Glasgow Royal Maternity Research Articles

Jean Mary Scott (née Neville)

Jane Cook and Jane Short write: Dr Scott, who became a considerable force in medical politics as regards the status of women doctors, died suddenly at her home in Pitlochry,...

Outcomes of pregnancy complicated by thyroid disease

To perform a case note review of pregnancies complicated by thyroid dysfunction to determine management and therapeutic intervention in relation to pregnancy outcome. A retrospective case note analysis of 81 ongoing pregnancies in 70 pregnant women with a history of thyroid dysfunction over a period of 5 years at the Glasgow Royal Maternity Hospital (GRMH), Glasgow, Scotland, United Kingdom. The results of thyroid function tests and whether a change in treatment was instituted were recorded. Thyroid function was assessed by standard laboratory reference ranges for free thyroxine (FT4) and thyroid stimulating hormone (TSH) in all trimesters. Other parameters were also noted. Medication levels needed to be increased in the hypothyroid group (45%), and decreased (38%) in the hyperthyroid group. Pregnancy outcome was good in majority of cases given appropriate replacement therapy for stated reference values.

First trimester maternal blood rheology and pregnancy induced hypertension

SummaryThis study evaluates the relationship between the first trimester assessment of maternal rheology and the subsequent development of pregnancy induced hypertension. This is a prospective observational study based in the Glasgow Royal Maternity Hospital, Scotland. From an original population of 744 consecutive antenatal attendees a total of 579 women were booked at less than 14 weeks' gestation. The main study group is a further subset comprising 251 primigravid women booking with a singleton pregnancy without essential hypertension. Previously published data from a group of non-pregnant women of similar age drawn from the same local community was used for external comparison. Blood samples were collected at the booking visit, from which fibrinogen, red cell aggregation, haematocrit and plasma, whole blood, relative and corrected viscosities were recorded. Information was obtained from the case notes in retrospect starting approximately 1 year after the first patients had first been recruited into the trial. The overall outcome of the pregnancies was noted with particular reference to pregnancy induced hypertension (PIH), birth weight, antepartum haemorrhage, pre-term labour, perinatal death, condition at delivery and neonatal complication. Our results show PIH is associated with a significantly raised mean blood viscosity and fibrinogen at time of booking. All significance disappears after adjustment for smoking, diastolic blood pressure and age. Viscosity is, however, only marginally non-significant (p = 0.07). In conclusion, blood rheology, in particular blood viscosity and fibrinogen, may play a predictive role in the development of pregnancy-induced hypertension. When combined with measurement of smoking and diastolic blood pressure at booking, these measurements could be used to calculate a risk score for the development of PIH, allowing targeting of antenatal care. Further data is required.

An audit of neonatal respiratory morbidity following elective caesarean section at term.

Studies have suggested that a reduction in neonatal respiratory morbidity may be achieved by delaying elective caesarean section until 39 weeks gestation. In 1997 staff at the Glasgow Royal Maternity Hospital were concerned at the level of neonatal respiratory morbidity following elective caesarean section. To determine the extent of neonatal respiratory morbidity following elective caesarean section at term. Then to present the findings, make recommendations and perform a repeat analysis. A retrospective analysis of all elective caesarean sections at term between October 1996 and October 1997 was performed. Labour ward, operating theatre and SCBU records were examined, followed by maternal and infant case note review. The gestational age at the time of caesarean section and any neonatal respiratory morbidity was recorded. The results were subsequently presented at a perinatal morbidity meeting and a recommendation made to delay elective sections until 39 weeks gestation. The audit was repeated between June 1999 and June 2000. The first cycle of the audit showed significantly lower rates of neonatal admissions with advancing gestation (p < 0.001). There was also a reduction in the number of infants requiring oxygen (p = 0.001), the number of infants requiring intensive care admission (p = 0.001) and ventilation (p = 0.003) with advancing gestation. In the second cycle of the audit there was a significant decrease in the number of elective caesarean sections performed prior to 39 weeks gestation (51% vs. 26%) (p < 0.0001). There were fewer neonatal admissions with respiratory morbidity between the two phases of the audit (26/292 vs. 18/327) (RR = 0.62, 95% CI 0.34-1.1). There was also a reduction in the number of infants requiring oxygen (RR = 0.5, 95% CI 0.23-1.06) the number of infants requiring intensive care admission (RR = 0.45, 95% CI 0.15-1.29) and the number of infants requiring ventilation (RR = 0.38, 95% CI 0.1-1.47). A reduction in neonatal respiratory morbidity can be achieved by delaying elective caesarean section until 39 weeks gestation.

