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12
th
Rep
oR
t o
f t
he p
eR
ina
ta
l a
nd
inf
an
t M
oR
ta
lit
y C
oM
Mit
tee o
f W
est
eR
n a
ust
Ra
lia
, Dea
th
s 2002-04
hP1
0489
NO
V’0
7 22
445
Produced by the Office of the executive Director of Public health© Department of health 2007
Department of health
12th Report of the Perinatal and Infant Mortality Committee of Western australia
Deaths 2002-04
Foreword:
Chairman’sreportItiswithpleasurethatIsubmit,onbehalfoftheCommittee,the12thPerinatalandInfantMortalityReportofinvestigationsofdeathsintheyears2002–04.
ThisisthesecondReportsincetheCommitteewasre-establishedinOctober2001.TheCommitteereviewscasesofperinatalandinfantdeathwitheachcasediscussedinade-identifiedformat.Thecriteriaforreviewwerewidenedforthistrienniumtoincludecasesof26weeksgestationalageormore,incomparisonwiththepreviouscut-offof32weeksgestation.AftertheCommittee’sdeliberations,lettersaresenttothemedicalpractitionersinvolvedineachcasetoinformthedoctorsofthedecisionsandtoprovideeducation.Thisinformationisconfidential.
AsshownintheReport,theperinatalandinfantmortalityratesinWesternAustraliacontinuetofall.TherehasalsobeenameaningfulreductionintheproportionofcasesinwhichtheCommitteecouldfindevidenceofpreventablemedicalfactors.Inthistriennium,87%ofinvestigateddeathshadnoidentifiedpreventablemedicalfactor,comparedwith69%inthe2000-01period.Theproportionofstillbirthsclassifiedas“unexplained”hasalsofalleninthistriennium,reflectingasignificantanddocumentedimprovementininvestigationofsuchcasesbypractitioners.
Stillbirthrateshoweverremainunchangedandtherateofpretermbirthisrising.Thesedataprovidecompellingevidenceoftheneedforinnovativeresearchtodiscovertheoriginsofthesemostseriouscomplicationsofpregnancy.Oneareathatwarrantsparticularattentionisthehighrateofmortalityassociatedwithuntowardaspectsofmaternalbehaviourandlifestyle.Whiletherateofsmokingappearstobedecreasing,theCommitteenotedhighratesofsubstanceabuse,poorcompliancewithmedicalcare,andcontinuationofhighermortalityratesinAboriginalpeople.
TheCommitteerecommendsareviewofhomebirthsinWesternAustralia.Whenthedataforthe2000-01and2002-04periodswerecombined,theperinatalmortalityrateforplannedhomebirthswasthreefoldhigherthantheratefortermdeliveriesinplannedhospitalbirths,andthisdifferencewasstatisticallysignificant.ThesedatahoweverdonotallowfordefinitiveconclusionstobereachedasthenumbersarerelativelysmallandtheCommitteeaddressesmortalityalone.Itisrecommendedthatanindependentreviewbeconductedofplannedhomebirths,withthereviewincludingmorbidityaswellasmortality.
Finally,asChairmanIwouldliketothankDrCatherineDouglasswhohastakentheleadroleinassemblinginformationandwritingtheReport,ElizabethNathanwhohasprovidedbiostatisticalsupport,VivienGeefromtheHealthInformationCentre,andDrMargaretStevens,ExecutiveDirector,PublicHealth,fortheirtirelessandenthusiasticeffortsthathaveensuredtheCommittee’sworkiseffective.IwouldalsoliketothankthemembersoftheCommitteewhocontributetheirtimefreelyasvolunteers.
12thReportofthePerinatalandInfantMortalityCommitteeofWesternAustralia,Deaths2002-04
1
TheReportcontainsevidencethattheeducationprovidedbytheCommitteeismakingacontributiontoperinatalandinfanthealthinWesternAustralia.CreditforthisachievementgoesnotonlytotheCommitteemembers,butalsotothemanymedicalpractitioners,midwives,nursesandotherhealth-careworkerswhoareworkingsohardtomakeadifference.
ItrustyouwillfindtheReportinformativeanduseful.
Respectfullysubmitted
ProfessorJohnNewnhamChair
12thReportofthePerinatalandInfantMortalityCommitteeofWesternAustralia,Deaths2002-04
2
Tableofcontents
1 Executive summary 7
2 Committee members 15
3 Methods 17
3.1 TheRoleofthePIMC 17
3.2 ReportingofBirthsandDeaths 17
3.3 DesignationofCasesforInvestigationbythePIMCin2002-04 17
3.4 CaseInvestigationMethods 18
3.5 CauseofDeathClassification 18
3.6 PreventabilityScale 18
3.7 MaternalBehaviouralFactors 19
3.8 AdequacyofInvestigationintoCauseofDeath 20
3.9 AutopsyUtility 20
3.10 EarlyPreventionFactors 21
3.11 StatisticalMethods 21
4 Results 23
4.1 StatewideData,WA2002-04 23
4.1.1 PerinatalandInfantMortalityRatesbyBirthWeight, GestationalAgeandRace,WA2002-04 23
4.1.2 PerinatalDeathsbyCauseofDeathandAboriginality,WA2002-04 26
4.1.3 InfantdeathsbyCauseofDeathandAboriginality,WA2002-04 28
4.1.4 StillbirthsandInfantDeathsbyMaternalSmokingStatus,WA2002-04 29
4.1.5 MortalityRatesbyMaternalAgeandAboriginality,WA2002-04 31
4.1.6 MortalityRatesbyMaternalResidence,WA2002-04 31
4.1.7 MortalityRatesandSocioeconomicFactors,WA2002-04 33
4.1.8 PretermdeliveriesbyNeonatalNurseryFacility,WA2002-04 33
4.1.9 TrendsinBirthRatesandMortalityRates,WA1990-2004 34
4.2 CasesInvestigatedbythePIMC,WA2002-04 37
4.2.1 InvestigatedDeathswithPreventableMedicalFactors– Overview,WA2002-04 37
4.2.2 InvestigatedDeathswithPreventableMedicalFactors– Systemsfactors,WA2002-04 38
4.2.3 InvestigatedDeathswithPreventableMedicalFactors– MedicalCareFactors,WA2002-04 39
4.2.4 InvestigatedIntrapartumDeathswithPreventableMedicalFactors, WA2002-04 39
4.2.5 InvestigatedStillbirthsbyCauseofDeath(PSANZPDC)and PreventabilityScore,WA2002-04 40
4.2.6 InvestigatedNeonatalDeathsbyCauseofDeath(PSANZPDC)and PreventabilityScore,WA2002-04 43
4.2.7 InvestigatedNeonatalDeathsbyCauseofDeath(PSANZNDC)and PreventabilityScore,WA2002-04 47
12thReportofthePerinatalandInfantMortalityCommitteeofWesternAustralia,Deaths2002-04
3
4.2.8 InvestigatedPost-neonatalDeathsbyCauseofDeath(PSANZNDC) andPreventabilityScore,WA2002-04 47
4.2.9 MaternalBehaviourandLifestyleFactors,WA2002-04 48
4.2.10InfantDeathswhichoccurredwhilstCo-Sleeping, InvestigatedCases,WA2002-04 50
4.2.11DataCollectionMaternalFactors,WA2002-04 50
4.2.12PerinatalMortalityRiskbyGestationalAge,InvestigatedCases, WA2002-04 51
4.2.13HomeBirths,InvestigatedCases,WA2002-04 51
4.2.14HomeBirths,InvestigatedCases,WA2000-04 52
4.2.15PathologyInvestigationsintoCauseofDeath,InvestigatedCases, WA2002-04 52
4.2.16EarlyPreventionFactors,InvestigatedCases,WA2002-04 53
5 Commentary 55
5.1 TheRoleofthePIMCinWA 55
5.2 PerinatalandInfantMortality:HowWACompareswithNationalRates 55
5.3 StatewideIssues,WA 56
5.4 Investigators’Comments:CaseInvestigationsWA2002-04 59
5.5 ReducingPerinatalandInfantDeathsinWA 59
5.5.1 Congenitalabnormalities 59
5.5.2 PretermBirth 60
5.5.3 Unexplainedantepartumdeath 61
5.5.4 SIDS 62
5.5.5 PreventableDeaths,WA2002-04 64
5.5.6 MaternalBehaviouralFactors 70
5.5.7 AboriginalHealth 73
5.5.8 HomeBirths 75
5.6 InvestigationsintoCauseofDeath,InvestigatedCases,WA2002-04 76
5.7 ParentalSupport,InvestigatedCases,WA2002-04 77
5.8 ClosingRemarks,PIMC,WA2002-04 77
References 77
6 Educational & discussion papers 83
6.1 EpiduralAnalgesiainLabour-SafetyandMonitoring 83
6.2 OptimisingOutcomeforWomenwithDiabetesinPregnancy 89
6.3 MonochorionicTwinPregnancies 95
7 Appendices 99
7.1 AppendixI:AbbreviationsandDefinitions 99
7.2 AppendixII:AppropriateInvestigationsFollowingStillbirthandInfantDeath 101
7.3 AppendixIII:PerinatalandInfantDeathsbyPSANZPDC,WA2002-04 103
7.4 AppendixIV:InfantDeathsbyPSANZNDC,WA2002-04 105
12thReportofthePerinatalandInfantMortalityCommitteeofWesternAustralia,Deaths2002-04
4
Tables & figuresTable1: PreventabilityScale 19
Table2: PreventableMedicalFactors 19
Table3: MaternalBehaviouralFactors 20
Table4: InvestigationstoAssessCauseofDeath 20
Table5: AutopsyUtility:CategoriesofConcordanceofClinical andPathologicalDiagnoses 21
Table6: Birth&DeathStatisticsbyBirthweight,WA2002-04 23
Table7: Birth&DeathStatisticsbyGestationalAge,WA2002-04 24
Table8: Births&DeathsbyRace,WA2002-04 24
Table9a: NumberofStillbirths,byCauseofDeath(PSANZPDC),WA2002-04 26
Table9b: NumberofNeonatalDeathsbyCauseofDeath(PSANZPDC),WA2002-04 26
Table9c: NumberandRateofPerinataldeathsbyCauseofDeath(PSANZPDC) andAboriginality,WA2002-04 27
Table10a: NumberofNeonatalDeaths,byCauseofDeath(PSANZNDC),WA2002-04 28
Table10b: NumberofPost-neonataldeathsbyCauseofDeath(PSANZNDC), WA2002-04 28
Table10c: NumberandRateofInfantdeathsbyCauseofDeath(PSANZNDC) andAboriginality,WA2002-04 29
Table11a: NumberandRateofPerinatalDeathsbyCauseofDeath(PSANZPDC) andMaternalSmokingStatus,WA2002-04 30
Table11b: NumberandRateofInfantDeathsbyCauseofDeath(PSANZNDC) andMaternalSmokingStatus 30
Table12: NumberandRateofStillbirths,NeonatalandPost-neonatalDeaths, byMaternalAgeandAboriginality,WA2002-04 31
Table13: NumberofPretermBirthsbyHospitalEstablishment,WA2002-04 33
Table14: PreventabilityScoresandTypeofdeath,InvestigatedCases,WA2002-04 37
Table15: Preventable“Systems”and“MedicalCare”Factors,InvestigatedCases, WA2002-04 38
Table16: PreventablefactorsinIntrapartumManagement,InvestigatedCases, WA2002-04 40
Table17a: NumberofStillbirthsbyCauseofDeath(PSANZPDC),Preventability ScoreandAboriginality,InvestigatedCases,WA2002-04 41
Table17b: NumberofNeonatalDeathsbyCauseofDeath(PSANZPDC), PreventabilityScoreandAboriginality,InvestigatedCases,WA2002-04 44
Table18a: NumberofNeonatalDeathsbyCauseofDeath(PSANZNDC),
PreventabilityScoreandAboriginality,InvestigatedCases,WA2002-04 47
Table18b NumberofPost-neonatalDeathsbyCauseofDeath(PSANZNDC), PreventibilityScoreandAboriginality,InvestigatedCases,WA2002-04 47
Table19: InvestigatedCaseswithMaternalBehaviouralFactors:Associated Factors,WA2002-04 49
Table20: NumberofDeathsinwhichMaternalBehaviouralFactorswere apparent,byAboriginality,InvestigatedCases,WA2002-04 49
Table21: NumberofInfantdeathswhichoccurredwhilstCo-Sleeping, byAboriginality,InvestigatedCases,WA2002-04 50
12thReportofthePerinatalandInfantMortalityCommitteeofWesternAustralia,Deaths2002-04
5
Table22: MaternalHeightandWeightRecords,InvestigatedPerinatal Deaths,WA2002-04 51
Table23: PerinatalMortalityRiskbyGestationalAge,InvestigatedPerinatal Deaths,WA2002-04 51
Table24: NumberofPlannedandActualHomeBirths,WA2000-2004 52
Table25: AutopsyUtilityforPerinatalandInfantDeaths,InvestigatedCases, WA2002-04 52
Table26: PathologyInvestigationstoAssessCauseofStillbirthsandInfant Deaths,InvestigatedCases,WA2002-04 53
Table27: InvestigatedCaseswith‘EarlyPrevention’Factors,WA2002-04 54
Table28: Stillbirths,NeonatalandPerinatalDeathsbyStateandTerritory,2004 55
Table29: InfantDeathsbyStateandTerritory,Australia1984-2004 56
Table30: ProportionofSpecialistObstetriciansworkinginRuralAreas, byStateorTerritoryinAustralia,2001 56
Table31: WANTS/RFDSTransfersin2001and2006,WA 57
Fig1: NumberofStillbirths,Perinatal,Neonatal,Post-neonatal andInfantDeathsbyAboriginality,WA2002-04 25
Fig2: RatesforStillbirths,Perinatal,Neonatal,Post-neonataland InfantMortalitybyAboriginality,WA2002-04 25
Fig3: PerinatalMortalityRatesbyCauseofDeath(PSANZPDC) andAboriginality,WA2002-04 27
Fig4: InfantMortalityRatesbyCauseofDeath(PSANZNDC)and Aboriginality,WA2002-04 29
Fig5: RatesofStillbirths,Perinatal,Neonatal,Post-neonataland InfantMortalitybyMaternalSmokingStatus,WA2002-04 30
Fig6: Perinatal&Post-neonatalMortalityRatesbyMaternalResidence, WA2002-04 32
Fig7: Perinatal&InfantMortalityRatesbySocioeconomicStatus,WA2002-04 33
Fig8: TrendsinBirthRatesbyAboriginality,WA1990-2004 34
Fig9: TrendsinProportionofMothersatExtremesofReproductiveAge, byAboriginality,WA1990–2004 34
Fig10: TrendsinPerinatalMortalityRates,WA1990-2004 35
Fig11: TrendsinPerinatalMortalityRatesbyAboriginality,WA1990-2004 35
Fig12: TrendsinInfantMortalityRates,WA1990-2004 35
Fig13: TrendsinInfantMortalityRates,byAboriginality,WA1990-2004 36
Fig14: TrendsinPretermBirthRates,byAboriginality,WA1990-2004 36
Fig15: TrendsinPretermPerinatalMortalityRates,WA1990-2004 37
Fig16a: NumberofStillbirthsbyCauseofDeath(PSANZPDC)and PreventabilityScore,InvestigatedCases,WA2002-04 41
Fig16b: NumberofNeonatalDeathsbyCauseofDeath(PSANZPDC)and PreventabilityScore,InvestigatedCases,WA2002-04 44Fig17: ProportionofCaseswithMaternalBehaviouralFactors, byTypeofdeath,InvestigatedCases,WA2002-04 48
12thReportofthePerinatalandInfantMortalityCommitteeofWesternAustralia,Deaths2002-04
6
1Executivesummary
ThePerinatalandInfantMortalityCommitteeofWesternAustralia1(PIMC;‘TheCommittee’)isastatutoryCommitteeundertheHealth Act 1911.
Thisisthe12thReportofthePIMC,containingdatarelatedtodeathsintheyears2002to2004inclusive.Historicallydeathauditshaveformedanimportantroleinpublichealth.ValuabledataareavailablehereinWesternAustralia(WA)duetothespecialprivilegesandprotectionprovidedtotheCommitteethroughitsstatutoryrights.TherearerecognizedlimitationstothescopeoftheCommittee’srole,asthelegislationdoesnotincludetheinvestigationofnon-fataladverseobstetricoutcomes.TheprimaryroleoftheCommitteeiseducational.
TheannualnumberofbirthsinWAhasbeenaround25,000birthsinrecentyears,althoughthereareindicationsthatthisisnowincreasing.Therewere26,792birthsinWAin2005.2Therewereannualaveragesof182stillbirths(20weeksgestationor400gbirthweight),55neonataldeaths(inthefirst28daysoflife),237perinataldeaths(stillbirthsandneonataldeathscombined)and87infantdeaths(deathsinthefirstyearoflife)peryearinWAin2002-04.BirthanddeathratesforAboriginalsaremuchhigherthanfortheCaucasianpopulation.
Perinatalandinfantmortalityrateshavecontinuedtodecline,duetosignificantreductionsintheneonatalandpost-neonatalmortalityrates,buttherehasnotbeenasignificantreductioninthestillbirthrateinthelasttwodecades.Theperinatalandinfantmortalityratesinthetriennium2002-04werelowerthanthosepublishedinthe11thReportpertainingtodeathsin2000–013andWAratescomparefavourablywithnationalfiguresintheseindices.4,5,6
TheCommittee’s11thReportwasbasedoninvestigationsofasubsetofperinatalandinfantdeathsofatleast32weeksgestationalage,selectedaccordingtocriteriasetbytheExecutiveDirector,PublicHealth(EDPH).Thissubsetofdeathswasconsideredunlikelytoberepresentativeofalldeaths.From2002onwards,theEDPHdirectedtheCommitteetoinvestigateabroaderrangeofcases,beingalldeathsof26weeksorgreatergestationalage.Ofthe167investigateddeathsintheyears2000and2001,51(31%)werefoundtohavepossiblepreventablemedicalfactors,with15(9%)ofthesedeathsconsideredpotentiallyavoidable.Datafortheyears2002-04indicatealowerproportionofdeathswithpossiblepreventablemedicalfactors,with59(13.3%)ofthe445investigateddeathsintheseyearscodedwithpossiblepreventablemedicalfactors,and18(4.0%)oftheseconsideredpotentiallyavoidabledeaths.Thus96%ofinvestigatedstillbirthsandinfantdeathsinWesternAustraliainthetrienniumof2002-04wereconsideredunavoidableinamedicalcontext.
Maternalbehaviouralfactorswereofparticularinterest.Overall,theprevalenceofsmokingwas28.0%inmothersexperiencingastillbirthorinfantdeathcomparedwith18.7%inthegeneralpopulationofmothers.Theprevalenceofsmokingwas22.7%inmothersexperiencingastillbirthand39.2%ofthoseexperiencinganinfantdeath.Inthesubgroupofinvestigateddeaths,30%ofmothersweresmokers,andotheraspectsofparentallifestylesuchasillicitsubstanceuseorpoorcompliancewithmedicalcare,wereassociatedwith22%ofdeaths.
Populationhealthbenefitsareassociatedwithimprovedlivingconditions,goodnutritionandavoidanceofharmfulsubstanceuse.Thesefactorsremainthechallengesinworkingforimprovedoutcomesforthoselivingindisadvantagedsocialcircumstances,particularlyformanyAboriginalpeople.
12thReportofthePerinatalandInfantMortalityCommitteeofWesternAustralia,Deaths2002-04
1 E
xecu
tive
sum
mar
y
7
Themajorcategoriesofstillbirthwerecongenitalabnormalities,prematurityduetospontaneouspretermbirths,and‘unexplained’.Improvedeffortsforprimarypreventionoffetalloss,particularlywithperi-conceptionalfolicacidsupplementation,andimprovedantenatalscreeningforabnormalities,remainareaswherefurtherreductionsinstillbirthratesmaybeachieved.Findingwaystopreventpretermbirthandunexplainedantepartumdeathremainprimaryhealthgoals.
Obesityanddiabetesmellitusaremajorcontemporaryhealthproblems.Theirincreasingprevalencesmayleadtoanincreaseinperinataldeaths.Preventionapproacheswillincludepublichealthinitiativestoreduceobesityandtheprovisionofspecialisedcareformorbidlyobeseanddiabeticwomen.
Suddeninfantdeathsyndrome(SIDS)isstilltheleadingsinglecategoryofinfantdeaths.Theincidencehasdeclinedinrecentyearswith‘safersleeping’educationprogramsbut‘at-risk’groupshavenotexperiencedthesameriskreduction.Publiceducationaboutsmokingavoidance,breastfeeding,andsafersleepingpracticesneedstobedirectedatthosemostatrisk.
SpecificeffortsarerequiredtoaddressthehighperinatalandinfantmortalityratesinAboriginalpeople.TargetedculturallyrelevanteducationalprogramsanddedicatedAboriginalantenatalclinicsmaybeofbenefit.
Therewasanimprovementintheproportionofcasesthathadpathologyinvestigationsperformedtoassesscauseofdeathinthecasesin2002-04comparedwiththosein2000-01.
TheworkofthisCommitteeisboundbytheprovisionsoftheHealth Act 1911,whichconfineitsworktothereviewofdeaths.Practitionersareremindedoftheimportanceofauditofbroaderperinataloutcomes,assessingpatientsatisfactionandmorbidityfactors,alongwithmortalityoutcomes.
12thReportofthePerinatalandInfantMortalityCommitteeofWesternAustralia,Deaths2002-04
1 E
xecu
tive
sum
mar
y
8
Fin
din
gs:
Key
Poin
ts:
Rec
omm
endat
ions:
Ove
rvie
w:
InW
este
rnA
ustr
alia
(W
A)
in2
002-
04t
here
wer
e74
,449
liv
ebir
ths
and
806
peri
nata
lan
din
fant
dea
ths
(546
sti
llbi
rths
,16
6ne
onat
ald
eath
san
d94
pos
t-ne
onat
ald
eath
s).
The
sti
llbi
rth
rate
was
7.3
per
1,0
00b
irth
s.
The
neo
nata
lm
orta
lity
rate
was
2.2
per
1,0
00liv
ebir
ths
The
per
inat
al m
orta
lity
rat
e w
as 9
.5 p
er 1
,000 b
irth
s.
The
pos
t-ne
onat
alm
orta
lity
rate
was
1.3
per
1,0
00liv
ebir
ths.
The
infa
nt
mor
tality
rat
e w
as 3
.5 p
er 1
,000 liv
ebir
ths.
Ris
k Fac
tors
for
sti
llbir
th a
nd infa
nt
dea
th:
Rat
eso
fst
illbi
rth
and
infa
ntd
eath
wer
ehi
gher
in
thos
ew
ith
mar
kers
for
low
ers
ocio
econ
omic
sta
tus.
Still
birt
han
din
fant
mor
talit
yra
tes
wer
esi
gnifi
cant
lyh
ighe
rin
mot
hers
who
sm
oked
,w
ith
the
grea
test
dif
fere
nce
bein
gin
th
epo
st-n
eona
talm
orta
lity
rate
whi
chw
asfi
ve-f
old
high
erin
smok
ing
mot
hers
.
The
pre
vale
nce
ofs
mok
ing
inp
regn
ancy
has
red
uced
fro
m
21.3
%o
fm
othe
rsw
hog
ave
birt
hin
200
0-01
to
18.7
%o
fm
othe
rs
who
gav
ebi
rth
in2
002-
04.
Abor
igin
alit
y:Com
pare
dw
ith
rate
sin
non
-Abo
rigi
nalm
othe
rs,
the
still
birt
hra
tew
asd
oubl
e,t
hen
eona
talm
orta
lity
rate
alm
ost
four
-fol
dhi
gher
,an
dth
epo
st-n
eona
talm
orta
lity
rate
five
-fol
dhi
gher
in
Abo
rigi
nalm
othe
rs.
Pre
term
:The
rew
ere
6,29
0pr
eter
mb
irth
s,g
ivin
ga
pret
erm
bir
thr
ate
(<37
wee
ks)
of8
.4%,
com
pare
dw
ith
8.2%
in
2000
-01
and
6.4%
in
1990
.
InW
At
here
hav
ebe
en
redu
ctio
nsin
the
peri
nata
lan
din
fant
mor
talit
yra
tes,
bu
tth
est
illbi
rth
rate
is
virt
ually
unch
ange
dov
ert
he
past
tw
ode
cade
s.
Low
ers
ocio
econ
omic
sta
tus
and
smok
ing
are
impo
rtan
tri
skf
acto
rsf
ors
tillbi
rth
and
infa
ntd
eath
.
Abo
rigi
nalpe
ople
hav
eco
nsid
erab
lyh
ighe
rra
tes
of
still
birt
han
din
fant
dea
th.
The
inc
iden
ceo
fpr
eter
m
birt
hha
sin
crea
sed.
Rec
omm
endat
ion 1
:A
nte
nat
al E
duca
tion
:Ant
enat
alp
ublic
hea
lth
prog
ram
ssh
ould
be
apr
iori
ty,
addr
essi
ng
g
smok
ing
cess
atio
n
g
good
nut
riti
on/p
eric
once
ptio
nalfo
lica
cid
supp
lem
enta
tion
g
heal
thy
wei
ght
g
earl
ypr
egna
ncy
scre
enin
gfo
rco
ngen
ital
abn
orm
alit
ies
g
avoi
danc
eof
alc
ohol
and
oth
erh
arm
fulsu
bsta
nces
Rec
omm
endat
ion 2
:So
cial
Issu
es:
Supp
ort
for
thos
ew
ith
soci
alr
isk
fact
ors
need
sto
be
impr
oved
.
2.1
Inc
reas
eds
uppo
rts
houl
dbe
giv
ent
oag
enci
esw
orki
ngt
oas
sist
fam
ilies
wit
hso
cial
ris
kfa
ctor
ssu
cha
spo
orh
ousi
ng,
dom
esti
cvi
olen
cea
nda
lcoh
ola
ndo
ther
sub
stan
ceu
se.
2.2
Out
reac
hse
rvic
esa
rer
ecom
men
ded
toim
prov
eco
mpl
ianc
ew
ith
ante
nata
lca
ref
ort
hose
wit
hsp
ecia
lne
eds.
ii
2.3
Scr
eeni
ngf
ord
epre
ssio
nan
ddo
mes
tic
viol
ence
is
reco
mm
ende
das
ar
outi
nein
ante
nata
lan
dpo
stna
tal
asse
ssm
ents
.
Rec
omm
endat
ion 3
:A
bor
igin
al c
are:
Inno
vati
vep
rogr
ams
are
requ
ired
to
addr
ess
the
high
rat
eso
fAbo
rigi
nalm
orta
lity.
3.1
Cul
tura
lly
appr
opri
ate
educ
atio
npr
ogra
ms
targ
etin
gnu
trit
ion,
dia
bete
san
dal
coho
lan
dot
her
subs
tanc
eus
epr
oble
ms
are
reco
mm
ende
d.
12thReportofthePerinatalandInfantMortalityCommitteeofWesternAustralia,Deaths2002-04
1 E
xecu
tive
sum
mar
y
9
Fin
din
gs:
Key
Poin
ts:
Rec
omm
endat
ions:
Cau
se o
f D
eath
:The
lea
ding
cat
egor
ies
ofs
tillbi
rth
byP
erin
atal
Soc
iety
of
Aus
tral
iaa
ndN
ewZ
eala
ndP
erin
atal
Dea
thC
lass
ifica
tion
(PS
AN
ZPD
C)
wer
eco
ngen
ital
abn
orm
alit
y26
.6%(
26%in
2000
-01)
,un
expl
aine
dan
tepa
rtum
dea
th1
8.3%
(22
%in
2000
-01)
and
sp
onta
neou
spr
eter
mb
irth
15.
6%(
11%in
2000
-01)
.
The
lea
ding
cat
egor
ies
ofn
eona
talde
ath
byP
SAN
Z-PD
Cw
ere
prem
atur
ity
40.4
%(
37%in
2000
-01)
,co
ngen
ital
abn
orm
alit
y22
.9%(
28%in
2000
-01)
and
per
inat
alinf
ecti
on7
.2%(
11%in
2000
-01)
.
The
lea
ding
cat
egor
ies
ofp
ost-
neon
atal
dea
ths
byP
erin
atal
So
ciet
yof
Aus
tral
iaa
ndN
ewZ
eala
ndN
eona
talD
eath
Cla
ssifi
cati
on(
PSAN
ZN
DC)
wer
eSu
dden
Infa
ntD
eath
Syn
drom
e(S
IDS)
23.
4%(
31%in
2000
-01)
,co
ngen
ital
abn
orm
alit
ies
23.4
%
(19%
in
2000
-01)
and
“ot
her”
whi
chinc
lude
sin
juri
esa
nd
inde
term
inat
eca
uses
of
deat
h27
.7%(
21%in
2000
-01)
.
INV
EST
IGA
TED
DEA
TH
S:
The
Com
mit
tee
inve
stig
ated
445
of
the
806
deat
hs(
256
still
birt
hs,
98n
eona
talan
d91
pos
t-ne
onat
ald
eath
s).
Pre
venta
ble
med
ical
fac
tors
96%(
427
of4
45)
ofinv
esti
gate
dde
aths
wer
eco
nsid
ered
un
avoi
dabl
ein
am
edic
alc
onte
xt(
prev
enta
bilit
ysc
ore
<4).
87%(
386
of4
45)
ofinv
esti
gate
dde
aths
had
no
iden
tifie
dpr
even
tabl
em
edic
alf
acto
r(p
reve
ntab
ility
sco
re=1
).
Thi
sco
mpa
res
wit
hin
vest
igat
edd
eath
sin
200
0-01
whe
re9
1%
(152
of
167)
wer
eco
nsid
ered
una
void
able
(pr
even
tabi
lity
scor
e<4
)an
d69
%(
115
of1
67)
had
noide
ntifi
edp
reve
ntab
le
med
ical
fac
tor
(pre
vent
abili
tys
core
=1).
The
rew
asa
red
ucti
on
int
hep
ropo
rtio
nof
cas
esw
ith
prev
enta
ble
med
ical
fac
tors
in
2002
-04
com
pare
dw
ith
thos
ein
200
0-01
,ho
wev
ert
here
wer
edi
ffer
ence
sin
the
sel
ecti
ono
fca
ses
for
inve
stig
atio
nov
ert
hese
tw
oti
me
peri
ods.
i
The
lea
ding
cat
egor
ies
of
still
birt
hw
ere
cong
enit
al
abno
rmal
ity,
“un
expl
aine
d”
and
spon
tane
ous
pret
erm
bi
rth.
The
rat
eof
une
xpla
ined
st
illbi
rth
has
redu
ced.
The
lea
ding
cau
ses
of
neon
atal
dea
thw
ere
prem
atur
ity
and
cong
enit
al
abno
rmal
ity.
The
lea
ding
cau
ses
ofp
ost-
neon
atal
dea
thw
ere
SID
S,
cong
enit
ala
bnor
mal
itie
san
d“o
ther
”w
hich
inc
lude
sin
juri
esa
ndind
eter
min
ate
caus
eso
fde
ath.
3.2
Out
reac
hpr
ogra
ms,
suc
has
hom
evi
sits
by
Abo
rigi
nal
heal
thw
orke
rs,
are
reco
mm
ende
d.
3.3
Ded
icat
eda
nten
atal
clin
ics
for
Abo
rigi
nalw
omen
may
be
ofb
enefi
tan
dsh
ould
be
cons
ider
ed.
Rec
omm
endat
ion 4
:St
atew
ide
Obst
etri
c U
nit
:The
est
ablis
hed
Stat
ewid
eO
bste
tric
Sup
port
Uni
tsh
ould
be
furt
her
expa
nded
in
its
role
to
assi
stin
the
deliv
ery
ofo
bste
tric
ca
rein
WA,
incl
udin
g:
4.1
Wor
kfor
cea
ndinf
rast
ruct
ure
advi
cea
ndp
lann
ing.
4.2
Sup
port
ing
skill
edo
bste
tric
sta
ffin
rura
lar
eas.
4.3
Pro
duci
nge
vide
nce-
base
dpr
acti
cep
roto
cols
app
licab
let
oea
cha
rea.
Rec
omm
endat
ion 5
:Pro
fess
ional
Tra
inin
g:M
edic
alp
ract
itio
ners
and
mid
wiv
ess
houl
dha
vet
rain
ing
and
prac
tice
dri
lls,
par
ticu
larl
yin
the
fol
low
ing
area
s:
5.1
Use
and
int
erpr
etat
ion
ofe
lect
roni
cfe
talhe
art
rate
m
onit
orin
gin
lab
our
5.2
Res
usci
tati
ono
fth
ene
wbo
rn
5.3
Man
agem
ent
ofo
bste
tric
em
erge
ncie
s,p
arti
cula
rly
shou
lder
dys
toci
a.
Rec
omm
endat
ion 6
:C
linic
al G
uid
elin
es:
On-
line
acce
sst
ocl
inic
alg
uide
lines
sho
uld
bea
vaila
ble
att
he
poin
tof
pat
ient
con
tact
.iii
12thReportofthePerinatalandInfantMortalityCommitteeofWesternAustralia,Deaths2002-04
1 E
xecu
tive
sum
mar
y
10
Fin
din
gs:
Key
Poin
ts:
Rec
omm
endat
ions:
The
59
case
sin
200
2-04
whe
rea
nyp
reve
nta
ble
med
ical
fa
ctor
sw
ere
iden
tifie
dco
mpr
ised
27
still
birt
hs,
29n
eona
tal
deat
hsa
nd3
pos
t-ne
onat
ald
eath
s.T
het
ypes
of
prev
enta
ble
med
ical
fac
tors
wer
edi
vide
din
to‘
syst
ems
fact
ors’
(15
cas
es),
‘m
edic
alc
are
fact
ors’
(50
cas
es)
and
‘bot
hsy
stem
san
dm
edic
al
care
fac
tors
’(6
cas
es).
The
mai
n‘s
yste
ms
fact
ors’
ide
ntifi
edw
ere:
Del
ays
inm
anag
emen
t:4
cas
es
Del
ays
int
rans
fer
toa
noth
eru
nit:
2c
ases
Supe
rvis
ion
ofm
othe
ran
dba
by(
co-s
leep
ing)
in
hosp
ital
:4
case
s
The
mai
n‘m
edic
al c
are
fact
ors’
ide
ntifi
edr
elat
edt
o:
Ant
enat
alm
anag
emen
t:2
1ca
ses
Med
ical
car
eof
the
neo
nate
:11
cas
es
Intr
apar
tum
man
agem
ent:
10
case
s
Earl
ier
refe
rral
ind
icat
ed:
6ca
ses
Iden
tific
atio
nof
abn
orm
alC
TG
tra
ces:
5c
ases
CTG
mon
itor
ing
indi
cate
d:4
cas
es
Tec
hnic
als
kills
inr
esus
cita
tion
of
new
born
:3
case
s
Tec
hnic
alo
bste
tric
ski
lls:
2c
ases
Dea
ths
wit
h ‘
pre
venta
ble
fac
tors
’ by
Cau
se o
f D
eath
:In
the
gro
upo
f27
sti
llbi
rths
whe
rea
nyp
reve
ntab
lem
edic
al
fact
ors
wer
eid
enti
fied,
the
mos
tfr
eque
ntc
ause
sof
dea
thb
yPS
AN
ZPD
Cw
ere:
Hyp
oxic
per
ipar
tum
ins
ult:
6c
ases
Feta
lgr
owth
res
tric
tion
:6
case
s
Mat
erna
ldi
abet
esm
ellit
us:
5ca
ses
Mat
erna
lhy
pert
ensi
on:
4ca
ses
Spec
ific
peri
nata
lco
ndit
ions
:4
case
s
INV
EST
IGA
TED
DEA
TH
S:The
pee
rre
view
pro
cess
of
the
Per
inat
ala
ndIn
fant
M
orta
lity
Com
mit
tee
foun
dth
atin
the
2002
-04
trie
nniu
m8
7%o
fde
aths
m
ett
heC
omm
itte
e’s
expe
ctat
ions
of
appr
opri
ate
med
ical
car
e,a
nd9
6%o
fde
aths
wer
eco
nsid
ered
un
avoi
dabl
ein
am
edic
al
cont
ext.
