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Objective: To evaluate the trends, proportions, risk factors, resource utilization, and outcomes of neonatal birth trauma in the US., Study Design: This cross-sectional study of in-hospital births used the Nationwide Inpatient Sample for 2006-2014. We divided the cases by type of birth trauma: scalp injuries and major birth trauma. Linear regression for yearly trends and logistic regression were used for risk factors and outcomes. A generalized linear model was used, with a Poisson distribution for the length of stay and a gamma distribution for total spending charges., Results: A total of 982 033 weighted records with neonatal birth trauma were found. The prevalence rate increased by 23% from (from 25.3 to 31.1 per 1000 hospital births). Scalp injuries composed 80% of all birth traumas and increased yearly from 19.87 to 26.46 per 1000 hospital births. Major birth trauma decreased from 5.44 to 4.67 per 1000 hospital births due to decreased clavicular fractures, brachial plexus injuries, and intracranial hemorrhage. There were significant differences in demographics and risk factors between the 2 groups. Compared with scalp injuries, major birth trauma was associated with higher odds of hypoxic-ischemic encephalopathy, seizures, need for mechanical ventilation, meconium aspiration, and sepsis. Length of stay was increased by 56%, and total charges were almost doubled for major birth trauma., Conclusions: Neonatal birth trauma increased over the study period secondary to scalp injuries. Major birth trauma constitutes a significant health burden. Scalp injuries are also associated with increased morbidity and might be markers of brain injury in some cases., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: One of the controversies in the management of twin gestations relates to mode of delivery, especially when the second twin is in a nonvertex presentation (Vertex/nonVertex pairs) and birth is imminent at extremely low gestation., Objective: We hypothesized that, for Vertex/nonVertex twins born before 28 weeks' gestation, cesarean delivery would be associated with a lower risk of adverse neonatal outcomes than trial of vaginal delivery. Our aim was to test this hypothesis by comparing the neonatal outcomes of Vertex/nonVertex twins born before 28 weeks' gestation by mode of delivery using a large national cohort., Study Design: This work is a retrospective cohort study of all twin infants born at 24 0/7 to 27 6/7 weeks' gestation and admitted to level III neonatal intensive care units participating in the Canadian Neonatal Network (2010-2017). Exposure is defined a trial of vaginal delivery for Vertex/nonVertex twins. Nonexposed (control) groups are defined as cases where both twins were delivered by cesarean delivery, either in vertex or nonvertex presentation (control group 1) or owing to the nonvertex presentation of the first twin (control group 2). Outcome measures are defined as a composite of neonatal death, severe neurologic injury, or birth trauma., Results: A total of 1082 twin infants (541 twin pairs) met the inclusion criteria: 220 Vertex/nonVertex pairs, of which 112 had a trial of vaginal delivery (study group) and 108 had cesarean delivery for both twins (control group 1); 170 pairs with the first twin in nonvertex presentation, all of which were born by cesarean delivery (control group 2); and 151 pairs with both twins in vertex presentation (vertex or nonvertex). In the study group, the rate of urgent cesarean delivery for the second twin was 30%. The rate of the primary outcome in the study group was 42%, which was not significantly different compared with control group 1 (37%; adjusted relative risk, 0.93; 95% confidence interval, 0.71-1.22) or control group 2 (34%; adjusted relative risk, 1.20; 95% confidence interval, 0.92-1.58). The findings remained similar when outcomes were analyzed separately for the first and second twins., Conclusion: For preterm Vertex/nonVertex twins born at <28 weeks' gestation, we found no difference in the risk of adverse neonatal outcome between a trial of vaginal delivery and primary cesarean delivery. However, a trial of vaginal delivery was associated with a high rate of urgent cesarean delivery for the second twin., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: This study sought to quantify perinatal and maternal morbidity and mortality associated with forceps and vacuum delivery compared with Caesarean delivery in the second stage of labour and to estimate whether these associations differed by pelvic station., Methods: The investigators conducted a population-based, retrospective cohort study of term singleton deliveries by operative delivery with prolonged second stage of labour in Canada (2003-2013) using national hospitalization data. The primary study outcomes were severe perinatal morbidity and mortality (i.e., seizures, assisted ventilation, severe birth trauma, and perinatal death) and severe maternal morbidity and mortality (i.e., severe postpartum hemorrhage, cardiac complication, and maternal death). Logistic regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) after stratifying by indication (dystocia or fetal distress). The Breslow-Day chi-square test for heterogeneity in ORs was used to test effect modification by pelvic station (outlet, low, or midpelvic)., Results: There were 61 106 deliveries included in the study. Among women with dystocia, forceps and vacuum deliveries were associated with higher rates of perinatal morbidity and mortality compared with Caesarean delivery (forceps: aOR 1.56; 95% CI 1.13-2.17; vacuum: aOR 1.44; 95% CI 1.06-1.97). Vacuum delivery was associated with lower rates of maternal morbidity and mortality compared with Caesarean delivery (dystocia: aOR 0.64; 95% CI 0.51-0.81; fetal distress: aOR 0.43; 95% CI 0.32-0.57). Pelvic station did not significantly modify the associations between forceps or vacuum and perinatal or maternal morbidity and mortality., Conclusion: Forceps and vacuum delivery is associated with increased rates of severe perinatal morbidity and mortality compared with Caesarean delivery among women with dystocia, whereas vacuum delivery is associated with decreased rates of severe maternal morbidity and mortality., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: We aimed to determine how serious adverse events in obstetrics were assessed by supervision authorities., Material and Methods: We selected cases investigated by supervision authorities during 2009-2013. We analyzed information about who reported the event, the outcomes of the mother and infant, and whether events resulted from errors at the individual or system level. We also assessed whether the injuries could have been avoided., Results: During the study period, there were 303 034 births in Norway, and supervision authorities investigated 338 adverse events in obstetric care. Of these, we studied 207 cases that involved a serious outcome for mother or infant. Five mothers (2.4%) and 88 infants (42.5%) died. Of the 207 events reported to the supervision authorities, patients or relatives reported 65.2%, hospitals reported 39.1%, and others reported 4.3%. In 8.7% of cases, events were reported by more than 1 source. The supervision authority assessments showed that 48.3% of the reported cases involved serious errors in the provision of health care, and a system error was the most common cause. We found that supervision authorities investigated significantly more events in small and medium-sized maternity units than in large units. Eighteen health personnel received reactions; 15 were given a warning, and 3 had their authority limited. We determined that 45.9% of the events were avoidable., Conclusions: The supervision authorities investigated 1 in 1000 births, mainly in response to complaints issued from patients or relatives. System errors were the most common cause of deficiencies in maternity care., (© 2018 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Objective: To quantify severe perinatal and maternal morbidity/mortality associated with midcavity operative vaginal delivery compared with caesarean delivery., Design: Population-based, retrospective cohort study., Setting: British Columbia, Canada., Population: Term, singleton deliveries (2004-2014) by attempted midcavity operative vaginal delivery or caesarean delivery in the second stage of labour, stratified by indication for operative delivery (n = 10 901 deliveries; 5057 indicated for dystocia, 5844 for fetal distress)., Methods: Multinomial propensity scores and mulitvariable log-binomial regression models were used to estimate adjusted rate ratios (ARR) and 95% confidence intervals (95% CI)., Main Outcome Measures: Composite severe perinatal morbidity/mortality (e.g. convulsions, severe birth trauma and perinatal death) and severe maternal morbidity (e.g. severe postpartum haemorrhage, shock, sepsis and cardiac complications)., Results: Among deliveries with dystocia, attempted midcavity operative vaginal delivery was associated with higher rates of severe perinatal morbidity/mortality compared with caesarean delivery (forceps ARR 2.11, 95% CI 1.46-3.07; vacuum ARR 2.71, 95% CI 1.49-3.15; sequential ARR 4.68, 95% CI 3.33-6.58). Rates of severe maternal morbidity/mortality were also higher following midcavity operative vaginal delivery (forceps ARR 1.57, 95% CI 1.05-2.36; vacuum ARR 2.29, 95% CI 1.57-3.36). Among deliveries with fetal distress, there were significant increases in severe perinatal morbidity/mortality following attempted midcavity vacuum (ARR 1.28, 95% CI 1.04-1.61) and in severe maternal morbidity following attempted midcavity forceps delivery (ARR 2.34, 95% CI 1.54-3.56)., Conclusion: Attempted midcavity operative vaginal delivery is associated with higher rates of severe perinatal morbidity/mortality and severe maternal morbidity, though these effects differ by indication and instrument., Tweetable Abstract: Perinatal and maternal morbidity is increased following midcavity operative vaginal delivery., (© 2017 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.)