A randomised controlled trial of admission electronic fetal monitoring in normal labour

Aim: to test the hypothesis that the use of admission Electronic Fetal Monitoring (EFM) for healthy pregnant women in spontaneous labour would result in an increase in continuous EFM when compared to women who have had no admission EFM. Design: a randomised controlled trial. Setting: the Midwives Birth Unit in Glasgow Royal Maternity Hospital, a major urban teaching hospital with approximately 5000 births per year. Participants: healthy pregnant women admitted in normal labour, deemed low risk based on the midwives’ birth unit admission criteria. Intervention: women were randomly allocated either to receive a routine 20-minute period of EFM at the time of admission (control group), or to receive no routine admission EFM (study group). Outcome measures: primary study outcomes, use of continuous EFM; and use of EFM additional to the admission test. Secondary outcomes: artificial rupture of membranes, use of fetal scalp electrode, fetal blood sample, syntocinon, epidural analgesia, number of vaginal examinations, rate of transfer to labour ward, and reason for transfer. Key findings: there was no statistically significant difference between the groups for use of continuous monitoring, but significantly more women in the control group did receive additional EFM. There was no statistically significant difference between groups for any of the interventions studied. Conclusion: the use of admission EFM did not in itself lead to a cascade of intervention. Other factors including setting of care and philosophy of caregivers may have an effect on the rate of intervention in labour.

Experience of reversal of sterilisation at Glasgow Royal Infirmary.

To review experience at the Glasgow Royal Infirmary with regard to women who underwent reversal of sterilisation, to obtain a profile of these women and to evaluate the procedure itself in terms of safety and restoration of fertility. A retrospective study based on case records from the Glasgow Royal Infirmary and from the Glasgow Royal Maternity Hospital, both of which share the same catchment area. Eighty-five women underwent reversal of sterilisation between 1 January 1994 and 31 December 1998 at the Glasgow Royal Infirmary. Follow-up at the Glasgow Royal Maternity identified 43/85 women. Patients were identified from relevant theatre log books and from records at the maternity hospital until December 2000 and their case notes reviewed. Having a new partner was responsible for 90% of requests. Median age at request for reversal was 34 years and most had been sterilised before the age of 30 years. There were few postoperative complications. Pregnancy occurred in at least 43% of women. Reversal of sterilisation is a safe and effective method of restoring fertility. The actual incidence of pregnancy after reversal is likely to be higher than the 43.5% recorded due to difficulties in achieving 100% follow-up.

Competencies of midwives with single or dual qualifications at the point of registration in Scotland

Objective: to compare and contrast competencies of midwives with single or dual qualifications at the point of registration in Scotland.Design: self-completing survey using the Glasgow Royal Maternity Hospital’s Skills’ Inventory by midwives at the point of registration and by Supervisors of Midwives analysed using non-parametric statistical tests. Content analysis of semi-structured interviews with experienced midwives and Supervisors of Midwives.Setting: midwifery education and practice settings throughout Scotland.Participants: 157 midwives at the point of registration, 166 Supervisors of Midwives.Measurements: Mann–Whitney and Kruskal Wallis analysis of skills of midwives at the point of registration in prenatal, labour, post-natal, neonatal areas and extended skills areas.Findings/implications for practice: all newly qualified midwives in Scotland, regardless of their educational preparation, are capable of providing care for women and babies in normal midwifery situations. While support for the direct entry programmes has been clearly demonstrated, this is not unanimous, although as more direct entry midwives take up positions, attitudes are becoming more positive.

An outbreak of Serratia marcescens in two neonatal intensive care units

Outbreaks of infection in neonatal intensive care units (NICUs) due to Serratia marcescens are well recognized. In some outbreaks no point source has been found, whereas in others cross-infection has been associated with contaminated ventilator equipment, disinfectants, hands and breast pumps. We report an outbreak due to S. marcescens that involved two geographically distinct NICUs. The outbreak occurred over a six week period; 17 babies were colonized, 12 at Glasgow Royal Maternity Hospital (GRMH) and five at the Queen Mothers Hospital (QMH). At GRMH three babies developed septicaemia, of whom two died. The outbreak isolates were of the same serotype and phage type and were indistinguishable on the basis of restriction fragment length polymorphism analysis. During the outbreak, two babies shown consistently to be negative on screening, were transferred between the two units. In addition, two members of medical staff attended both units. In QMH no means of cross infection was identified. However, in GRMH the outbreak strain of S. marcescens was isolated from a laryngoscope blade and a sample of expressed breast milk.

Antenatal use of enoxaparin for prevention and treatment of thromboembolism in pregnancy.

