Clinical experience with management of "near-miss" cases in obstetrics

Near-miss cases in life-threatening obstetric patients occurring over a one year period are analysed retrospectively with regards to morbidity measured in terms of hospital stay, utilisation of high dependency ward and intensive care beds and adequacy of clinical management. One-hundred and twenty two cases occurred among 9932 deliveries. Massive obstetric haemorrhage (54.2%) and hypertensive disorders of pregnancy (36.9%) were the two main diagnostic groups. Seventy one (58.2%) cases were referred from peripheral centres for obstetric management and 77 (63.1%) were not booked at this hospital for antenatal care. A majority were not ill-looking (92 cases) at the time of admission but turned for the worse in the course of labour. Interventional measures taken in clinical management were considered appropriate in all cases. Delay in instituting treatment was present in 6 cases. Remediable measures were recognised in 15 (12.3%). This study, apart from supplementing mortality audits, demonstrates that high risk obstetric patients can be triaged at the time of admission to labour wards by trained midwives and junior doctors in busy obstetric units without compromising standards of care.     

General-practitioner obstetrics: two styles of care

Two systems of general-practitioner obstetric care currently in use in England are compared. In one (Oxford) a large number of doctors, working with community midwives, have autonomous responsibility for the management of patients whose condition conforms with defined booking criteria. In the other (Dulwich) two practitioners, working with hospital midwives, operate a minimal selection policy, but all their patients are reviewed at 36 weeks' gestation by a specialist obstetrician. Despite the differing selection policies which created incongruities in the groups in respect of age, social class, and birthweight distribution, the outcomes in terms of mode of delivery showed no significant differences. The perinatal mortality rates were also similar and appeared to be better than those achieved nationally.     

Antenatal care in Belfast

A questionnaire study of mothers' views of the antenatal care provided in Belfast showed general satisfaction. Retrospective examination of their charts however showed in some cases that insufficient attention was paid to the medical and obstetric history in the selection of type of care made by the women and their doctors. Some women with high risk factors were booked for shared care and some patients at low risk were booked for total hospital care. The reasons for this are unclear.     

Quality of obstetric care provided for Asian immigrants in Leicestershire

Between 1976 and 1981 some 939 perinatal deaths occurred to women living in Leicestershire, of which 128 (14%) were to Asian women. The qualifications of the general practitioners, the gestation at which women start antenatal care, and perinatal death were used as structural, process, and outcome measures for evaluating the services provided to Asian immigrants within this population. Perinatal deaths were divided into four groups: congenital malformation, macerated stillbirth, asphyxia in labour, and immaturity. Asian mothers had one and a half times the risk of perinatal mortality when social class, parity, height, legitimacy, and the general practitioner's qualifications were taken into account. Asian and non-Asian mothers with general practitioners who were not on the obstetric list had more than twice the risk of a perinatal death when a similar adjustment was made. Recommendations include priority allocation of community midwives to practitioners not on the obstetric list, the establishment of postgraduate courses for such doctors, and the continued evaluation of the effect of such proposals on perinatal mortality.     

Spinal epidural abscess: presentation and treatment. A report of 21 cases.

OBJECTIVE: To examine the presentation, investigative findings, treatment and outcome in patients with spinal epidural abscess. DESIGN AND SETTING: The study was a retrospective analysis of all patients with this condition presenting to the Neurosurgical Units at the Royal Prince Alfred Hospital and Westmead Hospital, Sydney, during the period September 1984 to September 1987. PATIENTS: There was a total of 21 patients with an age range from 7-87 years (mean 47 years). Eleven cases were acute and ten chronic. The causative organism was Staphylococcus aureus in 15 of the 21 cases, the other organisms involved were Mycobacterium tuberculosis, Escherichia coli, Streptococcus and Pseudomonas aeruginosa. INTERVENTIONS: All patients were treated with a combination of surgery (decompression with or without fusion) and prolonged antibiotic administration. RESULTS: Of the 21 patients 11 had a good to excellent outcome while 10 had a poor outcome. CONCLUSION: The main determinant of outcome was the neurological state at presentation emphasising the importance of early diagnosis and prompt treatment.     

Why do obstetric patients go to the ICU? A 3-year-study

Background

Pregnant women are at risk to develop complications due to illness related to pregnancy or due to aggravation of pre-existing disease. These patients also require critical care and ICU admissions in some cases. To determine the current spectrum of diseases in an obstetric population resulting in admission to the intensive care unit (ICU) at a tertiary care hospital.

Methods

A retrospective case series study and analysis of data from obstetric patients admitted for critical care management.

Results

0.26% of the total obstetric patients admitted to the hospital required ICU admissions. 46% of patients were admitted to ICU for ventilator support. Pre-eclampsia and obstetrical hemorrhage were the common diagnosis for these patients.

