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For more information 

Pregnancy Outcome (Statistics) Unit 

Epidemiology Branch 

SA Health 

PO Box 6 

Rundle Mall 

Adelaide 5000
 

Telephone: (08) 8226 6371 

Fax: (08) 8226 6291 

www.health.sa.gov.au/pehs/pregnancyoutcome.htm
 

Non-English speaking: (08) 8226 1990 for information in languages 

other than English, call the interpreting and Translating Centre and 

ask them to call The Department of Health. This service is available 

at no cost to you.
 

  Department of Health, Government of South Australia. 

All rights reserved. ISSN: 1032-4801 

Printed December 2008.
 

November 2008 

Including the South 
Australian Protocol for 

Investigation of Stillbirths 

Maternal, Perinatal and 

Infant Mortality in South 


Australia 2007
 



TWENTY-SECOND REPORT OF THE MATERNAL,
 
PERINATAL AND INFANT MORTALITY COMMITTEE 

on maternal, perinatal and post neonatal deaths in 2007  
including the South Australian Protocol for investigation of Stillbirths 

SA HEALTH 

Adelaide 

November 2008 



November 2008 

Twenty second Report of the Maternal, Perinatal 
and Infant Mortality Committee on maternal,  
perinatal and post neonatal deaths in 2007 
including the South Australian Protocol for 
investigation of Stillbirths 

  SA Health 

Address 

Maternal, Perinatal and Infant Mortality Committee 

Pregnancy Outcome Unit 

SA Health, Government of South Australia 

PO Box 6, Rundle Mall, Adelaide 
South Australia  5000 
Australia 

www.health.sa.gov.au/pehs/pregnancyoutcome.htm 

Telephone 

(08) 8226 6371 or (08)  8226 6357 

Fax  (08) 8226 6291 

ISSN 1032 4801 

Suggested citation:
 

Maternal, Perinatal and Infant Mortality Committee.
 

Maternal, Perinatal and Infant Mortality in South Australia 2007.  


Adelaide: SA Health, Government of South Australia, 2008. 


ii 



Contents
 

Committees ..............................................................................................................vii
 
Maternal, Perinatal and Infant Mortality Committee .......................................... vii
 
Maternal Subcommittee .................................................................................... vii
 
Perinatal Subcommittee ................................................................................... viii
 
Post-neonatal Subcommittee ........................................................................... viii
 
Education Subcommittee ................................................................................... ix
 
Committee staff .................................................................................................. ix
 

Acknowledgements..................................................................................................ix
 

Summary ....................................................................................................................x
 

I Introduction..............................................................................................................1
 

II Maternal, Perinatal and Infant Mortality Statistics 2007 ......................................3
 
1. Maternal mortality 2007.......................................................................................3
 
2. Perinatal mortality 2007 ......................................................................................5
 

(1) Perinatal mortality rates ................................................................................5
 
(2) Birthweight-specific perinatal mortality..........................................................9
 
(3) Gestation-specific perinatal mortality ..........................................................10
 

3. Post-neonatal and infant mortality 2007............................................................11
 
III Causes of death 2007..........................................................................................16
 

1. Causes of maternal deaths 2007 ......................................................................16
 
2. Causes of perinatal deaths 2007.......................................................................16
 

(1) Classification of perinatal deaths ................................................................16
 
(2) Aboriginal perinatal deaths .........................................................................24
 
(3) Autopsies in perinatal deaths......................................................................26
 

3. Causes of post-neonatal deaths 2007...............................................................28
 
(1) Congenital abnormalities ............................................................................29
 
(2) Conditions originating in the perinatal period..............................................29
 
(3) Infection ......................................................................................................30
 
(4) Accidents, poisonings and violence ............................................................30
 
(5) Other causes ..............................................................................................31
 

Deaths of babies born interstate............................................................................33
 

iii 



IV Recommendations ..............................................................................................34
 
1. Maternal Subcommittee recommendations .......................................................34
 
2. Perinatal Subcommittee recommendations .......................................................34
 
3. Post-neonatal Subcommittee recommendations ...............................................37
 

V Education Subcommittee Report........................................................................41
 

APPENDIX 1 .............................................................................................................42
 

Terms of reference, Subcommittees of the Maternal, Perinatal and
 
Infant Mortality Committee.....................................................................................42
 

APPENDIX 2A...........................................................................................................44
 

Medical Certificate of Cause of Perinatal Death ....................................................44
 
APPENDIX 2B...........................................................................................................45
 

Doctor s Certificate of Cause of Death ..................................................................45
 
APPENDIX 3 .............................................................................................................47
 

Definitions..............................................................................................................47
 
APPENDIX 4 .............................................................................................................49
 

Perinatal Society of Australia and New Zealand-Perinatal Death
 
Classification (PSANZ-PDC), SA perinatal deaths, 2007 ......................................49
 

APPENDIX 5 .............................................................................................................53
 
Perinatal Society of Australia and New Zealand Perinatal Death
 
Classification (PSANZ-PDC), SA perinatal deaths by birthweight, 2007 ...............53
 

APPENDIX 6 .............................................................................................................54
 
Obstetric cause-specific classification of perinatal deaths, SA perinatal
 
deaths, 2007 (Amended Whitfield) ........................................................................54
 

APPENDIX 7 .............................................................................................................57
 

Perinatal Society of Australia and New Zealand-Neonatal Death
 
Classification (PSANZ-NDC), SA neonatal deaths, 2007......................................57
 

APPENDIX 8 .............................................................................................................59
 
South Australian Protocol for investigation of stillbirths .........................................59
 

Introduction .......................................................................................................59
 
Core investigations (to be performed in all cases of stillbirth): ..........................60
 
Genetic termination of pregnancy .....................................................................60
 
Congenital anomaly ..........................................................................................60
 
Vasculopathies..................................................................................................61
 
Pre-eclampsia or non-proteinuric hypertension.................................................61
 
Unexplained stillbirths .......................................................................................62
 

iv 



APPENDIX 9 .............................................................................................................63
 
Placental histology guidelines ...............................................................................63
 

APPENDIX 10 ...........................................................................................................64
 
Australian birthweight percentiles..........................................................................64
 

APPENDIX 11 ...........................................................................................................68
 
Co-sleeping while breastfeeding: advice to health professionals ..........................68
 

Recommendations ............................................................................................68
 
Advice to parents on sleeping in the same bed as your baby................................69
 

Recommendations ............................................................................................69
 

v 



Tables 
Table 1: Maternal mortality by category of death, in 5-year periods, 1961   2007........4
 
Table 2: Perinatal mortality, 2007 .................................................................................5
 
Table 3: Perinatal mortality rate, Australian states, 1990   2006..................................8
 
Table 4: Perinatal mortality by birthweight, 2007 .........................................................9
 
Table 5: Time of perinatal death by birthweight, 2007 ................................................10
 
Table 6: Perinatal mortality by gestational age at birth, 2007 .....................................10
 
Table 7: Post-neonatal deaths and death rates, 1986   2007 ....................................11
 
Table 8: Infant deaths (neonatal and post-neonatal) and death rates, 1986 - 2007....13
 
Table 9: Comparison of infant mortality rates across Australian states,
 

using ABS data, 1986   2006 .......................................................................15
 
Table 10: Classification of perinatal deaths, PSANZ-PDC, 2007..................................17
 
Table 11: Amended Whitfield Classification of perinatal deaths, 2007 .........................23
 
Table 12: Autopsy status of perinatal deaths by place of death, 2007..........................26
 
Table 13: Causes of post-neonatal deaths, 1986   2007..............................................28
 
Table 14: Birthweight percentile values (g) for live singleton males,
 

Australia, 1991-1994.....................................................................................66
 
Table 15: Birthweight percentile values (g) for live singleton females,
 

Australia, 1991-1994.....................................................................................67
 

Figures 
Figure 1: Maternal Mortality Ratio, 1961-2007 ...............................................................4
 
Figure 2: Perinatal mortality rate (stillbirths &gt;=400g / 20 weeks gestation,
 

all livebirths), 1986-2007 ...............................................................................6
 
Figure 3: Perinatal mortality rate (births &gt;=1,000g / 28 weeks gestation),
 

1986-2007.......................................................................................................7
 
Figure 4: Perinatal Mortality Rates, South Australia and Australia 1990-2005...............8
 
Figure 5: Post-neonatal death rates, 1986   2007 .......................................................12
 
Figure 6: Infant mortality rates, 1986 - 2007 ................................................................14
 
Figure 7: Infant mortality rates, South Australia and Australia, 1986-2006 ..................15
 
Figure 8: Perinatal deaths in 2007, by PSANZ-PDC (N=188)......................................18
 
Figure 9: Causes of perinatal deaths, amended Whitfield Classification, 2007............24
 
Figure 10: Age Distribution of Post-neonatal Deaths, 2007 ...........................................29
 

vi 



Committees
 

Maternal, Perinatal and Infant Mortality Committee 
Professor Jeffrey Robinson Obstetrician, Chairperson 

Dr Elinor Atkinson Obstetrician 

Dr Vineesh Bhatia  Neonatal paediatrician 

Dr Jonathan Hopkinson Obstetric anaesthetist 

Professor Marc JNC Keirse Obstetrician 

Professor T. Yee Khong  Pathologist 

Dr George Kokar General practitioner  

Dr Nicola Spurrier Paediatrician  

Dr Jane Warland Midwife 

Dr Brian Wheatley  Obstetrician  

Mrs Elizabeth Wood Midwife 

Assoc Professor Annabelle Chan Public health physician, Medical Secretary 

Maternal Subcommittee 
Professor Jeffrey Robinson Obstetrician, Chairperson 

Dr William Hague Obstetric physician  

Dr Elinor Atkinson Obstetrician 

Dr Jonathan Hopkinson Obstetric anaesthetist 

Professor T. Yee Khong  Pathologist 

Dr George Kokar General Practitioner 

Mrs Elizabeth Wood Midwife 

Assoc Professor Annabelle Chan Public health physician, Medical Secretary 

vii 



Perinatal Subcommittee 
Professor Marc JNC Keirse Obstetrician, Chairperson 

Professor Gustaaf Dekker Obstetrician, Deputy Chairperson 

Dr Rachel Chen General practitioner 

Dr Andrew Grieve Paediatrician 

Ms Margaret Hampton Manager, Aboriginal health service 

Dr Bevan Headley  Neonatal paediatrician 

Dr Jonathan Hopkinson Obstetric anaesthetist 

Professor T Yee Khong  Pathologist 

Dr Nicholas Manton Pathologist 

Dr Geoffrey Matthews Obstetrician 

Dr Linda McKendrick  Obstetrician 

Dr Scott Morris Neonatal paediatrician 

Mrs Julie Pratt Midwife 

Dr Jane Warland Midwife  

Assoc Professor Annabelle Chan Public health physician, Medical Secretary 

Post-neonatal Subcommittee 
Dr Nicola Spurrier Paediatrician, Chairperson  

Dr Susan M. Beal Paediatrician 

Dr Vineesh Bhatia   Neonatal paediatrician 

Dr Harry Burnell Paediatrician  

Professor Roger Byard Pathologist 

Dr Lynette Moore Pathologist 

Assoc Professor Annabelle Chan Public health physician, Medical Secretary 

viii 



Education Subcommittee 
Dr Brian Wheatley 

Mrs Julia Ats 

Dr Darren Roberts 

Dr David Morris 

Assoc Professor Annabelle Chan 

Committee staff 
Ms Robyn Kennare 

Obstetrician, Chairperson 

Midwife  

Obstetrician 

Obstetrician 

Public health physician, Medical Secretary 

Midwife / Minute secretary 

We would like to express our most sincere thanks to Dr Jeffrey Hillen, Dr David 
Morris and Dr Brian Peat who retired from the Committee in 2008. 

We welcome back Dr Elinor Atkinson and new members Dr Bevan Headley,  

Dr Geoffrey Matthews and Dr Darren Roberts to the Committee. 

Acknowledgements 
We gratefully acknowledge the valuable assistance of the following: 

  Medical practitioners who completed confidential reports on maternal, 
perinatal or post neonatal deaths and submitted autopsy reports; 

  The pathology departments of teaching hospitals for providing autopsy 
reports; 

  Ms Val Edyvean, Registrar of Births, Deaths and Marriages and staff of the 
Births, Deaths and Marriages Registration Division. 

  Mr Mark Johns, State Coroner, and the staff of the Coroner's Office; 

  Ms Robyn Kennare for preparing the graphs and tables. 

ix 



Summary 
This is the Twenty second Annual Report of the Maternal, Perinatal and Infant 
Mortality Committee, for the year 2007: 

1. 	 There were two direct maternal deaths in South Australia in 2007.  The 
maternal mortality ratio for direct and indirect deaths in the seven years 
2001 2007 was 8.8 per 100,000 women who gave birth, which is very low by 
international standards. It is slightly higher than in the preceding five year 
period but the number of deaths was small (11 in seven years compared 
with six in five years). 

2. 	 The Committee reviewed the 188 perinatal deaths occurring among babies 
born in South Australia in 2007. The perinatal mortality rate for all births 
(stillbirths of at least 400g or 20 weeks gestation and all live births) was 9.5 
per 1,000 births. The stillbirth rate was 6.7 per 1,000 births and the neonatal 
mortality rate 2.8 per 1,000 live births. The rates used for international 
comparisons, based on births of at least 1,000g birthweight and neonatal 
deaths within the first 7 days of life, were the lowest ever recorded in the 
state.  

3. 	 Eighty two percent of the perinatal deaths occurred in preterm babies (less 
than 37 weeks gestation). The leading cause of perinatal death in 2007 was 
again congenital abnormalities, which accounted for 32% of the deaths. 
Other important causes were spontaneous preterm birth (15%), fetal growth 
restriction (11%), stillbirth of unknown cause (10%) and specific perinatal 
conditions (9%). There were 19 stillbirths of unknown cause, a rate of 1.0 per 
1,000 births in 2007. This rate has fallen in recent years, compared with 2.0 
per 1,000 births in 1995 1998.  The Committee has distributed its protocol for 
the investigation of stillbirths to all obstetric units (Appendix 8). Twenty 
one deaths were attributed to fetal growth restriction. Poor fetal growth and 
preterm birth have been associated with smoking during pregnancy. Sixteen 
percent of women who gave birth in South Australia in 2007 smoked during 
pregnancy.  

4. 	 Sixteen babies of Aboriginal mothers died during the perinatal period. The perinatal 
mortality rate of 27.1 per 1,000 births for Aboriginal mothers in 2007 was much 
higher than that of 9.0 per 1,000 for non Aboriginal mothers. The rates of preterm, 
small for gestational age and low birthweight births for Aboriginal mothers also 
remain much higher. The proportion of Aboriginal women who smoked during 
pregnancy was 59.0% compared with 15.1% for non Aboriginal women. 

5. 	 The Committee also reviewed the 28 post neonatal deaths in 2007 among 
babies born in South Australia, two of which were babies of Aboriginal mothers. 
The post neonatal mortality rate remained very low at 1.4 per 1,000 live 
births.  Although there were no post neonatal deaths attributed to SIDS 

x 



(Sudden Infant Death Syndrome), the numbers of  sudden unexpected 
deaths in infancy  (SUDIs) have not fallen in recent years. These include 
deaths from SIDS, accidental asphyxiation and undetermined cause. These 
deaths often have similar associated factors including inappropriate 
sleeping practices. 

6. 	 The infant mortality rate in 2007 was 4.2 per 1,000 live births. The infant 
mortality rate for babies of Aboriginal mothers of 13.8 per 1,000 live births 
remained substantially higher than that of 3.9 for babies of non Aboriginal mothers. 

7. 	 From the review of maternal, perinatal and post neonatal deaths in 2007 
and recent years, the Committee makes the following new 
recommendations: 

  Blood pressure should be monitored for six weeks to three months after 
birth or until it has settled, if a diagnosis of pre eclampsia has been made. 

  Non steroidal anti inflammatory drugs should be avoided in women 
with pre eclampsia. 

  Once a decision to perform an emergency caesarean section has been 
made, it is recommended that fetal monitoring should continue until the 
commencement of surgery. 

  When feto maternal haemorrhage is suspected, flow cytometry should be 
considered to estimate the volume as it is more precise than the Kleihauer 
test. 

  A previous caesarean section is a contraindication for home birth. 

  The collecting of statistics on factors associated with SUDIs to assist 
strategies aimed at prevention of both SIDS and SUDIs. 

8. 	 Recommendations made in earlier years are the following: 

  Caring for pregnant women should be undertaken in a setting which is 
appropriate for the level of risk the pregnancy presents for the mother 
and/or the baby.  

  Review by a physician early in pregnancy of women with current or 
previous serious medical conditions. 

  Pregnant women travelling in motor vehicles need to wear seat belts at all 
times for safety. 

  Pregnant women with a Body Mass Index (BMI) greater than 35 are at 
higher risk from anaesthesia. A timely referral for an anaesthetic 
consultation should be considered for women with a high BMI. 

  That health professionals implement effective strategies to reduce 
smoking in pregnancy, including culturally appropriate smoking cessation 
interventions for Aboriginal women. 

xi 



  Testing the antibody status of Rhesus D negative women before the first 
administration of Anti D is important. A measurable titre of Anti D 
antibodies is an indicator of potential alloimmunisation and always 
requires investigation and a specialist opinion. 

  Early ultrasound determination of chorionicity is advised for twin 
pregnancies, followed by further surveillance for twin twin transfusion in 
monochorionic pregnancies. 

  Vigilance to ensure that fetal growth restriction is not missed. 

  Appropriate training and maintenance of competence in cardiotocograph 
(CTG) interpretation for all levels of medical and midwifery staff. 