The
pro
port
ion
of
inve
stig
ated
dea
ths
wit
h
prev
enta
ble
med
ical
fac
tors
w
aslow
erin
2002
-04
com
pare
dw
ith
2000
-01.
Key
area
sw
ere
iden
tifie
dw
here
im
prov
edm
edic
al
man
agem
ent
may
hav
eim
prov
edo
utco
me:
•fe
talgr
owth
res
tric
tion
•la
bour
•di
abet
esa
ndh
yper
tens
ion
inp
regn
ancy
•ne
onat
als
epsi
s
Rec
omm
endat
ion 7
:D
iabet
es in P
regn
ancy
:Rou
tine
man
agem
ent
ofp
atie
nts
wit
hdi
abet
esin
preg
nanc
ysh
ould
inv
olve
:
g
educ
atio
nan
ddi
etar
yad
vice
.
g
mon
itor
ing
bloo
dgl
ucos
ele
vels
to
asse
ssg
lyca
emic
co
ntro
l.
g
spec
ialis
tco
nsul
tati
on/
liais
onf
ort
hose
pat
ient
sw
ith
poor
gl
ycae
mic
con
trol
.
g
rout
ine
mon
itor
ing
off
etal
wel
lbei
ng,
incl
udin
gul
tras
ound
as
sess
men
tfo
rfe
talm
acro
som
ia.
Rec
omm
endat
ion 8
:O
bes
ity:
Ino
bese
wom
enu
ltra
soun
dex
amin
atio
nis
adv
ised
in
the
thir
dtr
imes
ter,
to
iden
tify
fet
uses
at
incr
ease
dri
skd
uet
om
acro
som
iao
rfe
talgr
owth
res
tric
tion
.
Rec
omm
endat
ion 9
:
Mult
iple
Pre
gnan
cy:
Man
agem
ent
ofm
ulti
ple
preg
nanc
yre
quir
esa
scer
tain
men
tof
cho
rion
icit
yat
12
wee
ksg
esta
tion
and
fre
quen
tul
tras
ound
as
sess
men
tso
ffe
talgr
owth
,as
per
gui
delin
esiii.
Rec
omm
endat
ion 1
0:
Mat
ernal
age
:In
old
erm
othe
rsu
ltra
soun
dex
amin
atio
nis
adv
ised
in
the
thir
dtr
imes
ter,
in
orde
rto
ide
ntif
yfe
talgr
owth
res
tric
tion
.
12thReportofthePerinatalandInfantMortalityCommitteeofWesternAustralia,Deaths2002-04
1 E
xecu
tive
sum
mar
y
11
Fin
din
gs:
Key
Poin
ts:
Rec
omm
endat
ions:
Int
heg
roup
of
29n
eona
talde
aths
whe
rea
nyp
reve
ntab
le
med
ical
fac
tors
wer
eid
enti
fied,
the
mos
tfr
eque
ntc
ause
sof
de
ath
byP
SAN
ZPD
Cw
ere:
Hyp
oxic
per
ipar
tum
ins
ult:
9c
ases
Peri
nata
lin
fect
ion:
5c
ases
No
obst
etri
can
tece
dent
:5
case
s
Mat
ernal
Beh
avio
ur:
Smok
ing
was
as
igni
fican
tri
skf
acto
r,a
ssoc
iate
dw
ith
30.0
%o
fin
vest
igat
edd
eath
sin
thi
str
ienn
ium
.
Oth
era
spec
tso
fm
ater
nalor
fam
ilyb
ehav
iour
whi
chm
ayh
ave
cont
ribu
ted
tot
heo
utco
me
ofs
tillbi
rth
orinf
ant
deat
h,s
uch
ass
ubst
ance
use
and
poo
rco
mpl
ianc
ew
ith
med
ical
car
e,w
ere
asso
ciat
edw
ith
98(
22%)
oft
he4
45inv
esti
gate
dde
aths
(42
st
illbi
rths
,16
neo
nata
lde
aths
and
40
post
-neo
nata
lde
aths
).
Int
his
grou
pof
98
mot
hers
,61
%w
ere
smok
ers
(n=6
1),
46%w
ere
Abo
rigi
nal(n
=45)
and
44%
liv
edin
aru
ralar
ea(
n=43
)
Int
hes
ubgr
oup
oft
hese
mot
hers
exp
erie
ncin
ga
post
-neo
nata
lde
ath
oft
heir
bab
ies
(n=4
0),
36m
othe
rsh
ads
igni
fican
tso
cial
pr
oble
ms
orp
oor
com
plia
nce
wit
hm
edic
alc
are
(40%
of
the
tota
lof
91
inve
stig
ated
pos
t-ne
onat
ald
eath
s).
21m
othe
rsh
ada
lcoh
olo
rot
her
subs
tanc
eus
epr
oble
ms
(23%
of
inve
stig
ated
pos
t-ne
onat
ald
eath
s)a
nd1
0ba
bies
suf
fere
dno
n-ac
cide
ntal
inj
urie
s(1
1%o
fin
vest
igat
edp
ost-
neon
atal
dea
ths)
.
Smok
ing
was
ass
ocia
ted
wit
h30
%o
fin
vest
igat
edd
eath
s.
Oth
erm
ater
nalor
fam
ily
lifes
tyle
fac
tors
suc
has
su
bsta
nce
abus
eor
poo
rco
mpl
ianc
ew
ith
med
ical
ca
re
wer
edo
cum
ente
din
22
%o
fin
vest
igat
edd
eath
s.
Inm
othe
rse
xper
ienc
ing
apo
st-n
eona
talde
ath
oft
heir
ba
byin
2002
-04,
40%
had
si
gnifi
cant
soc
ialpr
oble
ms.
10b
abie
sdi
ed
int
hep
ost-
neon
atal
per
iod
in2
002-
04d
uet
ono
n-ac
cide
ntal
in
juri
es.
Rec
omm
endat
ion 1
1:
Gro
up B
Str
epto
cocc
us
Guid
elin
es:
11.1
Gui
delin
esf
ors
cree
ning
for
Gro
upB
Str
epto
cocc
usa
t36
w
eeks
ges
tati
ono
fpr
egna
ncy,
and
int
rapa
rtum
ant
ibio
tic
trea
tmen
tfo
rca
rrie
rsa
rer
ecom
men
ded.
iii
11.2
Sta
ffs
houl
dbe
aw
are
ofg
uide
lines
to
redu
cet
her
isk
of
neon
atal
sep
sis.
iii
Rec
omm
endat
ion 1
2:
Neo
nat
al M
anag
emen
t is
sues
:The
new
lye
stab
lishe
dN
eona
talN
etw
ork
iss
uppo
rted
.
The
Neo
nata
lN
etw
ork
shou
ldb
ead
equa
tely
res
ourc
ed
and
supp
orte
dto
coo
rdin
ate
stat
ewid
ene
onat
alc
are
and
wor
kfor
ce.
12.1
Ab
aby
wit
hpo
orA
pgar
sco
res
(sus
pect
edb
irth
asp
hyxi
a)
shou
ldini
tial
lyb
em
anag
edin
ale
velII
orII
Ispe
cial
car
enu
rser
y,p
arti
cula
rly
bein
gaw
are
oft
hep
robl
ems
of
hypo
glyc
aem
iaa
ndm
etab
olic
aci
dosi
s.
12.2
Whe
ret
here
is
neon
atal
sho
ck(
e.g.
sep
sis,
bir
tht
raum
a/su
b-ga
leal
hae
mor
rhag
e),
staf
fsh
ould
be
awar
eof
the
ba
by’s
nee
dfo
rra
pid
intr
aven
ous
volu
me
repl
acem
ent.
12.3
Infa
nts
wit
hre
spir
ator
ydi
stre
sso
rot
her
sign
sof
sep
sis
shou
ldb
etr
eate
dpr
ompt
lyw
ith
anti
biot
ics.
Rec
omm
endat
ion 1
3:
Tra
nsp
ort
Issu
es:
13.1
Car
esh
ould
be
take
nto
del
iver
bab
ies
likel
yto
req
uire
sp
ecia
lnu
rser
yca
rein
ana
ppro
pria
tely
sta
ffed
and
eq
uipp
edh
ospi
tal.
13.2
Ref
erri
ngs
taff
are
enc
oura
ged
toa
ntic
ipat
etr
ansf
er,
phon
eea
rly,
and
clo
sely
lia
ise
wit
htr
ansp
ort
staf
f,t
oas
sist
in
prio
riti
sati
ono
ftr
ansp
ort
need
s.
12thReportofthePerinatalandInfantMortalityCommitteeofWesternAustralia,Deaths2002-04
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Fin
din
gs:
Key
Poin
ts:
Rec
omm
endat
ions:
Co-
slee
pin
g:33
une
xpec
ted
infa
ntd
eath
s(1
7.5%
of
the
189
inve
stig
ated
in
fant
dea
ths)
occ
urre
din
ass
ocia
tion
wit
hco
-sle
epin
g.
27o
fth
ese
deat
hso
ccur
red
inc
ombi
nati
onw
ith
sign
ifica
nt
soci
alp
robl
ems
orp
aren
talsu
bsta
nce
abus
e.
The
sed
eath
sal
loc
curr
edp
rior
to
5m
onth
sof
age
.T
wel
veo
fth
ede
aths
occ
urre
din
bab
ies
that
wer
epr
eter
mo
rle
sst
han
2.5
kgb
irth
wei
ght.
The
dea
ths
wer
ecl
assi
fied
byP
SAN
ZN
DC:
13o
fth
ese
deat
hs
wer
ecl
assi
fied
asS
IDS,
4d
uet
ose
psis
,2
due
toa
ccid
enta
las
phyx
iati
ona
nd1
4ot
her/
unde
term
ined
.
Hom
e bir
ths:
The
rew
ere
thre
ete
rmp
erin
atal
dea
ths
inp
lann
edh
ome
birt
hs
inW
Ain
2002
-04.
Dat
aw
asc
ombi
ned
for
the
year
s20
00-0
4to
allow
val
id
stat
isti
calan
alys
is.
The
rew
ere
six
peri
nata
lde
aths
in
the
846
plan
ned
hom
ebi
rths
in
2000
-04.
Fo
uro
fth
ese
six
case
sh
ad
prev
enta
ble
med
ical
fac
tors
.T
hep
erin
atal
mor
talit
yra
tein
this
gro
upw
as6
.7p
er1
,000
bir
ths,
com
pare
dw
ith
2.1
per
1,00
0bi
rths
in
term
del
iver
ies
that
wer
epl
anne
dho
spit
al
birt
hs,
whi
chw
asa
sta
tist
ical
lys
igni
fican
tdi
ffer
ence
.
Inve
stig
atio
ns
for
Cau
se o
f D
eath
:25
.8%o
fin
vest
igat
edd
eath
sha
din
suffi
cien
tpa
thol
ogy
inve
stig
atio
nsp
erfo
rmed
int
oth
eca
use
ofd
eath
.T
his
repr
esen
ted
asi
gnifi
cant
im
prov
emen
tsi
nce
2000
-01
whe
nov
er
half
the
dea
ths
inve
stig
ated
by
the
Com
mit
tee
had
insu
ffici
ent
path
olog
yte
sts
perf
orm
ed.
Co-
slee
ping
was
ass
ocia
ted
wit
h17
.5%o
fsu
dden
un
expe
cted
inf
ant
deat
hsin
2002
-04.
The
rew
asa
thr
ee-f
old
incr
ease
dpe
rina
tal
mor
talit
yra
tein
plan
ned
hom
ebi
rths
in
WAin
the
year
s20
00-0
4.
Sign
ifica
ntly
mor
epa
thol
ogy
inve
stig
atio
nsw
ere
perf
orm
edt
oas
sess
cau
se
ofd
eath
in
the
inve
stig
ated
de
aths
in
2002
-04
com
pare
dw
ith
2000
-01
Rec
omm
endat
ion 1
4:
Dat
a co
llec
tion
:Col
lect
ion
ofa
ddit
iona
lin
form
atio
non
mid
wif
ery
noti
ficat
ion
form
sis
rec
omm
ende
d.Q
uest
ions
abo
utn
umbe
rof
ant
enat
al
visi
ts,
mat
erna
lw
eigh
tan
dal
coho
lus
ear
esu
gges
ted.
Rec
omm
endat
ion 1
5:
Sudden
Infa
nt
Dea
th S
yndro
me:
Incr
easi
ngp
ublic
kno
wle
dge
abou
tw
ays
tor
educ
eSI
DS
is
advi
sed.
Spe
cial
att
enti
ons
houl
dbe
giv
ent
ode
liver
ing
info
rmat
ion
tof
amili
esw
ith
risk
fac
tors
,an
din
stit
utio
nst
hat
prov
ide
infa
ntc
are.
Ina
ddit
ion
tot
hec
urre
nte
duca
tion
abo
ut
safe
rsl
eepi
ngp
ract
ices
,th
ere
shou
ldb
em
essa
ges
abou
tth
ein
crea
sed
risk
of
infa
ntd
eath
rel
ated
to:
g
co-s
leep
ing
int
hep
rese
nce
ofp
aren
talsm
okin
g/al
coho
l/dr
ugu
se,
and
ins
mal
lba
bies
esp
ecia
lly
unde
rth
eag
eof
4
mon
ths.
g
co-s
leep
ing
ona
cou
ch
Pare
nts
shou
ldb
ead
vise
dth
att
here
is
ade
crea
sed
risk
of
SID
Sw
here
par
ents
roo
m-s
hare
wit
hth
eir
baby
in
ase
para
tec
otf
or
the
first
few
mon
ths
oflif
e,c
ompa
red
wit
hth
eba
bys
leep
ing
in
ase
para
ter
oom
to
its
pare
nts.
Rec
omm
endat
ion 1
6:
H
ome
bir
ths:
Ar
evie
wo
fho
me
birt
hsin
WAis
reco
mm
ende
dto
ass
ess
esse
ntia
lhe
alth
out
com
es,
incl
udin
gm
orbi
dity
and
mor
talit
y.
Rec
omm
endat
ion 1
7:
C
ause
of
Dea
th:
Tho
roug
hin
vest
igat
ion
toa
sses
sca
use
and
cont
ribu
ting
fac
tors
in
sti
llbi
rths
and
inf
ant
deat
hsis
reco
mm
ende
d,w
ith
refe
renc
eto
inv
esti
gati
ons
reco
mm
ende
din
App
endi
xII.
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i Notethatthecriteriaforinvestigationschanged.In2000-01thecriteriafordeathsrequiringinvestigationwerestillbirthsandneonataldeathsgreaterthan32weeksgestationwiththeexceptionofthoseknowntobecausedbylethalmalformationsorspecificinjuries,post-neonataldeathsduetoinfection,andotherdeathsatthediscretionoftheEDPH.In2002-04thecriteriafordeathsrequiringinvestigationweredeathsof26weeksorgreatergestationalage.
ii Outreachservices,suchasincreasingspecialistvisitstoruralareas/increasinguseofteleconferencing/assistingpatientswithtransportandaccommodationissuestoenableeasieraccesstoregionalandmetropolitanspecialistservices.
iii KingEdwardMemorialHospitalguidelinesforobstetrics:http://kemh.health.wa.gov.au/development/manuals/sectionb/index.htm
KingEdwardMemorialHospitalguidelinesforneonatology:http://kemh.health.wa.gov.au/services/nccu/guidelines/
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2Committeemembers
Permanentmembers
ProfessorJohnNewnham Chair;ProfessorObstetrics&Gynaecology,
TheUniversityofWesternAustralia(October2001–present)
ProfessorKarenSimmer DeputyChair;NeonatalPaediatrician(October2001–present)
ProfessorCarolBower Epidemiologist(October2001–present)
DrNoelFrench NeonatalPaediatrician(October2001–present)
DrMarySharp NeonatalPaediatrician(April2006–present)
DrJenniferSokol NeonatalPaediatrician(October2001–March2006)
DrAndrewWawryk Paediatrician(October2001–present)
Vacancy AustralianMedicalAssociationRepresentative
Provisionalmembers
A/ProfessorJanDickinson MaternalFetalMedicineSpecialist(October2001–April2007)
DrAnnabelleShannon GeneralPractitioner-Obstetrician(October2004–present)
DrJaneTalbot GeneralPractitioner-Obstetrician(August2004–April2007)
MsJulieWatson ClinicalMidwife(October2001–October2004)
MsRayeMcNally ClinicalMidwife(October2004–present)
Co-optedmembers
DrLindsayAdams NeonatalPaediatrician(May2005–present)
DrAdrianCharles PerinatalPathologist(October2001–present)
DrDonaldClarke Obstetrician(March2003–present)
DrEverett(Pat)Magann Obstetrician(October2001–March2003)
Medicalinvestigators
DrCatherineDouglass(Buccilli) GeneralPractitioner(October2001–present)
DrAntoniaLobo-Braganza Obstetrician(October2001–July2003)
DrPatrickPemberton NeonatalPaediatrician(October2001–present)
DrEricaShellabear Obstetrician(August2003–June2006)
Special thanks to:VivienGee,Coordinator,Maternal&ChildHealthUnit
ElizabethNathan,Biostatistician,WomensandInfantsResearchFoundation,forassistanceinstatisticalanalysis.
DrAntoniaShand,DrMichaelPaechandDrJanetHornbuckleforcontributingeducationalpapersforthisreport.
BrigitteGlocknerandteam,KingEdwardMemorialHospitalLibrary
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3Methods
3.1 The Role of the PIMCThePIMCexistsasastatutoryrequirementoftheHealth Act 19111,underthedirectionoftheEDPH.ThemembershipoftheCommitteecomprisesapanelofexperts,asprescribedbytheHealth Act 1911,withtheChairbeingtheProfessorofObstetricsatTheUniversityofWesternAustralia.TheEDPHappointsinvestigatorstoenquireintodeathsandtopresentde-identifiedcasesummariestotheCommitteeatmonthlymeetings.Approximatelytwentycasesummariesarepresentedateachmeeting.Thecircumstancesofeachcaseareconsideredandconstructivewrittenfeedbackisprovidedexclusivelytothemedicalpractitionerswhoprovidedclinicalcare.Eachcaseisassessedforcauseofdeath,possiblepreventablefactorsandotherissuesofpublichealthsignificance.TheCommitteeexaminescumulativedataobtainedfromanalysisofdeaths,alongwithbroaderstatewideperinataldata,toproposerecommendationsaimedatreducingperinatalandinfantmortalityrates.
TheCommittee’sroleiseducational,providingconfidentialwrittenfeedbacktopractitionersinvolvedinindividualcases,andtothemedicalprofessionandwidercommunitythroughpublishingreportssuchasthisfromtimetotime.
3.2 Reporting of Births and DeathsItisarequirementoftheHealth Act 19111thatstillbirthsandinfantdeathsarenotifieddirectlytotheEDPHbyattendingmedicalpractitioners.InformationisalsomadeavailabletotheEDPHfrommidwiferynotificationformsandtheRegistrarGeneral’sOffice(deathcertificates).TheEPDHdirectsanappropriatelyqualifiedmedicalinvestigatortoreviewthemedicalnotespertainingtoadeath.NationalPrivacyPrinciplesallowexemptionforthedisclosureofinformationwhenthedisclosureisrequiredorauthorisedby,orunderthelaw.7Thus,medicalnotespertainingtoadeathmustbereleasedtotheappointedinvestigatorwhenrequestedbytheEDPH.
Midwivesarerequiredtoreportallbirths(includingstillbirths)inWAtotheDepartmentofHealthviathe‘NotificationsbyMidwivesRegulations’1994.8Toensurecompletenessofrecords,notificationsarecross-referencedwithrecordsfromtheDepartmentofJusticeRegistryofBirth,DeathsandMarriages.Statisticsregardingalllivebirths,stillbirthsandinfantdeathsareregularlypublishedbytheHealthInformationCentre(HIC).2
Thedefinitionusedforstillbirthis‘afetusthatdoesnothaveaheartbeatoranysignoflife,whichis20weeksormoreingestationor400gormoreinbirthweight.’OtherdefinitionsaredescribedinAppendixI.
3.3 Designation of Cases for Investigation by the PIMC in 2002-04Ofthereporteddeaths,theEDPHdesignatesthosedeathstobefurtherinvestigated.
TheEDPHsetthecriterionfortheinvestigationofdeathsin2002-04as:
‘Allstillbirthsanddeathsofinfantsof26weeksorgreatergestationalage.’
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Bycontrast,fortheyears2000-01thecriteriafordeathsrequiringinvestigationwerestillbirthsandneonataldeathsgreaterthan32weeksgestationwiththeexceptionofthoseknowntobecausedbylethalmalformationsorspecificinjuries,post-neonataldeathsduetoinfection,andotherdeathsatthediscretionoftheEDPH.
Legalopinionregardingtherequirementforinvestigationofdeathsduetopregnancyterminationwassoughtin2004.ItwasdeemedthatitisnottheroleofthePIMCtoinvestigatetherapeuticpost-20weeksgestationpregnancyterminationsthatfallwithinthecriterionforinvestigation,asthereisastatutoryMinisterialpanelthatapprovessuchlateterminationsintheStateofWesternAustralia.9,10
3.4 Case Investigation MethodsForthosecasesthatmetthecriterionforinvestigation,lettersweresenttothenotifyingmedicalpractitionerstoexplaintheinvestigationprocessandtoobtainmedicalnotesregardingcases.Thenoteswereconveyedtotheinvestigatorswhocontactedanyotherrelevanthealthprovidersandhospitalsforfurtherinformation.Fromtheavailablenotes,casesummarieswerepreparedusingastandardelectronicformat.
AtthemonthlyPIMCmeetings,caseswerediscussedandclassifiedfor:
1.aetiologyofdeath,usingPSANZdeathclassifications
2.preventabilityscore
3.anymaternalfactorsthatmayhavecontributedtopooroutcome
4.thoroughnessofinvestigativework-upintothecauseofdeath
5.earlypreventionissues
AnelectronicdatasetfromcaseinvestigationswascreatedandusedtoproducestatisticsforthisReport.ThereweresomedifferencesbetweenthisdatasetandHICdatathatwasobtainedfromMidwiferyNotificationForms.
3.5 Cause of Death ClassificationInanalysisofdeathsfromtheyear2000onwards,theCommitteeappliedthe‘PerinatalSocietyofAustraliaandNewZealandPerinatalDeathClassification’(PSANZPDC)andthe‘PerinatalSocietyofAustraliaandNewZealandNeonatalDeathClassification’(PSANZNDC).11Whilstitwasdesignedforcodingneonataldeaths,theCommitteehasfoundthePSANZNDCusefultodescribepost-neonataldeathsaswell.InvestigatedcaseswereclassifiedatmonthlyPIMCmeetings.
3.6 Preventability ScaleInanalysisofdeathsfromtheyear2000onwards,theCommitteeuseda‘PreventabilityScale’toclassifydeathswithpossiblepreventablefactors(Table1).Thisscaleisusedtoassessaspectsofmedicalandnursingcare.Itdoesnotreflectaspectsofpatientlifestylethatmaycontributetopooroutcome.
Thepreventabilityofanadverseeventisdefinedas‘anerrorinmanagementduetofailuretofollowacceptedpracticeatanindividualorsystemlevel’andacceptedpracticeistakentobe‘thecurrentlevelofexpectedperformancefortheaveragepractitionerorsystemthatmanagesthepatient.’12
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Preventabilityscores‘2’and‘3’reflect‘lowlevels’ofpreventablemedicalfactorsindeathsthatareconsideredunavoidableinamedicalcontext.Preventabilityscoresgreaterthanorequalto‘4’codeforhigherlevelsofmedicalpreventabilityandareusedtocodepotentiallyavoidabledeaths.
Table 1: Preventability Scale
No preventability 1=virtuallynoevidenceforpreventability
Low preventability 2=Slight-to-modestevidenceforpreventability
3=Preventabilitynotlikely,lessthan50-50butclosecall
High preventability 4=Preventabilitymorelikelythannot,morethan50-50butclosecall
5=Strongevidenceforpreventability
6=Virtuallycertainevidenceforpreventability
Inthosecaseswherethepreventabilityscorewasgreaterthanorequalto‘2’,thepreventablefactorswerecodedfurther(seeTable2):
Table 2: Preventable Medical Factors
Systems factors: SignificantdelayinassessmentortreatmentDelayintransfertootherunitStaffingproblemEquipmentproblemFollow-upofabnormaltestresultSignificantdelayinperformanceofclinicalinvestigationCo-sleepingofmotherandbabyinhospital
Medical Care factors: Managementofantenatalproblems(otherthanobstetricdeliveryskills)Medicalcareofbaby(otherthanresuscitationofthenewborn)Identificationofabnormalfetalheartratepatternsoncardiotocographic(CTG)traceFetalheartratemonitoringnotperformedwhenindicatedTechnicalskillsforobstetricdelivery Technicalskillsforresuscitationofnewborn Earlierreferralindicated IntrapartummanagementdecisionsPostnataldepressionnotidentified
3.7 Maternal Behavioural FactorsTheCommitteenoteddocumentedmaternalorotherfamilybehaviourthatmayhavecontributedtopooroutcome.Maternalsmokingstatuswasconsidered.Inaddition,otherfamilylifestylefactorsthatmayhavecontributedtodeathswerecodedas‘MaternalBehaviouralFactors’(Table3).
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3.8 Adequacy of Investigation into Cause of DeathAninvestigatorreviewedthepathologytestsperformedforinvestigatedcasesandgradedthemwithreferencetoguidelinesforpathologyteststoassesscauseofstillbirthsandinfantdeaths(AppendixII,Section7.2)andconsiderationofthecircumstancesofeachcase(Table4).
Table 4: Investigations to Assess Cause of Death
1=adequateinvestigationsperformedtoinvestigatethecauseofdeath
2=someinvestigationsperformed,butabsenceofrelevantpathologytests(partially investigated)
3=few/noinvestigationstoinvestigatethecauseofdeath
Placentalhistopathologywasgenerallyconsiderednecessarytoadequatelyinvestigatethecauseofstillbirths,withexceptionssuchasprenatallydiagnosedtrisomy13.Whilstideallythoroughpost-mortemexaminationisperformed,thisisfrequentlynotdone,inaccordancewithparentalwishes,andwasnotconsideredessentialtobescoredas‘adequatelyinvestigated’inthiscontext.Intheassessmentofcauseofstillbirth,guidelines(AppendixII)alsorecommendamniocentesisandmaternaltoxicologytests,butthesearestillinfrequentlyperformed,andwerenotconsideredessentialtocodeas‘adequatelyinvestigated’inthistriennium.
Forinfantdeaths,eachcasewasconsideredonitsownmerits,accordingtothepriorclinicalhistoryandinvestigationsperformed.
3.9 Autopsy UtilityBenefitsofautopsyexaminationwereconsideredintheinvestigatedcasesthatunderwentexamination,andcodedaccordingtoan‘autopsyutilityscale’13(Table5):
Table 3: Maternal Behavioural Factors
Poorcompliancewithrecommendedmedicalcare
Domesticviolence
Otherserioussocialproblem(s)
Seriousmaternalpsychiatricdisorder,otherthansubstanceuse
Non-accidentalinjury(NAI)
Alcoholabuse
Marijuanause
Illicitintravenousdruguse/other‘harddrugs’use
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Table 5: Autopsy Utility: Categories of Concordance of Clinical and Pathological Diagnoses
1 = confirm Theclinicalandpathologicdiagnoseswereidenticalorsimilarenoughastonotalterfuturecounsellingorrecurrencerisk.
2 = change Theclinicalandpathologicdiagnosesdifferedenoughtoalterfuturecounsellingandtherecurrencerisk,suggestingtheautopsyprovidedclinicallyrelevantinformation.
3 = add Theclinicaldiagnosiswasnotalteredbutadditionalunexpectedfindingssuchasanomaliesthatrequiredcounsellingwerenotedontheperinatalautopsy,thusprovidingclinicallyrelevantinformation.
4 = inconclusive Theperinatalautopsydemonstratedneitheranobviouscauseofdeathnorsignificantcongenitalmalformations.
3.10 Early Prevention FactorsTheCommitteeconsideredcaseswhere‘earlyprevention’orearlyterminationofpregnancymayhavepreventeddeathaftertwentyweeksgestation.Caseswerecodedfor‘earlyprevention’factorswhereprenatalscreeningforfetalanomalyhadnotbeenperformedortherehadbeensomeotherproblemwithprenatalscreening.
Deathsthatoccurredinpregnanciesconceivedwithassistedfertilitytechniqueswerealsorecorded.
3.11 Statistical Methods Frequencydistributionswereusedtosummarisecategoricaldata.Mortalityratesandrelativeriskratioswiththeir95%confidenceintervalswereusedtocomparemortalitybysubgroupsofdata.Mantel-Haenszel,Chi-squaretestsandtrendanalysiswereusedtotestforgroupdifferences.Allhypothesistestsweretwosidedandp-values<0.05wereconsideredstatisticallysignificant.SPSS15.0(SPSSInc,ChicagoIL)andStatExact5.0(CytelSoftwareCorporation,Cambridge,MA)statisticalsoftwarewereusedfordataanalysis.
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4Results
TofacilitategreaterunderstandingofthebroaderpictureofperinatalandinfantmortalityinWA,statewidedata2arepresentedherepriortodetailingtheselectedpopulationofcasesinvestigatedbytheCommittee.
4.1 Statewide Data, WA 2002-04
4.1.1 Perinatal and Infant Mortality Rates by Birth Weight, Gestational Age and Race, WA 2002-04
Statisticsforlivebirths,stillbirthsandinfantdeathsbybirthweightsandgestationalageareshownforthecohort2002-04inTables6and7.2
Stillbirthratesarequotedper1,000totalbirthsandneonataldeathsarequotedper1,000livebirths.Stillbirthsandneonataldeathscombinedarequotedasaperinatalmortalityrate,per1,000totalbirths.Inasimilarmanner,neonatalandpost-neonataldeathfiguresarecombinedtogivetheinfantmortalityrate,whichisquotedper1,000livebirths.
Notethatratespublishedhere,assuppliedbytheHealthInformationCentre(HIC)oftheWADepartmentofHealth2arehigherthanpublishedAustralianBureauofStatistics(ABS)rates5,6fromtheRegistrarGeneralOfficesineachstateandterritory.TheseHIC-WAdataareproducedannuallyandareprovidedtotheNationalPerinatalStatisticsUnitoftheAustralianInstituteofHealthandWelfare(AIHW).14ThesedataaremorecomprehensivethanABSdata,asinadditiontonotificationsfromtheRegistrarGeneral’sOffice,theycombineinformationfrommidwiferynotificationforms,notificationsmadetotheEDPH,andtheCoroner’soffice.
Inthethree-yearperiodtherewere74,449livebirths,546stillbirths,166neonataldeathsand94post-neonataldeaths.Combiningneonatalandpost-neonataldeaths,thetotalnumberofinfantdeathswas260.
TheCommitteewasdirectedtoinvestigate256stillbirthsand98neonataland91post-neonataldeaths,makingatotalof445investigateddeaths.
Table 6: Birth & Death Statistics by Birthweight, WA 2002-04
Infant Weight(grams)
Total Births
Livebirths Stillbirths Neonatal Deaths Perinatal Deaths† Post-neonatal Deaths Infant Deaths‡
N N N Rate N Rate N Rate N Rate N Rate
<500
500-999
1000-1499
1500-1999
2000-2499
2500-2999
3000-3499
3500-3999
4000-4499
>=4500
277
366
464
999
3094
11698
27533
22436
6966
1162
42
262
423
967
3069
11654
27501
22414
6959
1158
235
104
41
32
25
44
32
22
7
4
848.4
284.2
88.4
32.0
8.1
3.8
1.2
1.0
1.0
3.4
37
46
15
11
10
14
21
5
5
2
881.0
175.6
35.5
11.4
3.3
1.2
0.8
0.2
0.7
1.7
272
150
56
43
35
58
53
27
12
6
981.9
409.8
120.7
43.0
11.3
5.0
1.9
1.2
1.7
5.2
0
8
3
4
14
23
22
16
4
0
0.0
30.5
7.1
4.1
4.6
2.0
0.8
0.7
0.6
0.0
37
54
18
15
24
37
43
21
9
2
881.0
206.1
42.6
15.5
7.8
3.2
1.6
0.9
1.3
1.7
Total 74995 74449 546 7.3 166 2.2 712 9.5 94 1.3 260 3.5
Numberofstillbirths+neonataldeathsinthecohort
Numberofstillbirths+livebirthsinthecohort
Numberofneonataldeaths+post-neonataldeathsinthecohort
Numberoflivebirthsinthecohort
†PerinatalMortalityRate(PMR)=
‡InfantMortalityRate(IMR)=
x1000
x1000
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Thestillbirthratewas7.3per1,000births(forbirthweight>=400gand/orover20weeksgestation),being7.4per1,000birthsformalesand7.2per1,000birthsforfemales.
Theneonatalmortalityratewas2.2per1,000livebirths.
Theperinatalmortalityratewas9.5per1,000births(forbirthweight>=400gand/orover20weeksgestation).
Thepost-neonatalmortalityratewas1.3per1,000livebirths.
Theinfantmortalityratewas3.5per1,000livebirths,being3.9per1,000livebirthsformalesand3.0per1,000livebirthsforfemales.
Comparedtotheyears2000-01,stillbirthrateswerevirtuallystatic,being7.4in2000-01and7.3per1,000birthsin2002-04,theperinatalmortalityratereducedfrom10.2to9.5per1,000totalbirths,theneonatalmortalityratereducedfrom2.8to2.2per1,000livebirthsandtheinfantmortalityratereducedfrom4.5to3.5per1,000livebirthsoverthetwotimeperiods.
Therewere3.1%oflivebirths(n=2,345)and9.2%ofstillbirths(n=50)frommultiplepregnancies.
Thepreterm(<37wks)birthratewas8.4%,havingincreasedfrom8.2%intheyears2000-01.
Pretermdeliveries(<37wks)accountedfor80.2%(n=438)ofstillbirthsand71.1%(n=118)ofneonataldeaths.
Verylowbirthweightbabies(<1,000g)accountedfor62%(n=339)ofthestillbirthsand35%(n=91)oftheinfantdeaths.
Therewere11.3%ofAboriginalbabiesoflowbirthweight(<2,500g),comparedwith5.1%ofnon-Aboriginalbabies,and3.5%ofAboriginalbabieswereverylowbirthweight(<1,500g),comparedwith1.3%ofnon-Aboriginalbabies.
Theperinatalmortalityrateforinfants>=1,500gbirthweightwas3.2per1,000births,andthatforinfants>=2,500gwas2.2per1,000births.
