Emergency Delivery Research Articles

Овариальная беременность у пациентки с эндометриозом

The clinical observation of ovarian pregnancy in a 29-year-old patient with newly identified ovarian and peritoneal endometriosis, which is considered as a risk factor for ectopic pregnancy in the literature, is presented. This observation proves that ovarian pregnancy presents significant difficulties for the diagnosis: in our study, the diagnosis was established only during laparoscopy. The ovarian resection and the excision of the endometriotic foci were performed, which subsequently contributed to the onset of pregnancy with a favorable outcome – emergency delivery. Key words: ovarian pregnancy, endometriosis, surgical treatment

Relationship of placental edge thickness and cervical length to gestational age at delivery in patients with placenta previa.

Background & Objective:Placenta previa and its accompanying fetomaternal complications are increasing day by day because of globally increasing rates of cesarean deliveries, trends of assisted reproductive techniques, and delaying pregnancies to later ages. Placenta previa is an important contributor to iatrogenic and mostly emergent preterm deliveries, which add to increased neonatal morbidity and mortality. The predictors of preterm deliveries can help clinician make necessary preparations for optimal fetomaternal outcome. The aim of the current study was to determine relationship of placental edge thickness and cervical length with gestation at delivery in patients having placenta previa.Methods:It was a descriptive case series study conducted in the department of obstetrics and gynecology, Medical Teaching Institute Lady Reading Hospital Peshawar from January 2020 till January 2021 .Seventy five patients fulfilled the inclusion criteria and were included in the study. Already diagnosed cases of placenta previa, with singleton alive pregnancies and gestation of 28 weeks or more were enrolled. Trans vaginal ultrasound was done to determine placental edge thickness and cervical length. Patients data on gestation at delivery were collected from hospital records.Results:A significant negative correlation between the placental edge thickness and gestational age at delivery was seen (r= -0.566, P= 0.001). The correlation between length of cervical canal and gestation at delivery was positive (r= 0.362, P=0.001). Also thick placental edge of > 2cm had significant association with birth before 37 weeks(P=0.023). A short cervix of less than 2.5 cm had also statistically significant association with birth before 37 weeks (P=0.022).Conclusion:There is linear inverse relationship of placental edge thickness with gestation at delivery. The relationship of cervical length with gestation is positive linear. Patients with thick placental edge are more likely to deliver preterm than those having thin placental edge.

DO PRÉ-NATAL AO PUERPÉRIO: MUDANÇAS NOS SERVIÇOS DE SAÚDE OBSTÉTRICOS DURANTE A PANDEMIA DA COVID-19

ABSTRACT Objective: to analyze changes in maternal health care during the Covid-19 pandemic, according to reports by health professionals. Method: qualitative research, conducted with managers, physicians, nurses, residents and nursing technicians working in a prenatal outpatient clinic, obstetric emergency department, delivery center and obstetric inpatient ward of a high complexity federal public hospital in the Northeast of Brazil. Data were collected from December 2020 to August 2021. The sample, chosen intentionally, sought the diversity of characteristics and situations, was closed by the criterion of saturation of meaning. A structured questionnaire and a semi-structured interview script were used for data collection. The interviews were recorded and transcribed. Content analysis was used in the thematic modality. Results: 28 professionals were interviewed. Changes in the dynamics of obstetric care were identified and categorized as: prenatal care; and childbirth/postpartum. In prenatal care, there was a decrease in elective consultations; increased time between consultations; delayed care due to paramentation; implementation of new hygiene protocols; limitation of the number of companions; creation of new environments such as the Covid-19 isolation room for symptomatic pregnant women; teleservice and work overload due to the increased demand coming from Primary Health Care. In childbirth/postparum, the reports indicated a reduction in the number of beds; testing and isolation of symptomatic patients; limitating walking, restriction of companions and mandatory use of mask by pregnant woman. Conclusion: the restructuring of services and the creation of new spaces to care for patients with Covid-19 led to a reduction in the availability of vacancies for prenatal and postpartum consultations. The changes were accompanied by new service rules, with setbacks regarding the guarantee of rights.

