Impact of surfactant administration through a thin catheter in the delivery room: A quality control chart analysis coupled with a propensity score matched cohort study in preterm infants.

INTRODUCTION: Most infants born before 30 weeks gestational age (GA) develop respiratory distress syndrome soon after birth. Methods of surfactant administration that avoid ventilation have been recently introduced. The aim of this study was to evaluate the impact of implementing a new procedure of less invasive surfactant administration (LISA) and determine whether it is associated with an improvement in respiratory outcome. METHODS: This single center cohort quality improvement study analyzed preterm infants born before 30 weeks GA between May 2010 and April 2016. Changes in health care practices and respiratory outcomes following the implementation of a LISA, i.e. the administration of surfactant through a thin catheter, were analyzed using quality control charts. Then, the effect of LISA on respiratory outcome was assessed by propensity score matching and logistic regression weighted by the inverse of the propensity score. RESULTS: During the study period, 379 infants were included. Of those that were not intubated at ten minutes of life, 129 received surfactant and were ventilated for one hour or more (InVent), 127 received LISA, five received surfactant with tracheal mechanical ventilation for less than one hour (InSurE), and 55 were only treated with nasal continuous positive pressure during the first hour of neonatal care (nCPAP). Quality-chart analysis revealed rapid implementation of the method with a concomitant decrease in required ventilation. LISA was associated with fewer tracheal ventilation days and a lower incidence of supplemental oxygen on day 28. When controlling for the propensity to be exposed or not to LISA, this procedure was not associated with a lower risk of death or bronchopulmonary dysplasia (BPD) at 36 weeks postmenstrual age. CONCLUSION: In this study, the successful implementation of the new method was associated with lower rates of mechanical ventilation, but without a significant reduction of grade I/II/III BPD or death.

Delivery room deaths of extremely preterm babies: an observational study.

OBJECTIVE: Many extremely preterm neonates die in the delivery room (DR) after decisions to withhold or withdraw life-sustaining treatments or after failed resuscitation. Specific palliative care is then recommended but sparse data exist about the actual management of these dying babies. The objective of this study was to describe the clinical course and management of neonates born between 22 and 26 weeks of gestation who died in the DR in France. DESIGN, SETTING, PATIENTS: Prospective study including neonates, who were liveborn between 22+0 and 26+6 weeks of gestation and died in the DR in 2011, among infants included in the EPIPAGE-2 study at the 18 centres participating in this substudy of extremely preterm neonates. Data were collected by a questionnaire completed by the professional caring for each baby. RESULTS: The study included 73 children, with a median (IQR) gestational age of 24 (23-24) weeks. Median (IQR) duration of life was 53 (20-82) min. All but one were both wrapped and warmed. Pain was assessed for 72%, although without using any scale. Gasping was described for 66%. Comfort medications were administered to 35 children (50%), significantly more frequently to babies with gasping (p=0.001). Mother-child contact was reported for 78%, and psychological support offered to parents of 92%. CONCLUSIONS: Non-pharmacological comfort care and parental support were routinely given. Comfort medication was given much more frequently than previously reported in other DRs. These data should encourage work on the indications for comfort medication and the interpretation of gasping.

Can we select fetuses with intra-abdominal calcification for delivery in neonatal surgical centres?

BACKGROUND: Prenatal ultrasound (US) diagnosis of fetal intra-abdominal calcification (iAC) is frequently caused by an in utero perforation causing meconium peritonitis. Our ability to predict which fetuses will require postnatal surgery is limited. The aim of our study is to correlate iAC and associated US findings with postnatal outcome. METHODS: A single centre retrospective review of all cases of fetal iAC diagnosed between 2004 and 2010 was performed. Maternal demographics, fetal US findings, and outcomes (need for surgery and mortality) were collected. Descriptive and comparative statistical analyses were performed. RESULTS: Twenty-three cases of iAC were identified. There were no cases of fetal demise or postnatal deaths. Three liveborns (13%) required abdominal surgery at a median of 2 days (0-3) for intestinal atresia. US findings of iAC and dilated bowel with (p=0.008) or without (p=0.005) polyhydramnios predicted a need for postnatal surgery as did the combination of iAC, polyhydramnios, and ascites (p=0.008). Conversely, iAC alone or associated with oligohydramnios, polyhydramnios, ascites, or growth restriction did not predict need for postnatal surgery. CONCLUSION: The majority of fetuses with iAC on prenatal US do not require surgery. Associated US findings (bowel dilation) can be used to select fetuses for delivery in neonatal surgical centres.