Therewere100post-20weeksgestationpregnancyterminationsinthetriennium2002-04.15
Table 7: Birth & Death Statistics by Gestational Age, WA 2002-04Gestational
Age (weeks)
Total Births
Livebirths Stillbirths Neonatal Deaths Perinatal Deaths Post-neonatal Deaths Infant Deaths
N N N Rate N Rate N Rate N Rate N Rate
20-27
28-32
33-36
37-43
<37
613
933
4744
68705
6290
300
861
4691
68597
5852
313
72
53
108
438
510.6
77.2
11.2
1.6
69.6
80
21
17
48
118
266.7
24.4
3.6
0.7
20.2
393
93
70
156
556
641.1
99.7
14.8
2.3
88.4
8
5
15
66
28
26.7
5.8
3.2
1.0
4.8
88
26
32
114
146
293.3
30.2
6.8
1.7
24.9
Table 8: Births & Deaths by Race, WA 2002-04Ethnicity Total
BirthsLivebirths
N
Stillbirths Neonatal Deaths Post-neonatal DeathsPMR p-value IMR p-value
N Rate N Rate N Rate
Caucasian
Aboriginal
Asian/Indian
Other
62920
4796
4390
2889
62510
4727
4365
2847
410
69
25
42
6.5
14.4
5.7
14.5
115
35
6
10
1.8
7.4
1.4
3.5
62
25
1
6
1.0
5.3
0.2
2.1
8.3
21.7
7.1
18.0
<0.001
0.381
<0.001
2.8
12.7
1.6
5.6
<0.001
0.140
0.009
Note:p-valuesrepresentdifferencesinmortalityratesbetweentheCaucasiangroupandeachethnicgroup(statisticallysignficantdifferencep<0.05)
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Ofthetotalbirths,83.9%ofmotherswereCaucasian,6.4%wereAboriginali,5.8%wereAsianand3.9%wereof‘other’racialdescent.TheperinatalandinfantmortalityratesinAsianbabieswerelowerthanforCaucasianbabies,butthedifferenceswerenotstatisticallysignificant.ThereweresignificantlyhigherperinatalandinfantmortalityratesinbabiesborntomothersidentifiedasAboriginaland‘other’racialdescent(Table8).
Themedianbirthweightforallstillbornbabiesbyracewas:Caucasian585g;Aboriginal690g;Asian700g;and‘other’510g.
Themedianbirthweightforallbabiesthatdied(combinedstillbirthsandinfantdeaths)byracewas:Caucasian895g;Aboriginal960g;Asian582g;and‘other’582g.
Comparedwithnon-Aboriginalmothers,thestillbirthratewasdoubleinAboriginalmothers(14.4versus6.8per1,000births),theneonataldeathratealmostfour-foldhigher(7.4versus1.9per1,000livebirths),andthepost-neonatalratefive-foldhigher(5.3versus1.0per1,000livebirths)(Figure2).
Fig 1: Number of Stillbirths, Perinatal, Neonatal, Post-neonatal and Infant Deaths by Aboriginality, WA 2002-04
Fig 2: Rates for Stillbirths, Perinatal, Neonatal, Post-neonatal and Infant Mortality by Aboriginality, WA 2002-04
iAboriginalisdefinedhereasbeingofAboriginalorTorresStraitIslander(TSI)racialdescent.
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4.1.2 Perinatal Deaths by Cause of Death and Aboriginality, WA 2002-04
StillbirthswereclassifiedaccordingtoPSANZPDCalone.Neonataldeathswereclassifiedintwoways,usingPSANZPDCandPSANZNDC.ThePSANZPDCclassificationsystemfocusesonpregnancyrelatedprecedentstoneonataldeaths,anddifferstothePSANZNDCthatdescribesneonataldeathsaccordingtothepathologyintheneonatethatledtodeath.
Tables9aand9bdescribestillbirthsandneonataldeathsby‘pregnancyrelated’causesofdeath,usingPSANZPDC,andTable9candFig3showperinataldeathsbyPSANZPDCandAboriginality.
AppendicesIIIandIV(Sections7.3and7.4)providefurtherdetailsofnumbersofcasesineachofthesub-categoriesofPSANZPDCandPSANZNDCfor2002-04.
Table 9b: Number of Neonatal Deaths by Cause of Death (PSANZ PDC), WA 2002-04 PSANZPDC N %
1.CongenitalAbnormality2.PerinatalInfection3.Hypertension4.AntepartumHaemorrhage5.2.Diabetes5.15.3-5.8.MaternalConditions6.1.Twin-twin6.2.FetomaternalHaemorrhage6.3.CordAbnormality6.4.UterineAbnormality6.5.BirthTrauma6.6.Trauma6.7.Hydrops6.8.OtherSpecificPerinatalConditions7.HypoxicPeripartumDeath8.FetalGrowthRestriction9.SpontaneousPreterm11.NoObstetricAntecedent
3812160151031001
155
6710
22.97.20.63.60.00.63.00.60.01.80.60.00.00.69.03.0
40.46.0
Total 166 100.0
Table 9a: Number of Stillbirths, by Cause of Death (PSANZ PDC), WA 2002-04 PSANZPDC N %
1.CongenitalAbnormality2.PerinatalInfection3.Hypertension4.AntepartumHaemorrhage5.2.Diabetes5.15.3-5.8.MaternalConditions6.1.Twin-twin6.2.FetomaternalHaemorrhage6.3.CordAbnormality6.4.UterineAbnormality6.5.BirthTrauma6.6.Trauma6.7.Hydrops6.8.OtherSpecificPerinatalConditions7.HypoxicPeripartumDeath8.FetalGrowthRestriction9.SpontaneousPreterm10.UnexplainedAntepartumDeath11.NoObstetricAntecedent
145233840155
189330333
163785
1000
26.64.27.07.32.70.93.31.60.50.50.00.50.50.52.96.8
15.618.30.0
Total 546 100.0
Themostcommoncategoriesofstillbirthwerecongenitalabnormalities(n=145;26.6%),unexplainedantepartumdeaths(n=100;18.3%)andprematurityduetospontaneouspretermdelivery(n=85;15.6%).Thecorrespondingproportionsintheperiod2000-2001werecongenitalabnormalities(26%),unexplained(22%)andspontaneouspretermbirth(11%).
TheleadingcausesofneonataldeathbythePSANZPDCwereprematurityduetospontaneouspretermbirth(n=67;40.4%),congenitalabnormality(n=38;22.9%)andperinatalinfection(n=12;7.2%).In2000-01,theproportionswereprematurity(37%),congenitalabnormality(28%)andperinatalinfection(11%).
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Table 9c: Number and Rate of Perinatal deaths by Cause of Death (PSANZ PDC) and Aboriginality, WA 2002-04
PSANZ-PDC
Aboriginality of MotherTotal
p-valuenon-Aboriginal Aboriginal
N Rate N Rate N Rate
1.CongenitalAbnormality2.PerinatalInfection3.Hypertension4.AntepartumHaemorrhage5.MaternalConditions6. SpecificPerinatalConditions7. HypoxicPeripartumDeath8.FetalGrowthRestriction9. SpontaneousPreterm10.UnexplainedAntepartumDeath11.NoObstetricAntecedent
17128314212502636
112946
2.40.40.40.60.20.70.40.51.61.30.1
127849356
4064
2.51.51.70.81.90.61.01.38.31.30.8
18335394621533142
15210010
2.40.50.50.60.30.70.40.62.01.30.1
0.9280.002
<0.0010.525
<0.0010.8270.0340.043
<0.0010.872
<0.001
Total 608 8.7 104 21.7 712 9.5 <0.001
†Perinataldeathscomprisestillbirthsplusneonataldeaths
Fig 3: Perinatal Mortality Rates by Cause of Death (PSANZ PDC) and Aboriginality, WA 2002-04
Theleadingcausesofperinataldeathwerecongenitalabnormality(n=183;25.7%)andprematurityduetospontaneouspretermbirth(n=152;21.3%).
Themostcommoncongenitalabnormalitieswerechromosomal(n=41),centralnervoussystem(n=38)andcardiovascular(n=33).
Perinatalinfectionwastheprimarycauseofdeathinasmallproportionofcases(n=35;4.9%).InfectionsincludedGroupBStreptococcalinfection(n=9),Ecoli(n=1),Listeriamonocytogenes(n=1),syphilis(n=1),“other”bacterialsepsis(n=10),viralinfection(n=9)[cytomegalovirus(n=4),parvovirus(n=1),herpessimplexvirus(n=2),rubella(n=1)andunspecifiedvirus(n=1)],toxoplasmosis(n=1)andunspecifiedorganism(n=3).
ThereweresignificantlyhigherperinatalmortalityratesinAboriginalbirthscomparedwithnon-Aboriginalbirths.IntheAboriginalgrouptherewerearoundten-foldincreasedrisksofperinataldeathduetomaternalconditionsincludingdiabetesmellitus(RR11.00;95%CI4.63-26.11)andofdeathswithoutanobstetricantecedent(RR9.77;95%CI2.76-34.62),five-foldincreasedriskofperinataldeathduetoprematurity(RR5.26;95%CI3.66-7.56)andtwotothree-foldincreasedrisksduetoinfection(RR3.66;95%CI1.60-8.39),hypertension(RR3.78;95%CI1.74-8.23),hypoxicperipartuminsult(RR2.82;95%CI1.08-7.34)andfetalgrowthrestriction(RR2.44;95%CI1.03-5.80).
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4.1.3 Infant deaths by Cause of Death and Aboriginality, WA 2002-04
Thissectiondescribesneonataldeathsandpost-neonataldeathsaccordingtothePSANZNDC.Aspreviouslydescribed,thePSANZPDCclassificationsystemfocusesonpregnancyrelatedprecedentstoneonataldeaths,anddifferstothePSANZNDCthatdescribesneonataldeathsaccordingtothepathologyintheneonatethatledtodeath.
ThePSANZNDCwasoriginallydesignedtodescribeneonataldeaths,buthasbeenadoptedbytheCommitteetodescribepost-neonataldeathsaswell,alsousingthedualclassificationsystems(PSANZPDCandPSANZNDC)forcomparativepurposes.
Tables10aand10bdescribeneonatalandpost-neonataldeathsbycauseofdeath,usingPSANZNDC,andTable10candFig4showcombinedinfantdeathsbyPSANZNDCandAboriginality.SeeAppendicesIIIandIV(Section7.3and7.4)fordetailsofthenumbersineachofthesub-categoriesofPSANZNDCfor2002-04.
Table 10a: Number of Neonatal Deaths, by Cause of Death (PSANZ NDC), WA 2002-04 PSANZNDC N %
1.CongenitalAbnormality2.ExtremePrematurity3.Cardio-RespiratoryDisorder4.Infection5.Neurological6.GastrointestinalTract7.1.SIDS7.2-7.9.Other
374226182451
13
22.325.315.710.814.53.00.67.8
Total 166 100.0
Table 10b: Number of Post-neonatal deaths by Cause of Death (PSANZ NDC), WA 2002-04PSANZNDC N %
1.CongenitalAbnormality2.ExtremePrematurity3.Cardio-RespiratoryDisorder4.Infection5.Neurological6.GastrointestinalTract7.1.SIDS7.2-7.9.Other
2233
1611
2226
23.43.23.2
17.01.11.1
23.427.7
Total 94 100.0
Theleadingcausesofneonataldeathsbytheneonatalclassificationsystem(PSANZNDC)inthetriennium2002-04wereprematurity(n=42;25.3%comparedwith30%in2000-01),congenitalabnormalities(n=37;22.3%,comparedwith26%in2000-01),cardiorespiratorydisorders(n=26;15.7%comparedwith13%in2000-01)andneurologicaldisorders(n=24;14.5%,comparedwith13%in2000-01)(Table10a).
Withtheexceptionofcongenitalabnormalities,whichcontributedtojustunderonequarterofdeathsinbothagegroups,theleadingcausesofpost-neonataldeathswerequitedifferenttothoseintheneonatalperiod(Table10b).Theleadingcategorywasthemixedgroupof“other”(n=26;27.7%)whichincludesaccidentalasphyxiaandinjuries,followedbySIDSandcongenitalabnormalities(bothcategoriesn=22;23.4%).Forcomparison,in2000-01thefigureswereSIDS31%,congenitalabnormalities19%and“other”21%.
Therewere34(13.1%)infantdeathsduetoinfection,theinvolvedorganismsbeingbacterial(n=28),viral(n=3),fungal(n=1)and‘other/unspecified’(n=2).
Table10candFigure4showthatthereweresignificantlyhigherinfantmortalityratesduetoprematurity(RR7.4;95%CI3.98-13.75),infection(RR6.16;95%CI2.94-12.88),SIDS(RR9.50;95%CI4.11-21.95),and‘undetermined/othercauses’(RR6.57;95%CI3.33-12.98),inAboriginalinfantsthaninnon-Aboriginalinfants.ThegreatestdisparityinriskwasforSIDS.
Thefindingsin2000-01weresimilar,withAboriginalinfantshavingsignificantlyincreasedrisksofdeathduetoinfection,extremeprematurityandSIDS/othercomparedwithnon-Aboriginalinfants.Therewasalsoasignificantlyincreasedriskofinfantdeathduetocongenitalabnormalitiesin2000-2001,whereasin2002-04theincreasedriskinthiscategorydidnotreachstatisticalsignificance.
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Table 10c: Number and Rate of Infant deaths by Cause of Death (PSANZ NDC) and Aboriginality, WA 2002-04
PSANZ NDC
Aboriginality of MotherTotal
p-valuenon-Aboriginal Aboriginal
N Rate N Rate N Rate
1.CongenitalAbnormality2.ExtremePrematurity3.Cardio-RespiratoryDisorder4.Infection5.Neurological6.GastrointestinalTract7.1SIDS7.2-7.9Other
52302524226
1427
0.70.40.40.30.30.10.20.4
7154
10309
12
1.53.20.82.10.60.01.92.5
59452934256
2339
0.80.60.40.50.30.10.30.5
0.088<0.001
0.111<0.001
0.256*
<0.001<0.001
Total 200 2.9 60 12.7 260 3.5 <0.001
*statisticsnotcomputed(noAboriginalcasesinthiscategory)
Fig 4: Infant Mortality Rates by Cause of Death (PSANZ NDC) and Aboriginality, WA 2002-04
4.1.4 Stillbirths and Infant Deaths by Maternal Smoking Status, WA 2002-04
Smokingstatuswasrecordedonallmidwiferynotificationforms(100%datacollection)inthetriennium2002-04,comparedwith99%intheyears2000-01.Inthetimeperiod2002-04,18.7%ofmothers(16.7%ofnon-Aboriginalwomenand48.3%ofAboriginalwomen)givingbirthweresmokers,comparedwith21.3%in2000-01.
In2002-04,28.0%ofmothersexperiencingastillbirthorinfantlossweresmokers,comparedwith30.8%ofmothersin2000-01.Theproportionofmotherswhosmokedwashigheramongstthosewhoexperiencedaninfantdeath(39.2%)comparedwiththosewhoexperiencedastillbirth(22.7%).
Figure5illustratesthesignificantlyincreasedrisksofstillbirthandinfantdeathrelatedtomaternalsmokinginWAin2002-04.Theperinatalmortalityratewas12.7insmokingmothersand9.0innon-smokers.Theinfantmortalityratewas7.4inmotherswhosmokedcomparedwith2.7innon-smokingmothers.Thegreatestdisparityinrateswasinthepost-neonatalperiod,wherethemortalityratewasfive-foldhigherininfantsofsmokingmotherscomparedwithinfantsofnon-smokingmothers(IMR3.7comparedwith0.7).
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Fig 5: Rates of Stillbirths, Perinatal, Neonatal, Post-neonatal and Infant Mortality by Maternal Smoking Status, WA 2002-04
Thereweresignificantlymoreperinataldeathsduetofetalgrowthrestriction,prematurity,spontaneouspretermlabourand‘noobstetricantecedent’inbirthstosmokingmotherscomparedtonon-smokingmothers(Table11a).
Table 11a: Number and Rate of Perinatal Deaths by Cause of Death (PSANZ PDC) and Maternal Smoking Status, WA 2002-04
PSANZ PDC
Smoking During Pregnancy
p-valueNo Yes
N Rate N Rate
1.CongenitalAbnormality2.PerinatalInfection3.Hypertension4.AntepartumHaemorrhage5.MaternalConditions6. SpecificPerinatalConditions7.HypoxicPeripartumDeath8.FetalGrowthRestriction9. SpontaneousPreterm10.UnexplainedAntepartumDeath11.NoObstetricAntecedent
15224323314392626
109793
2.50.40.50.60.20.70.40.41.81.30.1
31117
137
145
1643217
2.20.80.50.90.51.00.41.23.11.50.5
0.5340.0590.9000.1020.2010.1550.7100.0020.0030.562
<0.001
Total 537 9.0 175 12.7 <0.001
Table 11b: Number and Rate of Infant Deaths by Cause of Death (PSANZ NDC) and Maternal Smoking Status
PSANZ PDC
Smoking During Pregnancy
p-valueNo Yes
N Rate N Rate
1.CongenitalAbnormality2.ExtremePrematurity3.Cardio-RespiratoryDisorder4.Infection5.Neurological6.GastrointestinalTract7.1SIDS7.2-7.9Other
462821182046
15
0.80.50.40.30.30.10.10.3
13178
1652
1724
0.91.20.61.20.40.11.21.8
0.5130.0020.225
<0.0010.8680.370
<0.001<0.001
Total 158 2.7 102 7.4 <0.001
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Thereweresignificantlyhigherinfantmortalityratesduetoprematurity,infectionandSIDS/otherininfantsofsmokingmothers,comparedwithinfantsofnon-smokingmothers(Table11b).
4.1.5 Mortality Rates by Maternal Age and Aboriginality, WA 2002-04
Table 12: Number and Rate of Stillbirths, Neonatal and Post-neonatal Deaths, by Maternal Age and Aboriginality, WA 2002-04
Maternal Age
Stillbirths Neonatal Deaths Post-neonatal Deaths
non-Aboriginal Aboriginal non-Aboriginal Aboriginal non-Aboriginal Aboriginal
N Rate N Rate N Rate N Rate N Rate N Rate
<=1920-34>=35
24352101
7.96.57.7
19446
16.613.218.7
89627
2.61.82.1
6263
5.37.99.5
6558
2.01.00.6
1222
0.96.76.3
Total 477 6.8 69 14.4 131 1.9 35 7.4 69 1.0 25 5.3
Duringthetimeperiod2002-04,themeanmaternalageforallmotherswas29.2years,being29.0yearsin2002and29.3yearsintheyears2003and2004.Themeanmaternalagefornon-Aboriginalmotherswas29.5yearsandforAboriginalmotherswas24.4years.
InTable12thesignificantdisparityinstillbirthandinfantmortalityratesbetweennon-AboriginalandAboriginalbirthsisagainseen.Therewereslightlyhigherstillbirthandneonatalmortalityratesinnon-Aboriginalwomenattheextremesofreproductivelife(under-20yearsandover-34yearsagegroups),andhigherstillbirthratesinAboriginalwomenattheextremesofreproductivelife.SmallernumbersofAboriginalneonataldeathsandAboriginalandnon-Aboriginalpost-neonataldeathstomothersintheunder-20yearsandover-34yearsagegroupsprecludedconclusionsaboutthesegroups.
4.1.6 Mortality Rates by Maternal Residence, WA 2002-04
Womenlivinginthemetropolitanareaaccountedfor74.2%ofallbirths(n=55,656metrobirths;n=74,995totalbirths).
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Fig 6: Perinatal and Post-neonatal Mortality Rates by Maternal Residence, WA 2002-04
Figure6showssignificantdifferencesinmortalityratesfordifferentgeographiclocationswithinWesternAustralia.Thesefiguresarederivedusingmaternalpostcodesforresidence,anddonotalwaysreflectwherebirthsoccurred.
TheperinatalmortalityratesforwomenwhoresidedintheKimberleyandtheGreatSouthernweresignificantlyhigherthanthemetropolitanrate.Thesefindingsweredifferenttothosein2000-01whentheperinatalmortalityratesfortheGoldfields,Mid-West&Gascoyne,PilbaraandKimberleyregionswereallhigherthantheMetropolitan,CentralWheatbeltandSouthernpartsofthestate.TheperinatalmortalityrateintheGreatSouthernchangedsignificantly,beingsignificantlylowerthantheMetropolitanratein2000-01,andsignificantlyhigherin2002-04.
In2002-04theonlylocalitywherethepost-neonatalmortalityratewassignificantlyhigherthantheMetropolitanratewasinbirthstowomenwholivedintheMidwest-Murchisonarea.Thisdifferedtofindingsin2000-01whentherewerehigherratesintheGoldfields,Mid-West&GascoyneandKimberleyregions.
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RacialdifferencesarealsoshowninFigure6.PerinatalandinfantmortalityrateswereveryhighintheAboriginalpopulation,butthesmallproportionofAboriginalmothers(6.4%)comparedwithnon-Aboriginalmothersmeanthatthetotalnumbersofdeathsaresmall,andtherewerenopost-neonatalAboriginaldeathsinsomeareasintheyears2002-04.
4.1.7 Mortality Rates and Socioeconomic Factors, WA 2002-04
Figure7showsfurtherassessmentofsocioeconomicdistributionsofbirthsanddeaths,usingmaternalpostcodeasamarkerforsocioeconomicstatus.TheSocio-economicIndexesforAreas(SEIFA)publishedbytheABS16foreachCensusCollectionDistrictinWAwasusedtoallocateeachpostcodetoaSocioeconomicLevel.ThepostcodesaregroupedsothatLevelIrepresents‘leastdisadvantage’andLevelVIrepresents‘greatestdisadvantage’.
Fig 7: Perinatal & Infant Mortality Rates by Socioeconomic Status, WA 2002-04
Ingeneral,boththeperinatalandtheinfantmortalityrateincreasedasthesocioeconomicdisadvantageincreased.
4.1.8 Preterm deliveries by Neonatal Nursery Facility, WA 2002-04
Table 13: Number of Preterm Births by Hospital Establishment, WA 2002-04.KEMH Other Metro Rural Total
N % of total N N N
<28weeks<30weeks<32weeks<34weeks<1000g<1500g
521713
10541600542933
85.0%85.4%87.2%82.2%84.3%84.3%
496987
25257
104
435368954470
613835
12091947643
1107
Table13showsthenumberofpretermbirthsthatoccurredinthestate’sonlytertiaryobstetrichospital,KingEdwardMemorialHospital(KEMH),othermetropolitanhospitalsandruralhospitals.ThemajorproportionofpretermdeliveriesoccurredatKEMH,with85%ofbabiesoflessthan28weeksgestationalageand84%ofbabieslessthan1,000gbirthweightbeingdeliveredatthishospital.Theseproportionsweresimilartothosein2000-01.
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4.1.9 Trends in Birth Rates and Mortality Rates, WA 1990-2004
Figures8-15showtrendsinbirths,stillbirths,andinfantdeathsfrom1990-2004.2
BothAboriginalandnon-Aboriginalbirthrateshavedecreasedinthis15-yearperiod(Figure8).
Fig 8: Trends in Birth Rates by Aboriginality, WA 1990-2004
Inthe15years1990-2004anincreasingproportionofmothershavebeenagedover35years,andthishasbeenmostmarkedforthenon-Aboriginalpopulation(Figure9).Theproportionofnon-Aboriginalteenagemothershasbeensimilaroverthistimeperiod,andtherehasbeenasmallincreaseintheproportionofAboriginalteenagemothers.
Fig 9: Trends in Proportion of Mothers at Extremes of Reproductive Age, by Aboriginality, WA 1990–2004
Perinatalmortalityrateshavecontinuedtodeclinegradually.Thisreductionhasbeenstatisticallysignificantoverthelast14yrs(p=0.010),duetoalargereductionintheneonatalmortalityrate(p<0.001),buttherehasnotbeenastatisticallysignificantreductioninthestillbirthrateoverthistime(p=0.672)(Figure10).
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Fig 10: Trends in Perinatal Mortality Rates, WA 1990-2004
Fig 11: Trends in Perinatal Mortality Rates by Aboriginality, WA 1990-2004
TherehasbeenlittlechangeintheperinatalmortalityratesinbothAboriginalandnon-Aboriginalpeopleoverthepast15years(Figure11).Bycontrast,neonatal,post-neonatalandoverallinfantmortalityratesinnon-AboriginalandAboriginalpeoplehaveallsignificantlyreduced(Figures12and13).
Note: mortality rates for neonatal, post-neonatal and infant deaths have significantly reduced over time (p-values <0.001)
0
1
2
3
4
5
6
7
8
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Year
Ratepe
r10
00Live
births
Neonatal Post-neonatal Infant
Fig 12: Trends in Infant Mortality Rates, WA 1990-2004
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Fig 13: Trends in Infant Mortality Rates, by Aboriginality, WA 1990-2004
Note: Aboriginal and non-Aboriginal preterm birth rates have significantly increased over time (p=0.009 and p<0.001 respectively)
0
20
40
60
80
100
120
140
160
180
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004Year
Preterm
BirthRate/
100 0
Births
non-Aboriginal Aboriginal Total
Fig 14: Trends in Preterm Birth Rates, by Aboriginality, WA 1990-2004
Aboriginalmothershadhigherratesofpretermbirthsthannon-Aboriginalmothers.Inaddition,Aboriginalandnon-Aboriginalpretermbirthrateshavebothincreasedsignificantlyovertheperiod1990-2004,asshowninFigure14.Aboriginalpretermbirthsincreasedbyanaverageof1.9pretermbirths/1,000birthsperyear(1990-2004)andnon-Aboriginalpretermbirthsincreasedbyanaverageof1.3pretermbirths/1,000birthsperyear;thesedifferencesarestatisticallysignificant(p=0.009andp<0.001respectively).
Note: Aboriginal and non-Aboriginal preterm perinatal mortality rates have not significantly changed over time (p=0.786 and p=0.755 respectively)
0
5
10
15
20
25
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004Year
Preterm
Perina
tal
MortalityRate/
100 0
Births
non-Aboriginal Aboriginal Total
Fig 15: Trends in Preterm Perinatal Mortality Rates, WA 1990-2004
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Whilstpretermbirthrateshaveincreased,pretermperinatalmortalityratesinbothAboriginalandnon-Aboriginalwomenhavenotsignificantlychangedoverthistimeperiod(p=0.786andp=0.755respectively),asshowninFigure15.
4.2 Cases Investigated by the PIMC, WA 2002-04
4.2.1 Investigated Deaths with Preventable Medical Factors – Overview, WA 2002-04
TheCommitteewasdirectedtoinvestigate445ofthetotal806deathsinthetriennium2002-04,comprisingthosestillbirthsandinfantdeathspost26weeksgestationalage,andexcludingknownterminations.TheCommitteeinvestigated256ofthe546stillbirths,98of166theneonataldeaths,and91ofthe94post-neonataldeaths.Therewere372deathsinnon-Aboriginalmothersand73ofthedeathswereinAboriginalmothers.Thereweresixinvestigateddeaths(fivestillbirthsandoneneonataldeath)thatwerefoundtohavebeenlateterminationsofpregnancyforseverecongenitalabnormalities.Therewereafurthertwelvepost-26weekgestationpregnancyterminationsinthistrienniumthatwerenotreferredforinvestigation.
Therewereeightinvestigatedcases(3stillbirths,1neonataland4post-neonataldeaths)inbirthsoflessthan26weeksgestation.
Asaresultoftheinvestigations,therewereminorcorrectionsmadetotheHICdatasetobtainedfrommidwiferynotificationforms,suchascorrectionsofgestationalage.
TheCommitteescoredthecasesbya6point‘preventabilityscore’12,where1=virtuallynoevidenceforpreventabilityand6=virtuallycertainevidenceforpreventability(Table14).Caseswithscores>=4wereconsideredpotentiallyavoidabledeaths.Caseswithscoresof2or3hadoneormorepreventablemedicalfactorsbutwerethoughtunlikelytohavebeenavoidabledeaths.
Table 14: Preventability Scores and Type of death, Investigated Cases, WA 2002-04Preventability
ScoreStillbirths
NeonatalDeaths
Post-neonatalDeaths
Total
123456
224155520
68163532
8820100
380338
1152
Total 251 97 91 439
Totalis439investigatedcases,duetotheexclusionofsixcasesofpregnancytermination.
Ofthe445casesinvestigated,theCommitteecoded59cases(27stillbirths,29neonataldeathsand3post-neonataldeaths)ashavingany(evenslight-to-modest)evidenceofpreventability(preventabilityscore>=2),and18casesaslikelytohavebeenavoidable(preventabilityscore>=4).
Comment:
The peer review process of this Perinatal and Infant Mortality Committee showed that in the triennium 2002-04, 87% of deaths met the Committee’s expectations of appropriate medical care, and 96% of deaths were considered unavoidable in a medical context.
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Table15describesthetypesofpreventablemedicalfactorsthatwereidentifiedinthe59caseswithsomeevidenceofpreventability,categorisedbroadlyas‘systems’or‘medicalcare’factors.Therewere15caseswithany‘systems’factoridentifiedand50caseswithany‘medicalcare’factoridentified.Casesmayhavebeencodedwithmorethanonetypeofpreventablefactor.Sixcaseshadboth‘systems’and‘medicalcare’factorsidentified.
Table 15: Preventable ‘Systems’ and ‘Medical Care’ Factors, Investigated Cases, WA 2002-04
Number of Cases
Systems factors: Significantdelayinassessmentortreatment Delayintransfertootherunit Staffingproblem Equipmentproblem Follow-upofabnormaltestresult Significantdelayinperformanceofclinicalinvestigation Co-sleepingofmotherandbabyinhospital
154211114
Medical Care factors: Managementofantenatalproblems (otherthanobstetricdeliveryskills)Medicalcareofbaby(otherthanresuscitationofthenewborn)IdentificationofabnormalfetalheartratepatternsonCTGtraceFetalheartratemonitoringnotperformedwhenindicated Technicalskillsforobstetricdelivery Technicalskillsforresuscitationofnewborn Earlierreferralindicated Intrapartummanagementdecisions Postnataldepressionnotidentified
5021
1154236
101
*Note:casesmaybecodedmorethanonce.
4.2.2 Investigated Deaths with Preventable Medical Factors – Systems factors, WA 2002-04
“Systemsproblems”arenotalwaysascertainablefromthemedicalnotes.Forexamplethereisnodocumentationregardingstaffworkrosters.Itisrecognizedthatthedetectionofsystemsfactorsisunderestimatedbythemethodologyusedinthiswork.
Examplesofidentifiedsystemsfactors:
* A term baby born in a rural area following prolonged rupture of membranes developed early respiratory distress. Antibiotic therapy was administered, and Western Australian Neonatal Transport Service (WANTS) evacuation was arranged a short time later. Another priority case for Royal Flying Doctor Service (RFDS) led to a delay of several hours before the arrival of WANTS. Despite intensive resuscitation attempts the baby died in the first day of life. Earlier specialised help may have improved the outcome. Earlier communication with WANTS may have led to more rapid evacuation.
* An early neonatal death occurred in a preterm, growth restricted baby delivered by an elective Caesarean section in a small hospital. The baby’s condition deteriorated, requiring full resuscitation and transfer to a level III unit, with resultant delays in appropriate high-intensity care.
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Comments:
(see Recommendation 13):
• Care should be taken to deliver babies likely to require special nursery care in an appropriately staffed and equipped hospital.
• Referring staff are encouraged to anticipate transfer, phone early, and closely liaise with transport staff, to assist in prioritisation of transport needs.
4.2.3 Investigated Deaths with Preventable Medical Factors - Medical Care Factors, WA 2002-04
Thevastmajorityofdeathswerefoundtobeunavoidableinamedicalcontext.
Therewere21cases(15Caucasian,sixAboriginalwomen)identifiedwithpreventablemedicalfactorsrelatedtoantenatalmanagement.Ineightofthese21casestherewerematernalbehaviouralfactors(otherthansmoking)thatmayalsohavebeencontributory.
Therewere10cases(eightCaucasian,twoAboriginalwomen)where,inretrospect,betterdecisionsmayhavebeenmadeinthemanagementoflabour.ImprovedCTGapplicationandinterpretationmayhaveassistedinthreeofthesecases.
TherewerefourcaseswheretheadditionofintrapartumCTGmonitoring,inkeepingwithTheRoyalAustralianandNewZealandCollegeofObstetriciansandGynaecologists(RANZCOG)guidelines17mayhaveimprovedtheoutcome.
InfivecasesattendingpractitionersormidwivesdidnotidentifyimportantCTGfeatures.Inoneofthesecasesthedoctorhadrequestedthatthetracebefaxedtohim.Thiswasnotdone,andresultedinalatedetectionofanabnormalfetalheartratepattern.
Therewere11cases(nineCaucasian,twoAboriginalwomen)withpreventablemedicalfactorsrelatedtothemedicalcareofaninfant,withtwoofthesecasesalsocodedformaternalbehaviouralfactors(otherthansmoking).
Thereweresixcaseswhereearlierreferralmayhavealteredtheoutcome.
4.2.4 Investigated Intrapartum Deaths with Preventable Medical Factors, WA 2002-04
Intheinvestigatedcasesforthe2002-04triennium,therewere30intrapartumstillbirths.Ofthese,23hadnopreventablefactorsidentifiedinthemedicalcarereceived.Sevencaseshadpreventabilityscoresof>=2,andthreeofthesehadpreventabilityscores>=4.
Table16describessomeissuesidentifiedbytheinvestigationsthataroseinthemanagementofwomeninlabour.
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Table 16: Preventable factors in Intrapartum Management, Investigated Cases, WA 2002-04
Adelayintreatmentoccurredduetoacommunicationbreakdownwhenadoctorwasonleaveandhospitalstaffwereunawareofthis.
Intermittentratherthancontinuousfetalheartratemonitoringfollowinginductionoflabourwithprostaglandinswasassociatedwithadelayintherecognitionoffetaldistressintwocases.
Intermittentratherthancontinuousfetalheartratemonitoringwasperformedinapatientontreatmentforhypertension.Therewasfetaltachycardiafollowedbyanabruptlossofthefetalheartbeat,withoutearlierrecognitionofsignificantfetalcompromise.
Therewereproblemsintherecognitionofsinisterpatternsoffetalheartratetraces.
TherewasdelayindeliverybyCaesareansectioninthepresenceofsignificantfetaldistressintwocases.
Prolongedmaternalhypotensionfollowingtheinsertionofanepiduralmayhavecompromisedthefetus.
TherewasrapidfetaldemiseinthepresenceofmaternalfeverandvariabledecelerationsonCTGmonitoring,highlightingthedangeroffetalsepsisparticularlyinlabour.
Variableadherencetoroutineprotocols,suchascheckingmaternalbloodpressureafterepidural,androutineCTGmonitoringfollowingvaginaladministrationofprostaglandingelwerenoted.
Comments:
• Clear communication between staff members is a high priority.
• Improved knowledge of CTG monitoring techniques and interpretation is recommended.
• Sepsis may lead to very rapid fetal compromise.
Sections4.2.1-4.2.3consideredtypesofpreventablemedicalfactorsaccordingtosystemsfactorsandmedicalcarefactors,andsection4.2.4consideredmodifiablefactorsinintrapartumdeaths.Section4.2.5presentspreventablemedicalfactorsinanothermanner,accordingtocauseofdeath,tohelpidentifyspecificareaswherefutureeducationalattentionmaybeofmostbenefit.
4.2.5 Investigated Stillbirths by Cause of Death (PSANZ PDC) and Preventability Score, WA 2002-04
Table17aandFigure16ashowtheinvestigatedstillbirths(n=256)bycauseofdeath,andtheproportionofcaseswithanypreventablemedicalfactors(n=27;10.5%).
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Table 17a: Number of Stillbirths by Cause of Death (PSANZ PDC), Preventability Score and Aboriginality, Investigated Cases, WA 2002-04
PSANZ PDCTotal
Preventability Score Aboriginality of Mother
>=4 >=2 non-Aboriginal Aboriginal
N % N N % N % N %
1. CongenitalAbnormality
2. PerinatalInfection
3. Hypertension
4. AntepartumHaemorrhage
5. MaternalConditions
6. SpecificPerinatalConditions
7. HypoxicPeripartumDeath
8. FetalGrowthRestriction
9. SpontaneousPreterm
10.UnexplainedAntepartumDeath
11.NoObstetricAntecedent
32
15
31
18
17
19
15
29
3
77
0
12.5
5.9
12.1
7.0
6.6
7.4
5.9
11.3
1.2
30.1
0.0
0
0
0
0
3
1
3
0
0
0
0
0
1
4
0
5
4
6
6
0
1
0
0.0
6.7
12.9
0.0
29.4
21.1
40.0
20.7
0.0
1.3
0.0
32
10
23
17
9
17
13
25
2
73
0
14.5
4.5
10.4
7.7
4.1
7.7
5.9
11.3
0.9
33.0
0.0
0
5
8
1
8
2
2
4
1
4
0
0.0
14.3
22.9
2.9
22.9
5.7
5.7
11.4
2.9
11.4
0.0
Total 256 100.0 7 27 10.5 221 100.0 35 100.0
Fig 16a: Number of Stillbirths by Cause of Death (PSANZ PDC) and Preventability Score, Investigated Cases, WA 2002-04
Thecauseofdeathcategorieswiththehighestproportionofstillbirthswithpreventablemedicalfactors(preventabilityscore>=2)wereperipartumhypoxia(sixof15stillbirths;40.0%),maternalconditions(fiveof17stillbirths;29.4%),specificperinatalconditions(fourof19stillbirths;21.1%)andfetalgrowthrestriction(sixof29stillbirths;20.7%).
