption. The cost-effectiveness of the intervention was calculated as cost per disability-adjusted life year (DALY) averted. In order to test the assumptions included in this analysis, it was subjected to probabilistic and one-way sensitivity analyses. Incremental cost-effectiveness ratio (ICER), which measures the cost per disability-adjusted life-year averted by the intervention compared to status quo. From 2012 to 2016, there were 45,495 births at the Greater Accra Regional Hospital, of whom 5,734 were admitted to the newborn intensive care unit. The budget for the systems strengthening program was US $1,716,976. Based on program estimates, 307 (±82) neonatal deaths and 84 (±35) stillbirths were prevented, amounting to 12,342 DALYs averted. The systems strengthening intervention was found to be highly cost effective with an ICER of US $139 (±$44), an amount significantly lower than the established threshold of cost-effectiveness of the per capita gross domestic product, which averaged US $1,649 between 2012-2016. The results were found to be sensitive to the following parameters: DALYs averted, number of neonatal deaths, and number of stillbirths. An integrated approach to system strengthening in referral hospitals has the potential to reduce neonatal and intrapartum mortality in low resource settings and is likely to be cost-effective. Sustained change can be achieved by building organizational capacity through leadership and clinical training.

Guideline No. 391-Pregnancy and Maternal Obesity Part 1: Pre-conception and Prenatal Care.

This guideline will review key aspects in the pregnancy care of women with obesity. Part I will focus on pre-conception and pregnancy care. Part II will focus on team planning for delivery and Postpartum Care. All health care providers (obstetricians, family doctors, midwives, nurses, anaesthesiologists) who provide pregnancy-related care to women with obesity. Women with obesity who are pregnant or planning pregnancies. Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetrical anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2018. Grey (unpublished) literature was identified through searching the websites of health technology assessment and related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. The content and recommendations were drafted and agreed upon by the authors. Then the Maternal-Fetal Medicine Committee peer reviewed the content and submitted comments for consideration, and the Board of the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication. Areas of disagreement were discussed during meetings, at which time consensus was reached. The level of evidence and quality of the recommendation made were described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care. Implementation of the recommendations in these guidelines may increase obstetrical provider recognition of the issues affected pregnant individuals with obesity, including clinical prevention strategies, communication between the health care team, the patient and family as well as equipment and human resource planning. It is hoped that regional, provincial and federal agencies will assist in the education and support of coordinated care for pregnant individuals with obesity. SOGC guidelines will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter. This guideline was developed with resources funded by the SOGC. RECOMMENDATIONS.

Guideline No. 392-Pregnancy and Maternal Obesity Part2: Team Planning for Delivery and Postpartum Care.

This guideline will review key aspects in the pregnancy care of women with obesity. Part I will focus on Preconception and Pregnancy Care. Part II will focus on Team Planning for Delivery and Postpartum Care. All health care providers (obstetricians, family doctors, midwives, nurses, anaesthesiologists) who provide pregnancy-related care to women with obesity. Women with obesity who are pregnant or planning pregnancies. Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetric anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2018. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. The content and recommendations were drafted and agreed upon by the authors. Then the Maternal-Fetal Medicine Committees peer reviewed the content and submitted comments for consideration, and the Board of the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication. Areas of disagreement were discussed during meetings at which time consensus was reached. The level of evidence and quality of the recommendation made were described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care. Implementation of the recommendations in these guidelines may increase obstetrical provider recognition of the issues affecting pregnant individuals with obesity, including clinical prevention strategies, communication between the health care team, the patient and family as well as equipment and human resource planning. It is hoped that regional, provincial and federal agencies will assist in the education and support of coordinated care for pregnant individuals with obesity. SOGC guideline will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter. This guideline was developed with resources funded by the SOGC. RECOMMENDATIONS.

Hypoxia with acidosis in extremely preterm born infants was not associated with an increased risk of death or impaired neurodevelopmental outcome at 6.5years.