New interest in home birth have recently arisen in women at low risk pregnancy. Maternal and neonatal morbidity of women planning delivery at home has yet to be comprehensively quantified. We aimed to quantify pregnancy outcomes following planned home (PHB) versus planned hospital birth (PHos). We did a systematic review of maternal and neonatal morbidity following planned home (PHB) versus planned hospital birth (PHos). We included prospective, retrospective, cohort and case-control studies of low risk pregnancy outcomes according to planning place of birth, identified from January 2000 to June 2017. We excluded studies in which high-risk pregnancy and composite morbidity were included. Outcomes of interest were: maternal and neonatal morbidity/mortality, medical interventions, and delivery mode. We pooled estimates of the association between outcomes and planning place of birth using meta-analyses. The study protocol is registered with PROSPERO, protocol number CRD42017058016. We included 8 studies of the 4294 records identified, consisting in 14,637 (32.6%) in PHB and 30,177 (67.4%) in PHos group. Spontaneous delivery was significantly higher in PHB than PHos group (OR: 2.075; 95%CI:1.654-2.063) group. Women in PHB group were less likely to undergo cesarean section compared with women in PHos (OR:0.607; 95%CI:0.553-0.667) group. PHB group was less likely to receive medical interventions than PHos group. The risk of fetal dystocia was lower in PHB than PHos group (OR:0.287; 95%CI:0.133-0.618). The risk of post-partum hemorrhage was lower in PHB than PHos group (OR:0.692; 95% CI.0.634-0.755). The two groups were similar with regard to neonatal morbidity and mortality. Births assisted at hospital are more likely to receive medical interventions, fetal monitoring and prompt delivery in case of obstetrical complications. Further studies are needed in order to clarify whether home births are as safe as hospital births., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: To assess possible association between the incidence of approved claims for severe and fatal obstetric injuries and delivery volume in Denmark., Design and Setting: A nationwide panel study of labor units., Population: Claimants seeking financial compensation due to injuries occurring in labor units in 1995-2012., Methods: Exposure information regarding the annual number of deliveries per labor unit was retrieved from the Danish National Birth Register. Outcome information was retrieved from the Danish Patient Compensation Association. Exposure was categorized in delivery volume quintiles as annual volume per labor unit: (10-1377), (1378-2016), (2017-2801), (2802-3861), (3862-6659)., Main Outcome Measures: Five primary measures of outcome were used. Incidence rate ratios of (A) Submitted claims, (B) Approved claims, (C) Approved severe injury claims (120% degree of disability), (D) Approved fatal injury claims, and (C+D) Combined., Results: 1 151 734 deliveries in 51 labor units and 1872 submitted claims were included. The incidence rate ratios of approved claims overall, of approved fatal injury claims, and of approved severe and fatal injuries combined increased significantly with decreasing annual delivery volume. Face value incidence rate ratios of approved severe injuries increased with decreasing labor unit volume, but the association did not reach statistical significance., Conclusion: High volume labor units appear associated with fewer approved and fewer fatal injury claims compared with units with less volume. The findings support the development towards consolidation of units in Denmark. A suggested option would be to tailor obstetric patient safety initiatives according to the delivery volume of individual labor units., (© 2015 Nordic Federation of Societies of Obstetrics and Gynecology.)

Neonates are unusually vulnerable to iatrogenic injury due to small body size, delicate tissues, and immature immune systems. Investigation of an unexpected neonatal death in the hospital should begin with a review of the medical record and discussion with medical staff involved in the patient׳s care. Postmortem investigation should include a complete and well-documented autopsy. Additional investigations, such as microbiological studies and chemical and toxicological studies of postmortem and antemortem fluid samples, may be crucial in arriving at a diagnosis. Causes of iatrogenic injury include birth trauma, medication errors and adverse drug effects, hospital-acquired infection, and medical device malfunction, incorrect placement, and misuse. Autopsy is an important tool for understanding the cause of an unexpected death, improving the quality of care, and providing closure to parents and family., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Unlabelled: Obstetrical trauma is frequent among newborns alive and could represent a cause of perinatal death. The aim of this paper consists of presenting the authors experience regarding the diagnosis and treatment of skeletal and thoracic-abdominal organs related to traumatic birth., Material and Methods: Between 2000 and 2010, 33 patients with trauma at birth were included in the study. The type of the lesion and the therapeutical approach and results were analyzed., Results: Two categories of results were clearly differentiated: excellent for obstetric trauma involving limbs and soft parts and negative, disappointing results with 10 deaths in 12 cases treated for obstetric trauma of abdominal organs., Conclusions: Bone and soft tissue birth trauma are relatively easy to identify and treat, but the medical approach of thoraco-abdomnial organs birth trauma need clinical experience and technical possibilities.

The incidence of fatal injuries in children has been reported to be highest among children aged 1 to 4 years. Major causes of head injury include road traffic accidents, falls, and intentional or inflicted injury (such as nonaccidental injury syndrome). This study reviewed the profile of children (under 5 years of age) who had been admitted to a large urban medicolegal mortuary (in Pretoria, the capital city of South Africa), after having suffered fatal head injuries. This study was conducted over a 5-year period (from January 2004 through December 2008), and a total of 107 cases were identified for inclusion. These cases constituted nearly a fifth of admissions in this age group. The male-to-female ratio was 56%:44%, and the peak age of injury was less than 1 year. Most head injuries were sustained in road traffic accidents (70%) followed by falls (10%) and other types of blunt force injuries (9%). Only 1 case of nonaccidental injury syndrome (child abuse) was found. The great majority of deaths were deemed to have been accidental in nature (91%) with 6 (6%) homicides. Urgent review pertaining to the use of child restraint devices and the safety of pedestrians is required, and the institution of childhood injury registers could aid in reducing childhood fatalities in South Africa.

