Obstetric Unit Research Articles

Delayed Lactogenesis II in High-Risk Pregnancies: What Should We Care.

Background: The timely initiation of lactogenesis II is crucial for postpartum women, with delays having significant clinical implications. This study aimed to evaluate the determinants of delayed lactogenesis II (DOL II) in high-risk pregnant women to guide clinical interventions and postnatal care protocols. Methods: We conducted a study involving high-risk pregnant women who gave birth and were admitted to our hospital''s obstetric intensive care unit for postpartum surveillance and treatment from February 1, 2023, to April 30, 2024. We utilized Pearson correlation analysis and logistic regression to determine factors linked to DOL II. Results: Our study included 206 high-risk pregnant women, with 85 (41.26%) experiencing DOL II. Pearson correlation analysis indicated strong associations between DOL II and maternal age (r = 0.452), gestational hypertension (r = 0.514), gestational diabetes (r = 0.487), and delayed colostrum secretion (r = 0.506), all statistically significant (p < 0.05). Logistic regression analysis identified age 35 years or older (OR = 2.115, 95%CI: 1.785-2.466), gestational hypertension (OR = 2.404, 95%CI: 2.125-3.107), gestational diabetes (OR = 2.556, 95%CI: 2.008-2.879), and colostrum secretion later than one hour postpartum (OR = 3.126, 95%CI: 2.682-3.605) as independent risk factors for DOL II, all with p < 0.05. Conclusions: The incidence of DOL II is significantly elevated in high-risk pregnant women, especially those aged 35 or older, those with gestational diabetes and hypertension, and those who delay the initiation of breastfeeding. It is imperative that clinical practices prioritize enhanced prenatal care and health education, robust lactation support, and improved lactation awareness among postpartum women to reduce the prevalence of DOL II.

Xylazine Positivity in Opioid-Positive Drug Screens on an Inpatient Labor Unit.

Untreated opioid use disorder (OUD) is associated with significant morbidity in pregnancy. Recent reports have highlighted the rise of xylazine in the nonprescribed fentanyl supply. The frequency with which pregnant people with OUD are exposed to xylazine has not been characterized. We sought to describe the rate of xylazine detection in urine drug screens (UDS) from pregnant people admitted to a labor unit. We performed a cross sectional study of all UDS results from an inpatient obstetric unit at an urban tertiary care center from December 2022, when xylazine was added to the detection panel, through July 2023. We perform universal verbal drug screening, with subsequent urine drug screening only performed after a positive verbal screen and consent. The trend of opioid-positive urine drug screens also positive for xylazine from December to July was measured with the Cochran-Armitage test. Of 5662 people admitted to Labor and Delivery during the study period, 138 UDS were sent for 123 unique individuals. Ninety-eight (71%) of UDS were positive for nonprescribed substances. Of positive UDS, 36 (37%) were positive for nonprescribed opioids, and of these, 17 (47.2%) were positive for xylazine among 14 pregnant people. The trend of UDS positive for opioids that were also positive for xylazine increased significantly over time (P = 0.030), from 0% in December 2022 to 100% in July 2023. Over 8 months, xylazine positivity significantly increased in UDSs positive for nonprescribed opioids in an urban Midwestern hospital. These results underscore the critical need to study the impact of xylazine on obstetric outcomes.

Access to maternity care: challenges and solutions for improving equity across US communities.

Improving maternal health is a clinical and policy priority in the United States. We reviewed recent literature on access to maternity care and impacts on racial and geographic equity. New research indicates a wide range of consequences of obstetric unit closures, as well as health challenges for lower-volume obstetric units and those who travel long distances to care. As maternal mortality rates rise, maternity care access is declining in the US, especially in rural areas and communities with a higher proportion of Black, Latinx, or Indigenous residents. Lack of resources and financial strain are challenges for low-volume and Black-serving obstetric units, and targeted investments may help improve safety and access.

Co-designing Culturally Safe Indigenous Birth in High-Risk Obstetrics: Implementing Joyce's Principle with Inuit and Cree Families and Their Medical Providers.

Introduction. Maternal evacuation-the transfer of women from remote communities to urban hospitals for childbirth-negatively affects many Indigenous Peoples in Canada. A working group of perinatal service providers in Montreal sought to enhance cultural safety in a high-risk obstetrical unit serving evacuee Indigenous families. This article describes co-design, implementation, and evaluation of short-term cultural safety interventions with Indigenous stakeholders. Methods. Indigenous families and their non-Indigenous service providers displayed their recommendations for culturally safe birth using fuzzy cognitive mapping (FCMs). Joyce's Principle-a framework for securing culturally safe healthcare for Indigenous Peoples-guided their implementation. Results. Four high-priority FCM recommendations included an Indigenous-led cultural safety training for hospital staff. Third party evaluation showed a positive influence on cultural safety knowledge and actions. Discussion. Health services designed with Indigenous stakeholders in accordance with Joyce's Principle have the potential to enhance cultural safety of maternal evacuation.

