Consultant-led Obstetric Units Research Articles

Pulmonaryaspirationduringpregnancyor immediately postpartum in the UK: A population-based case-control study.

Pulmonary aspiration of gastric contents is the most frequent cause of death associated with complications of airway management during general anaesthesia. Pregnancy increases aspiration risk owing to factors including delayed gastric emptying and increased intragastric pressure. We describe the incidence, risk factors, management, and outcomes of maternal pulmonary aspiration in pregnancy in the UK. We conducted a population-based surveillance and case-control study. Between September 2013 and August 2016, all UK consultant-led obstetric units prospectively identified cases of pulmonary aspiration among parturient women using a pre-defined case definition, and reported them via the UK Obstetric Surveillance System (UKOSS). Controls (n=1982) were obtained from four UKOSS studies conducted between 2005 and 2014. We calculated the incidence of pulmonary aspiration using 2013-2015 maternities as the denominator. We explored potential risk factors for aspiration using univariable logistic regression and described outcomes. We identified 12 cases of pulmonary aspiration, giving an incidence of 5.2 per 1,000,000 maternities (95% CI 2.69-9.09). Cases were significantly less likely than controls to be multiparous (unadjusted odds ratio [uOR] 0.255, 95% CI 0.069-0.946), and significantly more likely to undergo caesarean section (uOR 24.89, 95% CI 3.18-194.85) and to receive general anaesthetic for caesarean section (p<0.001). Gestation was significantly shorter in cases than controls (uOR 0.782, 95% CI 0.702-0.870). Women who aspirated were significantly more likely to be admitted to the intensive therapy unit than controls (p<0.001). Infants of women who aspirated had significantly lower Apgar scores and were more likely to be admitted to the neonatal intensive care unit or to be stillborn compared with infants of women in the control group. Pulmonary aspiration is rare in UK obstetric anaesthetic practice; however, it remains a risk of general anaesthesia. Despite a large study population, our analyses lacked power to evaluate many potential risk factors. Future research should focus on developing methods to accurately identify pregnant women at risk of aspiration.

Maternal and neonatal outcome of births planned in alongside midwifery units: a cohort study from a tertiary center in Germany

BackgroundFor healthy women entering birth after uneventful pregnancy, midwife-led models of care have the potential to reduce interventions and increase the vaginal birth rate. In Germany, 98.4% of women are giving birth in consultant-led obstetric units. Alongside midwifery units (AMU) have been established in 2003. We compared the outcome of women registered for planned birth in the AMU at our hospital with a matched group of low-risk women who gave birth in standard obstetric care during the same period of time.MethodsWe used a retrospective cohort study design. The study group consisted of all women admitted to labor ward who had registered for birth in AMU from 2010 to 2017. For the control group, low-risk women were selected; additionally, matching was performed for parity. Mode of birth was chosen as primary outcome parameter for the mother. For the neonate, a composite primary outcome (5-min Apgar < 7 or umbilical cord arterial pH < 7.10 or transfer to specialist neonatal care) was defined. Secondary outcomes included epidural anesthesia, duration of the second stage of labor, episiotomy, obstetric injury, and postpartum hemorrhage. Non-inferiority was assessed, and multiple logistic regression analysis was performed.ResultsSix hundred twelve women were admitted for labor in AMU, the control group consisted of 612 women giving birth in standard obstetric care. Women in the study group were on average older and had a higher body mass index (BMI); birthweight was on average 95 g higher. Non-inferiority could be established for the primary outcome parameters. Epidural anesthesia and episiotomy rates were lower, and the mean duration of the second stage of labor was shorter in the study group; second-degree perineal tears were less common, higher-order obstetric lacerations occurred more frequently.Overall, 50.3% of women were transferred to standard obstetric care. Regression analysis revealed effects of parity, age and birthweight on the chance of transfer.ConclusionCompared to births in our consultant-led obstetric unit, the outcome of births planned in the AMU was not inferior, and intervention rates were lower. Our results support the integration of AMU as a complementary model of care for low-risk women.

Hormone-secreting adrenal tumours cause severe hypertension and high rates of poor pregnancy outcome; a UK Obstetric Surveillance System study with case control comparisons.

