Objectives  To determine whether the introduction of Obstetrics Emergency Training in line with the recommendations of the Clinical Negligence Scheme for Trusts (CNST) was associated with a reduction in perinatal asphyxia and neonatal hypoxic–ischaemic encephalopathy (HIE). Design  A retrospective cohort observational study. Setting  A tertiary referral maternity unit in a teaching hospital. Population  Term, cephalic presenting, singleton infants born at Southmead Hospital between 1998 and 2003 were identified; those born by elective Caesarean sections were excluded. Method  Five‐minute Apgar scores were reviewed. Infants that developed HIE were prospectively identified throughout this period. The study compared the period ‘pre‐training’ (1998–1999), with the period ‘post‐training’ (2001–2003). Main outcome measures  Five‐minute Apgar scores and HIE. Results  Infants (19,460) were included. Infants born with 5‐minute Apgar scores of ≤6 decreased from 86.6 to 44.6 per 10,000 births (P < 0.001) and those with HIE decreased from 27.3 to 13.6 per 10,000 births (P= 0.032) following the introduction of the training courses in 2000. Antepartum and intrapartum stillbirth at term rates remained unchanged, at about 15 and 4 per 10,000 births, respectively. Conclusion  The introduction of obstetric emergencies training courses was associated with a significant reduction in low 5‐minute Apgar scores and HIE. This improvement has been sustained as the training has continued. This is the first time an educational intervention has been shown to be associated with a clinically important, and sustained, improvement in perinatal outcome.

The mechanisms underlying cervical insufficiency, a cause of spontaneous second-trimester abortion and early preterm birth, remain poorly understood. There is, however, evidence that amniotic fluid (AF) infection is a key factor in pregnancy outcomes and postoperative complications. This study was an attempt to determine the frequency and clinical importance of intraamniotic inflammation in 52 patients with acute cervical insufficiency, defined as cervical dilation of 1.5 cm or more. The patients, seen at 17 to 29 weeks' gestation, had intact membranes, and were not having regular uterine connections. AF samples were cultured for aerobic and anaerobic bacteria and genital mycoplasmas, and assayed for matrix metalloproteinase-8; a level exceeding 23 ng/mL was deemed to represent the presence of intraamniotic inflammation.Intraamniotic inflammation was present in 42 of the 52 study patients (81%), and 4 patients (8%) had a positive AF culture. All culture-positive patients had intraamniotic inflammation. Among patients with intraamniotic inflammation but not AF infection, preterm delivery occurred within 7 days in 50%, and delivery before 34 weeks gestation, in 84%. More than half of newborn infants (55%) whose mothers had inflammation but not infection died within 24 hours of birth. The presence of intraamniotic inflammation was associated with a shorter interval between amniocentesis to delivery. The risk of an adverse pregnancy outcome did not differ between patients with intraamniotic inflammation and a negative culture on the one hand and, on the other, between those with confirmed AF infection. Fetal morbidity was not substantially altered by cesarean delivery.Whether the AF is culture-positive, a large majority of patients with acute cervical insufficiency have intraamniotic inflammation, and this is a risk factor for both preterm delivery and adverse pregnancy outcomes. ABSTRACTShoulder dystocia is an uncommon event that is largely unpredictable, and that may cause serious morbidity in both the mother and infant. Brachial plexus injury may be worsened by inappropriate treatment. This retrospective observational study compared the management and outcome of births complicated by shoulder dystocia before and after introducing 1 day of training that utilized a prototype shoulder dystocia training mannequin. Training included risk factors, recognition, documentation, helpful maneuvers, and a simulated shoulder dystocia scenario.A total of 15,908 pretraining births were compared with 13,117 taking place after the introduction of training. Rates of shoulder dystocia were similar: 2.04% in the pretraining group and 2.00% in the posttraining group. Before training, none of the several maneuvers recommended for the resolution of shoulder dystocia (including McRoberts' position, suprapubic pressure, internal rotation, delivery of the posterior arm, and the All-Fours-Maneuvers) were utilized in half or more of the affected infants. After training, in contrast, at least 1 of the recommended maneuvers was utilized in mor...

Objective  To determine whether the introduction of multi‐professional simulation training was associated with improvements in the management of cord prolapse, in particular, the diagnosis–delivery interval (DDI). Design  Retrospective cohort study. Setting  Large tertiary maternity unit within a University Hospital in the United Kingdom. Sample  All cases of cord prolapse with informative case record: 34 pre‐training, 28 post‐training. Methods  Review of hospital notes and software system entries; comparison of quality of management for umbilical cord prolapse pre‐training (1993–99) and post‐training (2001–07). Main outcome measures  Diagnosis–delivery interval; proportion of caesarean section (CS) in whom actions were taken to reduce cord compression; type of anaesthesia for CS births; rate of low (<7) 5‐minute Apgar scores; rate of admission to neonatal intensive care unit (NICU) (if birthweight >2500 g). Results  After training, there was a statistically significant reduction in median DDI from 25 to 14.5 minutes (P < 0.001). Post‐training, there was also a statistically significant increase in the proportion of CS where recommended actions had been performed (from 34.78 to 82.35%, P = 0.003). There was a nonsignificant increase in the use of spinal anaesthesia for CS, from 8.70 to 17.65%, and a nonsignificant reduction in the rate of low Apgar scores from 6.45 to 0% and in the rate of admission to NICU from 38.46 to 22.22%. Conclusions  The introduction of annual training, in accordance with national recommendations, was associated with improved management of cord prolapse. Future studies could assess whether this improved management translates into better outcomes for babies and their mothers.

