Term neonatal asphyxial seizures and peripartum deaths: lack of correlation with a rising cesarean delivery rate

Association of Unexpected Newborn Deaths With Changes in Obstetric and Neonatal Process of Care

IMPORTANCE

The death of a healthy term infant may signal patient safety and quality issues. Various initiatives aim to encourage clinicians to learn from these events, but little evidence exists regarding how exposure to an unexpected newborn death may alter clinician practice.

OBJECTIVE

To examine the association between an unexpected newborn death and changes in obstetric and newborn procedures that may be used in response to potential fetal distress or newborn complications.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used difference-in-differences analysis of 2011 to 2017 US vital statistics data from 477 US counties experiencing an unexpected newborn death during the study period. All in-hospital live births in the 477 counties during the study period were included. Data were analyzed from September 2019 to September 2020.

EXPOSURES

The death of an infant aged 0 to 7 days following an unremarkable pregnancy owing to causes other than birth defects, accidents/assaults, or sudden infant death syndrome.

MAIN OUTCOMES AND MEASURES

Primary outcomes included binary variables capturing intervention in labor/delivery (induction, augmentation, cesarean delivery, forceps/vacuum) and procedures to avert and mitigate newborn complications (assisted ventilation, surfactant replacement therapy, antibiotics for suspected sepsis, neonatal intensive care unit admission).

RESULTS

The main sample included 5.72 million births (2.54 million during preexposure time). Mean (SD) maternal age was 27.3 (5.8) years; 67% of mothers were White, and 12% were Black. Associations varied across the 4 estimated models. Following an unexpected newborn death, there was no significant increase in the probability of cesarean delivery in the full sample model (0.28 percentage points [pp]; 95% CI, -0.01 to 0.57 pp), but a significant increase in the other 3 models, with values ranging from 0.55 pp (95% CI, 0.21 to 0.88 pp) in the full sample model with matching to 0.66 pp (95% CI, 0.13 to 1.19 pp) in the 1-hospital county subsample with matching. There was a significant increase in the probability of newborn assisted ventilation in the full sample model with matching (0.46 pp; 95% CI, 0.08 to 0.83 pp), but no significant increase in the other 3 models, with estimates ranging from 0.33 pp (95% CI, -0.04 to 0.71 pp) to 0.69 pp (95% CI, -0.02 to 1.40 pp). An unexpected newborn death was not associated with a significant increase in antibiotic use in the full sample models (without matching: 0.19 pp; 95% CI, -0.00 to 0.39 pp; with matching: 0.22 pp; 95% CI: -0.02 to 0.46 pp), but was associated with a significant increase in both of the 1-hospital county subsample models (without matching: 0.38 pp; 95% CI, 0.02 to 0.73 pp; with matching: 0.39 pp; 95% CI, 0.01 to 0.77 pp).

CONCLUSIONS AND RELEVANCE

In some study models, an unexpected newborn death was associated with statistically significant increases in subsequent use of procedures to avert and mitigate fetal distress and newborn complications, which could reflect increases in identifying and proactively addressing serious potential complications or increased clinician caution applied across all cases. Future research should address whether these changes affect patient outcomes.

Continuing epidural analgesia during the second stage and ACOG definition of arrest of labor on maternal-fetal outcomes

Background

Despite an increase in the rates of epidural labor analgesia, continuation of epidural labor analgesia in the second stage of labor (CEADSSOL) was interrupted by care providers due to fears of increased risk of operative delivery and adverse neonatal outcomes. Therefore, we evaluated the effect of CEADSSOL and the newer American College of Obstetricians and Gynecologists (ACOG) definition of arrest of labor on the length of secondary stage of labor, newborn outcomes, and mode of delivery.

Methods

This is a retrospective cohort study. Data collection began during March 2014 and ended in May 2015, 1 year after implementation of both interventions. The primary outcome was the length of secondary stage of labor, mode of delivery and neonatal outcome (Apgar < 7, at 5 minutes). The implementation of continuing epidural analgesia during the second stage of labor was performed with 0.08%‐0.15% ropivacaine and 0.1‐0.2 µg/mL sufentanil.