Outcome of extremely low birth weight infants who received delivery room cardiopulmonary resuscitation.

OBJECTIVE: To determine whether delivery room cardiopulmonary resuscitation (DR-CPR) independently predicts morbidities and neurodevelopmental impairment (NDI) in extremely low birth weight infants. STUDY DESIGN: We conducted a cohort study of infants born with birth weight of 401 to 1000 g and gestational age of 23 to 30 weeks. DR-CPR was defined as chest compressions, medications, or both. Logistic regression was used to determine associations among DR-CPR and morbidities, mortality, and NDI at 18 to 24 months of age (Bayley II mental or psychomotor index <70, cerebral palsy, blindness, or deafness). Data are adjusted ORs with 95% CIs. RESULTS: Of 8685 infants, 1333 (15%) received DR-CPR. Infants who received DR-CPR had lower birth weight (708±141 g versus 764±146g, P<.0001) and gestational age (25±2 weeks versus 26±2 weeks, P<.0001). Infants who received DR-CPR had more pneumothoraces (OR, 1.28; 95% CI, 1.48-2.99), grade 3 to 4 intraventricular hemorrhage (OR, 1.47; 95% CI, 1.23-1.74), bronchopulmonary dysplasia (OR, 1.34; 95% CI, 1.13-1.59), death by 12 hours (OR, 3.69; 95% CI, 2.98-4.57), and death by 120 days after birth (OR, 2.22; 95% CI, 1.93-2.57). Rates of NDI in survivors (OR, 1.23; 95% CI, 1.02-1.49) and death or NDI (OR, 1.70; 95% CI, 1.46-1.99) were higher for DR-CPR infants. Only 14% of DR-CPR recipients with 5-minute Apgar score <2 survived without NDI. CONCLUSIONS: DR-CPR is a prognostic marker for higher rates of mortality and NDI for extremely low birth weight infants. New DR-CPR strategies are needed for this population.

Estudio epidemiológico global del síndrome de Down / Global epidemiological study of Down's syndrome

Introduction: In 1967, the Latin American Collaborative Study of Congenital Malformations (LASCM) was created. Currently, 180 hospitals in 76 cities of 9 Latin American countries participate, accumulating data from over 4.5 M births. The Clinical Hospital of the University of Chile (HCUCH) entered the study in 1967, as did 12 other institutions later on. Objectives: Verify changes (increase) in frequency of Down's Syndrome (DS) in Chile and Latin America, and modification of frequency in those countries where elective abortion is permitted. Patients y Method: Three samples were evaluated: Births at HCUCH, active chilean hospitals and the 180 hospitals in 9 LA countries between 1972 and 2009. DS frequencies in Chile and other countries were compared through the International Clearinghouse for Birth Defects Monitoring System. Results: DS frequency at HCUCH increased significantly from 1.03 per thousand births in 1972 to 2.93 /oo births 2009. Frequencies in all chilean hospitals are fairly homogeneous, all higher than average for LASCM, which is 1.88 per thousand. The chilean average is 2.47/ºº por the period between 1998-2005, with a range of 1.88 at HCUCH to 2.86 at the Hospital of Curicó. In the rest of the world, the rate of DS per birth has diminished significantly, being the lowest in Iran (0.32/o<>) and Spain (0.6/oo live births). Conclusion: Rate of DS births are higher in Chile than LASCM average (2.47/o<>), with a trend to increase. This is true in Latin America, where the average for the period between 2001-2005 was 2.89 per thousand live births. In Europe and Asia, these rates have decreased to very low numbers, such as 0.32/o<> in Iran and 0.6/o<> in Spain.

