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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

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


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


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


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


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


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.


1 E

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tive

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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.


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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


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

.


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.


1 E

xecu

tive

sum

mar

y

12

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

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-01

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the

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4:

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endat

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6:

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ome

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dity

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7:

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ause

of

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th:

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use

and

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ting

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llbi

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esti

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reco

mm

ende

din

App

endi

xII.


1 E

xecu

tive

sum

mar

y

13

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/


1 E

xecu

tive

sum

mar

y

14

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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23

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


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


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:


• 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:


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



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



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



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:


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:



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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:


• 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.

2. HealthInformationCentre(HIC)database,Gee,V.,PerinatalStatisticsinWesternAustralia,ReportsoftheWesternAustralianMidwives’NotificationSystem,DepartmentofHealth,WA.Editions20-23pertaintotheyears2002-05.

3. 11thReportofthePerinatalandInfantMortalityCommitteeofWesternAustralia,2000-01,DepartmentofHealth,WA.http://www.health.wa.gov.au/publications/documents/Perinatal%20Report%202000-01.pdf

4. Laws,P.J.,Grayson,N.,Sullivan,E.A.2006.Australia’sMothersandBabies2004.Perinatalstatisticsseriesno.18.AIHWcat.no.PER34.Sydney:AIHWNationalPerinatalStatisticsUnit.http://www.npsu.unsw.edu.au/ps18.pdf

5. AustralianBureauofStatistics:VitalStatisticsSeries:CausesofDeath3303SeriesforPerinatalStatistics;http://www.abs.gov.au/AUSSTATS/[email protected]/ProductsbyCatalogue/

6. AustralianBureauofStatistics:VitalStatisticsSeries:Deaths3302forInfantMortalityStatistics;http://www.abs.gov.au/AUSSTATS/[email protected]/ProductsbyCatalogue/

7. Australian Government. National Privacy Principles: Privacy Act 1988,(Commonwealth),http://www.privacy.gov.au/ACT/privacyact/

8. Western Australian Government. Midwives Notification System: forming part of the Health Act 1911, Part XIII.http://www.notifications.health.wa.gov.au/notifications/maternal/midwife.cfm#legislation

9. Western Australian Government. Amendment Abortion Act 1998,http://www.parliament.wa.gov.au/parliament/bills.nsf/43EBDD658FC50BA14825663400102F5D/$File/Act15.pdf

10. AbortionLawinAustralia,Natasha,C.,ResearchPaper11998-99,LawandBillsDigestGroup,31August1998;ParliamentofAustralia,ParliamentaryLibrary:http://www.aph.gov.au/library/pubs/rp/1998-99/99rp01.htm

11. PerinatalSocietyAustraliaNewZealand(PSANZ)DeathClassificationSystem:www.psanz.org.au

12. Wilson,R.,Runciman,W.,etal.TheQualityinAustralianHealthCareStudy.MedJAust.Vol163pp458-471;6Nov1995.

13. Saller,D.,Lesser,K.,etal.TheClinicalUtilityofthePerinatalAutopsy.JAMA,Feb22,1995;Vol273,No.8.

14. NationalPerinatalStatisticsUnitoftheAustralianInstituteofHealthandWelfare(AIHW),Australia’sMothersandBabies,PerinatalStatisticsSeries18.http://www.aihw.gov.au/publications/index.cfm/title/10374

15. Straton,J.,Godman,K.,Gee,V.(2005).InducedabortioninWesternAustralia1999-2004.ReportoftheWAAbortionNotificationSystem.DepartmentofHealth,WA.


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16. AustralianBureauofStatistics:CensusofPopulationandHousing2039seriesforsocio-economicclassifications.http://www.abs.gov.au/AUSSTATS/[email protected]/ProductsbyCatalogue/

17. RoyalAustralianandNewZealandCollegeofObstetriciansandGynaecologists(RANZCOG)ClinicalGuidelines:IntrapartumFetalSurveillance:www.ranzcog.edu.au/;Notethattheseguidelineshavebeenupdated,andthecurrentguidelinesare:IntrapartumFetalSurveillanceClinicalGuidelines2ndEd,March2006.