  The institution of streamlined arrangements between rural/level I 
hospitals and their regional level II/III maternity service in situations 
where there is a lack of on site CTG expertise; this includes easier access 
of rural practitioners to the consultant on call. 

  Appropriate antibiotic treatment for carriers of Group B Streptococcus 
and for women with risk factors such as prolonged rupture of 
membranes. 

  When induction of labour is deemed necessary in the presence of a 
uterine scar and an unripe cervix, careful consideration should be given 
to alternative options such as postponing the induction or caesarean 
section. 

  Further development and implementation of statewide perinatal 
protocols is recommended (www.health.sa.gov.au/ppg). 

  Use of the recently revised protocol for investigating stillbirths, which 
has been sent to all maternity units in South Australia (Appendix 8). 

  Seeking parental permission for autopsy, which may provide information 
most valuable in the counselling of parents and in the management of 
future pregnancies. The State Perinatal Autopsy Service (telephone 08 
8161 7333) is available at no cost to the parents, including those in 
country areas. Certain categories of death have to be reported to the State 
Coroner (see page 39). 

  Sending placentas for histological examination with all relevant clinical 
information in all cases of perinatal death (see Appendix 9). 

  An effective system of appropriate and ongoing support, supervision and 
referral should be offered to families with known risk factors for adverse 
child outcome, such as substance abuse, psychiatric illness, extreme 
youth of the mother or violence in the household. This should be 
continued at least throughout the first year of life, if not for a longer 
period of time. 

xii 



  Monitoring growth in children, which can be undertaken using the 
weight percentiles in the child s Personal Health Record (Blue Book), and 
investigating why a child is not thriving. 

  Immunisation of children to prevent infectious disease. 

  Vigilance to ensure that potential hazards in the home are removed from 
the infant s environment. 

  Vigilance to ensure safe feeding in children under four years of age. 
Foods that can break off into pieces should not be given, as accidental 
asphyxiation may occur. 

  Consideration should be given to better ways of identifying serious 
underlying illness in children presenting to clinicians, for example, Medic 
Alert bracelets. 

  Systems to facilitate referral by community nurses of high risk children to 
paediatricians or tertiary hospitals for urgent appointments need to be 
considered. 

  Hospitals with high paediatric throughput need provision of 24 hour
 
paediatric expertise.
 

  Appropriate paediatric protocols need to be available in all hospitals. 

  Professional advice should be sought for infants who are excessively 

drowsy or irritable. These infants should be considered seriously ill
 
unless proven otherwise. 


  Professional advice should be sought for infants who are feeding poorly, 
as these infants can become dehydrated very quickly. 

  Further research needs to be undertaken in relation to the incidence of 
community acquired Methicillin Resistant Staphylococcus Aureus 
(MRSA) infections, to help guide clinical practice in terms of antibiotic 
choice in sick children. This may include setting up systems to make 
hospital and community acquired MRSA infection a notifiable 
communicable disease. 

9.	 The Committee has previously recommended that a major public health 
campaign to promote safe sleeping and prevent sudden unexpected death 
in infancy needs to be implemented. The Committee is very pleased that 
such a campaign is to be implemented in South Australia. 

xiii 



xiv
 



I Introduction 
This is the Twenty second Annual Report of the South Australian Maternal, 
Perinatal and Infant Mortality Committee. The Committee was established in 
1985 under the South Australian Health Commission Act. Its terms of reference 
under Section 15 (formerly Section 16) of the Act are as follows: 

To advise the Chief Executive of SA Health on: 

1. 	 The pattern and causation of maternal, perinatal and infant deaths in the 
state; 

2. 	 The avoidability of any factors associated with such deaths and any 
measures which could be taken to assist with the prevention of such deaths, 
including improvements in health services in the state; 

3. 	 Education and training for members of the medical, midwifery and nursing 
professions and for the community generally in order to assist in the 
reduction of maternal, perinatal and infant morbidity and mortality in the 
state. 

The terms of reference of the Subcommittees (Maternal, Perinatal, Post neonatal 
and Education) are provided in Appendix 1.  Under the provisions of the new 
Health Care Act 2008, members of the Committee and its Subcommittees are 
authorised, under strict confidentiality rules, to conduct research into the causes 
of mortality and morbidity in the state, and legal protection is given to notifiers 
who provide information. 

The Subcommittees receive notifications of deaths from the following sources: 

1. 	 The Births, Deaths and Marriages Registration Division, from medical 
certificates of cause of perinatal death (Appendix 2A) and death certificates 
of children under 1 year of age and pregnancy related deaths (Appendix 
2B); 

2. 	 The Coroner's Office, from Coroner s findings; 

3. 	 Hospitals and medical practitioners, in cases of maternal death. 

Legislation governing the registration of births, deaths and marriages in South 
Australia was revised on 3 June 1996. The revised form of medical certificate of 
cause of death (Appendix 2B) identifies pregnancy within three months before 
death and whether the deceased was of Aboriginal or Torres Strait Islander origin. 

Further information is obtained from practitioners identified as having been in 
charge of clinical care through the completion of confidential medical reports, 
and these are supplemented by autopsy information from the Coroner's Office 
and hospital pathology services.  Case summaries are prepared by the 
Committee's senior midwife and the medical secretary for discussion by the 

1 



Subcommittees.  These do not contain any identifying information but the 
members are made aware of the type of health services available in each case, 
for example, location (metropolitan or country) and hospital category.  Where 
certain aspects of a case require clarification, a member of the Subcommittee 
may seek clarification from the practitioner concerned.  In the Post neonatal 
Subcommittee a paediatrician acts as the consultant for each case and obtains 
detailed clinical information where necessary.  The discussions aim to identify 
the factors associated with the death, and to assign a cause or causes of death in 
each case.  Comments or recommendations made by the Subcommittees are 
included in the Committee Report. 

Definitions used by the Committee are provided in Appendix 3 of this Report.  
The Committee receives notifications of maternal, perinatal and post neonatal 
deaths occurring in South Australia.  However, statistics presented for perinatal 
and post neonatal deaths relate only to those occurring in babies born in South 
Australia.  Deaths of South Australian born babies occurring in other states are 
also included in the statistics where information is available for them.  This 
Twenty second Report of the Committee incorporates information on maternal, 
perinatal and post neonatal deaths in South Australia in the year 2007. 

Findings relating to Aboriginal mothers and babies have been italicised for easy 
identification in response to the request of the Aboriginal Health Council of South 
Australia.  The Aboriginal Health Division of SA Health has a nominee on the 
Committee to address areas of concern in relation to Aboriginal maternal, perinatal and 
infant health. 

2 



II Maternal, Perinatal and Infant Mortality Statistics 2007 

1. Maternal mortality 2007 
The World Health Organization (WHO) defines maternal death as the death of a 
woman while pregnant or within 42 days of termination of pregnancy, 
irrespective of the duration and the site of the pregnancy, from any cause 
related to or aggravated by the pregnancy or its management, but not from 
accidental or incidental causes.1  This definition includes both direct and 
indirect maternal deaths (see Appendix 3).  In Australia, incidental deaths, 
where the pregnancy is unlikely to have contributed significantly to the death, 
have been included in the past, because of difficulty in classification between 
indirect and incidental deaths. 

The Australian Institute of Health and Welfare National Advisory Committee 
on Maternal Mortality complies with international reporting protocols2 and 
reports a maternal mortality ratio (see Appendix 3) which only includes 
pregnancy related deaths, that is, direct and indirect maternal deaths, per 
100,000 women who gave birth. The South Australian Maternal, Perinatal and 
Infant Mortality Committee will continue to review incidental deaths to ensure 
that indirect deaths are not missed. It will, however, report only maternal 
mortality ratios for pregnancy related deaths to be consistent with national and 
international protocols.  Pregnancy related deaths of women occurring from 42 
days to within a year of the end of pregnancy ( late maternal deaths ) are also 
reviewed, but these are not included in the South Australian statistics on 
maternal deaths or maternal mortality ratios. 

There were two direct maternal deaths in 2007.  Maternal deaths in South 
Australia for the three categories of deaths from 1961 to 2007 are presented in 
Table 1 by five year periods except for the most recent period of seven years 
(2001 2007). Maternal mortality ratios have been calculated for direct and 
indirect deaths (Table 1 and Figure 1). The maternal mortality ratio for the last 
seven year period 2001 2007 was 8.8 deaths per 100,000 women who gave birth. 
This is similar to the ratio of 8.4 for Australia for 2003 2005 2 but higher than the 
ratio for South Australia for the preceding five year period 1996 2000 which 
was 6.6 deaths per 100,000 women who gave birth. However, the number of 
deaths is small (11 in seven years, compared with six in five years). 

1 World Health Organization. International Statistical Classification of Diseases and Related Health 

Problems. Tenth Revision. Volume 2. Geneva: WHO, 1993. 

2 Sullivan EA, Hall B, King JF 2007. Maternal Deaths in Australia 2003 2005. Maternal Deaths Series no. 

3. Cat . no. PER 42. Sydney: AIHW National Perinatal Statistics Unit. 

3 



Of a total of 39 pregnancy related maternal deaths in the period 1986 2007, 17 were 
direct deaths and 22 were indirect deaths. Three of the 17 direct deaths and two of the 22 
indirect deaths were of Aboriginal women. As Aboriginal women accounted for only 
2%  3% of women who gave birth in South Australia during this period, this represents 
a high maternal mortality ratio for pregnancy related deaths among Aboriginal women 
when compared with non Aboriginal. 

Table 1: 	 Maternal mortality by category of death, in 5 year periods, South Australia, 
1961   2007 

Direct Indirect Incidental Total Direct and indirect maternal 

Years 
deaths deaths deaths deaths deaths 

Number Number Number Number Number Maternal 
mortality ratio* 

1961   1965 34 6 13 53 40 37.8 
1966   1970 21 4 8 33 25 23.7 
1971   1975 17 1 6 24 18 17.2 
1976   1980 6 6 2 14 12 12.9 
1981   1985 3 5 3 11 8 8.3 
1986   1990 4 8 4 16 12 12.3 
1991   1995 4 6 5 15 10 10.2 
1996 - 2000 2 4 5 11 6 6.6 
2001   2007** 7 4 2 13 11 8.8 

*Expressed as deaths per 100,000 women who gave birth
 

** Seven-year period
 

Figure 1: 	 Maternal Mortality Ratio, South Australia 1961 2007 

Direct and Indirect Deaths per 100,000 women who gave birth 
40 

30 

20 

10 

0 

M
at

er
n

al
 m

o
rt

al
ity

 ra
tio

 

1961-65 1966-70 1971-75 1976-80 1981-85 1986-90 1991-95 1996-00 2001-07 
Years 

4 



2. Perinatal mortality 2007 

(1) Perinatal mortality rates 
In 2007 there were 19,757 births in South Australia. These included live births of 
any gestation and stillbirths of at least 400g birthweight or 20 weeks gestation.  
There were 132 stillbirths and 19,624 live births. Fifty five live births died within 
28 days of birth (neonatal deaths).  In one perinatal death, it was not known 
whether the baby was stillborn or liveborn. Table 2 shows the numbers of 
stillbirths and neonatal deaths for specified birthweights or gestations. 

The perinatal mortality rate for all births in 2007 was 9.5 deaths per 1,000 births. 
The stillbirth rate was 6.7 per 1,000 births and the neonatal mortality rate 2.8 per 
1,000 live births. Forty eight of the 188 perinatal deaths (25.5%) were 
terminations of pregnancy and their exclusion would have resulted in a 
perinatal mortality rate of 7.1 deaths per 1,000 births. Fifty perinatal deaths 
(26.6%) were less than 400g birthweight. 

Perinatal mortality for international comparison includes only births of at least 
1,000g birthweight (or 28 weeks gestation if birthweight unavailable) and early 
neonatal deaths within the first seven days of life. This perinatal mortality rate 
was 2.6 deaths per 1,000 births, with a stillbirth rate of 2.0 per 1,000 births and 
an early neonatal mortality rate of 0.6 per 1,000 live births. All these rates for 
international comparison are the lowest ever recorded in the state.  

Table 2:  Perinatal mortality, South Australia, 2007 

Stillbirths Neonatal deaths Perinatal deaths 

Specified 
birthweight/ 
gestation 

Total 
births 

Live 
births Number 

Deaths 
per 

1,000 
births 

Number 

Deaths 
per 

1,000 
live 

births 

Number 
Deaths 

per 
1,000 
births 

?400g/20 weeks 
(all livebirths 
included) 
?500g/22 
weeks* 

19,757  

19,685  

19,624 

19,611 

132 

73 

6.7 

3.7 

55 

44 

29** 

2.8 

2.2 

1.5 

188   

118  

103 ** 

9.5 

6.0 

5.2 
?1,000g/28 
weeks* 19,570

  19,530 39 2.0 24 

11** 

1.2 

0.6 

64  

51 ** 

3.3 

2.6 
 	 Includes one perinatal death of a baby at term for which it is not known whether it was a stillbirth or a live birth. 

*	 For national statistics as recommended by WHO, only fetuses and infants of at least 500g birthweight, or, when 
birthweight is unavailable, the corresponding gestational age (22 weeks) or body length (25cm crown-heel), are 
included. For international comparison, only fetuses and infants of at least 1,000g birthweight, or when 
birthweight is unavailable, the corresponding gestational age (28 weeks) or body length (35cm crown-heel) are 
included. ** This number includes only neonatal deaths occurring within the first 7 days of life, as recommended 
by WHO for national and international comparisons. All other numbers for neonatal deaths refer to deaths 
within the first 28 days of life. Rates for neonatal deaths are expressed as deaths per 1,000 live births. 

5 



South Australian perinatal mortality rates, including stillbirth and neonatal 
mortality rates, for 1986 2007 from Committee data are presented in Figure 2 for 
all births. Rates for births of at least 1,000g birthweight (or when birthweight 
was unavailable, 28 weeks gestation) are presented in Figure 3.  Figure 3 
includes only early neonatal deaths, ie, occurring within the first seven days of 
life (WHO recommendation for international statistics). The graphs demonstrate 
that the fall in the perinatal mortality rate has received a greater contribution 
from the fall in the neonatal mortality rate than from that in the stillbirth rate. 
The stillbirth rate for all births (Figure 2) has not decreased over the last two 
decades. However, if only births of at least 1,000g birthweight are considered, a 
decrease is evident from 4.2 deaths per 1,000 births in 1986 to 2.0 deaths per 
1,000 births in 2007 (Figure 3). 

Figure 2:  Perinatal mortality rate (live births of any gestation and stillbirths 
&gt;=400g / 20 weeks gestation), South Australia 1986 2007 

0 
2 
4 
6 
8 

10 
12 
14 

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90

19
92

19
94

19
96

19
98

20
00

20
02

20
04

20
06

 

Year 

Perinatal mortality rate, deaths per 1,000 births 

Stillbirth rate, deaths per 1,000 births 

Neonatal mortality rate, deaths per 1,000 live births 

Live births of any gestation and stillbirths of at least 400g birthweight or 20 weeks gestation 

6 



Figure 3:  Perinatal mortality rate (births &gt;=1,000g / 28 weeks gestation), 
South Australia 1986 2007 

0 
1 
2 
3 
4 
5 
6 
7 

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88

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90

19
92

19
94

19
96

19
98

20
00

20
02

20
04

20
06

 

Year 

Perinatal mortality rate, deaths per 1,000 births 

Stillbirth rate, deaths per 1,000 births 

Early neonatal mortality rate, deaths per 1,000 live births 

Births of at least 1,000g birthweight or 28 weeks gestation if birthweight is unknown, early neonatal deaths (within 
the first 7 days of life), as recommended by WHO for international comparison 

Comparisons of perinatal mortality rates among Australian states by the 
Australian Bureau of Statistics 

Table 3 shows that the perinatal mortality rate for South Australia over the 
years has generally tended to be lower than the national rate. In 2004 and 2005, 
South Australia recorded the lowest rates in Australia.  Individual state 
perinatal mortality rates for 2007 have yet to be published by the Australian 
Bureau of Statistics (ABS). These rates for South Australia and Australia for 
1990 2005 from the ABS are presented graphically in Figure 4. The South 
Australian rates provided by the ABS differ from those provided by the 
Committee. The Committee s rates are based on births and deaths that occurred 
in the state in the year. Those of the ABS are based on births and deaths 
registered in Australia in the year for mothers usually resident in South 
Australia, irrespective of where and when they occurred. The ABS also excludes 
those births and deaths which are less than 400g birthweight; if birthweight is 
unavailable, gestation has to be at least 20 weeks for inclusion. 

7 



Table 3:  Perinatal mortality rate*, Australian states, 1990   2006 

Year NSW VIC Qld SA WA Tas NT ACT AUSTRALIA 
1990 11.7 11.6 10.2 11.0 10.4 10.6 18.1 13.8 11.3 
1991 11.0 9.8 11.1 9.0 10.3 11.9 18.2 12.5 10.6 
1992 11.8 9.4 10.6 9.9 9.8 9.1 19.3 9.4 10.7 
1993 9.5 8.5 9.4 8.8 8.3 10.0 21.1 7.7 9.2 
1994 9.2 9.3 8.9 8.5 8.3 8.4 16.9 6.9 9.1 
1995 8.9 9.2 9.8 9.9 9.3 9.7 16.3 9.2 9.4 
1996 11.0 8.8 10.0 8.6 10.2 9.5 12.6 8.8 10.0 
1997 9.8 8.5 9.1 8.2 8.1 11.6 15.5 6.6 9.2 
1998 8.1 7.7 9.6 7.2 7.5 9.8 13.1 12.2 8.3 
1999 8.1 9.2 8.2 6.6 8.3 10.7 16.1 11.7 8.5 
2000 7.7 7.9 8.9 8.2 8.4 10.6 14.5 8.3 8.3 
2001 7.8 8.7 9.7 8.5 7.9 5.6 12.2 8.3 8.4 
2002 7.2 8.3 8.8 8.3 7.1 12.9 10.4 5.6 8.0 
2003 6.8 8.8 7.8 8.3 8.2 11.9 15.2 9.4 8.0 
2004 7.2 9.2 8.4 6.9 7.4 6.9 11.2 11.0 8.0 
2005 7.4 9.9 8.8 7.3 7.7 8.5 14.6 10.4 8.5 
2006 na** na na na na na na na 8.5 

*	 Rates are expressed as deaths per 1,000 births for births of at least 400g birthweight (or if birthweight 
unavailable, 20 weeks gestation), neonatal deaths within the first 28 days of life, based on registered births 
according to usual residence of mother. 