Introducción: El ECLAMC (Estudio Colaborativo Latino Americano de Malformaciones Congenitas) fue creado en 1967. Actualmente, lo integran 180 hospitales de 76 ciudades de 9 países Latino Americanos y ha acumulado más de 4,5 millones de nacimientos. El Hospital Clínico de la Universidad de Chile (HCUCH) ingresó en 1967 y después otros 12 establecimientos chilenos. Objetivos: Verificar si la frecuencia de síndrome de Down (SD) está aumentando en Chile y Latino América y como se ha visto modificada en los países en que está permitido el aborto electivo. Pacientes y Método: Se estudió 3 muestras: Todos los nacimientos del HCUCH desde 1972 a 2009; de los hospitales chilenos activos y de los 180 hospitales de 9 países Latinoamericanos. Se comparó las frecuencias de SD de Chile y del ECLAMC con otros países que participan en el Internacional Clearinghouse for Birth Defects Monitoring System. Resultados: La frecuencia del SD en el HCUCH aumentó significativamente de 1,03 por mil nacimientos en 1972 a 2,93 por mil en 2009. Las frecuencias en los hospitales chilenos son muy homogéneas, todas más altas que el promedio del ECLAMC: 1,88 por mil. El promedio chileno para el período 1998-2005 fue de 2,47 por mil. Con un rango de 1,88 por mil del HCUCH y 2,86 por mil del Hospital de Curicó. En el resto del mundo se ha asistido a una disminución significativa de las tasas de SD, siendo las más bajas la de Irán: 0,32 por mil y España 0,60 por mil nacimientos vivos. Conclusión: En Chile, las tasas de SD son mayores al promedio del ECLAMC 2,47 por mil existiendo una tendencia al aumento de ellas lo mismo que en Latino América, donde el promedio para el período 20012005 fue de 2,89 por mil. En Europa y Asia las tasas han disminuido a cifras extremas, Irán 0,32 por mil y España 0,60 por mil.

Do differences in delivery room intubation explain different rates of bronchopulmonary dysplasia between hospitals?

OBJECTIVE: To investigate whether the wide variation in the frequency of bronchopulmonary dysplasia (BPD) between hospitals is due to differences in delivery room intubation rates. METHODS: Data on 1260 infants of birth weight <1500 g and 23-31 weeks gestational age, born in 1999-2002 and surviving to 36 weeks, were collected; 196 (15.6%) developed BPD defined as oxygen need at 36 weeks postmenstrual age. Generalised estimating equations and conditional logistic models adjusting for centre, gestational age, propensity score for intubation, and other potential confounders were used. RESULTS: Rates of BPD, delivery room intubation and mechanical ventilation for >24 h differed significantly between hospitals. Centres with high delivery room intubation rates had higher ventilation and BPD rates. Hospitals ventilating more often also did so for a longer time. Although delivery room intubation was associated with BPD in unadjusted analyses, neither delivery room intubation nor brief (<24 h) mechanical ventilation were risk factors for BPD in multivariate analyses adjusting for gestational age, case mix and other pre- and perinatal factors, indicating no causal effect or unmeasured confounding. Significant risk factors for developing BPD were low gestational age, prolonged ventilation (>24 h: adjusted OR (aOR) 2.4; >7 days: aOR 14.9), male sex (aOR 1.7), being small for gestational age (SGA; aOR 4.3) and late-onset sepsis (aOR 2.2). After taking into account these variables/procedures, centre differences remained significant but explained only about 5% of variance. CONCLUSIONS: Differences in BPD frequency between hospitals are explained by differences in procedures, chiefly mechanical ventilation, rather than by differences in initial management or case mix. Delivery room intubation and brief mechanical ventilation did not increase BPD risk.

Place of birth and characteristics of infants with congenital and early-onset hearing loss in a developing country.

