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Severe morbidity and death because of Rh disease have only been reduced by approximately 50% globally during the last 50 years, despite the advent of anti-Rh(D) immunoglobin prophylaxis, which has resulted in >160,000 perinatal deaths and 100,000 disabilities annually. This apparent failure to take appropriate preventive measures is of great concern. Thus, there is a great need to do much better. We wish to draw attention to the unnecessary continuing burden of Rh disease, to discuss some of the reasons for this failure, and to provide suggestions for a better way forward.

Objective The purpose of this study was to identify factors that contributed to severe maternal morbidity, defined by admission of pregnant women and women in the postpartum period to the intensive care unit (ICU) from 2010-2011 at Auckland City Hospital (ACH), a tertiary hospital that delivers 7500 women/year, and to determine potentially avoidable morbidity with the use of local multidisciplinary review. Study Design All admissions of pregnant women and women in the postpartum period (to 6 weeks) to the ICU at ACH from 2010-2011 were identified from hospital databases. Case notes were summarized and discussed by a multidisciplinary team. The presence of contributory factors and potentially avoidable morbidity were determined by consensus with a tool that was developed by the New Zealand Perinatal and Maternal Mortality Review Committee for the review of maternal and perinatal deaths. Specific recommendations for clinical management were identified by the multidisciplinary group. Results Nine pregnant women and 33 women in the postpartum period were admitted to the ICU from 2010-2011. Contributory factors were identified in 30 cases (71%); 20 cases (48%) were considered to be potentially avoidable; personnel factors were the most commonly identified avoidable causes. Specific recommendations that resulted from the study included the need for the development of guidelines for puerperal sepsis, improved planning for women at known risk of postpartum hemorrhage, enhanced supervision of junior staff, and enhanced communication through multidisciplinary meetings. Conclusion Forty-eight percent of severe maternal morbidity, which was defined as admission to the ICU at ACH from 2010-2011, was considered to be potentially avoidable by a local multidisciplinary review team; priorities were identified for improvement of local maternity services.

STUDY DESIGN: Linked birth and infant death data for the US from the National Center for Health Statistics analyzed nonanomalous singleton pregnancies between 2003 and 2005. Pregnancies were classified as high risk or low risk based on preexisting maternal complications. Outcomes of 8,785,132 live births and 12,777 FDs between 34 and 42 completed weeks’ gestation were examined. The risk of FD was determined using the following equation: # FD that occurred at a given GA all FD that occurred after that GA Total deliveries at a given GA all remaining undelivered pregnancies The FD risk of those remaining undelivered was compared with the neonatal death rate for each week of gestation. RESULTS: Between 34 and 40 weeks’ gestation, the FD risk of those remaining undelivered for all pregnancies declined and then increased at term. For high risk pregnancies, the FD risk of those remaining undelivered is substantially higher than for low risk pregnancies. The number of FDs that can be avoided by delivery exceeds the neonatal death rate between 37 and 38 weeks’ gestation in low risk pregnancies and at 36 weeks’ gestation in high risk pregnancies. CONCLUSION: These findings suggest that delivery at 39 weeks’ gestation in both high and low risk pregnancies would result in an increased number of perinatal deaths. Decisions regarding the “optimal time for delivery” should include the risk of remaining undelivered.

Sixteen cases of SHR are analyzed with respect to perinatal outcome, fetal scalp and umbilical arterial pH, and characteristics of the FHR pattern. There were no perinatal deaths in this series. The SHR is defined and a plan for management of the patient with SHR is proposed. A theoretical explanation of the pathophysiology of SHR is presented in terms of a fetal compensatory mechanism for hypoxia, based on these observations as well as a review of the literature. Biochemical data may provide valuable information permitting optimal management of patients with SHR patterns.

The value of prepartum fetal movement patterns as a sign of fetal health was compared with intrapartum fetal heart rate patterns. Prepartum rather than intrapartum surveillance appeared to be the most effective technique to avoid perinatal deaths. Furthermore, it is argued that, except for true birth trauma, the occurrence of cerebral palsy is seldom related to intrapartum factors.

