Hospital Maternity Unit Research Articles

Screening for chromosomal abnormalities in the first trimester using ultrasound and maternal serum biochemistry in a one‐stop clinic: a review of three years prospective experience

To evaluate the performance of a one-stop multidisciplinary clinic of screening for fetal chromosomal anomalies in the first trimester of pregnancy by a combination of maternal serum biochemistry and ultrasonography. Retrospective review of screening performance. District General Hospital maternity unit. All women booked for routine antenatal care at Harold Wood Hospital between 1 June 1998 and 31 May 2001. The population included 12,339 women with singleton pregnancies presenting at 10-14 weeks of gestation. Women were offered screening using a combination of maternal serum free beta-hCG and pregnancy associated plasma protein-A (PAPP-A) and fetal nuchal translucency thickness. Those with an estimated risk of >/=1 in 300 of carrying a fetus with trisomy 21 or trisomy 18 or trisomy 13 were offered the option of an invasive diagnostic test. Follow up of the outcome of all pregnancies was carried out. Uptake of screening and invasive testing, detection rate for fetal chromosomal abnormalities and false positive rate. The uptake of first trimester screening was 97.5% and the uptake of invasive testing in the increased risk group was 77%. The rate of detection of trisomy 21 was 92% (23 of 25), of trisomy 13 or 18 was 100% (all 15) and of all aneuploidies was 96% (49 of 51). The false positive rate was 5.2%. First trimester screening for trisomy 21 and other aneuploidies can be delivered in an efficient manner in a one-stop multidisciplinary clinic. The detection rates are far better than can be achieved by second trimester serum screening.

Term and preterm induction of labour for pregnancy-induced hypertension

Pregnancy-induced hypertension (PIH) is a common and potentially serious condition. Early delivery is often necessary. This study investigates the influence of gestational age and parity on the likelihood of vaginal delivery following labour induction in a UK district hospital maternity unit. The casenotes of 185 consecutive inductions for PIH between January 1997 and September 2000 were studied. Women with chronic hypertension, diabetes, multiple pregnancies or fetal death before labour were excluded. Gestational age varied between 31 and 42 weeks. Seventy-two per cent of the mothers were nulliparous; 58% had gestational hypertension (i.e. hypertension without proteinuria) and 42% had pre-eclampsia (i.e. hypertension with proteinuria). Vaginal delivery rates for nulliparous mothers with gestational hypertension were 50% at 34–36 weeks and 78% at 37–42 weeks; for those with pre-eclampsia rates were 0% at 31–33 weeks, 85% at 34–36 weeks and 78% at 37–42 weeks. Vaginal delivery rates for multiparous mothers with gestational hypertension were 100% at 31–36 weeks and 92% at 37–42 weeks; those with pre-eclampsia had a rate of 100% at all gestations.

Uptake of prenatal screening for chromosomal anomalies: impact of test results in a previous pregnancy.

To assess whether the uptake of prenatal screening for trisomy 21 in a subsequent pregnancy is influenced by being classified in the 'increased risk' or 'not at increased risk' group in the first pregnancy. District General Hospital Maternity Unit. Amongst a group of women attending for maternity care at this hospital, the maternity records were examined to find women having at least two pregnancies. Any prenatal screening record for each pregnancy was retrieved from the prenatal screening database. Prenatal screening for trisomy 21 was by a combination of maternal serum alpha-fetoprotein (AFP) and free beta-human chorionic gonadotrophin (beta-hCG) in the second trimester and by maternal serum free beta-hCG and pregnancy-associated plasma protein-A (PAPP-A) and fetal nuchal translucency (NT) thickness in the first trimester. Women were stratified according to their trisomy 21 risk into an 'increased risk' group (1: <250 in the second trimester and 1: <300 in the first trimester) or 'not at increased risk' group based on their first pregnancy. In a second pregnancy, the records were examined to see if the mother accepted prenatal screening in the second pregnancy. The rate of acceptance of screening in a subsequent pregnancy, depending on whether 'at increased risk' or 'not at increased risk' in the first pregnancy, was examined using chi square tests. In the second trimester study, 4601 women were identified with two pregnancies during the study period. Of these, 4559 women had prenatal screening in a subsequent pregnancy. Initially, 273 women were identified in the high-risk group, and of these 252 (92.3%) elected to have prenatal screening in a subsequent pregnancy. This compared with 4307 of 4328 (99.5%) women in the low-risk group. In the first trimester study, 1077 women were identified with two pregnancies during the study period. Of these, 1072 had prenatal screening in a subsequent pregnancy. Initially, 60 women were identified in the high-risk group, and of these 56 (93.3%) elected to have prenatal screening in a subsequent pregnancy. This compared with 1016 of 1017 (99.9%) in the low-risk group. Statistically, there was no difference between the rate of declining prenatal screening in a second pregnancy amongst those in the high-risk group in a first pregnancy or those in the low-risk group (p = 0.429 for second trimester screening and p = 0.794 for first trimester screening). Similarly, no difference could be demonstrated between rates when screening in the first or second trimester (p = 0.961) for those in the high-risk group. Despite the understandable anxiety associated with being identified in the high-risk group (as a false positive finding) in a previous pregnancy, this did not seem to deter women from accepting prenatal screening in a subsequent pregnancy.