18. FutureDirectionsinMaternityCare,DiscussionPaper,HealthWA,Oct2006.www.clinicalnetworks.health.wa.gov.au/maternitycare/docs/Consultation_Document.pdf

19. RANZCOGASMOct2006presentation:DrDianeMohen,dataprovidedbyRuralDoctorsAssociationandRANZCOGJuly2006.http://www.rdaa.com.au/http://www.ranzcog.edu.au/

20. ResponsetotheProductivityCommission’sHealthWorkforceStudyonbehalfofTheRoyalAustralasianCollegeofPhysicians,July2005.www.racp.edu.au

21. Birthingservicesinsmallruralhospitals:sustainingruralandremotecommunities2005.RuralDoctorsAssociation.http://www.rdaa.com.au/uploaded_documents/ACF32BF.pdf

22. RoyalFlyingDoctorServicepersonalcommunication:DrAngelaO’Connell,ActingMedicalDirector,RoyalFlyingDoctorService,3EagleDrive,JandakotWA6164;Ph(08)94176300(8/2/2007).

23. ‘YourBirthingChoice;planningaheadforbirth’1999;DepartmentofHealth,WA.http://www.health.wa.gov.au/publications/birthing/index.html

24. Sokol,J.TheWANTSMedicalManual:ManagementoftheSickNeonate.6thEdition,December2004.

25. Bateman,B.,Simpson,L.HigherrateofStillbirthattheextremesofReproductiveAge:AlargenationwidesampleofdeliveriesintheUnitedStates.AmJofObstetsandGynae(2006)194;pp840-5.

26. AMA.http://www.amawa.com.au

27. CounsellingservicesareavailablethroughthreeservicesatKingEdwardMemorialHospital:PerinatalLossService,SocialWorkDepartment,andDepartmentofPsychologicalMedicine:Ph(08)93402222,andthroughtheSocialWorkDepartmentofPrincessMargaretHospitalforchildren,Ph(08)93408222.

28. Maberly,G.,Stanley,F.Mandatoryfortificationofflourwithfolicacid:anoverduepublichealthopportunity.MJA2005;183(7):pp342-343.

29. Bower,C.,Stanley,F.J.CaseformandatoryfortificationoffoodwithfolateinAustralia,forthepreventionofneuraltubedefects.BirthDefectsResAClinMolTeratol2004;70:pp842-843.

30. CentersforDiseaseControlandPrevention.Spinabifidaandanencephalybeforeandafterfolicacidmandate–UnitedStates,1995-1996and1999-2000.MorbidityandMortalityWeeklyReport.May7,2004/53(17);pp362-365.

31. Tucker,J.,McGuire,W.Epidemiologyofpretermbirth.BMJ2004;329;pp675-678.

32. Wen,S.W.,Smith,G.,Yang,Q.,Walker,M.Epidemiologyofpretermbirthandneonataloutcome.(Review).SeminarsinFetalandNeonatalMedicine.9(6):pp429-35.2004Dec.

33. Murphy,D.,Fowlie,P.,McGuire,W.ObstetricIssuesInPretermBirth,BMJVolume329(7469),2October2004,pp783-786.

34. Iams,J.D.,Paraskos,J.,Landon,M.,Teteris,J.N.,Johnson,F.Cervicalsonographyinpretermlabor.ObstetGynaecol1994;84:pp40-6.

35. Colombo,D.Predictingspontaneouspretermbirth.BMJ10Aug02;325:pp289-90

36. Honest,H.,Bachmann,L.M.,Gupta,J.K.,Kleijnen,J.,Khan,K.S.Accuracyofcervicovaginalfetalfibronectintestinpredictingspontaneouspretermbirth:systematicreview.BMJ2002:325:pp301-04.

