Saving Mothers and Babies: Maternal and perinatal mortality audits

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Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: An essential tool in the initial and ongoing training and teaching of any …

Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: An essential tool in the initial and ongoing training and teaching of any healthcare worker – Miriam Adhikari, South African Journal of Child Health, Primary Newborn Care was written specifically for nurses, midwives and doctors who provide primary care for newborn infants in level 1 clinics and hospitals. It covers: Mother and Baby Friendly Care describes gentler, kinder, evidence-based ways of caring for women during pregnancy, labour and delivery. It also presents improved methods of providing infant care with an emphasis on kangaroo mother care and exclusive breastfeeding. It covers: Saving Mothers and Babies was developed in response to the high maternal and perinatal mortality rates found in most developing countries. Learning material used in this book is based on the results of the annual confidential enquiries into maternal deaths and the Saving Mothers and Saving Babies reports published in South Africa. It addresses: the basic principles of mortality audit, maternal and perinatal mortality, managing mortality meetings, ways of reducing maternal and perinatal mortality rates, This book should be used together with the Perinatal Problem Identification Programme (PPIP).

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  • 1. 4 Maternal and perinatal mortality auditsBefore you begin this unit, please take the An audit is a careful assessment of a situation.corresponding test at the end of the book toassess your knowledge of the subject matter. Youshould redo the test after you’ve worked through 4-2 Why conduct an audit of health care?the unit, to evaluate what you have learned. With a health audit it is possible to identify Objectives problems and then make plans to find solutions. It is the best way to find out what is happening in a clinical service and why When you have completed this unit you problems are occurring. If you do not know should be able to: where the problems lie, it is very unlikely that • Understand the meaning of a mortality you will able to solve the problems. You may audit. not even know that there is a problem. With a • Arrange and manage a perinatal mortality clear idea of the type and extent of a problem, steps can be taken to prevent or correct the meeting. problem. • Write a perinatal mortality report. • Use the Perinatal Problem Identification Therefore, by auditing a health service one can get a clear idea of where problems lie. This Programme (PPIP). will usually point one in the direction where solutions can be found. However, an audit alone does not solve the problems. To do thisAUDIT requires effort and commitment. An audit is often the best method of identifying4-1 What is an audit? problems.An audit is a thorough assessment, countor evaluation of a situation. In an auditinformation is systematically collected and thenpresented in a manner that can be understood.
  • 2. 52 SAVING MOTHERS AND BABIES4-3 What is a mortality audit? 4-6 How is a mortality audit done?This is an audit of people who die. Death is 1. The necessary information (data) must bea very definite end point for an investigation collected.into health care. However if the number of 2. The information must be analysed.deaths can be reduced, the care of all mothers 3. The information must be discussed andand infants who survive will also improve. A conclusions drawn.mortality audit therefore benefits many living 4. Plans must be made to correct anypeople and reduces morbidity in the survivors. problems which may have been detected. 5. A summary or report must be written.A maternal mortality audit looks at thenumber and causes of maternal deaths. Onlywomen who die between conception and 6 4-7 What is a morbidity audit?weeks after delivery are included in a maternal Morbidity is all the problems and illnessesmortality audit. which are not severe enough to cause death.A perinatal mortality audit looks at stillbirths Morbidity is more common than mortality, butand early neonatal deaths. A stillbirth is an the causes usually are the same. If mortalityinfant born dead and weighing 500 g or more. can be reduced, morbidity will also be less.An early neonatal death is a death occurring in It is important not to forget morbidity. Oftenan infant during the first week of life. morbidity can also be assessed as part of a mortality audit. By decreasing the number of mothers and infants 4-8 What is a maternal care audit? dying, the care of all mothers and infants will be improved. This is an investigation to identify and solve problems which occur in providing care for pregnant women. A maternal care audit4-4 Where and when is a mortality audit of would include many aspects of maternal care,a health care service carried out? other than just deaths, such as the number of women who:Usually an assessment of a health care serviceis done within a carefully defined area over 1. Receive antenatal care.a particular period of time. It is best if a 2. Deliver by various methods.mortality audit is done in a whole health 3. Have problems during pregnancy, deliveryregion over a one year period. This would and the peuperium.include all the clinics and hospitals in that Once this information is collected andregion. However, an audit can be made of a analysed, answers can be found to problemssingle clinic or hospital or a single hospital with maternal care.together with the attached clinics. 4-9 What is a perinatal care audit?4-5 Who conducts a mortality audit? This is an audit of care given to the fetus andThe responsibility for conducting an audit lies newborn infant. Perinatal means before,with the authority responsible for providing during and after birth. A perinatal care auditthe service. However, everyone working in that would include many aspects of perinatal care,service should be interested and involved in such as the number of:finding out where problems lie and in helpingto find answers to those problems. 1. Infants born alive. 2. Males and females. 3. Infants in different birth weight categories. 4. Deaths and the causes of these deaths.