The frequency of shoulder dystocia in different reports has varied, ranging 0.2-3% of all vaginal deliveries. Once a shoulder dystocia occurs, even if all actions are appropriately taken, there is an increased frequency of complications, including third- or fourth-degree perineal lacerations, postpartum hemorrhage, and neonatal brachial plexus palsies. Health care providers have a poor ability to predict shoulder dystocia for most patients and there remains no commonly accepted model to accurately predict this obstetric emergency. Consequently, optimal management of shoulder dystocia requires appropriate management at the time it occurs. Multiple investigators have attempted to enhance care of shoulder dystocia by utilizing protocols and simulation training., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: The purpose of the study was to investigate the trends and causes of regional disparities of infant mortality rate (IMR) in rural China from 1996 to 2008., Design: A population-based, longitudinal study., Setting: The national child mortality surveillance network., Population: Population of the 79 surveillance counties., Main Outcome Measure: IMR, leading causes of infant death and the RR of IMR., Results: The IMR in coastal, inland and remote regions declined by 72.4%, 62.9% and 58.2%, respectively, from 1996 to 2008. Compared with the coastal region, the RR of IMR were 1.7 (95% CI 1.6 to 1.9), 1.9 (95% CI 1.7 to 2.0) and 1.8 (95% CI 1.6 to 2.0) for inland region and 2.6 (95% CI 2.4 to 2.7), 3.2 (95% CI 3.0 to 3.5) and 3.1 (95% CI 2.7 to 3.4) for the remote region during 1996-2000, 2001-2005 and 2006-2008, respectively. The regional disparities existed for both male and female IMRs. The postneonatal mortality showed the highest regional disparities. Pneumonia, birth asphyxia, prematurity/low birth weight, injuries and diarrhoea were the main contributors to the regional disparities. There were significantly more infants who did not seek healthcare services before death in the remote region relative to the inland and coastal regions., Conclusion: The results indicated persistent existence of regional disparities in IMR in rural China. It is worth noting that regional disparities in IMR increased in the remote and coastal regions during 2001-2005 in rural China. These disparities remained unchanged during 2006-2008. The results indicate that strategies to reduce mortality caused by pneumonia, birth asphyxia and diarrhoea are keys to reducing IMR.

Objective: To evaluate whether for women with an uncomplicated twin pregnancy, elective birth at 37 weeks of gestation was associated with reduced risk of death or serious outcomes for babies, without increasing harm., Design: Randomised controlled trial., Setting: Maternity hospitals across Australia, New Zealand and Italy., Population: A total of 235 women with an uncomplicated twin pregnancy at 36(+6) weeks of gestation, with no contraindication to continuing their pregnancy., Methods: Using a computer-generated, central telephone randomisation service, 235 women were randomised to Elective Birth (birth at 37 weeks; n=116) or Standard Care (continued expectant management, with birth planned from 38 weeks; n=119). Outcome assessors were masked to treatment allocation., Main Outcome Measure: A composite of serious adverse outcome for the infant., Results: For women with an uncomplicated twin pregnancy, elective birth at 37 weeks of gestation was associated with a significant reduction in risk of serious adverse outcome for the infant (Elective Birth 11/232 [4.7%] versus Standard Care 29/238 [12.2%]; risk ratio [RR] 0.39; 95% CI 0.20-0.75; P=0.005), reflecting a reduction in birthweight less than the third centile using singleton gestational age-specific charts (Elective Birth 7/232 [3.0%] versus Standard Care 24/238 [10.1%]; RR 0.30; 95% CI 0.13-0.67; P=0.004). In a post hoc analysis using twin gestational age-specific charts, there was evidence of a trend towards a reduction in the primary composite of serious adverse infant outcome (Elective Birth Group 4/232 [1.7%] versus Standard Care Group 12/238 [5.0%]; RR 0.34; 95% CI 0.11 to 1.05; P=0.06)., Conclusion: The findings of our study support recommendations for women with an uncomplicated twin pregnancy to birth at 37 weeks of gestation., (© 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.)

Background: Information about the distribution of causes of and time trends for child mortality should be periodically updated. We report the latest estimates of causes of child mortality in 2010 with time trends since 2000., Methods: Updated total numbers of deaths in children aged 0-27 days and 1-59 months were applied to the corresponding country-specific distribution of deaths by cause. We did the following to derive the number of deaths in children aged 1-59 months: we used vital registration data for countries with an adequate vital registration system; we applied a multinomial logistic regression model to vital registration data for low-mortality countries without adequate vital registration; we used a similar multinomial logistic regression with verbal autopsy data for high-mortality countries; for India and China, we developed national models. We aggregated country results to generate regional and global estimates., Findings: Of 7·6 million deaths in children younger than 5 years in 2010, 64·0% (4·879 million) were attributable to infectious causes and 40·3% (3·072 million) occurred in neonates. Preterm birth complications (14·1%; 1·078 million, uncertainty range [UR] 0·916-1·325), intrapartum-related complications (9·4%; 0·717 million, 0·610-0·876), and sepsis or meningitis (5·2%; 0·393 million, 0·252-0·552) were the leading causes of neonatal death. In older children, pneumonia (14·1%; 1·071 million, 0·977-1·176), diarrhoea (9·9%; 0·751 million, 0·538-1·031), and malaria (7·4%; 0·564 million, 0·432-0·709) claimed the most lives. Despite tremendous efforts to identify relevant data, the causes of only 2·7% (0·205 million) of deaths in children younger than 5 years were medically certified in 2010. Between 2000 and 2010, the global burden of deaths in children younger than 5 years decreased by 2 million, of which pneumonia, measles, and diarrhoea contributed the most to the overall reduction (0·451 million [0·339-0·547], 0·363 million [0·283-0·419], and 0·359 million [0·215-0·476], respectively). However, only tetanus, measles, AIDS, and malaria (in Africa) decreased at an annual rate sufficient to attain the Millennium Development Goal 4., Interpretation: Child survival strategies should direct resources toward the leading causes of child mortality, with attention focusing on infectious and neonatal causes. More rapid decreases from 2010-15 will need accelerated reduction for the most common causes of death, notably pneumonia and preterm birth complications. Continued efforts to gather high-quality data and enhance estimation methods are essential for the improvement of future estimates., Funding: The Bill & Melinda Gates Foundation., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: To calculate perinatal mortality (stillbirth and early neonatal death: END) rates in the Upper East region of Ghana and characterize community-based stillbirths and END in terms of timing, cause of death, and maternal and infant risk factors., Methods: Birth outcomes were obtained from the Navrongo Health and Demographic Surveillance System over a 7-year period., Results: Twenty thousand four hundred and ninty seven pregnant women were registered in the study. The perinatal mortality rate was 39 deaths/1000 deliveries, stillbirth rate 23/1000 deliveries and END rates 16/1000 live births. Most stillbirths were 31 weeks gestation or less. Prematurity, first-time delivery and multiple gestation all significantly increased the odds of perinatal death. Approximately 70% of END occurred during the first 3 postnatal days, and the most common causes of death were birth asphyxia and injury, infections and prematurity., Conclusion: Stillbirths and END remain a significant problem in Navrongo. The main causes of END occur during the first 3 days and may be modifiable with simple targeted perinatal policies., (© 2011 Blackwell Publishing Ltd.)

