Large Obstetric Unit Research Articles

Labor outcomes in caseload midwifery compared with standard midwifery care: A cohort study.

Research has shown caseload midwifery to increase the chance of vaginal birth, but this may not be the case in settings with high vaginal birth rates in standard care. This study investigated the association between caseload midwifery and birth mode, labor interventions, and maternal and neonatal outcomes at a large obstetric unit in Denmark. Cohort study including medical records on live, singleton births fr om June 2018 until February 2022. Exposure was caseload midwifery care compared with standard midwifery care. The primary outcome was birth mode, and secondary outcomes were other outcomes of labor. Adjusted risk ratios (aRR) with 95% confidence intervals (CI) were estimated by log-binomial regression. Among 16,110 pregnancies, 3162 pregnancies (19.6%) received caseload midwifery care. Caseload midwifery was associated with fewer planned cesareans (aRR 0.63 [95% CI 0.54-0.74]) and emergency cesareans (aRR 0.86 [95% CI 0.75-0.95]). No differences in labor induction, use of epidural analgesia, oxytocin augmentation, or anal sphincter tears were observed. Caseload midwifery performed more amniotomies (aRR 1.14 [95% CI 1.02-1.27]) and tended to perform more episiotomies (aRR 1.19 [95% CI 0.96-1.48]). Postpartum hemorrhage (aRR 0.90 [95% CI 0.82-0.99]) and low Apgar score were less likely (aRR 0.54 [95% CI 0.37-0.77]), and early discharge more likely (aRR 1.22 [95% CI 1.17-1.28]) in caseload midwifery. In caseload midwifery care, a higher vaginal birth rate was observed with no increase in adverse outcomes, mainly due to a lower likelihood of planned cesarean. Also, fewer children were born with low Apgar scores.

6301325 A “CSE-ries” of questions. Current practice in combined spinal epidural anaesthesia for caesarean delivery across two large obstetric units

6301325 A “CSE-ries” of questions. Current practice in combined spinal epidural anaesthesia for caesarean delivery across two large obstetric units

Important aspects of intrapartum care described by first-time mothers giving birth in specialised obstetric units in Norway: A qualitative analysis of two questions from the Babies Born Better study

ObjectiveTo explore aspects of intrapartum care that were importanrt for primiparous women who had given birth in large obstetric units in Norway. MethodsWe used data from the Babies Born Better (B3) survey, version 1, which is an international, web-based qualitative survey. We performed a reflexive, thematic analysis of the responses to two questions about descriptions of aspects of positive care and areas of care requiring improvement during the intrapartum period. The responders could give up to three responses to each question and there were no word limits. ResultsIn all, 677 first time mothers who gave birth at the five largest specialised obstetric units in Norway during 2014–2015 were included in the study. The thematic analysis of the 2 205 responses resulted in three final themes: ‘Communication and positive interactions with the caregivers’, ‘Autonomy and active involvement in the labour process’, and ‘Safety, competence and quality of labour care’. ConclusionFor women who give birth for the first time in specialised obstetric units both relational aspect such as communication and respect, and environmental aspects such as facilities, are of importance. First-time mothers might be particularly vulnerable to absence of positive interactions with caregivers because they lack the resources former birthing experience can give. It is essential to give unexperienced birthing women special attention during childbirth because the first birth may influence decisions in following pregnancies.

Lifting the veil of secrecy: maternal and neonatal outcome of oocyte donation pregnancies in Germany

BackgroundIn Germany, performing fertility procedures involving oocyte donation is illegal, as stated by the Embryo Protection Law. Nonetheless, in our clinical routine we attend to a steadily rising number of pregnant women, who have sought oocyte donation abroad. Due to the legal circumstances many women opt to keep the origin of their pregnancy a secret. However, studies have shown, that oocyte donation is an independent risk factor for the development of pregnancy complications, such as preeclampsia.ObjectiveThe aim of this study is to evaluate maternal and neonatal outcomes of oocyte donation pregnancies in three large obstetric care units in Berlin, Germany.MethodsWe retrospectively analyzed all available medical data on oocyte donation pregnancies at Charité University hospital, Vivantes Hospital Friedrichshain, and Neukoelln in the German capital.ResultsWe included 115 oocyte donation (OD) pregnancies in the present study. Our data are based on 62 singleton, 44 twin, 7 triplet, and 2 quadruplet oocyte donation pregnancies. According to our data, oocyte donation pregnancies are associated with a high risk of adverse maternal and fetal outcome, i.e., hypertension in pregnancy, preterm delivery, Cesarean section as mode of delivery, and increased peripartum hemorrhage.ConclusionAlthough oocyte donation is prohibited by German law, many couples go abroad to seek reproductive measures using oocyte donation after former treatment options have failed. OD pregnancies are associated with a high risk of preeclampsia, C-section as mode of delivery, and peripartum hemorrhage. Detailed knowledge of the associated risks is of utmost importance to both the patient and the treating physician and midwife.