EachPSANZPDCcategoryisconsideredindetail,fromthatassociatedwiththehighestnumberofdeathstothatwiththelowest.
Therewere77cases(30.1%)classifiedasunexplainedantepartumstillbirths.
Oneofthesestillbirthshadapreventabilityscore>=2.
Therewere32stillbirths(12.5%)attributedtocongenitalabnormalities.Noneofthesehadapreventabilityscore>=2.
Therewere31stillbirths(12.1%)inmotherswithhypertension.
Fourofthesehadapreventabilityscore>=2.
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Examplesofcaseswithlow-levelpreventabilityscores:
* A woman with pre-eclampsia in the third trimester was treated with antihypertensive medication. A decision to induce labour was changed due to an unstable lie and fetal death occurred at 38 weeks.
* A young multiparous woman with a history of previous severe early-onset growth restriction presented in the third trimester with reduced fetal movements and borderline hypertension. A CTG was non-reactive but non sinister. She was advised to complete a kick chart, and sent home. She presented two days later with fulminant pre-eclampsia and a fetal death.
* A high-risk woman with past severe pre-eclampsia had a midwifery outpatient check in the third trimester. There was normotensive proteinuria with no record of fundal height. She subsequently presented with a
fetal death attributed to growth restriction.
Therewereafurthersixcasescodedwithnomedicalpreventabilitywherestillbirthoccurredinpatientsonmethyldopatreatmentforhypertension.
Therewere29stillbirths(11.3%)ingrowthrestrictedbabies.Sixofthesehadpreventabilityscoresof2or3.
Therewere19stillbirths(7.4%)relatedtospecificperinatalconditions.
Fourofthesehadpreventabilityscores>=2.
Example:
* A young Aboriginal woman with a twin pregnancy had documented discordant growth, without specialist
referral. Twin 2 died at 36 weeks, weighing 1.4kg.
Comments:
(see Recommendation 9):
• Guidelines for the management of twin pregnancies are available:
KingEdwardMemorialHospital(KEMH)guidelinesforobstetrics:http://kemh.health.wa.gov.au/development/manuals/sectionb/index.htm
• Chorionicity should be determined at 12 weeks gestation by ultrasound.
• Careful monitoring of fetal well-being is required in twin pregnancies.
• Early ultrasound assessment should identify twin pregnancies at increased risk of twin to twin transfusion syndrome. Those with monochorionic twin pregnancies should have ultrasound surveillance for fetal growth at 18, 24, 27, 30, 33 and 36 weeks gestation. Those with dichorionic pregnancies should have ultrasound monitoring at 18, 26, 30, 33 and 36 weeks gestation.
• Discordant growth in twins is an indication for specialist referral.
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Therewere18deaths(7.0%)relatedtoantepartumhaemorrhage.
Noneofthesestillbirthshadpreventablemedicalfactorsidentified.
Therewere17deaths(6.6%)relatedtomaternalconditions.
Fiveofthesehadpreventabilityscores>=2,andwereallassociatedwithmaternaldiabetesmellitus.
Examples:Diabetesmellitus:
* A young Aboriginal woman with poorly controlled diabetes and binge alcohol drinking had no treatment and no monitoring of fetal wellbeing. Fetal death occurred at 38 weeks.
* An Aboriginal woman with severe gestational diabetes had no specialist consultation although insulin therapy was commenced at 37 weeks. There was no monitoring to assess fetal wellbeing. Fetal death occurred at 38 weeks.
* An obese woman with gestational diabetes was not advised to commence blood glucose monitoring until near term. There was third trimester ultrasound evidence of macrosomia, but no monitoring of fetal wellbeing, and fetal death occurred at 39 weeks.
Comments:
(see Recommendation 7):
Routine management of patients with diabetes in pregnancy should involve:
• education and dietary advice.
• monitoring blood glucose levels to assess glycaemic control.
• specialist consultation/ liaison for those patients with poor glycaemic control, with earlier rather than later initiation of insulin and perhaps oral hypoglycaemic agents.
• routine monitoring of fetal wellbeing, such as ultrasound assessment for fetal macrosomia.
Therewere15stillbirths(5.9%)withhypoxicperipartuminsult.
Sixofthesehadpreventabilityscores>=2.
Theseweredocumentedintrapartumdeaths(seesection4.2.8).
Therewere15stillbirths(5.9%)duetoinfection.Oneofthesecaseshadapreventabilityscoreof2.
Therewere3deathsduetospontaneouspretermbirth.Noneofthesecaseshadanyidentifiedpreventablemedicalfactors.
4.2.6 Investigated Neonatal Deaths by Cause of Death (PSANZ PDC) and Preventability Score, WA 2002-04
Table17bandFigure16bshowinvestigatedneonataldeaths(n=98)bycauseofdeath,andtheproportionofcaseswithanypreventablemedicalfactors(n=29;29.6%).
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Table 17b: Number of Neonatal Deaths by Cause of Death (PSANZ PDC), Preventability Score and Aboriginality, Investigated Cases, WA 2002-04
PSANZ PDCTotal
Preventability Score Aboriginality of Mother
>=4 >=2 non-Aboriginal Aboriginal
N % N N % N % N %
1. CongenitalAbnormality2. PerinatalInfection3. Hypertension4. AntepartumHaemorrhage5. MaternalConditions6. SpecificPerinatalConditions7. HypoxicPeripartumDeath8. FetalGrowthRestriction9. SpontaneousPreterm10.NoObstetricAntecedent
37101216
155
1110
38.110.31.02.11.06.2
15.55.2
11.310.3
2100014011
4500039035
10.850.00.00.00.0
50.060.00.0
27.350.0
3391216
12596
39.310.71.22.41.27.1
14.36.0
10.77.1
4100003024
28.67.10.00.00.00.0
21.40.0
14.328.6
Total 98 100.0 10 29 29.6 84 100.0 14 100.0
Fig 16b: Number of Neonatal Deaths by Cause of Death (PSANZ PDC) and Preventability Score, Investigated Cases, WA 2002-04
Thecauseofdeathcategorieswiththehighestproportionofdeathswithpreventablemedicalfactors(preventabilityscore>=2)werehypoxicperipartumdeaths(nineof15neonataldeaths,60%),perinatalinfection(fiveoftenneonataldeaths,50%),specificperinatalconditions(threeofsixneonataldeaths,50%)anddeathswithnoobstetricantecedent(fiveoftenneonataldeaths,50%),suchaspostnatallyacquiredinfection.
EachPSANZPDCcategoryisconsideredindetail,fromthatassociatedwiththehighestnumberofdeathstothatwiththelowest:
Therewere37deaths(38%)attributedtocongenitalabnormalities,andfourofthesecaseshadpreventabilityscores>=2.
Thereweresevendeathsinpatientswhounderwentsurgeryforcongenitalcardiacdisease.Sixofthesecasesweregivenpreventabilityscores=1,andasinglecasewasscoredashavingslighttomodestpreventability(preventabilityscore=2).TheCommitteecommentedthatitdidnothavetheexpertisetoproperlyassesspreventabilityinthishighlyspecializedareaandnotedthatregularinternalaudittakesplaceinthisareaofpaediatricsurgery.
Therewere15deaths(15.5%)fromhypoxicperipartuminsultandnineofthesecaseshadpreventabilityscores>=2.
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Example:
An early neonatal death followed a significant delay in the decision to perform a Caesarean section in the presence of significant intrapartum fetal compromise (bradycardia, meconium amniotic fluid, adverse CTG changes) and failure to progress.
Comments:
In the presence of sinister CTG signs or other signs of fetal distress, fetal well-being should be assessed by fetal scalp pH monitoring or delivery should be expedited.
Example:Traumafromadifficultinstrumentaldelivery:
An unexpectedly large baby was delivered with difficulty by forceps, following multiple failed attempts with a vacuum extractor. The baby had low Apgar scores and became profoundly shocked with a subgaleal haemorrhage, dying in the neonatal period.
Comments:
(see Recommendation 12)
• Consider Caesarean section rather than persisting with difficult instrumental vaginal deliveries.
• Significant blood loss can occur from birth trauma (e.g. sub-galeal haemorrhage) requiring rapid treatment with volume administration and sometimes blood transfusion.
Therewere11deaths(11.3%)duetoprematurity(spontaneouspretermbirth).
Threeofthesehadidentifiedpreventablemedicalfactors.
Therewere10deaths(10.3%)fromperinatalinfection.Fiveofthesehadpreventabilityscores>=2.
Examples:
* A term Aboriginal baby was born in the presence of thick meconium amniotic fluid, and had a respiratory rate of over 70 breaths per minute from birth. Swabs were taken but antibiotics were not given. Ongoing tachypnoea was documented, with apparent lack of recognition of concerning signs of neonatal respiratory distress. When severe deterioration occurred several hours later, medical help was arranged. There was a delay of many hours between the onset of signs of neonatal respiratory distress and treatment, consultation and transfer.
* There was a long delay in the recognition of respiratory distress and administration of antibiotics in another newborn, who died with overwhelming group B streptococcus infection at 12 hours of age.
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Comments:
(see Recommendations 11 and 13)
• Routine antenatal screening for Group B Streptococcus is advised at 36 weeks gestation of pregnancy, with intrapartum antibiotic therapy for carriers. Staff should be aware of guidelines to reduce the risk of neonatal sepsis.
KingEdwardMemorialHospitalguidelinesforobstetrics:http://kemh.health.wa.gov.au/development/manuals/sectionb/index.htm
KingEdwardMemorialHospitalguidelinesforneonatology:http://kemh.health.wa.gov.au/services/nccu/guidelines/
• Rapid identification and treatment of infants with respiratory distress is a priority.
• Where a baby may require transfer, early consultation with Western Australian Neonatal Transport Service (WANTS) is advised.
• Nursing staff caring for sick neonates are encouraged to liaise with specialist neonatal nurses.
• Early administration of antibiotics is advised for neonates at increased risk of sepsis.
Therewere10neonataldeathswithoutanobstetricantecedent(10.3%)andfiveofthesedeathshadpreventabilityscores>=2.
Examples: There were three similar cases of term Aboriginal neonates who died in hospital whilst co-sleeping with their mothers following breastfeeding. All three were significantly growth restricted babies, below 2.5kg in birthweight. Two of the mothers were known to drink alcohol excessively and the third mother was known to use solvents and other substances. In one of these cases the mother was not rousable when the baby was found deceased. In another case the baby was cold when found. There was a question as to the adequacy of supervision in hospital in these cases.
Comments:
(see Recommendation 15)
Co-sleeping is a risk factor for sudden infant death, especially in:
• infants of smoking mothers
• preterm or low birth weight babies
• babies under the age of 4 months
• impaired maternal conscious state
Thereweresixdeaths(6.2%)relatedtospecificperinatalconditionssuchasfetomaternalhaemorrhageandiatrogeniccomplications(amniocentesis).
Threeofthesedeathshadpreventabilityscores>=2.
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4.2.7 Investigated Neonatal Deaths by Cause of Death (PSANZ NDC) and Preventability Score, WA 2002-04
Thissectionagainexaminesneonataldeaths,butusingthedifferentclassificationsystem,PSANZNDC.
Thecategorieswiththehighestproportionofdeathswithpreventablemedicalfactors(preventabilityscore>=2)wereelevenof21(52.4%)deathsduetoneurologicalconditions,sixoftwelve(50%)deathsduetoSIDS/otherandfiveofeleven(45%)deathsduetoinfection(Table18a).
Table 18a: Number of Neonatal Deaths by Cause of Death (PSANZ NDC), Preventability Score and Aboriginality, Investigated Cases, WA 2002-04
PSANZ NDCTotal
Preventability Score Aboriginality of Mother
>=4 >=2 non-Aboriginal Aboriginal
N % N N % N % N %
1.CongenitalAbnormality2.ExtremePrematurity3.Cardio-RespiratoryDisorder4.Infection5.Neurological6.GastrointestinalTract7.SIDS&Other
362
1211214
12
36.72.0
12.211.221.44.1
12.2
2031301
3045
1106
8.30.0
33.345.552.40.0
50.0
312
10101948
36.92.4
11.911.922.64.89.5
5021204
35.70.0
14.37.1
14.30.0
28.6
Total 98 100.0 10 29 29.6 84 100.0 14 100.0
4.2.8 Investigated Post-Neonatal Deaths by Cause of Death (PSANZ NDC) and Preventability Score, WA 2002-04
Table 18b: Number of Post-neonatal Deaths by Cause of Death (PSANZ NDC), Preventability Score and Aboriginality, Investigated Cases, WA 2002-04
PSANZ NDCTotal
Preventability Score Aboriginality of Mother
>=4 >=2 non-Aboriginal Aboriginal
N % N N % N % N %
1.CongenitalAbnormality2.ExtremePrematurity3.Cardio-RespiratoryDisorder4.Infection5.Neurological6.GastrointestinalTract7.SIDS&Other
2223
1510
48
24.22.23.3
16.51.10.0
52.7
0000001
0000102
0.00.00.00.0
100.00.04.2
2022
1010
32
29.93.03.0
14.91.50.0
47.8
201500
16
8.30.04.2
20.80.00.0
66.7
Total 91 100.0 1 3 3.3 67 100.0 24 100.0
Ofthe91investigatedpost-neonataldeaths,three(3.3%)hadpreventabilityscores>=2.
Therewere48deaths(51%)dueto‘other’causes,with23ofthesebeingSIDS.Therewere22deaths(24.2%)inbabieswithsignificantcongenitalabnormalities,and15deaths(16.5%)duetoinfection.
Thepost-neonataldeathswithpreventablemedicalfactorswerecategorisedhypoxicischaemicencephalopathy(n=1),possibleSIDS(n=1),andnonaccidentalinjury(n=1).
Example:non-accidentalinjury:
A woman with severe social disruption and illicit substance use was known to the Department of Community Development (‘welfare’). A medical practitioner had noted a bruise on the baby on one occasion. The baby died at a few months of age, with multiple fractures, new and old injuries, and brain haemorrhages.
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4.2.9 Maternal Behaviour and Lifestyle Factors, WA 2002-04
Statewidedatafor2002-04(section4.1.4)indicatedthat22.7%ofmothersexperiencingastillbirthand39.2%ofallmothersexperiencinganinfantdeathweresmokers(smokingprevalence28.0%alldeaths).Similarproportionswereseeninthesubgroupofinvestigatedcases(2002-04)where23.0%ofmothersexperiencingastillbirthand28.4%ofmothersexperiencinganinfantdeathweresmokers(24.5%forneonataldeathsand54.9%forpost-neonataldeaths).Theoverallprevalenceofmaternalsmokingininvestigateddeathswas30.0%.
Inadditiontosmoking,aspectsofmaternalorotherfamilylifestylethatmayhavecontributedtopooroutcomes,suchasalcoholorothersubstanceuse,wereassessedintheinvestigateddeaths.Such‘maternalbehaviouralfactors’wereidentifiedin98(22%)ofthe445investigateddeaths(42stillbirths,16neonataldeathsand40post-neonataldeaths).Theproportionsofcaseswithmaternalbehaviourfactors,bytypeofdeath(stillbirth,neonatalandpost-neonataldeath)areshowninFigure17,beingmostsignificantinpost-neonataldeaths.
Fig 17: Proportion of Cases with Maternal Behavioural Factors, by Type of death, Investigated Cases, WA 2002-04
Comments:
Maternal smoking was a significant risk factor for stillbirth or infant death, being associated with 30% of investigated deaths.
Other aspects of maternal or family behaviour that may have contributed to the outcome of stillbirth or infant death - such as substance use and poor compliance with medical care - were associated with 22% of the investigated deaths.
Table19providesdetailsofthecaseswith‘maternalbehaviouralfactors’(n=98mothers).Thereweresignificantcorrelationsbetweenthosewith‘maternalbehaviouralfactors’andwithsmokingandlivinginaruralarea.Inthegroupofmotherswith‘maternalbehaviouralfactors’60(61%)werealsosmokersand57(58%)livedinthemetropolitanarea,comparedwiththegroupofallmotherswhogavebirthin2002-04,whichcomprised18.7%smokersand74.2%wholivedinthemetropolitanarea.Ofthe98womenwith‘maternalbehaviouralfactors’,45(46%)wereofAboriginalrace.
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Table 19: Investigated Cases with Maternal Behavioural Factors: Associated Factors, WA 2002-04
All Deaths(N=98)
Stillbirths(N=42)
Neonatal Deaths(N=16)
Post-neonatal Deaths(N=40)
N % N % N % N %
Maternal characteristicsSmokerMaternalage(years)<=1920-34>=35MetropolitanpostcodeAssessmentPreventabilityscore>=2Preventabilityscore>=4Autopsyperformed
60
11771057
167
74
61.2
11.278.610.258.2
16.37.1
75.5
19
5325
25
84
24
45.2
11.976.211.959.5
19.09.5
57.1
11
21137
62
15
68.8
12.568.818.843.8
37.512.593.8
30
4342
25
21
35
75.0
10.085.05.0
62.5
5.02.5
87.5
Table20givesdetailsofthetypesofbehaviourthatmayhavecontributedtoanadverseoutcome.Alcoholabusewaslistedonlywherethenotesrecordedexcessivealcoholconsumption.Inthisgroupof98mothers,therewasdocumentationthat61motherswerepoorlycompliantwithmedicalcare,80motherswerepoorlycompliantwithcareorhadsomeotherserioussocialproblem,53mothershad“anysubstanceabuse”(21womendrankalcoholexcessively,18womenusedmarijuanaand22womenused“harddrugs”),15womenexperienceddomesticviolenceandeightwomenhadapsychiatricdisorder.
Ofthetotalgroupof445investigateddeaths,14%ofmotherswerepoorlycompliantwithmedicalcare,18%werepoorlycompliantwithcareorhadsomeotherserioussocialproblemand12%ofmothershad“anysubstanceabuse”.
Therewere35investigatedstillbirthsinAboriginalwomenandalmosthalfofthese(n=18cases)hadinfrequentantenatalattendanceorpoorcompliancewithrecommendedantenatalcare.Therewere84investigatedstillbirthsinnon-Aboriginalwomen,and13ofthesewomenhadinfrequentantenatalattendanceorpoorcompliancewithrecommendedantenatalcare.
Therewere91post-neonataldeathsinvestigatedbythePIMC.Ofthese,40hadmaternalbehaviouralfactorsidentified,comprising36motherswithsignificantsocialproblemsorpoorcompliancewithmedicalcare(40%ofall91investigatedpost-neonataldeaths),21motherswith“anysubstanceabuse”problems(23%of91investigatedpost-neonataldeaths)andtenbabieswhosufferednon-accidentalinjuries(11%of91investigatedpost-neonataldeaths).
Table 20: Number of Deaths in which Maternal Behavioural Factors were apparent, by Aboriginality, Investigated Cases, WA 2002-04
All Deaths Stillbirths Neonatal Deaths Post-neonatal Deaths
N=98
non-Aboriginal
N=20Aboriginal
N=22Total N=42
non-Aboriginal
N=11Aboriginal
N=5Total N=16
non-Aboriginal
N=22Aboriginal
N=18Total N=40
N % N % N % N % N % N % N % N % N % N %
Poorcompliance
Domesticviolence
Othersocialproblems
Maternalpsychiatricproblem
Nonaccidentalinjuryofinfant
Socialproblemsorpoorcompliance
Alcoholabuse
Marijuanause
Harddrugs
Anysubstanceabuse
61
15
20
8
10
80
21
18
22
53
62.2
15.3
20.4
8.2
10.2
81.6
21.4
18.4
22.4
54.1
13
3
1
0
0
15
1
5
7
12
65.0
15.0
5.0
0.0
0.0
75.0
5.0
25.0
35.0
60.0
18
0
2
0
0
18
6
6
2
12
81.8
0.0
9.1
0.0
0.0
81.8
27.3
27.3
9.1
54.5
31
3
3
0
0
33
7
11
9
24
73.8
7.1
7.1
0.0
0.0
78.6
16.7
26.2
21.4
57.1
7
1
2
0
0
9
0
1
3
4
63.6
9.1
18.2
0.0
0.0
81.8
0.0
9.1
27.3
36.4
2
0
0
0
0
2
3
0
1
4
40.0
0.0
0.0
0.0
0.0
40.0
60.0
0.0
20.0
80.0
9
1
2
0
0
11
3
1
4
8
56.3
6.3
12.5
0.0
0.0
68.8
18.8
6.3
25.0
50.0
7
5
9
7
5
19
2
4
7
11
31.8
22.7
40.9
31.8
22.7
86.4
9.1
18.2
31.8
50.0
14
6
6
1
5
17
9
2
2
10
77.8
33.3
33.3
5.6
27.8
94.4
50.0
11.1
11.1
55.6
21
11
15
8
10
36
11
6
9
21
52.5
27.5
37.5
20.0
25.0
90.0
27.5
15.0
22.5
52.5
Note:casesmaybecodedmorethanonce
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4.2.10 Infant Deaths which occurred whilst Co-Sleeping, Investigated Cases, WA 2002-04
Table 21: Number of Infant deaths which occurred whilst Co-Sleeping, by Aboriginality, Investigated Cases, WA 2002-04
Co-sleeping and any Associated Factors:
TotalNeonatal Deaths Post-neonatal Deaths
non-Aboriginal Aboriginal non-Aboriginal Aboriginal
N=33 N=4 N=4 N=12 N=13
N % N % N % N % N %
NodocumentedsocialproblemsSocialproblemsotherthansubstanceabuseSubstanceabuseSubstanceabuseorothersocialproblemsSmokingmotherBirthweight<2.5kgDeath<12weeksage
6
201727281025
18.2
60.651.581.884.830.375.8
1
223314
25.0
50.050.075.075.025.0
100.0
1
033424
25.0
0.075.075.0
100.050.0
100.0
2
86
101149
16.7
66.750.083.391.733.375.0
2
106
111038
15.4
76.946.284.676.923.161.5
Therewere33unexpectedinfantdeathsthatoccurredinassociationwithinfant/parentco-sleeping(17.5%ofthe189investigatedinfantdeaths).
Allofthe33babiesdiedpriorto4.5monthsofage,with25deathsbeingpriorto12weeksofageandeightdeathsinbabiesbetweentheagesof12weeksand4.5months.
Tenofthedeathswereinbabiesthatwerelessthan2.5kgbirthweight,withsixofthesebeingpretermandfourbeingsmallforgestationalage.Thereweretwofurtherdeathsinpretermbabiesthatweremorethan2.5kgbirthweight.(Totaldeathsinpretermbabies:n=8;totaldeathseitherpretermorsmallforgestationalage:n=12).
Themajorityofthesedeaths(n=28)wereintheinfantsofsmokingmothers.
Ofthe33infantdeathsassociatedwithco-sleeping,onehalfoccurredinnon-Aboriginalinfants(n=16)andonehalfinAboriginalinfants(n=17).
Ofthe33infantdeaths,27occurredincombinationwithsignificantsocialproblemsorparentalsubstanceabuse,andsixdeathsoccurredintheabsenceofanydocumentedmaternal/familybehaviouralfactor.
Sixoftheunexpectedinfantdeathsassociatedwithco-sleepingoccurredwhilstsleepingonacouch.
Fourneonataldeathsoccurredwhilstmothersandbabieswereco-sleepinginhospital.Allfourbabieswerelessthan2.5kginbirthweight.Threeofthesecaseswerepreviouslydescribedinsection4.2.6,andinvolvedgrowthrestrictedtermAboriginalneonates,andthefourthcasewasthedeathofapretermCaucasianbaby.
Thedeathswereclassifiedforcauseofdeath(PSANZNDC):SIDS(n=13),sepsis(n=4),accidentalasphyxiation(n=2)and‘other/undetermined’(n=14).Itmaybenotedthatthe13SIDSdeathsthatoccurredwhilstco-sleepingrepresentedoverhalfofthetotalSIDSdeathsinthetriennium(n=23;57%).
4.2.11 Data Collection Maternal Factors, WA 2002-04
ThereisnoroutinecollectionofdataonthenumberofantenatalappointmentswomenattendinWA.Improveddatacollectionregardingantenatalattendancemayallowforamoreaccurateassessmentoftherelationshipbetweenantenatalattendances,compliancewithmedicaladviceandpregnancyoutcomes.
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Thereisnoroutinecollectionofdataaboutalcoholanddruguseinpregnancy.IntheinvestigatedstillbirthsinWA2002-04therewasnoinformationaboutalcoholusein69(27%)ofmothersandnoinformationaboutothersubstanceusein120(47%)ofmothers.
Table22showsthatinthosewhohadastillbirth,maternalheightwasrecordedin212(82.8%)women,maternalweightin154(60.2%)womenandbothheightandweightwererecordedin135(52.7%)women.Maternalheightisrequestedonmidwiferynotificationforms,butmaternalweightisnotcollected.Inthepopulationofallmothersgivingbirthintheyears2002-04,maternalheightwasrecordedonthemidwiferynotificationformsin81.2%ofrecords.Itwasnotpossibletomakemeaningfulanalysesofrelationshipsbetweenbodymassindexandpregnancyoutcomesduetomissingheightandweightdatainahighproportionofmothers.
Table 22: Maternal Height and Weight Records, Investigated Perinatal Deaths, WA 2002-04
Data Collection
Perinatal Deaths Stillbirths Neonatal Deaths
(N=354) (N=256) (N=98)
N % N % N %
HeightrecordedWeightrecordedBothheightandweightrecorded
289165145
81.646.641.0
212154135
82.860.252.7
771110
78.611.210.2
4.2.12 Perinatal Mortality Risk by Gestational Age, Investigated Cases, WA 2002-04
Table23providesinformationabouttheratesofstillbirthandthesubgroupsofunexplainedstillbirths,neonataldeaths,andhypoxicperipartumdeaths,atdifferentgestationalagesusingHICdata(includinglivebirths)toenablecalculationsofrisk.2Stillbirthratesweremostcloselyrelatedtothedegreeofprematurity,whereasthepeakmortalityrateofunexplainedstillbirthswasinthegestationalagegroupof28-34weeks.Theperinatalmortalityrateduetoperipartumhypoxiawashighestintwogestationalagegroups(28-34weeksandin>42weeks)althoughtheabsolutenumberswerelow.Table 23: Perinatal Mortality Risk by Gestational Age, Investigated Perinatal Deaths, WA 2002-04
Gestational Age (weeks)
Total Births Livebirths Stillbirths
(all causes)Unexplained
Antepartum DeathsNeonatal Deaths
(all causes)
Perinatal Deathsdue to Hypoxic
Peripartum Death
N N N Rate N Rate N Rate N Rate
20-2728-34
35363738394041
42-43
6132115119123715360
1672814963233707660622
3002018117923555334
1670714941233427650620
3297121626212228102
52.245.910.16.74.91.31.51.21.33.2
62544987
1210
9.811.83.41.71.70.50.50.50.10.0
123142
116
101740
40.0
15.4
3.4
0.8
2.1
0.4
0.7
0.7
0.5
0.0
0
3
1
0
1
1
4
11
8
2
0.0
1.4
0.8
0.0
0.2
0.1
0.3
0.5
1.0
3.2
4.2.13 Home Births, Investigated Cases, WA 2002-04
Inthetriennium2002-04therewerethreetermgestationperinataldeathsamongstplannedhomebirths.Thehomebirthswerepre-bookedwithattendantmidwiferyantenatalandperipartumcare.Oneofthethreedeathswascodedwithanelementofmedicalpreventability,whereimprovedantenatalassessmentandmanagementmayhaveimprovedtheoutcome(preventabilityscoreof3).Inasecondcasetheparentsrefusedrecommendedmedicalcareafteradvicethatthereweresignsoffetalcompromise.Thethirdcasewasasuddenunexplainedstillbirthwithoutinvestigationstoassessthecauseofdeath.
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Insummary,oneofthethreecaseshad‘medical’preventability,anotherhad‘maternalfactors’present,andthethirdhadneithermedicalnormaternalpreventabilityfactorsevident,butdidnothavepost-morteminvestigations.
4.2.14 Home Births, Investigated Cases, WA 2000-04
DatawerepooledwiththosefromtheCommittee’s11thReportfortheyears2000-01,toallowforavalidstatisticalanalysis.TherewereatotalofsixunexpectedtermperinataldeathsamongstplannedhomebirthsrecordedinthefiveyearsJan2000–Dec04.Thesixdeathsoccurredbetween38and41weeksgestationalage,andinvolvedsingletonpregnancieswithnoovertcongenitalabnormalities.Twodeathswereantepartumandfourweretheresultofanintrapartumcomplication(twostillbirthsandtwoearlyneonataldeaths).Threeofthedeathsoccurredathomeandthreeoccurredinhospital.Oneofthesixbabiesdeliveredathome,andfivedeliveredinhospital.Fourofthesixcaseshadlow-levelmedicalpreventabilityscores(2or3)andtwocaseshadnoevidenceofpreventability.
Thetermperinatalmortalityratewas6.7per1,000totalbirths,comparedwithatermperinatalmortalityrateof2.1per1,000totalbirthsintheplannedhospitalbirthsinthesameperiod,whichwasastatisticallysignificantdifference(FisherExactp=0.013).
Inthe5-yearperiod,theaveragenumberofannualplannedhomebirthswas169,withtheaveragenumberthatdeliveredathomebeing138peryear.Thepercentageofplannedhomebirthsthatdeliveredathomewas82%.Ofthe700birthsthatoccurredathome,697werespontaneousvertexdeliveries,onewasatwin-birth,onevaginalbirthbybreechpresentation,onevaginalbirthrecordedas‘brow’presentation,andonewasanunspecified‘otherpresentation’delivery.
Trenddatashowthattheproportionofplannedhomebirthshasremainedfairlystableatbetween0.4–0.7%ofallbirthsoverthepast15years.2
Table 24: Number of Planned and Actual Home Births, WA 2000-2004
Year Planned homebirths Actual homebirths Planned Hospital Births
2000
2001
2002
2003
2004
160
182
153
186
165
122
144
121
163
150
24,570
24,286
23,787
23,641
24,429
Total 846 700 120,776
4.2.15 Pathology Investigations into Cause of Death, Investigated Cases, WA 2002-04
In2002-04,303ofthe445investigateddeaths(68%)underwentpost-mortemexamination,comprising69.5%ofstillbirths,60.2%ofneonataldeathsand73.3%ofpost-neonataldeaths.
Table25showsthebenefitsconferredbypost-mortemexamination,usingan‘autopsyutilityscale’;13thesefindingsaresimilartothosereportedin2000-01.3
Table 25: Autopsy Utility for Perinatal and Infant Deaths, Investigated Cases, WA 2002-04
Autopsy UtilityStillbirths
N=178Neonatal Deaths
N=59Post-neonatal Deaths
N=66Total
N=303
N % N % N % N %
ConfirmChangeAddInconclusive
46343959
25.819.121.933.1
24111212
40.718.620.320.3
6121236
9.118.218.254.5
765763
107
25.118.820.835.3
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Caseswereindividuallyassessedaccordingtotheadequacyofthepathologyinvestigationsperformedtoinvestigatethecauseofdeath(Table26).Ofthe445casesinvestigated,330(74.2%)wereconsideredadequatelyinvestigated,81(18.2%)caseswerepartiallyinvestigatedand34(7.6%)hadverylittleornoinvestigationsintothecauseofdeath.Inall,25.8%ofcaseshadinsufficientpathologicalinvestigationofthecauseofdeath.ThisrepresentedasignificantimprovementfromthedatapublishedinthePIMC11thReportofdeathsin2000-01,when53%ofdeathshadinsufficientpathologicalinvestigationsperformedtodeterminethecauseofdeath.3
Table 26: Pathology Investigations to Assess Cause of Stillbirths and Infant Deaths, Investigated Cases, WA 2002-04
Investigative Work Up
StillbirthsN=256
Unexplained Stillbirths
N=77
Infant DeathsN=189
Total DeathsN=445
N % N % N % N %
AdequateSomeinvestigationsFewinvestigations
1566733
60.926.212.9
441716
57.122.120.8
174141
92.17.40.5
3308134
74.218.27.6
AminorityofcaseshadafullrangeofinvestigationsasrecommendedinAppendixII(Section7.2),includingamniocentesis,Kleihauer-Betketestpriortoinductionoflabour,andmaternaldrugscreenforillicitsubstances.
Ofthe77unexplainedantepartumstillbirths,44(57%)hadadequateinvestigationsperformed,17hadsometestsperformedbutlackedimportantinvestigationssuchasplacentalhistopathology,and16cases(20.8%)hadfewornoinvestigationsintothecauseofdeath.Ofthese77unexplainedantepartumstillbirths,31.2%hadaKleihauer-Betketest,39%hadmaternalculturestaken,24.7%hadfetal/placentalculturestakenand71.4%hadanautopsyperformed.Pathologyassessmentofcaseswasmorethoroughin2002-04thanin2000-01when20%of‘unexplainedantepartum’stillbirthshadaKleihauer-Betketest,48%hadculturestakenand60%hadanautopsy.
4.2.16 Early Prevention Factors, Investigated Cases, WA 2002-04
Table27showsthat39oftheinvestigatedcases(8.8%ofthetotal445investigatedstillbirthsandinfantdeaths)wereidentifiedinwhich‘earlyprevention’orearlyterminationofpregnancymayhavepreventeddeathaftertwentyweeksgestation,orinwhichthepregnancywasconceivedbyassistedfertilitytechniquesincludinginvitrofertilisation(IVF),intracytoplasticsperminjection(ICSI)andclomidtreatment.
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Table 27: Investigated Cases with ‘Early Prevention’ Factors, WA 2002-04 Screening Factors:Patientpresentedtoolateforscreening Declinedscreeningorfollow-upamniocentesisDeclinedterminationofpregnancy Screeningnotdone–unknownifnotofferedorifdeclinedMiscommunicationinprenatalcounselling Falsenegativescreeningtest Total cases screening factors
9cases4cases2cases
10cases1case
5cases31 cases
Assisted Fertility techniques:ICSItwinpregnancy IVFsingletonpregnancy(notICSI) Clomidpregnancy–diabetesrelated Clomidpregnancy-multiplebirth Total cases assisted fertility
3cases1case
2cases1case
7 cases
Vaccine preventable diseases: CongenitalRubellasyndrome
1case
Total n=39 cases
Therewereninecaseswithlethalcongenitalabnormalitiesinwhichpatientspresentedtoolateforscreening.Therewerefourdeathsduetolethalcongenitalabnormalitieswherepatientsdeclinedtohaveprenatalscreeningandtwocaseswherepatientsdeclinedanofferofterminationofpregnancyinthepresenceoftrisomy13or18.Anotherpatienthadahigh-riskfirsttrimesterscreeningresultbutdeclinedtheofferofamniocentesis.
Thereweretendeathsofbabieswithlethalcongenitalabnormalitieswhereitwasunknownwhetherornotearlypregnancyscreeningwasoffered.Thenotesdidnotdocumentifscreeninghadbeenoffered,suggestingthatinatleastsomeofthesecasestheoptionhadnotbeendiscussed.Threeofthesecaseshadabnormalitiesdetectedby‘late’(post-20weeks)anatomyscanswhereitwasunclearastowhytheultrasoundscanshadbeenperformedlate.
Thereweresixcasesoflethalcongenitalabnormalitiesinwhichfalsenegativeresultswereobtainedonroutinescreeningtests.
