Understanding perinatal mortality

The term perinatal death is used to describe antepartum and intrapartum stillbirths, and early neonatal deaths. At term, intrapartum stillbirth and neonatal death are collectively referred to as delivery related perinatal death, and the incidence in nulliparous and multiparous women is approximately one in 1000 and one in 2000 births, respectively. Associated factors include advanced maternal age, small for gestational age, fetal macrosomia, breech labour and previous caesarean delivery. The impact of obstetric interventions in labour on delivery related perinatal death, including rising rates of caesarean delivery, is complex and unclear. The incidence of overall perinatal death is falling mainly as a result of improvements in the management of premature neonates and from decreased deaths secondary to intrapartum anoxia at term. This review will provide an overview of perinatal mortality with a particular emphasis on delivery related perinatal death at term.     

Mode of delivery and the risk of delivery-related perinatal death among twins at term: a retrospective cohort study of 8073 births

OBJECTIVE: To determine the risk of perinatal death among twins born at term in relation to mode of delivery. DESIGN: Retrospective cohort study. SETTING: Scotland 1985-2001. POPULATION: All twin births at or after 36 weeks of gestation, excluding antepartum stillbirths and perinatal deaths due to congenital abnormality (n= 8073). METHODS: The outcome of first and second twins was compared using McNemar's test and the outcome of twin pairs in relation to mode of delivery was compared using exact logistic regression. MAIN OUTCOME MEASURES: Intrapartum stillbirth or neonatal death of either twin. RESULTS: Overall, there were six deaths of first twins and 30 deaths of second twins (OR for second twin 5.00, 95% CI 2.00-14.70). The odds ratio for death of the second twin due to intrapartum anoxia was 21 (95% CI 3.4-868.5). The associations were similar for twins delivered following induction of labour and for sex discordant twins. However, there was no association between birth order and the risk of death among 1472 deliveries by planned caesarean section. There was death of either twin among 2 of 1472 (0.14%) deliveries by planned caesarean section and 34 of 6601 (0.52%) deliveries by other means (P= 0.05, odds ratio for planned caesarean section 0.26 [95% CI 0.03-1.03]). The association was similar when adjusted for potential confounders. Assuming causality, we estimate that 264 caesarean deliveries (95% CI 158-808) would be required to prevent each death. CONCLUSION: Planned caesarean section may reduce the risk of perinatal death of twins at term by approximately 75% compared with attempting vaginal birth. This is principally due to reducing the risk of death of the second twin due to intrapartum anoxia.     

Stillbirths in Western Australia 1980–1983: Influence of Race, Residence and Place of Birth

All stillbirths in Western Australia from 1980-83 weighing 1,000 g and over were identified from perinatal death certificates, and their causes and demographic correlates described. The stillbirth rate was 4.91 per 1,000 total births; nearly 65% were antepartum, 25% intrapartum and in 10% the time of death was unknown. The cause of death of most stillbirths was unknown (52%) or associated with lethal congenital malformations (13%), antepartum haemorrhage (12%) or maternal hypertension (8%). Whilst Aboriginal women had much higher stillbirth rates (10.80) than non-Aboriginal women (4.57), their patterns of time and causes of death were similar. Both antepartum and intrapartum stillbirth rates were much higher at low birth-weights and low gestational ages in both racial groups. Women living in rural areas who delivered in the metropolitan area had much higher antepartum (11.02) and intrapartum (3.31) stillbirth rates than either rural women delivering in rural areas (1.89 and 1.34) or metropolitan women delivering in the metropolitan area (2.72, 0.98). This reflects the transfer of rural high risk pregnant women or those with fetal death in utero, for delivery in metropolitan specialist hospitals.     