Results

There were a total 10 414 deliveries during the study period. The length of the second stage of labor has no significant differences among groups. The cesarean delivery rate decreased 4.1% (36% vs 40.1%, P = .0038). Moreover, no significant difference was found in neonatal Apgar scores less than 7 at 5 minutes between two phases. Maternal outcomes remained unchanged. Post‐intervention neonatal parameters including NICU admissions (P < .001), incidences of antibiotics usage (P < .0001), intubation (P = .0003), and 7 days mortality (P = .0020) were remarkably reduced compared to pre‐interventions.

Conclusion

The important finding of this study was the improvement in neonatal outcomes by implementing two simultaneous interventions without a cost of increased operative delivery.

Neonatal Seizures Among Low-Risk Pregnancies at Term: Risk Factors and Adverse Outcomes

OBJECTIVE

To examine risk factors and adverse outcomes for neonatal-maternal dyads among low-risk pregnancies at term with subsequent neonatal seizures.

METHODS

United States vital statistics data sets were used for this retrospective study. Inclusion criteria were low-risk women (without hypertensive disease or diabetes) with nonanomalous singleton pregnancies, who delivered after labor at 37-41 weeks of gestation. The primary composite neonatal adverse outcome included 5-minute Apgar score less than 5, assisted ventilation longer than 6 hours, and neonatal death. A secondary outcome was composite maternal adverse outcome. Multivariable Poisson regression models with robust error variance were used, with adjusted relative risk (aRR) and 95% CI reported.

RESULTS

Of 19.76 million live births during the study interval, 11.7 million (59.4%) met inclusion criteria. The rate of neonatal seizures after low-risk pregnancies delivered at term was 0.2 per 1,000 live births. The maternal risks factors associated with neonatal seizures included no prenatal care, smoking during pregnancy, being overweight or obese, and gestational age of 41 weeks. The strongest risk factors for neonatal seizures were chorioamnionitis (relative risk [RR] 5.04, 95% CI 4.40-5.77; aRR 3.27, 95% CI 2.84-3.76) and route of delivery, with operative vaginal (RR 3.62, 95% CI 3.20-4.09; aRR 3.02, 95% CI 2.66-3.43) and cesarean (RR 4.13, 95% CI 3.81-4.48; aRR 3.14, 95% CI 2.86-3.45) higher than spontaneous vaginal. Compared with neonates without seizures, those with seizures had higher risk of composite neonatal adverse outcome (RR 64.55, 95% CI 61.83-67.39; aRR 37.09, 95% CI 35.20-39.08). Compared with women who delivered neonates without seizures, those who delivered neonates with seizures had higher risk of composite maternal adverse outcome (RR 16.27, 95% CI 13.66-19.37; aRR 9.70, 95% CI 8.15-11.53).

CONCLUSION

We identified modifiable maternal risk factors associated with neonatal seizures among low-risk pregnancies at term. Though infrequent, neonatal seizures are associated with higher risk of adverse outcomes in neonatal-maternal dyads.

Perinatal mortality or severe neonatal encephalopathy among normally formed singleton pregnancies according to obstetric risk status:" is low risk the new high risk?" A population-based cohort study

OBJECTIVE

To evaluate the capacity of the current system of obstetric risk stratification at the outset of pregnancy to predict severe adverse perinatal outcome.

STUDY DESIGN

This retrospective cohort study of singleton pregnancies over a five year period (2009-2013) was performed at the Rotunda Hospital, Dublin, Ireland. High-risk or low-risk status was assigned retrospectively to a large consecutive cohort of women with a normally-formed singleton pregnancy on the basis of factors analyzed at the first prenatal hospital visit. The incidence of severe perinatal morbidity and mortality were compared between high- and low-risk groups to determine the predictive utility of risk stratification at the outset of pregnancy for severe perinatal morbidity.

RESULTS

During the study period, 41,044 patients registered for prenatal care. 25,702;(63%) were deemed low-risk and 15,342;(37%) high-risk. Low-risk women were statistically more likely to be nulliparous (p < 0.0001) and to have a spontaneous or operative vaginal delivery (p < 0.0001). High-risk women were more likely to be multiparous and to undergo Caesarean delivery (p < 0.0001). The perinatal mortality rate was 3.8 per-1000 in low-risk pregnancies and 6.1 per-1000 in the a priori high-risk group (p = 0.012). The incidence of severe neonatal encephalopathy (NNE) was 1.8 and 0.65 per-1000 in the low and high-risk groups respectively (p = 0.0025).

