This Week in Maternity - Screening for breech presentation study and South Dakotas high sleep related infant death rate
A study recently published has looked at the impact that screening for breech presentation at 36 weeks has on the birth. The study ‘Screening for breech presentation using universal late-pregnancy ultrasonography: A prospective cohort study and cost effectiveness analysis’ found that screening could lower the risk of breech delivery.
Researchers from Cambridge recruited 4000 women to the study. The women all received a scan at 36 weeks to help determine the position of the baby with 4.6% with a breech presentation. Those with a breech presentation were either given an ECV or counselled on their options – Cesarean section or vaginal birth.
Of the 179 women with a breech presentation more than half were previously undiagnosed. ECV was tried for 84 women but was only successful in 12. The types of delivery for the 179 women were:
The study also looked at the financial/economic implications of introducing the 36 week scan. The cost for adding the additional ultrasound would be £4.27 million annually however some of this would be offset by savings made from avoiding the complications associated with a breech delivery.
The study concludes:
‘This study shows that implementation of universal late-pregnancy ultrasound to assess foetal presentation would virtually eliminate undiagnosed intrapartum breech presentation in nulliparous women. If this procedure could be implemented into routine care, for example, by midwives conducting a routine 36-wkGA appointment and using a portable ultrasound system, it is likely to be cost effective. Such a programme would be expected to reduce the consequences to the child of undiagnosed breech presentation, including morbidity and mortality.’
The full study is available here.
Why are South Dakotas infant death rates so high?
Figures published on infant mortality rates due to sleep related disorders show that the rates in South Dakota are much higher than the national average.
The rate of 157.3 deaths per 100,000 births is 43% higher than the national average. Although the rate has been decreasing over the past 25 years the decrease has tapered off in the last few year. Sleep related cause include sudden infant death syndrome, accidental suffocation and strangulation. Between 2013 and 2017 95 babies in South Dakota died of sleep related causes following discharge from hospital.
Some of the possible risk factors contributing to sleep related deaths include:
To try and address the higher rate in South Dakota there are initiatives being implemented.
The America Academy of Paediatrics recommends a number of steps to support safe sleeping that includes placing the child on their back to sleep, keeping soft objects and bedding away from the sleeping area, avoiding smoking during pregnancy and after birth and avoid overheating.
This article details further information about the statistics and recommendations.
What does the NHS Long term plan say about maternity care?
The NHS Long term plan sets out how the NHS plans to provide care over the next 10 years addressing the changing nature of healthcare and the challenges being faced. Within the plan are provisions for maternity care. The plan outlines a number of goals including:
Saving babies live care bundle
The saving babies lives care bundle will be rolled out across all maternity units in England in 2019. The bundle has shown a 20% reduction in stillbirths across those units where it is already in place. There are also plans to expand the bundle to focus on prevention of pre-term birth.
Local maternity systems
All units will be part of local maternity systems which include a named maternity safety champion bringing together all aspects of maternity care.
Clinical negligence scheme
The clinical negligence scheme will continue to financially reward those units that deliver on 10 key safety actions.
Continuity of care
Work will continue on providing continuity of care with teams being set up across the country with a particular focus on care for BAME communities. Evidence suggests that for these community’s midwifery led continuity of care leads to improved clinical outcomes.
Learning from mistakes
The healthcare safety investigation branch will review all term stillbirths, early neonatal deaths and cases of severe brain injury in babies, as well as all maternal deaths reporting on lessons learned and how to avoid similar incidents.
Mental health services
There will be increased provision of mental health services both for mothers and fathers with care provided by specialist perinatal mental health services from preconception to 24 months after birth. Additionally, the types of therapies available will be expanded.
The plan also includes provision for neonatal care including better design of service to improve safety and effectiveness, development of the neonatal workforce and increased support for families.
The full plan and addition information can be found here. There is also a proposal for changes to legislation to help support the implementation of the long term plan that you can provide feedback on.
Pushing from below increases maternal complications
A study published in BMC Pregnancy and childbirth ‘Maternal and neonatal outcome of reverse breech extraction of an impacted fetal head during caesarean section in advanced stage of labor: a retrospective cohort study’ has found some significant differences in outcomes when comparing ‘pushing from below’ and reverse breech delivery of a baby with an impacted fetal head.
The retrospective study conducted in Switzerland analyzed the outcomes of 629 women whose baby was delivered via cesarean section in the later stages of labor. If difficulty was faced in disimpacting the fetal head either the reverse breech technique or head pushing was used. 82 women were in the head pushing group and 55 in the reverse breech.
The study found that outcomes were improved for women in the reverse breech group. They had lower uterine extension rates, a shorter operating time and less blood loss. There was no significant difference in the fetal outcomes however 2 babies in the head pushing group suffered skull fractures, one of which resulted in death.
The paper highlighted:
‘The deeply impacted fetal head is an obstetrical emergency situation, which requires a secure delivery technique to prevent undesirable maternal and neonatal consequences’
The full paper is available here.
Maternal and perinatal deaths dis-proportionally high following cesarean section in low- and middle-income countries.
The Lancet has published a study titled ‘Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis’.
The systematic review including 196 studies from 67 different countries looked at the risk of mortality in women who have had a cesarean section in low and middle income countries; estimating the cesarean deaths as a proportion of all deaths, the number of stillbirths and perinatal deaths along with risk of morbidity.
The review found that the cesarean section rate in most of the countries in the review was less than 10% with almost one quarter of cesareans being done for non-progress of labor. Findings for the rate of deaths per 1000 for those undergoing cesarean section were:
The review also found that women undergoing an emergency cesarean section were twice as likely to die than those undergoing an elective cesarean. A third of all the maternal deaths were attributed to post-partum haemorrhage and those cesareans performed in the second stage of labor were at higher risk of complications.