Men of Diverse Cultures: Knowledge and Attitudes About Breastfeeding

The purpose of this study was three-fold: (a) to describe the knowledge of and attitudes on breastfeeding of men from diverse racial backgrounds, (b) to determine the relationship between knowledge and attitude toward breastfeeding, and (c) to determine the relationship between specified demographic variables and men's knowledge or attitudes on breastfeeding. Descriptive An inner-city teaching hospital and its associated prenatal clinic located in the southern United States. One hundred men from diverse cultures who spoke either English or Spanish, were 18 years of age or older, and were present at either the hospital maternity units or associated prenatal clinic. Eighty-one percent (81%) of the men in this study indicated that they would prefer their infants to be breastfed. Ethnicity and age were found to be linked to attitudes and knowledge of breastfeeding. This study demonstrated that men had a strong desire that their infants be breastfed and wanted to be included in decisions concerning breastfeeding.

Fatigue as a predictor of postpartum depression.

The postpartum is a time when women commonly report increased fatigue that may contribute to depression. Studies have not examined fatigue alone as a predictor of postpartum depression. To examine whether and when fatigue in the early postpartum is predictive of postpartum depression. Correlational, longitudinal study. Two hospitals and participants' homes in central Pennsylvania. Convenience sample of 38 healthy women recruited from hospital maternity units within 24 hours after an uncomplicated birth. Fatigue was measured using the Modified Fatigue Symptom Checklist (MFSC) on Days 0, 7, 14, and 28 after childbirth. Depression was assessed using the Center for Epidemiological Studies-Depressive Symptomatology Scale (CES-D) on Day 28. After adjustments for multiple comparisons, a significant correlation was obtained between fatigue as measured by the MFSC and postpartum depression on Day 7 (r = .46; p < .05), Day 14 (r = .57), and Day 28 (r = .70). Fatigue on Day 0 was correlated with fatigue on Day 7 (r = .45), Day 14 (r= .58), and Day 28 (r = .34). Fatigue as early as 7 days postpartum is predictive of depression at Day 28 postpartum.

Pregnant women's perception of the implementation of smoking cessation advice

Objective To assess pregnant smokers'views on smoking cessation advice provided by health professionals who were following specific guidelines. These smoking cessation guidelines consisted of a nine-point intervention framework developed to achieve a reduction in the smoking and pregnancy rate. Design Data were collected through semi-structured interviews. Setting The participants were identified from three health and social care settings within one health board in Northern Ireland, namely: a hospital maternity unit, a community midwifery team and a general practitioner (GP) practice. Results Of the nine-point guidelines, some aspects such as establishing if the women smoked and their intention to quit were implemented at all initial consultations. However, none of the respondents reported receiving help in developing a quit plan or about educating their partner and family about the risks of active and passive smoking. Women accepted that assessing smoking status and providing advice was part of routine care and considered that this did not affect their relationship with health professionals. The respondents felt that smoking cessation advice should be sustained throughout pregnancy. Midwives were most likely to provide smoking cessation advice, yet respondents felt their GP to be the most appropriate person to do so. Conclusions These findings have implications for the delivery of smoking cessation advice. Providing appropriate advice and support for pregnant smokers at the end of their pregnancy may be as important as interventions at the beginning. Health professionals should maintain the level of smoking cessation advice provided throughout a woman's pregnancy.

Association of Maternal Endothelial Dysfunction With Preeclampsia

Chambers, John C.; Fusi, Luca; Malik, Iqbal S.; Haskard, Dorian O.; De Swiet, Michael; Kooner, Jaspal S.