  • 3. MATERNAL AND PERINATAL MOR TALITY AUDITS 535. Avoidable factors which may be associated opportunity to acknowledge good care and with these deaths. management. Perinatal mortality meetings are essential in any perinatal service.Once this information is collected andanalysed, answers can be found to problemswith perinatal care. Regular perinatal mortality meetings are a very effective method of identifying and solving many4-10 Can maternal and perinatal mortality perinatal problems.audits be combined?Yes. Maternal and perinatal care audits are 4-12 Who should attend a perinataloften considered together as both reflect mortality meeting?the standard of perinatal care. In practice,maternal and perinatal audits are done in the If possible, all the staff, including doctors andform of perinatal mortality meetings. However nurses, who work in that service (hospitalperinatal mortality audits are mainly about or clinic or a group of hospitals and clinics).perinatal deaths as these are far more frequent Unfortunately, some staff on duty and most ofthan maternal deaths (about 25 perinatal to the staff off duty will not be able to attend. Theeach maternal death in South Africa). findings of the perinatal mortality meeting should be made known to all staff.PERINATAL MORTALITY ERINATAL 4-13 Who should arrange perinatalMEETINGS mortality meetings? As perinatal mortality meetings are an integral part of a clinical service, the person in charge4-11 What is a perinatal mortality meeting? of the service or facility is responsible for theThis is a meeting to discuss all the aspects of meetings. In practice, it is usually a seniorrecent stillbirths and neonatal deaths. It is a doctor who arranges the perinatal mortalitymeeting where the extent of the problem is meetings. This is commonly an obstetricianidentified, causes and avoidable factors are or obstetric medical officer. However, it islooked for and likely answers are hopefully important that a senior midwife and doctorfound. Studying deaths will give an idea of involved with care of mothers and their infantsthe major problems in the care of mothers are closely involved in arranging and managingand infants in the area. Regular meetings the meetings. In a large hospital both anprovide motivation for data collection and obstetrician and paediatrician, and sometimesare associated with a fall in mortality rates. A a midwife, should jointly be responsible.perinatal mortality meeting is one of the mosteffective methods of conducting a maternal 4-14 How is a perinatal mortality meetingand perinatal audit. arranged? All the staff should be informed about the Regular perinatal mortality meetings can reduce nature, importance and benefits of a perinatal both the maternal and perinatal mortality rates. mortality meeting. They should then be invited by the person arranging the meeting. The most suitable time and venue should beRegular mortality meetings are an excellent decided upon after discussion with as many ofmethod of improving the standard of perinatal the staff as possible. Usually a waiting room,care and are a very effective way of teaching lecture room or boardroom is most suitable.health care workers how to prevent maternal The most convenient time is often over lunchand perinatal deaths. They also provide an or in the late afternoon. Each service should
  • 4. 54 SAVING MOTHERS AND BABIESagree on a time and venue where most staff 4-18 How are the deaths discussed at acan attend. The venue must be booked. perinatal mortality meeting?Permission from the local health authorities 1. The primary cause of all perinatal deathsmay be needed. and final cause of early neonatal deaths should be identified.4-15 How often should perinatal mortality 2. Any avoidable factors, missedmeetings be held? opportunities or substandard care shouldIn big services with deaths every few days, be identified and discussed. Could theperinatal mortality meetings are best held death have been prevented?every week. In smaller hospitals and clinics 3. A management plan must be discussed andwith fewer deaths, meetings are usually held agreed upon which could prevent a similaronce a month. With weekly meetings, it is death in the future.easier for the staff to remember the details of All participants of the meeting should togetherthe patient’s problem and management. identify the problems and find the best answers.4-16 What information should be collected 4-19 Why are good patient notes important?for a perinatal mortality meeting? When assessing the causes and avoidableIn addition to discussing any perinatal deaths, factors in a perinatal death, it is essential thata perinatal mortality meeting is often used to detailed, accurate maternal and newbornreview the delivery data since the last meeting. notes are kept. It is always important to keepTherefore, usually two sets of information are good notes. The labour chart (partogram) anddiscussed. Firstly the minimal data set collected details of attempts to resuscitate the infantfrom the labour ward register (basic delivery are particularly important. Cardiotocogramsinformation) is presented and discussed, and (CTGs) must not be discarded or lost, as theysecondly any perinatal deaths are reviewed. are an essential part of the notes.The minimal data set usually presentedincludes: 4-20 In summary, what are the steps in managing a perinatal mortality meeting?1. Number of normal, assisted and caesarean deliveries. 