Conclusion

Critically ill obstetric patients require a team approach of the obstetrician, anesthesiologist and intensive care specialist for the optimal care of these patients.     

Perinatal mortality at the Port Moresby General Hospital and St. Therese's Maternity Hospital 1972

A study was made of the 67 still-births and the 58 neonatal deaths that occurred among the 3,516 viable infants (birth weight 1,000 g. or more) that were born to public patients of the obstetric units of Port Moresby General Hospital and St. Therese's Maternity Hospital during the year 1972. The combined stillbirth and neonatal mortality rate was 35.5 per 1,000 births. The adverse effects of lack of antenatal care, delivery outside hospital, high parity, maternal anaemia, mulitple pregnancy, and low birth weight are demonstrated. Low birth weight (1,000 to 2,200 g.) of unknown cause accounted for 24.0 per cent of the deaths. In 16,8 per cent of cases the birth weight was more than 2,200 g. and the cause of death was unknown. Birth trauma accounted for 19.2 per cent of the deaths, congenital malformation for 11.2 per cent, antepartum haemorrhage for 11.2 per cent, toxaemia for 10.4 per cent, and maternal disease for 3.2 per cent. There were miscellaneous causes in 4.0 per cent of cases. Approximately 75 per cent of the deaths were considered to be the result of unfavourable factors in the mother's environment. Approximately 14 per cent were primarily the result of obstetric complications and might have been avoided by a higher standard of obstetric care. Improving the standard of obstetric care that is presently available in Port Moresby would probably reduce the perinatal mortality rate by not more than 5 per 1,000.     

Heroin users seeking methadone treatment

Seven hundred and sixty-seven patients applying to enter public methadone programmes in the western suburbs of Sydney underwent assessment in the Drug and Alcohol Unit at Westmead Hospital between 1986 and 1988. These patients had long histories of illicit drug use and most were involved in crime, prostitution and a drug subculture. Many abused multiple drugs, and almost all had been exposed to hepatitis B virus. However, human immunodeficiency virus (HIV) seropositivity rate was low. Methadone programmes, at least in Sydney's western suburbs, attract a very disadvantaged population for whom rehabilitation is likely to be a difficult, long-term process.     

孕产期全程护理对流动人口妊娠期糖尿病影响的研究

目的观察助产士孕产期全程护理对流动人口妊娠期糖尿病患者的影响。方法将2008年6月～2009年10月在我院产科门诊确诊的68例妊娠期糖尿病患者随机分为观察组和对照组,每组各34人,观察组和对照组在门诊均建立高危妊娠保健手册,定时产检,另对观察组的整个孕产期由高年资助产士定期对其进行一对一随访及健康教育。结果观察组的饮食及治疗的依从性好,血糖控制理想,并发症减少。结论孕产期全程护理有效提高流动人口妊娠期糖尿病患者的依从性,降低糖尿病对孕产妇及胎儿的影响。     

Perinatal mortality audit at Tikure Anbessa Teaching Hospital,Addis Ababa,Ethiopia: 1995 to 1996

Objectives

To determine the prevalence and causes of perinatal mortality rates at Tikure Anbessa hospital, Ethiopia, 1995–96

Design

A cross-sectional review of hospital records of all women who delivered at Tikure Anbessa Hospital. Data were collected prospectively.

Setting

Teaching Hospital of Tikure Anbessa, Addis Ababa, Ethiopia

Subjects

Women and neonates from 8986 deliveries. Deliveries exceeding 28 weeks of gestation or birth weight of 1000 grams were considered.

Materials and Methods

All deliveries were included for infants whose gestational age exceeded 28 completed weeks. When the gestational age was unknown, the birth weight of 1000 grams or more was considered. All perinatal deaths and obstetric complications were identified. Labour chart, mode of delivery and summary of delivery had been recorded by the responsible resident at a monthly combined obstetric and paediatric perinatal mortality meeting. Age of the mother, parity, booking status for antenatal care, obstetric complications, labour, mode of delivery, birth weight, gestational age, one and five minutes Apgar scores were collected.

Results

A total of 8986 deliveries were conducted during the study period. Of these 6933 (77.2%) were booked for antenatal care while the remaining 2053 (22.8%) were not booked in any health institution. The perinatal mortality rate of the hospital was 71.6 per 1000 live births. The risk of perinatal mortality was more than doubled among mothers who failed to book for antenatal care follow-up and no laboratory investigations was done were birth asphyxia followed by premature birth 15.4% and 12% respectively.

Conclusions

Perinatal mortality rates are high at Tikure Anbessa Hospital, Ethiopia. There is need to ensure that pregnant women are booked for antenatal care so as to provide adequate antenatal and perinatal health care.     

