F, V & V INOBGyN, 2010, 2 (4): 219-225 Original paper Confidential enquiries into quality of care of women in labour using Hypoxic Ischemic Encephalopathy as a marker A. DEKNIjF1, R. C. PATTINSON MRC Maternal and Infant Health Care Strategies Research Unit, Department of Obstetrics and Gynaecology, University of Pretoria, Kalafong Hospital, Pretoria, South Africa. 1Registrar, Department of Obstetrics and Gynaecology, KULeuven, Belgium. Correspondence at: Professor R.C. Pattinson, Department of Obstetrics and Gynaecology, Klinikala Building, University of Pretoria, PO Box 667, Pretoria, 0001. E-mail: [email protected] Abstract Objective:To identify avoidable factors contributing to neonatal morbidity and mortality due to “birth asphyxia” and to ascertain if hypoxic ischemic encephalopathy (HIE) alone could act as a good marker for avoidable factors associated with “birth asphyxia”. Setting:Kalafong Hospital, South Africa, a regional hospital unit that caters for mainly indigent urban population but also receives referrals from the Mpumalanga Province. Methods:All neonates and intrapartum stillbirths fulfilling the criteria of birth asphyxia born at the Kalafong Hospital during 2008 and 2009 were included. Neonates born at less than 34 weeks gestation, born with infection, major con- genital malformations or inborn errors of metabolism and intrapartum deaths due to abruption placentae were excluded. Neonates referred from Level 1 clinics postnatally, who qualified with these criteria, were also included in the study. The files were retrieved, and avoidable factors were identified. Avoidable factors were classified into 3 groups: patient associated, administrative and medical personnel associated problems. Results:In 2008 and 2009, 10117 babies were born at Kalafong Hospital. 224 babies with intrapartum related asphyxia were identified (22.1/1000 births). This group consisted of 14 intrapartum stillbirths, 85 neonates with mild asphyxia, 125 babies with severe asphyxia of which 41 had a neonatal near miss markers without HIE and 84 with HIE. Fifteen of the babies with HIE subsequently died. The number of avoidable factors identified per case file reviewed increased with the severity of the hypoxic event, mild asphyxia 0.74, neonatal near miss without HIE 0.85, HIE survivor 0.91, and stillbirth or neonatal death 1.29. Major avoidable factors for birth asphyxia were refusal of medical treatment, in- adequate facilities, no detection of or reaction to fetal distress, and incorrect management of second stage. The avoidable factors detected in neonates with HIE were the same as those detected in the whole group. Conclusion:The avoidable factors described in a confidential enquiry concentrating on the labour management of women delivering neonates with all grades of “birth asphyxia” were similar to those found in women delivering neonates with HIE. HIE in neonates is a clearly defined condition, making it a good marker to use to review the quality of intrapartum care received by the women who delivered neonates with HIE. Key words:Birth Asphyxia, Hypoxic Ischaemic Encephalopathy, Audit, Intrapartum Care, Quality of Care. Introduction babies die during labour and are stillborn. Intra- partum hypoxia is the most frequent mechanism of Over 900000 newborns each year die from labour- damage in these stillbirths, with the majority of related causes. This makes intrapartum hypoxia or deaths being at term in otherwise uncomplicated asphyxia the third most common cause of newborn pregnancies (CEMACH, 2008). Not surprisingly, a death (23%) after infections (36%) and preterm birth large proportion of these events are considered (28%) (Lawn et al., 2005). Another 1.1 million avoidable (Buchmann et al., 2002; Velaphi and 219 Pattinson, 2005) and audit of such perinatal deaths adverse outcomes, seeking to identify avoidable to ascertain the quality of care provided for the factors and to derive lessons for wider policy and women in labour therefore seems essential (Lawn et practice” (Pearson, 2008). al., 2005: Ward et al., 1995). In this study, a confidential enquiry was per- The majority of women losing babies to intra- formed to identify avoidable factors, missed oppor- partum hypoxia are women considered at low risk tunities and substandard care in the management of and with apparently normal labours. Buchmann and the labour of women who delivered babies diag- Pattinson (2005) showed that there were signs of nosed as having “birth asphyxia” in Kalafong Hos- probable