A direct comparison between Parkland Memorial Hospital in Dallas, Texas, and the National Maternity Hospital in Dublin, Ireland, on the basis of limited numbers taken from one year only (1983) led to the conclusion that the liberal use of cesarean section in Dallas was associated with a sevenfold decrease in intrapartum fetal deaths and a twofold decrease in neonatal seizures. However, when the scope of the survey is extended to include the year before (1982) and the year after (1984), a different picture emerges. During this extended period there were almost four times as many cesarean sections performed in Dallas with no significant difference in overall perinatal mortality, while for two of three years the incidence of neonatal seizures was twice as high in Dallas when compared with Dublin. The fact that high cesarean rates continue to rely on evidence of such a tenuous nature must remain a matter of concern.

In 1976, the Department of Obstetrics and Gynecology at the Prentice Women's Hospital was invited to provide obstetric services to patients of the Drug Dependence Program administered by the Department of Psychiatry at Northwestern University Medical School. Patients were referred in the early stages of pregnancy if they agreed to participate in the Drug Dependence Program at the same time. Between April, 1976, and October, 1980, 58 women received prenatal, intrapartum and postpartum care. Forty-two of these patients had been abusers of opiates; 16 were polydrug abusers. The obstetric performance of these women was characterized by an absence of major problems. The mean weight of all infants delivered was 2,935 gm. There were no perinatal deaths. The individual weights, lengths, and head circumferences of the newborn infants were distributed in a relatively normal manner. Ninety percent of the infants were delivered at 37 weeks or more of gestation.

The statistical study of a large number of eclamptic patients (n = 704), divided into five successive 3-year periods, was undertaken at the Hospital de Gineco-Obstetricia No. 2 del Centro Medico Nacional in Mexico City in order to detect significant changes in the therapeutic results and/or in the basic character of the disease, as it occurs in a large referral medical complex. The following variables were studied: maternal and perinatal deaths, obstetric profile, main clinical data of the eclamptic episode, frequency of cesarean operation, timing of delivery after admission, main therapeutic changes, frequency of complications in survivors of ante- and intrapartum eclampsia, and cause of death with associated complications. The study showed (1) a continuous increment in the number of cases from the first to the last period, (2) averages for maternal age (24.9 ± 0.45 years) and for previous parity (1.7 ± 0.19) unlike those commonly accepted, (3) a significant progression in the severity of the disease in recent years, (4) a frequency of 22.9% of important complications in survivors of ante- and intrapartum eclampsia, (5) a very limited overall influence of some therapeutic changes on the final outcome of complicated eclampsia, and (6) the impossibility of improving morbidity figures significantly during the 15 years of the study. It was concluded that prevention, early diagnosis, and timely simple medical care offer the only perspective for true medical progress in this particular problem.

In a referral perinatal center a detailed study was made of all the perinatal deaths that occurred during 1 year; they were analyzed according to primary diagnoses on the basis of a classification by R. L. Naeye which included the placenta. This method points to the areas in which special efforts at prevention should be made, and it should become a reliable basis for comparison.

The intrapartum fetal heart rate changes, type of labor, mode of delivery, and neonatal outcome were evaluated in 379 consecutive continuously monitored prolonged pregnancies (greater than 42 weeks by history and early examination). These represent only a fraction of the total prolonged gestation population. There were 56% multiparous women, 33% less than 20 years of age, and 95% with cephalic presentation. Oxytocin was given to 76% (48% induced, 28% enhanced). Delivery was by cesarean section in 13% of patients (9% of induced cases), and 15% had forceps deliveries. Fetal heart rate alterations were observed in high proportion. Cesarean section for cephalopelvic disproportion was indicated in 60% of operations, and 13% of the fetuses weighed greater than 4000 gm. Depression occurred in 15% of infants at 1 minute and in 4% at 5 minutes. Prolonged hospital stay was seen in 9%, and postmaturity syndrome in 19%. There were four perinatal deaths (two corrected). Active induction does not appear to increase the cesarean section rate. The durations of predelivery observation may be longer because the cervices are frequently unripe. There is a high incidence of fetal heart rate alterations. Induction appears justified as an active intervention to prevent some sudden unexplained deaths.

