One year audit of perinatal mortality at Kathmandu Medical College Hospital

Abstract

Perinatal mortality is a sensitive indicator of the quality of service provided to pregnant women and their new borns. Regular audit of perinatal mortality will help in finding out preventive factors and thus helps in reducing perinatal mortality rate in an institution.
This study was carried out to determine perinatal mortality rate (PMR) and the factors associated with it at KMCTH in the one year period (Bhadra 2059-Shrawan 2060)
This is a retrospective study of entire still births and early neonatal deaths that occurred at KMCTH during the one year period (Bhadra 2059-Shrawan 2060). The study was done by collecting the data of all stillbirths and early neonatal deaths from record books of the Special Care Baby Unit, Labour Room and operation theatre.
Out of 563 total births in the one year study period, 17 were still births (SB) and 10 were early neonatal death (ENND). Out of 17 SB, 7 were of < 1 kg and out of 10 ENND, 3 were of < 1 kg. Thus, perinatal mortality rate during the study period was 30.7 and extended perinatal mortality rate was 47.9 per 1000 births. Perinatal deaths were mostly due to extreme prematurity, birth asphyxia, septicemia and congenital anomalies. According to Wiggleworths classification, 18.5% of perinatal deaths were in Group I, 14.8% in Group II, 22.3% in Group III, 40.7% in Group IV and 3.7% in Group V. Intrapartum asphyxia was the commonest cause of perinatal deaths, but majority of these babies were of low birth weight. Prevention of preterm births, better care during intrapartum period, more intensive care of very low birth weight and preterm babies would help in reducing the present high perinatal mortality.

Full text

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Original Article
One year audit of perinatal mortality at Kathmandu Medical
College Hospital
S.R. Manandhar
1
, D.S. Manandhar
1
, M.R. Baral
1
S. Pandey
2
, S. Padhey
2
1
Department of Paediatrics,
2
Department of Obstetrics and Gynaecology, Kathmandu Medical College, Sinamangal,
Kathmandu
Abstract
Introduction: Perinatal mortality is a sensitive indicator of the quality of service provided to pregnant women and
their new borns. Regular audit of perinatal mortality will help in finding out preventive factors and thus helps in
reducing perinatal mortality rate in an institution.
Objective: This study was carried out to determine perinatal mortality rate (PMR) and the factors associated with it
at KMCTH in the one year period (Bhadra 2059 – Shrawan 2060)
Materials and Methods: This is a retrospective study of entire still births and early neonatal deaths that occurred at
KMCTH during the one year period (Bhadra 2059 –Shrawan 2060). The study was done by collecting the data of all
stillbirths and early neonatal deaths from record books of the Special Care Baby Unit, Labour Room and operation
theatre.
Results: Out of 563 total births in the one year study period, 17 were still births (SB) and 10 were early neonatal
death (ENND). Out of 17 SB, 7 were of < 1 kg and out of 10 ENND, 3 were of < 1 kg. Thus, perinatal mortality rate
during the study period was 30.7 and extended perinatal mortality rate was 47.9 per 1000 births. Perinatal deaths
were mostly due to extreme prematurity, birth asphyxia, septicemia and congenital anomalies. According to
Wiggleworth’s classification, 18.5% of perinatal deaths were in Group I, 14.8 % in Group II, 22.3 % in Group III,
40.7 % in Group IV and 3.7 % in Group V. Intrapartum asphyxia was the commonest cause of perinatal deaths, but
majority of these babies were of low birth weight. Prevention of preterm births, better care during intrapartum
period, more intensive care of very low birth weight and preterm babies would help in reducing the present high
perinatal mortality.
Key words: Perinatal Death Audit, Perinatal Mortality
erinatal mortality is a sensitive indicator of the
quality of service provided to pregnant women
and their newborns. Perinatal mortality audit in an
institution helps to find out not only the status of
quality of services provided but also helps to
determine the important causes of perinatal deaths
and take measures to reduce it. PMR is very high in
developing countries especially in South Asia region
countries. In Nepal, PMR was reported to be 47 /
1000 births (NDHS 2001*)
Materials and Methods
This is a retrospective study of the entire stillbirths
and early neonatal deaths that occurred at KMCTH
during one year period (Bhadra 2059 – Shrawan
2060). The study was done by collecting the data of
all stillbirths and early neonatal deaths from record
books of the Special Care Baby Unit, Labour Room
and operation theatre. The maternal characteristics
like age, parity, antenatal care, maternal diseases
during pregnancy and mode of delivery were
analyzed.
Perinatal death analysis was also done according to
birth weight, sex, gestational age, time of death. The
main causes of perinatal deaths were ascertained and
classified according to Wigglesworth’s classification.
Results
Out of 563 total births in the one year study period,
17 were stillbirths and 10 were early neonatal death
(ENND). Out of 17 still births, 7 were of < 1 kg and
out of 10 ENND, 3 were of < 1 kg. Thus, perinatal
mortality rate during the study period was 30.7 and
extended perinatal mortality rate was 47.9. Majority
of births occurred normally (70.1%), 26.4% babies
were delivered by caesarean section, 0.5% were
vacuum delivery, 0.9%were forceps delivery, 0.4%
were breech delivery, 0.5% were multiple pregnancy
and premature delivery 1.2%.
Correspondence:
Prof. D. S. Manandhar
Head, Department of Paediatrics
Kathmandu Medical College Teaching Hospital, Sinamangal
GPO Box. 921 Kathmandu
E mail: dsm @ healthnet. org. np
P
Kathmandu University Medical Journal (2003) Vol. 2, No. 3, Issue 7, 198-202