37. Parry,E.,Singh,T.,Dow,D.,Noovao,F.Improvedmanagementinthreatenedpretermlaborwithrapidfetalfibronectintesting.ObstetGynaecolSurv,Vol61(11).Nov2006.pp688-689;withEditorialcomments.

38. Matthews,T.,Doherty,D.,Hornbuckle,J.ImpactoffetalfibronectintestingontransferforthreatenedpretermlabourinruralWesternAustralia.Posterpresentation,RANZCOG2006ASM,Perth

39. KingEdwardMemorialHospital(KEMH)guidelinesforobstetrics:http://kemh.health.wa.gov.au/development/manuals/sectionb/index.htm

40. Gardosi,J.,Kady,S.,McGeown,P.,Francis,A.,Tonks,A.Classificationofstillbirthbyrelevantconditionatdeath(ReCoDe):populationbasedcohortstudy.BMJ2005;331;pp1113-1117.

41. Huang,D.Y.,Usher,R.H.,Kramer,M.S.,Yang,H.,Morin,L.,Fretts,R.C.Determinantsofunexplainedantepartumfetaldeaths.ObstetGynaecol2000;95:pp215-21.

42. Froen,J.F.,Arnestad,M.,Frey,K.,Vege,A.Saustadetal.Riskfactorsforsuddenintrauterineunexplaineddeath:epidemiologiccharacteristicsofsingletoncasesinOslo,Norway1986-1995.AmJObstetGynaecol2001;184:pp694-702.

43. Dodd,J.,Robinson,J.,Crowther,C.,Chan,A.StillbirthandneonataloutcomesinSouthAustralia,1991-2000.AmJObstetGynaecol2003;Vol189.Number6,pp1731-1736.

44. Yudkin,P.L.,Wood,L.,Redman,C.W.G.Riskofunexplainedstillbirthatdifferentgestationalages.Lancet1987;1:pp1192-4.


5 C

omm

enta

ry

78

45. Cotzias,C.S.,Paterson-Brown,S.,Fisk,N.Prospectiveriskofunexplainedstillbirthinsingletonpregnanciesatterm:populationbasedanalysis.BMJ1999.Vol319(7205),31July1999,pp287-288.

46. Fretts,R.,EtiologyandPreventionofStillbirth.AmJofObstetsandGynae(2005)193,1923-35

47. Shankar,M.,Navti,O.,Amu,O.,Konje,J.AssessmentofStillbirthRiskandAssociatedRiskFactorsinaTertiaryHospital,JofObstetrics&Gynaecology.22(1):pp34-8,2002Jan.

48. Fretts,R.,Boyd,M.,Usher,R.,Usher,H.TheChangingpatternoffetaldeath.1961-1988.ObstetGynaecol.1992;79:35-9

49. Blair,P.S.,Sidebotham,P.,Berry,P.J.,Evans,M.,Fleming,P.J.MajorEpidemiologicalchangesinsuddeninfantdeathsyndrome:a20yearpopulation-basedstudyintheUK.TheLancet,Vol367.Issue9507,28Jan2006,pp314-319

50. Thach,B.Whereshouldbabybeputbacktosleep?Editorial.TheJofPediatrics,July2005,147;pp6-7.

51. Blair,P.S.,Fleming,P.J.,Smith,I.J.,Ward-Platt,M.,Young,J.,etal.Babiessleepingwithparents:case-controlstudyoffactorsinfluencingtheriskofthesuddeninfantdeathsyndrome.BMJVol319.Dec1999.pp1457-1462

52. Blair,P.S.,Ward-Platt.M.,Smith,I.J.,Fleming,P.J.Suddeninfantdeathsyndromeandsleepingpositioninpretermandlowbirthweightinfants:anopportunityfortargetedintervention.Arch.Dis.Child2006;91;pp191-106