Prospective risk of stillbirth in multiple-gestation pregnancies: a population-based analysis

OBJECTIVE: To evaluate the prospective risk of stillbirth in multiple gestations. METHODS: We conducted a retrospective analysis of birth notifications and infant mortality records relating to all multiple gestations to residents in a predefined health district. The incidence of live births and stillbirths was used to calculate the prospective risk of stillbirth at each week of gestation. RESULTS: The risk of stillbirth in multiple gestations increased from 1:3333 at 28 weeks' gestation to 1:69 at 39 or more weeks' gestation. The stillbirth risk in multiple gestations at 39 weeks surpassed that of postterm singleton pregnancies (1:526). CONCLUSION: Multiple gestations at 37-38 weeks have a risk of stillbirth equivalent to that of postterm singleton pregnancy. Because multiple gestations rarely proceed beyond 39 weeks, and because stillbirth risk increases several-fold beyond this stage, elective delivery might be justified at this gestational age.     

Cesarean delivery surveillance system at a maternity hospital in Kabul, Afghanistan

OBJECTIVE: To use an active facility-based maternal and newborn surveillance system to describe cesarean delivery practices and outcomes in a resource-poor setting. METHODS: Using data from operating room logbooks, 392 cesarean deliveries were evaluated between April 1 and June 30 2006 at a large public maternity hospital in Kabul, Afghanistan. RESULTS: The perinatal mortality rate was 89 per 1000 births: 57% antepartum and 37% intrapartum stillbirths. Fetuses with normal birth weight comprised 85% of intrapartum stillbirths. Obstructed labor, uterine rupture, and malpresentation accounted for more than 50% of perinatal deaths. The cesarean delivery rate was 10.2% and there were 2 maternal deaths. CONCLUSION: The high percentage of intrapartum stillbirths among normal birth weight fetuses suggests a need for improved labor monitoring and surgical obstetric practices. The use of a facility-based perinatal surveillance system is critical in guiding such quality assurance initiatives.     

Monoamniotic twins: a retrospective controlled study

Monoamniotic twins are uncommon but are at high risk (reportedly 50%) for perinatal death, commonly from cord accidents. Until recently the diagnosis of monoamniotic twinning was seldom made before delivery, but modern ultrasound technology permits diagnosis during prenatal care, creating a management dilemma. This is a report of the experience with monoamniotic twins of 20 or more weeks' gestation at the University of Iowa Hospitals from 1961-1989. Twenty monoamniotic twin pregnancies were compared with 40 monochorionic, diamniotic controls regarding antepartum and intrapartum complications. Overall, monoamniotic twins were delivered earlier, were more likely to die in utero, and had lower birth weights than diamniotic twins. When only live-born twins were considered, however, there were no differences in gestational age at delivery, birth weight, or 5-minute Apgar scores. No fetal death occurred after 32 weeks, suggesting that prophylactic preterm delivery may not be indicated in all cases. Labor and vaginal delivery were not associated with an increased risk of fetal death.     

Fetal deaths in the United States. Influence of high-risk conditions and implications for management

OBJECTIVE: To estimate the effect of specific maternal-fetal high-risk conditions on the risk and timing of fetal death. METHODS: This study examined 10,614,679 non-anomalous singleton pregnancies delivering at or beyond 24 weeks' gestation, derived from the U.S. linked birth/infant death data sets, 1995-1997. Fetal death rates for pregnancies at low risk were compared with pregnancies complicated by chronic hypertension, gestational hypertensive disorders, diabetes, small for gestational age infants, and abruption. Adjusted relative risks as well as population-attributable risks for fetal death were derived by gestational age for each high-risk condition compared with low-risk pregnancies. RESULTS: The fetal death rate for low-risk pregnancies was 1.6 per 1000 births. Adjusted relative risk for fetal death was 9.2 (95% confidence interval [CI] 8.8, 9.7) for abruption, 7.0 (95% CI 6.8, 7.2) for small for gestational age infants, 1.4 (95% CI 1.3, 1.5) for gestational hypertensive disorders, 2.7 (95% CI 2.4, 3.0) for chronic hypertension, and 2.5 (95% CI 2.3, 2.7) for diabetes. Fetal death rates were lowest between 38 and 41 weeks. The fetal death rate (per 1000 births) for these high-risk conditions was 61.4, 9.6, 3.5, 7.6, and 3.9, respectively. Almost two thirds of fetal deaths were attributable to the pregnancy complications examined. CONCLUSION: High-risk conditions in pregnancy are associated with an increased risk for fetal death, particularly in the third trimester. Delivery should be considered at 38 weeks, but no later than 41 weeks, for these pregnancies.     