**	 Not available as not published by ABS for 2006 data. 

Source: Australian Bureau of Statistics. Catalogue No 3303.0 - Causes of Death, Australia, 2006, March 2008. 

Figure 4:  Perinatal Mortality Rates, South Australia and Australia 1990 2005 

Deaths per 1,000 births (of at least 400g birthweight or 20 weeks gestation if birthweight 
unavailable) 

0 

2 

4 

6 

8 

10 

12 

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ea

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1,
00

0 
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Australia South Australia 

19
90

19
91

19
92

19
93

19
94

19
95

19
96

19
97

19
98

19
99

20
00

20
01

20
02

20
03

20
04

20
05

 

Year 

Source: Australian Bureau of Statistics, Cat. No. 3303.0 - Causes of Death, Australia, 2005, March 2007 

8 



(2) Birthweight-specific perinatal mortality 
The distribution of stillbirths and neonatal deaths by birthweight and 
birthweight specific perinatal mortality rates for 2007 are provided in Table 4.  
Of the 188 perinatal deaths, 148 (78.7%) were of low birthweight (&lt;2,500g) and 
154 (81.9%) were preterm births (&lt;37 weeks gestation, Table 6). 

There were 132 stillbirths, accounting for 70.2% of the perinatal deaths in 2007. 
Of the 60 intrapartum deaths, 54 were under 750g birthweight (Table 5) and 42 
were terminations of pregnancy. Of the 55 neonatal deaths, 37 (67.3%) were low 
birthweight babies and five resulted from terminations of pregnancy. 

Table 4: 	 Perinatal mortality by birthweight, South Australia, 2007, (live births of any 
gestation and stillbirths of at least 400g or 20 weeks gestation) 

Stillbirths Neonatal deaths Perinatal deaths 

Birthweight 
(grams) 

Total 
births 

Live 
births Number 

Deaths 
per 

1,000 
births 

Number 

Deaths 
per 

1,000 
live 

births 

Number 
Deaths 

per 
1,000 
births 

&lt;400 50 9 41 820.0 9 1,000.0 50 1,000.0 
400-499 21 4 17 809.5 2 500.0 19 904.8 
500-749 64 39 25 390.6 15 384.6 40 625.0 
750-999 51 42 9 176.5 5 119.0 14 274.5 
1,000-1,499 132 125 7 53.0 3 24.0 10 75.8 
1,500-1,999 226 220 6 26.5 2 9.1 8 35.4 
2,000-2,499 821 816 5 6.1 1 1.2 6 7.3 
2,500-2,999 3,098 3,086 12 3.9 6 1.9 18 5.8 
3,000-3,499 7,081  7,073 7 1.0 6 0.8 14  2.0 
3,500-3,999 5,967 5,966 1 0.2 5 0.8 6 1.0 
4,000-4,499 1,954 1,954 0 0 0 0 0 0 
4500+ 290 289 1 3.4 1 3.5 2 6.9 
Unknown 2 1 1* na 0 0 1* na 
Total 19,757  19,624 132 6.7 55 2.8 188  9.5 

  Includes one perinatal death for which it is not known whether it was a stillbirth or a live birth (neonatal death). 

* This stillbirth was born at 20 weeks gestation 

na: not applicable 

9 



Table 5: 	 Time of perinatal death by birthweight, South Australia, 2007 (live births of 
any gestation and stillbirths of at least 400g birthweight or 20 weeks 
gestation) 

Stillbirths 
Birthweight	 Neonatal Uncertain if Total (grams)	 deaths Antepartum Intrapartum antepartum or 

intrapartum 
&lt;500 14 42 2 11 69 
500-749 10 12 3 15 40 
750-999 6 2 1 5 14 
1,000-1,499 6 1 0 3 10 
1,500-1,999 6 0 0 2 8 
2,000-2,499 5 0 0 1 6 
2,500-2,999 11 0 1 6 18 

14 3,000-3,499 5 2 0 6 
3,500-3,999 1 0 0 5 6 
4,000-4,499 0 0 0 0 0 
4,500+ 0 1 0 1 2 
Unknown 1* 0 0 0 1 
Total	 65 60 7 55 188  

* This stillbirth was born at 20 weeks gestation. 

  Includes one perinatal death of a baby at term for which it is not known whether it was a stillbirth or a live birth 
(neonatal death). 

(3) Gestation-specific perinatal mortality 
The distribution of perinatal deaths by gestational age is provided in Table 6. 

Table 6: 	 Perinatal mortality by gestational age at birth, South Australia, 2007 (live 
births of any gestation and stillbirths of at least 400g or 20 weeks gestation) 

Stillbirths Neonatal deaths Perinatal deaths 
Gestational Deaths Total	 Live Deaths	 Deaths age at birth per births births Number Number per 1,000 Number per 1,000 (weeks) 1,000 live births births births 
&lt;24 94 22 72 766.0 21 954.5 93 989.4 
24-27 88 72 16 181.8 10 138.9 26 295.5 
28-31 168 156 12 71.4 2 12.8 14 83.3 
32-36 1,328 1311 17 12.8 4 3.1 21 15.8 
37-41 17,996  17,980 15 0.8 18 1.0 34 1.9 
42+ 83 83 0 0 0 0 0 0 
Total 19,757  19,624 132 6.7 55 2.8 188 9.5 

  Includes one perinatal death for which it is not known whether it was a stillbirth or a live birth (neonatal death). 

10 



3. Post-neonatal and infant mortality 2007 
There were 28 post neonatal deaths in 2007 among babies born in South 
Australia, resulting in a post neonatal death rate of 1.4 deaths per 1,000 live 
births. No deaths were attributed to Sudden Infant Death Syndrome (SIDS), but 
there were 11 Sudden Unexpected Deaths in Infancy (SUDIs). This relatively 
new term includes deaths attributed to SIDS (see definition, Appendix 3), 
accidental asphyxiation and undetermined cause. As the current definition of 
SIDS is more stringent, some deaths attributed in earlier years to SIDS would 
now be classified as SUDIs in the  undetermined  group. This is because many 
of these SUDIs are associated with unsafe infant sleeping and bedding practices 
and as such would not meet the criteria for SIDS. This issue is discussed in 
greater detail in page 33, where for the first time the Committee has included a 
list of the risk factors associated with these deaths.  The numbers and rates of 
post neonatal deaths for South Australia for 1986 to 2007 are presented in Table 
7 and the rates in Figure 5, together with the relative contributions from SIDS 
and non SIDS deaths. 

Table 7:  Post neonatal deaths and death rates, South Australia, 1986   2007 

Post-neonatal deaths, Post-neonatal deaths Post-neonatal deaths 
all causes from SIDS from non-SIDS causes 

Year Deaths per Deaths per Deaths per 
Number 1,000 live Number 1,000 live Number 1,000 live 

births births births 
1986 65 3.3 41 2.1 24 1.2 
1987 74 3.8 49 2.5 25 1.3 
1988 53 2.7 32 1.6 21 1.1 
1989 71 3.6 36 1.8 35 1.8 
1990 61 3.1 31 1.6 30 1.5 
1991 39 2.0 19 1.0 20 1.0 
1992 41 2.0 23 1.1 18 0.9 
1993 37 1.9 13 0.7 24 1.2 
1994 30 1.5 11 0.6 19 1.0 
1995 46 2.4 15 0.8 31 1.6 
1996 26 1.4 11 0.6 15 0.8 
1997 34 1.8 8 0.4 26 1.4 
1998 27 1.5 7 0.4 20 1.1 
1999 36 2.0 5 0.3 31 1.7 
2000 21 1.2 5 0.3 16 0.9 
2001 24 1.4 6 0.3 18 1.0 
2002 26 1.5 3 0.2 23 1.3 
2003 24 1.4 4 0.2 20 1.1 
2004 31 1.8 1 0.1 30 1.7 
2005 27 1.5 2 0.1 25 1.4 
2006 27 1.4 3 0.2 24 1.3 
2007 28 1.4 0 0 28 1.4 

11 



Figure 5:   Post neonatal death rates, South Australia, 1986   2007 

4 

D
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1,
00

0 
liv

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3 

2 

1 

0 

All causes SIDS Non SIDS 
19

86

19
88

19
90

19
92

19
94

19
96

19
98

20
00

20
02

20
04

20
06

 

Year 

The infant mortality rate for South Australia for 2007 was 4.2 deaths per 1,000 
live births. This includes all 83 deaths of infants under 1 year of age, ie, the 55 
neonatal deaths and the 28 post neonatal deaths (Appendix 3). The infant 
mortality rate for babies of Aboriginal mothers (with two post neonatal deaths and 
six neonatal deaths out of 580 live births) was 13.8 deaths per 1,000 live births, 
compared with the infant mortality rate of 3.9 deaths per 1,000 live births for babies 
of non Aboriginal mothers. Infant mortality rates with the component post 
neonatal and neonatal death rates for South Australia for 1986 2007 are 
presented in Table 8 and Figure 6. 

12 



Table 8:   Infant deaths (neonatal and post neonatal) and death rates, South Australia, 
1986   2007 

Year Neonatal deaths Post-neonatal deaths Infant deaths 

Number Deaths per Number Deaths per Number Deaths per 
1,000 live births 1,000 live births 1,000 live births 

1986 85 4.3 65 3.3 150 7.6 
1987 93 4.8 74 3.8 167 8.7 
1988 89 4.6 53 2.7 142 7.3 
1989 93 4.7 71 3.6 164 8.3 
1990 92 4.6 61 3.1 153 7.7 
1991 66 3.4 39 2.0 105 5.4 
1992 79 3.9 41 2.0 120 6.0 
1993 72 3.6 37 1.9 109 5.5 
1994 66 3.4 30 1.5 96 4.9 
1995 71 3.6 46 2.4 117 6.0 
1996 70 3.7 26 1.4 96 5.1 
1997 59 3.2 34 1.8 93 5.0 
1998 46 2.5 27 1.5 73 3.9 
1999 38 2.1 36 2.0 74 4.0 
2000 57 3.2 21 1.2 78 4.4 
2001 64 3.6 24 1.4 88 5.0 
2002 54 3.1 26 1.5 80 4.5 
2003 42 2.4 24 1.4 66 3.7 
2004 52 3.0 31 1.8 83 4.8 
2005 63 3.5 27 1.5 90 5.0 
2006 38 2.0 27 1.4 65 3.5 
2007 55 2.8 28 1.4 83 4.2 

13 



Figure 6: Infant mortality rates, South Australia, 1986   2007 


0 
1 
2 
3 
4 
5 
6 
7 
8 
9 

10 
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88

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90

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19
94

19
96

19
98

20
00

20
02

20
04

20
06

 

Year 
Infant deaths per 1,000 live births 

Neonatal deaths per 1,000 live births 

Postneonatal deaths per 1,000 live births 

* Infant deaths include post-neonatal and neonatal deaths 

Comparisons of infant mortality rates for all Australian states for 1986 2006 from 
the Australian Bureau of Statistics 

These are presented in Table 9: the rates for 2007 are not yet available.  Rates for 
South Australia compared with Australia for 1986 2006 are shown in Figure 7. 
The South Australian infant mortality rate has been comparable with most of 
the other states and was the lowest of all the states in 2006. Please note that the 
ABS includes only registered births and deaths in any year of at least 400g 
birthweight (or 20 weeks gestation if birthweight unavailable) and adjusts for 
state of usual residence: hence rates reported may differ slightly from those 
reported by this Committee, eg in Table 8.  

14 



Table 9:  Comparison of infant mortality rates (deaths per 1,000 live births), across 
Australian states using ABS data, 1986   2006 

Year NSW Vic Qld SA WA Tas NT ACT Australia 
1986 9.0 8.6 8.7 7.4 8.8 11.4 16.0 8.5 8.8 
1987 8.5 8.1 9.3 8.6 8.4 10.0 15.6 9.0 8.7 
1988 9.2 7.8 8.4 7.9 8.5 9.6 19.2 8.1 8.7 
1989 8.7 6.5 8.5 7.4 7.8 10.6 14.5 6.5 8.0 
1990 8.1 7.8 7.7 8.5 8.6 8.9 15.2 9.4 8.2 
1991 7.2 6.5 7.6 5.5 7.2 9.0 14.2 7.6 7.1 
1992 7.4 5.6 7.9 6.1 7.0 6.6 15.5 6.3 7.0 
1993 6.2 5.4 7.0 5.2 5.9 5.9 15.3 4.3 6.1 
1994 6.3 5.1 6.2 4.7 5.6 7.5 11.3 4.7 5.9 
1995 5.7 4.9 6.3 5.8 5.1 5.8 13.3 4.8 5.7 
1996 5.8 5.0 6.4 4.9 6.5 4.5 11.5 5.7 5.8 
1997 5.2 4.9 5.8 4.7 5.3 6.5 12.5 3.8 5.3 
1998 4.3 4.7 6.4 4.0 5.0 5.7 12.4 6.0 5.0 
1999 5.8 5.6 5.7 4.3 4.7 7.6 11.7 5.6 5.7 
2000 5.2 4.5 6.2 4.6 4.3 5.8 11.7 4.2 5.2 
2001 5.3 4.8 5.9 4.6 5.1 6.2 10.7 3.0 5.3 
2002 4.6 5.0 5.8 5.1 4.3 6.2 11.3 3.4 5.0 
2003 4.6 5.1 4.8 3.7 4.1 7.0 8.4 5.8 4.8 
2004 4.6 4.5 5.2 3.2 3.9 3.6 10.7 6.9 4.7 
2005 4.9 5.1 5.1 5.1 4.6 3.5 9.6 5.5 5.0 
2006 4.9 4.3 5.3 3.2 4.9 3.9 8.9 5.1 4.7 

Source: Australian Bureau of Statistics. Catalogue No 3302.0   2006 Deaths Australia, November 2007 

Figure 7:  Infant mortality rates, South Australia and Australia, 1986 2006 

0 
1 
2 
3 
4 
5 
6 
7 
8 
9 

10 

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0 
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 Australia South Australia 

19
86

19
88

19
90

19
92

19
94

19
96

19
98

20
00

20
02

20
04

20
06

 

Year 

Source: Australian Bureau of Statistics. Catalogue No. 3302.0 - 2006 Deaths Australia, November 2007 

15 



III Causes of death 2007 

1. Causes of maternal deaths 2007 
There were two direct maternal deaths in 2007. One mother was in her twenties, 
in her first pregnancy, and had a previous history of headaches of 
undetermined cause. Her blood pressure was normal in early pregnancy but 
slightly elevated at 39 weeks. There was only a trace of protein in her urine, but 
her platelet level had fallen (although still within normal limits) and her urate 
level was high. In labour her blood pressure was also only slightly elevated but 
there was marked proteinuria. Both returned to normal after a normal birth. 
However, in the second week after giving birth she developed a headache, 
which appeared to improve. A few hours later she was unconscious and having 
fits. Although these ceased with magnesium sulphate, she remained 
unconscious, with severe hypertension, proteinuria and evidence of brain 
infarction. She died a few days later. Autopsy confirmed cerebral infarction. 
This was a direct maternal death from pre eclampsia (ICD10AM code O14.1) 
with cerebral infarction.  

The second mother, in her thirties, had her early antenatal care overseas. When 
first seen at a South Australian hospital in the second trimester, she was 
anaemic and had evidence of hydronephrosis, probably related to a previous 
renal calculus. A few weeks later she was diagnosed with a urinary tract 
infection, which was still present late in pregnancy and treated. It was not clear 
whether she had used the antibiotics prescribed earlier. Although the 
cardiotocograph was then normal, labour was induced with dinoprostone at 37 
weeks for unexplained fetal tachycardia noted at the last visit. Several hours 
later, she was distressed and vomiting, had difficulty breathing and commenced 
fitting. The uterus was hard and tonic and she was hypotensive. She then 
stopped breathing.  While she was being resuscitated, a caesarean section was 
performed to deliver her baby. She developed heavy bleeding, with an atonic 
uterus and disseminated intravascular coagulation and died a few hours later. 
The infant suffered from severe hypoxic ischaemic encephalopathy and died 
after a few weeks. This was a direct maternal death from amniotic fluid 
embolism (ICD 10AM code O88.2).  