fetal distress in 80% of intrapartum pital to identify areas where intrapartum care can be hypoxia cases (late decelerations and/or thick improved. Further cases of HIE were identified to meconium stained liquor) yet only 25% had an ascertain if the avoidable factors identified in these operative delivery due to fetal distress. This cases were similar to those occurring in other cases demonstrates there is often not an adequate response of “birth asphyxia”. to abnormal signs in labour. The core problems have been found to be: inadequate clinical skills; poor Methods recording of clinical findings, which lead to sub- standard (or no) management decisions; andlack of The study was performed at the Kalafong Hospital transport for women complicating during labour. of Pretoria, a regional hospital that caters for a Audit of deaths and neonatal near misses (defined mainly indigent urban population but also receives as neonates who almost died but survived) may referrals from the Mpumalanga Province. All babies provide information that can improve perinatal care with mild asphyxia, asphyxia with a near miss and prevent future deaths (Avenant, 2009). On their marker (more severe cases of asphyxia, but no HIE), own, low Apgar scores, ‘‘fetal distress’’ during HIE, and intrapartum stillbirths and neonatal deaths labour, metabolic acidosis at birth, and neonatal en- due to intrapartum hypoxia were identified. cephalopathy, do not provide convincing evidence Neonates born at less than 34 weeks gestation, born of severe intrapartum hypoxia. The term “birth with infection, major congenital abnormality or in- asphyxia” has been greatly miss-used and it is born errors of metabolism were excluded. Mild as- unclear as to what it actually represents, although phyxia was defined as a baby with a low Apgar most clinicians believe they can identify a case of and/or a low pH that did not require intubation as birth asphyxia. Nelson et al.(2007) defined the term part of resuscitation but was admitted to the neonatal “hypoxic ischemic encephalopathy” as the presence unit for observation. Criteria described by Avenant of encephalopathy developing in the first 24 hours (2009) for identifying neonatal near misses were after birth and metabolic acidemia associated with used (Table 1). Neonates considered to be a neonatal evidence of fetal distress and a low Apgar score. near miss due to intrapartum hypoxia were identified Nelson stated that the term ‘‘hypoxic ischemic from the neonatal near miss database of the Depart- encephalopathy’’ (HIE) should be reserved for ment of Obstetrics and Gynaecology. Intrapartum instances where the clinical and laboratory picture deaths and neonatal deaths classified as being due to fits with that description (Nelson et al., 2007). HIE intrapartum hypoxia were also identified using the correctly defined, provides the near miss outcome departmental database. The department identifies that best identifies surviving neonates that almost and discusses all cases of neonatal mortality and died as a result of intrapartum hypoxia, with or with- neonatal near misses weekly with paediatricians. out an antepartum predisposing cause (Buchmann Intrapartum deaths are discussed when they occur. and Velaphi, 2009). The perinatal death data is collected on the Perinatal An atmosphere of ‘guilt’ and blame, and in some Problem Identification Programme (PPIP) database cases even medico-legal liability often complicates (Pattinson 2003a). Neonates referred from Level 1 discussion of cases of “birth asphyxia” thus making clinics after birth, who also qualified using these it difficult to objectively evaluate the cases. Staff criteria , were also included in the study, using data involved in the management of babies with birth obtained from the neonatal care unit using their asphyxia might have the tendency to be deliberately neonatal database, in cooperation with a senior pae- defensive and may avoid open disclosure of events. diatrician. A cross check between the neonatal and Therefore, a confidential enquiry process might obstetric database was performed to ensure all cases provide the best mechanism for disclosure in a non- were identified. Cases fulfilling the criteria of HIE accusatory atmosphere. The United Kingdom’s were identified, all these neonates were by definition Confidential Enquiry into Maternal and Child Health also neonatal near misses. The files of the identified (CEMACH) states that ‘‘the primary purpose of a cases were retrieved, and AdK reviewed the cases confidential enquiry is to review deaths and other for avoidable factors. Unfortunately in 49 cases 220 F, V & V INOBGyN Table 1.