Designing the drone based end-to-end local supply chain distribution network

People in rural areas suffer due to lack of proper health care specifically during the emergency condition. Ontime delivery of emergency lifesaving medicine at the remote area is a one of the major concerns and one of the major reasons for this cause is the negligence and lack of proper transportation and road infrastructure. In this paper we have proposed a mixed integer non-linear programming (MINLP) model that is based on drone delivery for end-to-end local supply chain distribution network to ensure the fastest possible delivery of lifesaving medicine at the remote area. Moreover, we have used the Dijkstra algorithm to find the shortest path to deliver the lifesaving medicine at the patient home location using drone. The objective of this paper is to design an end-to-end local supply chain network to minimize the total delivery lead time of the lifesaving medicines under emergencies conditions. Also, the proposed MINLP model help to select the optimal healthcare facility location to minimize the total delivery lead time.

Clinical characteristics and outcomes of pregnant women admitted to the emergency department

Aim: To evaluate the demographic and obstetric characteristics, complaints, and outcomes of pregnant patients who presented to the emergency department (ED). Materials and Methods: Pregnant women aged 18 years and over who presented to the ED of our hospital between September 30, 2020, and September 30, 2021, were retrospectively included in the study. The clinical data of the patients were obtained from the hospital’s electronic database. The patients’ age, gestational week, complaints at the time of presentation to ED, distribution of diagnoses, and outcomes (admission and discharge) were recorded. Results: A total of 561 pregnant patients were included in the study. The mean age of the patients was 27.6±5.7 years, and 42.6% were in the third trimester. We found that 59.8% of the cases presented to ED for obstetric reasons and 40.2% for non-obstetric reasons. While 55.5% of the patients with obstetric presentations underwent emergency delivery, 51.3% of the those with non-obstetric presentations had respiratory tract infections. In addition, 90.7% of the patients with obstetric presentations were hospitalized. The hospitalization rate of those with obstetric presentations was statistically significantly higher than the non-obstetric presentation group (p<0.001). Conclusion: We found that the ED visits of pregnant women mostly occurred during the third trimester and for obstetric reasons. The early detection of life-threatening complications in pregnant women is critical for the health of both the mother and fetus. It is important to increase the awareness of clinicians concerning obstetric emergencies due to the special nature of this patient population and frequency of emergency surgical interventions.

General Anesthesia for Cesarean Section in a Pregnant Woman with Immune Thrombocytopenic Purpura (ITP): A Case Report and Review of the Literature

Background: Management of immune thrombocytopenia (ITP) during pre- gnancy can be challenging, particularly by identifying a threshold for safe administration of neuraxial/general anesthesia and minimizing postpartum hemorrhage. There is controversy over the safety of cesarean section (CS) in ITP patients. In this case report, we discuss general anesthesia management in a patient with ITP with severe thrombocytopenia. Case Presentation: A 28-year-old female with relapsed/refractory ITP and severe thrombocytopenia underwent general anesthesia and emergent cesarean section with successful outcomes and minimal bleeding. Platelet counts before CS were 5000 × 109 L, the patient received 1 unit of platelets before the procedure and 1 unit of platelet and tranexamic acid 500 mg was injected slowly during the procedure. No evidence of bleeding and no complications were observed in the patient or newborn. Conclusions: In an emergent circumstance, general anesthesia and cesarean section procedure were performed safely in a patient with severe thrombocytopenia, no hemorrhagic complications were seen for this patient or neonate. Objective of This Manuscript: To share our experience of a safe emergent CS procedure and general anesthesia in a patient with severe thrombocytopenia. Our experience may guide the management of ITP patients in emergent delivery circumstances.

Особенности центральной гемодинамики, функционального состояния вен нижних конечностей и перинатальные исходы у беременных женщин с начальными формами флебопатий