To examine the management and outcomes of adrenal tumours in pregnancy. A national observational, cohort study over 4 years using the UK Obstetric Surveillance System (UKOSS). Consultant-led obstetric units. Women with phaeochromocytoma, primary aldosteronism or Cushing's syndrome diagnosed before or during pregnancy. Clinical features of UKOSS cases were compared with those of women with adrenal tumours reported from 1985-2015. Nested case-control comparisons involving the UKOSS cases as well as those identified in the literature were performed for pregnancy outcome data using UKOSS controls with uncomplicated singleton (n = 2250) pregnancy and data from the Office of National Statistics (ONS). Incidence, management and frequency of adverse maternal and offspring outcomes of adrenal tumours in pregnancy. Fifteen pregnant women met the inclusion criteria: ten phaeochromocytoma, three primary aldosteronism and two Cushing's syndrome. All of the tumours had an incidence rate <2 per 100 000 pregnancies. Clinical symptoms were similar to those in non-pregnant women due to the hormones released. All women had severe hypertension, and in those diagnosed in pregnancy prior to conception. There was a significantly increased risk of adverse pregnancy outcomes in affected women, with increased rates of stillbirth, preterm labour and operative delivery. Adrenal tumours are associated with increased risks for pregnant women and their babies. Data on these tumours to inform practice are limited and international collaborative efforts are likely to be needed. Study of hormone-secreting adrenal tumours in pregnancy linked with high BP and high rates of fetal morbidity.

Macroprolactinomas and Nonfunctioning Pituitary Adenomas and Pregnancy Outcomes.

To examine the monitoring, management, and outcomes of pituitary tumors in pregnancy. A national, prospective, observational, population-based case series study was conducted in all U.K. consultant-led obstetric units over 3 years using the U.K. Obstetric Surveillance System. To evaluate rates of adverse pregnancy outcomes, women with a macroprolactinoma (10 mm or greater) or nonfunctioning pituitary adenoma, diagnosed before or during pregnancy, were compared with two comparison groups: 1) a U.K. Obstetric Surveillance System cohort with singleton (n=2,205) or twin (n=27) pregnancy; and 2) data from the Office of National Statistics (n=2,703,102). Main outcome measures were the incidence, management, and frequency of adverse maternal and offspring outcomes of pituitary tumors in pregnancy. There were 71 confirmed cases of pituitary tumors in pregnancy (49 macrolactinoma, 16 nonfunctioning adenomas, three acromegaly, three Cushing's disease). The women with pituitary tumors were 4 years older than comparison women (P<.001). None of the nine women treated with surgery or radiotherapy before pregnancy had symptomatic tumor expansion. This occurred in 6 of 40 women with macroprolactinomas and one of seven nonfunctioning adenomas diagnosed before conception and in three of five women with nonfunctioning adenomas diagnosed in pregnancy. Two women had pituitary apoplexy, both of whom also had symptoms of expansion of tumor or surrounding pituitary tissue. To within the level of accuracy possible, there was no evidence that pituitary tumors were associated with adverse pregnancy outcomes (pregnancy-induced hypertension, preeclampsia, preterm labor, stillbirth). Women with nonfunctioning adenomas were more likely to have cesarean delivery compared with women in a control group (relative risk 2.06, confidence interval 1.26-3.36, P=.035). The majority of women with macroprolactinomas and nonfunctioning adenomas have good pregnancy outcomes. Nonfunctioning pituitary adenomas occur more commonly in pregnancy than previously thought and can present de novo with symptoms of pituitary expansion in pregnancy.

The economic costs of intrapartum care in Tower Hamlets: A comparison between the cost of birth in a freestanding midwifery unit and hospital for women at low risk of obstetric complications

to compare the economic costs of intrapartum maternity care in an inner city area for 'low risk' women opting to give birth in a freestanding midwifery unit compared with those who chose birth in hospital. micro-costing of health service resources used in the intrapartum care of mothers and their babies during the period between admission and discharge, data extracted from clinical notes. the Barkantine Birth Centre, a freestanding midwifery unit and the Royal London Hospital's consultant-led obstetric unit, both run by the former Barts and the London NHS Trust in Tower Hamlets, a deprived inner city borough in east London, England, 2007-2010. maternity records of 333 women who were resident in Tower Hamlets and who satisfied the Trust's eligibility criteria for using the Birth Centre. Of these, 167 women started their intrapartum care at the Birth Centre and 166 started care at the Royal London Hospital. women who planned their birth at the Birth Centre experienced continuous intrapartum midwifery care, higher rates of spontaneous vaginal delivery, greater use of a birth pool, lower rates of epidural use, higher rates of established breastfeeding and a longer post-natal stay, compared with those who planned for care in the hospital. The total average cost per mother-baby dyad for care where mothers started their intrapartum care at the Birth Centre was £1296.23, approximately £850 per patient less than the average cost per mother and baby who received all their care at the Royal London Hospital. These costs reflect intrapartum throughput using bottom up costing per patient, from admission to discharge, including transfer, but excluding occupancy rates and the related running costs of the units. the study showed that intrapartum throughput in the Birth Centre could be considered cost-minimising when compared to hospital. Modelling the financial viability of midwifery units at a local level is important because it can inform the appropriate provision of these services. This finding from this study contribute a local perspective and thus further weight to the evidence from the Birthplace Programme in support of freestanding midwifery unit care for women without obstetric complications.

