Objective To identify intrapartum predictors of newborn encephalopathy in term infants. Design Population based, unmatched case-control study. Setting Metropolitan area of Western Australia, June 1993 to September 1995. Subjects All 164 term infants with moderate or severe newborn encephalopathy; 400 randomly selected controls. Main outcome measures Adjusted odds ratio estimates. Results The birth prevalence of moderate or severe newborn encephalopathy was 3.8/1000 term live births. The neonatal fatality was 9.1%. Maternal pyrexia (odds ratio 3.82), a persistent occipitoposterior position (4.29), and an acute intrapartum event (4.44) were all risk factors for newborn encephalopathy. More case infants than control infants were induced (41.5% and 30.5%, respectively) and fewer case infants were delivered by caesarean section without labour (3.7% and 14.5%, respectively). Operative vaginal delivery (2.34) and emergency caesarean section (2.17) were both associated with an increased risk. There was an inverse relation between elective caesarean section (0.17) and newborn encephalopathy. After application of a set of consensus criteria for elective caesarean section only three (7%) eligible case mothers compared with 33 (65%) eligible control mothers were sectioned electively. Of all the case infants, 113 (69%) had only antepartum risk factors for newborn encephalopathy identified; 39 (24%) had antepartum and intrapartum factors; eight (5%) had only intrapartum factors; and four (2%) had no recognised antepartum or intrapartum factors. Conclusions The causes of newborn encephalopathy are heterogeneous and many relate to the antepartum period. Elective caesarean section has an inverse association with newborn encephalopathy. Intrapartum hypoxia alone accounts for only a small proportion of newborn encephalopathy. These results question the view that most risk factors for newborn encephalopathy lie in the intrapartum period.

Objective To describe the management and outcomes of placenta accreta, increta, and percreta in the UK. Design A population‐based descriptive study using the UK Obstetric Surveillance System (UKOSS). Setting All 221 UK hospitals with obstetrician‐led maternity units. Population All women diagnosed with placenta accreta, increta, and percreta in the UK between May 2010 and April 2011. Methods Prospective case identification through the monthly mailing of UKOSS. Main outcome measures Median estimated blood loss, transfusion requirements. Results A cohort of 134 women were identified with placenta accreta, increta, or percreta: 50% (66/133) were suspected to have this condition antenatally. In women with a final diagnosis of placenta increta or percreta, antenatal diagnosis was associated with reduced levels of haemorrhage (median estimated blood loss 2750 versus 6100 ml, P = 0.008) and a reduced need for blood transfusion (59 versus 94%, P = 0.014), possibly because antenatally diagnosed women were more likely to have preventative therapies for haemorrhage (74 versus 52%, P = 0.007), and were less likely to have an attempt made to remove their placenta (59 versus 93%, P < 0.001). Making no attempt to remove any of the placenta, in an attempt to conserve the uterus or prior to hysterectomy, was associated with reduced levels of haemorrhage (median estimated blood loss 1750 versus 3700 ml, P = 0.001) and a reduced need for blood transfusion (57 versus 86%, P < 0.001). Conclusions Women with placenta accreta, increta, or percreta who have no attempt to remove any of their placenta, with the aim of conserving their uterus, or prior to hysterectomy, have reduced levels of haemorrhage and a reduced need for blood transfusion, supporting the recommendation of this practice.

The presence of a single umbilical artery is recognised as a soft marker for congenital anomalies, aneuploidy, earlier delivery and low birthweight. Most of the available data are derived from case series or highly selected populations and are therefore likely to be unrepresentative. In this retrospective case-comparison study, we firstly aimed to determine the incidence of a single umbilical artery in an unselected population and secondly to examine the clinical significance of this soft marker. Over a 40-month period, 107 cases were identified from a cohort of 35 066 births giving an incidence of 3.1 per 1000 total births and late pregnancy losses. The antenatal detection rate was only 30%. Compared to fetuses with normal cord vasculature, fetuses with a single umbilical artery were more likely to be delivered at an earlier gestation and to weigh less, were 1.7 times more likely to be delivered by a Caesarean section and 19% of the cases had a congenital anomaly. The perinatal mortality was 49.0 per 1000 total births, which was 6 times higher than the background hospital rate. The presence of a single umbilical artery is associated with a poorer perinatal outcome compared to that in fetuses with three vessels in the cord. Unfortunately, the antenatal detection rate is poor. Recognising the importance of this soft marker in counselling and management of pregnancies should provide the stimulus to improve detection rates.