1. A time and venue must be agreed upon2. Number of maternal deaths, if any. and the venue booked.3. Number of live born infants, stillbirths and 2. All relevant staff should be invited and early neonatal deaths. every effort made to ensure that they attend.4. The mortality rates. 3. A chairperson must be chosen to lead the NOTE Often the number of major complications meeting. during labour and delivery (abruptions, post 4. All the stillbirths and early neonatal deaths partum bleeds, eclampsia, etc) and reasons for (and maternal deaths if any) must be caesarean section (fetal distress, obstructed identified. labour, failed induction, etc) are also presented. 5. Someone must be responsible for preparing and presenting the cases.4-17 How should a perinatal death be 6. The clinical records of patients who havepresented? died must be found, read and summarised. 7. Summaries of the cases must be prepared1. The clinical record must be carefully for the meeting. They may be written or summarised. typed out with a copy handed to each2. The summary is presented at the meeting. participant or presented with an overhead3. Any points of uncertainly are clarified. projector.4. Each death is then discussed.
  • 5. MATERNAL AND PERINATAL MOR TALITY AUDITS 558. It is best to use a standard form to present ‘near miss’, as a lot can be learned from these the summary of each case. examples. A ‘near miss’ is a case where the9. The minimal data set is presented and patient was very ill and nearly died. It helps discussed. to discuss ‘near misses’ when there are only a10. The deaths are discussed after any errors in few deaths to discuss at a mortality meeting. the summary are corrected. Infants who have survived severe intrapartum11. A summary or record should be kept of the hypoxia (fetal distress) are particularly useful cases discussed and the conclusions agreed to discuss as ‘near misses’. upon.12. It is important to discuss the problem and 4-24 At which perinatal mortality meeting not the staff involved. should referred patients be discussed?Note that any maternal deaths are usually All patients who die at a hospital or clinic mustdiscussed at a perinatal mortality meeting be included. However, if a mother or child israther than holding separate meetings to referred from a clinic or hospital and dies atdiscuss only maternal deaths. another, that death should also be discussed at the clinic or hospital who referred the patient.4-21 What problems may occur with Often the cause and avoidable factors tookperinatal mortality meetings? place before referral.1. Some staff involved in particular cases Stillbirths are usually recorded at the hospital cannot attend. where they deliver but early neonatal deaths2. Individual staff may feel threatened if should be counted together with the deaths at problems of management are discussed. the clinic or hospital where the infant was born3. Problems of confidentiality may occur. rather than where it died. For example, if an4. It can become a witch hunt to find the staff infant is born at a clinic and then is referred who made a mistake. to a hospital where it dies, the death should be5. Patient notes cannot be found or are discussed both at the clinic and hospital but the incomplete. death should be listed with the clinic deaths.6. The cases and data are not prepared properly. 4-25 Should all perinatal deaths be7. Lessons learned are not used to improve discussed? care.8. A summary is not written. It is important that the number of deaths be presented and the causes and avoidable factors in all deaths agreed upon. However, if there are4-22 Is confidentiality important in a many deaths, there is often not enough time toperinatal morality meeting? discuss each in detail. Deaths with obviouslyThe content and discussion at the meeting avoidable factors must be discussed. Deathsshould be confidential. Usually the identity where important lessons can be learned mustof the patient is made known. However, the also be included.identity of the health care worker involvedshould be withheld at the meeting. Any 4-26 What is a ‘great save’?handouts used in the meeting are usuallydestroyed at the end of the meeting. This is when a good diagnosis was made and good care prevented a maternal or perinatal death. As perinatal mortality meetings can4-23 Should morbidity also be discussed at become very depressing, it is helpful to mentiona mortality meeting? a few ‘great saves’ as part of the meeting toIt is very useful to discuss a few seriously emphasise the good care that was given.ill patients who survived (morbidity), i.e. a
