Objective To use information collected by the Confidential Enquiry into Stillbirths and Deaths inInfancy to help obstetric, midwifery and paediatric practice in the management of shoulder dystocia. Main outcome measures Case notes were reviewed with respect to a range of perinatal variables.Comparisons were made with normative data from other studies when appropriate.Results Maternal obesity and big babies were over-represented in pregnancies complicated by fatal shoulder dystocia. Fetal compromise was recorded in 26% of labours. The median time interval between delivery of the head and the rest of the body was only five minutes. The lead professional at the time the head was delivered was a midwife in 65% of cases. Middle grade or senior obstetric staff were supervising 47Yi of cases by the time the body was delivered.Conclusions Antenatal prediction of shoulder dystocia is imprecise, and the majority of deliveries are attended by midwives. A relatively brief delay in delivery of the shoulders may be associated with a fatal outcome.

were analysed for their ethnic origins. Social classes IV and V predominated in all groups. A high proportion of Indian mothers fell into the low-risk group based on age and parity but had the highest stillbirth and perinatal mortality rates (15-1 and 27-5/1000 respectively) and infants of low mean birth weight (2986 g). Elderly and multiparous mothers were characteristic of the Pakistani and Bangladeshi groups. Young, primiparous mothers were more common among the West Indians and Europeans, in whom the stillbirth and perinatal mortality rates were low; infants in the European group had a mean birth weight higher than in any other group (3231 g). From these findings ethnic origin of the mother is apparently an important factor in perinatal mortality.

Objective To review delivery details of intrapartum-related fetal and neonatal deaths with singleton cephalic presentation and birthweight of 2500 g or more in which traumatic cranial or cervical spine injury or substantial difficulty at delivery of the head was a dominant feature. Design Review of freestyle summary reports and standard questionnaire responses submitted to the national secretariat for the Confidential Enquiry into Stillbirths and Death in Infancy (CESDI) during the 1994/1995 intrapartum-related mortality enquiry following regional multidisciplinary panel review. Setting United Kingdom.Sample Of the 873 cases of intrapartum-related deaths reported in the 1994 -1995 national enquiry, 709 weighed more than 2499 g. Reports from 181 (89 from 1994 and 92 from 1995) with a chance of meeting criteria for cranial or cervical trauma as significant contributors to death were examined in detail. Thirtyseven were judged to meet the criteria stated in the objectives (23 from 1994 and 14 from 1995) and form the basis for this review. Methods Electronic and hand search of CESDI records relating to intrapartum-related deaths. Main outcome measures Intrapartum events and features of care.Results There was evidence of fetal compromise present before birth in 33 of the 37 (89%) study group cases reviewed. One delivery was performed vaginally without instrumentation, and in one there was no attempt at vaginal delivery before caesarean section (CS) in the second stage of labour. Twenty-four cases (65%) were delivered vaginally and 11 (30%) by CS after failure to deliver vaginally with instruments. A single instrument was used in six cases of vaginal delivery (four ventouse and two Kjelland's forceps). At least two separate attempts with different instruments were made in 24 cases. Overall, the ventouse was used in 27 cases and forceps in 29 cases. In six cases, three separate attempts were made with at least two different instruments, all of which included use of ventouse. The grade of operator was recorded in 27 cases. Of these, a consultant obstetrician was present at only one delivery and no consultant was recorded to have made the first attempt to deliver a baby. In six cases, shoulder dystocia was also reported. Conclusions This study suggests a lower incidence of death from difficult cephalic delivery and cranial trauma than previously reported. The CESDI studies were believed to have achieved high levels of ascertainment for all intrapartum-related deaths from which the cases reported here were selected. Strictly applied entry criteria used in this study could have restricted the number of cases considered as could limited in vivo or postmortem investigations and lack of detailed autopsy. When cranial traumatic injury was observed, it was almost always associated with physical difficulty at delivery and the use of instruments. The use of ventouse as the primary or only instrument did not prevent this outcome. Some injuries occurred apparently without evidence of unreasonable force, but poorly judged persistenc...

Objective To examine problems encountered in classifying perinatal death using the systems proposed by Hey et al. (1986) and Cole et al. (1986). Subjects 451 deaths from a regional perinatal mortality survey of which 293 had a post mortem examination. Methods Documents from each death were reviewed by four assessors, one from each discipline, selected randomly from a pool of obstetricians, paediatricians, general practitioners and midwives. Each assessor classified the cause of death blind to the others. The degree of agreement between assessors was calculated for the full and shortened obstetric and fetal‐neonatal classifications using the kappa statistic for inter‐rater agreement. Results The kappa statistic, which is a measure of the proportion of agreement above chance, gave a value of 0.55 for the full obstetric classification and 0.58 for the full fetal and neonatal classification when all four assessors made an assignment. An assignment was omitted in 6.2%, but the kappa value of zero for these omissions suggested that this was a nonsystematic result due to random protocol violations. The grouped (shortened) classifications generated a higher kappa value of 0.62 for the nine point obstetric system and 0.67 for the six point fetal and neonatal (New Wigglesworth) system. Post mortem had little effect on agreement. The best agreement levels observed were for congenital anomaly. Conclusion This survey highlighted the complexity of the 22 and 24 point classifications, the uneven distribution of deaths within their categories, and the variable levels of agreement between professionals classifying deaths, thus questioning the validity of individual maternity units of health districts generating local data in this degree of detail for comparative purposes in regional and national statistics. Grouping the original categories led to greater agreement particularly for the New Wigglesworth classification. The role of post mortems in clarifying the cause of fetal and neonatal death needs further investigation.