Subgaleal hemorrhage in the newborn is a serious adverse event that is often unrecognized and under-appreciated. This retrospective case series aimed to determine perinatal factors associated with subgaleal hemorrhage and subsequent neonatal outcomes. Obstetric and neonatal details of 21 infants with subgaleal hemorrhage over a 10-year period were collected. The mother was primiparous in 95% cases, 48% had a prolonged second stage (>120 minutes) and 43% had prolonged rupture of membranes (>12 hours). Thirteen infants (62%) were born by instrumental vaginal delivery. Ten infants (48%) required resuscitation at delivery. The severity of subgaleal hemorrhage was mild in four infants (19%), moderate in 10 (48%) and severe in seven (33%). Hypovolemic shock developed in 10 infants (48%), encephalopathy in 13 (62%) and coagulopathy was present in five infants (24%). There were three (14%) deaths. Long-term outcomes were good in the surviving infants., (© 2011 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2011 Nordic Federation of Societies of Obstetrics and Gynecology.)

Background: It is rare for babies to die or be injured during birth in Norway. We aimed to investigate whether maternity care was inadequate in cases reported to the Norwegian Board of Health Supervision and to single out areas in maternity care where there is potential for improvement., Material and Method: The material consists of cases reported to the Norwegian Board of Health Supervision in the three-year period 2006-2008 in which babies died or were severely injured during delivery. We recorded data on: maternity unit, fetal monitoring, delivery method, personnel involved and type of inadequate maternity care., Results: The material consists of 81 cases. Babies died during or after deliver in 58 cases and were severely injured in 23 cases. The health trusts reported 42 of these events to the Board of Health Supervision; the remainder were reported by the patient ombudsman or the parents. There was inadequate fetal monitoring in 68 % of the births and delayed delivery in 67 %. A gynaecological specialist was not called for 44 % of the births. The number of cases of injuries in relation to the number of deliveries reported to the Board of Health Supervision was significantly higher for small maternity units (< 1000 births per year) than for larger units., Interpretation: Doctors and midwives need a better knowledge of fetal monitoring. Maternity units must develop sound procedures for singling out high-risk births, use of fetal monitoring, calling for a doctor and reporting to the Board of Health Supervision. Exercises in dealing with acute situations should be held. Small maternity units appear to be most vulnerable to adverse events.

Fetal malpresentation, including persistent occipitoposterior position, is a major cause of dystocia resulting in obstetric interventions. We studied malpresentation among 11 957 consecutive singleton deliveries from 1995 to 2004. There were 1 030 deliveries with a malpresentation (8.6%). Cephalic malpresentations occurred in 5.4% of deliveries (persistent occipitoposterior 5.2%, face 0.1%, brow 0.14%), and 3.1% had breech presentation and 0.12% a transverse lie. The odds ratios (OR) for cesarean section were 14.89 (95%CI 11.91-18.63) in breech presentation and 4.57 (95% CI 3.85-5.42) in persistent occipitoposterior presentation. With persistent occipitoposterior position, the OR for instrumental vaginal delivery was 3.84 (95%CI 3.14-4.70). Primiparity was associated with increased malpresentation risks, as 54.6% of those with malpresentations were primiparous compared with 41.7% of those without (OR 1.68, 95%CI 1.48-1.91, p < 0.001). Primiparous women required more cesarean sections (OR 1.92, 95%CI 1.50-2.47) and instrumental deliveries (OR 2.89, 95%CI 1.50-2.47). Malpresentation frequently leads to cesarean section or instrumental delivery, especially among primiparous women., (© 2011 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2011 Nordic Federation of Societies of Obstetrics and Gynecology.)

Background: More than 2·3 million children died in India in 2005; however, the major causes of death have not been measured in the country. We investigated the causes of neonatal and child mortality in India and their differences by sex and region., Methods: The Registrar General of India surveyed all deaths occurring in 2001-03 in 1·1 million nationally representative homes. Field staff interviewed household members and completed standard questions about events that preceded the death. Two of 130 physicians then independently assigned a cause to each death. Cause-specific mortality rates for 2005 were calculated nationally and for the six regions by combining the recorded proportions for each cause in the neonatal deaths and deaths at ages 1-59 months in the study with population and death totals from the United Nations., Findings: There were 10,892 deaths in neonates and 12,260 in children aged 1-59 months in the study. When these details were projected nationally, three causes accounted for 78% (0·79 million of 1·01 million) of all neonatal deaths: prematurity and low birthweight (0·33 million, 99% CI 0·31 million to 0·35 million), neonatal infections (0·27 million, 0·25 million to 0·29 million), and birth asphyxia and birth trauma (0·19 million, 0·18 million to 0·21 million). Two causes accounted for 50% (0·67 million of 1·34 million) of all deaths at 1-59 months: pneumonia (0·37 million, 0·35 million to 0·39 million) and diarrhoeal diseases (0·30 million, 0·28 million to 0·32 million). In children aged 1-59 months, girls in central India had a five-times higher mortality rate (per 1000 livebirths) from pneumonia (20·9, 19·4-22·6) than did boys in south India (4·1, 3·0-5·6) and four-times higher mortality rate from diarrhoeal disease (17·7, 16·2-19·3) than did boys in west India (4·1, 3·0-5·5)., Interpretation: Five avoidable causes accounted for nearly 1·5 million child deaths in India in 2005, with substantial differences between regions and sexes. Expanded neonatal and intrapartum care, case management of diarrhoea and pneumonia, and addition of new vaccines to immunisation programmes could substantially reduce child deaths in India., Funding: US National Institutes of Health, International Development Research Centre, Canadian Institutes of Health Research, Li Ka Shing Knowledge Institute, and US Fund for UNICEF., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Objective: To examine the risks of infant death and neonatal morbidity by week of gestation at term., Study Design: National U.S. birth cohort study on the basis of singleton live births in 1995-2001 at 37 to 41 completed weeks gestational age (GA), with exclusion of congenital anomalies. Main outcomes included neonatal, postneonatal, and cause-specific infant death; low-Apgar score at 5 minutes; receipt of neonatal mechanical ventilation >or=30 minutes; neonatal seizures; birth injury; and meconium aspiration syndrome. To reduce confounding by indication, we carried out a secondary analysis restricted to low-risk deliveries., Results: In non-Hispanic white women, the mortality rate decreased with increasing GA from 37 to 39 weeks, remained stable from 39 to 40 weeks, and then (for neonatal death) increased at 41 weeks. Rates of low 5-minute Apgar score and mechanical ventilation showed a U-shaped relation across term GAs, and rates of meconium aspiration syndrome and birth injury rose with increasing GA. Results were similar among infants born to low-risk mothers and in non-Hispanic black women., Conclusions: Term infants show considerable heterogeneity across gestational age in neonatal and late infant outcomes, even when born to mothers at low risk. Recent trends toward earlier labor induction may have adverse health impacts.

Objective: To examine birth weight related risks of fetal injury in connection with shoulder dystocia., Study Design: The investigation was based on a retrospective analysis of 316 fetal neurological injuries associated with deliveries complicated by arrest of the shoulders that occurred across the United States., Results: The study revealed that the distribution of birthweights for the high risk shoulder dystocia population differs from the standard birthweight distribution. The relative difference per birthweight interval is used to adjust an assumed 1:1000 baseline risk of injury due to shoulder dystocia following vaginal deliveries. These adjusted risks show a need to consider new thresholds for elective cesarean delivery., Conclusions: Current North American and British guidelines, that set 5000 g as minimum estimated fetal weight limit for elective cesarean section in non-diabetic and 4500 g for diabetic gravidas, may expose some macrosomic fetuses to a high risk of permanent neurological damage. The authors present the opinion that the mother, having been informed of the risks of vaginal versus abdominal delivery, should be allowed to play an active role in the critical management decisions.