CONCLUSION

Where low-risk status is assigned at registration, neonatal encephalopathy is more prevalent. This data is relevant for the design of prenatal care models and demonstrates that assignment of low obstetric risk on the basis of maternal or pre-pregnancy factors alone may erroneously be interpreted as conferring low-risk status to the fetus.

Developmental Maturation and Alpha-1 Adrenergic Receptors-Mediated Gene Expression Changes in Ovine Middle Cerebral Arteries

The Alpha Adrenergic Signaling Pathway is one of the chief regulators of cerebrovascular tone and cerebral blood flow (CBF), mediating its effects in the arteries through alpha1-adrenergic receptors (Alpha1AR). In the ovine middle cerebral artery (MCA), with development from a fetus to an adult, others and we have shown that Alpha1AR play a key role in contractile responses, vascular development, remodeling, and angiogenesis. Importantly, Alpha1AR play a significant role in CBF autoregulation, which is incompletely developed in a premature fetus as compared to a near-term fetus. However, the mechanistic pathways are not completely known. Thus, we tested the hypothesis that as a function of maturation and in response to Alpha1AR stimulation there is a differential gene expression in the ovine MCA. We conducted microarray analysis on transcripts from MCAs of premature fetuses (96-day), near-term fetuses (145-day), newborn lambs, and non-pregnant adult sheep (2-year) following stimulation of Alpha1AR with phenylephrine (a specific agonist). We observed several genes which belonged to pro-inflammatory and vascular development/angiogenesis pathway significantly altered in all of the four age groups. We also observed age-specific changes in gene expression–mediated by Alpha1AR stimulation in the different developmental age groups. These findings imply complex regulatory mechanisms of cerebrovascular development.

Predictors of Mortality in Neonates with Seizures; a Prospective Cohort Study

OBJECTIVE

The aim of this study was to analyze prognostic indicators for mortality in neonates with seizures in a level III Neonatal Intensive Care Unit (NICU).

PATIENTS AND METHODS

A cohort of 100 neonates with clinically manifested seizures hospitalized in the NICU during 4 years period was prospectively monitored for the first year of life. The cohort consisted of 33 preterm and 67 full-term babies with 60 male and 40 female infants.

RESULTS

The mortality rate in the first year of life of infants with seizures in the neonatal period was 23%. The most common cause of seizures was birth asphyxia for full-term infants and intra-periventricular hemorrhage for preterm infants. Death was more common in pre-term than term infants (p <0,005). Simple regression demonstrated statistically significant associations between death in the first year of life and a cluster of highly associated variables: resuscitation (p<0, 01), mechanical ventilation (p<0,01) and asphyxia (p<0,05). This cluster of variables significantly correlates with: gestational age (p<0, 05), birth weight (p<0, 05) and intracranial hemorrhage (p<0, 05).

CONCLUSION

In this cohort of neonates with seizures asphyxia requiring neonatal resuscitation was the primary risk factor for death.

Litigation related to intrapartum fetal surveillance

The role of intrapartum care including cardiotocography (CTG) monitoring in cases of perinatal neurological injury receives considerable debate in both clinical and medicolegal settings. The debate, however, has distracted attention from fundamental questions about the timing, mechanism, and preventability of perinatal injury. CTG tracings are used as a surrogate for asphyxia with the timing of intervention ("rescue") predicated on the presumed severity of asphyxia. Using CTG in this way has prevented intrapartum stillbirth, but it has not reduced the long-term injury in part, because, contrary to popular belief, the majority of intrapartum fetal injuries are unassociated with severe hypoxia or severe neonatal depression. This article describes the timing and mechanisms, including mechanical factors, of intrapartum perinatal injury and the benefit of using the CTG, not for the purpose of "rescue", but for identifying risk factors for fetal injury and keeping the fetus out of harm's way.