Perinatal Mortality in a Tertiary Obstetric Institution

At the Royal Women's Hospital, Melbourne in the 3 years 1987-1989 analysis of the records of 13,347 public patients revealed an overall perinatal wastage of 20.8 per 1,000 births. This seemingly high figure resulted from the fact that 45% of losses occurred in nonbooked and emergency admissions. Many patients were referred with major complications of pregnancy, especially gross prematurity, lethal congenital malformations and intrauterine deaths. During the 3-year period 74% of perinatal losses occurred before 33 weeks' gestation and only 10% were after 37 weeks. By comparison at a Victorian State level, 47% of perinatal deaths occurred before 33 weeks and more than 35% after 37 weeks' gestation. The major causes of perinatal wastage in both groups were similar. At the Royal Women's Hospital in the 3-year period lethal congenital abnormalities accounted for 19.1% of fetal wastage, premature labour, premature rupture of the membranes and cervical incompetence 16.2%, multiple pregnancy 14.7%, antepartum haemorrhage 14.0% and hypertensive disorders 9.7%. During the 3-year period 7.7% of hospital stillbirths were intrapartum compared to 27% for the State of Victoria. The stillbirth rate in Victoria has declined over the past decade, but to a lesser extent than the neonatal death rate. Over the 3-year period 1987-1989 the ratio of stillbirths to neonatal deaths was 3 to 2, and in 1989 there were nearly twice as many stillbirths as neonatal deaths (424 versus 240). Furthermore, 55% of stillborn infants in Victoria had birth-weights of more than 1,500 g compared to the Royal Women's Hospital figure of 36%.(ABSTRACT TRUNCATED AT 250 WORDS)     

Optimal gestational age for twin delivery.

OBJECTIVE: We evaluated the timing of twin delivery associated with perinatal outcome in gestations of at least 36 completed weeks. STUDY DESIGN: This was a retrospective analysis of infant and maternal hospital records for a consecutive series of twin deliveries at New York Hospital-Cornell Medical Center. The inclusion criteria were delivery after 36 weeks' gestation during a 7-year period (1987 to 1993), without congenital anomalies or early fetal demise. Adverse perinatal outcomes were compared between deliveries before 38 weeks' gestational age and those at or after 38 weeks' gestation. RESULTS: Of 776 twin deliveries during the study period, 329 met the inclusion criteria. Adverse perinatal outcome was significantly higher among the twin pregnancies that delivered before 38 weeks' gestation compared with those that delivered at or after 38 weeks' gestation. Twin pregnancies that delivered between 36 and 37 weeks' gestation were 13 times more likely to require neonatal intensive care compared with those who delivered at or after 38 weeks' gestation (95% confidence interval 1.8 to 95.9; p < 0.001). CONCLUSION: In uncomplicated twin gestations, delivery at between 36 and 37 weeks' gestation was not associated with a reduction in neonatal complications compared with deliveries at or after 38 weeks' gestation.     

Perinatal mortality and neonatal morbidity rates among twin pairs at different gestational ages: optimal delivery timing at 37 to 38 weeks' gestation

OBJECTIVE: The aim of this study was to determine the gestational age at delivery associated with the lowest rates of perinatal mortality, respiratory distress syndrome, and long hospital stays among twins, with pair rates used to account for both infants in each twin pregnancy. STUDY DESIGN: We conducted a population-based retrospective study that analyzed linked birth certificates, fetal and infant death certificates, and hospital discharge data for 8150 twin pairs born in Washington State during 1987 through 1997. The chi2 or Fisher exact test was used to assess the statistical significance. RESULTS: The nadirs of perinatal mortality rate, respiratory distress syndrome incidence, and long hospital stay rate were seen at delivery dates of 39, 40, and 38 weeks' gestation, respectively. Restriction to pairs delivered vaginally without the induction of labor revealed that the perinatal mortality rate was lowest for delivery at 37 weeks' gestation, the gestational age at which the highest numbers of such spontaneously timed pairs were born. CONCLUSION: Induction of labor should be routinely considered for twins at 37 to 38 weeks' gestation.     