To assess the safety and efficacy of enoxaparin use for thromboprophylaxis or treatment of venous thromboembolism during pregnancy. Retrospective review of casenotes of women who received enoxaparin during pregnancy. Obstetric Medicine Unit at Glasgow Royal Maternity Hospital. Data were obtained on 57 pregnancies in 50 women over six years. Information was obtained from case records in relation to outcome measures, the presence of underlying thrombophilia and indication for anticoagulation. Incidences of venous thromboembolism, haemorrhage, thrombocytopenia, peak plasma anti-factor Xa levels and symptomatic osteoporosis. There were no thromboembolic events in the thromboprophylaxis group. There were no incidences of heparin-induced thrombocytopenia. Twenty-two women had spinal or epidural anaesthesia and no complications were encountered. There was one instance of antepartum haemorrhage following attempted amniotomy in a woman with previously unknown vasa praevia. Two women sustained postpartum haemorrhage, both secondary to vaginal lacerations, resulting in blood loss > 1,000 mL. Blood loss following caesarean section was not excessive. No instances of vertebral or hip fracture were encountered. The median peak plasma anti-factor Xa level on a dose of 40 mg once daily was 0.235 U/mL; peak plasma anti-factor Xa levels were not affected by gestational age. The use of enoxaparin in pregnancy is associated with a low incidence of complications and a dose of 40 mg once daily throughout pregnancy provides satisfactory anti-factor Xa levels and appears effective in preventing venous thromboembolism.

Association of reduced selenium status in the aetiology of recurrent miscarriage.

To determine whether recurrent miscarriage is associated with reduced selenium status. Case-control study. Department of Obstetrics and Gynaecology, Glasgow Royal Infirmary and Glasgow Royal Maternity Hospital. Twenty nonpregnant women with a history of unexplained recurrent miscarriage, and 47 nonpregnant parous women with a history of at least one successful pregnancy and no more than one miscarriage. A 7 mL blood sample from each woman was collected into lithium heparin 'vacutainer' tubes. Samples were centrifuged at 3000 g for 15 minutes, and plasma was extracted and stored at -20 degrees C. Selenium concentrations were measured using a fluorescence spectrophotometer. The selenium concentrations in the two groups were compared and the differences examined using the Student's t test. Plasma selenium concentration (microg/L). The mean selenium concentration for women with a history of unexplained recurrent miscarriage was 67.7 microg/L (SD 16.4). The selenium level for the women with no history of recurrent miscarriage was 70.3 microg/L (SD 12.7). There was no difference in selenium concentrations between the two groups (P = 0.53). In this study there is no association between unexplained recurrent miscarriage and reduced selenium status, implying that reduced selenium status is not a factor in the pathogenesis of recurrent miscarriage. We can find no rationale for a trial of selenium therapy in women with a history of recurrent miscarriage.

Can childbirth be changed? — offering women a choice

This article discusses the implementation and evaluation of an initiative to routinely provide healthy women with five choices for the type of maternity care they receive (community- and hospital-based shared care, named midwife care, DOMINO and home birth). A cohort study of 345 women was carried out at the Glasgow Royal Maternity Hospital. The study aimed to: determine the proportion of women offered choice for their type of maternity care after the introduction of the initiative; determine the proportion of women choosing the different types of care and to examine the socio-demographic predictors of the choice of care; and examine women's attitudes to being offered a choice in the type of maternity care they receive and reasons for making particular choices. The study was carried out using a retrospective review of case records and self-report questionnaires from a consecutive sub-sample of 170 women. Of those eligible, 90% (95% CI: 86% to 93%) were offered choice of care type. Half of the eligible women chose community-based shared care, 36% chose named midwife care, 10% chose hospital-based shared care, 4% requested DOMINO care and less than 1% selected home birth. Women's choice of the type of care they received was unrelated to their socio-demographic characteristics. Women were satisfied with the way that choices were offered and valued being able to choose their type of care. The response rate of the questionnaire was 84%. This article concludes that it may be realistic to routinely offer women a variety of choices of the care type they receive given the support of the professional groups involved.

Can midwife-managed units improve continuity of care?