  • 6. 56 SAVING MOTHERS AND BABIES4-27 Is a perinatal mortality meeting a good report should be made available to all membersopportunity for teaching and learning? of the staff, especially the management.It is a wonderful opportunity and excellent Perinatal mortality meetings are only of limitedmethod of teaching and learning. When value if a report is not prepared, as action tothe cases are presented, the participants at improve specific aspects of care are usuallythe meeting should identify problems and based on the recommendation in the report.errors in the management. They should alsosuggest what should have been done to avoid Regular reports must be prepared, based on thethe problem or manage the problem better.Learning from ones’ mistakes is very effective. findings in the perinatal mortality meetings.Using case histories from previous perinatalmortality meetings are often used to teach 4-29 How is a perinatal mortality reportstudents in the classroom. prepared? A special form must be used to record the Attending perinatal mortality meetings is an main findings for each perinatal death excellent way of learning how best to care for discussed at a mortality meeting. This mothers and infants. information is then used to compile a summary of deaths. The form should detail: 1. The patient’s name together a summary of the relevant history, examination andPERINATAL MORTALITY investigations as well as the course of events.REPORTS 2. After discussion the primary cause of each perinatal death should be recorded (together with the PPIP code).4-28 What is a perinatal mortality report? 3. Again, after discussion the final cause of each early neonatal death should beA perinatal mortality report provides recorded (together with the PPIP code).a summary of all the deliveries and the 4. Any avoidable factors should be recordedcircumstances associated with each perinataldeath. The number of deaths, the frequency A very useful method of summarising all theof each cause of death, and the number of information collected from mortality meetingseach avoidable factor give an excellent idea is the Perinatal Problem Identificationof the problems in the service. This in turn Programme (PPIP). Whenever possible, theindicates where changes and improvements PPIP code should be added to the primary andare needed. Without this information it is final cause of death as well as any probably orvery difficult to improve the standard of care. possibly avoidable factor.The report must give clear indications of the The data collection sheet used at perinatalchanges that are needed. mortality meetings looks like the data entryA perinatal mortality meeting is the ideal screen of PPIP. This makes the transfer of datatime to record the most likely cause of each from the perinatal mortality data sheet to PPIPdeath and any avoidable factors which may a very simple task.have prevented the death. This very importantinformation must be recorded at eachmortality meeting and a summary writtenso that the mortality report can be prepared.Usually an annual report is written althoughreports may be needed more frequently. The
  • 7. MATERNAL AND PERINATAL MOR TALITY AUDITS 57PERINATAL PROBLEM similar to the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) used in the UnitedIDENTIFICATION Kingdom.PROGRAMME (PPIP) 4-31 How is the data entered onto the Perinatal Problem Identification4-30 What is the perinatal problem Programme?identification programme? The data is collected from the minimal data setThe Perinatal Problem Identification in labour ward and the data sheets completedProgramme (PPIP) is a simple, user-friendly at each perinatal mortality meeting. This datacomputer-based programme which presents a is then entered onto the data section of PPIP.summary of the problems related to maternal The space for each piece of data is clearlyand perinatal deaths. PPIP aims to reduce indicated by the headings. Once the data hasperinatal mortality. Once the basic perinatal been entered, PPIP automatically calculates alldata is entered, PIPP calculates and provides the results. If there are errors or missing data,the following: PPIP will indicate this to you. The results can be displayed as numbers on the screen, printed1. Perinatal care indices (e.g. stillbirth, early or presented as graphics. Entering data onto neonatal death and perinatal death rates). PPIP is quick and easy.2. Avoidable factors.3. Low birth weight rate. 4-32 What are the goals of the Perinatal4. Weight specific perinatal mortality rates. Problem Identification Programme?5. Perinatal care index.6. Stillbirth: early neonatal death rate. 1. To identify the perinatal mortality rates.7. Outcome by birth weight category. 2. To determine the causes of perinatal deaths in order to establish the pattern of disease.Once the information, which has been 3. To look for avoidable factors by examiningdiscussed at the perinatal mortality meetings, each death.has been entered, PPIP produces a summary 4. To seek solutions.which reports what has happened over aperiod of time. However, PPIP is only adiagnostic tool which identifies the number 4-33 Why is it important to establish theof perinatal, neonatal and maternal deaths, pattern of disease?classifies the causes of death and analyses The pattern of disease will indicate whatavoidable factors. It helps to point the way the major causes of death are. Similarly it isto finding solutions to clinical problems but, important to establish the pattern of avoidableby itself, it cannot improve the standard of factors. This information should be used to:patient care. This has to be done by the healthworkers themselves. 1. Plan what management is needed most urgently.Note that maternal deaths can also be entered 2. Decide on the best allocation of fundingas PPIP data. Then they can be analysed in the and resources.same way as perinatal deaths. 3. Direct research to answer the most NOTE PPIP was developed in the 1990s in important problems. South Africa by the Medical Research Council Therefore, once the pattern of disease and (MRC) Unit for Maternal and Infant Health Care avoidable factors are known, the most effective Strategies and has been extensively tested since 1996. It is based on the ICA Solution audit system way to reduce mortality can be sought. (Identification of all deliveries and deaths/ Cause of deaths/ Avoidable factors/ Solution). It is
