Diana M. Bond

Sleep position, fetal growth restriction, and late-pregnancy stillbirth: the Sydney stillbirth study.

OBJECTIVE: To identify potentially modifiable risk factors for late-pregnancy stillbirth. METHODS: This was a population-based matched case–control study of pregnant women at 32 weeks of gestation or greater booked into tertiary maternity hospitals in metropolitan Sydney between January 2006 and December 2011. The case group consisted of women with singleton pregnancies with antepartum fetal death in utero. Women in the control group were matched for booking hospital and expected delivery date with women in the case group. Data collection was performed using a semistructured interview and included validated questionnaires for specific risk factors. Adjusted odds ratios (ORs) were calculated for a priori-specified risk factors using conditional logistic regression. RESULTS: There were 103 women in the case group and 192 women in the control group. Mean gestation was 36 weeks. Supine sleeping was reported by 10 of 103 (9.7%) of women who experienced late-pregnancy stillbirth and by 4 of 192 (2.1%) of women in the control group (adjusted OR 6.26, 95% confidence interval [CI] 1.2–34). Women who experienced stillbirth were more likely to: have been followed during pregnancy for suspected fetal growth restriction, 11.7% compared with 1.6% (adjusted OR 5.5, 95% CI 1.36–22.5); not be in paid work, 25.2% compared with 9.4% (adjusted OR 2.9, 95% CI 1.1–7.6); and to have not received further education beyond high school, 41.7% compared with 25.5% (adjusted OR 1.9, 95% CI 1.1–3.5). None of the deaths to women who reported supine sleeping were classified as unexplained. CONCLUSION: This study suggests that supine sleep position may be an additional risk for late-pregnancy stillbirth in an already compromised fetus. The clinical management of suspected fetal growth restriction should be investigated further as a means of reducing late stillbirth. LEVEL OF EVIDENCE: II

Immediate delivery compared with expectant management after preterm pre-labour rupture of the membranes close to term (PPROMT trial): a randomised controlled trial.

BACKGROUND Preterm pre-labour ruptured membranes close to term is associated with increased risk of neonatal infection, but immediate delivery is associated with risks of prematurity. The balance of risks is unclear. We aimed to establish whether immediate birth in singleton pregnancies with ruptured membranes close to term reduces neonatal infection without increasing other morbidity. METHODS The PPROMT trial was a multicentre randomised controlled trial done at 65 centres across 11 countries. Women aged over 16 years with singleton pregnancies and ruptured membranes before the onset of labour between 34 weeks and 36 weeks and 6 days weeks who had no signs of infection were included. Women were randomly assigned (1:1) by a computer-generated randomisation schedule with variable block sizes, stratified by centre, to immediate delivery or expectant management. The primary outcome was the incidence of neonatal sepsis. Secondary infant outcomes included a composite neonatal morbidity and mortality indicator (ie, sepsis, mechanical ventilation ≥24 h, stillbirth, or neonatal death); respiratory distress syndrome; any mechanical ventilation; and duration of stay in a neonatal intensive or special care unit. Secondary maternal outcomes included antepartum or intrapartum haemorrhage, intrapartum fever, postpartum treatment with antibiotics, and mode of delivery. Women and caregivers could not be masked, but those adjudicating on the primary outcome were masked to group allocation. Analyses were by intention to treat. This trial is registered with the International Clinical Trials Registry, number ISRCTN44485060. FINDINGS Between May 28, 2004, and June 30, 2013, 1839 women were recruited and randomly assigned: 924 to the immediate birth group and 915 to the expectant management group. One woman in the immediate birth group and three in the expectant group were excluded from the primary analyses. Neonatal sepsis occurred in 23 (2%) of 923 neonates whose mothers were assigned to immediate birth and 29 (3%) of 912 neonates of mothers assigned to expectant management (relative risk [RR] 0·8, 95% CI 0·5-1·3; p=0·37). The composite secondary outcome of neonatal morbidity and mortality occurred in 73 (8%) of 923 neonates of mothers assigned to immediate delivery and 61 (7%) of 911 neonates of mothers assigned to expectant management (RR 1·2, 95% CI 0·9-1·6; p=0·32). However, neonates born to mothers in the immediate delivery group had increased rates of respiratory distress (76 [8%] of 919 vs 47 [5%] of 910, RR 1·6, 95% CI 1·1-2·30; p=0·008) and any mechanical ventilation (114 [12%] of 923 vs 83 [9%] of 912, RR 1·4, 95% CI 1·0-1·8; p=0·02) and spent more time in intensive care (median 4·0 days [IQR 0·0-10·0] vs 2·0 days [0·0-7·0]; p<0·0001) compared with neonates born to mothers in the expectant management group. Compared with women assigned to the immediate delivery group, those assigned to the expectant management group had higher risks of antepartum or intrapartum haemorrhage (RR 0·6, 95% CI 0·4-0·9), intrapartum fever (0·4, 0·2-0·9), and use of postpartum antibiotics (0·8, 0·7-1·0), and longer hospital stay (p<0·0001), but a lower risk of caesarean delivery (RR 1·4, 95% CI 1·2-1·7). INTERPRETATION In the absence of overt signs of infection or fetal compromise, a policy of expectant management with appropriate surveillance of maternal and fetal wellbeing should be followed in pregnant women who present with ruptured membranes close to term. FUNDING Australian National Health and Medical Research Council, the Womens and Childrens Hospital Foundation, and The University of Sydney.