OBJECTIVE: To determine the characteristics of infants with sensorineural hearing loss (SNHL) and the relationship with place of birth. METHODS: Subjects were drawn from hospital-based and community-based universal infant hearing screening programs concurrently conducted from May 2005 to April 2008 in Lagos, Nigeria. Maternal and infant characteristics of children born in hospitals and detected with SNHL were compared with those born outside hospitals. Each program consisted of a first-stage screening with transient-evoked otoacoustic emissions (TEOAE) followed by second-stage automated auditory brainstem response (AABR). Hearing status was confirmed by diagnostic auditory brainstem response, tympanometry and visual response audiometry. RESULTS: A total of 4718 infants were screened under the hospital-based program out of which 12 (0.3%) infants were confirmed with SNHL whereas 71 (1.0%) of the 7179 infants screened under the community-based program were confirmed with SNHL. Of all infants with SNHL 39 (47.0%) were born in hospitals suggesting that 27 (38.0%) of infants under the community-based program were born in hospitals. Prevalence of SNHL ranged from 4.0 per 1000 among infants born in government hospitals to 23 per 1000 among those born in family homes. Mothers of those born outside hospitals were significantly likely to belong to the Yoruba tribe (p<0.001), use herbal medications in pregnancy (p<0.001), deliver vaginally (p=0.004) but without skilled attendants at delivery (p<0.001). There were no significant differences among the infants themselves except that those born outside hospitals were significantly likely to be detected in the first 3 months of life compared to those born in hospitals (p<0.001). CONCLUSIONS: A significant proportion of infants with SNHL in many developing countries are likely to be born outside hospitals thus underscoring the need for community-oriented UNHS to facilitate early detection and intervention. Conventional risk factors for SNHL are unlikely to discriminate across places of birth. Pediatricians and otolaryngologists should consider a more active role in fostering community-oriented delivery of primary ear care services in this and similar settings in the developing world.

Luxación congénita de cadera: displasia evolutiva de la cadera (DEC) / Congenital dislocation of the hip: developmental displasia of the hip

The change of denomination of congenital hip luxation for evolutionary hip displasia is defined and explained, it incluyes luxation, subluxation and hip instability. The frequencies of this pathology in the Clinical Hospital of the University of Chile is reported. The finds of significant major frequency in female newborn children, breech presentation and left hip are communicated. Thefamily base of this pathology is confirmed. The recommendations of the experts’ Committee of the American Academy of pediatrics and those of the health department of Chile are given. It is emphasized that the diagnosis must be as precocious as possible and that the best method of diagnosis is Ortolani’s or Barlow maneuver, done by a professional of experience. It is indicated the oportunity in which the ultrasound scan and the hip X-ray must be done, also the recommended treatment. The use of the double diaper is scorned and its possible sequels arecommented.

Material and human resources for neonatal resuscitation in public maternity hospitals in Brazilian state capitals / Recursos materiais e humanos para a reanimação neonatal nas maternidades públicas das capitais brasileiras

CONTEXT AND OBJECTIVE: In 2002, the early neonatal mortality rate in Brazil was 12.42 per thousand live births. Perinatal asphyxia was the greatest cause of neonatal death (about 23 percent). This study aimed to evaluate the availability of the resources required for neonatal resuscitation in delivery rooms of public hospitals in Brazilian state capitals. DESIGN AND SETTING: Multicenter cross-sectional study involving 36 hospitals in 20 Brazilian state capitals in June 2003. METHODS: Each Brazilian region was represented by 1-4 percent of its live births. A local coordinator collected data regarding physical infrastructure, supplies and professionals available for neonatal resuscitation in the delivery room. The information was analyzed using the Statistical Package for the Social Sciences, version 10. RESULTS: Among the 36 hospitals, 89 percent were referral centers for high-risk pregnancies. Each institution had a monthly mean of 365 live births (3 percent < 1,500 g and 15 percent < 2,500 g). The 36 hospitals had 125 resuscitation tables (3-4 per hospital), all with overhead radiant heat, oxygen and vacuum sources. Appropriate equipment for pulmonary ventilation was available for more than 90 percent of the 125 resuscitation tables. On average, one pediatrician, three nurses and five nursing assistants per shift worked in the delivery rooms of each institution. Out of the 874 pediatricians and 1,037 nursing personnel that worked in the delivery rooms of the 36 hospitals, 94 percent and 22 percent, respectively, were trained in neonatal resuscitation. CONCLUSIONS: The main public maternity hospitals in Brazilian state capitals have the resources to resuscitate neonates at birth.