Ultrasonic measurements of fetal biparietal diameter (BPD) obtained by Real Time scanning (Dynamic Section Scan) and conventional compound scanning (Static Section Scan) in twenty patients were compared. A comparison between two operators, one of whom was relatively inexperienced, was also made, both measuring the same BPDs. The mean variance of 20 groups-of-four 'blind' measurements was reduced using dynamic scanning, particularly for the less experienced operator. A significant difference was observed between operators using conventional scanning but not when using dynamic scanning. Both operators were able to obtain results in a shorter time with dynamic scanning, the faster operator averaging less than one minute for each observation. Apparent advantages of dynamic scanning are discussed. The terms 'Dynamic Section Scan' and 'Static Section Scan' are suggested to emphasize the difference between the two imaging systems.

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Geburtsverlauf, maternale und neonatale Morbidität gelten als geburtshilfliche Qualitätsindikatoren. Fragestellung: Ziel der vorliegenden Studie war es, herauszufinden, ob ± unabhängig von bevölkerungsspezifischen Anamnese-Risikofaktoren ± Unterschiede im Geburtsmanagement von Bedeutung sind für den Zustand von Mutter und Kind. Methodik: Unsere Datengrundlage bildeten geburtshilfliche und perinatologische Routinedaten von 1991 ± 1995 aus zwei Klinikabteilungen in Solihull (England) und Ibbenbüren (Deutschland). Nach Bildung von ¹Standard-Primip-Gruppenª (Schwangere im Alter < 35 Jahre, nicht alleinstehend, ohne vorausgegangene Schwangerschaft, weiûe Hautfarbe, Tragzeit ³ 37 Wochen) zur Standardisierung der geburtshilflichen Risikoprofile untersuchten wir auf Unterschiede in Geburtsverlauf, maternale und perinatale Morbidität. Ergebnisse: Der Anteil an Vaginalentbindungen aus Schädellage, primären Sectiones (sowohl bei Schädel-als auch bei Beckenendlage), Neugeborenenverlegungen in eine Kinderklinik und Kindern mit Einsetzen regelmäûiger Spontanatmung innerhalb 1 Minute in Solihull war signifikant geringer als in Ibbenbüren; hingegen fanden sich öfter Oxytocingabe, Fetalblutanalyse, Periduralanästhesie, Episiotomie, Zangen-oder Vakuumentbindung aus Schädellage, vaginale Entbindung aus Beckenendlage, Reanimation des Neugeborenen, Blutverlust ³ 1000 ml sowie eine Plazentalösungsstörung signifikant häufiger. Schlussfolgerung: Obwohl das Geburtsmanagement unterschiedlich war, hatte dies keinen Einfluss auf eine klinisch relevante Aspyhxie der Neugeborenen, gemessen am 5-Minuten-Ap-Summary Objective: The course of labor and maternal and neonatal morbidity are indicators of quality of obstetric care. Standardized data collection permits comparisons of the quality of obstetric and perinatal care at different institutions in different countries. We measured the quality of maternal care at the unit level by comparing obstetric and perinatal data at units in England and Germany. Methods: We compared obstetric and perinatal data obtained between 1991 and 1995 at an obstetric unit in Solihull, England (16,884 deliveries), and one in Ibbenbüren, Germany (5048 deliveries). We analyzed Caucasian, nonsingle primiparas < 35 years with no previous pregnancy and a gestational age ³ 37 weeks. Results: Vaginal delivery of infants in cephalic presentation, elective cesarean delivery of infants in cephalic and breech presentation, transfer to a neonatal special-care unit, and onset of regular breathing within 1 min. were significantly more frequent at the German unit. Administration of oxytocin, fetal blood analysis, epidural anesthesia, episiotomy, forceps or vacuum delivery of infants in cephalic presentation, vaginal delivery of infants in breech presentation, neonatal resuscitation, maternal blood loss > 1000 mL, and abnormalities of placental separation were significantly more frequent at the English unit. Five-minute Apgar scores were similar. Conclusion: The differences in obstetric management did not lead to differences in rates...

We have investigated whether the attending obstetrician has an influence on the mode of operative delivery by examining practices of obstetricians working at a district general hospital in the United Kingdom over 3 years. Nulliparous women ( n = 1410) with a singleton, cephalic and term fetus who had an operative delivery were studied. The most senior obstetrician present at 89% of these deliveries was one of the 12 registrars training in the unit. The proportion of women delivered by each mode of vaginal or abdominal operative delivery by each registrar was compared. In nine of these registrars the proportion of women they delivered by at least one mode differed significantly from the others. Caesarean section after an unsuccessful attempt at operative vaginal delivery showed the largest variation and caesarean section before the second stage of labour showed the least, with vaginal operative delivery modes and caesarean section in the second stage without a trial of vaginal delivery intermediate between the two. The method can be used to provide a 'profile' of the preferences exercised by individual operators.