[Treatment of encephalopathy by hypothermia in the term newborn]

Criteria defining the involvement of severe perinatal anoxia in neonatal encephalopathy in at-term newborns at birth are stringent and are rarely all present. The simultaneous action of pre- and intrapartum factors preceding neonatal hypoxic-ischemic encephalopathy are often observed. Cooling is recommended as there is evidence that it reduces mortality without increasing major disability in survivors. It must be conducted following strict clinical and electroencephalographic criteria. Other strategies for brain protection remain difficult to establish. Follow-up must be long enough to detect cognitive deficiencies, which are frequent, even if cerebral palsy is not observed.

Variation in cesarean section rates is not related to maternal and neonatal outcomes

OBJECTIVE

The aim of this study was to compare the rate of cesarean sections in 12 delivery units in Finland, and to assess possible associations between cesarean section rates and maternal and neonatal complications.

DESIGN

Prospective multicenter cohort study.

SETTING

The 12 largest delivery units in Finland.

POPULATION

Total obstetric population between 1 January 2005 and 30 June 2005 (n = 19 764).

METHODS

Prospectively collected data on 2496 cesarean sections and data derived from the Finnish Birth Register on all deliveries in these units were compared. Cesarean section rates and maternal complication rates were adjusted for known risk factors.

MAIN OUTCOME MEASURES

Cesarean section rate, maternal complications related to cesarean section, and neonatal asphyxia.

RESULTS

The cesarean section rates varied significantly between the hospitals (12.9-25.1%, p < 0.0001), as did the maternal complication rates related to cesarean section (13.0-36.5%, p < 0.0001). There was no relation between maternal complications and the cesarean section rate. The differences remained after adjusting for risk factors. Neonatal asphyxia rates varied between 0.14 and 2.8% (p < 0.0001) and were not related to the cesarean section rates.

CONCLUSIONS

The rates of cesarean section, maternal complications and neonatal asphyxia vary markedly between different delivery units. Good maternal and neonatal outcomes can be achieved with cesarean section rates <15%.

A case-control study of hypoxic-ischemic encephalopathy in newborn infants at >36 weeks gestation

OBJECTIVE

The purpose of this study was to determine risk factors that are associated with hypoxic ischemic encephalopathy (HIE).

STUDY DESIGN

This was a case-control study that included newborn infants with HIE who were admitted to the hospital between January 2001 and December 2008. Two control newborn infants were chosen for each case. Logistic regression and classification and regression tree (CART) analysis that compared control infants and cases with grade 1 HIE and control infants and cases with grades 2 and 3 HIE was performed.

RESULTS

Two hundred thirty-seven cases (newborn infants with grade 1 encephalopathy, 155; newborn infants with grade 2 encephalopathy, 61; newborn infants with grade 3 encephalopathy, 21) and 489 control infants were included. Variables that were associated independently with HIE included higher grade meconium, growth restriction, large head circumference, oligohydramnios, male sex, fetal bradycardia, maternal pyrexia and increased uterine contractility. CART analysis ranked high-grade meconium, oligohydramnios, and the presence of obstetric complications as the most discriminating variables and defined distinct risk groups with HIE rates that ranged from 0-86%.

CONCLUSION

CART analysis provides information to help identify the time at which intervention in labor may be of benefit.

Prognostic factors and development of a scoring system for outcome of neonatal seizures in term infants

OBJECTIVE

To identify independent prognostic indicators and design a predictive scoring system for neurodevelopmental outcome for term infants who experienced clinical neonatal seizures.

STUDY DESIGN

Retrospective analysis of 120 term infants who experienced clinical neonatal seizures between July 1991 and June 2007 in a single academic pediatric neurology practice. Logistic regression analysis was applied to determine the independent prognostic indicators of an adverse outcome, which was defined as death, cerebral palsy, global developmental delay, and/or epilepsy. These indicators were then used to develop a scoring system.

RESULTS

A total of 53 infants had a normal outcome, 56 survived with one or more neurodevelopmental impairments (31 had cerebral palsy, 41 had global developmental delay, and 29 had epilepsy), and 11 died. Eleven variables were associated with adverse outcome on univariate analysis, but only method of delivery, time of seizure onset, seizure type, EEG background findings, and etiology were independent predictors on logistic regression analysis. A five-point scoring system was devised using these independent predictors with a sensitivity of 81.1% and a specificity of 84.0%.