Objective: To identify and describe the occurrence of neurological lesions that could have an effect on lamb mortality., Procedure: The central nervous system was investigated macroscopically (n = 92) and microscopically (n = 72) in lambs dying in the perinatal period during 3 years in flocks of adult Corriedale ewes. The central nervous system was removed intact and samples of cerebral cortex, basal ganglia, thalamus, hippocampus, mesencephalon, cerebellar cortex, medulla oblongata, and cervical spinal cord were scored microscopically for the severity of neuronal dead, cytotoxic and perivascular oedema, and haemorrhage., Results: Neurologic findings between birth and 6 days included haemorrhages in meninges, brain congestion and oedema, neuronal ischemic necrosis, intraparenchymal haemorrhages in medulla oblongata and cervical spinal cord, parasagittal cerebral necrosis, and periventricular leukomalacia. No significant lesions were found in anteparturient deaths or in those aged between 7 and 16 days. Oedema was more severe in the brain than in other regions of the central nervous system. Ischaemic neurons first appeared 24 hours post partum, increased linearly in number between 48 hours and 5 days post partum, and had a laminar distribution in the cerebral cortex, indicating a hypoxic-ischemic encephalopathy. Haemorrhages were most severe in the gray matter of medulla oblongata and cervical spinal cord, suggesting trauma due to instability of atlantoaxialis joint., Conclusion: Lesions in the central nervous system can explain most deaths at birth and within 6 days of birth. The lesions were hypoxic-ischemic and appeared to be related to birth injury.

Objective: In obstetrics, the care of patients in labor or with emergencies takes place day and night. Birth-related injury is among the worst of obstetric outcomes. This study sought to examine the relationship between time of birth and fetal injury resulting in death., Study Design: The Birth-Related Neurologic Injury Compensation Association (NICA) is a Florida organization that pays for the care of infants >2500 g with birth-related brain or spinal cord injury resulting in permanent impairment. We conducted a case-control study using all deaths from the NICA database from 1989 to 2002. Data were collected on the antepartum, intrapartum, and postpartum care of the mother and fetus/child. Time of birth was identified for all cases and compared with a randomly selected control group of 1000 births in 1996 from Florida., Results: Eighty deaths were identified in the NICA database of 447 total cases. Of the 80 cases, 36/80 (45%) were born from 11 pm to 8 am. Of the 999 controls (1 certificate sealed for adoption) 281 (28.1%) were born from 11 pm to 8 am. This yields an odds ratio of 2.09 (95% CI 1.29-3.40) for the association of nighttime birth with fetal injury resulting in death., Conclusion: Fetuses sustaining injuries resulting in death were more than twice as likely as controls to have been born from 11 pm to 8 am. Further studies are needed to determine the factors that affect this association and what changes might need to be made to optimize care regardless of time of day or night.

Objectives: To describe the trend and causes of neonatal deaths in a rural district in northern Ghana., Methods: Descriptive analysis of data collected from the Navrongo Demographic Surveillance System and verbal autopsies conducted on all neonatal deaths from 1995-2002., Results: Of 1118 recorded neonatal deaths 1068 (95.5%) could be analysed. Only 13.2% of deaths occurred at the health facility; 62.7% occurred in the early neonatal period, with prematurity (38%) and birth injuries (19%) as leading causes. Infectious causes (66%) were the major contributors to late neonatal deaths. Infanticide accounted for 4.9% of all neonatal deaths. The cause-specific mortality rate for neonatal tetanus remained under 2.5% throughout the 8-year period. Overall, the neonatal mortality rate declined at an average of 2.5 per 1000 live births per year: Down by nearly 50% from 40.9 (95%C.I. 34.1-46.8) in 1995 to 20.5 (95%C.I.17.3-22.7) in 2002., Conclusion: The various health interventions undertaken in this district have had the collateral effect of causing decline in neonatal mortality. Neonatal mortality could be further reduced by preventing and treating neonatal infections, having skilled attendance at delivery and the elimination of infanticide. Data from demographic surveillance sites may be useful in monitoring trends in child mortality.

To describe the presentation and outcome of infants who develop subgaleal hematoma (SGH), we compared perinatal factors, clinical and head imaging findings, and outcome in a cohort (N = 34) of all infants admitted to Saint Louis Children's Hospital neonatal intensive care unit with SGH from January 1991 to June 2003. All except three of the infants admitted with SGH had instrumental deliveries (31 of 34; 91.2%): 21 vacuum, eight vacuum followed by forceps, two forceps). There was also a high frequency of occurrence of associated intracranial hemorrhage (17 of 34; 50%: subarachnoid hemorrhage, n = 4; intraventricular hemorrhage, n = 4; intraparenchymal hemorrhage, n = 4; subdural hemorrhage, n = 11), and skull fracture (six of 34; 19.4%; three of six [50%] of them depressed fractures). There was mortality associated with SGH (four of 34, 11.8%); those who died had significant volume loss with anemia, coagulopathy, and shock requiring large volumes of blood and blood products transfusions. The presence of ICH did not correlate with the severity of SGH or mortality, but the severity of SGH correlates with mortality. Minor neurological abnormalities were noted in only four infants at discharge. In conclusion, SGH is an uncommon type of birth trauma, and is associated with delivery or attempted delivery by instrumentation (vacuum and/or forceps). Severe hypovolemia and coagulopathy, but not intracranial hemorrhage, were the most commonly associated clinical problems with mortality. ICH does not correlate with severity of SGH. A brain computed tomography or magnetic resonance imaging should be considered in evaluating a clinically symptomatic SGH. There is associated mortality in severe cases but short-term outcome in survivors is good.

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. Thirty-seven 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 persistence with attempts at vaginal delivery in the presence of failure to progress or signs of fetal compromise were the main contributory factor regardless of which instruments were used.

Autopsy is invaluable in identifying the causes of severe depression and very low Apgar score after birth and in assessing contributory conditions. Brain scans are increasingly used in the care of neonates who fail to respond to resuscitation at birth but their interpretation depends on the information gained from sound neuropathological studies. Asphyxia, both acute intrapartum asphyxia and chronic asphyxia, is an important cause of low Apgar scores. The gestational age and the nature of the asphyxial insult both have a profound influence on the ultimate pattern of injury. Asphyxia in the preterm brain tends to damage preferentially the white matter but some white matter damage is also seen in many infants who have an hypoxia-ischaemic insult at term though the predominant site of injury is to the central grey matter. The nature of the cellular damage and reactive change seen at autopsy is described. There is an association between low Apgar scores and intrauterine exposure to infection and maternal pyrexia. Detailed autopsy examination should include the search for infection. The placenta, cord and membranes should be examined in view of the mounting evidence of the association between intrauterine infection of the placenta and fetal membranes and prenatal brain damage. Additionally, the presence of placental thrombosis and infarction should be sought in relation to focal and global injury in the full term infant. Acquired prepartum lesions rarely cause the infant to present with a low Apgar score. The exception to this is severe damage to the brainstem and basal ganglia. Traumatic injury to the brain is now much less common than in previous decades. Subdural haemorrhage occurs more frequently than intraventricular or subarachnoid haemorrhage. Instrumental and assisted deliveries are associated with an increased incidence of subdural haemorrhage though these rarely cause significant long term damage. Careful autopsy, particularly of the neck and paravertebral tissues, spinal cord, brainstem and nerve roots is important where trauma is suspected. Tearing of nerve roots or fibre bundles in the spinal cord is readily demonstrated under the microscope using immunocytochemistry to beta-amyloid precursor protein. Disorders of the spinal cord, peripheral nerve and muscle as well as some metabolic diseases may cause a baby to be both floppy and weak. Metabolic disease, including peroxisomal disorders, non-ketotic hyperglycinaemia, lipid and glycogen storage disorders and mitochondrial diseases may cause profound hypotonia and respiratory failure at birth or shortly afterwards., (Copyright 2004 Elsevier Ltd.)