2. Causes of perinatal deaths 2007 

(1) Classification of perinatal deaths 
The Perinatal Subcommittee classified each of the 188 perinatal deaths which 
occurred in 2007 according to the Perinatal Society of Australia and New 
Zealand   Perinatal Death Classification (PSANZ PDC). This classification, 
together with the Australian birthweight/gestation percentile charts (for 

16 



singletons as well as twins), is available on the PSANZ website 
(www.psanz.org.au) and will be regularly updated by the PSANZ Perinatal 
Mortality Special Interest Group. The classification of perinatal deaths in 2007 
according to PSANZ PDC is as follows (Table 10): 

Table 10:  Classification of perinatal deaths, PSANZ PDC, South Australia, 2007 

PSANZ-PDC Number Percent Deaths per 1,000 
births 

1. Congenital abnormality 61 32.4 3.1 
2. Perinatal infection 14 7.4 0.7 
3. Hypertension 4 2.1 0.2 
4. Antepartum haemorrhage (APH) 12 6.4 0.6 
5. Maternal conditions 5 2.7 0.3 
6. Specific perinatal conditions 16 8.5 0.8 
7. Hypoxic peripartum death 4 2.1 0.2 
8. Fetal growth restriction 21 11.2 1.1 
9. Spontaneous preterm 29 15.4 1.5 
10. Unexplained antepartum death 19 10.1 1.0 
11. No obstetric antecedent 3 1.6 0.2 

Total 188 100.0 9.5 

The PSANZ PDC for perinatal deaths in 2007 is shown graphically in Figure 8 
and its breakdown by subgroups and birthweight groups is provided in 
Appendix 4 and Appendix 5.  

Congenital abnormalities were again the leading cause of perinatal death in 
2007, accounting for 32.4% of all deaths. The next leading causes were preterm 
birth due to spontaneous labour or pre labour rupture of membranes (15.4%), 
followed by fetal growth restriction (11.2%), unexplained antepartum death 
(10.1%) and specific perinatal conditions (8.5%).  

The death rate due to unexplained stillbirth remained relatively low at 1.0 per 
1,000 births compared with 2.0 per 1,000 births in 1995 1998.  However, the 
contribution of fetal growth restriction as a cause of perinatal death has 
increased and for the first time was greater than that of unexplained antepartum 
death. Sixteen out of 21 deaths from fetal growth restriction were antepartum 
stillbirths. 

17 



Antepartum 
haemorrhage 

6.4% 

Figure 8:  Perinatal deaths in South Australia 2007, by PSANZ PDC (N=188) 

No obstetric Specific perinatal antecedent Spontaneous 
conditions 1.6% preterm 8.5% 15.4% 

Perinatal infection
 
7.4%
 

Fetal growth 
restriction 

11.2% 

Unexplained 
antepartum death 

10.1% Congenital 
Hypoxic abnormality 

peripartum death 32.4% 
2.1% 

Hypertension 
2.1% Maternal 

conditions 
2.7% 

A brief description of each of the 11 groups follows. 

1.  Congenital abnormality   61 deaths 

This group of 61 deaths includes 43 terminations of pregnancy at 20 weeks 
gestation or more for fetuses with congenital abnormalities. The types of 
abnormalities were as follows: 

Central nervous system 12 
Cardiovascular 9 
Urinary tract 4 
Chromosomal 15 
Multiple 11 
Other 10 
Total 61 

Of the 12 babies with central nervous system abnormalities, three had neural 
tube defects and five had hydrocephalus alone. One baby had a cerebellar 
abnormality with hydrocephalus and another had a spinal cord abnormality. 
One baby had congenital myotonic dystrophy and another had sex linked 
myotubular myopathy. 

The nine infants with cardiovascular abnormalities had the following: 

18 



  Hypoplastic left heart syndrome   three babies:  

  Multiple cardiac abnormalities   three babies;  

  Cardiac and vascular abnormalities   three babies. 

Of the four babies with urinary tract abnormalities, one had congenital posterior 
urethral valves, two others had bladder neck obstruction with renal 
abnormalities and one had bilateral renal agenesis. 

Fifteen babies had chromosomal abnormalities, which were as follows: 

  Trisomy 21   four babies; 

  Trisomy 13   two babies;  

  Trisomy 18   three babies; 

  Turner syndrome with hypoplastic left heart syndrome   one baby; 

  Other autosomal anomalies   five babies. 

There were 11 babies with multiple congenital abnormalities. Three had 
diaphragmatic hernia associated with other defects. Three babies had neural 
tube defects associated with other defects, predominantly cardiovascular 
defects. Two other babies had major renal defects, including bilateral renal 
agenesis and cardiovascular defects. One had complete situs inversus and 
cardiac defects. One baby had Fryns syndrome with central nervous system and 
renal defects and the eleventh baby had neonatal Marfan syndrome.  

Of the ten babies with  other  fetal abnormalities, eight had musculoskeletal 
abnormalities. These consisted of four cases of osteogenesis imperfecta, two of 
other skeletal dysplasias, and two with other limb abnormalities. One baby had 
diaphragmatic hernia and another had amniotic band syndrome with limb 
defects.  

2.  Perinatal infection   14 deaths 

  Group B Streptococcus:  infections were noted in two stillbirths and one 
neonatal death. Both stillbirths occurred antepartum, one at 20 weeks 
gestation and the other at 36 weeks. The placentas in both cases showed 
abnormalities. The neonatal death followed spontaneous preterm labour at 
24 weeks gestation. 

  Escherichia coli sepsis   four deaths. One infant was an antepartum stillbirth 
at term. Another was stillborn after preterm labour at 24 weeks. Another 

19 



mother who had had recurrent vaginal bleeding experienced preterm 
prelabour rupture of membranes at 27 weeks and developed 
chorioamnionitis. The baby was delivered by emergency caesarean section 
but died in the neonatal period of septicaemia, meningitis and other 
complications of prematurity. One other death of a baby born at term was 
attributed to E coli infection. This birth was complicated by fetal distress 
and shoulder dystocia and the baby had a pulmonary haemorrhage. E coli 
and Enterobacter were cultured from the lungs and gastric contents. 

  Other bacterial infections : there was an intrapartum death following 
spontaneous onset of labour at term. There was evidence of cord 
inflammation and a gastric swab grew micro aerophilic Streptococci. 

  Unspecified bacterial infections: there was a neonatal death from the 
complications of infection and prematurity followed spontaneous preterm 
labour at 24 weeks. 

  There were two deaths from cytomegalovirus infection, one from 
parvovirus infection and two from unspecified organisms.  

3. Hypertension   4 deaths 

There was one death from unspecified chronic hypertension. This mother had 
no antenatal care and delivered a stillbirth at term. She was found to have 
severe hypertension without proteinuria, as well as diabetes. 

There were three deaths from pre eclampsia, one of which was associated with 
laboratory evidence of thrombophilia. One woman developed severe pre 
eclampsia for which termination of pregnancy was performed at 23 weeks. 
Another developed placental abruption with intrauterine fetal death. The third 
baby was very growth restricted and also died antepartum. 

4.  Antepartum haemorrhage   12 deaths 

Eleven deaths were due to placental abruption. Three mothers had laboratory 
evidence of thrombophilia and one was a heavy drug user. 

There was one death from antepartum haemorrhage of undetermined origin. 

5.  Maternal conditions   5 deaths 

One death was attributed to diabetes. This mother, who had poorly controlled 
diabetes with nephropathy, experienced an antepartum fetal death. There was 
evidence of placental insufficiency. 

Another death was attributed to maternal injury. This mother was involved in a 
motor vehicle accident which resulted in feto maternal haemorrhage and 
intrauterine death. 

The three remaining deaths in this group were attributed to other maternal 
conditions. One mother experienced uterine rupture of a classical caesarean 

20 



section scar in mid pregnancy with haemorrhage and intrauterine death. 
Another mother presented late in pregnancy having had gastric stapling earlier 
in pregnancy before she knew she was pregnant. She had an antepartum fetal 
death. The placenta showed evidence of uteroplacental insufficiency. A third 
mother died of amniotic fluid embolism in labour following induction of labour 
and her fetus died of the complications of hypoxic ischaemic encephalopathy. 

6.  Specific perinatal conditions   16 deaths 

These deaths were due to the following: 

  Twin twin transfusion resulting in deaths of a pair of twins, with infection 
contributing to the death of one twin.  

  Feto maternal haemorrhage   one antepartum fetal death. The fetus was 
hydropic and also had a minor chromosomal abnormality.  

  Antepartum cord complications   three deaths. A pair of monochorionic 
diamniotic twins died in utero following cord entanglement after 
spontaneous disruption of the separating membrane. The other death was a 
growth restricted fetus with a tethered cord insertion, probably resulting 
from a free floating amniotic band. This may have limited the mobility of 
the cord and compromised blood flow. Death occurred after amniocentesis. 

  Uterine abnormalities   four deaths. One death from cervical incompetence 
followed rupture of the membranes at 21 weeks gestation. Another 
occurred after membrane rupture at 22 weeks associated with a septate 
uterus. Two other deaths in mid pregnancy were associated with red 
degeneration of fibroids and spontaneous labour. Placental abruption 
complicated one of these births.  

  Birth trauma   one death. There was some evidence of fetal compromise 
during labour which may have increased the likelihood of haemorrhage in 
this case of a subgaleal haemorrhage following ventouse delivery. 

  Idiopathic hydrops fetalis   two antepartum deaths, one of which was 
associated with gestational diabetes.  

  Other specific perinatal conditions   three deaths. One death occurred three 
weeks after an amniocentesis. There was evidence of mild chorioamnionitis. 
Another was a twin in a monochorionic diamniotic twin pregnancy, for 
which emergency caesarean section was performed at 25 weeks gestation 
for discordant growth and abnormal umbilical artery Doppler flows. This 
twin had an abnormal placentation and died of the complications of 
prematurity. A third mildly growth restricted infant was born after 
induction of labour at term for pre eclampsia. This baby died from the 
complications of hyaline membrane disease, persistent pulmonary 
hypertension, patent ductus arteriosus and pulmonary haemorrhage. 

21 



 7.  Hypoxic peripartum death   4 deaths 

One death occurred of a macrosomic baby whose birth at home was 
complicated by shoulder dystocia. The baby s mother had had a previous 
caesarean section. Delay in the second stage of labour occurred for another baby 
whose head was in an occipito posterior position. Difficulty was encountered in 
disimpaction of the head at caesarean section. Another baby died from the 
complications of meconium aspiration syndrome including severe pulmonary 
hypertension, neonatal encephalopathy and acute tubular necrosis. In the fourth 
case there was evidence of fetal distress after induction of labour 10 days after 
term. The infant born by caesarean section more than a hour later was in poor 
condition and died a few days later. 

8. Fetal growth restriction   21 deaths 

Eighteen of the 21 growth restricted babies were preterm. There was one 
neonatal death and 20 stillbirths. 

There was evidence of reduced placental vascular perfusion in 17 growth 
restricted babies. Several of their mothers had laboratory evidence of 
thrombophilia or were smokers. 

In the remaining four deaths there was evidence of chronic villitis in one 
placenta and other placental pathology in three placentas. One of these mothers, 
a heavy smoker, also had laboratory evidence of thrombophilia and used other 
drugs. 

9.  Spontaneous preterm (&lt;37 weeks gestation)   29 deaths 

In 16 of the 29 deaths the membranes were intact or ruptured less than 24 hours 
before delivery. Of these, four had evidence of chorioamnionitis on placental 
histopathology and seven had no such evidence. In the remaining five there 
were no clinical signs of chorioamnionitis and the placenta was not examined. 

In 13 of the 29 deaths the membranes had been ruptured 24 hours or more 
before birth. Of these, 12 had evidence of chorioamnionitis on placental 
histopathology and in one there was no such evidence. 

10. Unexplained antepartum death   19 deaths 

There was evidence of reduced vascular perfusion in the placentas in four 
unexplained antepartum deaths, with laboratory evidence of thrombophilia in 
one of these. Five showed no placental pathology, with one of these also having 

22 



laboratory evidence of thrombophilia. In the remaining ten, there was other 
placental pathology and two of these also had laboratory evidence of 
thrombophilia. 

11. No obstetric antecedent   3 deaths 

Two of these deaths were sudden unexpected neonatal deaths associated with 
co sleeping. In one case the likely cause was accidental asphyxiation. In the 
remaining death, of a term baby, it was not known whether the baby was 
stillborn or liveborn. The cause of death remained unknown after an autopsy 
performed several days after the death. 

Whitfield Classification of perinatal deaths3 

The classification of the 188 perinatal deaths into the 12 groups of the amended 
Whitfield Classification is presented in Table 11 and Figure 9.  Subgroups of the 
classification are also included in Appendix 6. 

Table 11:  Amended Whitfield Classification of perinatal deaths, South Australia, 2007 

Amended Whitfield Classification Number of deaths % 
Deaths per 1,000 

births 
1. Spontaneous preterm 27 14.4 1.4 
2. Intrauterine growth restriction (IUGR) 21 11.2 1.1 
3. Unexplained intrauterine death 19 10.1 1.0 
4. Birth trauma 3 1.6 0.2 
5. Intrapartum asphyxia 4 2.1 0.2 
6 Hypertension 4 2.1 0.2 
7. Maternal disease 6 3.2 0.3 
8. Antepartum haemorrhage (APH) 12 6.4 0.6 
9. Fetal abnormality 61 32.4 3.1 
10. Haemolytic disease 0 0 0 
11. Infection 19 10.1 1.0 
12. Other 12 6.4 0.6 

Total 188 100.0 9.5 

3 Whitfield CR, Smith NC, Cockburn F, Gibson AAM. Perinatally related wastage   a proposed 

classification of primary obstetric factors. Br J Obstet Gynaecol 1986;93:694 703. 

23 



Figure 9: 	 Causes of perinatal deaths, amended Whitfield Classification, 
South Australia 2007 

Other Spontaneous 6.4% pre-term Infection
 14.4%
 10.1%
 

IUGR
 
11.2%
 

Unexplained 
intrauterine 

death 
10.1% 

Birth trauma 
Fetal 1.6% 

Intrapartum abnormality 
asphyxia 32.4% 

2.1% 
Maternal Hypertension 

APH disease 2.1% 
3.2% 6.4% 

Perinatal Society of Australia and New Zealand   Neonatal Death Classification 
The classification of the 55 neonatal deaths according to the Perinatal Society of 
Australia and New Zealand   Neonatal Death Classification (PSANZ NDC), 
formerly called the Australia and New Zealand Neonatal Death Classification 
(ANZNDC) is provided in Appendix 7. This classification is also available, 
together with PSANZ PDC, on the PSANZ website. 

Perinatal deaths of babies born interstate in 2007 

There was one neonatal death of a baby born at an interstate hospital, which 
will not be included in the South Australian perinatal mortality statistics. This 
was the baby of an Aboriginal mother. 

This mother was treated for urogenital infections during pregnancy and a high vaginal 
swab grew Group B Streptococcus.  She had minimal antenatal care and presented in 
the third trimester in spontaneous preterm labour. The baby had hypoglycaemia and 
hyaline membrane disease requiring oxygen therapy and was retrieved to a level III 
hospital in Adelaide. The baby was found to have septicaemia and was in poor condition 
with many complications of infection, prematurity and hypoxic ischaemic 
encephalopathy. It* died in the first week of life.  

(2) Aboriginal perinatal deaths 
There were 16 perinatal deaths (10 stillbirths and six neonatal deaths) among the 590 
births to Aboriginal mothers. Eleven were born in teaching hospitals, four in country 
hospitals and one at home. All but one were preterm births. Some factors associated with 

*The neuter gender is used here and elsewhere in this report for reasons of confidentiality. 

24 



these deaths were maternal smoking and substance use, diabetes, anaemia and 

infections, obesity and lack of antenatal care. The causes of the 16 deaths were as follows: 


  Congenital abnormalities three deaths.  

The abnormalities were Down syndrome and multiple abnormalities in two stillbirths 
and cardiovascular abnormalities in a neonatal death.  

  Infection   two stillbirths. 

One was due to Group B Streptococcal infection and the other to cytomegalovirus 
infection. 

  Maternal conditions   two stillbirths. 

One stillbirth was a growth restricted baby of a diabetic mother with nephropathy, 
who smoked and had little antenatal care. The second mother had gastric stapling in 
mid pregnancy before she knew she was pregnant. She lost weight after the 
procedure. The baby died in utero in late pregnancy. The placenta showed 
uteroplacental insufficiency. 

  Fetal growth restriction   two stillbirths and one neonatal death. 

One mother had a history of smoking, substance use and infections in pregnancy. 
The second mother had no antenatal care and went into labour and delivered a 
growth restricted stillborn baby at 26 weeks. There was evidence of uteroplacental 
insufficiency and thrombophilia. The third mother was a smoker who went into 
spontaneous labour at 22 weeks. There was evidence of chorioamnionitis and 
funisitis. 

  Spontaneous preterm   four neonatal deaths. 

One mother was a smoker and had no antenatal care. She had a urinary tract 
infection and went into spontaneous labour in mid pregnancy. Mycoplasma hominis 
was cultured from the fetal lungs and stomach, the placenta and vagina. A second 
mother went into spontaneous labour at 23 weeks. Mixed organisms were grown 
from the placenta. The third mother was a smoker, who was anaemic and had many 
other medical conditions. She presented at 23 weeks with preterm prelabour rupture 
of membranes followed by spontaneous labour a few days later. The fourth mother 
was also a smoker and had no antenatal care. She also had preterm prelabour rupture 
of membranes at 23 weeks. Labour was induced several days later as chorioamnionits 
developed. 

  Unexplained antepartum death   two stillbirths.  

Both mothers were anaemic and experienced intrauterine deaths, one in mid 

pregnancy and the other in the third trimester.
 

In 2007, the perinatal mortality rate for births to Aboriginal mothers was 27.1 per 1,000 
births compared with 9.0 per 1,000 births for non Aboriginal mothers.  

25 



The proportion of Aboriginal women who smoked during pregnancy in 2007 remained 
much higher than among non Aboriginal women (59.0% compared with 15.1%). 

The proportions of preterm births and small for gestational age births for Aboriginal 
mothers were also considerably higher than for non Aboriginal mothers (19.2% v 8.2% 
and 20.6% v 8.5% respectively). Overall the proportion of low birthweight births for 
Aboriginal mothers also remained much higher than that for non Aboriginal births 
(17.6% v 6.6%).   