Objective. To study the features of functional status of veins and central hemodynamics in women with early stages of phlebopathy during pregnancy and their role in perinatal outcomes. Patients and methods. Seventy pregnant women with early manifestations of chronic venous disorders were examined. The study group included 30 patients who gave birth to children with signs of ante-, intra-, postnatal hypoxia; the control group included 40 patients with normal physiological birth outcomes for newborns. When assessing the status of venous system, the elasticity index was calculated, and the severity of sludge syndrome was identified. Volumetric compression oscillometry was used to measure several central hemodynamic parameters in the second trimester. The relative gene expression of HIF1α transcription factor was calculated in the second and third trimesters. Morphological examination of the placenta was performed with determining the fetoplacental ratio and placental weight (g). Results. There was a statistically significant increase in the elasticity index during gestation in pregnant women in the study group. The first stage of sludge syndrome in the second trimester was detected in 70% of pregnant women in the study group, and the second stage of sludge syndrome was detected in 16.6% of patients. The relative expression of HIF1α in patients in the study group increased more than 2.5-fold in the second trimester and more than 3.5-fold in the third trimester. Pregnant women in the study group had statistically significant changes in all central hemodynamic parameters as compared with the control group. All women required emergency delivery. Fetal weight in the study group was statistically lower than in the control group. Apgar score at 1 minute of life in the study group was 6.5 (6; 7) and at 5 minutes – 7.5 (7; 8), in the control group it was 8 (8; 8) and 9 (8; 9), respectively (p > 0.001). The revealed changes in the placentas from women in the study group corresponded to hypoxic tissue injuries. Conclusion. Pregnant women with early stages of phlebopathy have specific features of central hemodynamics and venous functional status, which determine perinatal outcomes. Key words: pregnancy, phlebopathy, hemodynamics in pregnant women, placental morphology

The Feasibility of the Drone Delivery System for Woolworths

The report aims to assess the feasibility of Woolworths’ drone delivery system and propose a well-documented solution to this, enabling Woolworths to make decisions about improving its traditional delivery system. This paper analyzes the examples of UAV delivery in the actual situation, points out the existing problems, and then evaluates the feasibility of UAV delivery in the future. This report firstly analyzes the current situation of the use of UAVs and points out the shortcomings of Woolworths’ current delivery system. To be specific, from Woolworths’ point of view, the current distribution system is unsuitable for remote distribution, and the human cost is too high. It also did not produce the expected customer satisfaction, was heavily influenced by the environment and congestion, and did not meet the goal of “no contact” under coronavirus care. This report then evaluates Woolworths’ proposal for a “Drone Delivery System” in the framework of future state analysis. It describes the overall objective and breaks it down into several measurable goals, including enhancing customer loyalty, increasing sales revenue, improving delivery efficiency, and ensuring safety through contactless delivery. In addition, a risk assessment was conducted to identify potential risks associated with this new delivery system. Identify and assess the possibility, impact and treatment of potential risks through the risk register. Subsequently, this report identifies four gaps between Woolworths’ current and future state delivery systems, including emergency delivery failures high freight costs, unmet on-time delivery rates and high risk of COVID-19 infection, and recommends actions to close the gap. Finally, delivering solutions for Woolworths through use cases from a system, process, and people perspective helps the organization determine how to seize opportunities and implement solutions. The results show that there are still many problems in using UAVs for delivery at the present stage, and many aspects should be improved.

Overview of Emulgel as Emergent Topical Delivery: Recent Applications and Advancement

Emulgel is an emerging delivery system with added advantages over other topical delivery systems which is proven to be boon for cosmetics and dermatology. Emulgels are emulsion which is converted to Gel, which will make it a non greasy and enhances patient compliance. The amalgamation of the two systems would be advantages in term of high drug loading capacity and low skin irritation, site specific targeting avoiding first-pass metabolism and increase in bioavailability. Work carried out by researchers proved that, Emulgel/ Nanoemulgel loaded with drugs has been found effective in many topical disorders and it is emerging as potential drug delivery system in area of dermatology. In the present review current research works that carried out on Emulgel and nano emulgels are discussed and also highlighted the recent applications of Emulgel in transdermal as well as dental, ocular, vaginal, and other delivery system.

Emergent versus planned delivery in patients with placenta accreta spectrum disorders: A retrospective study.