CONTEXTO E OBJETIVO: Em 2002, a mortalidade neonatal precoce brasileira foi 12,42 para cada mil nascidos vivos e a asfixia perinatal foi responsável por 23 por cento dessas mortes. Este estudo visa avaliar a disponibilidade dos recursos necessários para a reanimação neonatal nas salas de parto de hospitais públicos brasileiros. TIPO DE ESTUDO E LOCAL: Estudo transversal multicêntrico de 36 maternidades, em 20 capitais brasileiras, em junho de 2003. MÉTODOS: As maternidades selecionadas em cada região brasileira representaram 1-4 por cento dos nascidos vivos da região. O coordenador local da pesquisa respondeu a um questionário estruturado com dados a respeito da estrutura física, os equipamentos e o pessoal disponível para a reanimação neonatal em cada maternidade. A análise descritiva foi feita por meio do programa Statistical Package for Social Science 10.0. RESULTADOS: 89 por cento das 36 maternidades eram referência para gestação de risco. Cada hospital tinha um número médio mensal de 365 nascimentos (3 por cento < 1.500 g e 15 por cento < 2.500 g). Os 36 hospitais tinham 125 mesas de reanimação (3-4/hospital), todas com calor radiante, fonte de oxigênio e vácuo. Equipamento adequado para ventilação pulmonar estava disponível em mais de 90 por cento das 125 mesas. Em média, um pediatra, três enfermeiras e cinco auxiliares de enfermagem trabalhavam por turno nas salas de parto de cada instituição. Dos 874 pediatras e 1.037 profissionais de enfermagem que atuavam nas salas de parto, 94 por cento e 22 por cento haviam recebido treinamento em reanimação neonatal respectivamente. CONCLUSÕES: As maternidades públicas das capitais brasileiras apresentam salas de parto com infra-estrutura adequada para a reanimação neonatal.

Episiotomy, hospital birth and cesarean section: technology gone haywire--what is the sutured tear rate at first births supposed to be?

One hundred percent of woman having a first vaginal birth from 1940-1990 had an episiotomy. It is still used for first births at a rate of 50-60% in many places. Perineal outcomes on first births are critical because the biggest risk factor for needing suturing on subsequent births is a previous episiotomy. No scientific evidence has demonstrated improved outcomes with episiotomy. This paper documents a rate of 99% intact perineums, 1% sutured perineums, in a group of 80 primipara in their early 20s at attended homebirths, average birth weight 3150 gm. Primipara women in their late-20s with 3400 gm babies experienced a 28% sutured tear rate at planned home-births. This suggests that homebirth with a motivated attendant, young age and birth weight of 3150 gm can almost always deliver vaginally without perineal damage. Episiotomy, hospital birth for healthy pregnancies and elective cesarean surgery are commonly practiced, dangerous, out-of-date medical routines unsupported by research.

Nacer en Chiloé: articulación de conocimientos para la atención del proceso reproductivo / To be born in Chiloé: bringing together systems of knowledge in reproductive care

En el Sistema Médico Tradicional de Chiloé, la gestación y el nacimiento se abordaban en forma natural, donde la mujer, familia y comunidad se involucraban activamente y este proceso destacaba por su carácter colectivo. Con la llegada del Sistema Médico Ofi cial a Chiloé, se implementa una modalidad de atención que hace perder la integralidad del parto y afecta el rol activo que la mujer tenía en él. Actualmente se busca volver a un enfoque integral de atención de la gestación y parto; desde el Estado se han impulsado programas que apuntan a ello, destacando en el último año las orientaciones del Sistema de Protección a la Infancia Chile Crece Contigo. Sin embargo, se hace necesario que estas orientaciones recojan las opiniones de las usuarias, sus parejas y familias y que al mismo tiempo tengan pertinencia cultural. El artículo recoge los principales resultados de una investigación cualitativa y cuantitativa que con este objetivo se desarrolló desde el Servicio de Salud Chiloé durante los años 2007 y 2008, abordando los procesos de gestación y parto en la red de salud pública de la Provincia de Chiloé desde la mirada tanto de las usuarias de distintas generaciones y realidades socioculturales y económicas, como de profesionales y técnicos de salud y parteras tradicionales, rescatando los elementos con los que tanto el sistema biomédico como el tradicional pueden contribuir para una construcción conjunta y pertinente de la atención de la gestación y parto en Chiloé.