CONCLUSIONS

In term infants, delivery via cesarean section, experiencing a seizure during the first 24 h of life, presenting with a seizure other than focal clonic, showing a moderately or severely abnormal EEG background, and having certain specific etiologies were the apparent major determinants for an adverse outcome.

Regional variation in the cesarean delivery and assisted vaginal delivery rates

OBJECTIVE

To examine regional variations in rates of primary cesarean delivery and assisted vaginal delivery in the population of British Columbia, while adjusting for the maternal characteristics and conditions that increase the likelihood of operative delivery.

METHODS

Using data from the British Columbia Perinatal Database Registry, we studied all deliveries in British Columbia between 2004 and 2007, excluding women who had a previous cesarean delivery (n=116,839). Our primary outcome of interest was mode of delivery, further defined as delivery by cesarean or assisted vaginal delivery. We calculated crude and risk-adjusted rates of primary cesarean delivery and assisted vaginal delivery across British Columbia's 16 Health Service Delivery Areas and examined cesarean delivery rates by indication for the procedure.

RESULTS

Crude primary cesarean delivery and assisted vaginal delivery rates varied markedly across the Health Service Delivery Areas ranging from 16.1 to 27.5 per 100 deliveries, and from 8.6 to 18.6 per 100 deliveries, respectively. The most common indication for cesarean delivery was dystocia, which accounted for 30.0% of all cesarean deliveries and varied more than fivefold across regions. After controlling for maternal characteristics and conditions known to increase the likelihood of cesarean delivery and assisted vaginal delivery, adjusted cesarean delivery rates varied twofold, ranging from 14.7 to 27.6 per 100 deliveries, while adjusted assisted vaginal delivery rates varied by more than twofold, ranging from 6.5 to 15.3 per 100 deliveries.

CONCLUSION

Our results illustrate substantial regional variation in the use of cesarean delivery that cannot be explained by patient illness or preferences. This variation likely reflects differences in practitioners' approaches to medical decision-making.

LEVEL OF EVIDENCE

II.

Comparative analysis of international cesarean delivery rates using 10-group classification identifies significant variation in spontaneous labor

OBJECTIVE

Cesarean section (CS) rates continue to rise throughout the developed world. The aim of this study was to highlight variations in obstetric populations and practices and to identify variations in CS rates in different institutions.

STUDY DESIGN

Data from 9 institutional cohorts (total, 47,402; range, 1962-7985) from 9 different countries were examined using a 10-group classification system based on 4 characteristics of every pregnancy, namely single/multiple, nulliparity/multiparity, multiparity with CS scar, spontaneous/induced labor onset and term (>or=37 weeks) gestation.

RESULTS

Overall CS rates correlated with CS rates in singleton cephalic nullipara (r = 0.992; P < .001). Whereas CS rates in induced labor were similar, greatest institutional variation were seen in spontaneously laboring multiparas (6.7-fold difference) and nulliparas (3.7-fold difference).

CONCLUSION

Ten-group analysis of international obstetric cesarean practice identifies wide variations in women in spontaneous cephalic term labor, a low-risk cohort amenable to effective intrapartum corrective intervention.

Decreasing diagnoses of birth asphyxia in Canada: fact or artifact

OBJECTIVE

We assessed temporal trends in birth asphyxia in Canada, to determine whether changes were real or secondary to changes in coding.

METHODS

We used data from the Canadian Institute for Health Information Discharge Abstract Database to study the national incidence of birth asphyxia, by using International Classification of Diseases codes. We also studied birth asphyxia by using data from the Nova Scotia Atlee Perinatal Database. In the Nova Scotia Atlee Perinatal Database, we defined a case of birth asphyxia as a live birth with an Apgar score at 5 minutes of < or =3, depression at birth requiring resuscitation with a mask for > or =3 minutes and/or intubation, or neonatal postasphyctic seizures.