Maternal and perinatal outcome in nulliparous women aged 35 and older

OBJECTIVE: To compare the maternal and perinatal outcome of nulliparous women 35 years and older at the time of delivery with nulliparous women 25-29 years old. METHODS: A retrospective review of maternal and newborn records of singleton gestations only for first birth in women aged 35 and older (study group n = 143) were compared with pregnancies of women aged 25-29 (control group, n = 148) delivered at the same period with respect to pregnancy complications and outcome. The study was performed at the Princess Badeea Teaching Hospital in North Jordan between January 1, 1996 and July 1, 2000. RESULTS: Most of the elderly nulliparous women were professionals (60%) and 20% had a history of infertility. Compared with women aged 20-29 years, women delivering their first child at or >35 years were at increased risk of weight gain, obesity, chronic and pregnancy-induced hypertension, antepartum haemorrhage, multiple gestation, malpresentation, and premature rupture of membranes. Women aged 35 years and older were also substantially more likely to have preterm labour, oxytocin use, and caesarean births. The older women differed significantly in neonatal outcomes: gestational age, birth weight, preterm delivery, low birth weight, small for gestational age, fetal distress and neonatal intensive care unit admissions. CONCLUSION: It is concluded that nulliparous women 35 years and older had higher risk of antepartum, intrapartum, and neonatal complications than nulliparous women aged 25-29 years, but these risks, for the most part, are manageable in the context of modern obstetrics. The excess rate of caesarean sections is only partially accounted for by gestational complications. Despite the increased risk of complications, perinatal death of the study group was similar to that of the control group. There were no maternal deaths.     

Restricted fetal growth in sudden intrauterine unexplained death

BACKGROUND: Unexplained antepartum stillbirth is a common cause of perinatal death, and identifying the fetus at risk is a challenge for obstetric practice. Intrauterine growth restriction (IUGR) is associated with a variety of adverse perinatal outcomes, but reports on its impact on unexplained stillbirths by population-based birthweight standards have been varying, including both unexplained and unexplored stillbirths. AIM: We have studied IUGR, assessed by individually adjusted fetal weight standards, in antepartum deaths that remained unexplained despite thorough postmortem investigations. METHODS: Antenatal health cards from a complete population-based 10-year material of 76 validated sudden intrauterine unexplained deaths were compared to those of 582 randomly selected liveborn controls. Birthweight <10th percentile of the individualized standard adjusted for gestational age, maternal height, weight, parity, ethnicity, and fetal gender was defined as growth restriction. RESULTS: 52% of unexplained stillbirths were growth restricted, with a mean gestational age at death of 35.1 weeks. Suboptimal growth was the most important fetal determinant for sudden intrauterine unexplained death (odds ratio 7.0, 95% confidence interval 3.3-15.1). Concurrent maternal overweight or obesity, high age, and low education further increase the risk. Overweight and obesity increase the risk irrespective of fetal growth, and while high maternal age increases the risk of the normal weight fetus, it is not associated to growth restriction as a precursor of sudden intrauterine unexplained death. CONCLUSIONS: IUGR is an important risk factor of sudden intrauterine unexplained death, and this should be excluded in pregnancies with any other risk factor for sudden intrauterine unexplained death.     