53. McGarvey,C.,McDonnell,M.,Hamilton,K.,O’Regan,M.,Matthews,T.AneightyearstudyofriskfactorsforSIDS:bedsharingvsnonbedsharing.ArchDisChild2006;91:pp318-23

54. Carpenter,R.G.,Irgens,L.M.,Fleming,P.,Huber,J.,Jorch,G.,Schreuder,P.Suddenunexplainedinfantdeathin20regionsinEurope:casecontrolstudy.TheLancet.Vol363,Issue9404;17Jan2004;pp185-191

55. Scragg,R.,Mitchell,E.A.,Taylor,B.J.,Stewart,A.W.,etal.BedSharing,SmokingandAlcoholintheSuddenInfantDeathSyndrome.BMJ1993.Volume307(6915),20Nov93,pp1312-1318

56. Tappin,D.,Ecob,R.,Brooke,H.Bedsharing,roomsharingandsuddeninfantdeathsyndromeinScotland.JPediatr2005;147:32-7

57. Gessner,B.D.,Porter,T.J.Bedsharingwithunimpairedparentsisnotanimportantriskfactorforsuddeninfantdeathsyndrome.Pediatrics2006;117:pp990-1

58. Fleming,P.,Blair,P.,McKenna,J.NewKnowledge,NewInsights,andNewRecommendations.Scientificcontroversyandmediahypeinunexpectedinfantdeaths.Arch.Dis.Child.2006;91;pp799-801

59. FromDeathWeLearn:LessonsfromtheCoroner,WesternAustralia,June2006.

60. Krous,H.F.,Beckwith,J.B.,Byard,R.W.etal.Suddeninfantdeathsyndromeandunclassifiedsuddeninfantdeaths:Adefinitionanddiagnosticapproach.Pediatrics2004;114:pp234-8.

61. Fremantle,J.,Read,A.W.,DeKlerk,N.,Charles,A.K.,McAullay,D.,Stanley,F.J.InterpretationofrecentsuddeninfantdeathsyndromeratesinWesternAustralia.J.Paediatr.ChildHealth(2005)41,pp669-670.

62. PersonalcommunicationwithSIDSandKidsWA,andDrJudithStraton,ChildandCommunityHealth,DepartmentofHealth,WA.

63. McKenna,J.,McDade,T.Whybabiesshouldneversleepalone:Areviewoftheco-sleepingcontroversyinrelationtoSIDS,bedsharingandbreastfeeding.PaediatricRespiratoryReviews(2005)6;pp134-152.

64. Campbell-Daley,K.UpdateonSuddenInfantDeathSyndrome.CurrentOpinioninPediatrics.Vol16(2),April2004,pp227-232.

65. ChildandCommunityHealth,DepartmentofHealth,WA(contact:LeandaVerrierph:0893236668).

66. KingEdwardMemorialHospitalguidelinesforneonatology:http://kemh.health.wa.gov.au/services/nccu/guidelines/

67. Crofts,J.,Bartlett,C.,Ellis,D.,Hunt,L.,Fox,R.,Draycott,T.,TrainingforShoulderDystocia,ObstetricsandGynecology,Vol.108,No.6,Dec2006,pp1477-1485.

68. Askie,L.M.,Duley,L.,Henderson-Smart,D.andStewart,L.Antiplateletagentsforpreventionofpre-eclampsia:ameta-analysisofindividualpatientdata.TheLancet,Volume369,Issue9575,26May2007-1June2007,pp1791-1798.

69. O’Donnell,C.P.F.,Stewart,M.J.,Mildenhall,L.F.NeonatalResuscitationinAustraliaandNewZealand.JofPaedandChildHealth42(2006)pp4-5.

70. Davis,P.G.,Tan,A.,O’Donnell,C.P.,Schulze,A.Resuscitationofnewborninfantswith100%oxygenorair:Asystematicreviewandmeta-analysis.Lancet2004;364:pp4-5.