The Wigglesworth pathophysiological classification was used to analyse perinatal deaths occurring in 5 health centres in Bangladesh. The aims were to assess the feasibility of this classification, to determine the causes of perinatal deaths and thereby to identify the areas in need of intervention. A total of 8058 births were recorded at 5 centres during the period of 11 months from mid-January to mid-December 2001. There were 1069 deaths in the perinatal period. Stillbirths were slightly more frequent (53.5%) than early neonatal deaths (46.5%). Among the stillbirths, fresh stillbirths predominated over normally formed macerated ones at all centers except BIRDEM, where the majority (52.5%) was macerated. The majority (71.6%) of perinatal deaths were in the groups comprising asphyxial conditions (46.8%), conditions associated with immaturity (13.3%), and normally formed macerated stillbirths (NFMSB, 11.5%). In the group, 'other specific conditions' which was responsible for 9.3% of perinatal deaths, all but one case was attributed to sepsis. When the cases were subdivided by birth groups, asphyxia predominated in all but the <1000g group, in whom immaturity was responsible. Conditions associated with immaturity were second highest in number. The majority of the perinatal deaths (83.4%) was in babies less than 2500g. The study has shown that the Wigglesworth classification can be used in different types of health facilities in Bangladesh by doctors, nurses and midwives. The areas which need intervention are antepartum care, obstetric and newborn care practices, and environmental factors responsible for the high prevalence of prematurity and low birth weight.

Objective: To identify the major causes of perinatal mortality in South Africa., Setting: Seventy-three state hospitals throughout South Africa representing metropolitan areas, cities and towns and rural areas., Method: Users of the Perinatal Problem Identification Programme (PPIP) amalgamated their data to provide descriptive information on the causes of perinatal death and the avoidable factors, missed opportunities and substandard care in South Africa., Results: A total of 8,085 perinatal deaths among babies weighing 1,000 g or more were reported from 232,718 births at the PPIP user sites. The perinatal mortality rates for the metropolitan, city and town, and rural groupings were 36.2, 38.6 and 26.7/1,000 births, respectively. The neonatal death rate was highest in the city and town group (14.5/1,000 live births) followed by the rural and metropolitan groups (11.3 and 10.0/1,000 live births respectively). The low birth weight rate was highest in the metropolitan group (19.6%), followed by the city and town group (16.5%) and the rural group (13.0%). The most common primary cause of perinatal death in the rural group was intrapartum asphyxia and birth trauma (rate 6.92/1,000 births) followed by spontaneous preterm delivery (5.37/1,000 births). The most common primary cause of death in the city and town group was spontaneous preterm delivery (6.79/1,000 births) followed by intrapartum asphyxia and birth trauma (6.21/1,000 births) and antepartum haemorrhage (5.7/1,000 births). The metropolitan group's most common primary causes were antepartum haemorrhage (7.14/1,000 births), complications of hypertension in pregnancy (5.09/1000 births) and spontaneous preterm labour (4.01/1,000 births). Unexplained intrauterine deaths were the most common recorded primary obstetric cause of death in all areas. Complications of prematurity and hypoxia were the most common final causes of neonatal death in all groups., Conclusion: Intrapartum asphyxia, birth trauma, antepartum haemorrhage, complications of hypertension in pregnancy and spontaneous preterm labour account for more than 80% of the primary obstetric causes of death.

Reasons for Performing Study: Thoracic trauma occurs in newborn foals and may cause associated clinical signs; this condition remains poorly documented., Objectives: The purpose of this study was to describe the pathological features of thoracic trauma in newborn foals presented for necropsy examination between 1990 and 2000., Methods: Necropsy reports of foals with thoracic trauma from 1990-2000 were reviewed. Subject details, clinical signs, thoracic and abdominal lesions were noted and analysed statistically., Results: Sixty-seven (9%) of 760 necropsied foals had thoracic trauma. In 19 foals, fractured ribs were considered to be the cause of death (Group A). The remaining foals had fractured ribs (Group B, n = 20) or rib contusions (Group C, n = 28) that were incidental findings. Ribs 3 to 8 accounted for 86% of the traumatised bones. The most common site of injury was the costochondral junction and an area immediately above it (94%). In Group A, all but 2 foals died within the first 8 days postpartum. Haemothorax and subsequent pulmonary collapse was cited most commonly as the cause of death (53%). Diaphragmatic rupture and hernia (n = 2) also occurred., Conclusions: The focal site, consistent location and presence of lesions during the first week post partum, all suggest that thoracic trauma in newborn foals probably occurs during parturition., Potential Relevance: The description of lesions and site of occurrence of thoracic trauma in foals will increase awareness and improve the diagnosis and treatment of this life threatening condition.

In various stressful conditions, the thymus is subjected to incidental involution, mostly due to the thymocytolytic effect of secreted glucocorticosteroids. The aim of this study was to examine acute thymic involution in sick neonates and to compare the morphological grade with some clinical and laboratory parameters. The influence of the illness on thymus tissue was investigated in 100 neonates who were treated and died in a neonatology intensive care unit. The preterm infants (n = 73) were born before the 37th week of gestation. Analysis of 57 placentas showed inflammation in 32% and circulatory disturbances in 23% of the cases. The causes of death were confirmed by autopsy: 35 were preterm infants with respiratory distress syndrome without infection, 22 were malformed, and 10 had birth trauma or asphyxia. In contrast, 29 of the preterm infants had an infection, mostly pneumonia or sepsis, and 4 of the term infants had such infections. Acute thymus involution was histologically graded (0-4) according to the method of van Baarlen (see text). Resting state (grade 0) was found in 25 of 38 neonates who lived <12 h. In 13 of 38 neonates who lived <12 h, thymus involution suggested prenatal stress. The grade of thymus involution related to the duration of illness (p < 0.001). Placental inflammation was associated with features of thymus involution (p < 0.048). Infection as a cause of death was connected to advanced thymus involution (p < 0.001). In preterm newborns, infection was more often connected with acute thymus involution than was respiratory distress syndrome (p < 0.003). Among the parameters measured in all available peripheral blood samples taken 24 h before death, only the lymphocyte count related to the grade of acute thymus involution (p < 0.05), with an increase in percentage of lymphocytes in peripheral blood smears from grade 0 to 2 and a decrease from grade 2 to 4. Although the white blood cell count is highly variable, a low percentage of lymphocytes might be a sign of advanced accidental thymus involution following acute stress., (Copyright 2003 S. Karger AG, Basel)