  • 8. 58 SAVING MOTHERS AND BABIES4-34 What is a feed back meeting? In only a few areas, such as the metropolitan area of Cape Town, are all deliveries in theKnowing the cause of death and identifying public sector included (i.e. population basedprobable avoidable factors does not, by itself, data).prevent a similar death occurring in future. Itdoes, however, help to plan ways to improvematernal and perinatal care. The information 4-36 What problems remain with the useprovided by mortality meetings and PPIP of the perinatal problem identificationmust now be given to the staff and community programme in South Africa?by way of feedback meetings. These meetings 1. Data are still incomplete and inaccurateare an essential part of the programme to from some provinces.improve care through learning how to better 2. Most of the information is being collectedmanage mothers and infants. in cities and towns with few reports fromFeedback meetings make a difference because rural areas.they empower health workers to review their 3. No information is available from the largemanagement of patients and to re-evaluate numbers of poor mothers who delivertheir management protocols. Simply knowing without skilled assistance at home.that your care is being monitored and 4. Only limited data are available fromreviewed and that you are accountable to your private hospitals.patients will improve care. 5. Most of the information is not population based, i.e. it does not include all the deliveries in the area. Feedback to health workers is an essential part of 6. Data is collected from the site of delivery improving service. only and not the place of residence. As a result, it is not known how many infants4-35 How are the data gathering sites are delivered annually in South Africa. Theregrouped? are probably a million births. As the number of sites providing perinatal data increases,If all the data from one or more perinatal a more accurate estimate of both maternalservices are entered, PPIP can separate the and perinatal deaths will be made. Thisresults into individual sites (e.g. clinics or information is vital for rational planning.hospital) or pool the data into services,districts, towns, rural areas or even provinces 4-37 How do results compare betweenor nationally. different areas?The perinatal data is divided into the following The perinatal mortality results vary widelysites: between sites indicating that socioeconomic1. Metropolitan (new mega-cities) with conditions and the standard of health care are access to tertiary care (intensive care). very different.2. Cities and towns with access to secondary 1. In rural sites intrapartum hypoxia is a (level 2) care. common primary cause of perinatal death3. Rural areas where mainly primary (level 1) indicating poor labour management and care is available. probably inadequate facilities for caesareanPerinatal information is grouped into section and infant resuscitation.provinces. Once information has been 2. In towns and cities spontaneous pretermcollected for a few years, changes over time delivery is a common identifiable primarycan be investigated to show improving or cause of perinatal death suggesting thatdeteriorating care. facilities for neonatal care are inadequate. Many of these mothers may have been
  • 9. MATERNAL AND PERINATAL MOR TALITY AUDITS 59 referred from rural areas because of CASE STUDY 1 preterm labour. There were also many infants where the cause of death was The first perinatal mortality meeting is unknown suggesting that the infants and arranged in a new hospital in order to audit their placentas were not carefully examined the service. Only the doctors working in the for signs of syphilis and poor fetal growth. labour ward are invited and it is decided to3. In metropolitan areas antepartum discuss stillbirths but not neonatal deaths. haemorrhage and hypertensive disorders Soon after the meeting starts, an argument were important, suggesting that these breaks out over the management of a patient. mothers had been referred from rural As the patient’s record is not available at the areas and towns and cities. Deaths due to meeting, no one is certain what treatment was intrapartum hypoxia were much lower in given. The meeting ends early as most of the metropolitan areas than towns and cities doctors feel that it is a waste of their time. and rural areas suggesting better labour and neonatal care. 1. What is an audit?As would be expected, a common final causeof neonatal death in rural areas is perinatal This is a careful review, evaluation orhypoxia while that in cities, towns and assessment of the perinatal service at themetropolitan areas is prematurity related. hospital. What patients have been delivered, how were they delivered, what deaths NOTE Because perinatal information is collected occurred, why did the patients die and could at the place of delivery rather than the home these deaths be avoided? address, referral patterns can bias the results. 