71. PMHandKEMHClinicalGuidelinesforNeonates:http://kemh.health.wa.gov.au/development/manuals/sectionb/11/7278.pdf

72. GuidelinesforCardiopulmonaryResuscitation(CPR)andEmergencyCardiovascularCare(ECC)ofPediatricandNeonatalPatients:NeonatalResuscitationGuidelines10.1542/peds.2006-0349.Pediatrics2006;117(5):e1029-1038.

73. Wyckoff,M.H.,Wyllie,J.Endotrachealdeliveryofmedicationsduringneonatalresuscitation.ClinicsinPerinatology.Vol33(1),pp153-160,2006.


5 C

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enta

ry

79

74. vanderHeide,P.,vanToledo-Eppinga,L.,vanderHeide,M.,vanderLee,J.Assessmentofneonatalresuscitationskills:areliableandvalidscoringsystem.Resuscitation(2006)71,pp212-221.

75. O’Donnell,C.P.F.,Davis,P.G.,Morley,C.J.NeonatalResuscitation:ReviewofventilationequipmentandsurveyofpracticeinAustraliaandNewZealand.JPaediatri.ChildHealth(2004)40,pp208-212.

76. Keenan,W.J.Neonatalresuscitation:Whatroleforvolumeexpansion?Paediatrics.Vol115(4)pp1072-1073,2005.

77. Tamuz,M.,Thomas,E.J.,Franchois,K.E.Definingandclassifyingmedicalerror:lessonsforpatientsafetyreportingsystems.QualSafHealthCare2004;13:pp13-20.

78. Panaretto,K.,Lee,H.,Mitchell,M.,Larkins,S.,Manessis,V.,Buettner,P.,Watson,D.ImpactofaCollaborativesharedantenatalcareprogramforurbanIndigenouswomen:aprospectivecohortstudy,MedJAust2005;182(10):pp514-519

79. KEMHcodeddata,providedbyMaureenHutchinson,clinicalmidwife,April2007.

80. Hulse,G.,Milne,E.,English,D.,Holman,C.Assessingtherelationshipbetweenmaternalopiateuseandneonatalmortality.Addiction.Vol93Issue7,pp1033-42,July1998.Onlinepublication1Oct2003.

81. PregnancyandParentingSubstanceUseProgram(PEPISU),contactdetailsin:DirectoryofWesternAustralianCommunityAlcoholandOtherDrugAgencies2006,WANADASept2006;www.wanada.org.au;contact:[email protected]

82. Gavin,A.L.,Gillam,C.HospitalAdmissionsduetoIntimatePartnerViolenceinWesternAustralia1994-2003.SchoolofPopulationHealthofTheUniversityofWesternAustralia,andWesternAustralianGovernment.

83. Klevens,J.,Sadowski,L.DomesticViolenceTowardsWomen.ClinicalEvidence2005;14:2223-2232,BMJPublishingGroup.

84. DomesticViolenceAdvocacySupportCentral.“DVASCentral”:Phone(08)92262370;Fax(08)92262377;Email:[email protected]

85. AustralianInstituteHealthandWelfare(AIHW)2005.ChildprotectionAustralia2003–04.AIHWCat.no.CWS24.Canberra:AIHW(ChildWelfareSeriesno.36).http://www.aihw.gov.au/publications/index.cfm/title/10095

86. AustralianInstituteofHealthandWelfare(AIHW)2005.Australia’swelfare2005.AIHWcat.no.AUS65.Canberra:AIHW.http://www.aihw.gov.au/publications/index.cfm/title/10186

87. RoyalAustralasianCollegeofPaediatriciansProtectingChildrenisEverybody’sBusiness:PaediatriciansRespondingtotheChallengeofChildAbuse,©RACP2000.www.racp.edu.au