199
Most of the perinatal deaths (PND) occurred among
primi mothers, most of them were in between 20 –35
years and had ANC > 4 visits. Among the PNDs,
majorities were delivered normally (51.8%), 22.2%
were premature deliveries and 7.4% were delivered
by caesarean section. While majority of stillbirths
were male (68.7%) but majority of ENND were
female (60%). Most of the PND were <1kg which
constituted 37%, 18.5 % of PNDs were in the weight
group of 1- 1.5 kg, 15% of PND were in between 1.5
– 2.5 kg and 29.5 % PND were > 2.5 kg. Over 76.8%
PND were pre term (<36weeks of gestation), out of
which 22.2% were 28 weeks and 55.6% were in
between 28 to 36 wks. Most of stillbirths were fresh
(70.5%) where as 29.5% were macerated. Causes of
most stillbirths were unknown (47%) where as 29.2%
were due to intra partum asphyxia (APH, obstructed
labour, tight cord around neck etc). Commonest
cause of ENND was extreme prematurity (60%),the
rest were due to birth
asphyxia(20%),Septicemia(10%) and Congenital
anomalies(10%). 40% of ENND occurred within
24hrs of birth while 30% occurred in between 24–
72hrs and most of them were asphyxiated. According
to Wiggleworths classification, 18.5 % PND were in
Group I, 14.8% in Group II, 22.3% were in Group III,
40.7 % were in Group IV and 3.7 % were in Group V
as shown in Tables 1-15.
Table 1: Deliveries and Perinatal mortality in one year
(Bhadra 2058 – Shrawan 2059)
Total no. of births: 563
Total no. of still births: 17
Total no. of still births
(excluding < 1 kg = 7 )
10
Total no. of ENND : 10
Total no. of ENND :
(excluding < 1 kg = 3 )
7
Total Perinatal Death: 17
PMR
30.7
Extended PMR:
47.9
Total Still birth rate 30.2
Still birth rate (excluding < 1 kg)
18.1
ENND rate 18.3
ENND rate (excluding < 1 kg)
12.9
Table 2 Types of deliveries at KMCTH:
Type of deliveries No. %
Normal delivery 395 70.1
Caesarian section 149 26.4
Forceps delivery 5 0.9
Vacuum delivery 3 0.5
Premature delivery 6 1.2
Breech delivery 2 0.4
Multiple pregnancy 3 0.5
Total no. of deliveries 563 100.0

200
Analysis of Perinatal Death:
Maternal Characteristics:
Table 3 Perinatal deaths according to maternal age.
SB ENND Total PND
Age
No. % No. % No. %
<20 yrs - - - - - -
20- 35 yrs 12 70.6 10 100.0 22 81.5
>35 yrs 5 29.4 - - 5 18.5
Total 17 100.0 10 100.0 27 100.0
Table 4 Perinatal deaths according to Parity
SB ENND Total PND
Parity
No. % No. % No. %
Primi 7 41.2 8 80.0 15 55.5
Multi 6 35.3 1 10.0 7 26.0
Grand
multi
4 23.5 1 10.0 5 18.5
Total 17 100.0 10 100.0 27 100.0
Table 5 ANC received by mother
SB ENND Total PND
ANC
No. % No. % No. %
< 4 times 7 41.1 2 20.0 9 33.3
> 4 times 10 58.9 8 80.0 18 66.7
No - - - - - -
Total 17 100.0 10 100.0 27 100.0
Table 6 Types of delivery of perinatal deaths
SB ENND Total PND
Types delivery
No. % No. % No. %
Normal delivery 10 58.8 4 40.0 14 51.8
Caesarian section 1 5.8 1 10.0 2 7.4
Breech delivery 2 11.8 - - 2 7.4
Twin delivery - - 3 30.0 3 11.2
Premature delivery 4 23.6 2 20.0 6 22.2
Total 17 100.0 10 100.0 27 100.0
Table 7 Perinatal deaths according to Sex
SB ENND Total PND
Sex
No. % No. % No. %
Male 11 68.7 4 40.0 15 57.6
Female 5 31.3 6 60.0 11 42.4
Total 16 100.0 10 100.0 26 100.0
• Sex of 1 perinatal death (SB) was not known due to extreme prematurity.

