Substandard care in delivery-related asphyxia among term infants: prospective cohort study.

OBJECTIVE: To assess substandard care factors in the case of delivery-related asphyxia. DESIGN: Prospective cohort study. SETTING: Catchment area of the Neonatal Intensive Care Unit (NICU) of the University Medical Center Utrecht; a region in the middle of the Netherlands covering 13% of the Dutch population. POPULATION: Term infants, without congenital malformations, who died intrapartum or were admitted to the Neonatal Intensive Care Unit due to asphyxia. METHODS: During a two-year period, cases were prospectively collected and audited by an expert panel. MAIN OUTCOME MEASURES: Substandard care factors. RESULTS: 37 735 term infants without congenital malformations were born. There were 19 intrapartum deaths, and 89 NICU admissions of which 12 neonates died. In 63 (58%) cases a substandard care factor was identified that was possibly (n= 47, 43%) or probably (n= 16, 15%) related to perinatal death or NICU admission. In primary care, substandard care factors were mainly the low frequency of examination during labor and delay in referral to secondary care. In secondary care, misinterpretation of cardiotocography and failure to respond adequately to clinical signs of fetal distress were the most common substandard care factors. CONCLUSIONS: Substandard care is present in a substantial number of cases with delivery-related asphyxia resulting in perinatal death or NICU admission. Improving the organization of obstetric care in the Netherlands as well as training of obstetric caregivers might reduce adverse outcomes.

Substandard care in antepartum term stillbirths: prospective cohort study.

OBJECTIVE: To assess substandard care factors in antepartum stillbirths at term. Design. Prospective cohort study. SETTING: A region in the middle of the Netherlands covering 13% of the Dutch population. POPULATION: Antepartum stillbirths (≥ 37 weeks) without congenital malformations. METHODS: During a two-year period, all antepartum term stillbirths were prospectively collected and audited by an expert panel. MAIN OUTCOME MEASURES: Substandard care factors. RESULTS: During the study period, 37 735 normally formed infants were delivered ≥ 37 weeks of gestation. There were 60 antepartum stillbirths (1.59 per 1,000, 95%CI 1.19-1.99). Most stillbirths occurred during apparently uncomplicated pregnancies. Twenty-one infants (35%) were small-for-gestational age but growth restriction was only suspected in 10 (47.6%) of these cases. Substandard care factors were identified in 21 (35%) cases. A relation between these factors and fetal demise was possible in nine (15%) and probable in seven (12%) of these cases. Inadequate management and recognition of suspected growth restriction (n=9) or hypertension (n=6) were the most common substandard care factors. Ten (16.7%) women felt none or decreased fetal movements for 24 hours or more before they consulted a doctor or midwife. CONCLUSION: Twenty-seven percent of all stillbirths were possibly or probably avoidable. Special attention to the recognition and adequate management of suspected growth restriction and hypertension as well as guidelines about patient information and management of decreased fetal movements might result in a reduction of stillbirths in the Netherlands.

Intrapartum fever at term: diagnostic markers to individualize the risk of fetal infection: a review.

UNLABELLED: Intrauterine infection is a serious complication during labor at term and is associated with adverse neonatal outcome. Early and accurate diagnosis is of great concern for both obstetrician and pediatrician with the use of current diagnostics. Clinical symptoms are often regarded as the main sign of intrauterine infection but this approach is highly unreliable and leads to both under- and overtreatment. Currently, no distinct fetal heart rate (FHR) patterns have been found that reliably identify neonates with intrauterine infection. Using a systematic literature search, this article reviews possible markers for the early detection of intrauterine or neonatal infection in maternal serum, amniotic fluid, and umbilical cord blood during labor at term. Maternal serum markers, with the possible exception of interleukin (IL)-8, are unreliable for the detection of intrauterine infection. In contrast, amniotic fluid levels of especially IL-6 and IL-8 are significantly associated with intrauterine infection. Umbilical cord blood IL-6 has been extensively investigated and is usually elevated in case of intrauterine or neonatal infection but shows only modest positive and negative predictive values (NPVs) for clinical use. Umbilical cord IL-8 concentration could be a valuable addition in the diagnostic process, as it has shown to have an NPV of 84% to 92% in the detection of neonatal infection and histological chorioamnionitis. Future research is essential and should focus on the combination of different markers and on the development of a prediction model, to improve the positive and NPVs of our arsenal to detect intrauterine and neonatal infections. Amniotic fluid and umbilical cord values of IL-6 and IL-8 levels are likely candidates for such a prediction model. TARGET AUDIENCE: Obstetricians & Gynecologists and Family Physicians LEARNING OBJECTIVES: After the completing the CME activity, physicians should be better able to evaluate the use of clinical chorioamnionitis with regard to histological evidence and as a diagnostic tool in early diagnosis of intra-amniotic infection. Asses the use of amniotic fluid IL-6 and IL-8 as diagnostic tools to detect early intra-amniotic infection and assess umbilical cord blood IL-8 in case of intrauterine- or neonatal infection using positive (PPV) and negative predictive values (NPV).