2. Who should be invited to a perinatal4-38 What is the Saving Babies report? mortality meeting?The Saving Babies report presents the results All the staff (nurses and doctors) who workof annual meetings which were started in in that service. In a hospital the nurses and2000 to collate PIPP data and identify major doctors working in labour ward, antenatalareas of concern from sites all over South and postnatal wards and the newborn nurseryAfrica. The findings and possible solutions should be invited.offered are presented in Saving Babies reports.The latest report covers the period 2003 to2006. The information on causes of death 3. Should only stillbirths be discussed?and avoidable factors are divided into results No. It is important that both stillbirths andfor large metropolitan areas (where tertiary neonatal deaths are discussed.care is available), cities and towns (wheresecondary care is available) and rural areas 3. How can you prevent one staff member(where only primary care is available). In time accusing another of poor care?it is hoped to obtain complete data from allregions and provinces. It is important that the discussion should be about the care of the patient and not who wasThe findings of the Saving Babies reports stress responsible for any incorrect care. Discipliningthe high perinatal mortality rates and high of staff, if it becomes necessary, must be donerates of low birth weight infants in many areas. privately and never at a perinatal mortality NOTE The latest Saving Babies report can be meeting. accessed at www.ppip.co.za
  • 10. 60 SAVING MOTHERS AND BABIES4. What is the aim of a perinatal mortality hospitals hold monthly meetings. If themeeting? meetings are held less frequently, the staff often cannot remember the cases. In largerIt is a meeting where management problems hospitals it is best to have a mortality meetingare identified and avoidable factors looked every week.for. The aim is to prevent similar problemsin other patients and, thereby, improve thestandard of care. 2. Why is it important to look for avoidable factors?5. Should maternal deaths also be Because this is the best way of preventingdiscussed at a perinatal mortality meeting? similar deaths in future. Avoidable factors, missed opportunities and substandard careYes. All maternal deaths and perinatal deaths must be identified whenever possible. This the(stillbirths and early neonatal deaths) should best way of learning how not to make mistakes.be discussed. Although the meetings arecommonly called perinatal mortality meetings,they are in fact combined maternal and 3. Should the name of the staff memberperinatal mortality meetings. Fortunately, who cared for a patient be made known?maternal deaths are far less common than It is best not to mention the names of the staffperinatal deaths, therefore perinatal meetings involved. The aim is to find the cause of deathare mostly about perinatal deaths. and any avoidable factors and not to hold a ‘witch hunt’. Otherwise the staff will not attend6. Why should the patient’s notes be taken the meeting or co-operate. Disciplining of staffto the meeting? must never be done in front of their colleagues, especially not at a mortality meeting.It is important to have a record of managementto avoid any uncertainty. A brief summary ofthe patient record should be made before the 4. Should an infant who is born at a clinic,meeting and made available to all who attend. but dies after transfer to hospital, beIn this way, the management given is clear to discussed?all the participants. All infants who are born at a clinic or hospital but die after referral must be discussed at the clinic perinatal mortality meeting as the causeCASE STUDY 2 of the death and avoidable factors can often be found in the management before transfer.A monthly perinatal mortality meeting is These infants are counted with the clinicarranged at a busy urban clinic. At the meeting deaths. Usually they are also discussed at thethe cause of each death was looked for. hospital perinatal mortality meeting but theirHowever, avoidable factors were not discussed deaths are not counted with the hospital deaths.as some of the nurses felt threatened. It wasdecided that infants who were referred to 5. Should the meeting be cancelled if nohospital and died there need not be discussed. deaths have occurred?If there were no deaths during the month, the It is important to hold regular meetings evenmeeting was usually cancelled. if there are no deaths to discuss. Interesting problems, sick patients who survived1. How often should a perinatal meeting be (morbidity) or ‘great saves’ can also beheld? discussed. Anyway, it is important to review allIt depends on the number and frequency of the referred infants and the delivery data sinceperinatal deaths. Most clinics and smaller the last meeting.