Midwives’ experiences regarding adverse events in obstetric units of the selected district of Gauteng province, South Africa

Adverse events are a global challenge and the leading cause of litigation in the world. In the current study, a qualitative, exploratory, and descriptive design was used to explore and describe the experiences of midwives in relation to adverse events that occurred in the obstetric units of the selected district of Gauteng province, South Africa. Non-probability purposeful sampling was used to select 25 midwives who work in obstetric units in the selected district of Gauteng Province, South Africa, In-depth face-to-face interviews were conducted with each participant at their workplace. Tesch method was used to analyse the data. Measures to ensure the trustworthiness of the study were observed. The study results revealed that midwives experienced a lack of recognition and acknowledgment of their efforts; poor support and unequal opportunities; blame, litigation, and psychological effects due to adverse events. The failure to recognize, acknowledge, and support midwives during an adverse event had a detrimental effect on productivity and affected the quality of maternal health care. For midwives to provide maternal health care services effectively regardless of an AE, adequate support, effective communication, and referral for appropriate counseling were recommended.

A review of the use of CT pulmonary angiography in pregnant and postpartum women at an academic centre

Background Pulmonary embolism (PE) is a common cause of maternal death during pregnancy and the puerperium yet data on its prevalence in middle-income countries is lacking. Methods We examined the medical records and CTPA (computed tomography pulmonary angiography) images of 67 women in an obstetric high care unit during pregnancy and the puerperium. We aimed to determine the prevalence of PE in a high-risk obstetric population undergoing CTPA, assess associated clinical features in this cohort, and determine the prevalence of alternative CT findings. Results CTPA detected PE in 11 women (16.42%) and alternative CT findings in 46 (68.6%). Women with PE had a lower systolic blood pressure than those without PE ( P = 0.001). Multiple gestation, preterm rupture of membranes, and gestational diabetes were linked to higher PE prevalence. Conclusions This study, set in an upper middle-income country, demonstrated a higher CTPA yield for PE and alternative diagnoses than in international literature, emphasising context-specific assessments.

Factors Associated with Maternal Morbidity in Patients with Eclampsia in Three Obstetric Intensive Care Units: A Retrospective Study.

(1) Introduction. Eclampsia is a rare complication that can occur during pregnancy and has a significant impact on maternal and neonatal outcomes. The aim of this study was to investigate the risk factors associated with significant maternal morbidity after an eclamptic seizure. (2) Methods. An observational retrospective study was performed in three maternity hospitals in Romania between 2015 and 2023 and included pregnant patients diagnosed with eclampsia. Clinical and paraclinical data were investigated, and the impact of several risk factors was assessed using multiple logistic regression analysis. The results were reported as risk ratios (RRs) and 95% confidence intervals (Cis). (3) Results. A total of 104 patients with preeclampsia, of whom 23 experienced eclamptic seizures, were included in this study. A total of 82.6% of the patients diagnosed with eclampsia experienced a form of significant morbidity (stroke, PRES syndrome, or any organ failure/dysfunction). Our regression analysis revealed that advanced maternal age (RR: 12.24 95% CI: 4.29-36.61, p = 0.002), the presence of thrombotic disorders (RR: 9.17, 95% CI: 3.41-23.70, p = 0.03), obesity (RR: 4.89, 95% CI: 0.78-18.15, p = 0.036), and smoking status (RR: 2.18, 95% CI: 0.13- 6.51, p = 0.042) significantly increase the risk of maternal comorbidities. (4) Conclusions. Careful monitoring of pregnant patients, adequate weight control during pregnancy, and correct anticoagulation of individual patients could reduce the extent of postpartum comorbidities that can result from an eclamptic seizure.

Effect of Nurse-Assisted Early Warning Intervention for Prevention of Venous Thromboembolism Following Cesarean Delivery

Abstract Objective The aim of the study is to assess the role of a nurse-assisted early warning intervention in improving prophylaxis against obstetric venous thromboembolism (VTE) and preventing VTE following cesarean delivery (CD). Methods A prospective cohort study conducted between January 1, 2020, and December 30, 2022, enrolled pregnant women who underwent CD in the obstetric unit of Women’s Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital. The patients were assigned to a control group (routine nursing care) or the intervention group (nurse-assisted early warning intervention) depending on whether or not the nurse-assisted early warning intervention had been implemented. The χ 2 test and Student’s t test were used for statistical analysis. The primary outcome was the incidence of systemic VTE following CD, and secondary outcomes were the rates of mechanical or pharmacologic prophylaxis receipts for VTE and the frequency and severity of adverse events related to pharmacologic prophylaxis. Results A total of 27,074 cases were enrolled. The incidence of symptomatic VTE following CD was significantly lower in the intervention group (0.29 per 1000 deliveries) than in the control group (2.4 per 1000 deliveries) (P &lt; 0.001). Significantly more cases received mechanical and pharmacological VTE prophylaxis in the intervention group than in the control group (respectively, 19.8% vs. 12.6% receiving mechanical prophylaxis and 0.9% vs. 0.2% receiving pharmacological prophylaxis). No cases of life-threatening bleeding occurred in either group. Conclusion The application of nurse-assisted early warning intervention may be an effective method for preventing VTE following CD.