Inonecasetherewasmiscommunicationintheprenatalcounsellingofapatientknowntobeatincreasedriskofhavingababywithaneuraltubedefect,wherethepatientthoughtfirsttrimesterscreeningwassufficient,andananatomyscanwasnotperformed,resultinginalatediagnosisofhydrocephalus.
Therewerethreedeathsinpregnanciesconceivedthroughclomidtherapy.Twoofthesedeathswerelikelytohavebeenduetodiabetesinthemother,andthethirdwasaneonataldeathduetoprematurityinaquadruplet.TherewerethreedeathsidentifiedintwinpregnanciesconceivedthroughtheIVFtechniqueofICSI.Onewasduetotwin-twintransfusionsyndrome(TTTS),onerelatedtodiscordantgrowthinthepresenceofacongenitalabnormality,andthethirdduetopretermbirth.Theantenatalnotesdidnotprovidedetailsastohowmanyembryosweretransferredtothemotherinthesecases.
Therewasoneneonataldeathduetocongenitalrubellasyndromewherethemothercontractedtheillnessearlyinfirsttrimester.
Itisunlikelythatthissummaryincludesallcaseswith‘earlyprevention’factors.Forexample,theremayhavebeenotherdeathsrelatedtomultiplebirthswheretheantenatalnotesdidnotspecifythatthepregnancywasaresultofanassistedfertilitytechnique.
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5Commentary
5.1 The Role of the PIMC in WATheroleofthePIMCistomakerecommendationstopractitionersandthehealthsystemtoreduceperinatalandinfantmortality.Thistaskinvolvesanalysesofindividualcasesandconsiderationofstatisticaldata.Italsorequiresconsiderationofavailableservicesandextrapolationstopredictpopulationrequirementsinthefuture.
5.2 Perinatal and Infant Mortality: How WA Compares with National Rates
TheannualnumberofbirthsinWAhasbeenaround25,000inrecentyears,althoughthereareindicationsthatthisisnowincreasing.Therewere26,792birthsinWAin20052.Therewereannualaveragesof182stillbirths(20weeksgestationor400gbirthweight),55neonataldeaths(inthefirst28daysoflife),237perinataldeaths(stillbirthsandneonataldeathscombined)and87infantdeaths(deathsinthefirstyearoflife)peryearinWAin2002-04.BirthanddeathratesforAboriginalsaremuchhigherthanthosefortheCaucasianpopulation.
Perinatalmortalityrateshavecontinuedtodeclinegradually,duetoasignificantreductionintheneonatalmortalityrate,buttherehasnotbeenasignificantreductioninthestillbirthrateinrecentdecades.Infantmortalityratesalsocontinuetodeclinegradually.Theperinatalandinfantmortalityratesinthetriennium2002-04werelowerthanthosepublishedinthe11thReportpertainingtodeathsin2000–01.Table28showsthatthestillbirthrateinWAcomparesfavourablywithnationalmortalityrates,andthattheneonatalmortalityratewasamongstthelowestofthestatesandterritoriesinAustraliain2004.ThistableisfromNationalPerinatalDataCollection(NPDC)andusesABSdataandstillbirthdefinitions(seeAppendixIfordefinitions).
Table 28: Stillbirths, Neonatal and Perinatal Deaths by State and Territory, 2004
NSW Vic Qld WA SA Tas ACT(a) NT Australia
Number
Livebirths(b)
Fetaldeaths
Neonataldeaths(c)
Perinatal deaths
85,065
561
212
773
63,082
618
207
825
50,563
347
198
545
25,340
188
61
249
17,408
113
51
164
5,483
37
12
49
4,893
33
23
56
3,452
22
19
41
255,586
1,919
783
2,702
Total births 65,626 63,700 50,910 25,528 17,521 5,520 4,926 3,474 257,205
Rate per 1000 births(d)
Fetaldeaths
Neonataldeaths(c)
Perinatal deaths
6.6
2.5
9.0
9.7
3.3
13.0
6.8
3.9
10.7
7.4
2.4
9.8
6.4
2.9
9.4
6.7
2.2
6.9
6.7
4.7
11.4
6.3
5.5
11.8
7.5
3.1
10.5
(a) 16.3%ofwomenwhogavebirthintheACTwerenon-ACTresidents.Caremustbetakenwheninterpretingrates.Forexample,forACTresidentswhogave
birthintheACT,therewere6.1fetaldeathsper1,000births,44neonataldeathsper1,000livebirthsand10.4perinataldeathsper1,000births.
(b) Includesneonataldeaths.
(c) ExceptinWAandNT,thesemayexcludeneonataldeathswithin28daysofbirthforbabiestransferredtoanotherhospitalorreadmittedtohospitalandthose
dyingathome.
(d) Fetalandperinataldeathrateswerecalculatedusingallbirths(liveandstillbirths).Neonataldeathrateswerecalculatedusingalllivebirths.
Sources:AIHW4andABS5
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Table29showsthatinfantmortalityratesinWAhavebeenamongstthelowestinAustraliainrecentyears.
Table 29: Infant Deaths by State and Territory, Australia 1984-2004
YearsNSW Vic Qld WA SA Tas ACT NT Australia(b)
rate rate rate rate rate rate rate rate rate
1984
1989
1994
1999
2000
2001
2002
2003
2004
9.2
8.7
6.3
5.8
5.2
5.3
4.6
4.6
4.6
8.8
6.5
5.1
5.6
4.5
4.8
5.0
5.1
4.5
9.0
8.5
6.2
5.7
6.2
5.9
5.8
4.8
5.2
7.6
7.4
4.7
4.3
4.6
4.6
5.1
3.7
3.2
10.7
7.8
5.6
4.7
4.3
5.1
4.3
4.1
3.9
11.8
10.6
7.5
7.6
5.8
6.2
6.2
7.0
3.6
13.8
14.5
11.3
11.7
11.7
10.7
11.3
8.4
10.7
10.0
6.5
4.7
5.6
4.2
3.0
3.4
5.8
6.9
9.2
8.0
5.9
5.7
5.2
5.3
5.0
4.8
4.7
(a) Infantdeathsper1,000livebirths.
(b) IncludesotherTerritories.
Source:ABSDeaths20046
5.3 Statewide Issues, WA
PrioritiesinMaternityandInfantHealthServicesinWA
Therehavebeengreatadvancesinthehealthofmothersandbabies,butthereareanumberofimportantchallengesintheprovisionofhealthservicesinthestateatpresent,whicharebrieflymentionedhere.Theseincludeworkforceshortages,ahighCaesareansectionrate,andchangingdemographicfeaturesofmothers.Inaddition,aconstantchallengeistoimprovehealthoutcomesforthoselivingindeprivedsocialcircumstances.
ThestateofWAhasexpansivedistances.Itisimportanttoconsiderhowhospitalservices,availablestaffandtransferservicesinmetropolitan,ruralandremoteareasareinter-relatedandhowchangesmayimpactonavailablehealthservicesandoutcomes.
Workforcefactors
Afocalissueinthedeliveryofmaternityandinfanthealthservicesisthecurrentworkforce.Thereisarecognisedworkforceshortageofobstetricians,GP-obstetricians,salariedmedicalofficerswithobstetricandneonatalskills,midwivesandneonatalnursesacrossthestate,particularlyinruralareas.18,19
WAdata[RoyalAustralasianandNewZealandCollegeofObstetricsandGynaecology(RANZCOG)2006]showaverysmallproportionofspecialistsinruralareas(Table30).19
Table 30: Proportion of Specialist Obstetricians working in Rural Areas, by State or Territory in Australia, 2001
State or Territory Total RANZCOG FellowsRural Fellows: % of State
Fellows
% Births to women resident outside major metropolitan
centre
Canberra 21 0 <1%
SA 102 4% 21%
Victoria 314 15% 21%
WA 99 8% 29%
NSW 377 18% 20%
NT 8 50% 52%
Queensland 202 26% 36%
Tasmania 24 20% 30%
Sources:ABSBirths2002.CatNo.3301.0:40-41andRANZCOGdataJuly2006;WiththankstoDrDianeMohen19.
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TheRoyalAustralianCollegeofPhysicianshasalsoindicatedthat,atleastintheimmediatefuture,therewillbeshortagesinalldisciplinesofthehealthworkforce,andthattheneedforneonatalpaediatricianshasincreased,despitethefallinperinatalmortality.20
Workforceshortagesandlossoflocalservicescanimpactoncommunitiesinmanyways.Theremaybesocialinconvenienceandfinancialimpactonfamilies,lossofcontinuityofcare,andanincreasedburdenoftransportingpatientswhocannotbecaredforlocally.Lossoffacilitiesmayalsoleadtolossofexperiencedstaff,furtherlimitingemergencyobstetricandneonatalservices.21Anexampleofthisde-skillinghasrecentlybeenseeninWAwiththeRFDSbeingcalledtoattendlow-riskmothersinspontaneoustermlabour,duetonolocalfacilities.22
Thereareidealsaboutmaternalchoiceinbirthingoptions,18,23althoughinpracticaltermsmanywomendonothavethechoicetodeliverneartheirhomes.
Patienttransferservices
Itisnoteworthythataround85%ofbirthsofverylowbirthweightbabiesoccurredinthestate’sonlytertiaryhospital,KEMH,throughouttheyears2000-04.Thisistheresultofapolicytotransferwomenearlyinpretermlabour,andistobecommended.
TheworkloadofWANTShasincreased.IntheyearJuly2001-June2002,WANTShadatotalof743transfers,iiwith507primarytransfers,including73retrievalsfromruralareasand236‘reversetransfers’.iiiThenumbershavesteadilyincreasedandin2006therewereatotalof1,074transfers,comprising664primarytransfers(n=150;22%fromruralareas)and410‘reversetransfers’.
Table31illustratesthatthenumberofWANTStransfersusingRFDShavealsoincreasedsignificantly.Reasonsfortheincreasedtransfernumbersarelikelytobemulti-factorial.
Table 31: WANTS/RFDS Transfers in 2001 and 2006, WATransfers using WANTS by source region, 2001 and 2006
Region Year 2001 Year 2006
CentralGoldfieldsGreatSouthernInterstateKimberleyMidwestPerthMetroPilbaraSouthWest
016141
1680
1116
226240
17151
1034
Total 82 129
Source:RFDS22
ii Primarytransferreferstothetransportofapatientfromalowertoahigherlevelhealthfacility,whenthepatientrequiresmoreintensivetreatmentorequipmentthanthatwhichisavailablelocally.
iii Reversetransferreferstothetransportofapatientfromahighertoalowerlevelhealthfacilityortohome,inconvalescence.
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StatewideObstetricUnit
Thereisanimportantreviewofmaternityservicesbeingundertakenatpresent,toaddresscurrentandfuturehealthservicerequirements,workforcerequirements,andtransferservices.18
Recommendation 4:
Statewide Obstetric Unit:
TheestablishedStatewideObstetricSupportUnit(SOSU)shouldbefurtherexpandedinitsroletoassistinthedeliveryofobstetriccareinWA,including:
• workforceandinfrastructureadviceandplanning.
• supportingskilledobstetricstaffinruralareas.
• producingevidence-basedpracticeprotocolsapplicabletoeacharea.
Provisionofperinatalserviceswouldideallybecoordinatedinastatewideapproach,withrecognitionofmultiplefactorsincludingworkforceissues,demographicchanges,andconsideringandbalancingtheneedforsmallerandlargerhospitalservices.ExpansionoftheactivitiesoftheestablishedStatewideObstetricSupportUnit(SOSU),alongwiththenewlyestablishedneonatalnetwork,mayhelptoaddresstheseimportantissues.WANTSprovidesahighlyvaluableserviceinprovidingconsultantadvice,andintransportingsickinfantstoappropriatespecialnurseries.24TheimportanceofWANTSandothertransportservicesshouldberecognizedandsupported.
Comments:
(see Recommendation 12):
Neonatal Network:
• The newly established Neonatal Network is supported.
• The Neonatal Network should be adequately resourced and supported to coordinate statewide neonatal care and workforce.
IncreasingCaesareansectionrates
In2004WesternAustraliahadthehighestCaesareansectionrateinAustralia.2Caesareansectionratescontinuetoriserapidly,formanyreasons.Womenarechoosingtostarttheirfamilieslaterinlife,withknownhigherrisksofcomplicationsinoldermothers,particularlyolderprimigravidwomen.25Thereisconcernabouttheincreasingnumberofwomenwithuterinescars,andtheincreasingnumberhavingmultiplerepeatCaesareansections.Theremaybeanassociatedlossofpracticalskillsintheperformanceofinstrumentalvaginaldeliveries.Caesareansectionsrequireanincreasedhospitalstay,andsignificantlyimpactonservices.The‘appropriateCaesareansectionrate’isacontentiousquestion.TherisingCaesareansectionrateisanimportantissuetobeconsidered,particularlybytheRANZCOG,SOSU,andhospitalserviceproviders.
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Otherissues
OtherimportantissuestoconsiderinperinatalserviceplanningincludeprovidingreadyaccesstohealthservicesespeciallyforthoseoflowersocioeconomicstatusandruralandAboriginalfamilies,therisingepidemicsofobesityanddiabetesmellitus,andtheagingpopulationofmothers.
5.4 Investigators’ Comments: Case Investigations WA 2002-04TheprimaryeducationalroleoftheCommitteeisemphasised.TheresumptionofactivityofthePIMCinlate2001wasinitiallymetwithsomeresistancebyasmallproportionofthemedicalcommunity.Therewasconcernaboutissuesofprivacyandconfidentiality.TheseareaswereaddressedbytheEDPH,andlegaladviceconfirmedthattheprovisionofmedicalrecordswasrequiredbylaw(the Health Act 1911)andwasinkeepingwiththeNationalPrivacyPrinciples,whichallowexemptionforthedisclosureofinformationwhenthedisclosureisrequiredbylaw.WiththepassageoftimetherehasbeenheightenedawarenessoftheroleofthePIMCsuchthatdoctorsapproachedforcasehistoriesarenowgenerallyawareoftheprocessandprovideinformationreadily.CompliancewiththePIMCrequirements,assetoutintheHealth Act 1911,wasmucheasiertoachievein2002-04thanpreviously.
Therewasanimprovementinthequalityofnote-keepingandsignificantimprovementsintheperformanceofinvestigationstoenquireintocausesofdeath.
TheInvestigatorsconsideredthattherewasagenerallyhighstandardofmedicalcareprovidedtopregnantwomenandneonates,withmanagementdecisionsreflectingeffortstopractiseevidence-basedmedicine.Thestandardofantenatalcarewasgenerallygood,withcloseadherencetorecommendationsforroutineantenatalscreeningtests,adviceaboutfolicacidsupplementation,diabetesscreeningandadministrationofprophylacticantiDinwomenwithRhesusnegativebloodgroup.Assessingthelevelofcareforinfantswassometimesdifficult,duetodifficultiesintracingnoteswheremultiplecareproviderswereinvolved.
TheInvestigatorsnotedthatmedicalandnursingpractitionersweresometimesquiteemotionallytraumatisedbyinvolvementwithastillbornbabyorinfantdeath.Theyreassuredthehealthprofessionalthattheinformationobtainedisconfidential,knownonlytotheauthorisedInvestigator,ChairmanofthePIMC,andtheEDPH,andthattheinformationispresentedtotheCommitteeinade-identifiedformat.FeedbackfromtheCommitteeiscommunicatedonlytotheattendingdoctorsandtotheEDPH.
De-briefingmaybehelpfulfollowingatraumaticevent,andpractitionersmayconsiderattendingprofessionalcounselling.Forexample‘ColleagueofFirstContact’isaserviceavailablethroughtheAustralianMedicalAssociation(AMA).26ThereisalsoprofessionaladviceandsupportavailablethroughKingEdwardMemorialHospital(KEMH)PerinatalLossService,DepartmentofPsychologicalMedicine,andatPrincessMargaretHospitalforchildren(PMH).27
5.5 Reducing Perinatal and Infant Deaths in WATheleadingcausesofstillbirthsandinfantdeathswerecongenitalabnormalities,pretermbirthsandSIDS.Abriefoverviewispresentedhere.
5.5.1 Congenital abnormalities
Congenitalabnormalitiesareasignificantpublichealthissue,beingassociatedwithpregnancyterminations,stillbirthsandinfantdeaths,andsurvivorswithseveredisabilities.
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CongenitalabnormalitiesweretheleadingcauseofstillbirthsandinfantdeathsinWAintheyears2002-04.Inthistrienniumtherewere205stillbirthsandinfantdeathsduetocongenitalabnormalities,with42oftheseduetocentralnervoussystemabnormalities.15AccordingtotheWAAbortionNotificationSystem,447(1.9%)ofthe23,997reportedabortionsintheseyearswereforsuspectedoridentifiedcongenitalabnormalities15.Thesedatashowthatover99.5%ofabortionswereundertakenpriorto20weeksgestation.Lateabortions(>=20weeksgestation)mustbeapprovedbyamedicalpanelappointedbytheMinisterforHealth9.Therewere100lateabortionsinWAin2002-04.
Primaryhealthinitiativesthatmakeanimpactonthenumberofbabieswithcongenitalabnormalitiesincludegoodmaternalnutrition,periconceptionalfolicacidsupplementationandavoidanceofharmfulsubstancesinearlypregnancy.Itisrecommended(Recommendation1)thateducationaleffortsinformthepublicofimportantpre-conceptioninformation,includinginformationabouttheincreasedriskofcongenitalabnormalitieswithincreasingmaternalageandthedecreasedriskofcentralnervoussystemcongenitalabnormalitieswithpericonceptionalfolicacidsupplementation.Thereisevidencethatfortifyingfoodswithfolicacidcansignificantlyreducetheincidenceofneuraltubedefects,thusreducingthenumberofbabiesaffectedbythisconditionandreducingthenumberofpregnancyterminations.Thereisalsoevidencethatmandatoryfortificationwithfolicacidissuperiortovoluntaryfortification.28,29,30
Therewere31caseswhere‘screeningfactors’wereidentifiedintheinvestigateddeathsWA2002-04,wheredeathsmayhavebeenpreventedafter20weeksgestation.Guidelinesaboutprenatalscreeningtestsandinterpretationofresultsareavailable:http://kemh.health.wa.gov.au/health/fetal_monitoring/
Recommendation 1:
Antenatal Education:
Antenatalpublichealthprogramsshouldbeapriority,addressing:
• smokingcessation
• goodnutrition/periconceptionalfolicacidsupplementation
• healthyweight
• earlypregnancyscreeningforcongenitalabnormalities
• avoidanceofalcoholandotherharmfulsubstances
5.5.2 Preterm Birth
Pretermbirth(delivery<37weeksgestation)isamajorchallenge,beingaleadingcauseofperinataldeath,aswellasamajorriskfactorfordisability.31,32InWA2002-04,itwasthesecondhighestcauseofperinataldeath.Aboriginalandnon-Aboriginalpretermbirthrateshavesignificantlyincreasedoverthe15years1990-2004inWA(p=0.009andp<0.001respectively).Nationalfiguresshowthat7.4%ofbirthsoccurredpretermin2004,withtrenddatashowingthattheprevalenceisincreasing.4Asimilarincreaseintheprevalenceofpretermbirthhasbeenseeninmostcountriesinrecentdecades.
Usefulpredictiveteststoidentifywomenwhoareatriskofpretermdeliveryareultrasoundassessmentofcervicallengthandfetalfibronectin.Thesetestshavehighnegativepredictivevalues,butpoorpositivepredictivevalues.33–36
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Negativeresultsinthesetestsmayhelppreventunnecessarytransferfromaruralsettingtoaregionalortertiarycentre,andassistindecisionsregardingadministrationofcorticosteroids.Forexample,awomanwithsymptomsofpretermlabourbutintactmembranesmaynotrequiretransferwherethereisanegativefetalfibronectintestandlongclosedcervix,assheismostlikelynotinpretermlabour.35However,wherethereremainssignificantclinicalconcernaboutariskofpretermdeliveryinanareawithoutneonatalfacilities,inuterotransferremainsthepreferredmanagementoption.Thereisstillsomequestionastowhetherclinicianswillaltertheirmanagementbasedonfibronectinresults37.PreliminaryWAdatahaveshownasmallbutsignificantreductioninruraltransfersforthreatenedpretermlaboursincetheintroductionoffetalfibronectintesting.38
Currentguidelinesforthemanagementofpretermlabourareavailableon-line:http://kemh.health.wa.gov.au/development/manuals/sectionb/index.htmAsinglecourseofantenatalcorticosteroidsisrecommendedinwomenwiththreatenedpretermlabourbetween24and34weeksgestation.
TheresultsofcurrenttrialsinWAstudyinginterventionsaimedatpreventingpretermbirthmayprovideinformationonbetterpreventionandtreatmentstrategies.
5.5.3 Unexplained antepartum death
ThereductioninperinatalmortalityinAustraliainrecentdecadeshasbeenalmostentirelyduetoareductioninneonatalmortalityrates.Thetwoleading‘causes’ofstillbirtharecongenitalabnormalitiesand‘unexplained’,whichhelpstoexplaintherelativelystaticnumbers.Ifresearchcanbegintofindaetiologicalfactorsinthe‘unexplained’group,possiblereductionsmaybeachievedinthefuture.Thoroughpost-mortemexaminationandpathologicalinvestigationsarerecommendedfollowingallstillbirths.Satisfactoryinquiryintodeathswillresultinfewer‘unexplored’cases,whichwouldotherwisebecategorizedinthe‘unexplained’group.Inaddition,improvedclassificationsystemsassistinidentifyingsub-groupswhichmayimproveourunderstandingandleadtocausesbeingilluminated.Forexample,whilsttheaetiologiesoffetalgrowthrestrictionaremulti-factorialandill-understood,itisabetterdescriptorthansimply‘unexplained’.Theprevalenceoffetalgrowthrestrictionwasnotobviouswitholderclassificationsystems,suchastheWigglesworthclassification,becausethesedeathswereinthegroupof‘unexplained’stillbirth,butthedesignationofthiscategoryofstillbirthinnewerclassificationsystems,suchasPSANZclassificationand“RelevantConditionatDeath”(ReCoDe)classification,allowsappreciationofitsimportance.40
Areviewoftheliteratureidentifiesthemostprevalentriskfactorsforstillbirthaspre-pregnancyobesity,lowersocioeconomicstatusandadvancedmaternalage.41,42,47Unexplainedstillbirthsanddeathsrelatedtofetalgrowthrestrictionarethetwocategoriesthatcontributemosttolatefetallosses.Latepregnancy(especially>39weeksgestation)isassociatedwithanincreasingriskofstillbirth41,43,44,45andcliniciansshouldhavealowthresholdtoarrangingultrasoundevaluationoffetalgrowthandwellbeingwherethereisanyclinicalconcern.46Stillbirthiscommonlyassociatedwithintrauterinegrowthrestriction,whichisoftennotidentifieduntilafterbirth.47,48Withtrendsofincreasingmaternalageandobesity,itmaybebeneficialformorewomentohavelategestationalultrasoundstoassessfetalwell-being,withparticularattentiontofetalabdominalcircumference,amnioticfluidvolumeandDopplerstudies,althoughthismayleadtoanincreaseininterventions.TheCommitteesuggeststheuseofaroutineultrasoundexaminationinthirdtrimesterforobesemothersandoldermothers,especiallythosewhosmokeorhaveotherriskfactors.
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Recommendation 8:
Obesity:
Inobesewomenultrasoundassessmentoffetalgrowthisadvisedinthethirdtrimester,toidentifymacrosomicfetusesandgrowthrestrictedfetuses.
Recommendation 10:
Maternal age:
Inoldermothers,ultrasoundexaminationisadvisedinthethirdtrimester,inordertoidentifyfetalgrowthrestriction.
5.5.4 SIDS
ReductioninthemortalityfromSIDShasbeenaconsiderablepublichealthachievement,basedonaneducationcampaignaboutavoidingtheknownriskfactorsofpronesleepingposition,smokingandexcessivebedding.However,therecontinuetobedeathsduetoSIDSwithknownavoidableriskfactors,particularlyinthehigh-riskgroupsofinfantsofsmokers,Aboriginalsandinfantsfromlowersocioeconomicbackgrounds.
TheproportionofSIDScaseswithcertainriskfactorshaschanged.Forexampleinthepast20yearsintheUKtheproportionofdeathswiththeriskfactorsofmaternalsmoking,deprivedsocioeconomicbackground,co-sleeping(especiallyonacouch)andpretermbirtharenowsignificantlyhigherthaninthepast.49
Maternalsmoking,amajorriskfactor,wasassociatedwith74%(17of23cases)ofSIDScasesinWA2002-04.
Co-sleeping
Theissueofco-sleepinghasemergedasamoreimportantfactorthanpreviouslyrecognized.Overthepast20years,theproportionofchildrenwhodiedfromSIDSwhilstco-sleepingwiththeirparentshasrisenfrom12%to50%intheUK(p<0.0001)buttheactualnumberofSIDSdeathsintheparentalbedhashalved(p=0.01).49SimilarlyinWAtherehasbeenareductionintotaldeaths,andjustoverhalfoftheSIDSdeathsin2002-04wereinassociationwithco-sleeping.
Thereisdebateaboutthemeritsanddangersofinfantparentbed-sharing.50Evidenceshowsanincreasedriskofsuddeninfantdeathininfantsbed-sharingwithmotherswhoaresmokers,particularlyininfantsundertheageoffourmonths,andin‘vulnerableinfants’bornpretermorlowbirthweight.51–56Thereisevidencethatsleepingonasofaisofparticularlyhighrisk.51,56
Studiesoftheriskofparentalbed-sharingonSIDSintheabsenceofknownriskfactorssuchassmokingandpretermbirth,havehadvariableresults.Somesub-groupdataanalyseshaveshownlittle(aroundtwo-fold)ornoextrariskofSIDS,51–54,57,58whileothershaveshownamuchgreaterassociation,suchasonerobuststudywhichshowedaneight-foldincreasedriskinnon-smokingmotherswhoco-sleptwithinfantslessthan11weeksofage.56
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Theriskofsuddenunexpectedinfantdeathassociatedwithco-sleepingislikelytobeunderestimatedbecausestudiesofSIDSandco-sleepingexcludedeathsdueto‘accidentalasphyxiation’andotherSIDS-likedeathswith‘indeterminatecauses’thatdonotquitefitthedefinitionofSIDS.WA2002-04datashowedatotalof33casesofunexpectedinfantdeathinassociationwithco-sleeping,withlessthanhalfoftheseattributedtoSIDS(n=13;39%).
Consideringcurrentevidence,itisreasonabletorecommendthatparentsavoidco-sleepingwhenthemothersmokedinpregnancy,wheneitherparenthasanimpairedconsciousstate,withinfantsundertheageoffourmonths,andwithinfantsbornpretermoroflowbirthweight.Co-sleepingonacouchshouldbeavoidedatalltimes.Thereisevidencethatroomsharinginaseparatecot(ratherbedsharing)withanadultisprotectiveandshouldbeencouragedinthefirstfewmonthsoflife.54,55
TheCoronerinWA59recommendsthatbedsharingbeavoided:
- whentheparentisasmoker,undertheinfluenceofalcohol/sedationorexcessivelytired
- withotherchildren/petsonthebed
- onasofa/waterbed,beanbagorsaggingmattress/adultbed
DefinitionsofSIDS:
ItisworthcommentingonchangesinthedefinitionofSIDS.UntilrecentlymanydeathssuchasaccidentalasphyxiabyoverlayinghavenotbeenclassifiedasSIDS,andanumberofdeathshavebeenclassifiedas‘unascertainable’.ManyofthesewouldfulfilthemostrecentlyacceptedcriteriaforSIDS,asagreedataninternationalmeetinginSanDiegoin2004:SIDSis‘thesuddenunexpecteddeathofaninfantunderoneyearofage,withonsetofthefatalepisodeapparentlyoccurringduringsleep,thatremainsunexplainedafterathoroughinvestigation,includingperformanceofacompleteautopsyandareviewofthecircumstancesofthedeathandtheclinicalhistory.’ThismayresultinanapparentincreaseinSIDSdeathsfromaround2005onwards.
AboriginalInfants
WAdatahaveshownamuchhigherriskofdeathduetoSIDSinAboriginalcomparedwithnon-Aboriginalinfants,asshowninFig4for2002-04,witharelativeriskof9.50(95%CI4.11-21.95).ConsideringtrenddatainWAfrom1980-2001,therateofdeathduetoSIDSwasthoughttohavedecreasedsignificantlyinbothpopulations,withthedifferenceinthedeclinebeingsignificantlygreaterinthenon-Aboriginalpopulation,howevercloseranalysisofdataincludingthegroupof‘unascertainabledeaths’aswellas‘SIDS’casesshowedthatthedecreaseindeathsinAboriginalinfantswasnotsignificant.61Thatis,thereductioninsuddenunexpectedinfantdeathsseeninnon-AboriginalinfantsinWAhasnotbeenexperiencedintheAboriginalpopulation.Methodstoaddressthisarebeingexplored.
Aprojectfundedthrough‘SIDSandKidsWA’andtheDepartmentofHealth,WAonSafe Sleeping in Aboriginal Communities hasincludedfocusgroupswithAboriginalwomenledbyAboriginalwomen.62TheprojecthasdevelopedinformationmaterialsforNoongarpeople,andhasrecentlyconductedfocusgroupswithKimberleyAboriginalgroupsandinterestedparties.TheconsultationprocessidentifiedAboriginalculturalandpracticalissuesthatdifferedmarkedlyfromSouthernAboriginalcommunities,especiallyinrespecttosafesleepingpractices.IngeneraltherewasalackofawarenessaboutSIDSriskfactorssuchaspronesleepingandprovidingasmoke-freeenvironmentforbabies.Kimberleycommunitiesviewedsafesleepingasaprotectivepracticeinrespecttosexualabuse.Co-sleepingwasreportedasacultural‘norm’andfacilitatedbreastfeeding.
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TherearemanyfactorstoconsiderinthebestapproachtowardsaddressingriskfactorsforSIDS,with‘awarenessoffamily,socialandethniccontext’.63Culturalandpracticalfactorsmustbeunderstoodandhighlighted.Theoptionofaseparatecotforababymaynotbeanoptioninsomefamilies,andmoreimportant‘safety’issuesmaysurroundtheareasofbonding,breastfeeding,thermoregulationandprotectionfromdomesticviolence.Ratherthana‘neverco-sleep’message,thebestcompromisemaybetostressprioritypublichealthissues:dissuadingmothersfromsmoking,drinkingalcoholandusingotherharmfulsubstanceswhilstpregnantandcaringforsmallchildrenandavoidanceofthepronesleepingpositionforinfants.TheMinisterialAdvisoryCouncilonthePreventionofDeathsinChildrenandYoungPeopleisalsolookingatthisissue.
Publiceducation:
Disseminationofinformationisrequiredtothosemostatriskandtostaffinvolvedinchild-care.64Usefuleducationalpamphletsforparentsandhealthprofessionalsabouttherisksofco-sleeping(particularlyinthepresenceofmaternalintoxication)wereincludedinthePIMC’s11thReport.3FurtherHealthDepartmentpolicyisbeingdevelopedinthisarea,withspecialreferencetoculturalissues.65
Recommendation 15:
Sudden Infant Death Syndrome:
IncreasingpublicknowledgeaboutwaystoreduceSIDSisadvised.Specialattentionshouldbegiventodeliveringinformationtofamilieswithriskfactors,andinstitutionsthatprovideinfantcare.Inadditiontothecurrenteducationaboutsafersleepingpractices,thereshouldbemessagesabouttheincreasedriskofinfantdeathrelatedto:
• co-sleepinginthepresenceofparentalsmoking/alcohol/druguse,andinsmallbabiesespeciallyundertheageof4months.
• co-sleepingonacouch.
ParentsshouldbeadvisedthatthereisadecreasedriskofSIDSwhereparentsroom-sharewiththeirbabyinaseparatecotforthefirstfewmonthsoflife,comparedwiththebabysleepinginaseparateroomtoitsparents.
5.5.5 Preventable Deaths, WA 2002-04
ThedatarelatingtotheCommittee’s11thReportcontainedinvestigationsofaspeciallyselectedsubsetofdeathsofatleast32weeksgestationalage,chosenatthediscretionoftheEDPH.Thesedatawerethoughttorepresentahigherproportionofpotentiallyavoidabledeaths,andwereconsideredunlikelytoberepresentativeofalldeaths.From2002onwardstheEDPHdirectedtheCommitteetoinvestigateabroaderrangeofcases,beingalldeathsfrom26weeksorgreatergestationalage,withtheexceptionofknownterminations.Ofthe167investigateddeathsintheyears2000-01,51(31%)werefoundtohavepossiblepreventablemedicalfactors,with15(9%)ofthesedeathsconsideredpotentiallyavoidable.Datafortheyears2002-04indicatealowerproportionofdeathswithpossiblepreventablefactors,with59(13.3%)of445investigateddeathsintheseyearscodedwithpossiblepreventablemedicalfactors,and18(4.0%)oftheseconsideredpotentiallyavoidabledeaths.
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Comments:
The peer review process of this Perinatal and Infant Mortality Committee showed that in the triennium 2002-04 87% of deaths met the Committee’s expectations of appropriate medical care, and 96% of deaths were considered unavoidable in a medical context.
Themainareaswherepreventablemedicalfactorswereidentifiedwereintheareasof:managementoflabour,fetalgrowth
Skills,KnowledgeandTraining
Specificrecommendationsthatflowedfromthecasereviewsarenowdiscussed.
Hypertensionanddiabetesaretwoofthemostcommonmedicalconditionstocomplicatepregnancy(7-10%and3-5%respectively)butoptimalmanagementhasbeenshowntoreducetheriskofpregnancylossconsiderably.46Thesewereareasofconcerninthepastthatarenowgenerallywellmanaged.TherewereasmallnumberofdeathsduetohypertensionanddiabetesmellitusidentifiedbytheCommitteein2002-04whereimprovedmedicalmanagementwasindicated.However,themainareaswheretheCommitteeconsideredthatmedicalmanagementmayhavebeenbetterwereinthemanagementoflabour,identificationoffetalgrowthrestriction,managementofperipartumsepsisandthesickneonate.
Readyaccesstoon-lineguidelines,atthepointofpatientcontact,isimportanttoensureup-to-datemanagementdecisions.39,66KEMHguidelinesontheinternetwerepreviouslyaccessibleonlybypassword,butthepasswordfeaturewasrecentlyremovedtoallowuniversalaccess,makingiteasiertoobtaincurrentmedicalmanagementadvice.
TheCommitteediscussedtheneedforadequatetrainingandretentionoftechnicalskillsfordoctorsandmidwives.Newtechniquesmaybebeneficialinthisrespect.Forexample,improvementsintechnicalabilitytomanageemergenciessuchasshoulderdystociahavebeenshownwithsimulationtrainingwithmanikins.67
Clearcommunicationandgoodteamworkwithotherstaffishighlyimportant,particularlyinemergencysituations.
Recommendation 5:
Professional Training:
Medicalpractitionersandmidwivesshouldhavetrainingandpracticedrills,particularlyinthefollowingareas:
• Useandinterpretationofelectronicfetalheartratemonitoringinlabour
• Resuscitationofthenewborn
• Managementofobstetricemergencies,particularlyshoulderdystocia.
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Recommendation 6:
Clinical Guidelines:
On-lineaccesstoclinicalguidelinesshouldbeavailableatthepointofpatientcontact.
Obstetriccare:
Hypoxicperipartumdeaths
Whilsthypoxicperipartumdeathsrepresented8.5%oftheinvestigatedperinataldeathsinWA2002-04(15stillbirthsand15neonataldeaths),almosthalfofthese(14deaths)hadpreventablemedicalfactors.
Thecorrectuseandinterpretationofelectronicfetalheartratemonitoringmayhaveassistedinninecases.TheCommitteesuggeststheneedforimprovedtrainingofstaffinmonitoringoffetalwellbeinginlabour.17
Diabetes
Fivedeathswithpreventablemedicalfactorsinthetriennium2002-04wereattributedtodiabetes.AdetailedupdateofmanagementofdiabetesinpregnancyisincludedinSection6.2EducationalPapers.