24 hour consultant obstetrician presence on the labour ward and intrapartum outcomes in a large unit in England: A time series analysis.

To explore the effect of introducing 24/7 resident labour ward consultant presence on neonatal and maternal outcomes in a large obstetric unit in England. Retrospective time sequence analysis of routinely collected data. Obstetric unit of large teaching hospital in England. Women and babies delivered between1 July 2011 and 30 June 2017. Births <24 weeks gestation or by planned caesarean section were excluded. The primary composite outcome comprised intrapartum stillbirth, neonatal death, babies requiring therapeutic hypothermia, or admission to neonatal intensive care within three hours of birth. Secondary outcomes included markers of neonatal and maternal morbidity. Planned subgroup analyses investigated gestation (<34 weeks; 34-36 weeks; ≥37 weeks) and time of day. 17324 babies delivered before and 16110 after 24/7 consultant presence. The prevalence of the primary outcome increased by 0.65%, from 2.07% (359/17324) before 24/7 consultant presence to 2.72% (438/16110, P < 0.001) after 24/7 consultant presence which was consistent with an upward trend over time already well established before 24/7 consultant presence began (OR 1.09 p.a.; CI 1.04 to 1.13). Overall, there was no change in this trend associated with the transition to 24/7. However, in babies born ≥37 weeks gestation, the upward trend was reversed after implementation of 24/7 (OR 0.67 p.a.; CI 0.49 to 0.93; P = 0.017). No substantial differences were shown in other outcomes or subgroups. Overall, resident consultant obstetrician presence 24/7 on labour ward was not associated with a change in a pre-existing trend of increasing adverse infant outcomes. However, 24/7 presence was associated with a reversal in increasing adverse outcomes for term babies.

Use of endoanal ultrasound for reducing the risk of complications related to anal sphincter injury after vaginal birth.

Use of endoanal ultrasound for reducing the risk of complications related to anal sphincter injury after vaginal birth.

Caseload midwifery as organisational change: the interplay between professional and organisational projects in Denmark.

BackgroundThe large obstetric units typical of industrialised countries have come under criticism for fragmented and depersonalised care and heavy bureaucracy. Interest in midwife-led continuity models of care is growing, but knowledge about the accompanying processes of organisational change is scarce. This study focuses on midwives’ role in introducing and developing caseload midwifery. Sociological studies of midwifery and organisational studies of professional groups were used to capture the strong interests of midwives in caseload midwifery and their key role together with management in negotiating organisational change.MethodsWe studied three hospitals in Denmark as arenas for negotiating the introduction and development of caseload midwifery and the processes, interests and resources involved. A qualitative multi-case design was used and the selection of hospitals aimed at maximising variance. Ten individual and 14 group interviews were conducted in spring 2013. Staff were represented by caseload midwives, ward midwives, obstetricians and health visitors, management by chief midwives and their deputies. Participants were recruited to maximise the diversity of experience. The data analysis adopted a thematic approach, using within- and across-case analysis.ResultsThe analysis revealed a highly interdependent interplay between organisational and professional projects in the change processes involved in the introduction and development of caseload midwifery. This was reflected in three ways: first, in the key role of negotiations in all phases; second, in midwives’ and management’s engagement in both types of projects (as evident from their interests and resources); and third in a high capacity for resolving tensions between the two projects. The ward midwives’ role as a third party in organisational change further complicated the process.ConclusionsFor managers tasked with the introduction and development of caseload midwifery, our study underscores the importance of understanding the complexity of the underlying change processes and of activating midwives’ and managers’ interests and resources in addressing the challenges. Further studies of female-dominated professions such as midwifery should offer good opportunities for detailed analysis of the deep-seated interdependence of professional and organisational projects and for identifying the key dimensions of this interdependence.