The aim of this study is to compare the clinical outcomes and to identify risk factors for emergent cesarean delivery and planned cesarean delivery in patients with placenta accreta spectrum (PAS) disorders in Vietnam.The medical records of patients admitted to our hospital with a diagnosis of PAS disorders >5 years were retrospectively reviewed.A total of 255 patients with PAS disorders were identified, including 95 cases in the emergent delivery group and 160 cases in the planned delivery group. The percentage of complete/partial placenta previa in the planned delivery group was significantly higher than that in the emergent delivery group (59.22% vs 32.16%, P = .027). Fewer patients in the planned group had vaginal bleeding compared with those in the emergent group (29 vs 36 cases, P < .001). The percentage of blood transfusion was similar between the 2 groups; however, the transfused units of pack red blood cells were greater in the emergent delivery group (5.3 ± 0.33 vs 4.5 ± 0.25 U, P = .036). When considering the neonatal outcomes, the data demonstrated that the planned delivery group had a significantly higher birth weight and a lower rate of preterm delivery than the emergent group (P < .001). The mean gestational age at delivery for the emergent group was 35.1 ± 0.27 weeks compared with 38.0 ± 0.10 weeks for the planned group (P < .001). The increased risk factors for emergent delivery were vaginal bleeding (odds ratio 2.86, 95% confidence interval 1.59–5.26) and preterm delivery (odds ratio 5.26, 95% confidence interval 2.13–14.29).Planned delivery is strongly associated with a lower need for blood transfusion and better neonatal outcomes compared with emergent delivery. Antenatal vaginal bleeding and preterm labor are risk factors for emergent delivery among patients with PAS disorders. Based on the results of this study, we recommend that the management strategies for patients with PAS disorders should be individualized to determine the optimal timing of delivery and to decrease the rate of emergent cesarean delivery.

Intrapartum epidural analgesia and emergency delivery rates due to fetal compromise by birth weight percentile

Epidural analgesia (EDA) is widely used for maternal pain relief during labour. However, hemodynamic changes induced by EDA may adversely affect placental perfusion. In fetuses who already suffer from reduced placental function, manifested by fetal growth restriction, this may carry a higher risk of intrapartum compromise. This study aims to determine the emergency delivery rates due to fetal compromise after EDA compared to alternative- and no analgesia across the spectrum of birth weight centiles.

EP.FRI.271 The impact of Surgical Assessment Unit on emergency and ambulatory surgical care in a district general hospital

Abstract Aims There has been a paradigm shift in the delivery of emergency and ambulatory surgical care necessitated by paucity of beds, improved expedited diagnostics and delayed transit in Emergency departments. The objective of a surgical assessment unit (SAU) is to reduce the number of semi-urgent admissions, provide direct access to urgent surgical admissions bypassing the ED, expeditious assessment by senior clinicians and to reduce the number of OPD follow up. In our setting, the SAU came into existence on all 5 working days at 12-hour daily schedule and its impact was evaluated retrospectively. Methods Prospectively maintained data base over a 2-month period was examined. Pre and post SAU figures were compared to judge any quantitative improvement in surgical services. Results During the audit period of 2 months there were 156 emergency patients and 190 ward attenders for follow up care. Majority of these patients were assessed within 4 hours and discharged or ambulated. Numbers being admitted overnight purely to facilitate investigations showed a decrease of 44.6% post SAU establishment. There was a reduction in post discharge outpatients appointments when compared to a similar time period pre SAU (14% difference). Conclusion The SAU, although initially conceived and designed purely to cope with increased admissions and to minimise breaching of emergency department targets, has shown quantitative and qualitative improvement in emergency and ambulatory surgical care delivery.

THE PARADOXICAL PRESENTATION OF PRE-ECLAMPSIA WITH DIFFUSE ALVEOLAR HEMORRHAGE AND VENOUS THROMBOSIS AS CLINICAL MANIFESTATIONS OF ANTIPHOSPHOLIPID SYNDROME