BJOG Editor's Choice

BJOG Editor's Choice

Provision and practice of specialist preterm labour clinics: a UK survey of practice

To identify the current status of specialist preterm labour (PTL) clinic provision and management within the UK. Postal survey of clinical practice. All consultant-led obstetric units within the UK. A questionnaire was sent by post to all 210 NHS consultant-led obstetric units within the UK. Units that had a specialist PTL clinic were asked to complete a further 20 questions defining their protocol for risk stratification and management. Current practice in specialist preterm labour clinics. We have identified 23 specialist clinics; the most common indications for attendance were previous PTL (100%), preterm prelabour rupture of membranes (95%), two large loop excisions of the transformation zone (95%) or cone biopsy (95%). There was significant heterogeneity in the indications for and method of primary treatment for short cervix, with cervical cerclage used in 45% of units, progesterone in 18% of units and Arabin cervical pessary in 5%. A further 23% used multiple treatment modalities in combination. A significant heterogeneity in all topics surveyed suggests an urgent need for networking, more evidence-based guidelines and prospective comparative audits to ascertain the real impact of specialist PTL clinics on the reduction in preterm birth and its sequelae.

Strategies to enhance assessment of the fetal head position before instrumental delivery: a survey of obstetric practice in the United Kingdom and Ireland

To establish the current practice of obstetricians with regard to assessment of women in labour before instrumental delivery. A national postal survey of obstetricians in consultant-led obstetric units in the United Kingdom and Ireland. Clinical assessment before instrumental delivery, factors associated with difficulty in determining the fetal head position, approaches used to enhance determination of the fetal head position, perceived accuracy rates in assessment of the fetal head position and willingness to participate in a clinical trial of ultrasound assessment of the fetal head position before instrumental delivery were explored. The response rate was 75%. The majority of obstetricians assess women clinically before instrumental delivery as recommended by guidelines. Both consultants and trainees reported the following factors as being associated with difficulty in diagnosing the fetal head position: inadequate maternal pain relief, fetal caput and clinical inexperience. Strategies used when experiencing difficulty in determining the fetal head position varied, with trainees more likely than consultants to seek a second opinion (40% vs. 5%, p<0.0001), reassess in an operating theatre (80% vs. 68%, p=0.048) or abandon the procedure in favour of caesarean section (14% vs. 6%, p=0.035). One in five obstetricians reported using abdominal ultrasound to aid diagnosis, with some consultants reporting the use of ultrasound as 'a great idea' and others being 'appalled'. One in eight consultants perceived that they made an incorrect diagnosis of the fetal head position at instrumental delivery in more than 10% of deliveries compared to one in four trainees. The contrasting views on the role of ultrasound to enhance the assessment of the fetal head position before instrumental delivery suggest that it should be evaluated in a randomised clinical trial.

Midwifery obstetric high dependency care training – a disaster waiting to happen?

BackgroundThe critically ill obstetric patient poses unique challenges to the healthcare profession. The last confidential enquiry recommended that there should be a properly equipped, staffed and supervised high dependency (HD)...

A national survey of obstetric early warning systems in the United Kingdom

Despite recommendations in the two most recent Confidential Enquiries into Maternal and Child Health (CEMACH) reports, and improvements in patient care using early warning scoring systems (EWS) in the general adult population, no validated system currently exists for the obstetric population. We performed an Obstetric Anaesthetists' Association (OAA) approved postal survey of all UK consultant-led obstetric anaesthetic units in November 2007 to assess opinions on the value and of such a system and how it could be implemented, and invited comments and samples of systems already in use. The response rate was 71%. Of those who replied a median usefulness score of 80% for a standardised national obstetric EWS was demonstrated. Eighty-nine percent of units thought it would be possible to implement a system, and although 96% of UK hospitals already use a non-obstetric EWS, only 23% of respondents thought this to be relevant to obstetric physiology and disease. Nine units returned copies of their obstetric EWS. Using extracts from some of the submitted versions we have designed and implemented a system locally and submitted it to the OAA for consideration. The survey results support CEMACH recommendations for a nationally agreed obstetric EWS.