On May 1, 1975, at Women's Hospital, Los Angeles County--University of Southern California Medical Center, a new antepartum fetal heart rate (AFHRT) protocol was put into clinical use. This included the widely used contraction stress test (CST) and a new concept of nonstress testing (NST). The NST was based on FHR response associated with fetal movements and was categorized as reactive (normal) or nonreactive (abnormal). The nonreactive fetus was then evaluated with a CST if not contraindicated. During the 24 months, May 1, 1975 to April 30, 1977, a total of 2,422 NST's were done in 1,169 patients with 1,547 (64 per cent) reactive and 829 (35 per cent) nonreactive. CST was done 939 times, with 851 (90.6 per cent) negative, 29 (3 per cent) positive, 13 (1.4 per cent) equivocal, and 46 (5.0 per cent) unsatisfactory. There were ten (3.3 per cent) perinatal deaths within one week of a negative CST, five (1.0 per cent) within one week of a reactive NST, and two (8.7 per cent) with a positive CST. A reactive NST was as predictive of good outcome as was a negative CST. Analysis of the nonreactive NST showed that two or more accelerations were not associated with abnormal CST's. Also, some nonreactive fetuses became reactive with oxytocin and had good outcome. These observations were utilized in the development of a newer, shorter NST which allows for fetal stimulation in an attempt to further define fetal well-being.

To assess postdate fetal risk, pregnancies in which menstrual history was confirmed by early ultrasound examination were reviewed; 5915 pregnancies within 1 week of term, 1408 1 to 2 weeks postdate, and 340 at least 2 weeks postdate. Fetal distress and meconium release were twice as frequent and meconium aspiration eight times as frequent postterm. Birth asphyxia was unrelated to gestational age. Fractures and palsies were more frequent because of primiparity and macrosomia. Only one antepartum fetal death occurred in 1748 postdate pregnancies. Review of 674 perinatal deaths at 37 plus weeks in Quebec showed no increase in deaths postterm. The increase in fetal distress and meconium aspiration postterm without an increase in birth asphyxia or fetal death may reflect greater responsiveness of the more mature fetus to mild asphyxic insults. Findings of this study could not justify increased fetal monitoring in postdate pregnancies.

The results of a prospective clinical management based on a fetal biophysical profile scoring method were evaluated in 1,184 referred high-risk patients. Six perinatal deaths occurred in the study group (perinatal mortality of 5.06 per 1,000); only one fetus suffered unpredictable and unpreventable death (true false negative rate 0.8 per 1,000). In addition, 13 fetuses with major congenital anomalies were detected as a result of ultrasound scanning for fetal biophysical activities. These data suggest that this method can be used effectively to screen and manage a high-risk population.

Fetal assessment and subsequent management of 137 patients with meconium or fetal heart rate abnormalities in the first stage of labor was determined by the fetal blood pH. In the majority of patients the fetal blood pH was 7.25 or more, and the fetus was considered to be adequately oxygenated. Twenty-three per cent of the fetuses were initially observed to have a pH of less than 7.25. Repeat pH estimations, both when the pH was between 7.15 and 7.25 and toward the end of labor, improved the diagnosis of intrauterine asphyxia. Fetal heart rate abnormalities as detected by auscultation were not commonly present in those patients with meconium in whom the fetal pH was less than 7.15. Seven cesarean sections were performed for fetal acidosis. There were 4 perinatal deaths, one of which was due to intrapartum anoxia. A significantly increased incidence of infants with low Apgar scores occurred among patients with a predelivery fetal blood pH of less than 7.25. The results suggest that a progressive deterioration of pH below 7.25 is an indication for intervention in labor and delivery of the fetus.

The results of 24 hour urinary estriol determinations in 47 prolonged gestations, 25 pre-eclamptic or chronically hypertensive gravidas, and 9 diabetic pregnancies are presented. The use of urinary estriol levels in determining the method and timing of delivery in these 81 complicated pregnancies is discussed. The fetal outcome, including case reports of 4 perinatal deaths, is provided. A brief critical evaluation of the usefulness of urinary estriols is included. "Serial urinary estriol determinations … offer promise of a useful laboratory aid and the only objective method thus far available to supplement clinical judgment." 1

Urinary estriol levels were obtained from 31 normal pregnant women and from 186 women attending the prenatal/diabetic clinic. The latter included 137 Class A (studied in three groups according to the degree of carbohydrate intolerance present), 32 Class B, 7 Class C, and 10 Class D patients. The results were not used to influence the clinical management. Mean values for the entire abnormal group were calculated weekly from 28 weeks until term. These values were used as the basis for comparison of the different classes studied. Only Classes C and D demonstrated depressed levels of excretion. Sixteen perinatal deaths occurred and 9 were considered avoidable had the estriol results been taken into consideration. The “estriol-preventable deaths” are described in detail. It is concluded that the assay presents a potentially valuable adjunct to the clinical management of the pregnant patient with disordered carbohydrate metabolism.