This study aimed to determine whether a midwife-managed programme could improve continuity of care over that achieved by shared care (i.e. care divided between hospital doctors, midwives and GPs). A randomized controlled trial (analysis by intention to treat) was conducted at the Glasgow Royal Maternity Hospital, which compared 648 women allocated to receive midwife-managed care and 651 allocated to receive shared care. The two main study outcomes were continuity of advice and continuity of carer. Data were collected via questions included in self-report questionnaires sent to women's homes at three time periods (response rates ranged from 63.1% to 85.3%) and a case record review. Women in the midwife-managed group reported receiving more consistent advice across all care periods. For example, during antenatal care, 51.0% of women in the midwife group reported receiving consistent advice all of the time, compared with 21.2% of women in the shared-care group (difference [diff] = 29.9%; 95% confidence interval [CI]; 24.1% to 35.6%). Overall, women in the midwife-managed group saw seven fewer care providers (midwife care mean = 10.0 [standard deviation [SD] = 6.3]; shared care mean = 17.1 [SD = 6.1], diff = -7.1; 95% CI; -8.4 to -5.8). At 7 months follow-up, 4.0% of women in the midwife group reported that they had seen too many or far too many staff during their care, compared with 28.3% of women in the shared care group (diff = -24.3%; 95% CI;-30.7% to -17.8%). These results suggest that midwife-managed care programmes can improve continuity of care.

Satisfaction with midwife-managed care in different time periods: A randomised controlled trial of 1299 women

Objective: to compare women's satisfaction with midwife-managed care with ‘shared care’ over three different time periods. Design: randomised controlled trial. Setting: Glasgow Royal Maternity Hospital, Glasgow, UK. Participants: 1299 women experiencing normal pregnancy (consent rate:82%). Six hundred and forty-eight women were randomised to midwife-managed care and 651 to ‘shared care’. Methods: three self-report questionnaires were sent to women's homes. The questionnaires examined: satisfaction with antenatal care at 34–35 weeks' gestation, and satisfaction with intrapartum, hospital- and home-based postnatal care at seven weeks postnatally. The third questionnaire reviewed satisfaction with intrapartum care seven months after delivery. Findings: women in both groups were satisfied. However, women in the midwife-managed group were more highly satisfied in relation to the dimensions examined: relationships with staff, information transfer, choices and decisions, and social support. The differences between the two groups were evident for all time periods (i.e. antenatal, intrapartum and postnatal periods) and were sustained at seven-month follow-up. This is illustrated in the mean scores for relationships with staff, as measured at 34–35 weeks' gestation (possible range −2; very negative attitudes to 2; very positive attitudes). Women in the midwife-managed group scored a mean of 1.22 compared to 0.74 for the ‘shared care’ group (mean diff: 0.48; 95% CI: 0.42 to 0.55). While women in both groups were more likely to make positive rather than negative comments in open-ended questions, the midwife-managed group were more likely to make positive comments whereas the ‘shared care’ group were more likely to make negative comments. Conclusion: midwife-managed care for healthy pregnant women which is integrated into existing services improves satisfaction with antenatal, intrapartum and postnatal care.

A new style of midwife-managed antenatal care: costs and satisfaction

Policy makers involved in planning maternity services should evaluate the effects on women receiving care as well as the implications for the NHS. This study considered the effect on women and their families receiving a new style of midwife-managed care in the antenatal period, in terms of both the cost to themselves and their satisfaction with the accessibility of care. This study was carried out as part of a randomized controlled trial to compare midwife-managed care with the traditional model of shared care. The setting for the randomized controlled trial was the Glasgow Royal Maternity Hospital, a major urban teaching hospital providing an integrated maternity service. The results demonstrated that decisions concerning the frequency and location of antenatal visits have significant cost implications for women and their families. The costs to women of attending antenatal clinics in different settings were found to vary widely. Women receiving midwife-managed antenatal care had slightly lower costs than women attending for shared care and higher levels of satisfaction with the accessibility of care.

The costs to the NHS of maternity care: midwife-managed vs shared

The objectives of this article are to compare the costs to the NHS of midwife-managed care and shared care. A randomized controlled trial was used. Women who were randomized to receive midwife-managed care but did not complete the care programme remained in the midwife-managed group for the purpose of analysis. The study took place in the Glasgow Royal Maternity Hospital, a major urban teaching hospital providing an integrated maternity service. A total of 1299 women experiencing normal healthy pregnancy took part in the study — 648 women were randomized to midwife-managed care and 651 to shared care. The main outcome measures were the costs to the NHS of providing the two alternative types of maternity care. Assuming a median caseload of 29 women per midwife in the midwife-managed group, there were no significant differences in the median costs of antenatal (midwife-managed=£287.60, shared care=£295.91, p=0.48) and intrapartum (midwife-managed=£240.90, shared care= £241.17, p=0.4) care. However, midwife-managed care was associated with significantly higher costs than shared care in the postnatal period (midwife-managed=£470.84, shared care=£352.03, p&lt;0.001). When sensitivity analysis was performed to examine the effect of increased caseload on costs, shared care was associated with higher costs antenatally (midwife-managed=£274.94, shared care=£295.91, p=0.05). However, midwife-managed postnatal care remained significantly more expensive than shared care (midwife-managed=£404.17, shared care=£352.03, p&lt;0.001). The costs of intrapartum care were not affected by this change in assumption. Differences in costs to the NHS largely reflected organizational differences between the two styles of care. Decisions concerning the provision of maternity services should not be based on costing information alone; information about clinical outcomes and women's satisfaction with care should also be considered. In the postnatal period, service providers would ultimately need to consider whether the increased costs of midwife-managed care were worth the enhanced levels of women's satisfaction measured in the randomized controlled trial.