Evaluation of an international educational programme for health care professionals on best practice in the management of a perinatal death: IMproving Perinatal mortality Review and Outcomes Via Education (IMPROVE).

BackgroundStillbirths and neonatal deaths are devastating events for both parents and clinicians and are global public health concerns. Careful clinical management after these deaths is required, including appropriate investigation and assessment to determine cause (s) to prevent future losses, and to improve bereavement care for families. An educational programme for health care professionals working in maternal and child health has been designed to address these needs according to the Perinatal Society of Australia and New Zealand Guideline for Perinatal Mortality: IMproving Perinatal mortality Review and Outcomes Via Education (IMPROVE). The programme has a major focus on stillbirth and is delivered as six interactive skills-based stations. We aimed to determine participants’ pre- and post-programme knowledge of and confidence in the management of perinatal deaths, along with satisfaction with the programme. We also aimed to determine suitability for international use.MethodsThe IMPROVE programme was delivered to health professionals in maternity hospitals in all seven Australian states and territories and modified for use internationally with piloting in Vietnam, Fiji, and the Netherlands (with the assistance of the International Stillbirth Alliance, ISA). Modifications were made to programme materials in consultation with local teams and included translation for the Vietnam programme. Participants completed pre- and post-programme evaluation questionnaires on knowledge and confidence on six key components of perinatal death management as well as a satisfaction questionnaire.ResultsOver the period May 2012 to May 2015, 30 IMPROVE workshops were conducted, including 26 with 758 participants in Australia and four with 136 participants internationally. Evaluations showed a significant improvement between pre- and post-programme knowledge and confidence in all six stations and overall, and a high degree of satisfaction in all settings.ConclusionsThe IMPROVE programme has been well received in Australia and in three different international settings and is now being made available through ISA. Future research is required to determine whether the immediate improvements in knowledge are sustained with less causes of death being classified as unknown, changes in clinical practice and improvement in parents’ experiences with care. The suitability for this programme in low-income countries also needs to be established.

Factors Associated with Recurrent Infant Feeding Practices in Subsequent Births A Population-Based Longitudinal Study

Background: Previous breastfeeding experience has been associated with subsequent infant feeding practices. However, few longitudinal studies have investigated formula-only feeding patterns or the full range of potentially associated characteristics. Objective: This study aimed to determine the recurrence of infant feeding practices and maternal, birthing, and infant characteristics associated with recurrent formula-only feeding and changes between exclusive breastfeeding and formula-only feeding across subsequent births. Methods: We conducted a population-based record-linkage study of 317 027 mothers, with a term singleton live-birth in 2007-2011, New South Wales, Australia. Infant feeding patterns were described using sequential birth pairs. For mothers with a first and second birth, robust Poisson regression was used to investigate the association between maternal, birthing, and infant characteristics and infant feeding patterns. Combined relative risks (RRs) were calculated for selected maternal characteristics. Results: Across 69 994 sequential birth pairs, the recurrence rate of formula-only feeding was 71%, and 92% for exclusive breastfeeding. Maternal characteristics < 25 years old, being Australian born or single, smoking during pregnancy, and living in lower socioeconomic areas were most strongly associated with repeat formula-only feeding (RR, 22.1; 95% confidence interval [CI], 18.6-26.3), changing from exclusive breastfeeding to formula-only feeding (RR, 9.0; 95% CI, 7.4-10.7), and being less likely to change from formula-only feeding to exclusive breastfeeding (RR, 0.47; 95% CI, 0.38-0.59). Conclusion: Infant feeding practices were strongly recurrent, highlighting the importance of successful breastfeeding for first-time mothers. Additional support for young mothers from disadvantaged backgrounds accounting for infant feeding history, experiences, and common barriers could improve recurrent exclusive breastfeeding and positively affect infant and maternal health.

An economic evaluation of planned immediate versus delayed birth for preterm prelabour rupture of membranes: findings from the PPROMT randomised controlled trial

This study is an economic evaluation of immediate birth compared with expectant management in women with preterm prelabour rupture of the membranes near term (PPROMT).

Bereaved parents’ experience of care and follow‐up after stillbirth in Sydney hospitals

Despite stillbirth being identified as one of the most traumatic events a woman can experience, there is a lack of evidence on which to inform best practice in hospital and follow‐up care.