88. AustralianBureauofStatisticsandtheAustralianInstituteofHealthandWelfare,TheHealthandWelfareofAustralia’sAboriginalandTorresStraitIslanderPeoples2001,ABSandAIHW,Canberra,2001,p.125;http://www.aihw.gov.au/publications/ihw/hwaatsip03/hwaatsip03-c06.pdf

89. WorldHealthOrganizationWebsite:www.who.int/en/

90. TheHealthandWelfareofAustralia’sAboriginalandTorresStraitIslanderPeoples2003AIHW.http://www.aihw.gov.au/publications/ihw/hwaatsip03/

91. Zubrick,S.R.,Lawrence,D.M.,Silburn,S.R.,Blair,E.,Milroy,H.,Wilkes,T.,Eades,S.,D’Antoine,H.,Read,A.,Ishiguchi,P.&Doyle,S.TheWesternAustralianAboriginalChildHealthSurvey:TheHealthofAboriginalChildrenandYoungPeople,TelethonInstituteforChildHealthResearch,Perth,2004.

92. Barker,D.Mothers,Babies,andDiseaseinLaterLife.BMJPublishingGroup:London,1994

93. ConsultingCitizens.EngagingwithAboriginalWesternAustralians.DepartmentoftheIndigenousAffairs,WesternAustralianGovernment.http://www.dia.wa.gov.au

94. DepartmentoftheIndigenousAffairsWesternAustralianGovernment,2005.OvercomingIndigenousDisadvantage,WAReport2005.DIA,Perth.http://www.dia.wa.gov.au/Publications/Files/OIDReport/OIDSingleVersion.pdf

95. Smith,J.D.Australia’sRuralandRemoteHealth.Asocialjusticeperspective.TertiaryPress2004.

96. Bastian,H.,Keirse,M.J.N.C.,Lancaster,P.A.PerinataldeathassociatedwithplannedhomebirthinAustralia:populationbasedstudy.BMJ1998;317(7155):pp384-8.

97. Crotty,M.,Ramsay,A.,Smart,R.,Chan,A.PlannedhomebirthsinSouthAustralia1976-1987.MJA1990;153:pp664-471.

98. Woodcock,H.C.,Read,A.W.,Bower,C.,Stanley,F.J.,Moore,D.J.AmatchedcohortstudyofplannedhomeandhospitalbirthsinWesternAustralia1981-1987,Midwifery1994Sep;10(3):pp125-35.

99. Ngenda,N.,Khoo,S.K.Failedhomebirths:Reasonsfortransfertohospitalandmaternal/neonataloutcome.AustNZJofObsandGyn.1996;36:3:pp275-278.

100.Johnson,K.C.,Daviss,B-A.SurveillanceandRiskAssessmentDivision,CentreforChronicDiseasePreventionandControl,PublicHealthAgencyofCanada,Ottawa.OutcomesofplannedHomeBirthswithcertifiedprofessionalmidwives:LargeprospectivestudyinNorthAmerica.BMJVol.330(7505)(pp1416-1419),2005.


5 C

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ry

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101.Births:finaldatafor2000.NationalVitalStatisticsReports.HyattsvilleMD:NationalCenterforHealthStatistics,2002;50(5).http://www.cdc.gov/nchs/births.htm

102.Schlenka,P.Safetyofalternativeapproachestochildbirth.PhDthesis,California:StanfordUniversity,1999,withdatapublishedin:Referenceabove.100

103.CentreforEpidemiologyandResearch.NSWDepartmentofHealth.NewSouthWales,MothersandBabies2004.NSWPublicHealthBull2005;16(S-4).

104.Laing,I.ClinicalAspectsofNeonatalDeathandAutopsy.SeminarsinNeonatology(2004)9,pp247-254.

105.PostMortemExaminationConsentFormandInformationforRelativesbooklet.http://www.health.wa.gov.au/postmortem/

106. SIDSandKidsWAhttp://www.skidsandkids.org/


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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

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