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Objective To evaluate the effectiveness of a new handheld vacuum delivery device.Design Randomised controlled trial.Setting Southmead Hospital, Bristol, UK.Population One hundred and ninety-four women requiring delivery with vacuum extraction.Methods Women were recruited into the study while still in early labour. If during delivery, vacuum extraction was indicated they were then randomly allocated to either a new handheld vacuum device, the Kiwi Omnicup, or to a 'standard' vacuum cup selected by the obstetrician. The 'standard group' consisted of the silastic (66/98, 67%) or the metal cups (32/98, 33%). Study data were recorded at completion of the delivery and at 24 -48 hours. An additional brief symptom questionnaire was completed by the mother at 10 days postnatally. Statistical analyses were done on an 'intention-to-treat' basis. Main outcome measures The primary outcome was the successful completion of delivery with the allocated instrument. Secondary outcomes were substantial fetal scalp trauma and substantial maternal trauma. Results The Omnicup was associated with a significantly higher failure rate than the standard cup [34% vs 21%, odds ratio (OR) ¼ 1.

II.

Herpes viruses are able to cross the placenta and infect the fetus. Being potentially neurotrophic, they might contribute-directly or indirectly-to cerebral palsy. This population-based case-control study examined the association between perinatal exposure to neurotrophic viruses and cerebral palsy in 414 white South Australian case patients having the disorder and 856 controls. Newborn infants were screened for viral nucleic acids of enteroviruses and herpes viruses using the polymerase chain reaction technique. The herpes group A viruses sought included herpes simplex virus (HSV)-1, HSV-2, Epstein-Barr virus, cytomegalovirus, and human herpes virus 8. The herpes group B viruses included varicella zoster virus and human herpes viruses 6 and 7.A significant association was found, at all gestational ages, between any type of viral exposure and the development of cerebral palsy. Herpes group B viruses increased the risk of all types of cerebral palsy (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.09-2.59). A similar risk was noted for the diplegic and hemiplegic subtypes of cerebral palsy. Associations with any of the other viruses tested for were not statistically significant. With a gestational age of 37 weeks or more, the risk of cerebral palsy increased if any herpes virus was detected (OR, 1.52; 95% CI, 1.09-2.13) and also with the detection of any virus (OR, 1.64; 95% CI, 1.17-2.28). With a gestational age less than 37 weeks, detection of a herpes group A virus decreased the risk of all types of cerebral palsy (OR, 0.65; 95% CI, 0.43-0.99). Detecting a herpes group B virus increased the risk of quadriplegia (OR, 2.87; 95% CI, 1.09-7.59). At no gestational age was the presence of more than one virus associated with the risk of cerebral palsy.Newborn infants in South Australia are commonly exposed to neurotrophic viruses, and this is especially the case for preterm infants. Exposure to a herpes group B virus nearly doubles the risk of cerebral palsy. It remans possible that other factors such as genetic susceptibility to infection, growth restriction, and prematurity are necessary for brain damage and cerebral palsy to occur. ABSTRACTAn estimated 60% to 80% of neonatal herpes simplex virus (HSV) infections are a result of the mother acquiring HSV-1 or HSV-2 close to the time of delivery. Although it is relatively uncommon for HSV to be acquired at the end of pregnancy, transmission takes place efficiently. This suggests that preventing maternal acquisition of HSV during pregnancy may effectively lower the risk of neonatal infection. This couples study was done to identify risk factors for acquiring HSV in at-risk pregnant women who were participating in a prospective study of HSV in pregnancy. They invited their partners to undergo serologic testing for type-specific HSV. A total of 3192 couples took part in the study. ABSTRACTThe investigators report a retrospective observational study carried out at a tertiary referral maternity unit within a teaching hospital to learn whether training in how to mana...

ProblemIn Zimbabwe, many health facilities are not able to manage serious obstetric complications. Staff most commonly identified inadequate training as the greatest barrier to preventing avoidable maternal deaths.ApproachWe established an onsite obstetric emergencies training programme for maternity staff in the Mpilo Central Hospital. We trained 12 local staff to become trainers and provided them with the equipment and resources needed for the course. The trainers held one-day courses for 299 staff at the hospital.Local settingMaternal mortality in Zimbabwe has increased from 555 to 960 per 100 000 pregnant women from 2006 to 2011 and 47% of the deaths are believed to be avoidable. Most obstetric emergencies trainings are held off-site, away from the clinical area, for a limited number of staff.Relevant changesFollowing an in-hospital train-the-trainers course, 90% (138/153) of maternity staff were trained locally within the first year, with 299 hospital staff trained to date. Local system changes included: the introduction of a labour ward board, emergency boxes, colour-coded early warning observation charts and a maternity dashboard. In this hospital, these changes have been associated with a 34% reduction in hospital maternal mortality from 67 maternal deaths per 9078 births (0.74%) in 2011 compared with 48 maternal deaths per 9884 births (0.49%) in 2014.Lessons learntIntroducing obstetric emergencies training and tools was feasible onsite, improved clinical practice, was sustained by local staff and associated with improved clinical outcomes. Further work to study the implementation and effect of this intervention at scale is required.