PPO.14 A 5 Year Retrospective Analysis of Stillbirth Trends in a Large Obstetric Unit – will lives be saved with increasing resources towards identification of and intervention in small for gestational age foetuses?

Recent guidelines suggest intensive monitoring and consideration for delivery at 37 weeks for all small for gestational age (SGA) foetuses.1 Adopting such an approach has considerable resource implications. This study...

Inadvertent hypothermia in a large obstetric unit

Inadvertent hypothermia in a large obstetric unit

Review: Potential druggable targets for the treatment of early onset preeclampsia.

Placental delivery is the only known cure for early onset preeclampsia, a major cause of maternal and neonatal morbidity and mortality worldwide. Prolonging pregnancy beyond 25weeks without undue maternal risk favors fetal survival, improves neonatal outcome and saves money. In vitro experiments using human placental tissue and in vivo studies employing "preeclamptic" animal models reveal the presence of likely druggable targets, especially within the maladapted intracellular nucleotide transduction pathways of preeclampsia. This review focuses on some novel pharmacological treatment options targeting early onset severe preeclampsia. Human and animal derived experimental data support the possible roles of nitric oxide donors (glyceryltrinitrate), aspirin, dietary supplements (calcium, l-Arginine, anti-oxidant vitamins), phosphodiesterase-5 inhibitors, statins, carbon monoxide and most recently, hydrogen sulfide. Extension of pregnancy or improvement of the disorder using means applicable in under resourced areas of the world would have a major positive impact on women's health globally. We therefore advocate the immediate launch of clinical trials testing simple innovative therapies in large obstetric units of developing countries such as South Africa or Brazil where preeclampsia is endemic and a regular killer of both mothers and offspring.

PL.75 An Audit of Lower Urinary Tract Injuries in a Large Obstetric Unit – 2 Year Outcome

ObjectiveThe main objective of this audit was to investigate the number of bladder injuries after delivery and compare it to the existent incidence in literature.MethodRetrospective medical record review of patients...

INPATIENT OBSTETRIC REFERRALS TO NEUROLOGY SERVICES: A CROSS-SECTIONAL SURVEY

ObjectiveTo evaluate the clinical profile of inpatient obstetric referrals to the neurology services and to determine the yield of neuroimaging studies in these patients.MethodsA retrospective cross-sectional study design was used...

Obstetric Admissions into the Intensive Care Unit in a Sub-urban University Teaching Hospital

Aims: Intensive care medicine is relatively young in developing countries and there are few studies showing obstetric utilization of the facilities in Intensive Care Units (ICU) in many developing nations. We sought to determine the ICU utilization by obstetric patients in our hospital, assess the spectrum of diseases necessitating admissions, the intervention required and outcome of such admissions. Methods: A 5 year retrospective review of all obstetric admissions into the ICU from January 2003 to December 2007. Subjects were included if they were admitted during pregnancy up to 42 days post partum. Data obtained included demographics, obstetric history, pre-existing medical problems, admission diagnosis, indication for ICU admission, intervention in the ICU and outcome. Results: Obstetric cases accounted for 1.5 % of total admissions into the ICU. These also represented 0.2% of total hospital deliveries. All the patients were admitted post partum. Eclampsia was the commonest primary obstetric diagnosis (58.8%) with neurological dysfunction as the commonest indication for ICU admission. Mortality rate among admitted cases was 41.2%. Conclusions: Obstetric patients form a small population of a third world multi-disciplinary ICU but mortality among this group was high. It is recommended that large obstetric units should establish there own ICUs with standard facilities which will facilitate improved care of critically ill pregnant women and thereby improve the outcome. NJOG 2011 Nov-Dec; 6 (2): 33-36 DOI: http://dx.doi.org/10.3126/njog.v6i2.6754

Peripartum use of cell salvage: a university practice audit and literature review