— Neonatal near miss markers. A. Respiratory failure/dysfunction: need for intubation and ventilation including nasal CPAP. B. Cardiac failure/dysfunction: need for adrenalin, other inotropic support or volume expansion. C. CNS failure/dysfunction: any convulsions or need for therapeutic anticonvulsants. D. Hypovolaemia: need for blood transfusion or volume expansion. E. Haematologic failure/dysfunction: need for phototherapy or exchange blood transfusion, need for neupogen to increase white cells. F. Endocrine failure/dysfunction: need to treat hypoglycaemia (additional glucose). G. Renal failure/dysfunction: haematuria and/or oliguria, anuria. H. Immunologic failure/dysfunction (congenital infection): CRP greater than or equal to 10 or a rising CRP. I. Musculo-skeletal morbidity: any fracture. j. GIT/Hepatic failure/dysfunction: jaundice, nil per os for more than 24 hours. (21.9%) cases, the file was not found. Avoidable The number of avoidable factors identified per case factors were classified into 3 groups: patient associ- file reviewed increased with the severity of the ated, administrative problems, and medical person- hypoxic event, mild asphyxia 0.74, neonatal near nel associated and the PPIP definitions for avoidable miss without HIE 0.85, HIE survivor 0.91, and still- factors were used (Pattinson 2003a; 2003b). birth or neonatal death 1.29 (Table 2). All cases were analysed by a single observer The avoidable factors of the whole study popula- (AdK), no patient identifiers were used in the analy- tion (all cases of birth asphyxia in all severities) were sis. The Chi Square test was used for categorical data analysed and the findings as shown in Figure 2. The and Students t test for continuous variables. Neonatal major avoidable factors were: refusal of medical near miss and stillbirth and neonatal death audit is treatment; inadequate facilities; no detection of or an established practice in the maternity unit. Permis- reaction to fetal distress; and incorrect management sion to perform these neonatal audits has been ob- of second stage of labour. Incorrect management of tained from the Ethics Committee of the Faculty of the second stage of labour included prolonged Health Sciences at the University of Pretoria. second stage without intervention and inappropriate use of vacuum or forceps. Other major avoidable Results factors included delay in seeking expert advice (in calling the doctor on call or referring to a next level In 2008 and 2009, 10117 babies were born at hospital), incorrect use or interpretation of the par- Kalafong Hospital. There were 224 babies with intra - togram, and lack of transport. In the HIE group partum related asphyxia (in all severities) identified alone, 50 avoidable factors were found. The avoid- (22.1/1000 births). Fourteen were intrapartum still- able factors associated with HIE cases alone (Fig. 3) births related to intrapartum asphyxia. The live were comparable with the whole group. The distri- born group consisted of 85 babies with mild as- bution of avoidable factors between patient related, phyxia, 125babies with severe asphyxia (12.4/1000 administrative problems, and medical personnel re- births) comprising 41 babies with asphyxia and a lated, was also similar. Again, the major avoidable neonatal near miss marker but no HIE, 84 neonates factor was incorrect management of second stage of with HIE (8.3/1000 births), of which 15 neonates labour, followed by denial of medical treatment, subsequently died. There were 29 perinatal deaths poor detection of or reaction to fetal distress. related to intrapartum asphyxia (2.8/1000 births) (Fig. 1, Table2). Discussion Another 20 stillbirths due to abruption placentae occurred in this time period but were excluded from A confidential enquiry into women delivering babies the evaluation. with “birth asphyxia” occurring at Kalafong Hospital The perinatal deaths tended to have a lower birth was performed on cases delivered in 2008 and 2009. weight than the other cases (Table 1). This group During this time period 210 neonates were born that also had more HIV infected mothers than the popu- were considered to have “birth asphyxia’; of these lation delivering at Kalafong which has a HIV infec- 125 were thought to have severe asphyxia, namely tion rate of 21.5%. The overall group of infected either requiring intubation for resuscitation, other as- babies had a higher HIV infection rate than the pop- sisted ventilation and/or HIE. Eighty-four cases had ulation delivering at Kalafong Hospital. HIE of which 15 subsequently died. There were No avoidable factors were found in 110 cases of more than five times the number neonates with HIE the 175 cases (63%) where the file was reviewed. cases than neonatal deaths due to intrapartum HyPOXIC ISCHEMIC ENCEPHALOPATHy AS A MARKER – DE KNIjFetAL. 