Clinical governance and CESDI: part 2

In the second of a two-part article the author describes the findings of the survey conducted in hospital maternity units in the South and West Executive NHS Region in England. The units were asked about their current risk management activity and implementation of the recommendations of the Confidential Enquiry into Stillbirths and Death in Infancy (CESDI). The results indicate that CESDI is recognised and its' more specific recommendations are adopted into clinical practice. However the link with risk management could be developed further. In addition, CESDI coordinators could provide additional education input to aid dissemination of CESDI findings.

Chapter Seventeen: Preventing Shaken Baby Syndrome

Summary Although the prevention of shaken baby syndrome is questioned by some professionals, there is no doubt that prevention is the ideal goal. Education about the dangers of shaking babies is paramount, especially in light of the fact that messages have historically been distributed that shaking is an acceptable practice. Such messages have included instructions regarding apnea as well as infant cardiopulmonary resuscitation. While it can be argued that the amount of shaking advised in these instances does not correlate with the amount of shaking needed to cause SBS, the important prevention message is that babies and children should never be shaken for any reason. This dictum, along with information about the specific injuries caused by shaking should be provided to everyone, from youngsters to senior citizens. Common approaches to educating the public are discussed and evaluation of these efforts will also be reviewed. Other programs in schools, hospital maternity units and through child care licensing are also being implemented. The responsibility for SBS prevention belongs to every professional who works with children and families and to each individual who cares for a baby or young child.

Association of maternal endothelial dysfunction with preeclampsia.

Preeclampsia is believed to result from release of placental factors that damage maternal vascular endothelium. However, because most studies have been conducted during pregnancy, it has not been possible to separate maternal from placental mechanisms underlying endothelial dysfunction in preeclampsia. To determine whether endothelial function is impaired in nonpregnant women with previous preeclampsia and whether endothelial dysfunction is mediated by oxidative stress. Case-control study conducted at 3 hospital maternity units in London, England, between July 1997 and June 2000. A total of 113 women with previous preeclampsia (n = 35 with recurrent episodes; n = 78 with a single episode) and 48 women with previous uncomplicated pregnancies, all of whom were at least 3 months (median, 3 years) postpartum. Brachial artery flow-mediated (endothelium-dependent) and glyceryl trinitrate-induced (endothelium-independent) dilatation were compared between previously preeclamptic women and controls. To investigate oxidative stress, these measurements were repeated after administration of ascorbic acid, 1 g intravenously, in 15 cases and 15 controls. Mean (SD) flow-mediated dilatation was lower in women with previous preeclampsia compared with controls (recurrent group, 0.9% [4.1%]; single-episode group, 2.7% [3.5%]; and control group, 4.7% [4.3%]; P<.001). In contrast, glyceryl trinitrate-induced dilatation was similar in the 3 groups (recurrent, 19.5% [5.9%]; single-episode, 21.0% [8.0%]; and control, 21.0% [8.3%]; P =.65). Impaired flow-mediated dilatation in previously preeclamptic women was not accounted for by recognized vascular risk factors. Ascorbic acid administration increased flow-mediated dilatation in previously preeclamptic women (baseline, 2.6% [3.3%]; after administration, 5.6% [3.0%]; P =.001) but not in controls (baseline, 6.2% [3.3%]; after administration, 6.7% [5.0%]; P =.72). Our results indicate that endothelial function is impaired in women with previous preeclampsia and is not explained by established maternal risk factors but is reversed by antioxidant ascorbic acid administration.

Evaluation of midwife-led care provided at the Royal Bournemouth Hospital

Objective: to compare the outcome of care given to women ‘booking’ for delivery in a midwife-led maternity unit with that for comparable women ‘booking’ for care in a consultant obstetric unit. Design and method: prospective cohort study with a quasi-experimental design and data extracted from case notes. Setting: east Dorset, midwife-led maternity unit at Royal Bournemouth Hospital and consultant-led maternity unit at Poole General Hospital. Subjects: two cohorts of women who satisfied the criteria for ‘booking’ at the Royal Bournemouth Hospital. Of these 794 ‘booked’ at Bournemouth from I November 1992 to 30 June 1993 and 705 ‘booked’ at Poole over the same period. Main process and outcome measures: care given, morbidity in women and their babies, transfers during the antenatal period and in labour. Findings: of the women who initially ‘booked’ for Bournemouth, 62.3% actually delivered there, 27.1% transferred before labour and a further 9.2% transferred during labour. No differences were seen between those ‘booked’ for Bournemouth or Poole in the proportions of low birthweight babies, babies who were transferred to special care or babies who had congenital abnormality. Higher proportions of babies whose mothers ‘booked’ for delivery in Poole were resuscitated and had one minute Apgar scores below seven but there was no difference in the five minute scores. Similar proportions of women had perineal tears but fewer of the women ‘booked’ for delivery in Bournemouth had an episiotomy. ‘Booking’ for Poole was associated with higher rates of induction and augmentation of labour and greater use of anesthesia. ‘Booking’ for Bournemouth was associated with a shorter first stage and a longer third stage of labour. Women ‘booked’ for delivery in Bournemouth were no more likely to be delivered by a midwife than those ‘booked’ for Poole. Conclusions: there was very little difference between the groups of women who intially ‘booked’ for delivery at the two units. There were differences in the patterns of care received, but no major differences in the outcome for the women or their babies were detected.

