Confidential Enquiries into Stillbirths and Deaths in Infancy (CESDI) have pointed to a high frequency of suboptimal intrapartum fetal care of a kind that, in the event of an adverse outcome, is hard to defend in court. In an effort to minimize liability, various strategies were applied in a district hospital labour ward--guidelines, cyclical audit, monthly feedback meetings and training sessions in cardiotocography (CTG). The effects of these interventions on quality of care was assessed by use of the CESDI system in all babies born with an Apgar score of 4 or less at 1 min and/or 7 or less at 5 min. 540 babies (4.3%) had low Apgar scores, and neither the percentage nor gestational age differed significantly between audit periods. In the baseline audit, care was judged suboptimal (grade II/III) in 14 (74%) of 19 cases, and in the next four periods it was 23%, 27%, 27% and 32%. In the latest audit period, after further educational interventions, it was 9%. Many of the failures to recognize or act on abnormal events were related to CTG interpretation. After the interventions there was a significant increase in cord blood pH measurement. There were no differences between audit periods in the proportion of babies with cord pH < 7.2. These results indicate that substantial improvements in quality of intrapartum care can be achieved by a programme of clinical risk management.
During the 10-year period, 1975-1984, 105 triplet pregnancies were delivered at Harare Maternity Hospital, Zimbabwe, among 286,338 pregnancies in the Greater Harare Unit, giving an incidence of triplets of 1:2,727. The mean gestational age at delivery was 32.5 wk with 81 women (77.1%) delivering before 37 wk. Primigravidas delivered at a significantly earlier mean gestational age (P less than 0.05) and had a higher perinatal mortality (P less than 0.001) compared with grand multigravidas. Of the 315 babies, 277 (87.9%) weighed less than 2500 g. The overall perinatal mortality rate was 327%, with a perinatal mortality rate of 146% for infants weighing greater than or equal to 1000 g. Women hospitalised for bed rest during the antenatal period had fewer perinatal deaths compared with those diagnosed during the antenatal period, but not hospitalised for bed rest (P less than 0.02). No difference was found in the mean gestational age at delivery or the mean birth weights between these two groups. Among infants greater than or equal to 28 wk gestation there were fewer perinatal deaths in triplets delivered by cesarean section compared with triplets delivered vaginally (P less than 0.0004). This suggests that cesarean section may offer the optimal mode of delivery in triplet pregnancy.
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