AlmosthalfoftheAboriginalwomenexperiencingstillbirthshadinfrequentantenatalattendanceorpoorcompliancewithrecommendedantenatalcare.Aboriginalwomenwithdiabetesmayhavehadimprovedoutcomesiftheyhadaccesstospecialiseddiabetesclinics.Someofthesewomenhadpoorcomplianceduetosocialortransportissues,andsomewerenotreferredtospecialisedcare.Thepatientassistedtransportscheme(PATS)providesfinancialsupportforwomenreferredtospecialistcareawayfromhome,buttherecontinuetobebarrierstowomenattendingspecialistservices,particularlywheretheyhaveotherdependants,andlimitedaccommodationoptionsinspecialistcentres.Forexamplesometimesthereishostelaccommodationavailableforthepatient,butnottherestofherfamily.Thesemaybesignificantdisincentivestotraveltoappointments.
Improvingaccesstospecialiseddiabetesservicesmaybeachievedthroughincreasingthenumberofsuchclinics,utilisingtelephonesupportfromtheclinics,andincreasingdomiciliaryservices(outreachfromthetertiaryandregionalcentres,toremoteareas).Inparticular,culturallyappropriateoutreachservices,withmultidisciplinaryteamsincludingAboriginalhealthworkersmayimprovecompliance.
Itisoftennecessaryforlocalgeneralpractitionersandmidwivestobeinvolvedinthemanagementofhigh-riskpatientsinruralareas,particularlywhenpatientsarereluctanttotraveltometropolitanorregionalspecialisedclinics.Wherethisoccurs,frequentliaisonwithspecialistsisrecommended.Patientsarealsoencouragedtoaccesstelephoneadviceformonitoringandadjustmentsoftreatments,suchasinsulindoses.
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Recommendation 7:
Diabetes in Pregnancy:
Routinemanagementofpatientswithdiabetesinpregnancyshouldinvolve:
• educationanddietaryadvice.
• monitoringbloodglucoselevelstoassessglycaemiccontrol.
• specialistconsultation/liaisonforthosepatientswithpoorglycaemiccontrol.
• routinemonitoringoffetalwellbeing,includingultrasoundassessmentforfetalmacrosomia.
Pre-eclampsia
Fourofthe30stillbirthsassociatedwithhypertensionhadpreventablemedicalfactors.Antihypertensivemedicationshouldbeusedwithprudenceinpregnancy.Treatmentmaymasktheprogressionofpre-eclampsia,andtimelydeliveryshouldbecarefullyconsideredinthepresenceofthisdisease.
Antenatallow-doseaspirintherapyhasbeenshowntoreducetheriskofrecurrentpre-eclampsia,birthpriorto34weeksgestationandperinataldeathinhighriskwomen,anditsuseisrecommended,alongwithconsultantmanagement.68
Twins
Earlyultrasoundassessmentshouldidentifytwinpregnanciesatincreasedriskoftwintotwintransfusionsyndrome.Itissuggestedthatthosewithmonochorionictwinpregnanciesshouldhaveultrasoundsurveillanceforfetalgrowthat18,24,27,30,33and36weeksgestation.Thosewithdichorionicpregnanciesshouldhaveultrasoundmonitoringat18,26,30,33and36weeksgestation.39FurtherdiscussionoftwinsisinSection6.3ofthisreport.
Thereweresixdeathsinpregnanciesconceivedthroughassistedfertilitytechniques,withfouroftheseinvolvingmultiplepregnancies.Carefulmonitoringandapplicationofassistedfertilitytechniquesisadvised,toreducetheincidenceofmultiplepregnancy.
Recommendation 9:
Multiple Pregnancy:
Managementofmultiplepregnancyrequiresascertainmentofchorionicityat12weeksgestationandfrequentultrasoundassessmentsoffetalgrowth,asperguidelines:
KingEdwardMemorialHospitalguidelinesforobstetrics:http://kemh.health.wa.gov.au/development/manuals/sectionb/index.htm
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NeonatalCareAsignificantproportionofnewbornsaregivensometypeofresuscitation.OfbabiesborninWAin2004,41.8%hadsomeformofresuscitation(mainlyoropharyngealandnasalsuctionandfree-flowoxygen);7.2%requiredmoreactiveresuscitationwithbagandmaskventilationorendotrachealintubation.2
Guidelinesaboutresuscitationhavelargelybeenbasedonprecedent,andmaybealteredwithnewresearch,forexamplesomeevidencechallengingthebeliefthatoxygenissuperiortoairforresuscitation.69,70ThishastoledtoKEMHandPMHadoptingtheuseofoxygenblendersandrecommendinginitialsettingsof30%oxygenintheresuscitationofthenewborn,pendingfurtherevidencebeingavailable.Theseneonatalcareguidelinesareavailableon-line.KEMHandPMHfollowtheAmericanAcademyofPaediatricsandAmericanHeartAssociationalgorithmforresuscitation,whichistaughtthroughtheNeonatalResuscitationProgram(NRP)inWA.72
Theendotrachealrouteofadministrationofdrugsisthoughttobeusefulwhereintravenousaccessisnotyetestablished,butthereislessdataaboutadministrationofdrugsgiventhisway.73Umbilicalvenousaccesscanusuallybesecuredreadilyinnewborns.Naloxoneshouldnotbegivenintheabsenceoflikelymaternalopiatedepression.
Medicalandmidwiferystaffmaybenefitfromregular‘drills’intechnicalskillsforresuscitationofthenewborn.Theuseoftrainingprogramswithmanikinsmaybehelpful.74
Usefuladviceaboutthecareofsickneonateandtransportissues,withattentiontopracticaladvice,isavailableintheWANTSMedicalManual,24withsummaryguidelines‘StabilisationandTransferoftheSickNeonate’availableinthe11thPIMCReport.3
Australiandatahaveidentifiedthatequipmentvariesbetweeninstitutions,andthisvariationreflectslackofclinicalevidencethatresultsinuncertaintyindecisionmaking.75Equipmentproblemsand/orfamiliaritywiththeavailableresuscitationequipmentmayhavebeenunidentifiedsystemsissuesintheWA2002-04caseswherethereweredifficultieswithresuscitationofthenewborn.ThemethodsusedbytheCommitteemakeitdifficulttodetectsuchproblems,astheyareusuallynotdocumented.
ParticularCommitteecommentsthatarosefromthecasereviewsofthedeathsinWA2002-04included:
a)CloseobservationshouldbemadeofanewbornwithlowApgarscoresandsuspectedbirthasphyxia.ThisisbestdoneinaneonatalintensivecareunitoratleastalevelIInursery.
b)Inthepresenceofunexpecteddifficultyinventilatingababy,oneshouldconsiderthepresenceofpneumothoraxordiaphragmatichernia.
c)Theimportanceofvolumeexpansionisstressed,particularlyinthecircumstancewhereitissuspectedthataninfanthaslostbloodvolume.
d)Infantsexpectedtodeliverpriorto34weeksgestationshouldbereferredtoKEMH,thestate’stertiaryperinatalcentre.
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Recommendation 12:
Neonatal Management issues:
ThenewlyestablishedNeonatalNetworkissupported.
TheNeonatalNetworkshouldbeadequatelyresourcedandsupportedtocoordinatestatewideneonatalcareandworkforce.
12.1 AbabywithpoorApgarscores(suspectedbirthasphyxia)shouldinitiallybemanagedinalevelIIorIIIspecialcarenursery,particularlybeingawareoftheproblemsofhypoglycaemiaandmetabolicacidosis.
12.2 Wherethereisneonatalshock(e.g.sepsis,birthtrauma/sub-galealhaemorrhage),staffshouldbeawareofthebaby’sneedforrapidintravenousvolumereplacement.
12.3 Infantswithrespiratorydistressorothersignsofsepsisshouldbetreatedpromptlywithantibiotics.
Recommendation 13:
Transport Issues:
13.1 Careshouldbetakentodeliverbabieslikelytorequirespecialnurserycareinanappropriatelystaffedandequippedhospital.
13.2 Referringstaffareencouragedtoanticipatetransfer,phoneearly,andcloselyliaisewithtransportstaff,toassistinprioritisationoftransportneeds.
GroupBStreptococcalSepsis
TheCommitteeadvisesthatpractitionersshouldhaveahighindexofsuspicionofsepsisin‘unwell’neonatesandfollowinghigh-risklabours,andantibioticsshouldbeadministeredquicklywherethereispotentialbacterialsepsis.Anyrespiratorydistressinanewbornshouldbetreatedswiftlyandthebabyshouldbetransferredtoaspecialcarenursery.
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Recommendation 11:
Group B Streptococcus Guidelines:
• GuidelinesforscreeningforGroupBStreptococcusat36weeksgestationofpregnancy,andintrapartumantibiotictreatmentforcarriersisrecommended:
KingEdwardMemorialHospitalguidelinesforobstetrics:http://kemh.health.wa.gov.au/development/manuals/sectionb/index.htm
• Staffshouldbeawareofguidelinestoreducetheriskofneonatalsepsis:
PMHandKEMHClinicalGuidelinesforNeonates:http://kemh.health.wa.gov.au/development/manuals/sectionb/11/7278.pdf
MedicalErrors
Thereareconsiderabledifficultiesinidentifyingandassessingmedicalerrors,near-missesandotheradverseeventsthatmayaffectpatientoutcome.77ThePIMCdoesnotassessbroaderissuesofmorbidity,norerrorsthatdonotresultindeaths.Healthcareprovidersareencouragedtoassesstheiroutcomes,includingassessmentsoferrorsornear-errors,toworktowardsbettersystems.
5.5.6 Maternal Behavioural Factors
Withreductionsindeathsassociatedwithmedicalfactors,parentalbehaviouralfactorsareincreasinglythefocusofthePIMC.
Compliance
Infrequentantenatalattendanceisassociatedwithanincreasedriskoftermstillbirth,aftercorrectingforsocioeconomicstatus.41Poormaternalcompliancewasafactorin14%ofinvestigateddeathsinWA2002-04.Inparticular,asignificantproportionofAboriginalmothersexperiencingaperinatalorinfantdeathhadpoorcompliancewithantenatalcare.Therearemanyreasonsforpoorattendance.Attendanceismorelikelyatculturallyacceptableandeasilyaccessedclinics.Forexample,acommunity-basedmodelofcarespecificallyforAboriginalmothersinQueenslandshowedsignificantlyimprovedattendanceforantenatalcare,andwhilstitdidnotshowasignificantreductionintheprevalenceoflowbirthweightorperinatalmortality,itdidshowreducedratesofpretermbirth.ConsiderationshouldbegiventoincreasingthenumberofdedicatedantenatalclinicsforAboriginalwomen.
Thereisnoroutinecollectionofinformationaboutnumberofantenatalattendances.Addingaquestionaboutantenatalattendancetomidwiferynotificationformsmayleadtoabetterunderstandingofcompliancefactors.
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SubstanceUse
Smokingandsubstanceuseareimportantmodifiableriskfactors.Smokingratesaredeclining,butstillrelativelyhighamongstthoseoflowersocioeconomicstatus.Thereareproblemsindatacollectionaboutillicitsubstanceuseinpregnancy,andtheextentoftheproblemisnotwellunderstood,butmaybeincreasing.ThenumberofpatientsusingillicitsubstancesatthetimeofpostnataldischargefromKEMHhasincreasedsteadilyfrom38womeninthesixmonthperiodJuly-December2004to88womeninthesixmonthperiodJuly-December2006,andsuggeststhattheremaybeanincreaseintheprevalenceofwomenwithseriousdruguseproblemsinpregnancy.79
Recommendation 14:
Data collection:
Collectionofadditionalinformationonmidwiferynotificationformsisrecommended.Questionsaboutnumberofantenatalvisits,maternalweightandalcoholusearesuggested.
Practitionersareurgedtoenquireintoandprovidecounsellingaboutsmoking,alcoholandothersubstanceuseinpregnancy.Theuseofmultidisciplinaryspecialisedchemicaldependencyclinicsarerecommendedformotherswithaddiction/substanceuseproblems,astheseareaparticularlyhighriskandchallenginggroup.
Thereisanincreasedriskofneonatalmortalityassociatedwithwomenusingopiatesinpregnancy.Inparticular,ameta-analysishasshownthatacombinationofheroinandmethadoneuseduringpregnancy,comparedtothosestabilisedonmethadone,isassociatedwithahigherrisk,thoughtlikelytobeduetothechaoticandhigh-risklifestyleassociatedwithillicitheroinuse,andnotsolelytotheuseoftheopiates.Itisrecommendedthatwomenwhouseillicitheroinduringpregnancyreceivespecialattentionoverandabovethatprovidedtowomenstabilisedonmethadone.80
Thepostnatalfollow-upofmothersusingillicitsubstancesisparticularlyimportant,withinvolvementofsocialworkersandotherwelfareagenciesstronglyrecommended.TheCommitteehaslimiteddataaboutthecurrentstateoffollow-upofsuchhigh-riskwomen,andthisisanareawherepotentialbenefitsmaybeseen.
Thereareanumberofservicesthatprovideassistancetomothersandfamilies.Theseincludechildhealthnurses,generalpractitioners,psychiatricservices,DepartmentofCommunityDevelopment,DepartmentofChildProtectionandnon-Governmentalagencies.Therearealsodedicatedservicesthatprovidecounselling,supportandoutreachservicestowomenwhoarepregnantand/orparentingandhaveproblematicalcoholand/orothersubstanceuse,suchasthePregnancyandParentingSubstanceUseProgram(PEPISU).81
Violence
DomesticviolencewasadocumentedprobleminfifteenwomenwhoexperiencedastillbirthorinfantdeathinWAin2002-04.Itisdifficulttoknowtheprevalenceofdomesticviolenceinthecommunity.
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Therewere946hospitaladmissionsduetointimatepartnerviolencerecordedinWAintheperiodJuly2002-December2003,inpeopleaged15yearsandover.Theratewas40.9per100,000populationand85%ofvictimswerefemale.82TherateforAboriginalpeople(n=677)was83timesgreaterthanfornon-Aboriginalpeople(n=284).Ruralresidentsaccountedfor71%ofhospitalisationsforthecareofvictimsofdomesticviolence,howeverruralresidentsrepresented24%ofthepopulationinWAduringthestudyperiod.82
Advocacyhasbeenshowntoreducere-abuse,andthereisevidencethatcounsellingandsafetyplanningarebeneficial.83KEMHnowscreensallpregnantwomenfordomesticviolenceattheroutinebooking-invisit.InformationandresourcesforthisareaareavailablethroughDomesticViolenceAdvocacySupportCentral(‘dvascentral’)84whichisapartnershipoforganisationsincludingLegalAid,WAPoliceServiceandotherGovernmentalorganisations,andYorgumAboriginalCounsellingService.
ChildAbuse
TeninfantdeathsinWA2002-04wereduetonon-accidentalinjury.TheincidenceofchildabuseissignificantinAustralia,moreprevalentinAboriginalcommunities,andthoughttobeunder-estimated.TheAustralianInstituteofHealthandWelfare(AIHW)hascollectedthenationalchildprotectiondatasincetheearly1990’s.Thedatacoverchildprotectionnotifications,investigationsandsubstantiations(formerlyreferredtoaschildabuseandneglect),childrenon‘careandprotectionorders’,thoseinout-of-homecareandthosereceivingintensivefamilysupportservices.Therearesignificantdifferencesinchildprotectionprocessesbetweenstates,sopublishedfiguresmustbeinterpretedwithcaution,buttheydoshowthatasignificantnumberofchildrenaresubjecttoabuseorneglect,withtheriskinAboriginalchildrenbeingconsiderablyhigherthaninnon-Aboriginalchildren.85,86In2003–04therateofchildrenenrolledinthechildprotectionsysteminAboriginalfamiliesinWAwasaround8timeshigherthaninnon-Aboriginalfamilies.Childrenatincreasedriskofchildabuseincludethoselivinginpoorhousingconditions,oflowsocioeconomicstatus,andfromsingleparentorblendedfamilies.85
TheRoyalAustralasianCollegeofPaediatricianshasadiscussionpaperaboutthecomplexissueofchildabuseandconsideringtheprobleminitsbroadersocialcontext.87TheCollegesuggeststhatwhenachildisatriskoforisbeingabused,actionmustbetakenquicklyandintensively.Itrecommendsaconsistentsystemsapproach,earlyinterventionprogramsandthatsocialpoliciesbereviewedtoimproveoutcomesforchildren,suchasinthejusticesystem.Itstatesthatpaediatriciansshouldplayakeyroleinchildprotection,andacknowledgestheimportanceofinvolvedprofessionalsandagenciesworkinginpartnershipforthebenefitofchildren.Thereiscommentontheneedtoimprovedatacollectionandreview,andfortrainingforthoseinvolvedinthiswork.
Summary:socialriskfactors
Alargenumberoforganisationsprovidesupporttothosewithsocialriskfactors.TheCommitteesuggeststhatsuchorganisationsbefurtherassistedintheirendeavours.Newinitiativesarealsosought.
AreviewoftheGovernmentalDepartmentsofCommunityDevelopmentandChildProtectionisinprocess.
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Theuseofspecialisedservicesmayimprovecomplianceandoutcomes,suchas:
DedicatedantenatalclinicsforAboriginalwomen
Specialistdiabetesservicesforpregnantwomenwithdiabetesmellitus
Alcohol/drugdependencyservicesforpregnantwomenwithaddiction
Psychiatricservicesforwomenwithmentalhealthproblemsinpregnancyandthepuerperium
Dedicatedantenatalandpostnatalservicesforadolescentmothers.
Recommendation 2:
Social Issues:
Supportforthosewithsocialriskfactorsneedstobeimproved.
2.1 Increasedsupportshouldbegiventoagenciesworkingtoassistfamilieswithsocialriskfactorssuchaspoorhousing,domesticviolenceandalcoholandothersubstanceuse.
2.2Outreachservicesarerecommendedtoimprovecompliancewithantenatalcareforthosewithspecialneeds.
2.3 Screeningfordepressionanddomesticviolenceisrecommendedasaroutineinantenatalandpostnatalassessments.
5.5.7 Aboriginal Health
Medicalandsocialadvanceshaveseenstrikingreductionsinstillbirthandinfantmortalityratesovertime,particularlyinfirstworldcountries.Theresultsshowninthisreporthighlightthattheremainingchallengesinreducingmortalityrateslielargelyinthepublichealthdomain-environmentalfactorssuchassocio-economicconditionsandlifestylefactors.Aboriginalpeoplehavemortalityratessimilartosomethirdworldcountries.
‘Many Aboriginal and Torres Strait Islander peoples, especially those living in remote communities, do not have adequate quality housing, reliable supplies of water and electricity or adequate sewerage and drainage systems…’
WorldHealthOrganization(WHO)datashowthatAustraliahasahigherinfantmortalityratethanmanyotherWesterncountries.89
Aboriginalbabieshaveincreasedrisksoflowbirthweightandpretermbirth,asshownintheWAdata2002-04.LowbirthweightinAboriginalinfantsisofparticularconcern,andknowntobeapredictorofpoorhealthanddisability.90,91
Lowbirthweightandfetalgrowthrestrictionalsohavefutureimplicationsofincreasedriskofdiabetes,cardiovasculardiseaseandobesityinadultlife.92Thereareissuessuchaslivinginremoteareas,withreducedaccesstohealthservices,disadvantagedlivingconditionsandincreasedexposuretoinfection.
‘Pregnancy and early childhood experiences impact on a child’s lifelong capacity for learning and development, their physical and mental health and wellbeing and their opportunities for educational, social and economic attainment.
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An important factor impacting on the early years of many Indigenous children is the issue of geographic remoteness and associated issues such as access to basic and specialist health infrastructure, and essential services such as potable water and safe rubbish and sewerage disposal. This is particularly relevant for discrete Indigenous communities where the condition of basic essential services can lead to environmental conditions impacting on health in ways not experienced by their mainstream or urban counterparts. For many this results in increased rates of infectious disease. In some very remote communities, the early diagnosis and treatment of childhood illnesses may be compromised by the condition of roads and the availability of transport to appropriate health services, among other things. Preventable diseases and illnesses may then
require services such as the Royal Flying Doctor Service, to access the necessary treatment.’90
ThediversityofAboriginalpeoplemustbekeptinmind.Therearesignificantdifferencesindifferentgroupsofpeople,includingculturalpracticesandlanguage.93Theneedtobeawareofthishasbeenhighlightedbytherecentworkinpublichealtheducationregardingsafersleepingpracticesforbabies(seeSection5.5.4).
NewwaysaresoughttoimprovethehealthandwelfareofAboriginalpeople.ThereissomeevidencethatantenatalclinicsdedicatedtoimprovingthehealthofAboriginalwomencanimproveoutcomes.78Anexampleofanothermethodthatmayprovebeneficialisthe‘SchoolsBasedHealthyEatingProgram’94:
The ‘Schools Based Healthy Eating Program’ is similar to projects trialled in Indigenous communities which have resulted in significant improvements in birthweight, decreases in hospitalisation for nutritional or gastroenteritis conditions, increases in regular school attendance, decreases in truancy, and improvements in mental health outcomes.
This strategy comprises:
the provision of a properly nutritious breakfast and lunch for children attending school;
education sessions for mothers and pregnant women regarding nutrition and child development, including a focus on ‘weaning’ foods;
the setting up of a grandmother/mothers’ group to oversee the program and to coordinate the delivery of informal training to community members in healthy shopping, cooking skills and related areas;
a program of regular visits to the local health clinics for children aged 0-12 years; and
a partnership with local stores to promote supply and access to foods with high nutritional value.
Importantpublichealthmessages,suchastherisksofsmoking,importanceofgoodnutritionandinfantsafetyissues,maybestbeaddressedineducationalprogramsatschool,armingyounggirlswithmoreknowledgeandskillspriortomotherhood.
TheWHOadvocateshealthpromotionthataimstoenablepeopletoincreasecontroloverandtoimprovetheirhealth.Thisincludescreatingasupportiveenvironment,providingaccesstoinformation,buildinghealthypublicpolicy,developinglifeskills,strengtheningcommunityactionandincreasingopportunitiesformakinghealthychoices(WHO1986).95
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Recommendation 3:
Aboriginal care:
InnovativeprogramsarerequiredtoaddressthehighratesofAboriginalmortality.
• Culturallyappropriateeducationprogramstargetingnutrition,diabetesandalcoholandothersubstanceuseproblemsarerecommended.
• Outreachprograms,suchhomevisitsbyAboriginalhealthworkers,arerecommended.
• DedicatedantenatalclinicsforAboriginalwomenmaybeofbenefitandshouldbeconsidered.
5.5.8 Home Births
DatafromtheNationalPerinatalStatisticsUnitshowthatinAustraliain2004,therewere589plannedhomebirths(0.2%ofallwomenwhogavebirth),andthehighestproportionofhomebirthsbystateorterritoryoccurredinWA.OfbabiesbornathomeinAustraliain2004,allwerelivebornandthemeanbirthweightwas3,698grams.Theproportionoflivebornbabiesoflowbirthweightbornathomewas1.5%,andtheproportionofpretermbirthswas0.3%.14ThisdatasuggeststhatthevastmajorityofplannedhomebirthsoccurinlowriskwomeninAustralia.Inthefiveyears2000-04,therewasasignificantlyincreasedriskofperinatalmortalityinbabiesoftermgestationamongstplannedhomebirthsinWA.
Asmallbutsignificantnumberofwomenchooseaplannedhomebirth.Ideallythatchoicewouldbe‘informedchoice’.ThecurrentrisksandbenefitsofhomebirthinAustraliaarenotwellunderstood,duetolownumbersandlackofrecentresearch.However,therewasanincreasedriskofperinatalmortalityinplannedhomebirthscomparedwithplannedhospitalbirthsinalargeAustralianstudyofhomebirths(1985–1990,n=7,002plannedhomebirths;1.4%lowbirthweight)whereanalysisofbirthsinthefouryears1985-1988forwhichthemostcomprehensivedatawereavailableshowedthatinbabiesofatleast2500gbirthweighttherewasaperinatalmortalityrateof5.7deathsper1000birthsinplannedhomebirthscomparedwith3.6deathsper1,000plannedhospitalbirths(RR1.6;95%CI1.1-2.4).96Intrapartumdeathnotassociatedwithcongenitalmalformationorextremeimmaturitywasthreetimesasfrequentinplannedhomebirthsthanitwasnationwide(RR3.0;95%C11.9-4.8).TherewasafivefoldincreasedstandardisedperinatalmortalityriskinaSouthAustralianstudyfrom1976to1987(standardisedperinatalmortalityratio=507;95%CI253-908).97Thesamestudyshowedanintrapartumasphyxialdeathrateof3.8per1000birthscomparedwithaSouthAustralianrateof0.5per1,000birthsin1986-87.OnesmallWAstudy(1983-1986,n=165plannedhomebirths)hadgoodoutcomes.AnotherWAstudy(1981-1987,n=976plannedhomebirths)showedatrendtowardsanincreasedperinatalmortalitythatwasnotstatisticallysignificant.98Allofthesestudiesshowedadecreasedincidenceofobstetricintervention.Womenrequestingaplannedhomebirthmayberesistanttotransfertohospitalandtoobstetricinterventionwhenclinicallyindicated.99
ArecentlargeprospectivestudyofplannedhomebirthsinlowriskwomenintheUSwaspublishedin2005(n=5,418plannedhomebirths).100Thisshowed‘similarperinatalmortalityriskstohospitalbirths’(1.7deathsper1,000plannedhomebirths),withreducedinterventionratesandnomaternaldeaths.Inthisstudycomparisonwasmadewithperinatalmortality
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ratesinallsingletonvertexbirthsat37weeksormoregestationintheUSinthesameyear,asreportedbytheNationalCentreforHealthStatistics,101whichtheauthorsstated‘actedasaproxyforacomparablelowriskgroup’althoughthiswouldhaveincludedhighandlowriskpregnancies.Thereweremeasured(andprobablyotherunmeasurable)differencesbetweenthegroupsofmothersthatplannedahomebirthandthosewhoplannedahospitalbirth.Theauthorsconsideredthis,andlookedatasub-groupofmothersfromCaliforniaforwhommoredatawereavailable.102Perinatalmortalityinthisgroupwas2.4per1,000forplannedhomebirths,andfortheplannedhospitalbirthswas1.9per1,000.Theauthorsmadestatisticaladjustmentsfordifferencesinriskprofilesandconsideredthattheriskwasslightlylowerforintendedhomebirths,howeversomedeathswereexcludedfromtheanalysisthatmayleadtoquestionsabouttheinterpretationofthedata.
Advocatesofhomebirthshaveoftenquoted‘safetydata’frominternationalstudies,butitisdifficulttoextrapolatefrominternationaldatatothesituationinAustraliawheretherearedifferencesinmanyrespects,includingtrainingandexperienceofmidwives,andgeography.ThedifficultyofemergencytransportservicestooffersaferetrievalsinWAisamajorconsideration.WhilsttherehavenotbeenanymaternaldeathsinplannedhomebirthsinWAinrecentyears,theremaybeconcernaboutthepotentialriskofmaternaldeath,particularlyduetopostpartumhaemorrhageinthehomesetting.TherewasasignificantlyincreasedriskofthirdstagecomplicationsinplannedhomebirthsinWA1981-1987.98
TheinformationpresentedfromtheWA2000-04analysisshowsthatthechoiceofhomebirthwouldappeartohaveput‘lowrisk’womenintoa‘higherrisk’categoryofperinataldeath,althoughpossibledemographicdifferencesinthegroupofwomenwhochosehomebirthcomparedtothosewomenwhochoseahospitalbirthhavenotbeenexamined.Inaddition,thereisnoinformationavailabletotheCommitteeregardingmorbidityoutcomesforwomenwhohadahomebirth.AformalreviewofhomebirthoutcomesinWAmayanswersomeofthesequestions.
Recommendation 16:
Home births:
AreviewofhomebirthsinWAisrecommendedtoassessessentialhealthoutcomes,includingmorbidityandmortality.
5.6 Investigations into Cause of Death, Investigated Cases, WA 2002-04Inthistriennium,theInvestigatorsnotedanincreasednumberofpathologyinvestigationsperformedtoassesscausalfactorsinstillbirths.ThisimprovementcoincideswithrenewededucationalactivityofthePIMCsince2001.
Post-mortemExamination
WAhasrelativelyhighratesofpost-mortemexaminationofstillbornbabiesandinfantdeaths(68%inWA2002-04)andtheseratesaregraduallyincreasing,whichisagainstthetrendseeninmanyotherplaces.Tocompare,in2004inNSWpost-mortemexaminationswerecarriedoutfor33%ofstillborninfantsand23.7%ofneonataldeaths.103Itisadifficulttimeforparentsandtheimportanceof‘excellentcommunicationskills’inexplanationofthebenefitsofautopsy,andinobtainingconsentfortheprocedureisacknowledged.104PractitionersareadvisedtoliaisewiththeperinatalpathologycentreofKEMHinobtaininginformation,brochures,andassistanceinadvisingfamiliesaboutautopsy.Perinatallossinformationisavailableon-line.105
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Recommendation 17:
Cause of Death:
Thoroughinvestigationtoassesscauseandcontributingfactorsinstillbirthsandinfantdeathsisrecommended,withreferencetoinvestigationsrecommendedinAppendixII.
5.7 Parental Support, Investigated Cases, WA 2002-04Casenotesgenerallydocumentedaveryhighlevelofcareandcompassionofferedtogrievingfamilies.Parentaldistressmaybeexacerbatedbylackofexplanationastothecauseoftheirchild’sdeath,andeffortsshouldbemadetothoroughlyinvestigatedeaths.Stillbirthslabelledas‘unexplained’continuetoperplexhealthprofessionalsandpatients.‘SIDSandKids’106provideexcellentsupportservicesforfamilieswhohavelostaninfantorchild.TherearealsoservicesofferedthroughKEMHandPMH.27
5.8 Closing Remarks, PIMC, WA 2002-04TheworkofthePIMCisanongoingprocess,auditingstillbirthsandinfantdeaths.Practitionersareremindedoftheimportanceofauditingtheirbroaderhealthoutcomes,includingmeasuresofmorbidity.
References1. Western Australian Government. Health Act 1911,Extracts336A-340AN.
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6Educational&discussionpapers
6.1 Epidural Analgesia in Labour - Safety and Monitoring
Michael Paech MBBS, DRCOG, FRCA, FANZCA, FFPMANZCA, FRANZCOG (Hon), DM (Pharm) ProfessorofObstetricAnaesthesia,TheUniversityofWesternAustralia
IntroductionThenumberofbirthsinAustraliain2003wasover256,000andtheCaesareansectionratewasalmost29%(AIHW,2006).Over90%ofthosehavinganoperativedeliveryreceivedacentralneuraxial(epidural,spinalorcombinedspinal-epidural)blockandathirdofthosehavingavaginaldelivery,including50%ofthoseintheirfirstlabour,useepiduralpainrelief.
Thisarticleaddressesaspectsofsafetyandmonitoringrelevanttoepiduralpainreliefforlabouranddelivery.Itisimportanttorecognisethata‘labourepidural’isnotagenericinterventionandthatamultiplicityoftechniquesisnowused(Paech,2003).Sincethemid-1990sidentificationof,anddrugadministrationinto,thesubarachnoid(alsoreferredtoasthespinalorintrathecal)space,priortoepiduralcatheterisation,hasbecomeanalternativemethodtotheconventional‘labourepidural’.This‘combinedspinal-epidural’(or‘CSE’)techniquehasanumberofdifferentcharacteristicsandimplicationswhencomparedwithatraditional‘epidural’.Furthermore,effectiveepiduralpainreliefcanbeachievedwithdifferentdrugcombinations,mostcommonlylocalanaestheticwithanopioid,andwithdifferentdrugsfromwithintheclass,administeredinarangeofconcentrationsanddoses.Theseanalgesicsolutionsmaybedeliveredbydifferentmeans(mostcommonlybymedicalormidwiferyadministeredintermittentboluses,butalsobycontinuousinfusionorpatient-controlledadministrationandmorerecentlybyautomatedbolusesandothercomputer-integratedvariants).Thesevariableshavecommonalities,butalsospecificanddifferentimplicationswithrespecttomaternalandfetalsurveillanceandcare.Allmaternityunitsofferinganaesthesia-basedpainservicesshouldhavemonitoringpoliciesandprotocolsbasedongeneralprinciples(ANZCAprofessionalstandardspublications,2006)andlocalpracticesthatdealwiththecomplexitiesofa‘labourepidural’.
Physiologicalimplicationsofthe“labourepidural”Manytypesofdrugshavecentralneuraxialandspinalcordanalgesicpropertiesandaresafetoadministerviathisroute.Forexample,epiduralclonidine(analpha2-adrenergicagonist)andneostigmine(ananticholinesterasedrug)areeffectiveinearlylabourandareoccasionallyusedasadjunctstootherepiduralanalgesicdrugs.Howeveritisverydifficulttodelivereffectiveepiduralpainreliefthroughoutlabouranddeliverywithoutadministrationoflocalanaesthetic(LA).Thisclassofdrugremainstheprincipalcomponentofepiduralsolutions,oftenincombinationwithanopioidsuchasfentanyl.Opioidsproduceanalgesiathroughmu-opioidreceptoragonistactivityatspinalcordandmorecephaladcentralnervoussystemlocations,andaremainlyaddedtoreducetheLArequirementandhenceundesirablesequelaeofnear-completenerveconductionblock.Thedegreeofautonomic,sensoryandmotorfibreblockoftheperipheralnerveasittraversestheepiduralspacevarieswiththeconcentrationandphysicalpropertiesoftheLAdrug(forthe‘labourepidural’,mostcommonlybupivacaine,ropivacaineorlevo-bupivacaine).TheeffectsarealsodeterminedbythedistributionofLA,whichisprincipallydependentondose,buteffectsonvasculartone,sensorymodalitiesotherthannociception(pain)andonmusclestrengthareinevitable.
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Thesemodificationsofneurophysiologyhavethepotentialtoaltermaternalbloodpressure(BP);reducemobility(dependingontechnique,5-70%ofwomencannotambulateshortlyaftera‘labourepidural’);anddiminishexpulsiveeffortandpoweratdelivery(increasingtherateofassistedvaginaldeliveryinnulliparouslabour,althoughCSEandlow-doseepiduraltechniqueshavelessimpactthanatraditionalhigh-doseLAepidural).Secondaryeffectsmayleadtochangeswithinthefeto-placentalcirculationthatadverselyaffectfetalstatus.
ImpaireduteroplacentalperfusionAstherearenocurrentmeansofbedsideassessmentofuteroplacentalperfusionpressureandbloodflow,maternalsymptoms,maternalbrachialBPandfetalheartratemonitoringarewidelyusedtoguidemanagementandastriggersforintervention.AverycommonproblemisfailureofattendingstafftounderstandthatmaternalbrachialarteryBPmaybenormalinthepresenceofinadequateuteroplacentalperfusionbecauseofaortocavalcompression,whichoccursin90%ofwomenattermlyinginthesupineposition.Thepotentialforasignificantreductioninmaternalcardiacoutput(withor withoutaccompanyinghypotension)isexacerbatedinthepresenceofthe‘labourepidural’becausecompensatorymechanismsarecompromised.Althoughtheseverityofvenacavaland/oraorticobstructionisattenuatedinthesittingpositionandbylateralpelvictilt,onlythefullleftlateralpositionreliablyreducesthiscomplication.Thisistheinitialmaternalpositionadvisedforallcasesofpossiblematernalorfetalcompromise,withtheexceptionofcardiacarrest,whereuterinedisplacementinthesupinepositionisrecommended(tomaximisetheeffectivenessofexternalcardiaccompressionsoncardiacoutput,whileavoidingaortocavalcompression).