In Chiloé’s Traditional Medical System, pregnancy and birth were conceived as natural processes, where woman, family and community were actively involved in what was seen as a collective activity. On the other hand, the arrival of the Official Medical System on Chiloé has meant a loss of the inclusive nature of giving birth and the active role of the woman in it. At the present time, there is an attempt to bring back a more integrated form of care during pregnancy and birthing. The State has initiated programmes of this kind, notably during the last year, with guidelines promoted by the Sistema de Protección a la Infancia: Chile Crece Contigo (System of Infant Protection: Chile Grows with You). Nevertheless, these initiatives should incorporate the views of the beneficiary women, their partners, and families, and also ensure that they are culturally appropriate. This article presents the main results of a qualitative and quantitative research into local opinions about this issue, carried out in 2007-2008 in the public health networks of the Province of Chiloé by the Health Service of Chiloé. The research investigated the processes of pregnancy and birthing from the point of view of both consumers from different generations, sociocultural and socioeconomic strata, and healthcare professionals and traditional midwives. The research highlights elements likely to be considered both for the biomedical and the traditional systems, in order to contribute to a joint and appropriate care of pregnancy and childbirth in Chiloé.

Factors that influence special care nursery admissions to a district hospital in South-western Sydney.

OBJECTIVES: To explore the socio-demographic factors and maternal characteristics that influence special care nursery (SCN) admission for infants of more than 34 weeks' gestation. Particularly, this paper aims (i) to estimate the incidence of SCN admission by various mothers' socio-demographic factors; and (ii) to investigate the relationship between SCN admission and mothers' socio-demographic and obstetric and gynaecological factors. METHODS: This was a cohort study of 10,148 pregnant women who accessed the birthing unit within a public district hospital in south-western Sydney in New South Wales, between 1998 and 2001. The main outcome measure was risk factors for SCN admission. RESULTS: The incidence of SCN admission was 11.7%. Multivariate analysis revealed that the risk factors for SCN admission were diabetes, gestational diabetes, high parity, pregnancy induced hypertension, living in suburbs with low education and occupation index, and no private health insurance status. CONCLUSIONS: The results from this large population-based study suggest that, apart from clinical/medical factors, admission to a special care nursery at a District Hospital was significantly affected by maternal insurance status and level of education and occupation.

[Risk injuries at operating and delivery rooms. EPINETAC Project 1996-2000]. / Accidentes biológicos en quirófanos y salas de parto. Proyecto EPINETAC 1996-2000.

BACKGROUND AND OBJECTIVE: Surgical areas have long been considered risky with regard to occupational exposures to blood-borne pathogens. The objective of study was to describe and evaluate the risk of occupational exposure to blood-borne pathogens at operating and delivery rooms, from reports of injuries in health care workers. SUBJECTS AND METHOD: Transversal study of percutaneous injuries occurring in operating and delivery rooms which were registered in the Spanish surveillance system EPINETAC (Exposure Prevention Information Network Accidents) between 1996 and 2000. We recorded data from the exposed health care worker, from the accident itself and from the exposure source. The risk of exposition was calculated by logistic regression. The dependent variable was the exposition in operating/delivery rooms. We calculated the rate of exposure, total and by occupational categories, per 10,000 surgical procedures in 3 surgical specialties. RESULTS: There were 3,625 percutaneous injuries reported. The exposure risk was higher in midwives [OR 36.6 (CI 95% 19.61-68.52)] than in staff [OR 12.6 (CI 95% 10.21-15.71)] or training doctors [OR 12.8 (CI 95% 10.34-15.98)]. The highest risk turned up during use of material [OR 1.37 (CI 95% 1.05-1.79)] and during preparation of material for reuse [OR 1.81 (CI 95% 1.27-2.59)]. The exposure rate, in gynecologic procedures, was 34.36 injuries per 10,000, in digestive surgery it was 24.61 per 10,000, and in trauma surgery it was 18.92 per 10,000 surgical procedures. CONCLUSIONS: The risk of occupational exposure to blood-borne pathogens in staff and training doctors was higher in operating and delivery rooms than in others areas. Obstetric and gynecologic procedures exhibited the highest risk of exposure.