RESULTS

Nationally, between 1991 and 2005, the incidence of birth asphyxia decreased significantly, from 43.8 to 2.4 cases per 1000 live births. The rate of decrease was highest between 1991 and 1998, corresponding to a period when strict Canadian and international criteria for the diagnosis of birth asphyxia were published. By comparison, neither national rates of related diagnoses nor Nova Scotia birth asphyxia rates, which ranged from 8.8 to 14.3 cases per 1000 live births, showed evidence of a decrease during the study period.

CONCLUSIONS

Comparisons of national trends in birth asphyxia diagnoses and trends in conditions associated with birth asphyxia, both nationally and in Nova Scotia, suggest that the dramatic decrease in the diagnosis of birth asphyxia is an artifact of changes in the use of International Classification of Diseases coding associated with the publication of stricter diagnostic definitions of birth asphyxia. We conclude that International Classification of Diseases codes are not useful for surveillance of birth asphyxia.

Antioxidant therapy and neuroprotection in the newborn

Injury to the perinatal brain is a leading cause of childhood mortality and lifelong disability. Despite recent improvements in neonatal care, no effective treatment for perinatal brain lesions is available. The newborn, especially if preterm, is highly prone to oxidative stress (OS) and to the toxic effect of free radicals (FRs). At birth, the newborn is exposed to a relatively hyperoxic environment caused by an increased oxygen bioavailability with greatly enhanced generation of FRs. Additional sources (e.g., inflammation, hypoxia, ischemia, glutamate and free iron release) occur, magnifying OS. In the preterm baby, the perinatal transition is accompanied by the immaturity of the antioxidant systems and the reduced ability to induce efficient homeostatic mechanisms designed to control overproduction of cell-damaging FRs. Improved understanding of the pathophysiological mechanism involved in perinatal brain lesions helps to identify potential targets for neuroprotective interventions, and the knowledge of these mechanisms has enabled scientists to develop new therapeutic strategies that have confirmed their neuroprotective effects in animal studies. Considering the growing role of OS in preterm newborn morbidity in respect to the higher risk of FR damage in these babies, erythropoietin, allopurinol, melatonin and hypothermia demonstrate great promise as potential neuroprotectans. This article provides an overview of the pathogenesis of FR-mediated diseases of the newborn and the antioxidant strategies now tested in order to reduce OS and its damaging effects.

Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety

In a health care delivery system with an annual delivery rate of approximately 220,000, a comprehensive redesign of patient safety process was undertaken based on the following principles: (1) uniform processes and procedure result in an improved quality; (2) every member of the obstetric team should be required to halt any process that is deemed to be dangerous; (3) cesarean delivery is best viewed as a process alternative, not an outcome or quality endpoint; (4) malpractice loss is best avoided by reduction in adverse outcomes and the development of unambiguous practice guidelines; and (5) effective peer review is essential to quality medical practice yet may be impossible to achieve at a local level in some departments. Since the inception of this program, we have seen improvements in patient outcomes, a dramatic decline in litigation claims, and a reduction in the primary cesarean delivery rate.

Nulliparous term singleton vertex cesarean delivery rates: institutional and individual level predictors

OBJECTIVE

This study was undertaken to determine individual and institutional level variables predictive of variations in nulliparous term singleton vertex cesarean delivery rates.

STUDY DESIGN

Retrospective cohort study of 28,863 nulliparous term singleton vertex births at 40 Arizona hospitals.

RESULTS

The average nulliparous term singleton vertex cesarean delivery rate was 22.0%, the lowest hospital rate was 10.3%, high, 34.2%. The following individual level variables increased the nulliparous term singleton vertex cesarean delivery rate in a multivariable model: increased mother's age, African American race, increased birthweight, labor induction, and the presence of medical conditions such as diabetes and hypertension. Of the institutional variables, after adjustment, the highest level of nursery or a higher percentage of government-paid births was associated with lower risks, whereas delivery at a hospital with the lowest level of care or with an obstetric and gynecology residency was associated with an increased risk of cesarean delivery.

CONCLUSION

Substantial variations in nulliparous term singleton vertex cesarean delivery rates were seen in this comparative analysis of 40 hospitals.

Trends in intrapartum fetal death, 1979-2003

OBJECTIVES

This study was undertaken to analyze trends in intrapartum fetal death and rates of perinatal autopsy over a 25-year period in Dublin, Ireland.