AsmallreductioninBPisexpectedaftera‘labourepidural’,buttheriskofseverematernalhypotension(5-20%)dependsonpatientfactors,thenatureofthe“labourepidural”andthedefinitionofhypotension.CommonlyappliedcriteriaareafallofsystolicBPtolessthan90mmHgorofgreaterthan20%frombaseline.Thelatterappearsmorerationalphysiologically,givenprogressivedeteriorationinbiochemicaloutcomesasmaternalBPfallsdocumentedwhenneonatesareaffectedbyspinalanaesthesiainducedhypotensionbeforeCaesareandelivery.Severematernalhypotensionoccursinfrequently(arateofapproximately1in20)whenaCSEorlow-doseLAandopioidepiduralsolutionisusedinlabour.Thetimecoursealsovarieswithtechnique,butintheabsenceofararecomplication(suchasahighblock)isusuallywithinthefirst30minutes.Subsequenttotheinitialdose,worrisomehypotensionisveryuncommonespeciallywithcontinuousinfusionorpatient-controlledepiduraldrugdelivery.
AlteredmaternalrespiratoryphysiologyandplacentalgasexchangeItispossiblethatadverseeffectsofmaternalhyperventilation(duetopain)onfetalgasexchange,demonstratedinanimalmodels,areattenuatedbythe‘labourepidural’.Episodicmaternaloxygendesaturationbetweencontractionsisseenintheabsenceofanalgesicsandadverselyaffectsmaternal-fetalgasexchange(Reynolds,1998).Suchepisodesareincreasedbysystemic(intramuscularorintravenous)opioidslikepethidine,andarereducedbyanepiduralusingLA.Whetherintrathecalorepiduralopioidcontributestomaternalhypoxaemicepisodesisunknown,butlowerplasmaconcentrationsofdrugsuggestthatanysecondaryfetaleffectislikelytobelessthanthatofsystemicopioid.Meta-analysisindicatesbetterneonataloutcomesfromwomenreceivinga‘labourepidural’comparedwiththosefromwomenreceivingsystemicopioids(Reynolds,2002).Severematernalrespiratorydepressionfromepiduralorintrathecalfentanylina‘labourepidural’isanexceptionallyrareevent.However,manyunitsmonitormaternalrespirationandsedationroutinelyifanopioidisadministeredduringlabour,irrespectiveoftherouteofadministration.
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Pharmacologicalimplicationsofthe“labourepidural”
Direct Drug Effects
BothLAandopioidshowsignificanttransplacentaltransfer,sodirectpharmacologicaleffectsonthefetuscanbeanticipated.Thepharmacokineticprinciplesandspecificsoftransferof“labourepidural”drugsarecomplex(Reynolds,1998).Clinicalstudiesindicatethatfetallevelsofthelong-actingamideLAdrugsareinsufficienttoalterneonatalneurobehaviourandthatlow-doseLA-opioidsolutionsdonotchangefetalelectrocardiography.Ingeneral,thedirecteffectsofLAandofintrathecalopioidareconsideredclinicallyunimportant.
Epiduralopioids,incontrast,producedose-dependentneonataleffectsthatareoccasionallyclinicallyrelevant.Repeatedorcontinuedmaternaladministrationofepiduralfentanylforseveralhoursproducesreadilydetectableneonatalplasmaconcentrations.However,anumberofobservationalstudiesoflow-doseLA-opioidsolutionsfoundnoeffectonneonatalApgarscore,acid-basestatusorneurobehaviouralresponsescomparedwithepiduralLAalone.Atconventionaldoserates(fentanyl30mcg/h)neonatalrespiratoryphysiologyatbirthisunchangedanddespiteaccumulativedosesofupto400mcgnodetectableeffectonneonatalrespirationorneurobehaviourwasfoundcomparedwithcontrolsnotreceivingopioid(Reynolds,1998).
Indirect Drug Effects
Inadditiontoindirectfetalandneonataleffectsasaresultofmaternalcardiovascularchanges,indirecteffectsmayresultfromalteredmaternalrespiratoryphysiologyandfromneuroendocrineresponsestorapidandprofoundpainrelief.Changesinfetalheartrate(FHR)within30minutesofa‘labourepidural’arewellrecognisedafterbothepiduralandCSEtechniquesandweretraditionallyascribedtoreduceduteroplacentalperfusionsecondarytomaternalhypotension.Intrathecalopioid,however,hasminimaleffectonmaternalBPandtheincidenceofsignificantFHRchangeremains15-20%afteraCSE‘labourepidural’.Aplausibleexplanationforsuchchangesisthelossofatocolyticeffectasplasmacatecholaminelevelsfallsubstantiallywhenpainisrelieved.Themyometrialrelaxationasaresultofabeta-sympathomimeticeffectofadrenalineisreducedcomparedwiththesustainedalpha-adrenergicactionofnoradrenaline,resultinginincreaseduterineactivityandreduceduteroplacentalflow(Madirosoff,2002;Littleford2004).ThetimecourseoftheseFHRchangesdiffers(usuallywithin10minutesforaCSEversus15-30minutesanepiduraltechnique)buttheperiodofincreaseduterineactivityisusuallybriefandfetalcompromiseisreadilycorrectable(vide infra,IntrauterineResuscitation).Insomewomen,maternaltemperaturerisesinresponsetoepiduralanalgesia,withapparentriskfactorsincludingthepre-epiduraltemperature,typeofepiduralsolution,increasingdurationofepiduralanalgesia,timesinceruptureofmembranesandnumberofvaginalexaminations.Themechanismisincompletelyunderstood.Overaperiodofhours,thistemperaturerisemayresultinthethresholdfor‘maternalpyrexia’beingreachedandtriggerbothmaternalinvestigationandtreatment,andsubsequentlyneonatalsepsisevaluation.Additionally,fetaltemperatureisdependentonuterinetemperatureandinanimalstudiesfetalhyperthermiaisassociatedwithhypoxiaandacidosis,whilecasecontrolstudiessuggestanincreasedriskofencephalopathy.Whetherthesepotentialconcernsareclinicallysignificantrequiresfurtherresearch,butatpresentthereisnoevidencethatthewidespreaduseofepiduralanalgesiainlabourinrecentdecadeshasledtoadverseneonatalsequelae(Mercier,1997;Banerjee,2003).
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Complications of the ‘labour epidural’
Thereareanumberofpotentialcomplicationsarisingdirectlyfromeitherthetechniqueordrugadministrationina‘labourepidural’.Detailisbeyondthescopeofthisarticle,butthemanagementofthehypotensivemother(oxygentherapy,positioning,intravenousvasopressorandinotropicdrugs,intravenousfluids,correctionofthecause);resuscitationoftheapnoeicwoman(clearandsecuretheairway,oxygenationandventilation,reversalofopioidwithnaloxone);themanagementoftheconvulsingpatient;andcardiopulmonaryresuscitation,shouldbefamiliartothosecaringforthesewomen.
Rare life-threatening complications of a ‘labour epidural’ include:
Severe maternal hypotension(supineposition):cardiovascularcollapse,unconsciousness
Vasovagal syncope:bradycardiccardiovascularcollapse,unconsciousness,convulsions
High autonomic, sensory and motor block(epidural,subduralorintrathecalspreadoflocalanaesthetic):respiratorydepression,apnoea,unconsciousness,severehypotension,cardiacarrest
High sensory blockalone(intrathecalopioid):mildbreathingdisturbance,difficultywithphonationandswallowing
Local anaesthetic toxicity(usuallyepiduralvenousinjection):centralnervoussystemsymptoms,convulsions,hypotension,cardiacarrest
Severe respiratory depression(highspreadofepiduralorintrathecalopioid):hypoventilation,apnoea,unconsciousness,hypoxiccardiacarrest
Monitoring the “labour epidural”
Theanticipatedphysiologicalandpharmacologicaleffectsofepiduralanalgesiamayoccasionallyadverselyaffectthemother,babyorboth.Routinemonitoringshouldincludematernalvitalsigns(includingtheseverityofpain,‘thefifthvitalsign’)andthefetalheartrate,althoughelectronicFHRmonitoringisnotmandatedintheabsenceofotherindications.Bloodpressureismostaccuratelymeasuredinthedependentarminthelateralpositionusingauscultation.Mostanticipatedeffectsaremaximalwithinthefirst30minutesofestablishingthe‘labourepidural’.Rareandunpredictablecomplications(Table2)arealsolikelytopresentwithinthistimeperiod.Vigilanceisparticularlyimportantatthisstageandcontinuoussurveillancebymedicalornursingstaffisanacceptedstandardofsafety.Inspecialcases,additionalmaternalmonitoring(pulseoximetry,directarterialbloodpressure)orfetalmonitoring(scalppH)maybeofvalue.
Manyunitsalsomonitorthelevelofsensoryblockafterestablishingepiduralanalgesiaandcontinuehourlythereafter.Sensorychangesduetointrathecalopioidorlow-doseLA-opioidepiduralsolutioncanbesubtleandtheformerarenotofvalueinassessingefficacy.Later,duringmaintenanceoftheepiduralanalgesia,sensoryblockassessmentprovesofgreaterbenefit,especiallyasameansof‘trouble-shooting’unsatisfactoryneuraldistributionofepiduralsolution.
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A suggested scheme for monitoring after establishing a ‘labour epidural’ is:
Routine5minutelyobservationsforatleast20minutesandpreferably30minutes-Maternal heart rate Maternal blood pressureMaternal respiration (rate ± pattern)Maternal conscious stateMaternal pain (0-10 numerical rating score)Fetal heart rate
andadditionalhourlyobservationsoncethe‘labourepidural’isestablished-Maternal sensory block (loss of cold or pinprick sensation)Maternal temperature
Optional,determinedbycircumstanceMaternalpulseoximetryMaternalarterialbloodpressureandarterialbloodgasanalysisMaternalcentralvenouspressure;transthoracicechocardiographyMaternalbiochemistryandhaematologyFetalscalppHoroximetry
Intrauterine Resuscitation
Althoughthephysiologicalandpharmacologicaleffectsofa‘labourepidural’mayoccasionallyleadtoareductionofuteroplacentalflow,maternalhypoxaemiaandfetalcompromise,whicharetheconsequencesoftheseeffects,canalmostalwaysberectifiedwithouttheneedforurgentdelivery(Mardirosoff,2002;Thurlow2002).Severematernalhypotensionisveryinfrequentifthesupinepositionisavoidedandisusuallyreadilycorrectablewithvasopressordrugssuchasephedrineandphenylephrine.
ApproximatelyhalftheFHRchangesseenaftera‘labourepidural’areattributabletoincreaseduterineactivity,socessationofoxytocinandtocolysiswithterbutalineoftenproducesarapidresolutionofthechanges.Theavailabilityofa‘labourepidural’servicedoesnotincreasetheincidenceofurgentCaesareansectionforfetaldistress,butoccasionallyunmasksacompromisedfetusorfetusdevelopinghypoxaemia.Thisallowsearlierdelivery,beforefurtherdeteriorationoccursduringlabour.
Intrauterineresuscitationisanimportantconceptthatcanbeappliedbothpriortoa‘labourepidural’ifthefetalstatusisalreadycompromised,ortothesituationofworrisomeFHRchangesoccurringaftera‘labourepidural’.Strategiesforintrauterineresuscitationatthetimeofa‘labourepidural’areto-
Stop the oxytocin infusion ± administer a tocolytic druge.g.terbutaline250mcgsubcutaneously
Position the woman in the full left lateral(tryrightlateralorknee-elbowpositionifrequired)
Give supplemental oxygen(athigh-flowratesof10-15L/minviaaface-mask)
Restore the pre-epidural maternal blood pressuree.g.ephedrine10mgintravenously
Consider infusion of intravenous crystalloid 1 L rapidly(cautioninthepreeclampticorfluid-restrictedparturient)
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FurtherReadingAIHWNationalPerinatalStatisticsUnit–report.Australia’smothersandbabies2003.www.npsu.unsw.edu.au
PaechM.Newertechniquesoflaboranalgesia.In:AnesthesiologyClinicsofNorthAmerica.ElsevierScience(USA)2003:21:1-17
TheAustralianandNewZealandCollegeofAnaesthetists(ANZCA)professionalstandardsdocumentP14(1998).Guidelinesfortheconductofmajorregionalanalgesiainobstetrics.www.anzca.edu.au
ReynoldsF.Effectsoflabouranalgesiaonthebaby.FetMatMedRev1998;10:45-59
ReynoldsF.SharmaSK,SeedPT.Analgesiainlabourandfetalacid-basebalance:ameta-analysiscomparingepiduralwithsystemicopioidanalgesia.BJOG2002;109:1344-1353
MardirosoffC,DumontL,BoulvainM,TramerMR.Fetalbradycardiaduetointrathecalopioidsforlabouranalgesia:asystematicreview.BJOG2002;109:274-281
LittlefordJ.Effectsonthefetusandnewbornofmaternalanalgesiaandanesthesia:areview.CanJAnesth2004;51:586-609
MercierFJ,BenhamouD.Hyperthermiarelatedtoepiduralanalgesiaduringlabour.IntJObstetAnesth1997;6:19-24
BanerjeeS,SteerPJ,IrestedtzL.Theriseinmaternaltemperatureassociatedwithregionalanalgesiainlabourisharmfulandshouldbetreated.IntJObstetAnesth2003;12:280-286
ThurlowJA,KinsellaSM.Intrauterineresuscitation:activemanagementoffetaldistress.IntJObstetAnesth2002;11:105-116
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6.2 Optimising Outcome for Women with Diabetes in PregnancyDr Janet Hornbuckle MB ChB MRCOG FRANZCOG
DiabetesMellitus(DM)isthecommonestmedicalconditiontocomplicatepregnancy.Between0.2%and0.5%ofallpregnanciesoccurinwomenwithType1DMandasimilarproportioninwomenwithType2DM.Inadditionafurther3-8%ofwomenwilldevelopgestationaldiabetes(GDM).Diabetesinpregnancyisassociatedwithanincreasedriskofcongenitalanomaly,perinatalmorbidityandmortality,andoperativedelivery.Accesstoamultidisciplinaryteamincludingobstetrician,physician,diabeteseducatoranddieticianoptimisespre-pregnancyandantenatalcare,aimingtoreduceperinatalmortalityratestothoseobservedinwomenwithoutdiabetes.
TheprevalenceofType2DMinyoungwomenisincreasingandthereneedstobeanincreasedawarenessofadversepregnancyoutcomeinthesewomen.RecentpublicationshavehighlightedthatwomenwithType2DMrequirethesamelevelofpre-pregnancyandantenatalcareasthosewithType1DM.1,2PregnantwomenwithType2DMaremorelikelytocomefromethnicminorities,liveindeprivedareasandhaveassociatedobesity.Differencesinculturalbackground,firstlanguage,lifestyleandaccesstomedicalcareneedtobeconsideredwhenprovidinghealthservicesforpre-pregnancycare,educationandpregnancycaretothesewomen.
GlycaemiccontrolandPregnancyOutcomeReportedperinatalmortalityratesininfantsborntowomenwithpre-existingDMare3-4timeshigherthaninthecorrespondinggeneralpopulation.3Itisestimatedthatupto50%ofperinataldeathsintheoffspringofthesewomenaresecondarytocongenitalanomalies.Theriskofmajorcongenitalanomaliesintheoffspringofwomenwithpre-existingDMisatleasttwicethatofthegeneralpopulationwithpredominantlycardiovascular(3timeshigherrisk)andneuraltubedefects(3-4timeshigherrisk)accountingfortheincrease.3Antenataldiagnosisofcertaincardiacconditionsdecreasestheriskofneonatalmortalityandconsiderationshouldbegiventoreferringwomenwithpre-existingDMforspecialistfetalechocardiography,particularlywhereglycaemiccontrolhasbeensuboptimal.
PericonceptionalglycaemiccontrolmaybeevaluatedbymeasurementofglycosylatedhaemoglobinA1c(HbA1c).AlthoughtheidealthresholdforHbA1chasnotbeenestablished,theriskofcongenitalanomalyandspontaneousmiscarriageincreaseswithincreasingHbA1clevel.4-6Pretermlabour,pre-eclampsiaandperinatalmortalityarealsorelatedtosub-optimalpericonceptionalcontrolasmeasuredbyHbA1clevels.5-7
Goodglycaemiccontrolthroughouttheantenatalperiodaimstoreduceratesoflatestillbirthandfetalmacrosomiawiththeassociatedincreasedriskofoperativedeliveryandshoulderdystocia.
PrepregnancycareForwomenwithpre-existingDMnear-normalmetaboliccontrolbeforeandaroundconceptionreducescongenitalanomalyrates,stillbirthandneonatalmortalityratesandverypretermbirth.8Unfortunatelyrecommendationsforpre-pregnancycareappeardifficulttotranslateintopractice.Even15yearsaftertheStVincentdeclaration9only30-40%ofwomenachievegoodglycaemiccontrolbytheendofthefirsttrimesterletaloneduringthecriticaltimeofearlyorganogenesis,before7weeksgestation.WomenofreproductiveagewithDMshouldbegivenappropriatecontraceptiveadviceemphasisingtheimportanceof‘pregnancyplanning’andglycaemiccontrol.Inparticularwomenbeingtreatedforsubfertilityneedtohavegoodglycaemiccontrolbeforeconception.
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Womenwithpre-existingDM,bothType1andType2,shouldbereferredforpre-conceptioncarebothtooptimisetheirglycaemiccontrolandreviewco-existingmedicalconditionsanddrugtherapies.Inparticularwomenwithevidenceofmicrovasculardisease,e.g.nephropathy,neuropathy,retinopathy,andthosewithpre-existinghypertensionshouldbereferredforspecialistopinionpriortopregnancywherepossibleorassoonaspregnancyisdiagnosedfor‘unplanned’pregnancies.Womenshouldaimforgoodglycaemiccontrolforaminimumof3monthsbeforetryingtoconceive.AtargetHbA1coflessthan7.5%isrecommendedpriortoconception.
Highdosefolicacidsupplementation(5mgdaily)shouldbecommencedpriortoconceptionandcontinueduntilatleast12weeksgestationbecauseoftheincreasedriskofneuraltubedefects.Bothangiotensin-convertingenzyme(ACE)inhibitorsandstatinsarecontraindicatedinpregnancyandshouldbeceasedpriortoconception.Forwomenwithpre-existinghypertensionmethyldopaistheantihypertensivedrugofchoice.LowdoseAspirin(100mgdaily)shouldbeconsideredoncepregnancyhasbeenconfirmed,especiallyforthosewomenwithmicrovasculardiseasetotrytoreducetheriskofpre-eclampsia.
Inadditiontoroutine‘pregnancyscreeningbloodtests’thefollowingbaselineinvestigationsarerecommended:HbA1c,thyroidfunctionandthyroidautoantibodyscreen,renalfunctionandurineprotein/creatinineratio.
Bloodglucoselevels:Monitoring,GoalsandTreatmentWomenwithpre-existingDMshouldbeencouragedtoincreasethefrequencyofbloodglucoselevel(BGL)monitoring.Asaminimum,afastinglevelandthree‘2hourpostprandial’levelsshouldbedocumenteddailyparticularlyduringthefirstandthirdtrimesters.Thisallowsforpromptadjustmentofinsulindosestooptimiseglycaemiccontrol.Thosenotalreadyonafourtimesdailyinsulinregimenshouldbechangedtosucharegimenwithashortactinginsulin(e.g.Novorapid)immediatelybeforethethreemainmealsandanintermediatelongactinginsulin(e.g.Protophane)inthelateevening.
TargetBGL’sareafastinglevelof<5.5mmol/land4-7mmol/lforthetwohourpostprandiallevel.Thereshouldbecloseliaisonbetweenthesupervisingspecialistordiabeteseducatorandthewoman.Sheshouldbeadvisedtocontactherhealthcareprofessionaliflevelsareelevatedformorethantwodaysorifherlevelsare>8mMfastingor>10mMpostprandialononeoccasion.ReviewoftheBGLrecordbookandalsotheglucosemeterisrecommendedaswomenfrequentlymis-reporttheirBGL’s.
FrequencyoftestingwilldependonpatientmotivationandthelevelofBGLcontrol.Womenshouldbeencouragedbyadvicethatgoodglycaemiccontrolwithinthesetargets(achievedbyfrequentmonitoringandappropriateadjustmentoftreatment)willsignificantlyreducefetalanomaliesandmacrosomia,reduceepisodesofmaternalhypoglycaemia/hyperglycaemiaandreduceratesofneonatalhypoglycaemia.
GestationalDiabetesGestationaldiabetes(GDM)affects5-8%ofwomeninAustralia.Theincidenceislikelytoincreasewiththeanticipatedobesityepidemic.GDMreferstowomenwhoarediagnosedwithdiabetesforthefirsttimeinpregnancy,regardlessofwhetherDMpersistsintothepostpartumperiod.
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ScreeningforGestationalDiabetesIdentificationandappropriateinterventionforwomenwhodevelopGDMhasbeenshowntoimprovepregnancyoutcome.10ConsequentlyallwomenshouldbeofferedscreeningforGDM.Thetablebelowcontainsasuggestedscreeningstrategybylevelofriskandgestation.ScreeningforGDMidentifieswomenatriskforType2DMinlaterlifeandtheopportunitytoaddresshealthandlifestyleissuestoprolongthediseasefreeintervalcanbetaken.
Table I: Screening for Gestational Diabetes Pre 24 weeks* 24 - 28 29 - 32
Low Risk GCTGCT
Ifnopriortesting
Medium Risk• Maternalageof>30years• Womenwithafamilyhistoryofdiabetes• Incasesofmaternalobesity• Hypertensionpriorto20weeks• Previousmacrosomicbaby(>4000grams)
1.Performarandombloodglucose(RBG)*
InterpretationofRBG• If>5.5mmol/Lproceed
toaGTT.• If<5.5mmol/Lrepeat
RBGevery6-8weeksandrequestGTTat26-28weeks
GCTIfabnormalproceedto
GTTOr>11=GDM
GTTIfnopriortesting
High Risk• Alloftheabove• Historyofunexplainedstillbirth• Previousbabywithcongenitalanomalies• PreviousGestationalDiabetes• Ethnicity• Aboriginal,Asian,IndianandMiddleEasterngroups.
GTT
GTTIfnopriortesting
Abbreviations:GCT–glucosechallengetestGTT–glucosetolerancetest
ManagementofGDMWomenfoundtohaveGDMshouldbepromptlyreferredtoadiabeteseducatoranddietician.Theimportanceofregularexerciseandahealthydietonglycaemiccontrolisemphasisedandselfcapillaryglucosemonitoringcommenced.Foodandexercisediariesmayactasmotivationaltoolsandassistinidentifyingthosewomenwhorequiremedicationtoachievegoodglycaemiccontrol.ThesametargetlevelsforBGL’sareusedandreviewofBGL’sshouldcontinueateveryantenatalvisit.IftheBGL’sarewithinthetargetrangethenthe‘4-pointprofile’maybeundertaken2-3timesweekly.Iftheyareoutsidethetargetrangethenreferraltoadiabetesphysicianshouldbearrangedandtreatmentcommenced.WomenshouldbeencouragedtoreportBGL’soutsidethetargetrangeearlyandgivenanappropriatepointofcontactsothattheymayeasilydoso.Dietarymodificationisunlikelytoaddresshighfastingglucoselevelsandmedicationshouldbeconsideredearlyinthesewomen.
RandomisedcontrolledtrialscomparingoralhypoglycaemicagentsandinsulinforthemanagementofGDMarecurrentlyinprogress.UntilthesedataareavailableinsulinremainstherecommendedmedicationforwomenwithGDM(andType2DM)requiringtreatmenttoachievegoodglycaemiccontrol.
FetalGrowthandSurveillanceGlycaemiccontrolinthesecondandthirdtrimesteriscloselyrelatedtothedegreeoffetalmacrosomiawiththepercentageofglucosereadingsabovetargetinthethirdtrimesterbeingthebestindicator.11Fetalabdominalcircumference(AC)>90thcentileat34weeksisstronglycorrelatedwithbirthweight.12Serialultrasoundassessmentisroutinelyusedtoidentifyfetuseswithacceleratedorsuboptimalgrowth.However,theaccuracyofultrasoundestimationoffetalweightdecreaseswithincreasingbirthweight.Generallytheretendstobeanover-estimationoftheweightofsmallinfantsandanunderestimationoftheweightof“largefor
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gestationalage”infants.BothlargeandaverageweightinfantsofwomenwithDMtendtohavetheirweightunderestimated.13Forpregnanciesinwomenwithpre-existingDM,serialfetalgrowthsurveillanceshouldcommenceat28weeks.Thismayactasamotivationaltoolforwomenwithsuboptimalglycaemiccontrol.WomenwithGDMrequiringmedicaltreatmentshouldalsocommenceserialfetalgrowthsurveillanceoncemedicaltreatmentisdeemednecessary.ForwomenwithGDMandborderlineglycaemiccontrol,estimationoffetalweightmayassistinthedecisiontocommencehypoglycaemictreatment.
WomenwithGDMcontrolledbydietshouldhaveanultrasoundforfetalgrowthparametersat34weeksorsoonerifthereisclinicalsuspicionofmacrosomia.Iftheabdominalcircumference(AC)is>90thcentileanadditionalscanat38weeksisrecommendedtodeterminetheestimatedfetalweight.
Apolicyofincreasedfetalsurveillanceisrecommendedinthethirdtrimestertoattempttoreducestillbirthrates,howeverthereislittleevidencetoguideeitherthemodalityorfrequencyofsurveillance.Fetalheartratemonitoring(CTG),biophysicalprofileandumbilicalarteryDopplerareallusedtoassessfetalwellbeingindiabetespregnancies.Stillbirthunrelatedtocongenitalanomaliesoccursacrossallbirthweightssuggestingthatfactorsotherthanplacentalinsufficiencyareinvolved.UmbilicalarteryDopplershouldstillbeusedtoidentifythosepregnanciesatriskfromplacentalinsufficiency,howeversignificantcompromisemayoccurinthosewithanormalDopplerwaveform.Twice-weeklyCTGmonitoringinthethirdtrimesterisassociatedwithalowperinatalmortalityratethoughthismethodofsurveillancehasnotbeenproveninlargeclinicalstudies.Certainlywomenwithpoorglycaemiccontrol(bothhypoglycaemiaandhyperglycaemia),hypertension,fetalgrowthrestrictionorfetalmacrosomiashouldcommenceCTGmonitoringtwiceweeklyfrom34weeksgestation.Fallinginsulinrequirementsinthelatethirdtrimesterarethoughttobeanindicationforincreasedfetalsurveillance.
TimingofbirthForwomenwithpre-existingdiabetesandforthosewithGDMrequiringmedicationdeliveryat38-39weeksisrecommended.ForthosewithdietcontrolledGDMbirthshouldbeplannedaround40weeks.
MaternaldiabetesisariskfactorforoperativedeliveryandCaesareansectionratesrangefrom25-80%representingwidevariationinobstetricpractice.ShoulderdystociaratesareincreasedinpregnancieswithDM(3.2%cf0.5%)andforinfantswithbirthweight>4,000gshoulderdystociaoccursin5%.AlthoughEFWbyultrasoundassessmentislessreliableinlargeinfantsandinfantsofwomenwithDM,considerationshouldbegiventoanelectiveCaesareansectionforthosewithanEFW>4,250g.14ElectiveCaesareansectionshouldalsobeconsideredwheretheACis>95thcentileandthereisadifferenceintheAC/HCmeasurementofmorethan40mmbecauseoftheincreasedriskofshoulderdystocia.
Healthprofessionalscaringforwomeninlabourshouldbeconfidentinperformingtherecommendedadditionalmanoeuvresrequiredtomanageshoulderdystociaandregularmultidisciplinary‘drills’shouldbeundertakentomaintainconfidenceandskilllevels.
IntrapartumConsiderationsAllwomenwithType1DMshouldcommenceaglucose/insulininfusioninlabour.WomenwithType2DMorGDMshouldhaveBGLestimation2hourlyandaglucose/insulininfusioncommencediftheBGLis>7mmol/l.TherateofinsulininfusionshouldbeadjustedtomaintainBGL’sbetween4-7mmol/l.Maternalhyperglycaemiaandthusfetalhyperglycaemiaresultsinafetallacticacidemiawhichisusuallycompensated.Howeverifthefetusbecomeshypoxic
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thereisrapiddecompensationwithassociatedacidosis.Optimalintrapartumglycaemiccontrolreducesthefrequencyofabnormalfetalheartratepatternsandimprovesneonataloutcome.Continuouselectronicfetalmonitoringisrecommendedforallwomenwithdiabetesinpregnancy.Inadditionmacrosomicfetuseshaveincreasedoxygenrequirementssothesebabiesinparticularareatincreasedriskofintrapartumhypoxia.Promptevaluationandinterventionofanynon-normalfetalheartratepatternshouldbeundertaken.
PostpartumcareType 1 DM
Insulinrequirementsfallimmediatelyafterbirthandmanywomenreturntotheirpre-pregnancydosesorlowerforsometimepostpartum.Themainriskishypoglycaemiaparticularlywithbreastfeeding.BGL’sshouldcontinuetobemonitoredwithadditionalchecksovernightduringbreast-feeding.TargetBGL’sare5-10mmol/lwhilstbreast-feedingandinsulindosesadjustedaccordingly.Womenshouldreceiveappropriateadviceregardingcontraceptionandtheimportanceofpre-pregnancycareandglycaemiccontrolemphasised.Followupwiththeirusualdiabetesspecialistshouldcontinue.
Type 2 DM
WomenwithType2DMmaynotrequirehypoglycaemicagentsforsometimeafterthebirth.Bothglibenclamideandmetforminappearinsmallamountsinthebreastmilkbutitisreasonabletousethesewithbreastfeedingifrequired.ThewomanshouldcontinuetomonitorherBGL’s2-3daysperweekandhaveappropriatefollow-upwithherGPorDiabetesspecialist.
GDM
MostwomenwithGDMreverttonormoglycaemiaatthetimeofbirth.A4-pointBGLshouldbeundertakenonday2or3postpartum.Bloodglucosemonitoringmaythenbeceasedifinthenormalrange.ItisrecommendedthatwomenwithGDMhavediabetes(considerchangetoDMscreening(GTT)6-12weekspostpartumandthereafterfastingorrandombloodglucoseevery1-2years.Promptreferraltoadiabetesormedicalclinicisrecommendedforwomenwhoremainhyperglycaemicafterthebirth.
As40-50%ofwomenwhohavehadGDMwilldevelopType2DMlaterinlife,theopportunityforlifestylecounsellingforthepreventionofType2DMshouldbetaken.Thisincludesadviceregardinghealthyeatingpatterns,weightcontrolandregularphysicalactivityofmoderateintensityfor30minuteseachday,contraception,pre-pregnancyplanningandtheneedforannualcheckontheirbloodglucoselevels.EffectivecontraceptionisessentialforwomenwithGDM.HoweverthereisanincreasedriskofdevelopingType2DMinwomenwithGDMwhoreceiveeithertheprogesteroneonlypillorinjectableprogestinpostpartum.15,16Alternativenon-hormonalcontraceptionshouldbeconsideredforwomenwhoarebreastfeeding.
SummaryThereisnodoubtthatoptimisingpre-pregnancyandantenatalglycaemiccontrolimprovesoutcomesforwomenwithDMandtheiroffspring.Education,motivationandimprovingbothcontraceptionandpre-pregnancycareinwomenwithDMisapriority.ForthosewomenfoundtohaveGDM,modificationtotheirlifestyleshouldbemadenotonlytoimprovepregnancy
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outcomebutalsotoreducetheriskofdevelopingType2DMlaterinlife.Healthprofessionalsandthoseplanninghealthcareprovisionshouldensurethatthereiseasyaccesstopre-pregnancyandantenatalcareforthesewomenbothwithpre-existingDMandthoseatriskofGDM.
Summary Points:The prevalence of diabetes is increasing in pregnancy.Tight control of diabetes before and during pregnancy significantly improves outcomes.Team management is recommended.Optimal intrapartum glycaemic control reduces the frequency of abnormal fetal heart rate patterns and improves neonatal outcome.
Pre-existingDMinpregnancy: • Referpre-pregnancyforspecialistreviewandoptimisecontrol• Highdosefolicacid-5mgdaily• Fourtimesperdayinsulinregimenwithfrequentmonitoring• Targetglucoselevelsfasting<5.5mMand2hrpost-prandial4-7mM• Teammanagement(includingexerciseanddietaryadvice)
GDM: • Screeningforallwomen• Teammanagementandtightcontrol,asforthosewithpre-existingDM
FetalSurveillance: • forthoseontreatmentforDM,serialultrasoundassessmentfrom28weeks• forthosewithdiet-controlledGDM,ultrasoundat34weeksorearlierandrepeatultrasound
at38weeksforinfantswithAC>90thcentile• CTGtwiceweeklyfrom34weeks
Peripartummanagement: • forthoseontreatmentforDM,deliver38-39weeks • forthoseondiet-controlledGDM,deliverby40weeks• bewatchfulforincreasedriskofoperativedeliveryandshoulderdystocia• considerelectiveCaesareansectionformacrosomia *
glucose/insulininfusioninlabourforallthosewithtype1DM• monitorBGLinlabourandglucose/insulininfusionifhyperglycaemic• continuouselectronicfetalmonitoring• watchforhypoglycaemiapostpartum
Postpartumfollowup: • screenfortype2DMinthosewithGDM
References:1 ClausenTD,HellmuthE,MathiesenEetal.PoorpregnancyoutcomeinwomenwithType2Diabetes.DiabetesCare
2005;28:323-328
2 VerheijenEC,CritchleyJA,WhitelawDC,TuffnellDJ.Outcomesofpregnanciesinwomenwithpre-existingtype1ortype2diabetes,inanethnicallymixedpopulation.BJOG.2005;112:1500-3
3 MacintoshMC,FlemingKM,BaileyJAetal.Perinatalmortalityandcongenitalanomaliesinbabiesofwomenwithtype1ortype2diabetesinEngland,Wales,andNorthernIreland:populationbasedstudy.BMJ2006;333:177
4 EversI,ValkH,VisserG.RiskofcomplicationsofpregnancyinwomenwithType1diabetes:nationwideprospectivestudyintheNetherlands.BMJ2004;328:915-920
5 TempleR,AldridgeVetal.,AssociationbetweenoutcomeofpregnancyandglycaemiccontrolinearlypregnancyinType1Diabetes:populationbasedstudy.BMJ2002;325:1275-1276
6 DiabetesandPregnancyGroup.Frenchmulticentricsurveyofoutcomeinwomenwithpregestationaldiabetes.DiabetesCare2003;26:2990-2993
7 HsuC,HongSetal.,Glycosylatedhaemoglobinininsulindependentdiabetesrelatedtopre-eclampsia.AmJPerinatology1998;15:199-202
8 NeilsenGL,MollerM,SorensenHT.HbA1cinearlydiabeticpregnancyandpregnancyoutcomes:aDanishpopulation-basedcohortstudyof573pregnanciesinwomenwithtype1diabetes.DiabetesCare2006;12:2612-
9 Workshopreport.DiabetescareandresearchinEurope:theSaintVincentdeclaration.DiabetMed1990;7:360.
10 CrowtherCA,HillerJE,MossJRMcPheeAJetal.Effectoftreatmentofgestationaldiabetesmellitusonpregnancyoutcomes.NEnglJMed.2005;352:2477-86
11 HerranzL,PallardoLF,HillmanN,Martin-VaqueroP,VillarroelA,FernandezA.Maternalthirdtrimesterhyperglycaemicexcursionspredictlarge-for-gestationalageinfantsintype1diabeticpregnancy.Diabetes Res Clin Pract 2006
12 TaylorR,LeeC,Kyne-GrzebalskiDetal.ClinicaloutcomesofpregnancyinwomenwithType1Diabetes.ObstetGynecol2002;99:537-41
13 SokolRJ,ChikL,DombrowskiMP,ZadorIE.Correctlyidentifyingthemacrosomicfetus:Improvingultrosonographybasedprediction.AmJObstetGynecol2000;182:1489-95
14 ConwayDL.Choosingrouteofdeliveryforthemacrosomicinfantofadiabeticmother:Caesareansectionversusvaginaldelivery.JMaternalFetalNeonatalMed2002;12:442-448
15 KjosSL,PetersRK,XiangA,ThomasD,SchaeferU,BuchananTA.Contraceptionandtheriskoftype2diabetesmellitusinLatinawomenwithpriorgestationaldiabetesmellitus.JAMA1998;280:533-8
16 XiangAH,KawakuboM,KjosSL,BuchananTA.Long-actinginjectableprogestincontraceptionandriskoftype2diabetesinLatinowomenwithpriorgestationaldiabetesmellitus.Diabetescare2006;29:613-7
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6.3 Monochorionic Twin PregnanciesAntonia Shand MBChB, FRANZCOG Maternalfetalmedicinefellow,KingEdwardMemorialHospitalandSchoolofWomenandInfants’Health,UniversityofWesternAustralia
Althoughzygosityreferstothetypeofconception,whatprincipallyimpactsuponfetaloutcomeinmultiplepregnanciesischorionicity.Monozygotictwinsresultfromthesplittingofonefertilisedovumduringthefirsttwoweeksofembryogenesis.Approximately75%ofmonozygotictwinsaremonochorionicdiamniotic(MCDA),withanoverallincidenceofonein400pregnancies,althoughthisincidenceisthoughttobeincreasingduetoadvancedreproductivetechniquessuchasintracytoplasmicsperminjection(ICSI).1Themajorityoftheremaining25%ofmonozygoustwinpregnanciesaredichorionicdiamniotic(DCDA)wherecleavagehasoccurredbeforeday3post-conception.Averysmallnumberofmonozygotictwinpregnanciesaremonochorionicmonoamnioticwherecleavagehasoccurredafter8postconceptiondays.