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Antiphospholipid Syndrome (APS) is an autoimmune disorder clinically defined by the presence of antiphospholipid antibodies (aPL), history of arterial or deep venous thrombosis (DVT), and/or repeat episodes of early pregnancy loss. Due to the increased risk for thrombosis, often overlooked is a rare and seemingly paradoxical association between APS and diffuse alveolar hemorrhage (DAH) - a disorder characterized by non-localized alveolar bleeding. Rare manifestation of APS presenting with preeclampsia, DAH, and DVT offers a variety of multi-disciplinary challenges. CASE PRESENTATION: A 34-year-old G6P3 woman at 28 weeks gestation with a remote history of pulmonary embolism (PE), presented to the Emergency Department with a two-day history of dyspnea and hemoptysis. Exam was remarkable for sinus tachycardia, grade 3 systolic murmur at the apex, and increased work of breathing with bilateral pulmonary rhonchi. Computed tomography (CT) scan demonstrated centrally predominant opacities without signs of PE. Bronchoscopy was significant for diffusely hemorrhagic airways with progressively hemorrhagic serial lavage aliquots. Emergent delivery was performed in the setting of Preeclampsia while high-dose steroids were administered for DAH. The patient returned to baseline over the next 3 days without returning signs of hemoptysis. Lupus anticoagulant was positive but PT and PTT were both normal. Steroids were discontinued and therapeutic enoxaparin was started for a possible novel diagnosis of APS.Six days later, she reexhibited hemoptysis. Repeat CT revealed bilateral alveolar infiltrates consistent with the recurrence of DAH. Disproportionate left lower extremity edema and a femoral vein DVT were also discovered. Anticoagulation was again withheld, high-dose steroids were re-started, and an inferior vena cava filter was placed. Repeat lupus anticoagulant testing was positive. In addition, the dilute russell viper venom time (DRVV) was prolonged in the setting of normal PT/PTT, confirming APS diagnosis. She recovered within five days and was prescribed warfarin for chronic anticoagulation, glucocorticoids were tapered, while rituximab infusions were initiated as glucocorticoid-sparing therapy. DISCUSSION: This case highlights challenges associated with the diagnosis and management of rare simultaneous manifestations of APS. In particular, the management of DAH in this scenario is unique because unlike the glucocorticoid-responsive antibodies of ANCA-associated vasculitides, aPL are not known to cause alveolar capillaritis; therefore, the role of steroids is unclear. CONCLUSIONS: Chronic anticoagulation is an absolute requirement for long-term management of APS. Yet as this case exemplifies, in the case of concomitant DAH, administration of glucocorticoids, and subsequently glucocorticoid-sparing immunosuppression is recommended as the safest approach to avoid life-threatening hemorrhage. REFERENCE #1: Cartin-Ceba R, Peikert T, Ashrani A, Keogh K, Wylam ME, Ytterberg S, Specks U. Primary antiphospholipid syndrome-associated diffuse alveolar hemorrhage. Arthritis Care Res (Hoboken). 2014 Feb;66(2):301-10. doi: 10.1002/acr.22109. PMID: 23983016. REFERENCE #2: Stoots SA, Lief L, Erkan D. Clinical Insights into Diffuse Alveolar Hemorrhage in Antiphospholipid Syndrome. Curr Rheumatol Rep. 2019 Sep 6;21(10):56. doi: 10.1007/s11926-019-0852-7. PMID: 31493005; PMCID: PMC7102334. REFERENCE #3: Janowiak P, Sieminska A, Porzezinska M, Smolenska Z, Suchanek H, Jassem E. Difficulties in the treatment of recurring diffuse alveolar hemorrhage accompanying primary antiphospholipid syndrome: a case report and literature review. Adv Respir Med. 2018;86(3). doi: 10.5603/ARM.2018.0020. PMID: 29960279. DISCLOSURES: No relevant relationships by Eric Knott, source=Web Response no disclosure on file for Eric Lang; No relevant relationships by Claudia Saborit, source=Web Response