Among 16,046 births in Saginaw hospitals from July 1, 1956, to July 1, 1959, there occurred 520 perinatal deaths. The mortality rate for A.M.A. perinatal period II averaged 32.4 per 1,000 births. Prematurity was a factor in 69 per cent of perinatal deaths. The premature salvage of liveborn infants weighing 1,000 grams or over was 90.7 per cent. One hundred forty-six cases of perinatal death (28.1 per cent) were judged to have been preventable. Although it is probable that not all of these babies could have been salvaged, it was felt that in none of these cases was an optimum level of physician and hospital care or of patient cooperation achieved. In addition to the collection of statistical information, this study has focused the attention of physicians in Saginaw County on the perinatal problem. Each of the Saginaw hospitals has established regular Perinatal Mortality Conferences in its teaching program. Marked improvements have appeared in the recording of data on obstetrical and newborn charts. Growing interest in the causes of perinatal deaths is reflected in the increasing number of autopsies and placental examinations.

A survey of 8½ years of perinatal mortality records from the Methodist Hospital of Dallas is presented. The presentation is motivated by the slow decline of perinatal mortality in the United States since 1950 and the lag of this decline behind that of western Europe. The survey encompasses 28,313 births and 689 perinatal deaths. Immaturity is found to be the largest single category and also to be associated with all other categories in 66 per cent of the deaths. The question is raised of a relationship between the increasing number of deaths from respiratory distress in the immature neonate and the amount of sedation and type of anesthesia used during premature labor and delivery.

1. 1. A review of 6,860 cases of electively induced labors has been presented. 2. 2. The most effective method of inducing labor is simple amniotomy. 3. 3. Eighty-two and three-tenths per cent of the patients were in labor within 4 hours, and only 2.3 per cent had a latent period of over 24 hours. 4. 4. Pitocin stimulation was used in patients with prolonged latent periods or desultory labors with intrapartum fever. 5. 5. Serious though must be given to performance of cesarean section when the latent period is prolonged and infection is present, if labor cannot be stimulated within 24 to 36 hours. 6. 6. There was one maternal death related to induction. 7. 7. The principal fetal hazards were (a) prematurity, 3.1 per cent; (b) prolonged latent period, 5.0 per cent; (c) malpresentation, 0.9 per cent; (d) prolapsed cord, 0.3 per cent. 8. 8. There were 6,889 babies born. Of these, 37, or 0.6 per cent, were 9. stillborn, and 55, or 0.8 per cent, died neonatally. The perinatal mortality was 1.4 per cent. 10. 9. Thirty-nine of the perinatal deaths (0.6 per cent of the babies delivered) were directly related to the elective induction. 11. 10. A conservative attitude should be maintained by the specialist toward the elective induction of labor. The average general physician should allow labor to start spontaneously.

A 10 year analysis of 450 consecutive perinatal deaths in Perinatal Period I among 24,097 births at The Jewish Hospital of St. Louis (1958 to 1968) revealed an over-all perinatal mortality rate of 18.8 per 1,000 live births. This analysis confirmed the national observation of increased perinatal mortality in Negro births with a Negro perinatal mortality rate of 28.6 per 1,000 live births in contrast to a white perinatal mortality rate of 16.9 per 1,000 live births. The difference in perinatal mortality rates could not be related entirely to differences in prenatal care, incidence of prematurity, specific causes of death, or preventable factors. It is suggested that other determinants, perhaps nonmedical, are yet to be identified. Highest research priority should be given to the three major groups which comprised 51 per cent of all perinatal deaths in the study: abnormal pulmonary function, congenital malformations, and “no demonstrable cause.” Present achievement falls short of what can be accomplished, as evidenced by an 11.3 per cent incidence of preventable perinatal deaths.

The bactericidal properties of amniotic fluid normally protect fetuses from late gestational infections by bacteria. Recently, such infections were found responsible for nearly a third of the perinatal deaths in Addis Ababa, Ethiopia. This prompted an analysis of the antimicrobial activity of amniotic fluid in patients in that city. The antimicrobial activity of fluid from 53 women, collected at term, was measured by a semiquantitative plate-count technique. Only one of the fluid samples was bactericidal, 12 were bacteriostatic, and 40 were noninhibitory to bacterial growth.