201
Table 8 Perinatal deaths according to weight
SB ENND Total PND
Weight
No. % No. % No. %
< 1 kg 7 41.2 3 30.0 10 37.0
1 - < 1.5 kg 3 17.6 2 20.0 5 18.5
1.5- < 2.5kg 3 17.6 1 10.0 4 15.0
> 2.5 kg 4 23.6 4 40.0 8 29.5
Total 17 100.0 10 100.0 27 100.0
Table 9 According to gestational age
SB ENND Total PND
Gestational Age
No. % No. % No. %
< 28 wks 6 35.3 - - 6 22.2
28 - 36 wks 9 53.0 6 60.0 15 55.6
37 - 41 wks 2 11.7 1 10.0 3 11.1
42 wks & above - - 3 30.0 3 11.1
Total 17 100.0 10 100.0 27 100.0
Table 10 Types of stillbirth:
Still birth No. %
Fresh 12 70.5
Macerated 5 29.5
Total 17
100.0
Table 11 Causes of stillbirth
Causes SB %
Maternal factors: Intra partum Asphyxia
5 29.2 %
a) Antepartum haemorrhage 2 11.8
b) Obstructed labour 1 5.8
c) Intra uterine asphyxia 1 5.8
d) Maternal disease (RHD +MS) 1 5.8
Foetal factors:
4 23.8 %
a) Congenital anomalies 3 18.0
b) Tight cord around neck 1 5.8
Unknown 8 47.0 %
Total 17 100.0
Table 12 Causes of ENND
Causes ENND %
Extreme Pre maturity 6 60.0
Birth Asphyxia 2 20.0
Septicemia 1 10.0
Congenital Anomalies 1 10.0
Total 10 100.0
Table 13 ENND by time of death:
Time of death ENND %
< 1 hr of birth 2 20.0
1 -- 24 hrs of birth 4 40.0
24-- 72 hrs of birth 3 30.0
> 72 hrs of birth 1 10.0
Total 10 100.0

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Table 14 ENND by Apgar score:
ENND ENND
APGAR
At 1’
No. %
APGAR
At 5’
No. %
1 – 3 5 50.0 1 -- 3 4 40.0
4 – 7 4 40.0 4 -- 7 2 20.0
8 – 10 1 10.0 8 -- 10 4 40.0
Total 10 100.0 Total 10 100.0
Table 15 Perinatal Death Analysis by Wigglesworth’s Classification:
SB ENND Total PND
Wigglesworth’s
Classification
No. % No. % No. %
Group I 5 29.4 - - 5 18.5
Group II 3 17.6 1 10.0 4 14.8
Group III - - 6 60.0 6 22.3
Group IV 9 53.0 2 20.0 11 40.7
Group V - - 1 10.0 1 3.7
Total 17 100.0 10 100.0 27 100.0
Discussion
PMR and EPMR in this hospital during the study
period were found to be still high compared to PMR
and EPMR reported by other hospitals (Patan hospital
– PMR: 19.5, NMR: 7.8 / Prashuti Griha – PMR:
29.5, EPMR: 34.8). (Ref. 3). At Prashuti Griha main
cause of PND was birth asphyxia where as infection
was the main cause of PND at Patan hospital and
TUTH at Kathmandu. In this study, 60% PND were
due to extreme prematurity, 20% were due to birth
asphyxia and 10% of each was due to infection and
Congenital anomalies. Death due to birth asphyxia
among term babies was not seen. Probably this was
due to use of partographs, good intrapartum
monitoring and timely interventions. Caesarean
section rate was fairly high (26.4%) in comparison to
other hospital (Prashuti Griha-7%)
Conclusion
In this retrospective study, most of perinatal deaths
were occurred in Group III and Group IV of
Wiggleworth’s classification, which showed that
there were two common causes of perinatal deaths-
extreme prematurity with VLBW and intra partum
asphyxia. Preventing premature delivery, better
monitoring, care during intra partum period and
intensive care of very low birth weight would help in
reducing the PMR in this hospital.
References
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1997:35. 146 – 149
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