  • 11. MATERNAL AND PERINATAL MOR TALITY AUDITS 616. Is there time to teach at a perinatal or more frequently, a special feedback meetingmortality meeting? should be arranged to review the service.Just attending the meeting should be a learningexperience, especially if the participantscan jointly spot the clinical problems and CASE STUDY 4management errors. All the staff can learnfrom the discussion. The meeting can be an At a monthly mortality meeting the numberopportunity for teaching, especially if there are of vaginal, assisted and caesarean deliveries istopics which staff want to learn about. reported. In addition the indications for the caesarean sections are given together with the number of serious complications suchCASE STUDY 3 as placental abruptions. One maternal death due to eclampsia, 6 stillbirths and 2 early neonatal deaths are presented. One stillbirthDuring a perinatal mortality meeting the causes was due to untreated syphilis, 2 due to fetalof death and avoidable factors are carefully hypoxia during labour and the remaining 3recorded and entered onto the PPIP data sheets. were macerated with no obvious cause. The 2The staff are told they will receive a summary of neonatal deaths were very immature infantsthe PPIP data at a feedback meeting. weighing less than 1000 g.1. What does ‘PPIP’ stand for? 1. Why is it important to present thePPIP stands for the Perinatal Problem number of deliveries at a perinatalIdentification Programme. This is a simple, mortality meeting?user-friendly computer-based system where Because it is important to review the workloadthe important maternal and perinatal data are and the method of deliveries. Too many or tooentered and calculations, such as the perinatal few caesarean sections may indicate that themortality rate, avoidable factors and low incorrect method of delivery is being offeredbirth weight rate are given. PPIP identifies to many mothers. This may be a cause ofthe number of perinatal deaths, classifies the mortality or morbidity.causes and analyses avoidable factors. 2. Should the indications for caesarean2. What is the aim of PPIP? sections and major labour complicationsTo lower the perinatal mortality rate. PIPP be discussed?helps nurses and doctors find solutions to In a busy hospital it is important to be sureperinatal problems. that the correct indications for caesarean and assisted deliveries are being used. The3. Can any clinic or hospital use PPIP? incorrect method of delivery may be a causeYes. Any clinic or hospital that delivers mothers of perinatal death. Recurring pregnancy orand cares for their infants should use PPIP. It is labour complications, such as eclampsia, mayeasy to learn how to enter data with PPIP. indicate incorrect care.4. What is a feedback meeting? 3. Why is it important to identify the probable cause of stillbirth?The findings of the perinatal mortality meetingsand the analyses made by PPIP must be made Because complications such as congenitalavailable to all the staff at a feedback meeting. syphilis are preventable. It is important to findRegular feedback to the staff should form part out why this mother with syphilis was notof the perinatal mortality meetings. Annually, correctly treated and what were the avoidable
  • 12. 62 SAVING MOTHERS AND BABIESfactors. In this way other deaths due to syphilis 1. Spontaneous preterm labour (labourmay be prevented. before 37 weeks gestation) • Idiopathic (no obvious cause found).4. What can be learned from a stillbirth due • Preterm labour with chorioamnionitis)to fetal hypoxia in labour? • Preterm prelabour rupture of theThe details of the case should be described so membranes (with no obviousthat the participants at the mortality meeting chorioamnionitis).can decide whether the fetal condition was • Preterm prelabour rupture ofcorrectly monitored and whether the death the membranes (with obviouscould have been avoided. For example, fetal chorioamnionitis)heart rate deceleration may have been missed • Cervical incompetence.or meconium stained liquor ignored. 