Background
Methods
Setting
Study population
Criteria of realistic best quality of care
Data extraction and analysis
Results
Background characteristics
Case-control study BW ≥2000 g | |||
---|---|---|---|
Cases Pre-hosp. Stillbirths | Cases Intra-hosp. Stillbirths | Controls Apgar 7–10 | |
N (%) | |||
Of all women in the study:
| (n = 67) | (n = 72) | (n = 249) |
Age | |||
<20 years | 2 (3.0 %) | 7 (9.7 %) | 26 (10.4 %) |
20–29 years | 26 (38.8 %) | 35 (48.6 %) | 122 (49.0 %) |
30–39 years | 27 (40.3 %) | 28 (38.9 %) | 83 (33.3 %) |
≥40 years | 8 (11.9 %) | 2 (2.8 %) | 15 (6.0 %) |
Information missing | 4 (6.0 %) | 0 (0.0 %) | 3 (1.2 %) |
Parity on admission | |||
Para 0a | 14 (20.9 %) | 39 (54.2 %) | 105 (42.2 %) |
Para 1–4 | 33 (49.3 %) | 23 (31.9 %) | 99 (39.8 %) |
Para ≥ 5 | 17 (25.4 %) | 10 (13.9 %) | 35 (14.1 %) |
Information missing | 3 (4.5 %) | 0 (0.0 %) | 10 (4.0 %) |
Antenatal care | |||
≥4 visits | 31 (46.3 %) | 38 (52.8 %) | 103 (41.4 %) |
1–3 visits | 23 (34.3 %) | 26 (36.1 %) | 111 (44.6 %) |
Not attended | 0 (0.0 %) | 1 (1.4 %) | 0 (0.0 %) |
Information missing | 13 (19.4 %) | 7 (9.7 %) | 35 (14.1 %) |
HIV | |||
Negative | 54 (80.6 %) | 62 (86.1 %) | 211 (84.7 %) |
Positive | 0 (0.0 %) | 2 (2.8 %) | 0 (0.0 %) |
Information missing | 13 (19.4 %) | 8 (11.1 %) | 38 (15.3 %) |
Gestational age | |||
No information on LMP/gestation weeks | 46 (68.7 %) | 49 (68.1 %) | 181 (72.7 %) |
Previous obstetric history | |||
Of multiparous women: | (n = 50) | (n = 33) | (n = 134) |
Previous death of child/childrenb,c | 18 (36.0 %) | 12 (36.4 %) | 30 (22.4 %) |
1 previous CS | 7 (14.0 %) | 8 (24.2 %) | 8 (6.0 %) |
≥2 previous CSs | 2 (4.0 %) | 2 (6.1 %) | 10 (7.5 %) |
Case-control study BW ≥2000 g | |||
---|---|---|---|
Cases Pre-hosp. Stillbirths | Cases Intra-hosp. Stillbirths | Controls Apgar 7–10 | |
N (%) | |||
Mode of delivery | |||
Of all women in the study: | (n = 67) | (n = 72) | (n = 249) |
Spontaneous vaginal | 45 (67.2 %) | 46 (63.9 %) | 213 (85.5 %) |
Vaginal breech | 3 (4.5 %) | 5 (6.9 %) | 5 (2.0 %) |
Vacuum extraction | 1 (1.5 %) | 0 (0.0 %) | 0 (0.0 %) |
Caesarean sectiona,b | 15 (22.4 %) | 20 (27.8 %) | 26 (10.4 %) |
Mode of delivery unknown | 3 (4.5 %) | 1 (1.4 %) | 5 (2.0 %) |
Maternal outcome | |||
Of all women in the study: | (n = 67) | (n = 72) | (n = 249) |
Maternal deaths | 2 (3.0 %) | 1 (1.4 %) | 0 (0.0 %) |
Post partum haemorrhagec | 7 (10.4 %) | 10 (13.9 %) | 14 (5.6 %) |
Episiotomy/spontaneous tearsd,e | 6 (9.0 %) | 19 (26.4 %) | 79 (31.7 %) |
Of vaginal deliveries: | (n = 49) | (n = 51) | (n = 218) |
Prolonged admission, ≥1 dayf | 9 (18.4 %) | 0 (0.0 %) | 3 (1.4 %) |
Of caesarean sections: | (n = 15) | (n = 20) | (n = 26) |
Prolonged admission, ≥5 days | 1 (6.7 %) | 3 (15.0 %) | 2 (7.7 %) |
‘Fresh’ versus ‘macerated’ stillbirths | |||
Of all women in the study: | (n = 67) | (n = 72) | (n = 249) |
Classification not recorded | 36 (53.7 %) | 41 (56.9 %) | NA |
Admission and partograph use
Case-control study BW ≥2000 g | |||
---|---|---|---|
Cases Pre-hosp. stillbirths | Cases Intra-hosp. Stillbirths | Controls Apgar 7–10 | |
N (%) | |||
Progress on admission and referrals | |||
Of all women in the study: | (n = 67) | (n = 72) | (n = 249) |
Before labour paina | 5 (7.5 %) | 2 (2.8 %) | 12 (4.8 %) |