Major postpartum hemorrhage: survey of maternity units in the United Kingdom.

BACKGROUND: To determine current clinical practice among different maternity units in the United Kingdom for the management of major postpartum hemorrhage. METHODS: A postal questionnaire was sent to 258 maternity units in the UK. It was developed to identify the definition of major postpartum hemorrhage, and to identify the medical and surgical interventions used for postpartum hemorrhage, as considered by each unit, and the type and use of thromboprophylaxis following surgery for major hemorrhage after delivery. RESULTS: A total of 212 (82%) returned the questionnaire, but 13 units indicated that the questionnaire was not applicable to them, leaving 199 (82%) for analysis. There was a lack of agreement between the different units regarding the definition and interventions for major postpartum hemorrhage. The majority of the units use oxytocin, ergometrine and carboprost as a 'first-line' for the treatment of postpartum hemorrhage. Hysterectomy was the most common surgical procedure (89% of units had performed at least one hysterectomy for major hemorrhage in the last 5 years). There was a lack of agreement regarding the use and choice of thromboprophylaxis following surgery for major hemorrhage. CONCLUSIONS: Current management of major postpartum hemorrhage varies considerably. There is an urgent need to identify protocols that will reduce the need for hysterectomy in women with major hemorrhage who are unresponsive to conventional medical therapy.

Care management problems on the labour ward: 5 years' experience of clinical risk management.

This is a retrospective review of 310 reports by staff following clinical risk incidents on the labour ward between 1996 and 2000 in a district general hospital with 3600 deliveries per year. Care management problems were identified and Reason's model of critical incident analysis applied to classify them into person- and system-based problems. Care management problems occurred in 165 (53%) cases, representing 0.9% of all deliveries. The main person-based problems were errors in CTG interpretation (22%), poor operative technique (22%) and non-standard practice/poor clinical judgement (19%). System-based problems included insufficient staff numbers (45%), ineffective teamwork/communication (39%) and inadequately maintained equipment (7%). Structured analysis of clinical incident reports can identify the extent and nature of obstetric care management problems and highlight important contributory areas potentially amenable to improvement.

Atresia esofágica y malformaciones asociadas / Esophageal atresia and associated malformations

Background: Survival of newborns with esophageal atresia and tracheoesophageal fistula has increased in the last years. Aim: To assess the prevalence of esophageal atresia and describe associated malformations in Chilean newborns. Material and methods: All births occurring between January 1983 and June 1998 were studied. All malformed children were registered and the next non malformed born child was considered as control. Results: During the study period, 50,965 births occurred and 3,336 malformed children were born. Eighteen (3 stillborn) had esophageal atresia with a rate of 3,53 per 10,000 born alive. Overall survival was 73 percent. Survival among children classified in Waterson groups A and B was 100 percent and 50 percent among those classified in group C. Seventy two percent had associated malformations, being congenital cardiopathies and skeletal malformations the most frequent. VACTERL association was found in 44 percent of children. All stillborn children had other severe malformations. When compared to controls, malformed children had a lower weight, a lower gestational age, their mothers had a higher age, a higher frequency of relatives with malformations and a higher frequency of maternal diseases during the first trimester of pregnancy. Conclusions: The rate of esophageal atresia found in this study is similar to that reported in other Chilean obstetrical units as part of the Latin American Study of Congenital Malformations (ECLAMC)