Objective: To classify 239 cases of perinatal death in a newly introduced classification system for underlying causes of perinatal death., Design: Prospective, descriptive., Setting: Dutch healthcare region Delft-Westland-Oostland (DWO)., Materials and Methods: In 10 years (1983-1992), all cases of perinatal death with a birthweight above 500 g (n=239) were included into the study. We used a classification model based upon the underlying cause of death using simple principles of obstetrical and neonatal pathology. A team consisting of a gynaecologist, neonatologist and pathologist classified all cases of perinatal death into seven groups to determine the "most-probable" cause of death., Results: Birth trauma was seen in two cases (0.8%). Infections were seen in 16 cases (6.8%). Acute/subacute placental pathology in 77 cases (32.2%) and chronic placental pathology in 50 cases (21%). Bloodtype antagonism was seen in two cases (0.8%). Lethal congenital malformations in 55 cases (23%). Complications of pre-viable delivery in 20 cases (8.4%). Unclassifiable were 17 cases (7%): two cases could not be classified despite thorough investigation (1%) and 15 cases were lost for follow-up (6%)., Conclusions: Classification of perinatal death causes by using our fundamental classification system gives insight in the possible underlying causes of death. The results of such a classification can be used as guidelines for preventive measures in the future.

Objective: To validate a newly introduced classification system for the registration of perinatal mortality., Design: Descriptive., Setting: Dutch Healthcare region Delft-Westland-Oostland (DWO)., Material and Methods: In a 10-years period (1983-1992), all cases of perinatal death with a birthweight above 500 g (n=239) were included into the study. Six assessors: four gynaecologists and two paediatricians were asked to classify all cases using a classification model proposed by the authors. This model is based on the underlying cause of death using simple principles of obstetrical and neonatal pathology: birth trauma, infection, placenta or cord pathology, pathology of immune tolerance of mother and fetus, congenital malformation of the fetus and complications of a pre-viable delivery. Therefore, we used the term fundamental classification. The six assessors worked independently of each other in classifying all cases of perinatal death, were not involved in the original development of the system and were unaware of the results of the classification of their colleagues. Agreement beyond chance between assessors was calculated using kappa's coefficient for multiple observers and multiple test results., Results: Overall kappa was 0.70 (95% confidence interval (C.I.) 0.68-0.72). Reproducibility was poor for the categories trauma and unclassifiable, fair for the categories infections and placental/cord pathology, and very good to excellent for the categories maternal immune system pathology, congenital malformations and complications of prematurity., Conclusions: The proposed system showed a good level of agreement and appeared to be simply applicable. It offers a good insight in the underlying cause of death with the possibility for recognising preventive factors in future pregnancies and will enable (inter)national comparisons in causes of perinatal death. A reliable uniform registration of perinatal death based on the underlying causes should be the basis for improvement of the quality of perinatal care.

While cranial birth injuries in term infants are well recognized, to date, only small case series have been described. In an attempt to further define the spectrum of cranial birth injuries, we analyzed 41 consecutive cranial birth injuries at our institution over the period 1991-1998. The most common clinical presentations were apnea (39%) and seizures (37%). Average Apgar scores were 5.7 at 1 min and 7.3 at 5 min; 54% of infants had abnormally low Apgar scores at 1 min and 31% had abnormally low scores at 5 min. The most common intracranial lesion was subdural hemorrhage, present in 73% of infants; most had either a tentorial (57%) and/or interhemispheric (50%) location. Operative treatment was required in 5 infants (12%). Two of the 41 infants (4.8%) died. The study group was compared with a control group of 63 randomly selected births without cranial injury. Using a stepwise logistic regression model, independently significant variables included neonatal birth weight, Apgar scores at 1 and 5 min and mode of delivery. Compared with the controls, the study group had a significantly higher incidence of forceps and/or vacuum deliveries. Combining vacuum, forceps and urgent cesarean section deliveries together as 'urgent' and elective cesarean and spontaneous vaginal deliveries as 'nonurgent', we could find no significant differences between these two groups. Our data conflict with those of Towner et al. [N Engl J Med 1999;341:1709-1714], and suggest that the method of assisted delivery, rather than the urgency of the delivery or dysfunctional labor per se, is a more important variable in cranial birth injuries., (Copyright 2001 S. Karger AG, Basel)

Objective: To investigate if in a planned vaginal breech delivery parity or birthweight is associated with neonatal outcome., Design: Retrospective analysis of local data from the National Obstetric Registration of the Netherlands., Method: The study concerned outcomes of 516 births of singletons with breech presentation after pregnancies > 37 weeks in the period 1 January 1995 to 31 December 1999 at the Medical Centre Leeuwarden, the Netherlands; there were 448 planned vaginal breech deliveries. Nulliparous and multiparous were separately studied in four birthweight groups (< 3000 g, 3000-3499 g, 3500-3999 g and > or = 4000 g)., Results: None of the neonates born by primary caesarean experienced birth trauma. In the group with planned vaginal breech delivery 2% of the neonates of nulliparous and 3% of multiparous mothers experienced neonatal morbidity. There was one case of perinatal mortality due to birth trauma (0.2%). The total perinatal morbidity was 6% with no differences between nulliparae and multiparae and between the birthweight groups. In nulliparous, the percentage of emergency caesarean sections rose from 20% in the < 3000 g birthweight group to 62% in the > or = 4000 g birthweight group., Conclusion: Following a planned vaginal breech delivery, no differences were observed in neonatal outcome between nulliparous and multiparous women and between the four birthweight groups. The extent to which the figures were influenced by the selection for primary caesarean section is not clear.

The study includes all 151 deceased newborns with traumatic subcapsular haemorrhage of the liver for the 3-year period between 1992 and 1994 in the University Maternity Hospital "Maĭchin dom"--Sofia. We compared the frequency and the causes for the hepatic rupture and how they depend on the way of delivery. We established a significantly higher frequency in the group of neonates undergone breech delivery /17.2%/ then in the group with head presentations /5.7%/. In the last group 3 of neonates were born by caesarean section. We conclude that the breech presentation increases the risk of hepatic birth injuries. Other predisposing factors are the perinatal asphyxia and the immaturity.

This retrospective study, including all postnatal died newborns from 1992 to 1994 in our hospital, shows, that the mortality rate among the breech presentations is several times higher then this among the cephalic presentations. Inborn malformations, specially those of CNS, and birth trauma are with significant higher frequency causes of death in the first group. Intrapartal asphyxia, intraventricular haemorrhages and respiratory distress syndrome are equally presented in the neonatal mortality structure of the newborns in breech and cephalic presentation.

The Jamaican Perinatal Morbidity and Mortality Survey (1986-1987) revealed nine cases of a previously unreported form of birth-related injury in the English-speaking Caribbean--occipital osteodiastasis. Aspects of the clinical and pathological features of this form of occipital bone injury are presented and discussed. Our findings suggest that this lesion might occur more often than is currently accepted.

Pathology case records of 3,514 aborted fetuses, stillborn foals, or foals that died < 24 hours after birth and of 13 placentas from mares whose foals were weak or unthrifty at birth were reviewed to determine the cause of abortion, death, or illness. Fetoplacental infection caused by bacteria (n = 628), equine herpesvirus (143), fungi (61), or placentitis (351), in which an etiologic agent could not be defined, was the most common diagnosis. Complications of birth, including neonatal asphyxia, dystocia, or trauma, were the second most common cause of mortality and were diagnosed in 19% of the cases (679). Other common diagnoses were placental edema or premature separation of placenta (249), development of twins (221), contracted foal syndrome (188), other congenital anomalies (160), and umbilical cord abnormalities (121). Less common conditions were placental villous atrophy or body pregnancy (81), fetal diarrhea syndrome (34), and neoplasms or miscellaneous conditions (26). A diagnosis was not established in 16% of the cases seen (585). The study revealed that leptospirosis (78) was an important cause of bacterial abortion in mares, and that infection by a nocardioform actinomycete (45) was an important cause of chronic placentitis.