The Development of a midwifery council

This abstract illustrates the development of shared governance through a midwifery council at the Leicester General Hospital Maternity Unit. It incorporates a general introduction to the model of shared governance developed, and demonstrates the unique and exciting development of a specialized midwifery council. The main focus is on the early implementation of the midwifery council, challenges encountered and benefits derived.

Kangaroo care for well low birth weight infants at Harare Central Hospital Maternity Unit--Zimbabwe.

To describe the experience in a newly established Kangaroo Care Unit (KCU) at a tertiary level hospital and to identify factors associated with poor outcome in this unit. Cross sectional study. Kangaroo Care Unit at Harare Central Hospital, Zimbabwe. Mothers admitted to the KCU and their well preterm infants. Discharge home or referral back to the Neonatal Unit (NNU) for conventional care. 613 mother infant pairs were studied from May 1994 to December 1996. The median age for all mothers was 23 years (Q1 = 15, Q3 = 26). Fifty four percent of the infants were female. Median age at admission to KCU was 12 days (Q1 = 1, Q3 = 25). Seventy two percent of infants were discharged home from the KCU. The rest (28%) were referred back to NNU for conventional care. The odds of being referred back to the NNU were significantly higher if the infant was male OR = 1.82 (95% CI: 1.25 to 2.66); if the birth weight was < 1 500 gms OR = 1.52 (95% CI: 1.04 to 2.22); if the admission weight to the KCU was < 1500 grams OR = 2.16 (95% CI: 1.42 to 3.29) or if the age on admission to KCU was 14 days or more OR = 2.15 (95% CI: 1.44 to 3.29). These factors remained significant after adjusting for confounding. Mother's age, parity, booking status or whether admission was during the cold months or not had no significant bearing on the outcome in this unit. Reasons for referral back to NNU included apnoea (27%); respiratory distress (27%); aspiration pneumonia (18%); neonatal jaundice (8%); poor feeding (7%); ill mother (5%); sepsis (4%) and diarrhoea (3%). On multivariate analysis birth weight was the strongest predictor for being referred back to the NNU OR = 10.753 (95% CI: 6.026-19.186). Establishment of a KCU at a tertiary level hospital is feasible. Kangaroo care for well preterm infants is suitable for most mothers and their preterm infants. Infants were more likely to be referred back for conventional care if they were male, very low birth weight and if the age at admission was greater than two weeks. Further studies are needed to determine the long term survival of these infants.

Physiological Effects of Infant Exposure to Environmental Tobacco Smoke: A Passive Observation Study

This study explored infant physiologic responses of exposure to environmental tobacco smoke (ETS) using a longitudinal passive observation study with a control group. Fifteen smoking and 15 non-smoking mothers were initially contacted in hospital maternity units, with home visits made when their infants were 2, 4, and 6 weeks old. Exposure to ETS was measured using infant urinary nicotine and cotinine levels. The physiologic effects of infant ETS exposure were measured by rectal temperature, pulse rate, respiratory rate, blood pressure, and oxygen saturation. The smoking mothers in this sample were poorer, had less education, and were less likely to be married than the mothers who did not smoke. At birth, the infants of smoking mothers had higher diastolic blood pressure than infants of non-smoking mothers (p < .008). Mothers who smoke cigarettes should be educated that maternal smoking behavior can affect an infant's cardiovascular function. Parents should also be counseled about the risks of smoking in close proximity and/or in an enclosed space with an infant, especially in a motor vehicle.

