Neonatal Birth Trauma: Analysis of Yearly Trends, Risk Factors, and Outcomes.

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.

Mode of delivery and neonatal outcomes in extremely preterm Vertex/nonVertex twins.

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 240/7 to 276/7 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.

Morbidity and Mortality Associated With Forceps and Vacuum Delivery at Outlet, Low, and Midpelvic Station.

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.

An evaluation by the Norwegian Health Care Supervision Authorities of events involving death or injuries in maternity care.

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.

Planned home versus planned hospital births in women at low-risk pregnancy: A systematic review with meta-analysis.

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.

Perinatal and maternal morbidity and mortality among term singletons following midcavity operative vaginal delivery versus caesarean delivery.

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.

Severe and fatal obstetric injury claims in relation to labor unit volume.

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.

Iatrogenic injury and unexpected hospital death in the newborn.

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.

Fatal head injuries in children under the age of 5 years in Pretoria.

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.

Obstetrical trauma--therapeutic dilemmas?

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.

Shoulder dystocia.

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.

Elective birth at 37 weeks of gestation versus standard care for women with an uncomplicated twin pregnancy at term: the Twins Timing of Birth Randomised Trial.

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.

Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000.

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.

Geographical disparities of infant mortality in rural China.

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.

Stillbirths and early neonatal mortality in rural Northern Ghana.

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.

Subgaleal hemorrhage: risk factors and outcomes.

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.

Neonatal deaths and injuries.

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.

Malpresentations--impact on mode of delivery.

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.

Causes of neonatal and child mortality in India: a nationally representative mortality survey.

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.