(3) Autopsies in perinatal deaths 
Autopsies were performed in 88 of the 188 perinatal deaths (46.8%). Five of the 
autopsies were limited, which is defined as autopsies that include a detailed 
external examination of the body and growth parameters, radiological survey, 
placental histology, and examination and dissection of one or more cavities 
(such as chest and/or abdomen) or organs, but not the whole body.  
Microbiology and/or cytogenetic studies may have been undertaken with 
consent.  Before 2004 a small number of cases which had external examination 
of the body and growth parameters, radiological survey and placental histology 
only were included as having autopsies. In 2007, such examinations were 
performed in 12 perinatal deaths which did not have autopsy. All of these were 
undertaken in metropolitan level III hospitals. 

The distribution of autopsies by place of death is presented in Table 12.  

Table 12:  Autopsy status* of perinatal deaths by place of death, South Australia, 2007  

Place of death 
Deaths Autopsies performed* 
Number Number Percent of deaths 

Metropolitan Level III** hospitals (teaching) 132 50* 37.9 
Other metropolitan teaching hospitals 22 14 63.6 
Metropolitan private hospitals 18 12 66.7 
Country hospitals 10 9 90.0 
Home 4 2 50.0 
Interstate hospitals 1 0 0 
Unknown 1 1 100.0 
Total 188 88* 46.8 

*	 Includes 5 limited autopsies 

**	 Levels as defined in  Operational Policy, Guidelines and Standards for Maternal and Neonatal Services in South 
Australia. Adelaide: Department of Human Services, January 2000 . 

Placental histological examination was undertaken in 167 perinatal deaths 
(88.8%) in 2007.  

The falling proportion of autopsies in perinatal deaths is of concern. A good 
quality autopsy is invaluable in confirming antenatal diagnoses, eliciting other 

26 



findings of clinical significance, particularly significant negative ones, and 
determining the time course of events leading to death.4 5 It may thus be 
invaluable in alleviating parental guilt, helping with the grieving process and 
parental counselling, and gaining understanding of the patterns and evaluation 
of fetal and neonatal disease.  Parental permission should therefore be sought as 
often as possible.   

Medical practitioners are advised that the State Perinatal Autopsy Service is 
available at no cost to the parents and this includes transportation and return of 
the body from the place of death, including country regions.  This Service may 
be contacted by telephone.  The number is (08) 8161 7333. 

All hospitals with maternity services will have received a folder with 
information on the Service. The Department of Health has produced an Autopsy 
Request and Authority form for use for all non coronial autopsy examinations 
together with a booklet entitled  The Hospital Autopsy Process. When a person 
dies     information for family and friends.  These forms should be used and are 
available from the Perinatal Autopsy Service (Phone (08) 8161 7333). 

4 Gordijn SJ, Erwich JJ, Khong TY. Value of the perinatal autopsy: critique. Pediatr Dev Pathol 

2002;5:480 488. 

5 Becher JC, Laing IA, Keeling JW, McIntosh N. Restoring high neonatal autopsy rates. Lancet 

2004;364:2019 2020. 

27 



3. Causes of post-neonatal deaths 2007 
In 2007 there were 28 post neonatal deaths notified of infants born in South 
Australia. Autopsies were performed in 15 of the 17 coronial cases (88.2%). Only 
one autopsy was performed in the remaining 11 non coronial cases. The 
autopsy rate was thus 57.1% (16 out of 28 cases) for post neonatal deaths in 
2007.  The causes of death are presented in Table 13, together with comparative 
statistics for 1986   2006. There are now significantly more deaths classified as 
due to  other  cause. In addition to a true reduction in SIDS deaths over time, 
this also probably reflects the way the Committee is now applying a more 
stringent definition of SIDS to the classification of infant deaths. 

Table 13:  Causes of post neonatal deaths, South Australia, 1986   2007 

Causes of death 
1986   2006 2007 

Number Percent Number Percent 
SIDS 323 39.4 0 0 
Congenital abnormalities 176 21.5 7 25.0 
Conditions originating in the perinatal period 105 12.8 6 21.4 
Accidents, poisonings and violence 79 9.6 5 17.9 
Infections 65 7.9 1 3.6 
Other 72 8.8 9 32.1 
Total 820 100.0 28 100.0 

Among the 28 post neonatal deaths in 2007, there were 18 males and 10 females.  
One infant was a twin. Eleven infants (39.3%) were born preterm.  The 
distribution by age at death of the 28 infants (Figure 10) shows that most of the 
deaths occurred in the earlier months of the post neonatal period.  Two of the 28 
post neonatal deaths (7.1%) were children of Aboriginal mothers. 

28 



Figure 10: Age Distribution of Post neonatal Deaths, South Australia, 2007 


8
 

0 
1 

2 
3 
4 

5 

6 
7 

N
u

m
be

r 
o

f d
ea

th
s 

1 2 3 4 5 6 7 8 9 10 11 
Age in months 

(1) Congenital abnormalities 
Congenital abnormalities accounted for seven post neonatal deaths (25.0%) in 
2007.  Three infants were born at term. The abnormalities were as follows: 

  Encephalopathy of unknown cause in a preterm infant with anaemia; 

  Hypoplastic left heart syndrome; 

  Multiple complex cardiovascular abnormalities including total anomalous 
pulmonary venous drainage, with asplenia and abdominal situs inversus; 

  Multiple abnormalities in four infants. One was considered to have 
VACTERL association (vertebral anomalies, anal atresia, cardiac defects, 
tracheo esophageal fistula, renal anomalies, limb reduction defects). 
Another had Zellweger syndrome, a rare disorder characterised by the 
reduction or absence of peroxisomes, cell structures which rid the body of 
toxic substances, in the cells of the liver, kidneys and brain. A third infant 
had Schinzel Giedion syndrome, an autosomal recessive condition with 
dysmorphism and including central nervous system and renal 
abnormalities.  

(2) Conditions originating in the perinatal period 
There were six deaths in this group. All but one were preterm births.  

Four of these deaths followed spontaneous preterm labour or rupture of 
membranes.  

One mother experienced preterm prelabour rupture of membranes at 15 weeks 
gestation. The pregnancy was monitored with serial ultrasounds and 
betamethasone was given for fetal lung maturity. Labour was induced at 29 
weeks for hypertension and oligohydramnios and caesarean section performed 

29 



for failure to progress in labour. The infant suffered prematurity complications 
and died of respiratory failure from severe pulmonary hypoplasia. 

The second mother went into preterm labour at 29 weeks with a twin 
pregnancy. This twin experienced the complications of prematurity and died of 
periventricular leucomalacia with extensive cystic degeneration of the brain. 

The infant of the third mother was born at 25 weeks after prolonged preterm 
prelabour rupture of membranes and died of chronic lung disease at five 
months of age. 

A fourth infant born at 23 weeks gestation after spontaneous labour also 
suffered severe chronic lung disease with profound hypoxic episodes and died 
of multiorgan failure. 

One death was associated with growth restriction. This pregnancy was 
complicated from seven weeks gestation by recurrent episodes of bleeding. 
Fetal growth restriction was detected at 22 weeks and the pregnancy monitored 
by serial ultrasound. Caesarean section was performed at 27 weeks for 
abruption and fetal growth restriction. The infant experienced many 
complications of prematurity and died of severe chronic lung disease at six 
months. 

One death in this group was attributed to a specific perinatal condition, 
persistent fetal circulation. This infant was born at term and appeared well until 
it was one month of age, when it developed severe respiratory distress with 
cyanosis and rapid deterioration to cardiac arrest. Autopsy demonstrated 
cardiomegaly complicating pulmonary hypertension with muscularisation of 
the walls of intraparenchymal pulmonary arteries. 

(3) Infection 
This 11 month old infant s death was attributed to Streptococcus pneumoniae 
meningitis demonstrated at autopsy. The infant had been unwell for two days 
with poor feeding and a low grade fever. There was one episode of vomiting. 
The infant was found pale and lifeless after being put to bed. 

(4) Accidents, poisonings and violence 
There were five deaths in this group. 

A 10 month old infant died of hypoxic ischaemic encephalopathy following 
submersion in water into which its stroller accidentally rolled. 

An 11 month old infant died of a subarachnoid haemorrhage and brain injury 
subsequent to pulling over a bedside lamp, separating it from its shade, and 
landing on its metal frame struts. 

A seven month old infant died of injuries sustained in a collision between a boat 
and a channel marker. The infant was being carried in its parent s arms on the 
boat and both were pitched against the dashboard in the accident. 

30 



Two infants died of accidental asphyxia. A 10 month old infant was co sleeping 
with a family member who was unconscious from an overdose of medication. A 
five month old infant was placed to sleep in a cot with soft bedding which 
sagged. It was found prone with its face in a pillow. It appeared likely that this 
infant s face was trapped in a trough formed by the canvas base of the cot. 

(5) Other causes 
There were nine deaths of undetermined cause, two of which occurred in Aboriginal 
infants. 

One infant was born preterm and spent two months in hospital. At six months 
of age it was placed to sleep on a beanbag where it was found cyanosed. 

Another infant was born mildly preterm. It was irritable for two days before its 
death at one month of age. It was placed to sleep in its pram which had a soft 
concave base. It was found lifeless and appeared to have been in the prone 
position for some time. 

Another one month old baby was co sleeping with its parents who had been 
drinking alcohol. The infant was found lifeless beside a parent. 

Another one month old infant was placed to sleep in a pram in a warm
 
environment and found lifeless shortly after. Overheating may have been a 

factor.  


A five month old infant had been growth restricted in utero. There was a 
background of parental smoking and substance abuse. It had been ill with a 
respiratory infection. It was placed to sleep under a blanket in a warm and 
humid room. Overheating may have been a factor in the death. 

The sixth infant had a parental history of alcohol consumption and smoking. At 
one month of age, it was found lifeless in a cold room in which it had been 
placed to sleep. Hypothermia may have contributed to its death.  

A three month old infant had a background of family smoking and drug use. It 
was co sleeping and found lifeless with evidence of being in the prone position. 

Another rather large three month old infant was found with its face partially 
submerged in a soft quilt, close to the side of its cot. There was some anterior 
lividity. 

The ninth infant was two months of age and co sleeping between its parents. 
There was a history of parental smoking and heavy alcohol consumption. Some 
organisms were cultured from the blood and a lung swab and there was a focal 
necrotic area in the brain. 

In 2007, there were no deaths attributed to SIDS. One of the reasons for this may 
be that in more recent years the Committee has not attributed deaths to SIDS 
where unsafe sleeping arrangements were present. In some of the deaths 
attributed to SIDS in the past, there may have been circumstances such as co 

31 



sleeping, which raise the possibility that some of these deaths may have been 
due to accidental asphyxia.  As the autopsy findings in cases of asphyxia in 
infants may be identical to those found in SIDS, differentiation of these entities 
may be extremely difficult.  

For this reason comprehensive death scene examination and parental 
interview by trained personnel have become essential features in the 
assessment of unexpected infant death. Cases have occurred in South 
Australia where both accidental and non accidental asphyxia have been 
initially incorrectly diagnosed as SIDS due to the non specificity of autopsy 
pathology.  Pertinent information may assist in formulating an initially 
correct diagnosis. 

32 



Sudden Unexpected Deaths in Infancy (SUDIs) 

Sudden deaths from the three categories of SIDS, accidental asphyxiation and 
undetermined cause have been included as  Sudden Unexpected Deaths in 
Infancy . The distinction between these deaths is quite difficult and may be 
arbitrary. Over the last few years there have been about 10 such sudden 
unexpected post neonatal deaths a year. There has been no reduction in these 
deaths between 1998 and 2007. 

In 2007, there were 11 such deaths in South Australia. They consisted of: 

SIDS   no deaths; 

Accidental asphyxiation   two deaths;  

Undetermined cause   nine deaths. 

The following were some risk factors associated with the deaths: 

Unsafe bedding   seven deaths; 

 Smoking among close family members   seven deaths; 

Not breast fed at time of death   five deaths; 

Prone position   four deaths; 

Co sleeping   four deaths; 

Maternal depression   four deaths ; 

Teenage mother   four deaths; 

Heavy consumption of alcohol by family members   three deaths. 

These deaths are potentially preventable. The Committee has previously 
recommended the renewal of a major public health campaign about safe 
sleeping practices and prevention of sudden unexpected deaths of infants and 
is pleased that this will be implemented. 

Deaths of babies born interstate 

There were two post neonatal deaths of infants born interstate or overseas in 
South Australia in 2007.  One was an Aboriginal baby who died at one month of age of 
central nervous system and cardiac abnormalities. Another infant aged nine months 
suffered head and crush injuries in a motor vehicle accident. 

33 



IV Recommendations 

1. Maternal Subcommittee recommendations 
New recommendations 

1.	 Blood pressure should be monitored for six weeks to three months after 
birth or until it has settled, if a diagnosis of pre eclampsia has been made. 

2.	 Non steroidal anti inflammatory drugs should be avoided in women with 
pre eclampsia. 

Recommendations from earlier years 

The year in which the recommendation was first made is provided in
 
parentheses. 


1. 	 The care of women with current or previous serious conditions during 
pregnancy should only be undertaken in settings which are equipped to 
deal appropriately with such situations (2002). 

2. 	 Strong consideration should be given for review by a physician early in 
pregnancy of women with current or previous serious medical conditions 
(2003). 

3. 	 Pregnant women travelling in motor vehicles need to wear seat belts at all 
times for safety (1991, renewed in 2001). The South Australian Department 
of Transport, Energy and Infrastructure recommends that the lap part of the 
seat belt should be worn as low as possible, below the unborn child. It 
should be over the upper thighs and across the pelvis. The sash part of the 
seat belt passes above the stomach and between the breasts.6 The seat belt 
should be worn at all times when the vehicle is in motion.  

2. Perinatal Subcommittee recommendations 
New recommendations 

1. 	 Once a decision to perform an emergency caesarean section has been made, 
it is recommended that fetal monitoring should continue until the 
commencement of surgery. 

2.  When feto maternal haemorrhage is suspected, flow cytometry should be 
considered to estimate the volume as it is more precise than the Kleihauer 
test. 

6 South Australian Department for Transport, Energy and Infrastructure. Seat belts and pregnancy. 

Adelaide. November 2006. www.stopthink.sa.gov.au 

34 



3.  A previous caesarean section is a contraindication for home birth. 

Recommendations made in earlier years remain pertinent. 

The year in which the recommendation was first made is provided in 
parentheses. 

1. 	 It is important to care for pregnant women in a setting that is appropriate 
for the level of risk the pregnancy presents for the mother and/or the baby. 
For example, women with severe hypertension or insulin dependent 
diabetes should be managed in at least a level II hospital with 24 hour on 
site medical cover (2002). Planned home birth for twins, breech 
presentations and post term infants is associated with unacceptably high 
risks.7,8  (2004). Similarly, women with serious maternal conditions should 
be cared for in hospitals with adequate comprehensive adult services (2006).  

2. 	 Pregnant women with a Body Mass Index (BMI) greater than 35 are at 
higher risk from anaesthesia.9 A timely referral for an anaesthetic 
consultation should be considered for women with a high BMI (2005). 

3. 	 Implementation of effective strategies to reduce smoking in pregnancy10 

remains important (2002), including culturally appropriate smoking cessation 
interventions for Aboriginal women (2004). 

4. 	 Testing the antibody status of Rhesus D negative women before the first 
administration of Anti D is important. A measurable titre of Anti D 
antibodies is an indicator of potential alloimmunisation and always requires 
investigation and a specialist opinion (2006). 

5. 	 Early ultrasound determination of chorionicity is advised for twin 
pregnancies, followed by further surveillance for twin twin transfusion in 
monochorionic pregnancies (2005). 

6. 	 Vigilance is required in the recognition of fetal growth restriction. Fetal 
growth restriction was considered the cause of death for 11.2% of perinatal 
deaths in 2007.  Practitioners are asked to be vigilant so that fetal growth 
restriction is not missed (2002). 

7 Bastian H, Keirse MJNC, Lancaster PAL. Perinatal death associated with planned home birth in 

Australia: population based study. BMJ 1998; 317: 384 388. 

8 Mehl Madrona L, Mehl Madrona M. Physician  and midwife attended home births. Effects of breech, 

twin, and post dates outcome data on mortality rates. J Nurse Midw 1997; 42:91 98 

9 Confidential Enquiries into Maternal and Child Health. Why mothers die 2000 2002. The Sixth Report 

of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press, 

CEMACH 2004: http://www.cemach.org.uk (accessed November 13 2008). 

10 Lumley J, Oliver SS, Chamberlain C, Oakely L. Interventions for promoting smoking cessation during 

pregnancy. Cochrane Database of Systematic Reviews 2004, Issue 4.Art. No.: 

CD001055.DOI:10.1002/14651858.CD001055.pub2. 

35 



7. 	 Appropriate training and maintenance of competence in cardiotocograph 
(CTG) interpretation for all levels of medical and midwifery staff (2000). 

8. 	 The institution of streamlined arrangements between rural/level I hospitals 
and their regional level II/III maternity service in situations where there is a 
lack of on site CTG expertise (2000). This includes easier access of rural 
practitioners to the consultant on call (2005). 

9. 	 Appropriate antibiotic treatment for carriers of Group B Streptococcus and 
for women with risk factors, such as prolonged rupture of membranes 
(2004). 

10.  When induction of labour is deemed necessary in the presence of a uterine 
scar and an unripe cervix, careful consideration should be given to 
alternative options, such as postponing the induction or caesarean section 
(2005). 

11.  Further development and implementation of the statewide perinatal 
protocols is recommended (www.health.sa.gov.au/ppg) (2000). 