Latent phase of laboura,b | 18 (26.9 %) | 40 (55.6 %) | 56 (22.5 %) |
First stage of labour | 23 (34.3 %) | 29 (40.3 %) | 153 (61.4 %) |
Second stage of labour | 15 (22.4 %) | 0 (0.0 %) | 25 (10.0 %) |
Stage of labour on admission unknown | 6 (9.0 %) | 1 (1.4 %) | 3 (1.2 %) |
Referral from smaller health centrec | 10 (14.9 %) | 11 (15.3 %) | 12 (4.8 %) |
Partograph use | |||
Of women in first stage of labour: | (n = 39) | (n = 69) | (n = 207) |
The partograph at least partially appliedd | 27 (69.2 %) | 66 (95.7 %) | 183 (88.0 %) |
Of women with the partograph applied: | (n = 27) | (n = 66) | (n = 183) |
First cervical dilatation in active labour plotted correctly on the alert line | 18 (66.7 %) | 53 (80.3 %) | 166 (90.7 %) |
Foetal heart rate (FHR)
Case-control study BW ≥2000 g | ||
---|---|---|
Cases Intra-hosp. Stillbirths | Controls Apgar 7–10 | |
N (%) | ||
Of women with at least one FHR reading:
| (n = 72) | (n = 204) |
FHR in normal range on admission (110–160 beats per min.) | 72 (100.0 %) | 202 (99.0 %) |
Foetal distress detected prior to delivery | 15 (20.8 %) | 0 (0.0 %) |
<90 min. between any 2 recordings of FHRa | 12 (16.7 %) | 67 (32.8 %) |
Median time from last FHR till delivery or detected IUFD (min.)b,c | 210 | 120 |
Labour progress
Case-control study BW ≥2000 g | |||
---|---|---|---|
Cases Pre-hosp. Stillbirths | Cases Intra-hosp. Stillbirths | Controls Apgar 7–10 | |
N (%) | |||
Surveillance in latent phase of labour | |||
Of women admitted before active labour: | (n = 23) | (n = 42) | (n = 68) |
Assessment of cervical dilatation during active laboura,b | 9 (39.1 %) | 37 (88.1 %) | 44 (64.7 %) |
Assessment of labour progression | |||
Of women in first stage of active labour: | (n = 39) | (n = 69) | (n = 207) |
<5 h. between any 2 recordings of cervical dilatation in active labour c | 39 (100.0 %) | 42 (60.9 %) | 167 (80.3 %) |
<3 h. between any 2 recordings of uterine contractionsd | 33 (84.6 %) | 18 (26.1 %) | 120 (58.0 %) |
Alert line crossede | 2 (5.1 %) | 33 (47.8 %) | 51 (24.5 %) |
Action line crossedf | 1 (2.6 %) | 16 (23.2 %) | 21 (10.1 %) |
Maternal vital signs
Discussion
1. Strengthened risk assessment on admission, with particular focus on foetal heart rate, blood pressure, temperature, and previous obstetric history. |
2. Improved routine surveillance during latent and active phase of labour, regarding all key parameters (foetal heart rate, dilatation of cervix and descent, contractions, maternal vital signs, and urinary output). |
3. Increased prioritization of women with already diagnosed intrauterine foetal death for routine assessments during labour. |
4. Timely prevention and management of prolonged labour, with focus on alternative and less harmful interventions than oxytocin infusion for labour augmentation (e.g. artificial rupture of membranes and emptying of bladder), and more restrictive dosages and improved surveillance when oxytocin is administered. |
5. Reduction of caesarean sections after intrauterine foetal death, by improved management of prolonged labour, and enforcement of vacuum extraction and craniotomy use. |
6. Improved management of severe hypertensive disorders, with particular focus on antihypertensive treatment. |
7. Better intrapartum documentation as well as record keeping. |