Extra-amniotic saline infusion versus extra-amniotic prostaglandin F 2α for cervical ripening and induction of labor

Objective: To compare the effectiveness of extra-amniotic saline infusion versus extra-amniotic prostaglandin F 2α for cervical ripening, induction of labor and achievement of vaginal delivery in patients with unfavorable cervices. Method: A randomized trial of extra-amniotic saline infusion versus extra-amniotic prostaglandin F 2α performed at Harare Central Hospital Maternity Unit, Zimbabwe. One hundred and sixty-four patients were recruited from those referred to Harare Central Hospital Maternity Unit who required induction of labor for either maternal or fetal indications. Results: 162 patients (extra-amniotic PgF 2α group, N=81; extra-amniotic saline infusion group, N=81) had complete information. Two patients (one from each group) were lost to follow up. The demographic characteristics of the patients and the indications for induction were not statistically different. There was a marginally statistically significant difference in the change of Bishop Score in favor of the extra-amniotic saline infusion (4.0, S.D.=1.4) as compared to (4.5, S.D.=1.5) for extra-amniotic PgF 2α ( P value=0.047). All other parameters showed no statistically significant differences. Maternal and fetal complications were minimal and not significantly different. Extra-amniotic saline infusion was however almost six times cheaper than PgF 2α. Conclusion: Extra-amniotic saline infusion is as effective as PgF 2α, safe, but much cheaper than PgF 2α and should be seriously considered as a method of first choice in resource-poor settings.

UK study of intrapartum care for low risk primigravidas: a survey of interventions.

STUDY OBJECTIVE: To determine the extent of intrapartum intervention received by primigravidas. DESIGN: Cross sectional survey of NHS hospitals in the UK. SETTING: One hundred and one randomly selected hospital...

Clinical effectiveness: the potential for change in maternity care

Aim: To assess the potential for improved clinical effectiveness through the use of research‐based evidence in obstetric care. Design: A questionnaire survey to obtain evidence about (i) the usage of reviews of controlled perinatal trials, and (ii) the attitudes of professionals towards the reviews and their practice, relating to 27 areas of clinical care addressed by the reviews. Subjects and setting: All doctors and midwives working in two teaching hospital maternity units (Units X and Y). Main outcome measures: The use of the reviews. For each of the 27 areas of clinical care, (i) whether a majority of professionals were in agreement with research‐based evidence, and (ii) how perceived current practice compared with research‐based evidence. Results: For most areas of clinical care (21/27 in unit X, 20/27 in unit Y) a majority of professionals agreed with the research‐based evidence. However, for a large proportion of these areas (16/21 in unit X, 12/20 in unit Y), practice appeared to be inconsistent with research‐based evidence. Conclusion: There is a considerable opportunity to improve clinical effectiveness, as in many of the areas of care examined professionals agree with research‐based evidence, but clinical practice appears to be inconsistent. The approach used in this study could be used to help develop practices for promoting clinical effectiveness.

A baby-friendly hospital initiative in northern China

In the People’s Republic of China, an approach has been adopted to ensure that all children born as a result of the one-child policy are healthy. The World Health Organization/United Nations Children’s Fund (WHO/UNICEF) has encouraged the Chinese Government to embrace this philosophy. Part of this approach has resulted in an attempt to increase the breastfeeding rates. This report describes a visit by two nursing faculty members of a Canadian university to an urban hospital maternity unit in the northeast of China, where the staff were attempting to incorporate this philosophy into their maternity care with the assistance of nursing faculty members from the local university. The method chosen to integrate this philosophy was the Baby-Friendly Hospital Initiative initiated by WHO/UNICEF.

A Baby-Friendly Hospital initiative in northern China.

In the People's Republic of China, an approach has been adopted to ensure that all children born as a result of the one-child policy are healthy. The World Health Organization/United Nations Children's Fund (WHO/UNICEF) has encouraged the Chinese Government to embrace this philosophy. Part of this approach has resulted in an attempt to increase the breastfeeding rates. This report describes a visit by two nursing faculty members of a Canadian university to an urban hospital maternity unit in the northeast of China, where the staff were attempting to incorporate this philosophy into their maternity care with the assistance of nursing faculty members from the local university. The method chosen to integrate this philosophy was the Baby-Friendly Hospital Initiative initiated by WHO/UNICEF.

Incidence of infection after caesarean section: a study.

This article reports a study of the incidence of infection in patients undergoing Caesarean section in a district general hospital maternity unit. A literature review was carried out and data were collected on operating circumstances, catheterisation, rates of infection, antibiotic therapy and post-discharge infection surveillance. A high incidence of infection was discovered and there was no evidence of a systematic approach to antibiotic therapy. The author highlights the need for further research on a larger group of patients and describes changes in practice which have occurred locally since completion of the study.