12.  The Committee recommends use of the South Australian protocol for 
investigating stillbirths including a systematic approach to investigate the 
potential involvement of thrombophilias (Appendix 8) (protocol published 
in 1998, recommendation made after revision in 2002). This statewide 
protocol for the investigation of all stillbirths has been sent to all maternity 
units in South Australia (2000). 

13.  Autopsy often provides considerable information that is not available 
otherwise and should be strongly recommended (1992). The continuing 
decrease in the autopsy rate in perinatal deaths over the past few years 
remains a serious concern. When parents decline autopsy, we recommend 
that photographic and X ray documentation be obtained (2003). It is also 
important to document the clinical appearance of the infant in the case 
record in all cases of perinatal death (2004). The State Perinatal Autopsy 
Service is available at no cost to parents, including parents in country 
areas, and may be contacted on (08) 8161 7333 (2006). 

14.  Placentas should be sent for examination in all cases of perinatal death 
(2003) and should be accompanied with all relevant clinical information. 
(See Appendix 9) (2006). 

15.  The Subcommittee also recommends the use of the birthweight for 
gestational age percentile charts for singletons11 and twins12 prepared using 

11 Roberts CL, Lancaster PAL. Australian national birthweight percentiles by gestational age. Med J 

Aust 1999; 170:114 118. 

12 Roberts C, Lancaster P. National birthweight percentiles by gestational age for twins born in 

Australia. J Paediatr Child Health 1999; 35:278 282. 

36 



national perinatal data, which are available on the PSANZ website with the 
PSANZ perinatal death classifications (www.psanz.org.au) (1998). The 
singleton charts have been reproduced in Appendix 10 with the permission 
of the Medical Journal of Australia. 

3. Post-neonatal Subcommittee recommendations 
New recommendations 

In reviewing the causes of death in 2007 and other recent years, the Committee 
has been concerned about the number of deaths in which adverse factors such 
as smoking, alcohol and substance abuse, bed sharing when intoxicated, 
physical abuse and poor social circumstances are present. The Committee has 
also noted the decline in the number of deaths from SIDS but the corresponding 
significant contribution to post neonatal mortality of SUDIs, which include 
SIDS, deaths from accidental asphyxiation and deaths of undetermined cause.  

The Committee therefore recommends: 

The collecting of statistics on factors associated with SUDIs to assist strategies 
aimed at prevention of both SIDS and SUDIs. 

Recommendations made in earlier years 

The year in which the recommendation was first made is provided in
 
parentheses.
 

1. 	 Health professionals providing care both in the antenatal and postnatal 
period should ensure that all parents and carers are provided with 
information about safe infant sleeping practices and prevention of sudden 
unexpected deaths in infancy (1996). 

  Babies should be placed on their backs to sleep.  Sleeping supine is not 
contraindicated in babies with gastro oesophageal reflux (1998).   

  Falling asleep with the infant at the breast may be hazardous (1996). 
Other forms of co sleeping or bed sharing may be hazardous, particularly 
if the adults are intoxicated or sedated (see Appendix 11) (1993). 

  Potential hazards must be removed from the infant s sleeping 
environment. Babies must not be placed in cots with pillows, U pillows, 
cot bumpers, large soft toys, thick blankets or quilts or any other items 
which may overheat or suffocate the infant (1993).  

  Infants should not be left to sleep unattended in stroller prams or 
bouncinettes (1993). 

  Ensure that all new cots meet Australian Standards and only use old ones 
which do. Mattresses which do not fit cots properly should not be used, 

37 



especially in cots that have unsupported webbing. Do not use very soft 
mattresses or inflatable mattresses which may vary in their firmness and 
present spaces in which an infant s head or face may be trapped (1993). 

  Care should be taken when placing infants to sleep on mattresses on the 
floor as infants may roll off and become wedged (2006). 

The Committee is concerned about the number of sudden unexpected infant 
deaths in the last few years, many of which are associated with excessive or 
inappropriate bedding or other unsafe sleeping practices. We have 
recommended a repeat major public health campaign on safe infant sleeping 
and prevention of sudden unexpected deaths of infants and are very pleased 
that this will be implemented.  

2. 	 An effective system of appropriate and ongoing support, supervision and 
referral should be offered to families with known risk factors for adverse 
child outcome, such as parental substance abuse, parental psychiatric 
illness, household violence, extreme youth of the mother and poor social 
circumstances. This should be continued at least throughout the first year of 
life, if not for a longer period of time (1997). 

3. 	 Systems to facilitate referral by community nurses of high risk children to 
paediatricians or tertiary hospitals for urgent appointments need to be 
considered (2006). 

4. 	 Recording and charting of child s weight. 
The Subcommittee stresses the importance to both parents and health 
professionals of recording the child s weight in the Personal Health Record 
(Blue Book) and charting the weight on the percentile growth charts to 
identify children who are not thriving. It is important to investigate why a 
child is not thriving (2001). Any child who is not thriving should be referred 
to a medical practitioner (2003). 

5. 	 The Subcommittee stresses the importance of immunisation in the 
prevention of infectious disease in children (2001). There is some evidence 
that there is a reduced rate of SIDS in immunised compared with non 
immunised children13. 

6. 	 Vigilance is needed to ensure that potential hazards in the home are 
removed from the infant s environment. These include long hanging curtain 
cords, which may catch around the neck, and water in containers or baths in 
which an infant may drown (1998). Infants should never be left unattended 
in a bath or near water, even for a minute (1993). This applies also to water 
features in gardens (2005). Parents should not be reassured by the presence 
of an older sibling in the bath with the infant (2004). This warning also 

13 Mitchell EA, Stewart AW, Clements M, Ford RPK, on behalf the New Zealand Cot Death Study 

Group. Immunisation and the sudden infant death syndrome. Arch Dis Child 1995;73:498 501. 

38 



applies to infants placed in devices such as ring bath seats (2002). These 
devices have been banned in some Australian states due to deaths from 
drowning associated with their use.  

7. 	 Vigilance is always needed to ensure safe feeding for children under four 
years of age. Foods which can break off into pieces and cause choking 
should not be given, e.g. raw carrot, celery sticks, grapes, pieces of apple, 
cherry tomatoes, sausages, frankfurts, popcorn, nuts, hard lollies and corn 
chips. Food for toddlers should be finely chopped. Children should be 
supervised while eating. If they run, play, laugh or cry while eating, they 
are more likely to choke on their food (2001). The Committee was pleased to 
note that there were no deaths in 2007 from feeding accidents. 

8. 	 Consideration should be given to better ways of identifying serious 
underlying illness in children presenting to clinicians, for example, by 
Medic Alert bracelets (2005). 

9. 	 Hospitals with high levels of paediatric throughput need provision of 24 
hour paediatric expertise. Appropriate protocols regarding detection and 
management of potentially life threatening paediatric conditions need to be 
developed, reviewed, distributed to and supported by all hospitals treating 
children (2004). 

10.  Urgent medical advice should be sought for all infants who are excessively 
drowsy, irritable and/or are feeding poorly. These infants, who may not be 
showing the classical signs of infection, should be considered seriously ill 
until proven otherwise. Small infants also become dehydrated very rapidly 
(1992). Health professionals are reminded that intravenous fluids are 
lifesaving for any sick infant. Infants with cyanotic heart disease are more 
prone to the complications of dehydration and specialist advice should be 
sought (2004). Urgent retrieval may be necessary for any infant who is 
thought to be suffering from a significant bacterial infection (2003). The 
Subcommittee notes that infection remains an important cause of infant 
death.  

11.  The Committee recommends that further research be undertaken on the 
incidence of community acquired Methicillin Resistant Staphylococcus 
Aureus (MRSA) infections to help guide clinical practice in terms of 
antibiotic choice in sick children.  This may include setting up systems to 
make hospital and community acquired MRSA infection a notifiable 
communicable disease (2005). 

Reporting of deaths to the State Coroner 

The following are some categories of death which must be reported to the State 
Coroner under The Coroner s Act 2003 (www.austlii.edu.au/): 

  a death by unusual, unexpected, unnatural, violent or unknown cause.  

39 



  a death during, as a result of or within 24 hours of a surgical, invasive or 
diagnostic procedure including the administration of an anaesthetic for the 
carrying out of the procedure. 

  a death within 24 hours of being discharged from a hospital or having 

sought emergency treatment at a hospital. 


  a death in a hospital or treatment facility for the treatment for a drug 

addiction. 


  a death of a child subject to a custody or guardianship order under the
 
Children s Protection Act 1993. 


  a patient death in an approved treatment centre under the Mental Health 
Act 1993.  

The Committee would like to draw attention once again to the importance of 
autopsy in eliciting the cause of death. This cause of death should always be 
carefully recorded in the maternal medical record for future pregnancies. 

There have been several cases in which autopsy has identified a previously 
unsuspected cause of death.  This is most valuable in the management of future 
pregnancies and counselling of parents, including grief counselling.  A detailed 
examination of the death scene by appropriately trained personnel in cases of 
unexpected death is also essential in eliciting causative or potentially 
contributory factors.  Standard protocols such as those developed by SAPOL 
(South Australian Police) and SIDS and Kids South Australia should be used in 
those circumstances. 

The Maternal, Perinatal and Infant Mortality Committee would also like to 
draw attention to four websites that offer important information: 

  The South Australian Pregnancy Information website of the Department of 
Health: www.health.sa.gov.au/pregnancy 

  The South Australian Perinatal Practice Guidelines website:  

www.health.sa.gov.au/ppg
 

  The SIDS website is www.sidsandkids.org from which hospital staff may 
print information in different languages. 

  The South Australian Parenting and Child Health website www.cyh.com.au 
of Child and Youth Health. 

This Committee report is also available on the Department of Health Pregnancy 
Outcome Unit s website: www.health.sa.gov.au/pehs/pregnancyoutcome.htm. 

40 



V Education Subcommittee Report 
The twelfth annual educational meeting, organized by the Education 
Subcommittee of the Maternal, Perinatal and Infant Mortality Committee, was 
held on the evening of 1st October 2008.  

This was the second year in which the meetings have been named  The Annual 
Dr Brian Pridmore Perinatal Forum  in memory of the late Dr Brian Pridmore. 
Dr Pridmore chaired the first meetings which commenced in 1997 to facilitate a 
recommendation that private perinatal units in the metropolitan area be 
involved in some form of regular peer review and continuing professional 
education for their midwifery and medical staff.  The enthusiastic response to 
the meetings from midwives and medical practitioners led to their expansion to 
include personnel from all the perinatal services within the state.  

The desire to conduct these meetings on a regular basis led to the formation of 
the Education Subcommittee. The intention was also to allow a forum for 
dissemination of findings and recommendations from the Maternal, Perinatal 
and Infant Mortality Committee to practitioners. 

The topic of the twelfth meeting was intrapartum anaesthesia and analgesia and 
was titled  Pain Pain Go Away?  It was held at the Women s and Children s 
Hospital. Two clinical scenarios were presented to cover issues such as 
complications of epidural blocks, asymmetrical blocks, obesity as a complicating 
factor, most appropriate drugs for different stages of labour and neonatal 
resuscitation. Dr Marion Andrew presented the latest research findings on oral 
intake in labour. An electronic voting system was used to display audience 
responses to questions. The responses generated an interactive discussion 
between the panel members and the audience of 67 people. The session was not 
intended to include the non pharmaceutical methods of pain relief in labour, 
which is a topic warranting a separate session. 

The panel members were Dr Marion Andrew (anaesthetist), Dr Anthony Colby 
(anaesthetist), Dr Steven Scroggs (obstetrician), Ms Liuda Stalba Smith 
(midwife) and Dr Anthony Chitti (paediatrician). The audience included 
anaesthetists, obstetricians, obstetric registrars, midwives working in a range of 
settings, general practitioners and midwifery students.  

Dr Brian Wheatley, Chair of the Education Subcommittee directed the audience 
to the website for the annual Committee report and the section with the 
Committee recommendations, encouraging those present to read them.  

The Subcommittee thanks the panel and participants for their continued 
support of what will continue to be an important part of perinatal services 
within South Australia. 

41 



APPENDIX 1 

Terms of reference, Subcommittees of the Maternal, Perinatal and Infant 
Mortality Committee 

Maternal Subcommittee 

1. 	 To review the causes of death associated with pregnancy and childbirth; to 
determine whether these may have been preventable, and to establish what 
were the avoidable factors, if any, presented in the case history. 

2. 	 To report to the Maternal, Perinatal and Infant Mortality Committee. 

3. 	 To undertake review, educational and advisory roles as appropriate from 
time to time, by initiation or by invitation. 

Perinatal Subcommittee 

1. 	 To review each perinatal death from an obstetric, paediatric and
 
pathological perspective and to collate this information. 


2. 	 To determine and monitor the epidemiology of perinatal deaths in South 
Australia. 

3. 	 To identify avoidable factors and confidentially provide feedback 

information to clinicians. 


4. 	 To identify areas which need special study and/or action. 

5. 	 To liaise with other national and international perinatal mortality study 
groups. 

6. 	 To report to the Maternal, Perinatal and Infant Mortality Committee. 

Post neonatal Subcommittee 

1. 	 To review the causation of post neonatal deaths in South Australia. 

2. 	 To prepare education commentaries for inclusion in the Annual Report of 
the Maternal, Perinatal &amp; Infant Mortality Committee. 

3. 	 To report to the Maternal, Perinatal and Infant Mortality Committee. 

4. 	 To liaise with other national and international mortality study groups. 

5. 	 To set priorities for special studies into causes of death in this age group. 

Education Subcommittee 

1. 	 To provide an annual interactive forum for the continuing education of 
midwives and medical practitioners involved in the provision of perinatal 
services within the metropolitan and regional South Australia. 

42 



2. 	 To act as an additional means of communication to the above providers, 
other health professionals and the community generally from the other 
subcommittees of the Maternal, Perinatal and Infant Mortality Committee. 

3. 	 The membership and chairperson will be nominated by the chairperson of 
the Maternal, Perinatal and Infant Mortality Committee. 

4. 	 The membership shall consist of: 

  An obstetrician in metropolitan private practice. 

  A neonatal paediatrician in metropolitan private practice. 

  A midwife from the metropolitan private hospital services. 

  An epidemiologist / medical secretary from the Pregnancy Outcome Unit. 

5. 	 The Subcommittee may co opt members as required. 

43 



APPENDIX 2A 
Medical Certificate of Cause of Perinatal Death 

44
 



APPENDIX 2B 
Doctor s Certificate of Cause of Death 

45
 



46
 



APPENDIX 3 

Definitions 

Live birth: the complete expulsion or extraction from its mother of a product of 
conception, irrespective of the duration of pregnancy, which after such 
separation breathes or shows any other evidence of life, such as beating of the 
heart, pulsation of the umbilical cord or definite movement of voluntary 
muscles, whether or not the umbilical cord has been cut or the placenta is 
attached. 

Stillbirth: birth of a fetus at or after 20 weeks gestation and/or with a 

birthweight of 400g or more, with no signs of life at birth. 


Women who gave birth: women who gave birth after a pregnancy ending with 
the birth of one or more live births and/or stillbirths. 

Maternal death is defined as the death of a woman while pregnant or within 42 
days of termination of pregnancy, irrespective of the duration and the site of the 
pregnancy, from any cause related to or aggravated by the pregnancy or its 
management, but not from accidental or incidental causes.14 

Maternal deaths are classified as follows: 

1. 	 Direct obstetric deaths: those resulting from obstetric complications of the 
pregnant state (pregnancy, labour and puerperium), from interventions, 
omissions, incorrect treatment, or from a chain of events resulting from any 
of the above. 

2. 	 Indirect obstetric deaths:  those resulting from previous existing disease or 
disease that developed during pregnancy and which was not due to direct 
obstetric causes, but which was aggravated by physiologic effects of 
pregnancy. 

3. 	 Incidental deaths in pregnancy: examples of incidental deaths are deaths 
from drowning and road accidents, where the pregnancy is unlikely to have 
contributed significantly to the death, although it may be possible to 
postulate a remote association. 

In order to avoid missing indirect deaths which may be difficult to distinguish 
from incidental deaths occurring in pregnant women, the Maternal, Perinatal 
and Infant Mortality Committee reviews all deaths in pregnancy and within 42 
days of the end of pregnancy. However, only direct and indirect deaths 

14 World Health Organization. International Statistical Classification of Diseases and Related Health 

Problems. Tenth Revision. Volume 2. Geneva: WHO, 1993. 

47 



(pregnancy related deaths) are included in the calculation of the maternal 
mortality ratio. 

Maternal mortality ratio: 

Number of direct and indirect maternal deaths in a year 
=  100,000 

Number of women who gave birth in the same year 

Stillbirth rate: 

Number of stillbirths in a year 
=  1,000 

Number of livebirths and stillbirths in the same year 

Neonatal death: death of a liveborn infant within 28 days of birth 

Neonatal death rate: 

Number of neonatal deaths in a year 
=  1,000 

Number of livebirths in the same year 

Perinatal death: includes stillbirth and neonatal death. 

Perinatal mortality rate: 

Number of stillbirths + neonatal deaths in a year 
=  1,000 

Number of stillbirths + livebirths in the same year 

Post neonatal death: death of a liveborn infant occurring between 28 days and 
the first birthday 

Post neonatal death rate: 

Number of post - neonatal deaths in a year 
=  1,000 

Number of livebirths in the same year 

Infant death: death of a liveborn infant within the first year of life 

Infant deaths include neonatal and post neonatal deaths.  