Why do obstetric patients go to the ICU? A 3-year-study

Background

Pregnant women are at risk to develop complications due to illness related to pregnancy or due to aggravation of pre-existing disease. These patients also require critical care and ICU admissions in some cases. To determine the current spectrum of diseases in an obstetric population resulting in admission to the intensive care unit (ICU) at a tertiary care hospital.

Methods

A retrospective case series study and analysis of data from obstetric patients admitted for critical care management.

Results

0.26% of the total obstetric patients admitted to the hospital required ICU admissions. 46% of patients were admitted to ICU for ventilator support. Pre-eclampsia and obstetrical hemorrhage were the common diagnosis for these patients.

Conclusion

Critically ill obstetric patients require a team approach of the obstetrician, anesthesiologist and intensive care specialist for the optimal care of these patients.     

Risk of adverse maternal outcome following macrosomic birth in Nigeria

Objective: To determine the risk of adverse maternal outcome associated with obstetric intervention in labour.Methods:All cases of macrosomic births conducted at the University of Calabar Teaching Hospital,Calabar,between January 1st 1994 and December 31st 2000 were reviewed.Measure of treatment/intervention effect was calculated as relative risk for adverse maternal outcome,using spontaneous vaginal births as control.Results:Frequency of mode of delivery was as follow: vaginal births,139(60.7%);instrumental vaginal deliveries,16(7%);and abdominal deliveries,74(32.3%).Obstetric intervention occurred in 90(39.3%) cases.Sixty-four(28%) cases did not book for antenatal care,with 42 cases(18.3%) requiring obstetric intervention.About one in every two parturients(1: 2.1) in this study,requiring obstetric intervention at delivery had been interfered with at unorthodox health facilities.Relative risks for postpartum haemorrhage,wound sepsis and paralytic ileus were significantly high in parturients with abdominal delivery;while in parturients with instrumental vaginal delivery relative risks were significantly high for puerperal sepsis,paralytic ileus and obstetric palsy.There were no maternal deaths.Conclusion:Obstetric intervention in parturients with macrosomic births was high due to labour complications;and was associated with significant risk for adverse maternal outcome,especially in parturients with unskilled interference.     

The challenge of grandmultiparity in obstetric practice

INTRODUCTION: Traditionally grandmultiparity has been considered to be an obstetric hazard both to the mother and foetus. Compounding factors are low socioeconomic status, poor female literacy and social deprivation. In developed populations with improved and optimal obstetric services, parity per se is no longer considered a significant risk for adverse obstetric and perinatal outcome. OBJECTIVES: To compare the obstetric and perinatal outcome between grandmultiparas and second gravidas with previous one delivery as well as analyse certain socio demographic features in the two groups. METHODOLOGY: Case records from Maternity Hospital, Kathmandu, an inner city tertiary care centre were retrospectively studied. 106 cases of grandmultiparous patients were compared with 110 cases of second gravidas who had previously delivered once which was taken as the control group. Biosocial features as well as obstetric and perinatal outcome were analyzed. RESULTS: Rural residents comprised 60.4% of the grandmultiparous group versus 27.7% of the control group. A predominance of early marriage as well as an older age profile was noted in the grandmultipara. ANC attendance was documented to be much lower among grandmultipara with 26.4% having absolutely no antenatal care. A higher frequency of hypertensive disorders in pregnancy, preterm birth, anaemia, malpresentations, multiple pregnancy and premature rupture of membranes, postpartum haemorrhage and retained placenta was noted in the grandmultipara which also had a slightly higher caesarean delivery rate. The salient adverse perinatal outcome was found to be intrauterine foetal death, preterm birth and neonatal sepsis. CONCLUSION: In our set up, grandmultiparity continues to challenge our obstetric practice with its associated increased likelihood of maternal and perinatal complications. Concerted effort should be directed to reducing high parity in the community through effective family planning initiatives and specialized antepartum and intrapartum supervision of this group should be available.     

Ultrasound derived fetal growth curves for a Jamaican population

The objective of this study was to develop fetal growth curves and percentile growth charts for a Jamaican population. Four hundred and ninety-nine Jamaican women of African origin were enrolled in a prospective study from the antenatal clinic of the University Hospital of the West Indies, Kingston, Jamaica. Serial ultrasound scans were performed between 14 and 37 weeks gestation to measure fetal growth. The ultrasound measurements performed were biparietal diameter, head and abdominal circumference and femoral length. A total of 2574 ultrasound scans were performed on the 499 women (mean 5.2 per woman). From these data, centiles for fetal growth curves for the four fetal measurements were constructed and percentile tables were created for a Jamaican population. Birthweight varies between ethnic groups and, therefore, so must fetal growth rates. At present, fetal growth in Jamaica is assessed using standards which are based on data derived from Caucasian populations. Fetal growth curves using data from this study would more accurately identify a fetus that is at risk and hence, provide information which could improve obstetric care. These new growth curves should provide data, which will improve obstetric decision making.     