Fetal death during labor: an epidemiologic indicator of level of obstetric care

The effect of level of perinatal care on rates of intrapartum fetal death was studied in births of infants weighing greater than 1000 gm in New York City in 1976 to 1978. With potential confounding by birth weight, gestational age, and several other variables controlled, intrapartum fetal death rates decreased as intensiveness of care increased. Compared with births in Level 3 maternity units (perinatal intensive care), births in Level 1 units (community hospitals) had a 61% excess risk of intrapartum fetal death (p less than 0.01) and births in Level 2 units (intermediate level of care) had a 35% excess risk (p = 0.06). The effect of hospital level on intrapartum fetal death rates could not be attributed to differences in the classification of fetal deaths during labor across hospital levels, since no compensatory differences in late antepartum fetal death rates were found. Our findings in a total population are compatible with several studies carried out in single hospitals that have reported declines in intrapartum fetal death rates, especially in births more closely attended during labor. Fetal deaths that occur in labor, as contrasted with fetal deaths occurring before labor, constitute a perinatal outcome that is especially sensitive to level of obstetric care.     

Breech delivery at term: do the perinatal results justify a trial of labour?

This is a retrospective study conducted at Princess Badee'a Teaching Hospital in North Jordan to compare neonatal loss and morbidity in term singleton breech infants delivered either vaginally or by caesarean section. In this study, all singleton term breech presentation at 37 completed weeks' gestation were reviewed. Three hundred and eight singleton term babies, presenting by the breech were studied. Intrapartum deaths, neonatal deaths and Apgar scores in vaginal and caesarean delivery were compared. After exclusion of infants with lethal congenital malformations and antenatal stillbirths, the incidence of intrapartum and neonatal deaths associated with vaginal births was 3.5% compared with 1.3% in infants born abdominally. The number of low Apgar scores were similar in both groups. We concluded that caesarean section for term singleton breech presentation is associated with good neonatal outcome and this may influence the decision of obstetricians about the mode of delivery.     

The risk of perinatal mortality with each week of expectant management in obese pregnancies

Introduction: The risk of stillbirth associated with maternal obesity increases with gestational age; however, it is unclear if earlier delivery reduces the overall perinatal mortality rate. Our objective was to compare the risk of perinatal mortality associated with each additional week of expectant management to that of immediate delivery.

Methods: This was a retrospective cohort study of singleton non-anomalous births in Texas between 2006 and 2011. Analyses were stratified based on maternal pre-pregnancy BMI class. For each BMI class, we calculated the rate of neonatal death and stillbirth at each week of gestation from 34 to 41 weeks. A composite risk of perinatal mortality associated with 1 week of expectant management was estimated combining the stillbirth rate of the current week and the neonatal death rate of the following week. This was compared with the rate of neonatal death of the current week.

Results: After all exclusions, 2,149,771 births remained for analysis. In the normal weight group, stillbirth risk increased from 0.8 per 10,000 births at 34 weeks to 5.7 per 10,000 births at 42 weeks, whereas the neonatal death risk decreased from 76.5 per 10,000 births at 34 weeks to 30.4 per 10,000 births at 42 weeks, there were no differences between expectant management and delivery for any gestational week. In the obese group, stillbirth risk increased from 1.8 per 10,000 births at 34 weeks to 10.5 per 10,000 births at 42 weeks, whereas the neonatal death risk decreased from 67.7 per 10,000 births at 34 weeks to 26.2 per 10,000 births at 42 weeks, the perinatal mortality risk favored delivery at 39 weeks (RR: 1.17; 99% CI: 1.01–1.36) and not thereafter. In contrast, in the morbidly obese group, stillbirth risk increased from 8.8 per 10,000 births at 34 weeks to 83.7 per 10,000 births at 42 weeks, whereas the neonatal death risk decreased from 63.6 per 10,000 births at 34 weeks to 15.5 per 10,000 births at 42 weeks, the perinatal mortality risk favored delivery from 38 weeks (RR: 1.53; 99% CI: 1.16–2.02) through 41 weeks (RR: 5.39; 99% CI: 1.83–15.88).

Conclusion: The findings reported here suggest that delivery by 38 weeks in gestation minimizes perinatal mortality in pregnancies complicated by maternal morbid obesity.     