Objective To describe on a national basis ethnic differences in severe maternal morbidity in the United Kingdom.Design National cohort study using the UK Obstetric Surveillance System (UKOSS).Setting All hospitals with consultant led maternity units in the UK.Participants 686 women with severe maternal morbidity between February 2005 and February 2006.Main outcome measures Rates, risk ratios, and odds ratios of severe maternal morbidity in different ethnic groups.Results 686 cases of severe maternal morbidity were reported in an estimated 775 186 maternities, representing an estimated incidence of 89 (95% confidence interval 82 to 95) cases per 100 000 maternities. 74% of women were white, and 26% were non-white. The estimated risk of severe maternal morbidity in white women was 80 cases per 100 000 maternities, and that in non-white women was 126 cases per 100 000 (risk difference 46 (27 to 66) cases per 100 000; risk ratio 1.58, 95% confidence interval 1.33 to 1.87). Black African women (risk difference 108 (18 to 197) cases per 100 000 maternities; risk ratio 2.35, 1.45 to 3.81) and black Caribbean women (risk difference 116 (59 to 172) cases per 100 000 maternities; risk ratio 2.45, 1.81 to 3.31) had the highest risk compared with white women. The risk in non-white women remained high after adjustment for differences in age, socioeconomic and smoking status, body mass index, and parity (odds ratio 1.50, 1.15 to 1.96).Conclusions Severe maternal morbidity is significantly more common among non-white women than among white women in the UK, particularly in black African and Caribbean ethnic groups. This pattern is very similar to reported ethnic differences in maternal death rates. These differences may be due to the presence of pre-existing maternal medical factors or to factors related to care during pregnancy, labour, and birth; they are unlikely to be due to differences in age, socioeconomic or smoking status, body mass index, or parity. This highlights to clinicians and policy makers the importance of tailored maternity services and improved access to care for women from ethnic minorities. National information on the ethnicity of women giving birth in the UK is needed to enable ongoing accurate study of these inequalities.

ObjectivesTo describe the characteristics, management and outcomes of women giving birth at advanced maternal age (≥48 years).DesignPopulation‐based cohort study using the UK Obstetric Surveillance System (UKOSS).SettingAll UK hospitals with obstetrician‐led maternity units.PopulationWomen delivering at advanced maternal age (≥48 years) in the UK between July 2013 and June 2014 (n = 233) and 454 comparison women.MethodsCohort and comparison group identification through the UKOSS monthly mailing.Main outcome measuresPregnancy complications.ResultsOlder women were more likely than comparison women to be overweight (33% versus 23%, P = 0.0011) or obese (23% versus 19%, P = 0.0318), nulliparous (53% versus 44%, P = 0.0299), have pre‐existing medical conditions (44% versus 28%, P < 0.0001), a multiple pregnancy (18% versus 2%, P < 0.0001), and conceived following assisted conception (78% versus 4%, P < 0.0001). Older women appeared more likely than comparison women to have pregnancy complications including gestational hypertensive disorders, gestational diabetes, postpartum haemorrhage, caesarean delivery, iatrogenic and spontaneous preterm delivery on univariable analysis and after adjustment for demographic and medical factors. However, adjustment for multiple pregnancy or use of assisted conception attenuated most effects, with significant associations remaining only with gestational diabetes (adjusted odds ratio [aOR] 4.81, 95% CI 1.93–12.00), caesarean delivery (aOR 2.78, 95% CI 1.44–5.37) and admission to an intensive care unit (aOR 33.53, 95% CI 2.73–412.24).ConclusionsWomen giving birth at advanced maternal age have higher risks of a range of pregnancy complications. Many of the increased risks appear to be explained by multiple pregnancy or use of assisted conception.Tweetable abstractThe pregnancy complications in women giving birth aged 48 or over are mostly explained by multiple pregnancy.