Antenatal Pulmonary Embolism: Risk Factors, Management, and Outcomes

Objectives To estimate the incidence of antenatal pulmonary embolism and describe the risk factors, management and outcomes. Design A national matched case–control study using the UK Obstetric Surveillance System (UKOSS). Setting All hospitals with consultant-led maternity units in the UK. Participants A total of 143 women who had an antenatal pulmonary embolism between February 2005 and August 2006. Two hundred and fifty nine matched control women. Methods Prospective case and control identification through the UKOSS monthly mailing. Main outcome measures Incidence and case fatality rates with 95% CIs. Adjusted odds ratio estimates. Results One hundred per cent of UK consultant-led obstetric units contributed data to UKOSS. A total of 143 antenatal pulmonary embolisms were reported, representing an estimated incidence of 1.3 per 10 000 maternities (95% CI 1.1–1.5). Seventy per cent of women had identifiable classical risk factors for thromboembolic disease. The main risk factors for pulmonary embolism were multiparity (adjusted odds ratio [aOR] 4.03, 95% CI 1.60–9.84) and body mass index ≥ 30 kg/m2 (aOR 2.65, 95% CI 1.09–6.45). Nine women who had a pulmonary embolism should have received antenatal thromboprophylaxis with low-molecular-weight heparin (LMWH) according to national guidelines; only three (33%) of them did. Six women (4%) had a pulmonary embolism following antenatal prophylaxis with LMWH; three of these women (50%) were receiving lower than recommended doses. Two women had recurrent pulmonary emboli (1.4%, 95% CI 0.2–5.1%). Five women died (case fatality 3.5%, 95% CI 1.1–8.0%). Conclusions Significant severe morbidity from thromboembolic disease underlies the maternal deaths from pulmonary embolism in the UK. This study has shown some cases where thromboprophylaxis was not provided according to national guidelines, and there may be scope for further work on guideline implementation.

313. A Survey of Knowledge of Local Anaesthetic Toxicity among Clinical Staff in a Consultant Led Obstetric Unit in the UK

313. A Survey of Knowledge of Local Anaesthetic Toxicity among Clinical Staff in a Consultant Led Obstetric Unit in the UK

A Survey of Knowledge of Local Anaesthetic Toxicity among Clinical Staff in a Consultant Led Obstetric Unit in the UK

A Survey of Knowledge of Local Anaesthetic Toxicity among Clinical Staff in a Consultant Led Obstetric Unit in the UK

313: A Survey of Knowledge of Local Anaesthetic Toxicity among Clinical Staff in a Consultant Led Obstetric Unit in the UK

313: A Survey of Knowledge of Local Anaesthetic Toxicity among Clinical Staff in a Consultant Led Obstetric Unit in the UK

A national survey of safe practice with epidural analgesia in obstetric units

The National Patient Safety Agency (NPSA) identified practice improvements with regard to epidural injections and infusions and released a patient safety alert on 28th March 2007. Prior to this, the Obstetric Anaesthetists' Association had considered the draft document and wished to assess current compliance in UK obstetric units. A postal survey of consultant-led obstetric anaesthetic units in the UK was performed in September 2006 to look at practice prior to the release of the safety alert. The response rate was 89%. Many units are already following the guidance from the NPSA but nearly one in four units have experience of wrong route drug errors related to confusion between systems for intravenous and regional drug administration.

Antenatal pulmonary embolism: risk factors, management and outcomes

To estimate the incidence of antenatal pulmonary embolism and describe the risk factors, management and outcomes. A national matched case-control study using the UK Obstetric Surveillance System (UKOSS). All hospitals with consultant-led maternity units in the UK. A total of 143 women who had an antenatal pulmonary embolism between February 2005 and August 2006. Two hundred and fifty nine matched control women. Prospective case and control identification through the UKOSS monthly mailing. Incidence and case fatality rates with 95% CIs. Adjusted odds ratio estimates. One hundred per cent of UK consultant-led obstetric units contributed data to UKOSS. A total of 143 antenatal pulmonary embolisms were reported, representing an estimated incidence of 1.3 per 10,000 maternities (95% CI 1.1-1.5). Seventy per cent of women had identifiable classical risk factors for thromboembolic disease. The main risk factors for pulmonary embolism were multiparity (adjusted odds ratio [aOR] 4.03, 95% CI 1.60-9.84) and body mass index > or = 30 kg/m2 (aOR 2.65, 95% CI 1.09-6.45). Nine women who had a pulmonary embolism should have received antenatal thromboprophylaxis with low-molecular-weight heparin (LMWH) according to national guidelines; only three (33%) of them did. Six women (4%) had a pulmonary embolism following antenatal prophylaxis with LMWH; three of these women (50%) were receiving lower than recommended doses. Two women had recurrent pulmonary emboli (1.4%, 95% CI 0.2-5.1%). Five women died (case fatality 3.5%, 95% CI 1.1-8.0%). Significant severe morbidity from thromboembolic disease underlies the maternal deaths from pulmonary embolism in the UK. This study has shown some cases where thromboprophylaxis was not provided according to national guidelines, and there may be scope for further work on guideline implementation.