It is not clear whether perinatal acidosis can predict poor outcomes in extremely preterm infants and we investigated associations between intrapartum hypoxia and mortality and neurodevelopmental outcomes. We used nationwide data on 705 infants from the Extremely Preterm Infants in Sweden Study, delivered at 22-26weeks of gestation during 2004-2007. Comprehensive neurodevelopmental assessments were performed on survivors at 2.5 (n=456) and 6.5 (n=441) years of corrected age. Gestational age-related changes in umbilical cord arterial pH were compared with reference values for term newborn infants, and base excess was also calculated. Associations between low blood gas values (<10th percentile) and mortality and neurodevelopmental outcome were estimated. Cord blood determination was more common in surviving infants (P<.001), with pH determined in 322/705 (46%) and base excess in 311/705 (44%). Extremely preterm infants had higher pH values than term infants (P<.0001), with no change from 22 to 26weeks of gestation (P=.61, r2 =.001). Multiple logistic regression showed no association between low blood gas values and risk of death or neurodevelopmental impairment at 6.5years (P≥.17). Hypoxia with acidosis at birth was not associated with an increased risk of death or impaired neurodevelopmental in extremely preterm born children at 6.5years.

Scaling Up Safer Birth Bundle Through Quality Improvement in Nepal (SUSTAIN)\u2014a stepped wedge cluster randomized controlled trial in public hospitals

BackgroundEach year, 2.2 million intrapartum-related deaths (intrapartum stillbirths and first day neonatal deaths) occur worldwide with 99% of them taking place in low- and middle-income countries. Despite the accelerated increase in the proportion of deliveries taking place in health facilities in these settings, the stillborn and neonatal mortality rates have not reduced proportionately. Poor quality of care in health facilities is attributed to two-thirds of these deaths. Improving quality of care during the intrapartum period needs investments in evidence-based interventions. We aim to evaluate the quality improvement package—Scaling Up Safer Bundle Through Quality Improvement in Nepal (SUSTAIN)—on intrapartum care and intrapartum-related mortality in public hospitals of Nepal.MethodsWe will conduct a stepped wedge cluster randomized controlled trial in eight public hospitals with each having least 3000 deliveries a year. Each hospital will represent a cluster with an intervention transition period of 2 months in each. With a level of significance of 95%, the statistical power of 90% and an intra-cluster correlation of 0.00015, a study period of 19 months should detect at least a 15% change in intrapartum-related mortality. Quality improvement training, mentoring, systematic feedback, and a continuous improvement cycle will be instituted based on bottleneck analyses in each hospital. All concerned health workers will be trained on standard basic neonatal resuscitation and essential newborn care. Portable fetal heart monitors (Moyo®) and neonatal heart rate monitors (Neobeat®) will be introduced in the hospitals to identify fetal distress during labor and to improve neonatal resuscitation. Independent research teams will collect data in each hospital on intervention inputs, processes, and outcomes by reviewing records and carrying out observations and interviews. The dose-response effect will be evaluated through process evaluations.DiscussionWith the global momentum to improve quality of intrapartum care, better understanding of QI package within a health facility context is important. The proposed package is based on experiences from a similar previous scale-up trial carried out in Nepal. The proposed evaluation will provide evidence on QI package and technology for implementation and scale up in similar settings.Trial registration numberISRCTN16741720. Registered on 2 March 2019.

Ultrastructure of placenta in antenatal fetal death

The current obstetrical protocols and the improved perinatal services have led to a significant decrease in the intrapartum and neonatal mortality; however, the rate of antenatal fetal death remains high. In a search for a mechanism of this abnormality, we conducted a comprehensive morphological study of the placental ultrastructure in women with antenatal fetal death. Aim: to determine the ultrastructural characteristics of the placenta in these women. Materials and methods. We analyzed 60 cases of antenatal fetal death and conducted an electron microscopic study of placental terminal chorionic villi. The placenta samples were fixed in 2.5% glutaraldehyde, then processed in alcohol at increasing concentration and acetone for dehydration, and finally polymerized in araldite resin. Ultrathin sections were obtained using an ultra-microtome and then examined with an electron microscope. Results. In 53 (88.3%) women, antenatal fetal death occurred in the early gestation period and in 7 (11.7%) women – at a period of 38-41 weeks. In the main group, the age of women ranged from 18 years to 42 years, and in the comparison group – from 22 to 37 years. In the main group, 16 (26.6%) women were in the late reproductive period (36 years and older). Among the women with antenatal fetal death, the most common diagnoses were: chronic fetoplacental insufficiency (CFPI) – 23 (39%), fetal development retardation syndrome (FDRS) – 16 (27%), and premature detachment of a normally situated placenta (PDNSP) – 10 (17%). Changes in the syncytiotrophoblast structure were detected in patients of both groups; in these changes, signs of vacuolization and destruction were most common. In women of the main group, sclerotic stroma and infiltration by mononuclears were found, whereas loosening and swelling of the stroma were detected in both groups. Changes in the vascular bed were revealed in 100% of cases with antenatal fetal death and in 40% in comparison group. Conclusion. In antenatal fetal death, the most common causes were: CFPI, FDRS, and PDNSP. In the morphological terms, there were destructive changes in the syncytiotrophoblast, edematous-destructive, sclerotic and necrotic changes in the stromal terminal chorionic villi, vascular changes (hypovascularization, stroma obliteration, stasis and erythrocyte sludging, formation of erythrocyte thrombi in the lumens of blood vessels), dysfunctional changes in endotheliocytes, and inflammatory changes.

