1. Thoughts from an Uzbekistan point of view
High perinatal asphyxial and birth trauma losses in well grown fetuses: ...what is going on.....?
Thoughts from an Uzbekistan point of view
Tashkent, December 2008
Rick Porter

2. My role as a Consultant in Uzbekistan

3. The Asian Development Bank (ADB) Project
The Government of Uzbekistan asked the ADB for help in improving Women and Child Health (WCH) in 2002
The project did not in fact start until 2007
I was asked to act as a Quality Improvement Consultant
Part of my role was to consider the state of guidelines and protocols in Uzbekistan

4. My conclusions
It is excellent that local protocols are developing in hospitals across Uzbekistan
However there is evidence that many units do not understand what the protocols are intended to achieve
Many protocols are written like textbooks (or answers to exams), rather than as guides for staff to use, possibly at 3am, when faced with a problem

5. My conclusions
There were also many protocols that were totally identical in different hospitals
This suggests that some hospitals had no interest in contributing to their own protocols
This means that they had no sense of ‘ownership’ of the protocols, and were unlikely to use them well in practice

6. My conclusions
Protocols are not just an academic exercise, they are designed to improve practice and to improve safety of women and their babies

7. The Asian Development Bank (ADB) Project
An initial background report was written
This was an essential part of my other role: to assess how perinatal mortality figures might be improved in Uzbekistan

8. Initial findings in this report
‘There is a high proportion (65%) of infant mortality among full-term newborns with body weight above 2.5 kg.
In other countries high infant mortality is most often associated with births of pre-term newborns with low birth weight.
Asphyxia and birth injuries are predominant in the structure of neonatal mortality.’

9. Initial findings: continued
‘The rate of neonatal mortality is completely inconsistent with the high rate of deliveries in obstetric facilities and with the existing level of skilled medical personnel in attendance for labour and deliveries at those facilities.
.... the rate of neonatal mortality in Uzbekistan is similar to that in countries where the percentage of such health providers is low.’

10. In other words:
It is difficult to explain the high numbers of well-grown babies, and the high proportion of asphyxia and birth trauma, in the perinatal losses
In the UK this figure would be <35%, and of those <20% (therefore <10% of the total) would be asphyxial, and virtually none would involve birth trauma

11. In other words (continued)
Furthermore, in the UK the perinatal mortality rate would be 6-7/1000 (compared to >20/1000 in Uzbekistan)
This happens despite levels of hospital delivery that mirror, and in some cases exceed, those seen in Western European countries
The conclusion must be that the care given in maternity hospitals in Uzbekistan is simply not adequate

12. What is the problem?
After site visits and discussions with doctors and midwives, I observe:
The nature and quality of fetal heart monitoring in labour appears to be inadequate
The fact that forceps/ventouse deliveries are virtually non-existent is a major problem

13. Basic facts Labour is the most dangerous journey we ever make
Second stage of labour is by far the most dangerous part of that journey
The longer second stage lasts the more dangerous it becomes for the fetus

14. Basic facts (2)
Therefore we must monitor the fetus with the greatest care in second stage
We must be ready to intervene rapidly if there is evidence of fetal distress
However, our interventions must be safe

15. Fetal monitoring in second stage of labour
Is intended as an aid to determine whether the fetus is becoming distressed
Must be frequently performed to identify sudden fetal distress
Is pointless if not combined with ways of delivering the fetus rapidly if there is a need

16. Forceps/ventouse deliveries (instrumental deliveries)
Exist for two purposes:
A) To deliver in cases of prolonged second stage of labour
B) To deliver in cases of acute fetal distress in second stage of labour
Are safe if properly trained professionals perform them
In the UK, they make up 10-12% of deliveries, a figure that has been stable for more than 30 years

17. Compare Uzbekistan: England: Caesarean section: (?) c.6-7%
Instrumental deliveries: <1%
TOTAL = 7-8%
England:
Caesarean section: 22%
Instrumental deliveries: 11%
TOTAL = 33%

18. This is difference of 4-fold between the two countries
Where does the ‘truth’ lie?
Is 33% excessive and 7-8% brilliantly low intervention obstetrics?
Is 33% the right figure and 7-8% a reflection of negligently non-interventionist care?
Is the answer somewhere between?

19. An instrumental delivery rate of 11% over more than 30 years...
Is wholly unlikely to be entirely unnecessary
Indeed the consistent level is very interesting given the dramatic increase in caesarean sections (from 6 to 18% between 1970 and 1999)
This probably means that clinicians are responding to a perceived need to deliver babies, at a lower threshold by both means

20. Clearly clinicians in the UK would and could not stop performing instrumental deliveries
Are they wrong?
If they did so, what alternatives would there be?
However good obstetric care is, there will always be some labours where unexpected and severe fetal distress will occur in second stage.... and something has to be done....

21. Fundal pressure as a means of aiding delivery
Is not safe for either mother (uterine injury or rupture) or the fetus (head and neck trauma)
Is not as effective in aiding rapid delivery as forceps or ventouse
Was abandoned in the considerable majority of western countries decades ago

22. This should not, in 2008, be considered as an alternative to instrumental delivery

23. Conclusions
The combination of inadequate fetal monitoring in labour (and particularly in second stage), inability to perform instrumental deliveries, and the use of fundal pressure to aid delivery is probably a large part of the explanation of the very unsatisfactory perinatal mortality figures in Uzbekistan

24. Afterthought
Worrying enough though this is, is it possible that there are other aspects of the management of second stage that are contributing to the problem?
If forceps/ventouse are not used, is it possible – or even probable - that oxytocin is being overused in second stage – with clear risks associated....?

25. The way forward Major change in management of second stage of labour
Re-introduction of forceps/ventouse into obstetric practice
High degree of surveillance of fetal heart rate in labour
(Probably) greater use of caesarean section for fetal distress in labour

26. The way forward (2)
Introduction of evidence-based guidelines for ante-natal and intrapartum care with practical flow diagrams and algorithms
Locally written protocols for the management of several conditions/complications, designed to deal in an easily used manner with the issues