Delivery in the 'grey zone': collaborative approach to extremely preterm birth.

During the recent New South Wales and Australian Capital Territory consensus workshop on Perinatal Care at the limits of viability, recommendations were made in the areas of education, counselling and management. Critically, there was a consensus that between 23 weeks and zero days and 25 weeks and six days of gestation, it was reasonable to offer the option of non-initiation of resuscitation and intensive care. Within this, obligation to treat increases as the gestation advances. Implications of the statement for obstetricians are discussed in this article.

Getting an evidence-based post-partum haemorrhage policy into practice.

BACKGROUND: Post-partum haemorrhage (PPH) is a potentially life-threatening complication of childbirth occurring in up to 10% of births. The NSW Department of Health (DoH) issued a new evidence-based policy (Framework for Prevention, Early Recognition and Management of Post-partum Haemorrhage) in November 2002. Feedback from maternity units indicated that there were deficiencies in the skills and experience is needed to develop the written protocols and local plans of action required by the Framework. METHODS: All 96 hospitals in NSW that provide care for childbirth were surveyed. A senior midwife completed a semistructured telephone interview. RESULTS: Ninety four per cent of hospitals had PPH policies. Among hospitals that provided a copy of their policy, 83% were dated after the release of the DoH's Framework, but 22% contained an incorrect definition of PPH. Only 71% of respondents in small rural and urban district hospitals recalled receiving a copy of the Framework. There was considerable variation in the frequency of postnatal observations. Key factors that impede local policy development were resources, entrenched practices and centralised policy development. Enabling factors were effective relationships, the DoH policy directive (Framework), education and organisational issues/time. CONCLUSIONS: Greater assistance is needed to ensure that hospitals have the capacity to develop a policy applicable to local needs. Maternity hospitals throughout the state provide different levels of care and NSW DoH policy directives should not be 'one size fits all' documents. Earlier recognition of PPH may be facilitated by routine post-partum monitoring of all women and should be consistent throughout the state, regardless of hospital level.

Perinatal care at the borderlines of viability: a consensus statement based on a NSW and ACT consensus workshop.

Perinatal care at the borderlines of viability demands a delicate balance between parents' wishes and autonomy, biological feasibility, clinicians' responsibilities and expectations, and the prospects of an acceptable long-term outcome - coupled with a tolerable margin of uncertainty. A multi-professional workshop with consumer involvement was held in February 2005 to agree on management of this issue in New South Wales and the Australian Capital Territory. Participants discussed and formulated consensus statements after an extensive consultation process. Consensus was reached that the "grey zone" is between 23 weeks' and 25 weeks and 6 days' gestation. While there is an increasing obligation to treat with increasing length of gestation, it is acceptable medical practice not to initiate intensive care during this period if parents so wish, after appropriate counselling. Poor condition at birth and the presence of serious congenital anomalies have an important influence on any decision not to initiate intensive care within the grey zone. Women at high risk of imminent delivery within the grey zone should receive appropriate and skilled counselling with the most relevant up-to-date outcome information. Management plans can thus be made before birth. Information should be simple, factual and consistent. The consensus statements developed will provide a framework to assist parents and clinicians in communication, decision making and managing these challenging situations.

Trends in postpartum haemorrhage.

OBJECTIVE: To assess trends and outcomes of postpartum haemorrhage (PPH) in New South Wales (NSW). METHODS: A population-based descriptive study of all 52,151 women who had a PPH either during the hospital stay for the birth of their baby or requiring a re-admission to hospital between 1994 and 2002. Data were obtained from the de-identified computerised census of NSW hospital in-patients and analysed to examine trends over time. The outcome measures included maternal death, hysterectomy, admission to intensive care unit (ICU), transfusion and major maternal morbidity, including procedures to reduce blood supply to the uterus, acute renal failure and postpartum coagulation defects. RESULTS: From 1994 to 2002 both the number and adjusted (for under-reporting) rate of PPH during the birth admission increased from 8.3% of deliveries to 10.7%. The rate of PPH adjusted for maternal age and mode of delivery was similar to the unadjusted rate. There was a sixfold increase in the rate of transfusions from 1.9% of women who haemorrhaged to 11.7%. Hospital readmissions for PPH declined from 1.2% of deliveries to 0.9%. These were statistically significant changes. There were no significant changes in the rate of hysterectomies, procedures to reduce blood supply to the uterus, admissions to ICU, acute renal failure or coagulation defects. CONCLUSION: The increased rate of PPH during the birth admission is concerning. The increase in PPH could not be explained by increasing maternal age or caesarean sections. Linked birth and hospital discharge data could determine whether the increase in PPH is caused by other changes in obstetric practices or