Prescribing intramuscular opioids for labour analgesia in consultant-led maternity units: a survey of UK practice

Intramuscular opioids are widely used for analgesia in labour. We conducted a postal survey to establish current prescribing and monitoring guidelines for intramuscular opioids in consultant-led obstetric units in the UK. A postal questionnaire was sent between December 2005 and January 2006 to the lead obstetric anaesthetist of all 234 consultant-led obstetric units in the UK. We enquired about dose regimens of intramuscular opioids in labour and monitoring of mother, fetus and neonate. The response rate was 71%; 84.4% of responding units used pethidine and 34.1% diamorphine. Meptazinol and morphine were available in 13.8% and 13.2% of units respectively. Some units used more than one opioid. The choice of opioid was dictated mainly by tradition (65.3%) and familiarity (40.7%). Prophylactic antiemetics were co-administered in 73.7% of units, the most commonly used being prochlorperazine (30.5%). Vital signs were monitored in 91.6% of units: in total 10.2% measured haemoglobin oxygen saturations and 4.8% respiratory rate. Pain scores were recorded in 13.7% of units. When compared with previous studies the use of intramuscular diamorphine is increasing in UK consultant-led obstetric units, although pethidine remains the widely used opioid. At present this change cannot be justified by a suitably powered, randomised study comparing intramuscular pethidine with diamorphine.

Use of steroids, tocolytics and antibiotics in the management of preterm labour in Wales

Summary The management of preterm labour (PTL) remains contentious. Many regimes are used for the management of this common condition and in utero transfer of pregnant women to another unit is not unusual in British practice. Medical staff in the accepting unit may have little or no experience with one or more drug regimes used in this condition which used in isolation and in combination with others may have disastrous consequences for the mother. We have assessed the variation in practice for the management of preterm labour in all consultant-led obstetric units in Wales using a postal questionnaire. The percentage of units with written guidelines for the management of PTL was 40%. All units used corticosteroids although the regimes used varied. Fourteen of the 15 units used tocolytics. Ritodrine and nifedipine were the most frequently used tocolytics but there was much variation in practice. Only seven (46.7%) units used antibiotics and five of these were randomising women in PTL to the ORACLE study. Postal surveys may not reflect accurately what actually happens in clinical practice. These data demonstrate that there is no common policy for the management of PTL even in a relatively small region such as Wales. We would suggest that the development of a regional policy for the management of preterm labour would be a significant step forward in the management of this controversial, but important cause of neonatal morbidity and mortality.

Is a rising caesarean section rate inevitable?

To determine the indications for singleton caesarean sections in Scotland in 1994. Prospective survey of singleton caesarean sections using information provided by clinicians entering data onto a computer in labour wards. Twenty-three consultant-led obstetric units in Scotland. Women undergoing caesarean section in participating Scottish maternity units during 1994. Using routinely collected data it was found that the caesarean section rate varied by maternal age, parity, gestation, history of previous section and hospital of delivery, but there was no difference by area of deprivation. 87.4% (8369/9573) of Scottish caesarean sections were included in the survey of which 8098 were in women with singleton pregnancies. Most singleton caesarean sections were undertaken in primiparae (50.5%), 31.2% were in women with a history of previous section and 18.3% were in multiparous women who had not had a previous section; 38.9% of the operations were elective, 13.9% were emergencies before labour and 47.2% were emergencies during labour. Four main indications--elective section for breech presentation (10.7% of all sections); emergency caesarean section before labour because of fetal problems (2.8%); emergency caesarean section during labour for fetal distress and/or failure to progress (30.3%); repeat section for reasons other than above (16.2%) accounted for 60% of all caesarean sections in women with no other recorded complications. 7.7% of all singleton caesarean sections (19.8% of elective operations) were associated with maternal request for the operation. The survey has identified why caesarean sections are performed by Scottish obstetricians and highlighted some areas where there would be scope to increase the vaginal delivery rate. Before this can be attempted, agreement must be reached by clinicians about effective management of particular problems. Women also need to have ready access to evidenced-based information about caesarean section.