STUDY DESIGN

A retrospective multicenter analysis of 508,342 nonanomalous infants 500 g or more, delivering in 3 tertiary-referral university institutions between 1979-2003.

RESULTS

There has been a significant downward trend in the rate of intrapartum fetal death over the past 25 years (P < .0001). Nulliparous labors were statistically more likely to be complicated by an intrapartum fetal demise than parous labors (odds ratio, 1.49; 95% confidence interval [CI], 1.16-1.92; P = .0018). Intrapartum deaths secondary to hypoxia fell significantly over the study period (P < .0001). Infants of multiple gestations were twice as likely to die in labor as singletons (odds ratio, 2.2; 95% CI, 1.22-3.74; P = .0058). Rates of perinatal autopsy fell significantly over the 25 years studied (P < .0001).

CONCLUSION

There has been a significant fall in rates of intrapartum fetal death. This has primarily resulted from a reduction in deaths attributable to intrapartum hypoxia. Infants of multiple gestations still retain a significantly higher chance of intrapartum death. The fall in uptake rates of perinatal autopsy in recent years is concerning.

Is intrapartum asphyxia preventable?

The contribution of intrapartum events to asphyxia-related mortality and morbidity and the degree to which it may be prevented are controversial. We examined trends in asphyxia-related mortality and morbidity in a single large regional perinatal centre. Between 1994 and 2005, the rate of asphyxia fell from 2.86/1000 births in 1994 to 0.91/1000 births in 2005 (P < 0.001). Hypoxic-ischaemic encephalopathy of all grades fell from 2.41 to 0.77/1000 live births (P < 0.001). This substantial and steady fall in the rate of asphyxia-related mortality and morbidity over a 12-year period suggests that a significant proportion of cases of intrapartum asphyxia may be preventable.

Variation in the rates of operative delivery in the United States

OBJECTIVES

This study was undertaken to examine the national and regional rates of operative delivery among almost one quarter million births in a single year in the nation's largest healthcare delivery system, using variation as an arbiter of the quality of decision making.

STUDY DESIGN

We compared the variation in rates of primary cesarean and operative vaginal delivery in facilities of the Hospital Corporation of America during the year 2004.

RESULTS

In 124 facilities representing almost 220,000 births during a 1-year period, the primary cesarean and operative vaginal delivery rates were 19% +/- 5% (range 9-37) and 7% +/- 4% (range 1-23). Within individual geographic regions, we consistently found variations of 200-300% in rates of primary cesarean delivery and variations approximating an order of magnitude for operative vaginal delivery.

CONCLUSION

Within broad upper and lower limits, rates of operative delivery in the United States are highly variable and suggest a pattern of almost random decision making. This reflects a lack of sufficient reliable, outcomes-based data to guide clinical decision making.

Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement

OBJECTIVE

This study was undertaken to assess the utility of the nulliparous term singleton vertex cesarean birth (NTSV CB) measure as a quality improvement tool for use at the hospital level.

STUDY DESIGN

We prospectively collected data on all NTSV births in Sutter Health's 20 birthing units over a 3-year period, 2001 through 2003, totaling 41,416 births. Hospital rates of NTSV CB, obstetric practices, and infant outcomes were calculated and compared by using weighted logistic analyses. In addition, we examined the effect of maternal age on the NTSV CB measure by using direct standardization with US norms for nulliparous women.

RESULTS

There was large variation noted in the NTSV CB rate among the 20 hospitals, with unadjusted rates ranging from 10.5% to 30.2%. Strong correlations were found between CB rates and labor induction rates (r = 0.57, P < .0001) and with early labor admission rates (r = 0.62, P < .0001). The strongest correlation was found between NTSV CB rates and a combined measure of induction and early labor admission (r = 0.73, P < .0001). Rates of term 5-minute Apgar score below 7 were not correlated with the NTSV CB rate. Hospital nulliparous maternal age distribution varied markedly and direct standardization led to significant changes in the NTSV CB rate.

CONCLUSION

NTSV CB rate is strongly influenced by elective obstetric practices. The addition of an easily performed maternal age adjustment makes it the most promising CB quality measure for use at the hospital level.