Obstetrical hemorrhage is the second leading cause of direct maternal mortality (18% of maternal deaths) in developed countries and is the leading cause of severe maternal morbidity. The rising rate of obstetrical hemorrhage attributed to the repeated cesarean sections and invasive placental disorders, requiring blood transfusion has emphasized the need for alternatives to allogeneic blood donation. The Shaare Zedek Medical Center is a teaching hospital with the largest obstetric service in the region-13,500 live births per year. The medical records of all parturients requiring use of intraoperative cell salvage system (IOCS) (2007-2011) were reviewed to evaluate our experience with this unique system and possible complications in the obstetrical milieu of a large obstetric unit. Using our combined medical records, we found that IOCS is a rapid method of blood replacement that allows blood bank service recruitment and presents no adverse reaction to the parturient. However, this sophisticated system is appropriate for tertiary surgical centers and its routine use should be assessed by national medical boards.

Introduction of cell salvage to a large obstetric unit: the first six months

Introduction of cell salvage to a large obstetric unit: the first six months

Rapid testing for group B streptococcus during labour: a test accuracy study with evaluation of acceptability and cost-effectiveness

To determine the accuracy, acceptability and cost-effectiveness of polymerase chain reaction (PCR) and optical immunoassay (OIA) rapid tests for maternal group B streptococcal (GBS) colonisation at labour. A test accuracy study was used to determine the accuracy of rapid tests for GBS colonisation of women in labour. Acceptability of testing to participants was evaluated through a questionnaire administered after delivery, and acceptability to staff through focus groups. A decision-analytic model was constructed to assess the cost-effectiveness of various screening strategies. Two large obstetric units in the UK. Women booked for delivery at the participating units other than those electing for a Caesarean delivery. Vaginal and rectal swabs were obtained at the onset of labour and the results of vaginal and rectal PCR and OIA (index) tests were compared with the reference standard of enriched culture of combined vaginal and rectal swabs. The accuracy of the index tests, the relative accuracies of tests on vaginal and rectal swabs and whether test accuracy varied according to the presence or absence of maternal risk factors. PCR was significantly more accurate than OIA for the detection of maternal GBS colonisation. Combined vaginal or rectal swab index tests were more sensitive than either test considered individually [combined swab sensitivity for PCR 84% (95% CI 79-88%); vaginal swab 58% (52-64%); rectal swab 71% (66-76%)]. The highest sensitivity for PCR came at the cost of lower specificity [combined specificity 87% (95% CI 85-89%); vaginal swab 92% (90-94%); rectal swab 92% (90-93%)]. The sensitivity and specificity of rapid tests varied according to the presence or absence of maternal risk factors, but not consistently. PCR results were determinants of neonatal GBS colonisation, but maternal risk factors were not. Overall levels of acceptability for rapid testing amongst participants were high. Vaginal swabs were more acceptable than rectal swabs. South Asian women were least likely to have participated in the study and were less happy with the sampling procedure and with the prospect of rapid testing as part of routine care. Midwives were generally positive towards rapid testing but had concerns that it might lead to overtreatment and unnecessary interference in births. Modelling analysis revealed that the most cost-effective strategy was to provide routine intravenous antibiotic prophylaxis (IAP) to all women without screening. Removing this strategy, which is unlikely to be acceptable to most women and midwives, resulted in screening, based on a culture test at 35-37 weeks' gestation, with the provision of antibiotics to all women who screened positive being most cost-effective, assuming that all women in premature labour would receive IAP. The results were sensitive to very small increases in costs and changes in other assumptions. Screening using a rapid test was not cost-effective based on its current sensitivity, specificity and cost. Neither rapid test was sufficiently accurate to recommend it for routine use in clinical practice. IAP directed by screening with enriched culture at 35-37 weeks' gestation is likely to be the most acceptable cost-effective strategy, although it is premature to suggest the implementation of this strategy at present.

