Outcome in low risk pregnancies

Meconium-stained amniotic fluid and the need for paediatrician attendance

AIM

To determine perinatal parameters among term newborn infants born by vaginal delivery with meconium-stained amniotic fluid (MSAF) that needed paediatrician assistance.

METHODS

Paediatricians who were in attendance in the delivery room due to MSAF among term infants completed 775 reports regarding the infants' delivery conditions, and the assistance provided. We defined 'paediatrician attendance needed' for a subgroup of infants for whom we retrospectively determined that paediatrician attendance in the delivery room was required.

RESULTS

'Paediatrician attendance needed' was determined in 31 (4%) cases. Among cases with documented normal foetal monitor, only 10 (1.8%) were defined as 'paediatrician attendance needed', a percentage significantly lower than among infants born following non-reassuring foetal monitor: 21 (9.7%) (p < 0.001). 'Paediatrician attendance needed' was predicted by non-reassuring foetal monitor [OR 6.02 (CI 2.72-13.31), p < 0.001], maternal fever [OR 6.34 (1.92-20.92), p = 0.002] and younger maternal age (for every year) [OR 0.889 (CI 0.82-0.96), p = 0.003].

CONCLUSIONS

Term newborn infants born by vaginal delivery with MSAF with documented normal tracing foetal monitor are at low risk of the need for paediatrician assistance. Paediatrician attendance in the delivery room in labour involving MSAF should be recommended when non-reassuring foetal monitor tracing is observed and should also be considered when maternal fever is recorded, and/or thick meconium is observed.

Midwives' perception of the intrapartum risk of healthy nulliparae in spontaneous labour, in The Flanders, Belgium

OBJECTIVE

to explore midwives' perception of intrapartum risk for healthy nulliparous women in spontaneous labour at term of a healthy singleton pregnancy, in the Belgian Flanders, and to compare these results with those of a previous study undertaken in England.

DESIGN

survey of the care midwives would advocate and their perception of intrapartum risk using a standardised scenario. This study replicates part of a survey undertaken with British midwives (Mead & Kornbrot 2004b). With an added section to capture the particulars of the Belgian situation and explore the likelihood of midwives being fully responsible for the whole intrapartum care of healthy women, including their delivery. The questionnaire was translated into Dutch by MR and distributed by the Flemish Midwives' Association (Vlaamse Organisatie van Vroedvrouwen-VLOV).

PARTICIPANTS

all 845 midwives and 143 student midwives who were members of VLOV were sent a questionnaire with their invitation to take part in their annual conference. Two hundred and seventy-five midwives and 107 students attended the conference, and 128 questionnaires were returned at the conference: 99 midwives (36% of the attendees), 26 students (24% of attendees), with three unidentified respondents. This convenience sample represented 12% of all midwives and 18% of all students.

ANALYSIS

SPSS for Windows was used for the statistical analysis. Descriptive statistics were used and differences between categorical variables were analysed using chi(2) and Fisher's Exact tests, and differences between continuous variables were analysed by analysis of variance.

FINDINGS

midwives generally described a more medicalised approach to intrapartum care on admission and during the first stage of labour than their British counterparts, but were much more optimistic about the chances of healthy women in spontaneous labour achieving a normal delivery within 12 hours. However, Belgian midwives had only a limited ability to undertake normal deliveries because of the high proportion of obstetricians who fulfil this responsibility. This contravenes the European Union (EU) directive on the activities of the midwife.

KEY CONCLUSIONS

despite much greater involvement of obstetricians in the care, of women suitable for full midwifery care, and a more medicalised approach to intrapartum care, the Belgian Flanders have a significantly lower caesarean section rate than the UK. The inability of Belgian midwives to fulfil the activities of the midwives as identified by the EU directives raises questions about the migration of midwives trained in Belgium to other EU member states.

Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey

AIM

To compare perinatal morbidity and mortality for babies delivered in water with rates for babies delivered conventionally (not in water).

DESIGN

Surveillance study (of all consultant paediatricians) and postal survey (of all NHS maternity units).

SETTING

British Isles (surveillance study); England and Wales (postal survey).

SUBJECTS

Babies born in the British Isles between April 1994 and March 1996 who died perinatally or were admitted for special care within 48 hours of birth after delivery in water or after labour in water followed by conventional delivery (surveillance study); babies delivered in water in England and Wales in the same period (postal survey). MAIN OUTCOME MEASURESE Number of deliveries in water in the British Isles that resulted in perinatal death or in admission to special care within 48 hours of birth; and proportions (of such deliveries) of all water births in England and Wales.

RESULTS

4032 deliveries (0.6% of all deliveries) in England and Wales occurred in water. Perinatal mortality was 1.2/1000 (95% confidence interval 0.4 to 2.9) live births; 8.4/1000 (5.8 to 11.8) live births were admitted for special care. No deaths were directly attributable to delivery in water, but 2 admissions were for water aspiration. UK reports of mortality and special care admission rates for babies of women considered to be at low risk of complications during delivery who delivered conventionally ranged from 0.8/1000 (0. 2 to 4.2) to 4.6/1000 (0.1 to 25) live births and from 9.2 (1.1 to 33) to 64/1000 (58 to 70) live births respectively. Compared with regional data for low risk, spontaneous, normal vaginal deliveries at term, the relative risk for perinatal mortality associated with delivery in water was 0.9 (99% confidence interval 0.2 to 3.6).

CONCLUSIONS

Perinatal mortality is not substantially higher among babies delivered in water than among those born to low risk women who delivered conventionally. The data are compatible with a small increase or decrease in perinatal mortality for babies delivered in water.

Review and assessment of selection criteria used when booking pregnant women at different places of birth

OBJECTIVE

To describe and assess the selection criteria currently being used when booking women for different places of birth.

DESIGN

A cross-sectional survey.

SETTING

The South and West region of England.

SAMPLE

The 27 NHS Trusts who provide maternity care in the South and West region of England.

MAIN MEASURES

Selection criteria used when booking pregnant women for different places of birth; length of time criteria in use; whether criteria applied individually or as part of a risk score; and method by which criteria developed.

RESULTS

The response rate was 81%; 128 different, individual criteria, used as the basis to select women for different places of birth, were identified. No single criterion appeared on all the sets of criteria. None of the trusts who responded used the criteria in order to calculate a risk score. In all but one case the criteria were being used to select women who might be suitable for birth outside a consultant-led maternity unit. Only two trusts used sets of criteria which identified, to any extent, 1. outcomes for which women could be at risk and 2. strategies that should be implemented to reduce that risk. Over half the trusts were able to identify a rationale for the particular set of criteria which they used but in only two cases was any reference made to an evidence base.

CONCLUSIONS

A large variety of criteria are being used as a basis on which to book women for different places of birth but they appear to be poorly focused on particular adverse outcomes. To be effective, selection criteria must identify quantifiable differences in the risk of particular preventable adverse outcomes for births booked at different locations. Furthermore, there must be evidence that the risk could be reduced by a selecting a particular location. A systematic review is required to determine which selection criteria, if any, should be employed at booking.