Objrctivr-To compare matorrial mortalities attributable to vaginal delivery, elective caesarean section (CS) and intrapartum CS. Design-The number of deaths axsociated with each method of delivery was ascertained among unselected and among low-risk women by detailed rctrospectivc review of the casenotes of women who died after delivery. The frequency of each method of delivery throughout the study period was ascertained from the computer database and enhanced by analysis of the case-notes of unselected groups of women. Setring-The Peninsula Maternity Services (Cape Town) during the years 1975-1986 inclusive. Subjrct.7-A total of 108 maternal deaths arising from 263 075 maternities provided accurate information. The relative frequency of vaginal and ahdominal delivcry was determincd from the computer databasc. The ratio of elective CS to emergency prepaituni CS to intrapartum CS was obtainecl by review of the first 200 operations in the years 1975, 1977. t979, 19x2 and 1983. Mirin oirfconzr mrasurrs-(i) Mort;ility rates associated with the different methods of delivery in unselcctcd women and in women who were healthy before surgery: (ii) mortality rates apparently attributable to the method of delivery. Rrsuk-The overall relative risk of mortality associated with caesarean section compared with vaginal dclivcry was 7 decreasing to .5 after the exclusion of women with medical or lifethreatening antenatal complications (eg. haemorrhage, hypertension). The relative risk associated with intrapartum compared with elective sections was 2.3 dccreaaing to 1.3 after the exclusion of women with medical disordcrs or life-threatening complications. The relative risk of maternal mortality which was apparently attrihutable to intrapartum compared with elective sections was 1.7. Howcvcr. the 9 % confidence intervals of these values, even from this large data-set, are wide. Nevertheless, these rates arc in broad agreement with an approximation derived lrom the British confidential enquiries into maternal deaths. Conclusion-The attributable relative mortalities of caesarean section compared with vaginal delivery and of intrapartum compared with elective caesarean section are lower than the overall relative niortalities of these onodes of delivcry and are approximately 5: 1 arid I .5: 1 respectively. These data are crucially important in the decision to recommend clcctivc caesarean section compared with trial of labour.

The aetiology of non-iatrogenic causes of peripheral ischaemia and gangrene presenting either at birth or within a few hours of delivery is unknown in the majority of 56 confirmed cases. In this review of 47 cases occurring since 1941 the aetiology was clear in only 6, four due to compression by the encircling umbilical cord. There was no clear association with gestational age, birth weight, maternal age or type of delivery. Seven were infants of poorly controlled diabetic mothers and these may constitute a subgroup due to altered haemostatic mechanisms. Pregnancy hypertension was an association in 7 cases, oligohydramnios in 6. There is only limited support for birth trauma, sepsis, and thrombo-emboli from the ductus arteriosus as causes. There is indirect evidence that thrombo-emboli can migrate from the placental bed to the fetus. In recent years death from this condition has been rare with surgical thrombectomy increasingly successful in late presenting cases. When gangrene is established at birth surgical amputation, autoamputation, or some loss of function is usual. Peripheral ischaemic insults presenting at birth may be part of a wider spectrum of disorders, both prenatal and perinatal, attributable to occlusive vascular disruption.

The findings indicate a significant and relatively strong relationship between the quality of epilepsy management in primary care (proportion of seizure-free patients) and an important care outcome (epilepsy-related emergency hospitalisation). The findings support the current and future use of Quality Outcomes Framework indicators to measure the quality of epilepsy care.

No abstract

Geographically widespread outbreaks involving commonly isolated organisms and where the vehicles of infection are commonly eaten foodstuffs pose particular difficulties at a technical and organizational level. An outbreak of Salmonella typhimurium infection, affecting 39 people, spread over a wide area in North West England and North Wales in April and May 1991, was detected thanks to the practice of sending specimens to the national reference laboratory where phage typing and characterizing of antibiotic resistance patterns enabled the identification of a cluster of distinctive isolates (S. typhimurium DT193 resistant to sulphonamides, trimethoprim and furazolidone). An investigation, involving twenty environmental health departments in addition to health authorities and the Public Health Laboratory Service, showed an association between the illness and eating loose sliced cooked ham (P = 0.004). Detailed tracing of the chain of supply of the ham showed this to be particularly cooked ham originating from a single small local producer (P = 0.00003). Further investigation of that producer revealed that a batch of ham distributed on one day in early April was undercooked due to a malfunction in cooking equipment.