[Mortality and morbidity among full-term neonates in a neonatal intensive care unit in the Utrecht region, the Netherlands]. / Mortaliteit en morbiditeit van aterme pasgeborenen op de neonatale intensivecareunit in de regio Utrecht.

OBJECTIVE: To gain an insight into perinatal mortality and morbidity in full-term infants without congenital abnormalities admitted to a neonatal intensive care unit (NICU). DESIGN: Retrospective analysis. METHOD: In this study, all full-term infants, who were born in the period 1997-2003 without congenital disorders and admitted to the NICU at the Wilhelmina Children's Hospital in Utrecht, the Netherlands were included. Information about the delivery, NICU-admission and follow-up until the age of 18 months was obtained from the hospital charts. RESULTS: In total 597 full-term neonates were admitted to the NICU during the study period; this is equivalent to 3-4 per 1,000 full-term neonates in the Utrecht region. Of these, 47% were admitted on account of asphyxia, 17% with respiratory problems and 12% with infections. In 79% of all NICU admissions the delivery had taken place under secondary care; in 29% labour had started under exclusive care of a primary level midwife, because the pregnancy had been defined as low-risk. 21% of the neonates were admitted to the NICU following delivery under exclusive primary care. Almost 15% of the infants died in the NICU, in 89% due to asphyxia. Of the surviving infants following perinatal asphyxia, 15% had a permanent disability at the age of 18 months. CONCLUSION: Post-partum admission of a fundamentally healthy full-term neonate to the NICU is a serious adverse perinatal outcome, and warrants further investigation. The various factors that influence these admissions should be analysed in more detail, for instance by means of perinatal audits.

Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study.

OBJECTIVE: To compare incidences of perinatal mortality and severe perinatal morbidity between low risk term pregnancies supervised in primary care by a midwife and high risk pregnancies supervised in secondary care by an obstetrician. DESIGN: Prospective cohort study using aggregated data from a national perinatal register. SETTING: Catchment area of the neonatal intensive care unit (NICU) of the University Medical Center in Utrecht, a region in the centre of the Netherlands covering 13% of the Dutch population. PARTICIPANTS: Pregnant women at 37 weeks' gestation or later with a singleton or twin pregnancy without congenital malformations. MAIN OUTCOME MEASURES: Perinatal death (antepartum, intrapartum, and neonatal) or admission to a level 3 NICU. RESULTS: During the study period 37 735 normally formed infants were delivered at 37 weeks' gestation or later. Sixty antepartum stillbirths (1.59 (95% confidence interval 1.19 to 1.99) per 1000 babies delivered), 22 intrapartum stillbirths (0.58 (0.34 to 0.83) per 1000 babies delivered), and 210 NICU admissions (5.58 (4.83 to 6.33) per 1000 live births) occurred, of which 17 neonates died (0.45 (0.24 to 0.67) per 1000 live births). The overall perinatal death rate was 2.62 (2.11 to 3.14) per 1000 babies delivered and was significantly higher for nulliparous women compared with multiparous women (relative risk 1.65, 95% confidence interval 1.11 to 2.45). Infants of pregnant women at low risk whose labour started in primary care under the supervision of a midwife had a significant higher risk of delivery related perinatal death than did infants of pregnant women at high risk whose labour started in secondary care under the supervision of an obstetrician (relative risk 2.33, 1.12 to 4.83). NICU admission rates did not differ between pregnancies supervised by a midwife and those supervised by an obstetrician. Infants of women who were referred by a midwife to an obstetrician during labour had a 3.66 times higher risk of delivery related perinatal death than did infants of women who started labour supervised by an obstetrician (relative risk 3.66, 1.58 to 8.46) and a 2.5-fold higher risk of NICU admission (2.51, 1.87 to 3.37). CONCLUSIONS: Infants of pregnant women at low risk whose labour started in primary care under the supervision of a midwife in the Netherlands had a higher risk of delivery related perinatal death and the same risk of admission to the NICU compared with infants of pregnant women at high risk whose labour started in secondary care under the supervision of an obstetrician. An important limitation of the study is that aggregated data of a large birth registry database were used and adjustment for confounders and clustering was not possible. However, the findings are unexpected and the obstetric care system of the Netherlands needs further evaluation.