Confidential Enquiries into Stillbirths and Deaths in Infancy (CESDI) have pointed to a high frequency of suboptimal intrapartum fetal care of a kind that, in the event of an adverse outcome, is hard to defend in court. In an effort to minimize liability, various strategies were applied in a district hospital labour ward--guidelines, cyclical audit, monthly feedback meetings and training sessions in cardiotocography (CTG). The effects of these interventions on quality of care was assessed by use of the CESDI system in all babies born with an Apgar score of 4 or less at 1 min and/or 7 or less at 5 min. 540 babies (4.3%) had low Apgar scores, and neither the percentage nor gestational age differed significantly between audit periods. In the baseline audit, care was judged suboptimal (grade II/III) in 14 (74%) of 19 cases, and in the next four periods it was 23%, 27%, 27% and 32%. In the latest audit period, after further educational interventions, it was 9%. Many of the failures to recognize or act on abnormal events were related to CTG interpretation. After the interventions there was a significant increase in cord blood pH measurement. There were no differences between audit periods in the proportion of babies with cord pH < 7.2. These results indicate that substantial improvements in quality of intrapartum care can be achieved by a programme of clinical risk management.

Fetal intestinal volvulus is a rare life-threatening condition usually manifesting after birth. It appears on prenatal ultrasound imaging as a twisting of the bowel loops CASE REPORTA 26-year-old woman, gravida 3, para 1, with a history of one termination of pregnancy and one normal delivery underwent a fetal anatomy scan at 20 weeks' gestation, which was normal. At 31 weeks' gestation, the woman presented with reduced fetal movements and abdominal pain, which had been present for the preceding 48 h. Cardiotocography (CTG) showed no episodes of high variation, a short-term variation of 3.2 and reduced baseline variability of < 5 beats per min without accelerations. Fetal head circumference and femur length were on the 50 th percentile, but abdominal circumference was > 95 th percentile for gestational age and polyhydramnios was noted. Fetal ascites and dilated bowel loops were observed (Figures 1 and 2), but there was no evidence of pleural or pericardial effusion. No other fetal abnormalities were noted. Umbilical artery Doppler imaging showed positive end-diastolic flow. However, fetal movements were absent and the peak systolic velocity in the middle cerebral artery was increased, suggesting fetal anemia as a possible cause of the abnormal fetal heart rate patterns. A live 1860-g male was delivered by emergency Cesarean section, with Apgar scores of 3 and 6 at 1 min and 5 min, respectively. Umbilical artery pH was 6.9 and the base excess was −12.0. The neonate was anemic (hemoglobin 10.8 g/dL), and was resuscitated with endotracheal intubation and blood transfusion. The abdomen was distended and tense with dark discoloration of the skin (Figure 3).Ultrasound examination at 2 h after birth showed a large amount of free fluid mixed with echogenic particles

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