Changes in prostaglandin synthesis and metabolism associated with labour, and the influence of dexamethasone, RU 486 and progesterone

The objective was to compare the changes in prostaglandin synthesis and metabolism occurring within the fetal membranes that are associated with the onset of parturition and to study the effect of steroid hormones on prostaglandin metabolism. A tissue explant study was made of discs of amnion and chorion obtained from 24 pregnant women at 37-42 weeks' gestation following spontaneous labour and delivery (12 women) and elective caesarean section (12 women). Significantly more prostaglandin E2 (PGE2) and PGF2 alpha were synthesized by amnion obtained following spontaneous labour than elective caesarean section. Arachidonic acid stimulated both PGE2 and PGF2 alpha synthesis by amnion in both groups. Phorbol myristoyl acetate stimulated PGE2 synthesis in both groups. There was no difference between the groups in the capacity of the chorion to metabolize prostaglandins. Mifepristone (RU 486) reduced the metabolism of added PGE2 following spontaneous labour, while dexamethasone and progesterone had no effect on prostaglandin metabolism. In conclusion, the increase in concentration of PGE2 and PGF2 alpha associated with the onset of spontaneous labour is the result of an increase in synthesis rather than a reduction in metabolism. There was no decrease in metabolism to account for the increase in prostaglandin concentrations and, with the exception of mifepristone, metabolism was not altered by the addition of steroid hormones.

Implementation and evaluation of a midwifery development unit

This article describes the implementation and evaluation of a programme of care at the Midwifery Development Unit, Glasgow Royal Maternity Hospital. This care programme is being provided as part of a ‘Choices for Care’ initiative.

Midwifery development unit at Glasgow Royal Maternity Hospital

This article discusses the first midwifery development unit (MDU) to be set up in the UK. The structure of the unit and the development of the care programme, spread over a 3-year period, is detailed.

An evaluation of postnatal care individualised to the needs of the woman

Traditionally, in Scotland women have been visited daily in their own home until the 10th postnatal day. There has been concern about the ability of such a service to offer continuity of care. A ‘before and after’ study was undertaken at Glasgow Royal Maternity Hospital to assess the effects of introducing individualised postnatal care. In the first stage information was collected on 106 women to obtain baseline information. In the second stage information was collected on 114 women who had experienced individualised care. The women in the two stages were not significantly different in terms of age, parity, mode of delivery and problems encountered. The average number of midwives visiting during the postnatal period fell from 3.7 to 2.5 and the average number of visits fell from 6.5 to 5.7 visits. Both forms of care, standard and individualised, were popular with women, but the proportion who felt a daily visit necessary dropped significantly. Continuity of care was improved with individualising care to the needs of the woman and women were satisfied with this type of care. The change is likely to be cost effective, since a higher quality of care can be provided for the same, or slightly less cost.

The management of hypertensive disease in pregnancy

Hypertension occurs in around 15% of all pregnancies. The majority of the patients do well, but it remains a significant cause of maternal and neonatal mortality and morbidity. The essence of good management is an accurate diagnosis of the problem, the assessment of the risk to the mother and the baby, and individualised treatment of the severe patient. This article will describe the system of care developed at the Glasgow Royal Maternity Hospital over the last twelve years by a specialist team. The mainstay of management is the Daycare Assessment Unit which delivers inpatient monitoring on an outpatient basis. This allows an accurate assessment of the hypertension and the risk to the patient to be made without need of admission to hospital. By screening out the low risk patient, more intensive efforts can be directed at those who most need it. Antihypertensive drugs are used to lower blood pressure if this is thought to be appropriate. Delivery remains the only cure, but the optimal timing and place of the delivery can make a significant difference to the mortality and morbidity of the mother and baby. Postpartum management in the severely affected patient requires the maintenance of vigilance until recovery is complete. Fluid overload is a common occurrence post delivery and measures should be taken to prevent this. Pregnancies complicated by hypertension should result in a successful outcome for mother and baby in the majority of pregnancies.