A parsimonious explanation for intersecting perinatal mortality curves: understanding the effect of plurality and of parity

BACKGROUND: Birth weight- and gestational age-specific perinatal mortality curves intersect when compared across categories of maternal smoking, plurality, race and other factors. No simple explanation exists for this paradoxical observation. METHODS: We used data on all live births, stillbirths and infant deaths in Canada (1991-1997) to compare perinatal mortality rates among singleton and twin births, and among singleton births to nulliparous and parous women. Birth weight- and gestational age-specific perinatal mortality rates were first calculated by dividing the number of perinatal deaths at any given birth weight or gestational age by the number of total births at that birth weight or gestational age (conventional calculation). Gestational age-specific perinatal mortality rates were also calculated using the number of fetuses at risk of perinatal death at any given gestational age. RESULTS: Conventional perinatal mortality rates among twin births were lower than those among singletons at lower birth weights and earlier gestation ages, while the reverse was true at higher birth weights and later gestational ages. When perinatal mortality rates were based on fetuses at risk, however, twin births had consistently higher mortality rates than singletons at all gestational ages. A similar pattern emerged in contrasts of gestational age-specific perinatal mortality among singleton births to nulliparous and parous women. Increases in gestational age-specific rates of growth-restriction with advancing gestational age presaged rising rates of gestational age-specific perinatal mortality in both contrasts. CONCLUSIONS: The proper conceptualization of perinatal risk eliminates the mortality crossover paradox and provides new insights into perinatal health issues.     

Incidence of stillbirth and perinatal mortality and their associated factors among women delivering at Harare Maternity Hospital, Zimbabwe: a cross-sectional retrospective analysis

BACKGROUND: Death of an infant in utero or at birth has always been a devastating experience for the mother and of concern in clinical practice. Infant mortality remains a challenge in the care of pregnant women worldwide, but particularly for developing countries and the need to understand contributory factors is crucial for addressing appropriate perinatal health. METHODS: Using information available in obstetric records for all deliveries (17,072 births) at Harare Maternity Hospital, Zimbabwe, we conducted a cross-sectional retrospective analysis of a one-year data, (1997-1998) to assess demographic and obstetric risk factors for stillbirth and early neonatal death. We estimated risk of stillbirth and early neonatal death for each potential risk factor. RESULTS: The annual frequency of stillbirth was 56 per 1,000 total births. Women delivering stillbirths and early neonatal deaths were less likely to receive prenatal care (adjusted relative risk [RR] = 2.54; 95% confidence intervals [CI] 2.19-2.94 and RR = 2.52; 95% CI 1.63-3.91), which for combined stillbirths and early neonatal deaths increased with increasing gestational age (Hazard Ratio [HR] = 3.98, HR = 7.49 at 28 and 40 weeks of gestation, respectively). Rural residence was associated with risk of infant dying in utero, (RR = 1.33; 95% CI 1.12-1.59), and the risk of death increased with increasing gestational age (HR = 1.04, HR = 1.69, at 28 and 40 weeks of gestation, respectively). Older maternal age was associated with risk of death (HR = 1.50; 95% CI 1.21-1.84). Stillbirths were less likely to be delivered by Cesarean section (RR = 0.64; 95% CI 0.51-0.79), but more likely to be delivered as breech (RR = 4.65; 95% CI 3.88-5.57, as were early neonatal deaths (RR = 3.38; 95% CI 1.64-6.96). CONCLUSION: The frequency of stillbirth, especially macerated, is high, 27 per 1000 total births. Early prenatal care could help reduce perinatal death linking the woman to the health care system, increasing the probability that she would seek timely emergency care that would reduce the likelihood of death of her infant in utero. Improved quality of obstetric care during labor and delivery may help reduce the number of fresh stillbirths and early neonatal deaths.     