221 Fig. 1.— Avoidable factors in women with neonates with “birth asphyxia” Table 2.— Characteristics of the neonates born with “birth asphyxia”. Mild Asphyxia Asphyxia + HIE but survived SB (n = 14) and Total Group (n = 85) NNM w/o HIE (n = 69) NND (n = 224) (n = 41) (n = 15) Mean birth weight(g) 3010 3019 3097 2846 3032 Mean maternal age 24 27 25 26 25 Attended ANC (%) 98.8 92.7 100 100 98.2 Twin pregnancy (%) 2.4 0 1.4 4.0 1.8 RPR pos (%) 1.2 2.4 1.4 6.1 2.7 HIV pos (%) 24.7 26.8 18.8 28.6 24.6 NVD (%) 45.9 46.3 58.0 53.1 48.7 Forceps/vacuum (%) 15.3 7.3 14.5 6.2 12.9 Caesarean-section (%) 38.8 46.3 27.5 34.7 37.1 Number of files reviewed 67 40 54 14 175 Number avoidable factors 50 34 49 18 151 (NND 9; SB 9) Number of avoidable factors per 0.74 0.85 0.93 1.29 0.86 reviewed case NNM – Neonatal near miss, HIE – Hypoxic ischemic encephalopathy, SB – Stillbirth, NND – Neonatal death, ANC – Antenatal care, RPR – Rapid Plasma Reagin for syphilis, NVD – normal vaginal delivery. asphyxia. This group of HIE cases makes a useful intrapartum hypoxia. The review of all these cases number to audit to identify failures within the health will identify problems with intrapartum care and by system. The avoidable factors of the HIE group were addressing the problems all women in labour should similar to the avoidable factors found in the whole benefit. group. HIE is an easily identifiable clinical condition The biggest limitation of this study was the case which is not readily confused with other conditions. notes that could not be retrieved (21.9% of cases). Thus an analysis of the case management of the However, the sample was large enough to be able to woman and the neonate that developed HIE can be identify the major management problems of women readily used to identify problems in the management in labour. The low number of avoidable factors of labour. Neonatal deaths and intrapartum stillbirths found in cases of birth asphyxia (37%) was unex- should continue to be reviewed, the additional HIE pected but in part may be due to the large number of cases will enable a more rapid assessment of prob- missing files. The avoidable factors were distributed lems with intrapartum management without incor- mainly in the neonatal near miss and stillbirth and porating cases where there was doubt about neonatal death groups, with the least being found in 222 F, V & V INOBGyN Fig. 2.— Avoidable factors in women with neonates with “birth asphyxia” Fig. 3.— Avoidable factors in women with neonates with HIE the mild birth asphyxia group. In other words the although it did not affect the final outcome”. The more severe the hypoxia the more often avoidable Scottish rate of intrapartum-related asphyxia meet- factors were identified. In a Scottish report on severe ing their case definition was 1.5/1000 births. Their intrapartum events (Kernaghan et al., 2005) similar case definition was essentially HIE, neonatal deaths figures were reported namely: “55% of cases were and intrapartum deaths due to intrapartum hypoxia. judged as ‘appropriate care, well managed’ and 5% Using the same definition the rate at Kalafong as ‘incidental sub-optimal care, lessons can be learnt Hospital was 9.7/1000 births. HyPOXIC ISCHEMIC ENCEPHALOPATHy AS A MARKER – DE KNIjFetAL. 223 This “birth asphyxia” group as a whole (24.6%) stage of labour without intervention, but also and the stillbirths and neonatal deaths due to inappropriate use of forceps or vacuum. Attempted intrapartum hypoxia (28.6%) in particular had a assisted delivery failed in a number of cases, after higher rate of HIV infection than the population de- which a caesarean section was performed. This sug- livering at Kalafong which had a HIV infection rate gests the selection of cases for assisted delivery was of 21.5%. Although not designed to assess the im- sub-optimal. Other problems in this group were pact of HIV infection on intrapartum outcomes, the delay in seeking expert advice (calling the doctor on finding is in keeping with and increased prevalence duty, referring to a