Objective To determine whether the disparity gap is closing between stillbirth rates for Indigenous and non-Indigenous women and to identify focal areas for future prevention efforts according to gestational age and geographic location.Design Population-based retrospective cohort study.Setting Queensland, Australia.Population All singleton births of at least 20 weeks of gestation or at least 400 g birthweight. MethodsRoutinely collected data on births were obtained for the period 1995 to 2011. Indigenous and non-Indigenous stillbirth rates and percent reduction in the gap were compared over time and by geographic location and gestational age.Main outcome measures All-cause and cause-specific stillbirth rates (per 1000 ongoing pregnancies).Results Over the study period there was a 57.3% reduction in the disparity gap. Although marked reductions in the gap were shown for women in regional (57.0%) and remote (56.1%) locations, these women remained at increased risk compared with those in urban regions. There was no reduction for term stillbirths. Major conditions contributing to the disparity were maternal conditions (diabetes) (relative risk [RR] 3.78, 95% confidence intervals [95% CI] 2.59-5.51), perinatal infection (RR 3.70, 95% CI 2.54-5.39), spontaneous preterm birth (RR 3.08, 95% CI 2.51-3.77), hypertension (RR 2.22, 95% CI 1.45-3.39), fetal growth restriction (RR 1.78, 95% CI 1.17-2.71) and antepartum haemorrhage (RR 1.58, 95% CI 1.13-2.22). ConclusionsThe gap in stillbirth rates between Indigenous and non-Indigenous women is closing, but Indigenous women continue to be at increased risk due to a number of potentially preventable conditions. There is little change in the gap at term gestational ages.

A prospective, randomized, double-blind trial was conducted to assess contribution to postoperative analgesia of intermittent instillation of 0.25% bupivacaine beneath the rectus sheath in 70 women delivered by lower uterine segment Caesarean section. The operations were performed via a Pfannenstiel incision under spinal anaesthesia. Background intravenous narcotic analgesia was provided with a patient controlled analgesia system (PCAS) using a standard morphine regimen. Overall (44 hr) mean morphine consumption was significantly greater in the placebo (saline) group compared to the treatment group (84.2 mg versus 63.3 mg. Two tailed t test p < 0.001). The most significant intergroup differences in narcotic use were found in the first 4 hours and between 24 and 36 hours after commencing PCAS (Two tailed t test p = 0.014 and 0.003 respectively). Subjective pain scores were assessed with a 10 cm visual analogue scale (VAS). The mean peak VAS score was greater in controls (5.37) than the treatment group (4.25) between 18 and 24 hours postoperatively (Mann-Whitney U = 424, p = 0.027). There were no intergroup differences in pain scores for any other time period. The overall incidence of nausea was lower in the treatment group compared to the control group (Chi squared with Yates' correction p = 0.046) and a lower degree of sedation was seen in those receiving bupivacaine between 4 and 8 hours after commencing PCAS (Mann-Whitney U = 427, p = 0.028). No differences in other narcotic related side-effects (vomiting and pruritus) were shown between groups. Regular instillation of 0.25% bupivacaine beneath the rectus sheath of women delivered by Caesarean section reduces their morphine requirements by 25% in the 44 hours after operation, with an associated reduction in both nausea and early sedation.

Objective: To determine whether high maternal parity has any effect on pregnancy outcome independent of other maternal characteristics. Design and setting: Retrospective observational study using the database of a referral obstetric unit in a 280‐bed regional hospital in far north Queensland. Participants: All 15 908 women who had singleton births between 1992 and 2001, comprising 653 women with grand multiparity (≥ 5 previous births at gestation ≥ 20 weeks) and 15 255 women with lower parity. Main outcome measures: Spontaneous vaginal birth, postpartum haemorrhage (estimated blood loss > 500 mL), placental retention requiring manual removal, blood transfusion associated with the birth, and perinatal death. Results: Women with grand multiparity were significantly older than those with lower parity, more likely to be Indigenous, not to have had antenatal care, to have smoked during pregnancy and to have had one or more previous caesarean sections. On univariate analysis, women with grand multiparity were more likely to have a postpartum haemorrhage (9.2% v 5.3%) and blood transfusion (2.8% v 1.5%). However, multivariate logistic regression analysis of women who began labour (ie, did not have an elective caesarean section) showed that grand multiparity was not significantly associated with postpartum haemorrhage or blood transfusion when other maternal characteristics were included in the model (regression coefficients [95% CI], 1.36 [0.99–1.87] and 1.09 [0.59–2.02], respectively). However, they remained more likely to have a spontaneous vaginal birth (regression coefficient [95% CI], 2.10  [1.56–2.74]). Conclusions: Women with grand multiparity do not have an increased likelihood of poor pregnancy outcomes. Birth‐suite protocols which dictate extra interventions as routine during labour in these women should be revised.

SummaryA random controlled trial was performed to compare the effects of the dorsal and left‐tilt delivery positions upon fetal acid‐base status. The dorsal position was associated with a time‐related decrease in fetal pH, whereas the left tilt position was not.

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