Objectives-To quantify the proportion of potentially avoidable emergency short term admissions to hospital and to identify ways in which they could have been avoided. Design-Confidential enquiry by peer review group. Setting St Mary's Hospital, Newport, Isle of Wight. Subjects-All emergency, short term admissions (discharged home within five days) to medicine, general surgery, orthopaedics, gynaecology, ENT, and ophthalmology specialties for 28 (24 hour) days over a six month period in 1994. Main outcome measures-Appropriateness of admissions decided by the peer group, the peer group's opinion of ideal management, and the patients' views on the appropriateness of their admission. Results-Altogether 139 cases satisfied the inclusion criteria. Complete data were collected on 123 cases and the peer group considered 81 in the time available. Twenty one ofthe 81 cases were judged "potentially avoidable". These represent 9.5% (95% CI

Summary. The outcome of 313 mature singleton breech deliveries, covering a 3‐year period at the Queen Charlotte's Hospital, is reviewed. Maternal and fetal outcome were analysed by the intention to deliver vaginally compared with planned caesarean section. There was no serious fetal morbidity or mortality in either of these groups despite considerable mechanical difficulty with vaginal delivery of the head in one patient. One woman in this group required hysterectomy for haemorrhage after an emergency caesarean section. Planned caesarean sections were carried out in 125 cases (40%). Trial of vaginal delivery was abandoned in 59 (40%) of the 149 women where this was attempted. Epidural analgesia appears to increase the duration of the second stage of labour in those who were delivered vaginally. Younger women and those with smaller babies were more likely to succeed with a trial of vaginal delivery but there was no relation between birthweight and the radiological obstetric conjugate and success or failure of trial of labour.

The impacts of foot‐and‐mouth disease (FMD) on food security in developing countries are difficult to quantify due to the scarcity of accurate data on the prevalence and incidence of affected villages. This is partly due to resource constraints as well as the logistical challenges of conducting regular diagnostic testing in remote locations. In this study, we used descriptive analysis and latent class analysis (LCA) models to analyse data collected during a field survey of 160 villages in central Myanmar in the Mandalay and Sagaing Regions over the 2012–2016 time period. We evaluated the performance of verbal reports made by village householders and headmen against serological data to retrospectively determine the FMD‐infection status of our study area and to identify factors contributing to under‐reporting. Blood samples were collected from approximately 30 cattle per village in both the 6‐ to 18‐month age range and over 18‐month age range to distinguish between recent and historic exposure. Village householders were asked to identify pictures of FMD‐affected cattle amongst pictures of cattle affected with other common endemic diseases to assess the accuracy of their verbal reporting. The serological results confirmed that FMD is endemic in central Myanmar with village‐level seroprevalence estimated at 56% for animals 6–18 months of age and 80% when all age groups were considered together. Most village householders were familiar with the clinical signs of FMD‐affected cattle (72%). Based on the results from the LCA models, the village headman had a sensitivity of 77% and specificity of 75% for identifying FMD outbreaks in their village, whereas individual householders had a higher sensitivity and lower specificity of 80% and 56%, respectively. The level of disagreement between the different sources was correlated with the total number of cattle in the village and may potentially be worse in villages where endemic FMD may have led to a high level of natural immunity in cattle and subsequent masking of clinical signs. However, other regional effects such as the intensity of FMD extension efforts cannot be ruled out. Overall, the results suggest that verbal reports of FMD outbreaks from village headmen may be a useful tool to integrate into active FMD surveillance programmes in developing countries.