Infant mortality rate: 

Number of infant deaths in a year 
=  1,000 

Number of livebirths in the same year 

Sudden Infant Death Syndrome (SIDS): The sudden unexpected death of an 
infant less than one year of age, with onset of the fatal episode apparently occurring 
during sleep, that remains unexplained after a thorough investigation, including 
performance of a complete autopsy and review of the circumstances of death and 
the clinical history.15 

15 Krous HF, Beckwith JB, Byard RW, Rognum TO, Bajanowski T, Corey T et al. Sudden infant death 

syndrome and unclassified sudden infant deaths: a definitional and diagnostic approach. Paediatrics 

2004;114(1):234 8. 

48 



APPENDIX 4 

Perinatal Society of Australia and New Zealand-Perinatal Death 
Classification (PSANZ-PDC), SA perinatal deaths, 2007 

No. % 
1. CONGENITAL ABNORMALITY(including terminations for congenital 

abnormalities) 61 32.4 

1.1 Central nervous system 12 6.4 
1.2 Cardiovascular system 9 4.8 
1.3 Urinary tract 4 2.1 
1.4 Gastrointestinal tract 0 0 
1.5 Chromosomal 15 8.0 
1.6 Metabolic 0 0 
1.7 Multiple/ non chromosomal syndromes 11 5.8 
1.8 Other 10 5.3 

1.81 Musculoskeletal 8 
1.82 Respiratory 0 
1.83 Diaphragmatic hernia 1 
1.84 Haematological 0 
1.85 Tumours 0 
1.88 Other specified congenital abnormality 1 

1.9 Unspecified 0 0 
2. PERINATAL INFECTION 14 7.4 

2.1 Bacterial 9 4.8 
2.11 Group B Streptococcus 3 
2.12 E coli 4 
2.13 Listeria monocytogenes 0 
2.14 Spirochaetal, e.g. Syphilis 0 
2.18 Other bacterial 1 
2.19 Unspecified bacterial 1 

2.2 Viral 3 1.6 
2.21 Cytomegalovirus 2 
2.22 Parvovirus 1 
2.23 Herpes simplex virus 0 
2.24 Rubella virus 0 
2.28 Other viral 0 
2.29 Unspecified viral 0 

2.3 Protozoal e.g. Toxoplasma 0 0 
2.5 Fungal 0 0 
2.8 Other specified organism 0 0 
2.9 Other unspecified organism 2 1.1 

49 



No. % 
3. HYPERTENSION 4 2.1 

3.1	 Chronic hypertension: essential 
3.2	 Chronic hypertension: secondary, e.g. renal disease 
3.3	 Chronic hypertension: unspecified 
3.4	 Gestational hypertension 
3.5	 Pre-eclampsia 

3.51 With laboratory evidence of thrombophilia 
3.6 Pre-eclampsia superimposed on chronic hypertension 

3.61 With laboratory evidence of thrombophilia 

0 0 
0 0 
1 0.5 
0 0 
3 1.6 
1 

0 0 
0 

3.9 Unspecified hypertension 0 0 
4. ANTEPARTUM HAEMORRHAGE (APH) 12 6.4 

4.1 Placental abruption 11 5.9 
4.11 With laboratory evidence of thrombophilia 3 

4.2 Placenta praevia 0 0 
4.3 Vasa praevia 0 0 
4.8 Other APH 0 0 
4.9 APH of undetermined origin 1 0.5 

5. MATERNAL CONDITIONS 5 2.7 
5.1 Termination of pregnancy (other than for congenital fetal abnormality) 0 0 
5.2 Diabetes / Gestational diabetes 1 0.5 
5.3 Maternal injury 1 0.5 

5.31 Accidental 1 
5.32 Non-Accidental 0 

5.4 Maternal sepsis 0 0 
5.5 Lupus obstetric syndrome 0 0 
5.6 Obstetric cholestasis 0 0 
5.8 Other specified maternal conditions 3 1.6 

6. SPECIFIC PERINATAL CONDITIONS 16 8.5 
6.1	 Twin-twin transfusion 2 1.1 
6.2	 Feto-maternal haemorrhage 1 0.5 
6.3	 Antepartum cord complications (e.g. cord haemorrhage, true knot with 3 1.6 

evidence of occlusion) 
6.4	 Uterine abnormalities, eg bicornuate uterus, cervical incompetence 4 2.1 
6.5	 Birth trauma (typically infants of &gt;24 weeks gestation or &gt;600g 1 0.5 

birthweight) 

50 



No. % 
6.6	 Alloimmune disease 

6.61 Rhesus 
6.62 ABO 
6.63 Kell 
6.64 Alloimmune thrombocytopenia 
6.68 Other 
6.69 Unspecified 

6.7	 Idiopathic hydrops 
6.8	 Other specific perinatal conditions (includes iatrogenic conditions such as 

rupture of membranes after amniocentesis, termination of pregnancy for 
suspected but unconfirmed congenital abnormality) 

0 0 
0 
0 
0 
0 
0 
0 
2 1.1 

3 1.6 

7. HYPOXIC PERIPARTUM DEATH (typically infants of &gt;24 weeks gestation or 
&gt; 600g birthweight) 

4 2.1 

7.1	 With intrapartum complications 
7.11 Uterine rupture 
7.12 Cord prolapse 
7.13 Shoulder dystocia 
7.18 Other 

7.2	 Evidence of non-reassuring fetal status in a normally grown infant (e.g. 
abnormal fetal heart rate, fetal scalp pH/lactate, fetal pulse oximetry without 
intrapartum complications) 

7.3	 No intrapartum complications and no evidence of non- reassuring fetal 
status 

7.9	 Unspecified hypoxic peripartum death 

3 
0 
0 
1 

2 

1 

1.6 

0.5 

0 0 

0 0 
8. FETAL GROWTH RESTRICTION (FGR) 21 11.2 

8.1 With evidence of reduced vascular perfusion on Doppler studies and/or 17 9.0 
placental histopathology (e.g. significant infarction, acute atherosis, maternal 
and or fetal vascular thrombosis or maternal floor infarction 

8.2 With chronic villitis 1 0.5 
8.3 No placental pathology 0 0 
8.4 No examination of placenta 0 0 
8.8 Other specified placental pathology 3 1.6 
8.9 Unspecified or not known whether placenta examined 0 0 

9. SPONTANEOUS PRETERM (&lt;37 weeks gestation) 29 15.4 
9.1 Spontaneous preterm with intact membranes, or membrane rupture &lt;24 

hours before delivery 
9.11 With chorioamnionitis on placental histopathology 
9.12 Without chorioamnionitis on placental histopathology 
9.13 With clinical evidence of chorioamnionitis, no examination of placenta 
9.17 No clinical signs of chorioamnionitis, no examination of placenta 

16 

4 

7 

0 
5 

8.5 

9.19 Unspecified or not known whether placenta examined 0 

51 



No. % 

9.2 Spontaneous preterm with membrane rupture ?24 hours before delivery 13 6.9 
9.21 With chorioamnionitis on placental histology 12 
9.22 Without chorioamnionitis on placental histology 1 
9.23 With clinical evidence of chorioamnionitis, no examination of placenta 0 
9.27 No clinical signs of chorioamnionitis, no examination of placenta 0 
9.29 Unspecified or not known whether placenta examined 0 

9.3 Spontaneous preterm with membrane rupture of unknown duration before 0 0 
delivery 
9.31 With chorioamnionitis on placental histology 0 
9.32 Without chorioamnionitis on placental histology 0 
9.33 With clinical evidence of chorioamnionitis, no examination of placenta 0 
9.37 No clinical signs of chorioamnionitis, no examination of placenta 0 
9.39 Unspecified or not known whether placenta examined 0 

10. UNEXPLAINED ANTEPARTUM DEATH 19 10.1 
10.1 With evidence of reduced vascular perfusion on Doppler studies and/or 4 2.1 

placental histopathology (e.g. significant infarction, acute atherosis, 
maternal and/or fetal vascular thrombosis or maternal floor infarction) 

10.2 With chronic villitis 0 0 
10.3 No placental pathology 5 2.6 
10.7 No examination of placenta 0 0 
10.8 Other specified placental pathology 10 5.3 
10.9 Unspecified unexplained antepartum death or not known whether placenta 0 0 

examined 
11. NO OBSTETRIC ANTECEDENT 3 1.6 

11.1 SIDS 0 0 
11.11 SIDS Category IA: Classic features of SIDS present and completely 

documented. 
11.12 SIDS Category IB: Classic features of SIDS present but incompletely 

documented. 
11.13 SIDS Category II: Infant deaths that meet Category I except for one or 

more features. 
11.2 Postnatally acquired infection 0 0 
11.3 Accidental asphyxiation 1 0.5 
11.4 Other accident, poisoning or violence (postnatal) 0 0 
11.8 Other specified 0 0 
11.9 Unknown / Unexplained 1 0.5 

11.91 Unclassified Sudden Infant Death 1 
11.92 Other Unknown / Undetermined 

TOTAL 188 100.0 

52 



APPENDIX 5 

Perinatal Society of Australia and New Zealand Perinatal Death 
Classification (PSANZ-PDC), SA perinatal deaths by birthweight, 2007 

Birthweight (g) Total 
PSANZ-PDC 

&lt;500 500 
-749 

750 
-999 

1,000 
-1,499 

1,500 
-1,999 

2,000 
-2,499 2,500+ No. % 

1 Congenital 
abnormality 33 10 3 2 2 1 10 61 32.4 

2 Perinatal* 
infection 2 5 1 1 0 0 4 14* 7.4 

3 Hypertension 1 1 0 1 0 0 1 4 2.1 

4 Antepartum 
haemorrhage 2 6 0 0 0 0 4 12 6.4 

5 Maternal 
conditions 0 2 0 1 0 1 1 5 2.7 

6 Specific 
perinatal 6 1 3 1 1 0 4 16 8.5 
conditions 

7 Hypoxic 
peripartum 0 0 0 0 0 0 4 4 2.1 
death 

8 Fetal growth 
restriction 6 3 4 2 1 3 2 21 11.2 

9 Spontaneous 
preterm 16 10 3 0 0 0 0 29 15.4 

10 Unexplained 
antepartum 3 2 0 2 4 1 7 19 10.1 
death 

11 No obstetric 
antecedent 0 0 0 0 0 0 3 3 1.6 

Total 69 40 14 10 8 6 40 188* 100 
% 36.7 21.3 7.4 5.3 4.3 3.2 21.3 100 % 

* includes one stillbirth at 20 weeks gestation of unknown birthweight 

53 



APPENDIX 6 

Obstetric cause-specific classification of perinatal deaths, SA perinatal 
deaths, 2007 (Amended Whitfield) 

No % 
1. SPONTANEOUS PRETERM &lt;37 weeks, normally 

formed, appropriately grown. 
27 14.4 

1.1	 Multiple pregnancy 5 
1.2	 Previous bleeding 3 
1.3	 Previous spontaneous rupture of membranes 10 

&gt;12 hours before labour 
1.4	 Cervical incompetence 1 
1.5	 Other, eg uterine malformation 2 
1.6	 Idiopathic 6 

2. INTRAUTERINE GROWTH RESTRICTION (IUGR) 
&lt;10th percentile for gestational age 

21 11.2 

3. UNEXPLAINED INTRAUTERINE DEATH 
Normally formed fetuses without IUGR where fetal death 
is known to have preceded labour in the absence of any 
other primary complication 

19 10.1 

4. BIRTH TRAUMA ?1,500g, with evidence of lethal 
trauma at autopsy even when labour and delivery were 
not complicated by mechanical difficulty 

3 1.6 

4.1 Cord complication	 2 
4.2 Breech delivery	 0 
4.3 Caesarean section	 0 
4.4 Forceps delivery	 0 
4.5 Ventouse delivery	 1 
4.6 Other delivery	 0 

5. INTRAPARTUM ASPHYXIA ?1,500g with evidence of 
intrapartum hypoxia and confirmed by hypoxic changes 
at autopsy 

4 2.1 

5.0	 Vaginal 2 
5.1	 Cord complication 0 
5.2	 Breech delivery 0 
5.3	 Caesarean section 2 
5.4	 Forceps delivery 0 
5.5	 Ventouse delivery 0 
5.6	 Other delivery &amp; unspecified 0 

54 



No. % 
6. HYPERTENSION 4 2.1 

6.0 Unspecified 0 
6.1 Pre-existing hypertension 1 
6.2 Pre-eclampsia 3 
6.3 Pre-existing hypertension and pre-eclampsia 0 

7. MATERNAL DISEASE 6 3.2 
7.0 Unspecified 0 
7.1 Maternal injury 1 
7.2 Abdominal operation 1 
7.3 Diabetes/Gestational diabetes 1 
7.4 Malignancy 0 
7.5 Infection 0 
7.8 Maternal death 1 
7.9 Other 2 

8. ANTEPARTUM HAEMORRHAGE (APH) 12 6.4 
8.1 Placental abruption 11 
8.2 Placenta praevia 0 
8.3 APH undetermined origin 1 
8.4 Vasa praevia 0 

9. FETAL ABNORMALITY 61 32.4 
9.1 Central nervous system 12 
9.2 Cardiovascular system 9 
9.3 Urinary tract 4 
9.4 Gastrointestinal tract 0 
9.5 Chromosomal 15 
9.6 Metabolic 0 
9.7 Multiple 11 
9.9 Other 10 

10. HAEMOLYTIC DISEASE 0 0 
10.1 Rhesus incompatibility 0 
10.2 Other feto-maternal blood group incompatibility 0 

(eg Kell) 
10.3 Haemoglobinopathy 0 

55 



No. % 
11. INFECTION Pathological evidence of infection required. 

Infections occurring as primary factors including deaths 
with chorioamnionitis or congenital pneumonia 
preceding membrane rupture. 

19 10.1 

11.0 Unspecified 3 
11.1 Streptococcus, Group B 3 
11.2 Escherichia coli 4 
11.3 Other bacterial 6 
11.4 Toxoplasma 0 
11.5 Syphilis 0 
11.6 Cytomegalovirus 2 
11.7 Other viral 1 
11.8 Fungal 0 
11.9 Other 0 

12. OTHER 12 6.4 
12.1 Non-immune hydrops 2 
12.2 Feto-maternal haemorrhage 1 
12.3 Twin-twin transfusion 2 
12.4 Accident, poisoning or violence (Postnatal) 1 
12.5 SIDS 0 
12.8 Unknown / unexplained 2 
12.9 Other 4 
TOTAL 188 100.0 

56 



3
APPENDIX 7 

Perinatal Society of Australia and New Zealand-Neonatal Death 
Classification (PSANZ-NDC), SA neonatal deaths, 2007 

No % 
1. CONGENITAL ABNORMALITY 16 29.1 
1.1 Central nervous system 2 3.6 
1.2 Cardiovascular system 3 5.5 
1.3 Urinary tract 1 1.8 
1.4 Gastrointestinal tract 0 0 
1.5 Chromosomal 4 7.3 
1.6 Metabolic 0 0 
1.7 Multiple/ non chromosomal syndromes 5 9.1 
1.8 Other congenital abnormality 1 1.8 
1.81 Musculoskeletal 1 
1.82 Respiratory 0 
1.83 Diaphragmatic hernia 0 
1.84 Haematological 0 
1.85 Tumours 0 
1.88 Other specified congenital abnormality 0 
1.9 Unspecified congenital abnormality 0 0 
2. EXTREME PREMATURITY 19 34.5 

(typically infants of &lt;=24 weeks gestation or &lt;=600g birthweight) 
2.1 Not resuscitated 19 34.5 
2.2 Unsuccessful resuscitation 0 0 
2.9 Unspecified or not known whether resuscitation attempted 0 0 

.3. CARDIO-RESPIRATORY DISORDERS 5 9.1 
3.1 Hyaline membrane disease / Respiratory distress syndrome (RDS) 0 0 
3.2 Meconium aspiration syndrome 1 1.8 
3.3 Primary persistent pulmonary hypertension 1 1.8 
3.4 Pulmonary hypoplasia 2 3.6 
3.5 Chronic neonatal lung disease (typically, bronchopulmonary dysplasia) 0 0 
3.8 Other 1 1.8 

57 



No. % 
4. INFECTION 3 5.5 
4.1 Bacterial 2 3.6 
4.11 Congenital bacterial 2 
4.12 Acquired bacterial 0 
4.2 Viral 0 0 
4.21 Congenital viral 0 
4.22 Acquired viral 0 
4.3 Protozoal e.g. Toxoplasma 0 0 
4.4 Spirochaetal e.g. Syphilis 0 0 
4.5 Fungal 0 0 
4.8 Other 0 0 
4.9 Unspecified organism 1 1.8 
5. NEUROLOGICAL 10 18.2 
5.1 Hypoxic ischaemic encephalopathy / Perinatal asphyxia (typically infants of 4 7.3 

&gt;24 weeks gestation or &gt;600g birthweight) 
5.2 Intracranial haemorrhage 6 10.9 
5.8 Other 0 0 
6. GASTROINTESTINAL 0 
6.1 Necrotising enterocolitis 0 0 
6.8 Other 0 0 
7. OTHER 2 3.6 
7.1 Sudden Infant Death Syndrome (SIDS) 0 0 
7.11 SIDS Category IA: Classic features of SIDS present and completely documented. 
7.12 SIDS Category IB: Classic features of SIDS present but incompletely documented. 
7.13 SIDS Category II: Infant deaths that meet category I except for one or more features. 
7.2 Multi-system failure - only if unknown primary cause or trigger event 0 0 
7.3 Trauma 0 0 
7.8 Other specified 1 1.8 
7.9 Undetermined / Unknown 1 1.8 
7.91 Unclassified Sudden Infant Death 1 
7.92 Other Unknown / Undetermined 0 
TOTAL 55 100.0 

58 

0 



APPENDIX 8 

South Australian Protocol for investigation of stillbirths 

Working party members: 

Dr R Watson (Chair) 

Professor MJNC Keirse 

Professor G Dekker 

Professor TY Khong 

Dr W Hague 

Introduction 

The perinatal mortality rate for South Australia in 2007 of 2.6 deaths per 1,000 
births for infants of at least 1,000g birthweight or 28 weeks gestation is low by 
international standards. The rate for infants of at least 400g birthweight or 20 
weeks gestation was 9.5 deaths per 1,000 births that year. Seventy percent of 
these perinatal deaths were stillbirths.  The Perinatal Subcommittee of the South 
Australian Maternal, Perinatal and Infant Mortality Committee seeks, amongst 
other roles, to identify patterns and avoidable factors in perinatal deaths within 
the state. In 2007, 10% of stillbirths had no cause identified, possibly, in part due 
to the lack of a systematic and up to date approach to the investigation of 
stillbirths for which there is no immediate obvious cause. Currently protocols 
for investigating such cases vary markedly between hospitals and generally 
have not kept pace with advances in obstetric knowledge, particularly in the 
area of vasculopathies. 