Malformaciones congénitas en gemelos / Congenital malformations in twins

Background: A higher prevalence of congenital malformations among twins than among single has been reported in the literature. Aim: To study the incidence of congenital malformations in twins in the maternity hospital of the University of Chile in the period 1983-1997. Material and methods: As part of the Latin American Collaborative Study of Congenital Malformations, every newborn in the maternity hospital was examined by a neonatologist and congenital malformations were recorded in a special file. Results: In the study period there were 48.663 deliveries of single pregnancies and 448 deliveries of twin pregnancies, giving birth to 886 twins borns alive and 17 stillbirths (1.9 percent mortality). Of these, there were 423 twins, 17 triplets, a sextuple delivery and two siamese. Seven point one percent of twins born alive and 6.5 percent of single newborns had a congenital malformation. The prevalence of malformations in twins and single stillbirths was 35.2 and 17.2 percent respectively (p <0.04). In four pairs and siamese newborns, malformations typical of monozygotic twins were present, such as an acardiac fetus with Trap sequence, a papyraceous fetus and two with hydroanencephaly. Twelve twins had malformations attributable to uterine compression. Conclusions: This study did not find a higher frequency of malformations comparing twins with single babies born alive, but in stillbirths there was a significant difference between single and twin stillbirths (7.1 percent versus 35.2 percent, respectively, p <0.05)

Perfil de la morbilidad del recién nacido en la Unidad de Neonatología del Hospital Clínico de la Universidad de Chile durante 1996 y 1997 / Morbility profile of the newborn in neonatology unit at Hospital Clínico Universidad de Chile during 1996 and 1997

Se analizan los egresos y se presenta la morbilidad acaecida entre 1996 y 1997 en la Unidad de Neonatología del Hospital Clínico de la Universidad de Chile. La mortalidad se analiza en publicación aparte. Sobre un universo de 4827 partos producen 1231 egresos. La principal causa de egreso es el sindrome ictérico (40,2 por ciento) seguidos por hipoglicemia (9,8 por ciento), prematurez (8,8 por ciento), sindrome de dificultad respiratoria (5,4), enfermedad hemolítica (5,1 por ciento), infecciones neonatales (4,8 por ciento). La infección grave está presente en el 7,3 por ciento de los neonatos. El promedio general de días de estada es de 6,6 días. El 62,7 por ciento corresponde a RN de mas de 3000g de peso que evolucionan con una estada de 2,9 días promedio en contraste con el 8 por ciento de niños de menos de 1500g que tienen un promedio de 42,2 días. Se hace necesario una clasificación diagnóstica que tenga aplicación clínica y que sea fácilmente comprensible y comparable a otras casuísticas

Malformaciones del aparato urinario en recién nacidos de la maternidad Hospital Clínico de la Universidad de Chile / Urinary tract malformations in the department of obstetrics of the Universidad de Chile clinical hospital, in the period 1982-1997

Background: The prevalence of urinary malformations at birth is steadily increasing, probably due to the availability of better diagnostic techniques Aim: To assess the prevalence of renal agenesis, hidroureteronephrosis and polycystic kidney at birth in the obstetric wards of the University of Chile Clinical Hospital. Patients and methods: As a part of the Latin American Collaborative Study of Congenital Malformations, 54.039 consecutive births at the Maternity, between January 1982 and December 1997, were studied. Results: Eighty three newborns had urinary tract malformations (15.3/10000). Fourteen (2.6/10000) had renal agenesis, 34 (6.3/10000) had hidroureteronephrosis and 35 (6.5/10000) had polycystic kidney. Eleven percent of these children were stillbirths and 35 percent died in the first days of life. Fifty six percent were male, 34 percent female and 10 percent had ambiguous sex. Mean birth weight was 2750 g, mean gestational age was 35.4 weeks and mean maternal age was 28 years old. Twenty three percent of mothers had a history of previous abortions, 8 percent had a history of stillbirths and 10 percent a history of metrorrhagia during the first trimester of pregnancy. Twenty five percent of children had a relative with a malformation and 48 children had other associated malformations such as pulmonary hypoplasia, external malformations caused by extreme oligoamnios or internal malformations such as utereral, urinary bladder, uretral or external genitalia agenesis. Conclusions: The prevalence of urinary malformations in this hospital was higher than in other hospitals participating in the collaborative study. This difference could be due to an under registration of malformations in other hospitals