助产士产前门诊对初产妇焦虑抑郁情绪和分娩结局的影响

目的探究并分析助产士产前门诊对初产妇焦虑抑郁情绪和分娩结局的影响。方法选择2011年11月～2012年11月在我院产科定期产检并分娩的112例初产妇作为研究对象,应用随机数字表法将其分为常规护理组和护理干预组。常规护理组孕产妇接受常规产前门诊,而护理干预组孕产妇在此基础上接受助产士产前门诊;比较两组初产妇焦虑抑郁情绪和分娩结局,以探讨助产士产前门诊对初产妇焦虑抑郁情绪和分娩结局的影响。结果护理干预组焦虑抑郁标准分、剖宫产率、产后2 h出血量和新生儿1 min Apgar评分均明显低/少于常规护理组,差异有统计学意义（P〈0.05）。结论助产士产前门诊能够有效减少孕产妇的焦虑抑郁程度,提高自然分娩率,降低剖宫产率,改善分娩结局。     

The first year of a midwifery-led model of care in Far North Queensland

OBJECTIVE: To describe a midwifery-led model of care in Far North Queensland and the outcomes obtained in its first year of operation. DESIGN, SETTING AND PARTICIPANTS: Prospective analysis of data for all women who were booked for antenatal care with the midwifery-led unit at Mareeba District Hospital (MDH) and who gave birth during its first year of operation, from 27 June 2005 to 30 June 2006. MAIN OUTCOME MEASURES: Number of women giving birth at MDH; antenatal, intrapartum and postpartum transfers to a higher-level referral centre (Cairns Base Hospital [CBH]); and labour and delivery outcomes. RESULTS: Of the 203 women who were booked for antenatal care at MDH and gave birth in the 12-month period, 170 were categorised as low risk and suitable to give birth at MDH. Of these, 147 (86%) did give birth at MDH, while 17 women (10%) had their care transferred antenatally to CBH, and six (4%) were transferred intrapartum. Of the 33 women categorised as high risk, 22 (67%) gave birth at CBH as planned, seven (21%) had elective caesarean sections performed by a general practitioner at MDH, and four (12%) presented to MDH in labour and gave birth there with no complications. Of the 158 women who gave birth at MDH, 146 (92%) had a spontaneous vertex delivery. CONCLUSION: Outcomes for the first year of operation of the midwifery-led model of care are consistent with a viable maternity unit, with delivery outcomes and transfer rates that compare favourably with other similar units in Australia.     

Perinatal outcome and antenatal care in a black South African population.

The relationship between perinatal outcome and antenatal care was investigated at King Edward VIII Hospital, Durban, by a case control retrospective study of pregnancy records in 165 perinatal deaths and 156 infants surviving the perinatal period. 82% of the mothers of live infants had booked for antenatal care compared with only 60% of those who experienced a perinatal death. Hospital booking was associated with a higher infant birthweight. For those who booked earlier there was no reduction in total perinatal mortality or the stillbirth:neonatal death ratio, and many of the mothers of highest risk failed to book. This suggests that the better perinatal outcome in booked mothers may have been secondary to the type of mother who chose to book, rather than the actual antenatal care. To help reduce perinatal mortality, methods must be employed which reach those mothers who are most likely to fail to book.     

Antenatal monitoring of the high risk fetus

Fetus may be at high risk of perinatal mortality or morbidity or childhood morbidity either due to congenital malformations, genetically inherited disorders, chromosomal aberrations or due to antenatal and/or intrapartum hypoxia. Environmental hazards of infection, radiation and drug ingestion or maternal medical disorders are associated with some risk to the fetus. So it is important to identify those at risk by obtaining a detailed medical and family history. Maternal age and past obstetric history would also suggest the high risk nature of the pregnancy. A detailed clinical examination of the mother and the pregnancy will add further information. It is equally known that patients with no risk factors prior to pregnancy become at risk if they develop obstetric disorders of antepartum haemorrhage, pregnancy induced hypertension or diabetes. Therefore not only initial surveillance but continued care is important to identify those at risk. It is good practice to rule out congenital malformations, recognise multiple pregnancy and determine the gestational age in the early second trimester (18-21 weeks) by an ultrasound scan. This is of value in giving optimal care when a pregnancy turns from low to high risk. Aspects of monitoring the high risk fetus by simple clinical means and by appropriate technology is discussed.