A working party was set up in 1997 by the Perinatal Subcommittee to address 
this issue. It is hoped that the result will facilitate a more systematic and 
uniform approach to the investigation of stillbirths, resulting not only in a 
greater understanding of the demographics and underlying pathology, but the 
possibility of more accurate diagnosis and counselling, and potentially a 
reduction in recurrences. 

In order to adequately assess causative and contributing factors in cases of 
stillbirth, certain investigations will be required in all cases, while others can be 
directed to discovering underlying factors for an obvious cause of death. Lastly, 
some investigations are best suited to those cases in which no cause of death is 
apparent.  The following protocol attempts to provide a logical approach to 
each of these areas. 

59 



Core investigations (to be performed in all cases of stillbirth): 
  A detailed history and examination of the mother along with a careful 
review of the antenatal record can often provide clues to intercurrent 
infection, previously undiagnosed pre eclampsia, drug use or intra hepatic 
cholestasis of pregnancy. 

  Autopsy of the stillbirth. With parental consent, autopsy should be 
conducted by the State Perinatal Autopsy Service. 

  Guthrie card. Where permission for an autopsy has been declined, parents 
should be asked if blood can be taken for the Newborn Screening Guthrie 
Card that is requested for all babies in Australia. This blood could be drawn 
from a heel prick or from the cut end of the umbilical cord of the placenta. 

  Histopathology of placenta. Whether or not an autopsy is performed the 
placenta should be placed in a dry sterile container (no formalin or saline), 
the container surrounded in ice and forwarded to the State Perinatal 
Autopsy Service. Histopathological examination combined with other 
investigations can provide a diagnosis for a current pregnancy and 
information that can be helpful in planning another pregnancy. 

  Maternal blood should be drawn for a Kleihauer test and sent along with a 
sample of maternal serum with the placenta with or without the baby. A 
slide for Kleihauer will be prepared but only examined if required. 

  External examination of the baby.   In cases where parental consent for 
autopsy cannot be obtained, external examination of the baby by a 
pathologist experienced in this area, where possible, should be sought. If 
this is not possible an X ray of the baby and/or a clinical photograph 
should be taken and sent to a major centre for review. 

Genetic termination of pregnancy 
In cases where a termination of pregnancy has been carried out for fetal 
malformation, an autopsy may still be desirable to confirm the diagnosis or 
discover unexpected associated malformations. 

Congenital anomaly 
Investigations to be performed when an intrauterine fetal death occurs in
 
conjunction with a known fetal abnormality: 


  Karyotype   preferably on amniotic fluid obtained by amniocentesis since 
this provides the least contaminated sample, but if maternal consent for this 
cannot be obtained then on cord blood (if obtainable) or fetal skin. The 
sample should be obtained, but karyotyping should only proceed if an 
anomaly which is indicative of a chromosomal abnormality is found at birth 
or autopsy.  

60 



  Maternal serology for syphilis, CMV, Toxoplasma, Herpes and Parvovirus.  
Serum should be taken and forwarded with the baby. Investigation for 
congenital infection should be pursued if anomalies indicative of infection 
are found (for example, hydrocephalus, hepatomegaly, cataracts, 
calcification of brain or placenta). 

  Maternal antibody screen   serum forwarded with baby for later 
investigation if hydrops is evident at autopsy. 

Vasculopathies 
Pre eclampsia/hypertension, placental abruption and intrauterine growth 
restriction. 

All should have a thrombophilia screen comprising   

1.  At time of delivery: 

  Anti cardiolipin antibody. 

  Lupus anticoagulant. 

  Activated Protein C Resistance. 

2.  At three months post partum: 

  Activated Protein C Resistance if previous result low or borderline (&lt;2.5). 

  Homocysteine   may be done earlier if follow up uncertain. 

  Protein S. 

Pre-eclampsia or non-proteinuric hypertension 
Attention is drawn to those investigations for monitoring maternal welfare 
published by the Australasian Society for the Study of Hypertension in 
Pregnancy.16 

Those with early onset pre eclampsia (&lt;28 weeks) should also have 

  Anti nuclear antibody 

  Fetal karyotype (see "Congenital anomaly") 

In cases of placental abruption a history of trauma, including domestic or other 
violence, should be sought. The Kleihauer slide (see "Core investigations") 
should be examined if the diagnosis is in doubt and in all Rhesus negative 
women to determine the required dose of anti D. 

16 Brown MA, Hague WM, Higgins J, Lowe S, McGowan L, Oats J, Peek MJ, Rowan JA, Walters BNJ. 

Consensus Statement. The detection, investigation and management of hypertension in pregnancy. Aust 

NZ J Obstet Gynaecol 2000;40:133 138. 

61 



Where intrauterine growth restriction is evident without further evidence of a 
vasculopathy (hypertension, abruption), the following should be performed in 
addition to the thrombophilia screen: 

  Maternal serology for CMV, Toxoplasma and Rubella (if not immune) on 
held maternal serum (see "Core investigations ") 

  Fetal karyotype (see "Congenital anomaly ) 

  Maternal urinary drug screen as well as a drug related history 

Intrapartum deaths which are associated with hypertension, abruption or 
intrauterine growth restriction should be investigated as such, but in the 
absence of these and when the fetus is over 1,000g:  

  Kleihauer slide examined (See "Core investigations") 

  Cord (or heart) blood (haemoglobin, platelets, nucleated red blood cells) 

Unexplained stillbirths 
In the absence of discernible factors pertaining to fetal demise, or any obvious 
congenital anomaly, in addition to the  Core investigations :  

  Maternal serum bile acids   cord blood bile acids if possible. 

  Maternal serum glucose. 

  Thrombophilia screen (see "Vasculopathies"). 

  Maternal serology   syphilis, CMV, Toxoplasma, Herpes, Parvovirus. 

  Microbiology   fetal throat swab, placental intermembranous swab. 

  Drug history and urine drug screen. 

  Cord or heart blood   haemoglobin, platelets, nucleated red blood cells, 
blood group (for anti D if mother Rhesus negative). 

  Maternal antibody screen. 

  Kleihauer slide examined. 

62 



APPENDIX 9 

Placental histology guidelines 
Histological examination of the placenta provides additional information about 
perinatal deaths and placentas should be sent for examination where possible. 

As a guide, placentas and all relevant clinical information should be sent to 
Pathology at least from: 

  All stillborn infants, early neonatal deaths and mid trimester miscarriages. 

  All multiple pregnancies with same sex infants. 

  All triplet and higher order multiple pregnancies. 

  All cases of discordant twin growth with greater than 20% weight 
difference. 

  All cases of prolonged rupture of membranes or suspected chorioamnionitis 
or maternal fever (any cause). 

  All preterm deliveries. 

  All cases where birthweight is less than the 10th percentile or greater than 
the 95th percentile for gestational age. 

  All cases of fetal malformation. 

  All cases of pregnancy complicated by oligohydramnios, polyhydramnios 
or placental abnormalities detected prenatally (vascular channels, 
chorioangioma, etc). 

  All cases with a physical abnormality in the placenta (eg. a mass, abnormal 
colour, malodour). 

  All cases subjected to chorion villus sampling or amniocentesis, if 
complications occur. 

  All cases of pre existing diabetes, pre eclampsia, systemic lupus 
erythematosus and documented thrombophilias known to be associated 
with fetal hazard.  

  All cases of placental abruption. 

  All cases where the infant is transferred to a Level III nursery or the infant is 
severely depressed at birth (Apgar score &lt;5 at five minutes). 

  All instances where either mother or baby is retrieved shortly after birth. 

  All cases of maternal death. 

63 



APPENDIX 10 

Australian birthweight percentiles 

64
 



Australian birthweight percentiles for
 
singleton girls
 

Weight (grams) Percentile 
5000
 

4000
 

3000
 

2000
 

1000
 

0 

3 

97 

75 

50 

25 
10 

90 

22 24 26 28 30 32 34 36 38 40 42 44
 
Gestational age (weeks)
 

From: Roberts CL &amp; Lancaster PAL. Australian national birthweight percentiles by gestational age. 
MJA 1999;170: 114-118.  Copyright 1999. The Medical Journal of Australia - reproduced with permission. 

65
 



Table 14:  Birthweight percentile values (g) for live singleton males, Australia, 1991 1994  


Gestation No. births Mean Standard Percentile (gm)
 
(weeks) (gm) Deviation 1st 3rd 5th 10th 25th 50th 75th 90th 95th 97th 99th
 
20 27 385 76 330 380 430 

21 43 447 66 410 440 490 

22 74 495 80 400 440 490 540 600 

23 95 607 92 470 500 550 610 660 710 780 

24 135 690 129 470 480 520 610 680 780 860 930 990 

25 180 791 132 560 580 620 700 785 870 980 1000 1030 

26 235 921 158 610 620 720 840 920 1020 1130 1160 1170 

27 284 1017 209 610 650 740 900 1000 1140 1280 1350 1440 

28 361 1157 240 570 670 720 850 1000 1170 1300 1440 1550 1600 1790 

29 397 1316 261 670 760 840 950 1170 1340 1480 1640 1740 1810 1900 

30 571 1477 313 730 860 960 1080 1270 1490 1680 1860 1950 2050 2270 

31 743 1682 311 910 1070 1130 1310 1490 1670 1870 2070 2170 2280 2450 

32 1117 1875 378 1020 1150 1230 1400 1640 1890 2100 2320 2470 2690 2980 

33 1471 2142 415 1210 1360 1450 1640 1900 2120 2370 2650 2920 3060 3300 

34 2657 2358 418 1310 1560 1670 1840 2100 2350 2600 2870 3080 3250 3530 

35 4092 2610 413 1600 1830 1960 2110 2360 2590 2850 3140 3330 3490 3770 

36 8788 2835 432 1780 2020 2150 2320 2560 2820 3100 3380 3570 3730 3960 

37 18660 3089 442 2030 2270 2380 2550 2800 3080 3370 3660 3840 3960 4200 

38 51404 3317 431 2310 2520 2620 2780 3030 3310 3600 3870 4050 4160 4390 

39 72871 3471 426 2500 2690 2790 2940 3180 3460 3750 4020 4200 4310 4520 

40 141553 3610 432 2630 2830 2920 3070 3320 3600 3890 4170 4340 4460 4680 

41 55946 3739 443 2730 2930 3030 3180 3440 3730 4030 4310 4490 4600 4820 

42 14781 3787 463 2730 2950 3040 3210 3470 3780 4090 4390 4570 4680 4910 

43 1267 3698 501 2510 2770 2910 3080 3360 3680 4000 4360 4580 4670 4970 

44 409 3612 474 2620 2720 2850 3050 3290 3590 3900 4270 4440 4530 4790 

From: Roberts CL &amp; Lancaster PAL. Australian national birthweight percentiles by gestational age. MJA 1999; 170: 114 
118.
 

  Copyright 1999. The Medical Journal of Australia-reproduced with permission
 

66 



Table 15:  Birthweight percentile values (g) for live singleton females, Australia, 1991 1994  


Gestation No. births Mean Standard Percentile (gm)
 
(weeks) (gm) Deviation 1st 3rd 5th 10th 25th 50th 75th 90th 95th 97th 99th
 
20 12 418 184 345 

21 25 414 55 400 420 440 

22 71 485 85 400 430 480 540 600 

23 79 591 103 470 520 580 640 740 

24 115 661 95 490 500 540 600 660 720 780 830 850 

25 136 760 116 510 560 620 700 750 840 900 960 980 

26 188 865 158 540 550 680 780 865 960 1040 1130 1180 

27 231 944 183 600 620 730 830 950 1070 1180 1250 1280 

28 287 1060 228 610 700 760 900 1070 1200 1340 1400 1440 

29 325 1233 247 630 720 810 890 1070 1250 1400 1510 1580 1660 1820 

30 440 1403 275 740 860 945 1045 1220 1420 1560 1730 1885 1950 2100 

31 548 1581 336 800 990 1050 1140 1360 1590 1765 2000 2130 2330 2560 

32 877 1797 383 920 1070 1170 1340 1560 1780 2000 2230 2470 2640 2970 

33 1200 2038 403 1135 1280 1385 1520 1790 2040 2265 2515 2755 2955 3150 

34 2086 2282 439 1260 1440 1570 1760 2010 2260 2530 2810 3090 3290 3510 

35 3418 2523 433 1520 1740 1840 2030 2260 2490 2760 3100 3340 3500 3710 

36 7320 2738 433 1740 1950 2060 2220 2450 2720 3000 3300 3505 3650 3860 

37 16105 2967 432 1940 2170 2280 2430 2680 2960 3240 3520 3700 3830 4050 

38 47809 3187 419 2220 2420 2520 2660 2900 3170 3460 3730 3900 4020 4220 

39 68846 3329 412 2390 2580 2670 2820 3050 3320 3600 3860 4030 4140 4340 

40 137570 3463 414 2530 2720 2810 2950 3180 3450 3730 4000 4170 4280 4490 

41 53260 3577 421 2630 2820 2910 3050 3290 3560 3850 4130 4300 4410 4620 

42 13318 3627 442 2630 2830 2930 3080 3320 3610 3920 4210 4370 4500 4700 

43 1285 3539 463 2460 2710 2770 2950 3240 3540 3840 4120 4320 4430 4620 

44 433 3490 448 2420 2590 2720 2930 3180 3490 3800 4070 4230 4320 4470 

From: Roberts CL &amp; Lancaster PAL. Australian national birthweight percentiles by gestational age. MJA 1999: 170: 114 
118.
 

  Copyright 1999. The Medical Journal of Australia-reproduced with permission
 

67 



APPENDIX 11 

Co-sleeping while breastfeeding: advice to health professionals 
Bed sharing while breastfeeding has been associated in some studies with 
unexpected infant death.  This was usually when the mother was very fatigued 
or under the influence of alcohol or drugs and therefore difficult to arouse once 
asleep.  The mechanism is not thought to be the mother physically compressing 
the infant but rather the breast interfering with the infant s airflow.  Some 
infants are particularly susceptible to respiratory arrest from minor airway 
occlusion.  Bed sharing with a parent who smokes (even if not smoking in bed 
and not breastfeeding) increases the risk of Sudden Infant Death Syndrome 
(SIDS). 

Recommendations 

1. 	 Mothers are encouraged to sit up, in or out of bed, with a light on while 
breastfeeding at night.  When a mother is unable to sit up unassisted, 
breastfeeding should be supervised. 

2. 	 Mothers who are taking medication which is sedating or who are
 
excessively fatigued are to be supervised while breastfeeding.
 

3. 	 A pre requisite to unattended breastfeeding is a verbal assurance from the 
mother that clarifies to the staff that the mother is in no significant 
discomfort, is lucid and feels competent to breastfeed. 

4. 	 Infants should sleep in a cot next to their mother s bed when she is sleeping. 

5. 	 Pregnant women should receive written information antenatally about the 
risks when breastfeeding and sedated or fatigued, and about co sleeping 
especially if a parent is a smoker.  This information should be included in 
any breastfeeding information, which is distributed in antenatal clinics or 
antenatal classes. 

NOTE: Adapted from Flinders Women and Children Department of Flinders Medical Centre, Adelaide, 2002, with 
permission. 

68 



Advice to parents on sleeping in the same bed as your baby 
Bed sharing while breastfeeding has been associated in some studies with 
unexpected infant death.  This has usually been when the mother was very 
fatigued or under the influence of alcohol or drugs and therefore difficult to 
arouse once asleep.  The mechanism is not thought to be the mother physically 
compressing the infant but rather the breast interfering with the infant s airflow.  
Some infants are particularly susceptible to respiratory arrest from minor 
airway occlusion.  Bed sharing with a parent who smokes (even if not smoking 
in bed and not breastfeeding) increases the risk of Sudden Infant Death 
Syndrome (SIDS). 

Recommendations 

1. 	 If you plan to bring your baby to bed, sit up with a light on while
 
breastfeeding. 


2. 	 If you are unable to sit up, are taking medication that sedates you, or are 
excessively tired, it would be a good idea to have someone else in the room 
while you are breastfeeding. 

3. 	 When you plan to go to sleep, it may be better to put your baby in a cot next 
to your bed. 

4. 	 If you decide to keep your baby in your bed, the mattress should be firm, 
soft quilts or pillows should not be placed under your baby, he/she should 
be placed on his/her back and waterbeds should not be used. 

5. 	 If you smoke or have smoked during pregnancy, it would be better if you 
didn t bed share with your baby, as this has been associated with an 
increased risk of SIDS. 

NOTE: Adapted from Flinders Women and Children Department of Flinders Medical Centre, Adelaide, 2002, with 
permission. 

69 


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