next level of care), incorrect use of perinatal deaths due to intrapartum asphyxia de- and interpretation of the partogram, and delay in scribed in the same population (Pattinson et al., making the diagnosis of abnormalities in labour such 2010). as breech presentation. One of the goals of this study was to identify Inevitably recommendations advise a programme avoidable factors related to managing labour and of further training of medical personnel, (both mid- then to make recommendations so that these prob- wives and doctors) in the skills required to manage lems could be avoided in the future. labour. This must include training in the inter - Strikingly in the patient related group of avoidable pretation of cardiotocographs. Emphasis will need factors, missed opportunities and sub-standard care to be put on the second stage of labour, with training there were a large proportion of patients declining sessions in assisted deliveries using mannequins medical treatment: in the case notes this was (Draycott et al., 2006; 2008). Furthermore, the recorded as ‘uncooperative’. An epidural service is introduction of a checklist to promote decision not available in the labour ward at Kalafong Hospi- making in the labour ward while using the partogram tal. The high number of “uncooperative” women might be valuable. In general, organising more might be the result of patients not receiving adequate effective teaching and training occasions for the staff alternative pain relief, and sometimes become diffi- dealing with patients in labour and ensuring all are cult to manage. Introducing strict protocols for pain trained and involved in simulation training exercises relief in labour, and, ideally the option for an should decrease the amount of neonates suffering epidural anaesthesia, in combination with coun- from intrapartum asphyxia (Siassakos et al., 2009). selling at the antenatal clinic about what to expect in labour, might solve this problem. Conclusion In the administrative problems group, the prob- lems identified have been detected before, namely The avoidable factors described in a confidential inadequate transport (especially when pregnant enquiry concentrating on the labour management of women are referred between two different health women delivering neonates with all grades of “birth institutions), inadequate facilities (especially asphyxia” were similar to those found in women availability of adequate equipment for assisted delivering neonates with HIE. “Birth Asphyxia” is a deliveries), and insufficient staff (especially doc- poorly defined condition with many causes. HIE in tors). However, there was also a reasonable number neonates results from intrapartum hypoxia and is a of cases where there was no reason noted for the clearly defined condition. Thus analysing the intra- delay in treatment indicating poor record keeping. partum care of women who delivered neonates with An obstetric unit should be organised such that there HIE is useful to identify problems in the manage- is the ability to intervene as soon as the decision is ment of women in labour in general. By studying made to do so. Another remarkable finding was that these relatively few cases, problems identified in in all but one case, there was no note of active intra- intra partum care can be addressed leading to uterine resuscitation. Aside from left lateral tilt, there improved care of all women in labour. was no note of the use of tocolytica or amnio- infusion. All staff, also from referring centres, should Acknowledgements be made aware that introducing intra-uterine resuscitation could decrease the damage the delay in We would like to thank Professor Suzanne Delport for giving us access to the neonatal database and for getting definitive treatment might cause in the fetus confirming the diagnosis of hypoxic ischaemic encephalo - and mother. pathy in those babies affected. The majority of avoidable factors were medical personnel related, and not related to lack of facilities and transport as is often supposed. A significant References number of cases were found with inadequate Avenant T. 'Neonatal near miss : a measure of the quality of management of the second stage of labour. This obstetric care'. Best Pract Res Clin Obstet Gynaecol. 2009; inadequate management included prolonged second 23(3):369-74. 224 F, V & V INOBGyN Buchmann Ej, Pattinson RC, Nyathikazi N. Intrapartum-related Nelson KB. Is it HIE? And why that matters. 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