During the 8-year period 1973 to 1980, antenatal cardiotocographic monitoring was performed on 3,006 high-risk pregnancies selected from a total obstetric population of 37,856 patients. A critical fetal reserve was detected in 72 patients (2.3%) whose pregnancies resulted in 20 perinatal deaths and 52 infants who survived the neonatal period; 45 of these infants have been assessed at ages ranging from 2 months to 8 years, 9 months. Growth was below the tenth percentile in 25.0% for weight, 23.3% for length, and 22.5% for head circumference at the review examination. Neurological abnormalities were detected in 12 infants but the abnormality was major in only four, including one who has familial interstitial polyneuropathy. The quality of survival of infants delivered of pregnancies complicated by critical fetal reserve is satisfactory; 93.2% had no neurological impairment likely to interfere with quality of life and indeed 13.5% had superior intelligence. Cardiotocographic evidence of critical fetal reserve does not signify that the fetus is doomed; delivery by cesarean section is indicated if the fetus is viable and has no ultrasonic evidence of untreatable major malformation.

A retrospective analysis of 174 consecutive singleton perinatal deaths at or after term pregnancy in an inner-city hospital was undertaken to determine avoidable causes of death. Adequate material was available in 161 cases. Twenty-eight infants with major malformations were excluded. The remaining 133 infants (95 stillbirths and 38 neonatal deaths) constituted the study population. An avoidable cause was defined as departure from the recognized standards of perinatal care that contributed to the deaths. Avoidable factors were present in 69 of 95 (73%) stillbirths. Contributing maternal/social and obstetric factors were present in 40 of 69 (58%) and 29 of 69 (42%) cases, respectively. Avoidable factors were found in 34 of 38 (89%) neonatal deaths. Contributing obstetric, maternal/social, and pediatric factors were present in 20 of 34 (59%), 12 of 34 (35%), and 2 of 34 (6%) cases, respectively. These results suggest that maternal/social causes were present more often than medical causes as a contributing factor in avoidable perinatal deaths at or after term pregnancy.

A prospective cytogenetic survey of 425 female and 358 male spontaneous aborters and their 430 abortuses (310 of which were karyotyped) revealed four women and two men as balanced translocation carriers (three Robertsonian translocations and three reciprocal translocations), as well as a woman with an XXX karyotype. Karyotyping was successful in five of their abortuses: four abortuses had inherited unbalanced translocation products and the other abortus had a balanced 13q14q translocation plus trisomy 18. It was concluded from these observations that translocation chromosomes carried by aborters are transmitted to their abortuses. The frequency of structural chromosome anomalies among the aborters (0.8 per cent) was higher than that found in the general adult population (0.3 per cent). The rates of translocation carriers were higher among the aborters with a history of recurrent abortions (2.7 per cent) as well as among the aborters with a history of perinatal deaths (3.6 per cent) than among those without such histories (0.6 per cent). Data are presented on 18 couples whose two (or three) successive spontaneous abortuses were karyotyped.

Recent developments have emphasized the need to monitor perinatal mortality statistics by small geographic areas. A method is presented which separates county-specific perinatal mortality rates into a component reflective of socioeconomic, behavioral, and environmental variables, and a component that relates more directly to hospital-based intra- and postpartum care. Major differences in geographic variations were observed between the crude rate and the two components. An arbitrary index of the need for perinatal health services was created by combining the two components with the number of perinatal deaths in each county. Although there are some obvious limitations, the index serves as a useful guidepost for monitoring perinatal mortality on a statewide basis.

In a series of 5,001 pregnant patients, 4 perinatal deaths and 2 cases of severe neonatal morbidity were explained by counting fetal erythrocytes in the maternal circulation. The omission of this simple test would have left these 6 cases unexplained. This paper outlines the necessity of counting fetal erythrocytes in the maternal circulation after every delivery, in vaginal blood loss during the third trimester of pregnancy, and when blood is aspirated at amniocentesis. Fetal erythrocyte counting is a valuable aid in fetal care and in perinatal mortality and neonatal morbidity studies. The indications for fetal erythrocyte counting are described.

Evaluation of numbers of perinatal deaths in a population rather than death rates shows that neither preterm infants nor those of low birth weight constitute as great a majority as is usually believed. Original data from the British Perinatal Mortality Survey and from hospitals in Baltimore were supplemented by 16 reported series and 4 made available by colleagues. About 40 to 60 per cent of all deaths occurred in infants weighing more than 2,500 grams or having a gestational age of more than 37 weeks. The problems inherent in the deaths of full-term and full-sized infants must not be overlooked because death in these groups is more readily preventable at the present state of our knowledge than that of small or immature infants.