MANAGEMENT OF TYPE A DISSECTION IN PREGNANCY: SITE AND TEAM CAN MAKE THE DIFFERENCE

Introduction Aortic dissection is rare in pregnancy but associated with poor maternal and neonatal outcomes. We present a case of delayed diagnosis of type A aortic dissection in pregnancy in a previously healthy woman to raise awareness and highlight the value of an integrated, multidisciplinary approach. Methods A 38-year-old, G1P0 woman was transferred to our hospital with a type A aortic dissection diagnosed at 30 weeks of pregnancy. The patient had no significant medical history and her pregnancy was uneventful. At 29 weeks gestation, however, she developed central chest pain. Her local hospital excluded a diagnosis of pulmonary embolism and discharged her home. She represented 3 days later with shortness of breath and orthopnoea. On the second day of this admission, Type A aortic dissection was diagnosed on computed tomography of the chest. She was transferred to our hospital for access to multiple specialist services including cardiothoracic surgery and high-risk obstetrics, neonatal and adult critical care. On arrival, an ad hoc MDT convened in the emergency department by a senior team of cardiothoracic surgeons, obstetricians, anaesthetists and neonatologists agreed immediate intervention was required. She went directly to theatres for delivery of the baby and dissection repair. Awake establishment of invasive blood pressure monitoring was followed by an opiate-based cardiostable induction of anaesthesia and intubation in a head-up position. The caesarian section was uneventful and exceptional measures to minimise blood loss were not required. The ascending aorta and hemi-arch were repaired on cardio-pulmonary by-pass with circulatory arrest time of 19 minutes without intraoperative complications. The baby was electively intubated and transferred to neonatal ICU in stable condition. Mother and baby were both extubated the following day and discharged home after a week. Discussion Acute aortic dissection should always be included in the differential of acute chest pain in pregnant women. It most commonly occurs during the third trimester or the early postpartum period and it can sometimes present in women with no previous history of aortopathy. High clinical suspicion, careful history taking and examination, CT, MRI or echocardiography can establish the diagnosis. Optimum management to ensure the survival of both mother and fetus varies with gestational age and planning to ensure this requires a complex balance of expertise between specialities. In the third trimester, emergency delivery followed by surgical aortic repair probably offers the best survival chances for both. Institutions which offer senior input from multiple specialities are crucial for the timely management of these complex cases. This need for urgent intervention from outside cardiothoracic surgery in cases with multiple issues must be considered when regional care models for the management of aortic dissection cases are being designed.

Feminist Postdigital Inquiry in the Ruins of Pandemic Universities

During Covid-19, higher education made an unprecedented entry into the domestic sphere. However, not all students welcomed the emergency delivery of online courses. Consequently, some learners have been developing resistant practices to technology-driven learning, including being on mute and turning off cameras, but these silences, gaps and evasions are difficult to grasp through normative perspectives. Meanwhile, big tech continues to profit significantly from its encroachment on pedagogy. Conversely, we need alternate conceptions of learners’ varying responses to technologies. To develop a novel perspective, the study considers the Middle East’s traditional mashrabiyya windows, which are carved through an elaborate wooden latticework screen of geometric patterns and designed to deflect rather than let in the light. This mashrabiyya structure is applied as a theoretical metaphor to consider Arab women learners’ technological veiled affordances of filters, avatars and not replying. The mashrabiyya feminist postdigital framework develops unique inquiry into learners’ subtle practices; the authors’ self-reflexivity; and analysis of a (silent) email exchange and a Twitter avatar. Theorising suggests silences, invisibilities and disconnection are not necessarily a deficit but refractive responses enabling students and educators to stay below the radar.

Automotive Ground Vehicles' Resilience to HEMP Attack: An Emergency Management Mitigation Plan

United States exposure to attack from a nuclear weapon of mass destruction (WMD) optimized to generate a high‐altitude electromagnetic pulse (HEMP) is a concern in national security forums. Such an attack could lead to widespread damage to the electrical components of many critical infrastructures. The purpose of this study was to develop a framework to better understand the hazard risks from a HEMP attack on non‐military (non‐MIL), “electronics‐heavy” automotive ground vehicles that could inform an effective emergency management response and recovery plan. A hybrid emergency management and engineering hazards risk analysis utilizing a Failure Modes and Effects Analysis (FMEA) format helped visualize the critical vehicle electronics subsystems and components, and their respective potential failure modes. A design of experiments test plan was developed to quantify the risks, and to develop a pathway to validate cost‐effective mitigation countermeasures based on present‐day best practices for HEMP hardening. The proposed emergency management plan emphasized strategic implementation of HEMP mitigation countermeasures to support continuity in emergency services and delivery of community lifelines to the public. The results of this study will serve as a foundation for future HEMP projects with automotive ground vehicles that will support the FEMA National Preparedness Goal, Presidential Executive Order 13865, and the recent FY2020 National Defense Authorization Act (NDAA) legislation. The methodologies can also apply to other critical infrastructure segments.