Introduction of cell salvage to a large obstetric unit: the first six months

Background We introduced red-cell salvage to our obstetric unit following a two-month period of training and education. We report a service evaluation of the first six months of activity from May to October 2007. Methods The indications for using cell salvage were: placenta praevia, suspected placental abruption, multiple pregnancy, multiple repeat caesarean, previous history of post partum haemorrhage, refusal of blood transfusion, caesarean section at full dilatation, low preoperative haemoglobin and at the discretion of the theatre team. Results The cell saver was used for 46 patients with a blood loss (median; range) of 800 (200–2000) mL and a heterologous transfusion rate of 22% (10 cases). Blood was processed and returned in 19 cases of which nine were emergency and 10 elective. The median volume (range) of blood returned was 390 (200–800) mL. For the unit as a whole the percentage of all theatre cases who received a heterologous transfusion fell from 10.2% for the equivalent time period in the preceding year to 7.9% during the six month period that cell salvage was in use ( P = 0.126, χ 2). There were no adverse reactions following the administration of processed blood. Conclusion We have successfully introduced cell salvage to our unit in a relatively short period of time and have used it for the largest series of patients reported in the UK.

Cord prolapse audit: recognition, management and outcome

Cord prolapse is a rare obstetric emergency associated with increased risks of perinatal mortality. Given the rarity of this complication and associated perinatal mortality and morbidity, multi-disciplinary skills and drills are promoted as a means to ensure that all staff are appropriately skilled in the management of this condition. The aim of the audit was to investigate in one large obstetric unit standards of practice in relation to the management of cord prolapse. All women who presented with a cord prolapse over a 30-month period were identified and a retrospective audit of their records was performed to evaluate compliance against agreed standards of care. The results showed that in line with previous studies prematurity and breech presentation were major risk factors. The mean time between diagnosis and delivery was 16.2 minutes. Manoeuvres to relieve pressure on the umbilical cord were largely poorly documented, as was communication with the woman and their partners. The results demonstrate the need to strengthen training programmes to include these aspects of care.

Intrapartum Stillbirths in Hospital Unrelated to Uteroplacental Vascular Insufficiency

The aim of this study was to investigate the causes of intrapartum asphyxia and its relationship to placental abnormalities. Twenty intrapartum fetal death autopsies carried out over a 10-year period in one hospital pathology department associated with a large obstetric unit were reviewed. All the intrapartum fetal deaths occurred in the hospital, while the mothers were being monitored during and after labor. On morphologic grounds, all the fetal deaths were thought to be caused by intrapartum asphyxia. Seven of the intrapartum fetal deaths were associated with intrauterine infection causing funisitis, and in 6 of these cases, chorioamnionitis was present as well. Two cases were caused by placental abruption, and 1 case was caused by cord compression. In 8 of the 10 remaining cases in which the placenta was examined, a minor placental abnormality was detected in only 1 case. Five of the 10 cases had a mild astrocytosis in the intracerebral periventricular white matter, suggestive of intrauterine ischemia at least 12 hours before death. Five of the 10 cases were thought by the delivering obstetrician to have umbilical cord abnormalities. The main conclusions from this study are that, except in cases of intrauterine infection, placental vascular abnormalities are unlikely to be associated with intrapartum asphyxia leading to fetal death during labor. The number of cases with umbilical cord abnormalities raises the possibility that cord accidents may be a significant cause of intrapartum stillbirth.

Thromboelastography in abruptio placentae

Summary The purpose of this study was to document thromboelastographic (TEG) changes in abruptio placentae and to compare these results with that of conventional tests used to monitor coagulation. This was a prospective study of 30 patients with abruptio placentae. All coagulation investigations including the TEG were performed on admission, immediately following delivery, and after periods of 4 hours and 24 hours. Results showed that standard coagulation tests detected coagulation abnormalities except the platelet count returned to normal limits within 24 hours of delivery. There was strong correlation between fibrinogen levels and the TEG parameters, ma and k time ( r=0.8). There was moderate correlation between platelet count and ma ( r=0.6). In conclusion, minor abnormalities in the clotting profile are clinically unimportant. The TEG does not detect such minor abnormalities because of its inherent ability to test the coagulation cascade as a whole. Major abnormalities are clinically relevant and the TEG detect 75% of them. Further, the TEG establishes the diagnosis of hypercoagulability an early sign of disseminated intravascular coagulation. Although standard laboratory tests are still necessary to detect coagulation abnormalities on admission, the TEG is a useful test in large obstetric units where laboratory results are not immediately available for the purposes of monitoring and treating ongoing coagulation defects.