2. Infections • Syphilis.5. Can macerated stillbirth be prevented? • Amniotic fluid infection (severeIf all the information is available, avoidable chorioamnionitis).factors such as no serology screening for • Malaria.syphilis, poor fetal movements for the past 3. Antepartum haemorrhageweek or poor symphysis-fundal growth maybe identified as avoidable factors. These are • Abruptio placenta (without hypertension).examples of how regular mortality meetings • Abruptio placenta (with hypertension).can improve patient care and also provide a • Placenta praevia.very valuable learning opportunity for the staff. 4. Intrauterine growth restriction (infant underweight for gestational age, usually with6. Why is it important to discuss the early wasting and fetal hypoxia)neonatal deaths of very small infants? • ‘Idiopathic’ (maternal underweight,Because there may have been avoidable smoking, alcohol, or cause unknown butfactors which resulted in preterm delivery. excluding hypertension).Complications of pregnancy such as diabetes • Post term ( gestation beyond 42 weeks).or hypertension may have been responsible.If they were correctly managed, it may have 5. Hypertensionbeen possible to continue the pregnancy until • Proteinuric hypertension (pre-eclampsia).the infant was viable. It is only by discussing • Chronic hypertension.each perinatal death that complications of • Eclampsia.pregnancy and labour can be better diagnosedand managed in future. 6. Fetal abnormality • Subdivided into organ systems (e.g. central nervous system).PPIP CLASSIFICATIONS OF • Multiple abnormalities (may bePERINATAL DEATHS recognisable syndromes) • Chromosomal abnormality (e.g. Down syndrome).These are included as a reference only. • Non-immune hydrops.The primary causes of stillbirth and early 7. Traumaneonatal death • Stuck breech (dies of hypoxia).The most important subdivisions are: • Trauma due to assisted delivery (forceps or vacuum).
  • 13. MATERNAL AND PERINATAL MOR TALITY AUDITS 63• Ruptured uterus. • Hypoxic ischaemic encephalopathy.• Motor vehicle accident or personal assault. • Meconium aspiration (resulting from fetal hypoxia).8. Intrapartum hypoxia • Persistent fetal circulation (persistent• Labour related (prolonged labour, pulmonary hypertension). cephalopelvic disproportion, hypertonic 3. Infection (acquired before, during or after uterus). delivery)• Meconium aspiration.• Cord prolapse. • Septicaemia.• Cord around the neck (3 or more times). • Pneumonia. • Congenital syphilis.9. Maternal disease • HIV infection/AIDS.• Diabetes mellitus. 4. Congenital abnormalities• Cardiovascular. • Subdivisions into organ systems, e.g.10. Unexplained intra-uterine death central nervous system.• Macerated. • Chromosomal abnormalities, e.g. Down• Fresh. syndrome. • Biochemical abnormalities, e.g. severeThe final causes of neonatal death hypoglycaemia.The most common subdivisions are: 5. Trauma (during delivery)1. Prematurity related (born too soon) • Sites such as subaponeurotic haemorrhage.• Extreme immaturity (less than 28 weeks or 6. Other 1000 g and usually die of repeated apnoea). 7. Unknown• Hyaline membrane disease (died of respiratory distress). A more detailed classification of primary• Necrotising enterocolitis (usually seen in causes of perinatal death is given in the preterm infants). Perinatal Problem Identification Programme• Intraventricular haemorrhage. (www.ppip.co.za). Each subdivision is given a specific code. Maternal mortality data can also2. Birth asphyxia (most have fetal hypoxia) be entered in a similar fashion.• Asphyxia (fail to breathe adequately after delivery).