Dialogic pedagogy and semiotic-dialogic inquiry into visual literacies and augmented reality

Technological determinism has been driving conceptions of technology enhanced learning for the last two decades at least. The abrupt shift to the emergency delivery of online courses during COVID-19 has accelerated big tech’s coup d’état of higher education, perhaps irrevocably. Yet, commercial technologies are not necessarily aligned with dialogic conceptions of learning while a technological transmission model negates learners’ input and interactions. Mikhail Bakhtin viewed words as the multivocal bridge to social thought. His theory of the polysemy of language, that has subsequently been termed dialogism, has strong correlations with the semiotic philosophy of American pragmatist Charles Sanders Peirce. Peirce’s semiotic philosophy of signs extends far beyond words, speech acts, linguistics, literary genres, and/or indeed human activity. This study traces links between Bakhtin’s dialogism with Peirce’s semiotics. Conceptual synthesis develops the semiotic-dialogic framework. Taking augmented reality as a theoretical case, inquiry illustrates that while technologies are subsuming traditional pedagogies, teachers and learners, this does not necessarily open dialogic learning. This is because technologies are never dialogic, in and of themselves, although semiotic learning always involves social actors’ interpretations of signs. Crucially, semiotic-dialogism generates theorising of the visual literacies required by learners to optimise technologies for dialogic learning.

Midwife Competency Standards and Midwife Authority in Emergency Delivery Services

Midwife as a professional has Competency standards of midwife consist of nine competencies which organize basic knowledge, additional knowledge, and skills of midwives in providing services. Midwife authorities are currently regulated under PMK No. 1464 in 2010 concerning License and Operation of Midwives Practice in which emergency authority during labour is limited by the conditions of the place. This study uses an approach method that is normative juridical, it is a way of examining law research conducted over reading materials or merely secondary data and using the method of deductive thinking as well as the criterion of coherence truth. Not every assessment in labour can be performed independently by midwives. Based on the competency standards of the midwife in Kepmenkes 369 in 2007 concerning the standard of the midwifery profession, competencies required in a midwife profession covers a very wide knowledge and skills, while the authorities of the profession can be said limited. In terms of their presence in a city close to secondary/ tertiary health care facilities, their role is very limited. Reviewing aspects of applicability of the law, it is not limited by space and time, so that there is a consistency of law, law certainty, therefore, relates to the regulation of competency standard that is associated with midwife authority becomes inconsistent. Keyword: Midwife, Competency, Authority, and Emergency in Labor Abstrak: Bidan sebagai tenaga profesional memiliki Standar kompetensi bidan yang terdiri dari sembilan kompetensi yang mengatur pengetahuan dasar, pengetahuan tambahan, dan keterampilan bidan dalam memberikan pelayanan. Kewenangan bidan saat ini diatur dalam PMK No. 1464 Tahun 2010 tentang Perizinan dan Penyelenggaraan Praktek Bidan dimana kewenangan darurat selama persalinan dibatasi oleh kondisi tempat. Penelitian ini menggunakan metode pendekatan yang bersifat yuridis normatif, yaitu suatu cara pemeriksaan penelitian hukum yang dilakukan atas bahan bacaan atau data sekunder semata dan menggunakan metode berpikir deduktif serta kriteria kebenaran koherensi. Tidak setiap pengkajian dalam persalinan dapat dilakukan secara mandiri oleh bidan. Berdasarkan standar kompetensi bidan dalam Kepmenkes 369 tahun 2007 tentang standar profesi bidan, kompetensi yang dibutuhkan dalam profesi bidan meliputi pengetahuan dan keterampilan yang sangat luas, sedangkan kewenangan profesi dapat dikatakan terbatas. Dalam hal kehadiran mereka di kota yang dekat dengan fasilitas kesehatan sekunder/tersier, peran mereka sangat terbatas. Meninjau aspek keberlakuan undang-undang, tidak dibatasi oleh ruang dan waktu, sehingga ada konsistensi hukum, kepastian hukum, oleh karena itu terkait dengan pengaturan standar kompetensi yang dikaitkan dengan kewenangan bidan menjadi tidak konsisten. Kata Kunci: Bidan, Kompetensi, Wewenang, dan Kegawatdaruratan Dalam Persalinan

#36: A Review of Maternal and Neonatal Characteristics and Outcomes in Pregnant Women with Serious Infectious Complications from Injection Drug Use