A Global Perinatal Health Indicator Falters in Afghanistan

ABSTRACTThrough the life of a global health project in a maternity hospital in Kabul, Afghanistan one indicator—intrapartum mortality—was taken to represent the quality of emergency obstetric care and was at the center of a struggle over project management. The indicator was also contested by Afghan clinicians, and so was adapted, in which process the relationship between the indicator and women’s lives outside the hospital was made clear. As the indicator faltered, new possibilities for intervention emerged, although these were not fully realized. Global health governance and financing must be flexible enough to respond when indicators falter.

Prédiction échographique du risque de rupture utérine après césarienne : LUSTrial, un essai randomisé pragmatique

BackgroundThe data from literature show that trial of labor and elective repeat cesarean delivery after a prior cesarean delivery both present significant risks and benefits, and these risks and benefits differ for the woman and her fetus. The benefits to the woman can be at the expense of her fetus and vice-versa. This uncertainty is compounded by the scarcity of high-level evidence that preclude accurate quantification of the risks and benefits that could help provide a fair counseling about a trial of labor and elective repeat cesarean delivery. An interesting way of research is to evaluate the potential benefits of a decision rule associated to the ultrasound measurement of the lower uterine segment (LUS). Indeed, ultrasonography may be helpful in determining a specific risk for a given patient by measuring the thickness of the LUS, i,e, the thickness of the cesarean delivery scar area. Although only small and often methodologically biased data have been published, they look promising as their results are concordant: ultrasonographic measurements of the LUS thickness is highly correlated with the intraoperative findings at cesarean delivery. Furthermore, the thinner the LUS becomes on ultrasound, the higher the likelihood of a defect in the LUS. Finally, ultrasound assessment of LUS has an excellent negative predictive value for the risk of uterine defect. Therefore, this exam associated with a rule of decision could help to reduce the rate of elective repeat cesarean delivery and especially to reduce the fetal and maternal mortality and morbidity related to trial of labor after a prior cesarean delivery. Methods/designThis is a pragmatic open multicenter randomized trial with two parallel arms. Randomization will be centralized and computerized. Since blindness is impossible, an adjudication committee will evaluate the components of the primary composite outcome in order to avoid evaluation bias. An interim analysis will be planned mid-strength of the trial. Ultrasound will be performed by expert sonographers after certification by the main investigator. Women aged 18 years or older are eligible for this trial if they have a singleton pregnancy in cephalic presentation at a gestational age from 36 to 38 weeks, a previous low transverse cesarean delivery and sign the informed consent sheet. Women will be asked to participate in this study when they reach a term of 36 to 38 weeks of gestation. After agreement, women will be randomized into two groups: in the study group, they will have the LUS measured by ultrasound and the patient will be informed that, based on a threshold value of 3.5mm for the ultrasound measurement of the LUS thickness, the patient with a higher measurement will be considered at low risk and will be encouraged to choose a trial of labor whereas the patient with a measurement is equal to or less than this threshold will be considered at risk and encouraged to choose an elective repeat cesarean; in the control group, ultrasound LUS measurement will not be performed. The mode of delivery will be decided according to standard practice at the center. The primary composite outcome will include: uterine rupture, uterine dehiscence, hysterectomy, thromboembolic complications, transfusion, endometritis, maternal mortality, fetal prenatal and intrapartum mortality, hypoxic-ischemic encephalopathy and neonatal mortality. DiscussionThis trial assesses the efficacy of ultrasound measurement of the lower uterine segment in women with a prior cesarean delivery in reducing fetal and maternal morbidity and mortality and it will provide evidence in order to establish clinical recommendations. Trial registrationClinicalTrials.gov identifier: NCT01916044 (date of registration: 5 August 2013).