Journal of the Royal Society of Medicine

Confidential Enquiries into Stillbirths and Deaths in Infancy (CESDI) have pointed to a high frequency of suboptimal intrapartum fetal care of a kind that, in the event of an adverse outcome, is hard to defend in court. In an effort to minimize liability, various strategies were applied in a district hospital labour ward—guidelines, cyclical audit, monthly feedback meetings and training sessions in cardiotocography (CTG). The effects of these interventions on quality of care was assessed by use of the CESDI system in all babies born with an Apgar score of 4 or less at 1 min and/or 7 or less at 5 min.

540 babies (4.3%) had low Apgar scores, and neither the percentage nor gestational age differed significantly between audit periods. In the baseline audit, care was judged suboptimal (grade II/III) in 14 (74%) of 19 cases, and in the next four periods it was 23%, 27%, 27% and 32%. In the latest audit period, after further educational interventions, it was 9%. Many of the failures to recognize or act on abnormal events were related to CTG interpretation. After the interventions there was a significant increase in cord blood pH measurement. There were no differences between audit periods in the proportion of babies with cord pH <7.2.

These results indicate that substantial improvements in quality of intrapartum care can be achieved by a programme of clinical riskmanagement.

Surgeons will sometimes advise against an operation because the patient is ‘old and frail’. A simple starring system (one to five), based on performance and lifestyle, has been devised to assess the biological age of elderly patients. 10 consultant surgeons and 10 trainees answered questions about their treatment recommendations for hypothetical patients of standard age and medical history but with various star ratings and surgical conditions. 1000 decisions were available for analysis.

The four and five star patients (those leading an independent existence) were recommended 266 interventions, the one and two star patients 55. Trainees were more inclined to intervene than consultants, recommending operations in half the patients rather than one-third.

These results indicate that decisions on surgical management are strongly influenced by the patient's star rating or biological age. If the starring method proves reproducible in other patient groups and settings, it could allow better communication on an important factor in clinical decisions.

The secretions of sebaceous and apocrine glands fulfil an important thermoregulatory role in cold-stressed and heat-stressed hunter-gatherers. In hot conditions the secretions emulsify eccrine sweat and thus encourage the formation of a sweat sheet and discourage the formation and loss of sweat drops from the skin. In colder conditions sebum changes its nature and repels rain from skin and hair.