Abstract Background Pregnant people who inject drugs (PWID) and their infants are unique populations that have emerged from the opioid epidemic. Numerous studies have evaluated vertical transmission of HIV, HCV, sequelae of neonatal abstinence syndrome, and maternal and fetal mortality in these mother-infant dyads; however there still remains a large knowledge gap regarding how serious infections in pregnant PWID affect more proximal outcomes such as fetal and maternal distress leading to preterm delivery, risk of neonatal sepsis, need for invasive diagnostic procedures to rule-out neonatal sepsis such as lumbar puncture, neonatal intensive care unit (NICU) admission, and potential consequences of prolonged intrauterine antibiotic exposure. Methods We identified pregnant PWID ≥18 years old with serious infectious complications (defined as (sepsis, endocarditis, osteomyelitis, epidural abscesses, septic arthritis/bursitis, thrombophlebitis, and skin and soft tissue infections requiring IV antibiotics) admitted between 2017–2018 to the University of Kentucky Medical Center and their neonates treated at Kentucky Children’s Hospital. Patients were identified using positive urine or serum pregnancy test results, IVDU-associated ICD9/10 codes, infectious disease, neonatology, and obstetrics notes. Results 261 women with infectious complications from IVDU were identified, 25 were pregnant and 16 dyads were able to be matched with identification of 14 viable neonates born at the University of Kentucky. Mean maternal age was 31 years and median 30 years. Mean gestational age (GA) at time of admission was 25 weeks with median 29 weeks. Sepsis was the most common complication reported 18 (72%) followed by endocarditis 11 (44%). Staphylococcus aureus was the most isolated organism (16) 64% with 12 (48%) of isolates identified as MRSA and MSSA comprising 4 (16%). 96% were screened for HCV, with 72% HCV antibody positive and 32% with detectable viral load. There was 1 reported maternal death, 1 spontaneous abortion and 2 intrauterine fetal demises (IUFD) in the 3rd trimester and no neonatal deaths. Average GA at time of delivery was 33 weeks with median 36 weeks. 6 (42%) were routine deliveries with 3 (22%) deliveries for emergent maternal indications and 5 emergent deliveries for fetal indications (36%). 12 neonates (86%) required NICU admission with average length of stay 17 days and median 10 days. 10 (71%) underwent limited sepsis screen with 9 (64%) receiving at least 48 hours of antibiotics and 3 (22%) receiving an extended course. However none of the blood cultures yielded any organisms. All passed their hearing screening and had no evidence of renal dysfunction or cytopenias. Conclusions Pregnant PWID dyads may be at increased risk for morbidity and mortality secondary to infectious complications of IVDU. The majority of neonates were delivered early for either fetal distress or maternal distress. 2 mothers suffered IUFD in the 3rd trimester and the majority of the neonates required NICU admission (86%) due to prematurity-related factors, concern for neonatal abstinence syndrome or concern for infectious complications. Over half received 48+ hours of antibiotics in the NICU however none of the neonatal blood cultures yielded an organism. Larger cohort studies are needed to better ascertain risk in these expanding populations.

Obstetric outcome after emergency cervical cerclage: A prospective observational study performed in CSI Kalyani hospital, Chennai

Cervical insufficiency is a well documented etiological factor in preterm delivery. This study was conducted to evaluate the efficacy and safety of Emergency cervical cerclage in women who presented with advanced cervical changes such as cervical dilatation and bulging fetal membranes. The study was prospective observational study performed in the department of obstetrics and gynaecology CSI Kalyani General Hospital, Chennai, Tamil Nadu over a duration of 18 months. This study included all women who presented in late second trimester with advanced cervical dilatation (2 to 4cms) for whom emergency cervical cerclage was done by McDonald technique. Out of the 15 patients for whom emergency cerclage was performed, 3 had spontanous abortion after cerclage, 6 had PROM and 5 of these patients had term delivery. The time interval between emergency cervical cerclage and delivery was 11 weeks. No surgical complications were reported. The mean gestational age at delivery was 32 weeks. 11 fetuses were live born after the period of viability. 3 of these babies were admitted to NICU. Post emergency cervical cerclage, the outcomes in terms of prolongation of pregnancy, live births and neonatal survival are better.