Monochorionicdiamniotictwinshavea3-10foldhigherperinatalmortalityrateandahigherrateofmorbiditythandichorionictwins,whohaveahigherperinatalmortalityratethansingletons.Thisismainlyduetocongenitalanomalies,complicationsofprematurityandplacentalabnormalitiesincludingtwintotwintransfusionsyndrome(TTTS)andintrauterinegrowthrestriction(IUGR).
DiagnosisThediagnosisofchorionicityisbestmadeinthefirsttrimesterandcanbemadeasearlyas7weeksontransvaginalultrasound.Themostreliableultrasoundindicatorofdichorionicityisacombinationofthe‘lambdasign’or‘twinpeak’and/orthepresenceoftwoseparateplacentae(FigureI).Themostusefulindicatorofmonochorionicityisthe‘T’sign(FigureII).2Inthesecondandthirdtrimestersdeterminationofchorionicitymaybelessaccurateandisbasedonidentificationoffetalgender,numberofplacentae,intertwinmembranethicknessandthepresenceorabsenceofthe‘T’or‘lambda’signs.Therehavebeennoprospectivestudiesshowingthatknowledgeofchorionicityandmanagementofcomplicationshasimprovedfetaloutcomes.3
Figure I.Dichorionicdiamniotictwinpregnancy.Arrowshows‘twinpeak’sign
Figure II.Monochorionicdiamniotictwinpregnancy.Arrowshows‘Tsign’andthininter-twinmembrane
PrematurityOfthe25,111womenwhogavebirthinWesternAustraliain2004,58.6%ofmultiplebirthsweredeliveredpreterm(<37weeksgestation)comparedto7.1%ofsingletonbirths.4Prematurityisassociatedwithadverseperinataloutcomesincludingperinataldeath,respiratorydistresssyndrome,chroniclungdisease,cerebralpalsy,neurologicalmorbidity,
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hearingproblemsandvisualproblems.InastudybySebireetalMCDAtwinshadahigherrateofbeingbornbefore32weeksthanDCDAtwins(9%vs.5.5%).5ThiswassimilartoastudybyLeducetal,whereevenaftertwinswithTTTSwereexcluded,34.4%ofMCDAtwinsdeliveredlessthan34weekscomparedto22.5%ofDCDAtwins.6
GrowthrestrictionMonochorionictwinsaretwiceaslikelytohavea25%birthweightdiscordancethandichorionictwinsandtobelessthanthe10thcentileatbirth(31.2%vs.15.4%).6TwinswithIUGR(definedasanestimatedfetalweightlessthanthe10thcentileforgestationalage)requireclosemonitoringtoassistinthecorrecttimingofdelivery.UltrasoundwithDopplerhasbeenshowninhighriskpregnanciestoimproveperinataloutcomes.7TheexacttimingofscreeningmultiplepregnanciesatriskofIUGRisuncertain.ThereisnotreatmenttopreventIUGR.
Congenital anomaliesaremorecommonintwinpregnanciesthaninsingletonpregnancies.Indizygoustwinstheriskofcongenitalmalformationsinatleastonetwinistwicethatofsingletons.Inmonozygoustwinsthereisanincreasedrateofstructuralmalformations(notchromosomalorgeneticabnormalities)andtwinsmaybediscordantforanomalies.Brain,facial,gastrointestinal,anteriorabdominalwall,neuraltubeandcardiacabnormalitiesarethemorecommonabnormalitiesreported.
Screeningforaneuploidyintwinpregnanciesisbestperformedinthefirsttrimesterwithnuchaltranslucency.Amniocentesishassimilarmiscarriageratestothatofsingletonpregnancies.Chorionicvillussamplingistechnicallypossiblehowevermaybedifficult,withthepotentialforcontaminationandforinadequatesamplingofbothfetuses.8Selectiveterminationofpregnancyismoredifficultduetotheneedforcordocclusioninmonochorionictwinpregnancies.
Twin to twin transfusion syndrome (TTTS)isaparticularcomplicationofmonochorionictwinplacentationandoccursinupto15%ofmonochorionictwinpregnancies.5TTTSusuallyoccursinthemidtrimesteranduntreateditresultsin80-90%perinatalmortalityanda15-50%riskofhandicapinthesurvivors.
ThediagnosisofTTTSismadeonultrasoundwithpolyhydramnios(maximumverticalpocket>=8cm)intherecipienttwinandoliguricoligohydramnios(maximumverticalpocket<=2cm)inthedonorbeingthebasicstandardcriteria.9Sonographicstagingincludesamnioticfluidvolumeassessment,assessmentofthepresenceorabsenceofthedonortwinbladder,monitoringofDopplerflowintheumbilicalarteryandductusvenosusandpresenceofhydropsfetalisand/orfetaldeathinoneorbothtwins.9
ContemporarytreatmentofTTTSiswithlaserablationoftheinter-twinvascularanastamosesand/oramnioreduction.ThegoaloftreatmentofTTTSistoprolongpregnancy,preventpretermlabourandpreventthedeathofonetwininuterobecauseofthesubsequentriskofneurologicalinjurytothesurvivingco-twin.FetoscopiclaserablationofanastomoseshasbeenshowntobebetterthanamnioreductionintreatingTTTSinarandomisedcontrolledtrial.10Howeverlasertreatmentleadtoonlyonesurvivoratbirthin76%ofpregnanciestreatedwithlaserascomparedtoa56%rateofonetwinsurvivalincasestreatedbyamnioreduction(relativeriskofthedeathofbothfetuses,0.63;95percentconfidenceinterval,0.25to0.93;P=0.009).10
Deathofoneorbothtwinsmaybecausedbypretermlabourwhichmaybeasaresultofpretermprelabourruptureofthemembranes,infection,abruptionorpolyhydramnios.Fetaldemisemayalsobecausedbyplacentalinsufficiencyorcontinuingfetal-fetalbloodtransfusionleadingtoanaemia/polycythaemia.
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LaserablationiscurrentlybeingperformedinAustraliainPerth,Brisbane,SydneyandMelbourne.Itisahighlyspecialisedtreatmentthatcanbeperformedasearlyas16weeksgestationandhasasteeplearningcurve.11
Neonatal Morbidity
Twinshavea5foldincreasedriskofcerebralpalsycomparedtosingletons.12Fetaldeathofatwinisfrequentlyassociatedwithsevereneurologicalmorbidity,includingcerebralpalsy,inthesurvivingco-twin.Therehavebeennostudiesdeterminingtheeffectofchorionicityincerebralpalsyhowevertwinstudiesusingconcurrentgenderandnon-concurrentgenderasasurrogatemarkerhaveshownthatcerebralpalsyismuchmorecommonintwinsofsimilargenderwhentheco-twindiesin-utero.12Monochorionictwinsaremorelikelytobeadmittedtotheneonatalintensivecareunitandhaveanintraventricularhaemorrhage,evenaftertwinswithTTTSareexcluded.6
Maternal morbidity
Womenwithtwinpregnanciesaremorelikelytohavepre-eclampsia,gestationaldiabetes,anaemiaandneedanoperativedeliveryorCaesareansection.Antepartumhaemorrhageandpostpartumhaemorrhagearemorecommon.Asmallnumberofwomen(4%)willrequireaCaesareansectionforthedeliveryofthesecondtwinafteravaginaldeliveryforthefirsttwin.13
Timing and mode of delivery
Forvaginaldeliverytobeconsideredinatwinpregnancythepresentingtwinshouldbeinacephalicpresentation,continuouselectronicfetalmonitoringandanepiduralshouldbeavailableandexperiencedobstetric,paediatricandmidwiferystaffshouldbepresent.ItisstillunclearwhethervaginaldeliveryorCaesareansectionistheoptimalmodeofdeliveryintwinpregnanciesandfurtherstudiesarecurrentlyunderwaytoaddressthisissue.AlthoughsomeauthorsbelievethatallmonochorionictwinsshouldbedeliveredbyCaesareansectionbecauseoftheriskofintrapartumtwintotwintransfusion,othershavefoundnoincreasedneonatalmortalityormorbiditywithvaginaldeliveryinMCDAtwinscomparedtoDCDAtwins.14
TimingofdeliveryinMCDAtwinsisalsocontroversial.Retrospectivedatashowanincreasingriskofadversepregnancyoutcomesforalltwinswithadvancinggestationalagewiththelowestriskofperinatalmortalityandmorbidityoccurringbetween36and38weeksgestation.3,13ArecentretrospectivestudybyBarigyeetalof151uncomplicatedmonochorionictwinpregnanciesshoweda4.6%rateofunexpectedintrauterinedeathsatamediangestationalageof34+1weeks.15Althoughsomeauthorsadvocateelectivepretermdeliveryformonochorionictwins,insufficientinformationiscurrentlyavailabletorecommendthis.3,16
Conclusion
MCDAtwinpregnanciesareuncommonbutareassociatedwithasignificantlyincreasedriskofperinatalmorbidityandmortality.Thediagnosisofmultiplepregnancyandthedeterminationofchorionicityisbestmadeinthefirsttrimester.AlthoughthereisnoevidencefromrandomisedcontrolledtrialsthatscreeningforTTTSandIUGRimprovesperinataloutcomes,thecomplicationsofMCDAtwinpregnanciescanbemonitoredwithultrasoundinordertoensuretheappropriateantenatalmanagement,suchassteroidstomaturefetallungs,transfertoaunitwithtertiaryneonatalcarefacilities,electivepretermdeliveryandtreatmentforTTTS.
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Suggested management of MCDA twin pregnancies
Ultrasound
1. Determinechorionicityinalltwinsinthefirsttrimester
2. Offernuchaltranslucencyscreeningtoallmotherswithtwinpregnancies
3. 16weekscan
4. 19weektertiaryscan
5. 22weekscan
6. 25weekscan
7. 2-4weeklyscansuntildeliveryif<20%growthdiscordance
8. Aimfordeliveryafter37weeks
9.Considervaginaldeliveryif1sttwincephalic,andappropriateobstetric,anaesthetic,paediatricandmidwiferysupportavailable
10. ReferifanysignsofTTTStotertiarycentre
11.Considerreferraltotertiarycentreifgrowthdiscordance>20%orIUGRorabnormalumbilicalarteryDopplerstudies,and/oroligohydramnios
References1. SchachterM,RazielA,FriedlerS,StrassburgerD,BernO,Ron-ElR.Monozygotictwinningafterassistedreproductive
techniques:aphenomenonindependentofmicromanipulation.Hum. Reprod.2001;16(6):1264-1269.
2. CarrollSG,SoothillP,Abdel-FattahSA,PorterH,MontagueI,KylePM.Predictionofchorionicityintwinpregnanciesat10–14weeksofgestation.BJOG: an International Journal of Obstetrics and Gynaecology2002;109(182-186).
3. DoddsJ,CrowtherC.Evidence-basedcareofwomenwithamultiplepregnancy.Best Practice & Research in Clinical Obstetrics & Gynaecology.2005;19:131-153.
4. GeeV,GodmanK.PerinatalStatisticsinWesternAustralia,2004.TwentysecondAnnualReportoftheWesternAustralianMidwives’NotificationSystem.Department of Health Western Australia,2006.
5. SebireNJ,SnijdersRJM,HughesK,SepulvedaW,NicolaidesKH.Thehiddenmortalityofmonochorionictwinpregnancies.BJOG: An International Journal of Obstetrics and Gynaecology1997;104(10):1203-1207.
6. LeducL,TakserL,RinfretD.Persistenceofadverseobstetricandneonataloutcomesinmonochorionictwinsafterexclusionofdisordersuniquetomonochorionicplacentation.Am J Obstet Gynecol2005;193:1670-5.
7. NeilsonJ,AlfirevicZ.Dopplerultrasoundforfetalassessmentinhighriskpregnancies.Cochrane Database of Systematic Reviews1996(4).
8. TaylorMJ,FiskNM.Prenataldiagnosisinmultiplepregnancy.Best Practice & Research in Clinical Obstetrics & Gynaecology2000;14(4):663-75.
9. QuinteroRA,MoralesWJ,AllenM,BornickP,JohnsonP,KrugerM.StagingofTwin-TwinTransfusionSyndrome.Nature1999;19(8):550-555.
10.SenatM,DeprestJ,BoulvainM,PaupeA,WinerN,VilleY.Endoscopiclasersurgeryversusserialamnioreductionforseveretwin-to-twintransfusionsyndrome.N Engl J Med2004;351(2):136-144.
11.ChanF.-Y.CR,SoongB,BornickP,AllenM,QuinteroR,.Learningcurveforfetoscopiclasersurgeryforseveretwin–twintransfusionsyndromecanbeshortened.Ultrasound in Obstetrics & Gynecology2005;26:309-375.
12.PharoahPeter.RiskofCerebralPalsyinMultiplePregnancies.Obstet Gynecol Clin N Am2005;32:55-67.
13.SoucieJE,YangQ,WenSW,FungKFK,WalkerM.Neonatalmortalityandmorbidityratesintermtwinswithadvancinggestationalage.Am J Obstet Gynecol2006;195(172-7).
14.SauA,ChalmersS,ShennanAH,MaxwellD.Vaginaldeliverycanbeconsideredinmonochorionicdiamniotictwins.BJOG: An International Journal of Obstetrics and Gynaecology2006;113:602-604.
15.BarigyeO,PasquiiL,GaleaP,ChambersH,ChappellL,FiskN.Highriskofunexpectedlatefetaldeathinmonochorionictwinsdespiteintensiveultrasoundsurveillance:aCohortstudy.PLoS Med2005;2(6):e172.
16.Cleary-GoldmanJ,D’AltonM.UncomplicatedMonochorionicDiamnioticTwinsandtheTimingofDelivery.PLoS Med 2005;2(6):e180.
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7Appendices
7.1 Appendix I: Abbreviations and Definitions
Abbreviations:ABS AustralianBureauofStatisticsAC abdominalcircumferenceAIHW AustralianInstituteofHealthandWelfareAMA AustralianMedicalAssociationBGL bloodglucoselevelBP bloodpressureCI confidenceintervalCSE combinedspinalepiduralCTG cardiotocographDCDA dichorionicdiamniotictwinpregnancyDIA DepartmentofIndigenousAffairsDM diabetesmellitusDVAS DomesticViolenceAdvocacySupportEDPH ExecutiveDirectorofPublicHealthFHR fetalheartrateGCT glucosechallengetestGDM gestationaldiabetesmellitusGTT glucosetolerancetestGP-obstetrician GeneralPractitionerwithobstetricskillsHbA1C glycated(glycosylated)HaemoglobinHIC HealthInformationCentreofWesternAustraliaICSI intracytoplasmicsperminjectionIUGR intrauterinegrowthrestrictionIVF invitrofertilisationKEMH KingEdwardMemorialHospitalLA localanaestheticMCDA monochorionicdiamniotictwinpregnancyNPDC NationalPerinatalDataCollectionNRP NeonatalResuscitationProgramPATS PatientassistedtransportschemePEPISU PregnancyandParentingSubstanceUseProgramPIMC PerinatalandInfantMortalityCommitteeofWesternAustraliaPMH PrincessMargaretHospitalPSANZ PerinatalSocietyofAustraliaandNewZealandPSANZPDC PerinatalSocietyofAustraliaandNewZealandPerinatalDeathClassificationPSANZNDC PerinatalSocietyofAustraliaandNewZealandNeonatalDeathClassificationRFDS RoyalFlyingDoctorServiceRANZCOG TheRoyalAustralianandNewZealandCollegeofObstetriciansandGynaecologistsReCoDe RelevantConditionatDeath,classificationsystemRBG randombloodglucoseRR relativeriskSEIFA Socio-economicIndexesforAreasSIDS SuddenInfantDeathSyndromeSIDSandkids SupportgroupforfamiliesaffectedbysuddeninfantorchildhooddeathSOSU StatewideObstetricSupportUnitTSI TorresStraitIslanderTTTS TwintotwintransfusionsyndromeWA WesternAustraliaWANTS WesternAustralianNeonatalTransportServiceWHO WorldHealthOrganization
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Definitions:
Aboriginal/Indigenous: ApersonwhoidentifiesthemselvesasanAboriginalorTorresStraitIslander,orwhoisidentifiedassuchbythecommunitywithinwhichhe/shelives.
Aboriginal/Indigenousinfant: BorntoaparentwhoidentifiesasanAboriginalorTorresStraitIslander,orisidentifiedassuchbyaresponsiblepersononadmissiontohospital.
Livebirth: Thecompleteexpulsionorextractionfromitsmotherofaproductofconception,irrespectiveofthedurationofthepregnancywhich,aftersuchseparation,breathesorshowsanyotherevidenceoflifesuchasbeatingoftheheart,pulsationoftheumbilicalcordordefinitemovementofvoluntarymuscles,whetherornottheumbilicalcordhasbeencutortheplacentaisattached;eachproductofsuchabirthisconsideredliveborn.
Stillbirth/FetalDeath: Deathpriortothecompleteexpulsionorextractionfromitsmotherofaproductofconceptionof20ormorecompletedweeksofgestationorof400gormorebirthweight.Thedeathisindicatedbythefactthataftersuchseparationthefetusdoesnotbreatheorshowanyotherevidenceoflifesuchasbeatingoftheheart,pulsationoftheumbilicalcord,ordefinitemovementofvoluntarymuscles.iv
Stillbirthrate: Thenumberofstillbirthsper1,000totalbirths.
Neonataldeath: Thedeathofaliveborninfantwithin28daysofbirth.
Neonatalmortalityrate: Thenumberofdeathsofliveborninfantsunder28daysofageper1,000livebirths.
Perinataldeath: Astillbirthorneonataldeath.
Perinatalmortalityrate: Thenumberoffetalandneonataldeathsper1,000totalbirths.
Infantdeath: Thedeathofaliveborninfantwithinthefirstyearoflife(priortothefirstbirthday).
ivThisdefinitionofstillbirthisusedbytheHealthInformationCentreofWA,thePIMC,andtheNationalperinataldatacollection(NPDC).Therearedifferencesindefinitionsusedbyotherinstitutions,e.g.
ABSdefinition:Afetusthatdoesnothaveaheartbeatoranysignoflife,whichis400gormoreinbirthweightor,ifbirthweightisunavailable,greaterorequalto20weeksingestation.
WHOdefinition:forfetaldeathisforinfantswithbirthweightgreaterorequalto500g,or22weeksgestationwherebirthweightisunknown.
Infantmortalityrate: Thenumberofdeathsofinfantsunderoneyearofageper1,000livebirths.
Post-neonataldeath: Thedeathofaliveborninfantoccurringintheremainderofthefirstyear(28–364days).
Post-neonatalmortalityrate: Thenumberofdeathsofliveborninfantsfrom28daystooneyearofageper1,000livebirths.
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7.2 Appendix II: Appropriate Investigations Following Stillbirth and Infant Death
Stillbirths
Thoroughinvestigationintothecauseofdeathisrecommended.Evenwherethecauseappearsobvious,additionalinformationmaybeobtainedthatmayassistinthemanagementofthewomanandherfuturepregnancies.Inthissensitiveperioditmaybedifficulttodiscussinvestigations,butifnotrequestedattheappropriatetime,theopportunitytoobtainvaluableinformationmaybelost.
Whenfetaldeathisdiagnosed,orfollowingastillbirth,reviewtheantenatalandperipartumnoteswithattentiontopastmedicalandobstetrichistory,familyhistory(e.g.geneticdisorders/hypertension/thrombophilia/diabetes/thyroiddisease),possibleinfections,exposuretoanimalsortoxicchemicals,andsubstanceuse.Historymayprovideinformationsuggestiveofpre-eclampsia,diabetes,cholestasisofpregnancy,orantepartuminfection.Thereshouldbeareviewoftheroutineantenatalbloodtests(maternalfullbloodcountandbloodgroupantibodyscreen),andantenatalinfectiousdiseasescreening(rubella,syphilis,HIV,HepatitisB&C).
Autopsyexaminationshouldbeencouragedatalltimes.Whereparentsdeclinefullautopsy,optionsfor“externalonly”orastep-wiseapproachareavailable.Placentalhistopathologyprovidesmuchinformation,andmostparentswillconsenttothiseveniftheydeclineautopsyexamination.Whereautopsyisdeclined,consentshouldalsobesoughtformetabolicstudiesusingabloodspot(collectedonaGuthriecard),x-ray(babygram)andclinicalphotographsoftheinfant.Post-mortemultrasound(eitherinuteroorexutero)providesanatomicalinformationwhichisparticularlyusefulforthepathologistforassessingintra-cranialanatomy,asthebrainisoftenautolysedanddifficulttoexamine.Amniocentesissamplesarerecommendedforkaryotypingandmicrobiology.Samplesoftissuescollectedpost-mortemhaveahighfailurerateforchromosomalstudies,sosamplesobtainedearlierthroughamniocentesisarerecommended.Amnioticfluidsamplesalsoprovidehelpfulmicrobiologicalinformationwherethereisaquestionofascendinggenitalinfectionorviralinfection.Forstillbirthofahydropicfetus,discussionwithamaternalfetalmedicinespecialistisrecommendedinordertotailorspecificinvestigations.
TheKleihaeur-Betketestisrecommendedasaroutine.Thistestdetectsfetalbloodcellsinthematernalcirculation,indicatingfeto-maternalhaemorrhage.Thistestisoflittleuseunlessperformedpriortotheonsetoflabour.
Ameasurementforglycatedhaemoglobin(HbA1C)issuggestedtoassistindiagnosisofdiabetes.Womenwithunexplainedstillbirthhaveanincreasedriskofglucoseabnormalitiesinsubsequentpregnancies.Therefore,ifgestationaldiabetesmellitusissuspected,formalglucosetestingshouldbeundertakeninthenextpregnancy.
Inthepresenceofpre-eclampsia,maternalliverfunction,uricacidandcoagulationstudiesmaybeindicated.Inthepresenceofmaternalpruritus,checkmaternalserumbileacidsandliverfunction.Itisrecommendedtoroutinelyperformurinetoxicologyscreeningforillicitsubstancesbutconsentshouldbeobtainedforthis.
Placentalswabsarerecommendedasaroutine.Othermicrobiologicalswabs(maternalhighvaginal,endocervicalandthroatswabs)andmaternalbloodculturesareonlyrecommendedinthepresenceofmaternalfever.RoutinelyrecommendedmaternalserologicaltestsareforCytomegalovirus,Toxoplasmagondii,ParvovirusB19andHerpessimplexvirus.Testingforsyphilisandotherinfectiousdiseasesissuggestedwhereclinicallyindicated.
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Sixweeksfollowingaperinatalloss,consultantliaisonisadvisedinordertotailorinvestigationsappropriately.Notethatthrombophiliascreeningandauto-immunestudiesareonlyrecommendedinthepresenceofplacentalpathologyand/orevidenceoffetalgrowthrestriction.Thesecostlyinvestigationshavealowyield.
Infantdeaths
Forneonataldeaths,manyoftheaboveinvestigationswillbeappropriate.Liaisonwithapaediatricianisrecommendedtoassistinappropriateinvestigations.
Review antenatal history:e.g.exposuretoinfectionordrugs.Symptomsofpre-eclampsiaorcholestasis?
Investigation of a Stillbirth:
Pre-labour, or as soon as possible following stillbirth:
Ultrasound for:•amniocentesis• fetalanatomy
Blood tests:• fullbloodcount
Kleihauer-Betke(prelabour)
•HbA1C•glucose•serology:CMV,
HSV,Toxoplasma,ParvovirusB19
Toxicology tests:•Obtainconsentfor
urinaryscreeningtestsforalcoholanddrugsofabuse
If febrile:•highvaginalswab•endocervicalswab•bloodculture• throatswab
If clinically indicated, add:•bileacids•Syphilisserology•Rubellaserology•HIVserology• thrombophiliascreen•thyroidfunctiontests•autoantibodytests
If clinical suggestion of pre-eclampsia add:•coagulationstudies• redbloodcellantibodies• liverfunctiontests•uricacid
Ifhydropic,discusswithmaternofetalmedicine
specialist.
Amniotic fluid:•karyotype•microbiology
After delivery encourage parents to consent to full autopsy examination.
Thorough examination of baby.•photosifpossible.•considercranialultrasoundif
notdoneprior.
Yes to autopsy:Autopsyoptions:Full/stepwise/limited
Plus:PlacentalhistopathologyPlacentalswabsformicrobiology
Consider:•babygram(xray)Guthrie(bloodspottest)• fetallivervirology/PCRtests
No to autopsy: Stronglyrecommend:PlacentalhistopathologyPlacentalswabsformicrobiology
Consider:•Guthrie(bloodspot)•Karyotype,infantskinbiopsy
orothertissue• Infantearandthroatswabs
Comments:•Forinfantdeathsmanyoftheseinvestigationswillbeappropriate.
Discusswithneonatologist.•Todiagnosefetomaternalhaemorrhage,Kleihaeur-Betketestmustbe
takenpriortotheonsetoflabour.
ConsultantAdvice:
Perinatal Loss Service: KingEdwardMemorialHospitalCoordinator:Phone93402222,page3430,or93402128orpageon-callSeniorRegistrarinObstetrics,viaswitchboard93402222
Neonatal deaths: PrincessMargaretHospitalforChildrenPagetheon-callNeonatalIntensiveCareConsultant,viaswitchboard93408222
Post-Neonatal deaths: PrincessMargaretHospitalforChildrenPagetheon-callPaediatricIntensiveCareConsultant,viaswitchboard93408222
Approvedmulti-lingualcopiesofthePost Mortem Examination Consent FormandtheNon-Coronial Post Mortem Examinations, Information for Relativesbookletareavailableonthewebat:http://www.health.wa.gov.au/postmortem/
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7.3 Appendix III: Perinatal and Infant Deaths by PSANZ PDC, WA 2002-04
PSANZ PDC CODEType of Death Total
Deaths
PND All Deaths
SB NND PNND % %
1 Congenital abnormality 145 38 22 205 25.7 25.4
1.1Centralnervoussystem 36 2 4 42 5.3 5.2
1.2Cardiovascularsystem 21 11 4 36 4.5 4.5
1.3Urinarysystem 13 3 0 16 2.2 2.0
1.4Gastrointestinalsystem 4 1 2 7 0.7 0.9
1.5Chromosomal 33 9 4 46 5.9 5.7
1.6Metabolic 0 2 1 3 0.3 0.4
1.7Multiple/non-chromosomal 22 3 1 26 3.5 3.2
1.8Othercongenitalabnormality 2 2 0 4 0.6 0.5
1.81Musculoskeletal 6 1 1 8 1.0 1.0
1.82Respiratory 0 2 1 3 0.3 0.4
1.83Diaphragmatichernia 2 2 2 6 0.6 0.7
1.85Tumours 3 0 1 4 0.4 0.5
1.88Otherspecifiedcongenitalabnormality 3 0 1 4 0.4 0.5
2 Perinatal Infection 23 12 2 36 4.9 4.5
2.11GroupBStreptococcus 4 5 1 10 1.3 1.2
2.12Ecoli 1 0 0 1 0.1 0.1
2.13Listeriamonocytogenes 1 0 0 1 0.1 0.1
2.14Spirochaetal(syphilis) 1 0 0 1 0.1 0.1
2.18Otherbacterial 6 2 1 9 1.1 1.1
2.19Unspecifiedbacterial 0 2 0 2 0.3 0.2
2.2Viral 1 0 0 1 0.1 0.1
2.21Cytomegalovirus 4 0 0 4 0.6 0.5
2.22Parvovirus 1 0 0 1 0.1 0.1
2.23Herpessimplexvirus 1 1 0 2 0.3 0.2
2.24Rubellavirus 0 1 0 1 0.1 0.1
2.3Protozoal(Toxoplasma) 1 0 0 1 0.1 0.1
2.9Otherunspecifiedorganism 2 1 0 2 0.4 0.2
3 Hypertension 38 1 1 40 5.5 5.0
3.4Gestationalhypertension 2 0 0 2 0.3 0.2
3.5Pre-eclampsia 32 1 1 34 4.6 4.2
3.6Pre-eclampsiasuperimposedonchronic 4 0 0 4 0.6 0.5
4 Antepartum haemorrhage 40 6 1 47 6.5 5.8
4.1Placentalabruption 39 6 1 46 6.3 5.7
4.3Vasapraevia 1 0 0 1 0.1 0.1
5 Maternal conditions 20 1 0 21 2.9 2.6
5.1,5.3,5.5,5.8:“other”maternalconditions 5 1 0 6 0.8 0.7
5.2Diabetesmellitus 15 0 0 15 2.1 1.9
6 Specific perinatal conditions 42 11 3 56 7.4 6.9
6.1Twin-twintransfusionsyndrome 18 5 0 23 3.2 2.9
6.2Fetomaternalhaemorrhage 9 1 0 10 1.4 1.2
6.3Antepartumcordcomplication 3 0 0 3 0.4 0.4
6.4Uterineabnormality 3 3 1 7 0.8 0.9
6.5Birthtrauma 0 1 0 1 0.1 0.1
6.61Rhesus 3 0 0 3 0.4 0.4
6.7Idiopathichydrops 3 0 0 3 0.4 0.4
6.8Otherspecificperinatalconditions 3 1 2 6 0.6 0.7
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PSANZ PDC CODEType of Death Total
Deaths
PND All Deaths
SB NND PNND % %
7 Hypoxic peripartum death 17 15 2 34 4.5 4.2
7.1Withintrapartumcomplications 5 9 1 15 2.0 1.9
7.11Uterinerupture 1 0 0 1 0.1 0.1
7.12Cordprolapse 1 1 1 3 0.3 0.4
7.18Otherintrapartumcomplication 1 0 0 1 0.1 0.1
7.2Evidencenon-reassuringfetalstatus 2 2 0 4 0.6 0.5
7.9Unspecifiedhypoxicperipartumdeath 7 3 0 10 1.4 1.2
8 Fetal Growth Restriction 37 5 1 42 5.9 5.2
8.1Withreducedvascularperfusion 17 4 0 21 2.9 2.6
8.2Withchronicvillitis 1 0 0 1 0.1 0.1
8.3Noplacentalpathology 14 1 0 15 2.1 1.9
8.4Noexaminationofplacenta 5 0 0 5 0.7 0.6
9 Spontaneous preterm birth 85 67 6 158 21.3 19.6
10 Unexplained antepartum death 100 0 0 101 14.0 12.5
10.1Withreducedperfusion/placentalpathology 5 0 0 5 0.7 0.6
10.2Withchronicvillitis 2 0 0 2 0.3 0.2
10.3Noplacentalpathology 59 0 0 60 8.3 7.4
10.4Noexaminationofplacenta 26 0 0 26 3.7 3.2
10.5Withotherspecifiedplacentalpathology 7 0 0 7 1.0 0.9
10.9Unspecifiedornotknownifplacentaexamined 1 0 0 1 0.1 0.1
11 No obstetric antecedent 0 11 57 67 1.5 8.3
11.1SIDS 0 1 19 20 0.1 2.5
11.2Postnatallyacquiredinfection 0 0 12 12 0.0 1.5
11.3Accidentalasphyxiation 0 5 9 14 0.7 1.7
11.4Otheraccident,poisoningorviolence(postnatal) 0 0 8 8 0.0 1.0
11.8Otherspecified 0 0 1 1 0.0 0.1
11.9Unknown/undetermined 0 4 8 12 0.6 1.5
7.4 Appendix IV: Infant Deaths by PSANZ NDC, WA 2002-04
PSANZ NDC CODEType of Death Infant Deaths
Neonatal Post-Neonatal N %
1 Congenital Abnormalities 37 22 59 22.7
1.1Centralnervoussystem 2 4 6 2.3
1.2Cardiovascularsystem 11 4 15 5.8
1.3Urinarysystem 3 0 3 1.2
1.4Gastrointestinal 1 2 3 1.2
1.5Chromosomal 8 4 12 4.6
1.6Metabolic 2 1 3 1.2
1.7Multiple/nonchromosomalsyndromes 3 1 4 1.5
1.8Othercongenitalabnormality 7 4 11 4.2
1.83Diaphragmatichernia 0 1 1 0.4
1.85Tumours 0 1 1 0.4
2 Extreme prematurity (typically <24 wks) 42 3 45 17.3
2.1Notresuscitated 11 0 11 4.2
2.2Unsuccessfulresuscitation 17 3 20 7.7
2.9Unspecifiedifresuscitationattempted 14 0 14 5.4
3 Cardio-respiratory disorders 26 3 29 11.2
3.1Hyalinemembranedisease/Respiratorydistress 16 0 16 6.2
3.2Meconiumaspirationsyndrome 2 0 2 0.8
3.3Primarypersistentpulmonaryhypertension 1 0 1 0.4
3.4Pulmonaryhypoplasia 4 1 5 1.9
3.5Chronicneonatallungdisease 0 2 2 0.8
3.8Other 3 0 3 1.2
4 Infection 18 16 34 13.1
4.1Bacterial 1 0 1 0.4
4.11Congenitalbacterial 12 1 12 5.0
4.12Acquiredbacterial 1 13 14 5.4
4.2Viral 0 1 1 0.4
4.21Congenitalviral 2 0 2 0.8
4.5Fungal 0 1 1 0.4
4.8Other 1 0 1 0.4
4.9Unspecifiedorganism 1 0 1 0.4
5 Neurological 24 1 25 9.6
5.1Hypoxicischaemicencephalopathy/perinatalasphyxia 21 1 22 8.5
5.2Intracranialhaemorrhage 3 0 3 1.2
6 Gastrointestinal 5 1 6 2.3
6.1Necrotisingenterocolitis 5 1 6 2.3
7 Other 14 58 62 23.8
7.1SIDS 0 5 5 1.9
7.11ConsistentwithSIDS 0 4 4 1.5
7.12PossibleSIDS 1 13 14 5.4
7.2Multisystemfailure 3 1 4 1.5
7.3Trauma 2 8 10 3.8
7.8Other 5 9 14 5.4
7.9Undetermined/Unknown 3 8 11 4.2
Abbreviations:SB–stillbirthNND–neonataldeathPND–perinataldeathPNND–post-neonataldeath
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Produced by the Office of the executive Director of Public health© Department of health 2007
Department of health
12th Report of the Perinatal and Infant Mortality Committee of Western australia
Deaths 2002-04