In this retrospective review, data is presented of birth trauma seen among 4288 live born infants admitted to the special care unit of a large hospital over a three year period. Hypoxaemic brain injury resulting from birth asphyxia was by far the commonest form of birth trauma in this sample and it was the main cause of death, in many infants. All infants diagnosed as having sustained intracranial haemorrhage died while none of the other types of birth injuries were associated with any deaths. The need is emphasised to handle "high risk" deliveries with extra care while at the same time seeking solutions to the risk factors as well as lifting the overall standard of living of women in the community.

The authors have studied pregnancy, delivery and early neonatal status of macrosomic infants (> or = 4000 g) delivered between January 1, 1984, and December 31, 1992. The control group comprised age--and parity--matched pregnant women and their newborns weighing 3000 to 3999 g. From 9980 singleton pregnancies, 2021 (20.3%) macrosomics were delivered. The incidence of macrosomia was 16.7% in the primiparous group, 23.1% in the parity 2-4 group, and 28.2% in the multiparous group (parity > or = 5) (P < 0.001). The rates of macrosomic infants for pregnant adolescents (aged < or = 19 years), pregnant women aged 20-34 years and old pregnant women (> or = 35 years) were 12.0%, 20.6% and 21.5%, respectively (P < 0.001). Macrosomia was not influenced by occupation and antenatal visits (P > 0.05). The rates of > or = 16 kg weight gain in the macrosomic and control groups were 36.2% (mean 14.30 +/- 4.66 kg) and 16.7% (mean 12.18 +/- 4.82 kg), respectively (t = 12.05; P < 0.001). Of 546 pregnant women with fetal macrosomia subjected to oral GT testing, glucose intolerance was found in 20.0% and gestational diabetes in 4.8%. The rates of glucose intolerance and gestational diabetes in 259 control subjects were 13.9% and 2.3%, respectively (P < 0.05). Light (index 1-4) and moderate (index 5-7) forms of EPH gestosis were more common in the macrosomic group, whereas no difference was observed for severe forms (index > or = 8) between the groups (P > 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Post-mortem examinations were carried out on 65 calves which were stillborn or died within 24 hours of birth. All calves came from a large dairy unit with about one thousand cattle of the Schwarzbuntes Milchrind breed. To evaluate the perinatal losses, the farm records of parturitions from 1985-1990 were used. The calves had gross damage of the CNS, the musculature, subcutaneous tissue and internal organs such as lung and intestines. It may be assumed that a lesser degree of similar damage would also be present in the surviving calves. The level of perinatal losses is determined particularly by deaths following prolonged parturition due to foetal oversize in heifers and young cows, but also by the birth of immature calves of low weight after pregnancy of normal or decreased duration and by twin pregnancies with high total calf mass and relative immaturity of the calves.

A survey on perinatal handicaps must follow some standards: a) homogeneous population; b) univoc method of evaluation; c) 7 years follow-up; d) case control study. From ethnic and geographical point of view, Trentino is in a favorable condition; all pathologic cases come in the only 3th Level Center (Trento), and all neurological evaluations were made from the same specialist up to primary school. Now case control survey is starting. In district of Trento neonates without congenital malformations have risk for severe residual handicaps of 0.08%; under 1500 g the risk is 6.5% while in the group 1500-2499 the risk is 0.53%. A better prevention program during pregnancy and in Intensive Care Unity may reduce the severe outcome in the 1500-2499 group of neonates.

In a community-based intervention trial to reduce childhood mortality from pneumonia the intervention area included 58 villages (6176 children aged 0-4 years) and the control area 44 villages (3947 children) in Gadchiroli, India. The interventions included mass education about childhood pneumonia and case-management of pneumonia by paramedics, village health workers, and traditional birth attendants (TBAs) who were trained to recognise childhood pneumonia and treat it with co-trimoxazole. Parents sought treatment, and coverage was 76% without active case-detection efforts. The case-fatality rate among the 612 cases treated by health workers was 0.8%, compared with 13.5% in the control area. After a year of intervention pneumonia-specific childhood mortality was significantly lower in the intervention than in the control area (8.1 vs 17.5 deaths per 1000 children under 5 years); the difference between the areas was greatest in children under 1 year. The differences in infant mortality (89 vs 121 per 1000) and total under-5 mortality (28.5 vs 40.7 per 1000) were highly significant. Mortality from other causes remained similar in the two areas but neonatal mortality due to birth injury and prematurity was significantly lower in the intervention area, presumably owing to the combination of better maternal and neonatal care by the TBAs trained in the project and the availability of treatment for pneumonia. The cost of co-trimoxazole was US $0.025 per child per year ($2.64 per child saved).

Objective: To identify the causes of obstetric accidents., Design and Setting: Analysis of case records at the Medical Protection Society's London office covering the five years 1982-6., Subjects: Cases that had come to litigation which had resulted in stillbirth, perinatal or neonatal death, central nervous system damage to the baby, or maternal death and in which there was an opinion from a senior obstetrician consulted by the society. Of 147 cases reviewed, 64 met the criteria for the study., Main Outcome Measures: The principal findings of the expert reviewers., Results: Three major topics of concern emerged common to most of the 64 cases. These were inadequate fetal heart monitoring, mismanagement of forceps, and inadequate supervision by senior staff. In 11 of the 64 cases cardiotocography was omitted, in 19 cases the trace was missing, in six cases the trace was unreadable, and in 14 of the remaining 28 cases signs of fetal distress went unnoticed or were ignored. In 31 cases forceps were used to aid delivery or were tried and abandoned in favour of caesarean section. In 16 cases two or more attempts to use forceps were made. Five infant deaths were directly attributed to mismanaged forceps. In 20 cases senior staff were criticised by the expert reviewer for failure to come to the labour ward. In many of these cases they may have given advice over the telephone, but the inadequacy of records made it impossible to tell. In these cases the labour and birth were managed by junior staff, usually a senior house officer. In six cases when senior staff did come they suggested that no action was needed., Conclusion: These few cases should not be dismissed as isolated incidents in obstetric practice in Britain. They reflect more general problems--namely, concerning the ability of junior doctors to interpret fetal heart traces accurately, their ability to use forceps, and the participation of senior staff in running a labour ward and delivery suite.

Prolapse of the umbilical cord occurred 69 times in 30112 deliveries. The incidence was higher in abnormal presentations, particularly in compound presentation (11.1%), and in breech presentation (2.9%), especially when these occurred in association with prematurity. Twenty-five (36.2%) of the 69 infants died; 21 of these were dead at the time of diagnosis of cord prolapse, two died in the neonatal period of respiratory distress syndrome, and two died from complications of breech extraction. Reduction in perinatal mortality will be possible only if early diagnosis of cord prolapse can be made by means of vaginal examination or fetal heart monitoring, and the birth trauma associated with difficult vaginal delivery prevented.