Moderate to severe neonatal encephalopathy with suspected hypoxic-ischaemic encephalopathy in cooled term infants born in Tygerberg Academic Hospital: Characteristics of fetal monitoring and modifiable factors

Abstract


 Background. In South Africa, in babies >2 500 g, intrapartum asphyxia is the main cause of neonatal death or stillbirth in those who were alive prior to labour. In a developing population, ~60% of neonatal encephalopathy (NE) has evidence of intrapartum hypoxic ischaemia. Therapeutic hypothermia for term babies born with NE can improve neonatal prognosis and long-term survival.
 Objectives. To identify the healthcare worker- and system-related modifiable factor(s) that were associated with NE in babies of ≥36 weeks’ gestation born at Tygerberg Hospital (a secondary/tertiary referral hospital) between 1 January 2016 and 30 December 2018.
 Methods. This was an observational cross-sectional study analysing data from the Tygerberg Hospital Hypoxic Ischaemic Encephalopathy database, the electronic labour ward register, the mortality database and clinical data from patient folders.
 Results. A total of 118 babies were admitted for head cooling, and therefore included in the study. The hospital in-born rate for serious encephalopathy is 5.5/1 000 in singleton live-born babies (9/1 000 rate for live-born deliveries ≥36 weeks). A sentinel event was identified in 19 (16%) cases. Delay in accessing theatre was the main system-related modifiable factor (25/58 or 43% of cases delivered by emergency caesarean delivery). The average decision-to-incision time was 1 hour 40 minutes, while the average bed occupancy in the emergency maternity centre was 102%. Failure to recognise or respond to an abnormal cardiotocograph was the dominant avoidable factor related to healthcare workers in 34 cases (36.4%).
 Conclusion. Babies born with severe NE place a burden on parents, healthcare staff and resources. Careful intrapartum care, including utilisation of protocols for the use of oxytocin, are imperative. It is recommended that improved access to emergency theatres and appropriately trained staff for maternity units should be a priority for healthcare planners.

Clinical Equipment as a Potential Impediment to Optimal Intrapartum Monitoring and Delivery for Pregnant Women in South Africa

“…Reliability in this study was ensured by conducting a pre-test on 10% (7) of the study population in the labour unit. The pilot or pre-test assessed whether the questionnaires measured what they intended to measure and if the time allocated was adequate.…”

“…The World Health Organisation reports that it is a requirement that basic essential equipment is always available in sufficient quantities in maternity units for utilisation during labour and childbirth [4]. However, midwives in sub-Saharan Africa experience difficulties providing optimum care to pregnant women and their babies, mainly challenged by increasing deliveries with a lack of essential resources in labour units [5][6][7]. Similarly, in the Philippines, midwives reported that essential routines, monitoring and assessment during labour were not sufficiently conducted due to being compounded by inappropriate infrastructure and supplies [8].…”