The study concludes:
‘The risk of maternal death following caesarean section is disproportionately high in LMICs, and women in sub-Saharan countries have the worst outcomes. The risks do not appear to have reduced over the past nearly 30 years, and are high in countries with a low rate of caesarean sections. Offspring outcomes are poor after a caesarean section, with high stillbirth and perinatal mortality. Emergency caesarean sections, particularly when undertaken in the second stage of labor, is a major risk factor for maternal and perinatal deaths, maternal near miss, and other major complications.’
The full study is available here.
Cesarean delivery associated with higher morbidity for women over 35
In a study titled ‘Risk of severe maternal morbidity associated with cesarean delivery and the role of maternal age: a population-based propensity score analysis’ researchers looked at 6 regions across France covering 119 maternity units. A total of 4908 women were part of the study.
In those women with maternal morbidity over 85% of women had a post-partum haemorrhage with an increased risk of severe maternal morbidity for women with cesarean deliveries during labor. The risk of maternal morbidity for women with cesarean section before labor was significantly higher only for women over 35.
The study highlights that cesarean section was associated with a significantly higher risk of severe morbidity when compared to vaginal delivery. The risk for women over 35 was particularly significant for those undergoing cesarean both before and during labor.
It is important to recognize and evaluate both the risks and benefits when performing a cesarean section.
The full study is available here.
This Week in Maternity - Patient safety curriculum, coroner investigative power and breastfeeding peer support
UK Government consultation – Giving coroners power to investigate still births
The UK government has launched a consultation on proposals to give coroners power to investigate all full term still births.
Currently coroners are only able to investigate deaths of babies who have shown signs of life after they were born. The proposal would enable coroners to provide parents with information on the cause of death as well as providing recommendations to avoid further deaths. It is stated that under the proposed system:
You can provide your views on the proposal by completing an online survey available here.
Patient Safety Curriculum
The Patient Safety Movement foundation has developed patient safety curriculum and education resources for healthcare professionals. It is aimed at developing knowledge, skills and behaviors to support improvement of patient safety and reduction of errors.
The resources can be used by those providing education on patient safety to help facilitate teaching. It provides information on how to get started with using the resource along with educational materials.
The curriculum covers 8 topics; error science, system science, human factors, technology, teamwork and communication, leadership and leading change, culture of safety and patient oriented safe care.
For each topic learning objectives are provided along with examples of demonstrating how they are met. There are videos, clinical cases and local experience examples provided along with further clinical resources and suggested reading.
The curriculum is available here.
Breastfeeding support via phone – A randomized controlled trial
A randomized trial has been published looking into the impact proactive telephone-based peer support has on breastfeeding.
The randomized trial conducted across 3 Australian hospitals involved more than 1000 women. The women were randomized to 2 groups – 1 with normal care and the other with normal care plus proactive phone-based support from a trained peer volunteer for up to 6 months post-partum. Only first-time mothers were included in the study.
The study measured the number of babies receiving any breast milk at six months finding that 75% of infants in the peer support group were receiving breast milk compared to 69% with only the usual support. Women in the peer support group had a 23% lower risk of stopping breastmilk feeding.
The study concludes:
‘Providing first time mothers with telephone-based support from a peer with at least six months personal breastfeeding experience is an effective intervention for increasing breastfeeding maintenance in settings with high breastfeeding initiation.’
The study is available here.
Dr Lesley Roberts, Consultant Obstetrician & Gynecologist shares her thoughts on cesarean section and maternal requests.
'Since the change in the NICE guideline we have seen increasing numbers of ladies requesting and even demanding elective LSCS.
Some trusts have decided to deny such requests.
We are in Surrey and recently I have been approached from ladies in other counties many miles from us whose requests have been denied.
We need to have a much better debate around the whole issue of choice in childbirth. We have something like a postcode lottery in relation to what is and is not available to mothers and their partners.
The litigation costs are very high when things do not go well, and many women (and men) suffer the psychological consequences of a birth that did end up being as they had hoped.
I suspect if all ladies were given the option many more would request a caesaerean section.
I am not in the caesarean for all camp as I personally chose to aim for a vaginal birth and was lucky enough to be able to experience the joy of homebirth as well as the unexpected need for an emergency LSCS on another occasion.
What I advocate is that there should be a choice and that choice is a fully informed one.
Lets get the debate going.'
Webinar: Implementing Best Practice PPH Bundle
The institute for perinatal quality improvement has a free webinar series to provide education and support on important perinatal quality improvement topics.
The latest webinar will be on ‘Implementing best practice PPH bundle’ covering policies, practices and procedures, reviewing key parts of the PPH bundle and discussing how it can be implemented.
The webinar series library also contains webinars on other important topics including baby friendly guidelines, care of African American and black mothers and utilizing telehealth.
To sign up to the webinar and access previous recordings click here.
Why Do Hundreds of US Women Die Annually in Childbirth?
800 women in the US die each year during pregnancy or within 42 days after delivery highlights a report from JAMA network. The report outlines the lack of standardization in reporting across states and the incomplete data on causes of death.
Review committees across states are analyzing patient records to identify what went wrong however some committees and unfunded and under resourced. Suitable analysis of the data and relevant action can lead to significant reduction in maternal deaths as demonstrated by Hospital Corporation of America.
It is estimated that more than 60% of pregnancy related deaths can be prevented with major causes including:
Work is being done to try and tackle some of these causes through action including:
The full articles available here provides more details on the current situation.
Maternal deaths and injuries – USA Today investigation