Preeclampsia into eclampsia: toward a new paradigm

OBJECTIVE: This study was undertaken to characterize aspects of the natural history of eclampsia.Study Design: A retrospective analysis was performed on the records of patients with eclampsia who were delivered at two tertiary care hospitals. RESULTS: Fifty-three pregnancies complicated by eclampsia were identified. Thirty-seven of the women were nulliparous. The mean age was 22 years (range, 15-38 years). Mean gestational age at the time of seizures was 34.2 weeks' gestation (range, 22-43 weeks' gestation). Twenty-eight women had antepartum seizures (53%); 23 of the 28 had seizures at home. Nineteen women had intrapartum seizures (36%). Eight of these women had seizures while receiving magnesium sulfate, and 7 had therapeutic magnesium levels. Six women had postpartum seizures (11%), 4 >24 hours after delivery. Headache preceded seizures in 34 cases. Visual disturbance preceded seizures in 16 cases. The uric acid level was elevated to >6 mg/dL in 43 women. There were no maternal deaths or permanent morbidities. There were 4 perinatal deaths. Two patients had intrauterine fetal deaths at 28 and 36 weeks' gestation. These mothers had seizures at home. One infant died of complications of prematurity at 22 weeks' gestation and one died of respiratory complications at 26 weeks' gestation. There were 4 cases of abruptio placentae, 1 of which resulted in fetal death. Of the 53 cases of eclampsia, only 9 were potentially preventable. One of these was that of a woman who was being observed at home. The other 8 women were hospitalized and had hypertension and proteinuria. Only 7 women could be considered to have severe preeclampsia before seizure (13%), and 4 of these 7 women were receiving magnesium sulfate. CONCLUSIONS: Eclampsia was not found to be a progression from severe preeclampsia. In 32 of 53 cases (60%) seizures were the first signs of preeclampsia. In this series eclampsia appeared to be more of a subset of preeclampsia. Only 9 cases of eclampsia were potentially preventable with current standards of practice. Our paradigm for this disease, as well as our approach to seizure prophylaxis, should be reevaluated.     

Schwangerschaft am Termin

In Germany 75% of the total perinatal mortality is caused by antenatal fetal deaths and 40% of stillbirths occur at or later than 38 weeks of gestation. The rate of stillbirths increases 3 to 4-fold between 37 and 42 weeks of gestation relative to ongoing pregnancies. Mothers with advanced maternal age and primiparae are at higher risk of stillbirth. Neonatal complications show a continuous increase between 37 and 42 weeks of gestation. Pregnancy beyond 40 weeks is associated with significant risks to the pregnant women such as increased rate of cesarean delivery, operative vaginal delivery, postpartum hemorrhage, endomyometritis and birth injuries. At a gestational age of 41 weeks and accurate pregnancy dating, induction of labor is recommended without causing an increase in the frequency of cesarean deliveries. If additional risks for placental insufficiency are present, delivery from 37 weeks onwards might improve maternal and fetal outcome.     

Audit of neonatal deaths of nonmalformed infants of 34 or more weeks' gestation: unavoidable catastrophic events or suboptimal care?

BACKGROUND: The neonatal death rate (death < or = 28 days/1000 live births) has decreased and the level is now so low that it has been questioned whether further improvement is possible. The aim of this study was to categorize nonmalformed infants of 34 weeks' or more gestational age dying in the neonatal period to analyze if these deaths might have been prevented. MATERIAL AND METHODS: We used the audit method to study neonatal deaths during 1986-98 in a county population of approximately 240 000 inhabitants. RESULTS: Twenty-six neonatal deaths from a population of 41 901 live births were analyzed. The neonatal deaths were found to be associated with antepartum hypoxia (six cases); intrapartum catastrophes (seven cases); intrapartum monitoring deficiencies (five cases); resuscitation and stabilization after birth (two cases); infection (one case); sudden infant death syndrome (four cases); and peritonitis (died at home, one case). Suboptimal care was recorded in 16 cases. Neonatal death was unlikely to be associated with suboptimal care in six cases, but in 10 cases suboptimal care might or was likely to have brought about the fatal outcome. CONCLUSION: Avoiding suboptimal care might or is likely to prevent neonatal death in 10/26 (38.5%) of nonmalformed infants of 34 weeks' or more gestational age. Such improvements may, however, only slightly influence the neonatal death rate, with a reduction from 4.4 to 4.2/1000 live births.