MEDIAN EPISIOTOMY APPROACH IN A MINIATURE POMERANIAN WITH VULVAL HYPOPLASIA: A CASE REPORT

This case report details the episiotomy approach employed in managing vulval hypoplasia in a two year old Miniature Pomeranian bitch. The animal was presented to the Teaching Veterinary Clinical Complex, Veterinary Gynaecology and Obstetrical Unit, Madras Veterinary College, displaying a history of greenish black discharge and continuous straining for two hours. The animal was bred before 64 days. Physical examination revealed a small vaginal opening, measuring approximately 1.5 cm in length. Digital examination indicated fetal hind limbs and tail extending into the vaginal passage, while all other vital parameters were within the normal range. Attempts to induce uterine contractions using Inj. Oxytocin and 10 % Calcium gluconate in 5 % DNS proved unsuccessful. Therefore, under local anesthesia (2 % Lignocaine injection), median episiotomy was made and a single live male puppy was successfully delivered with mild traction. Closure of the incision site was accomplished using PGA 1/0 with a simple interrupted suture pattern. The patient had uneventful recovery after 5 day treatment regimen, involving a single dose of subcutaneous Inj. Cefovecin (antibiotic) and anti-inflammatory drugs, along with meticulous wound management.

"I managed to stand on my own. I saved my baby's life.": qualitative analysis of birth experiences from women living with HIV in Cape Town, South Africa.

There is growing recognition of obstetric violence in health facilities across the globe. With nearly one in three pregnant women living with HIV in South Africa, it is important to consider the influence of HIV status on birth experiences, including potential experience of obstetric violence as defined by the Respectful Maternity Care Charter. This qualitative analysis aims to understand the factors that shape birth experiences of women living with HIV, including experiences at the nexus of HIV status and obstetric violence, and how women react to these factors. Data were collected in a Midwife Obstetric Unit in Gugulethu, Cape Town, South Africa, through 26 in-depth interviews with women living with HIV at 6-8weeks postpartum. Interviews included questions about labor and early motherhood, ART adherence, and social contexts. We combined template style thematic analysis and matrix analysis to refine themes and subthemes. Participants described a range of social and structural factors they felt influenced their birth experiences, including lack of resources and institutional policies. While some participants described positive interactions with healthcare providers, several described instances of obstetric violence, including being ignored and denied care. Nearly all participants, even those who described instances of obstetric violence, described themselves as strong and independent during their birth experiences. Participants reacted to birth experiences by shifting their family planning intentions, forming attitudes toward the health facility, and taking responsibility for their own and their babies' safety during birth. Narratives of negative birth experiences among some women living with HIV reveal a constellation of factors that produce obstetric violence, reflective of social hierarchies and networks of power relations. Participant accounts indicate the need for future research explicitly examining how structural vulnerability shapes birth experiences for women living with HIV in South Africa. These birth stories should also guide future intervention and advocacy work, sparking initiatives to advance compassionate maternity care across health facilities in South Africa, with relevance for other comparable settings.

Disease spectrum and short-term outcomes of obstetric patients with cardiac disease admitted to an obstetric critical care unit in South Africa

Disease spectrum and short-term outcomes of obstetric patients with cardiac disease admitted to an obstetric critical care unit in South Africa

A Survey of Obstetric Anaesthesia Services and Practices in the United Kingdom.

Background Variability in obstetric anaesthetia practice and care delivered within the UK is under-explored. The ObsQoR study explored structures, processes, and outcomes of obstetric anaesthesia in 107 hospitals within the UK's National Health Service, and the results of the hospital-level survey are reported here. Methods Hospitals were surveyed to assess obstetric anaesthesia provision, practice, and care delivery. Questions explored staffing, service provision and training, facilities present, clinical practices, outcome measurement, and key indicators of quality in obstetric anaesthesia. Results We received responses from 106 participating hospitals, representing 69% of all UK obstetric units. One hundred (94%) hospitals had a dedicated consultant obstetric anaesthetist within working hours, with 27 (25%) of hospitals' duty anaesthetists having additional clinical responsibilities outside the care of obstetric patients outside of working hours. Around 102 hospitals (98%) offer multidisciplinary team training, of which 95 (93%) use a simulation-based method. Dedicated high-risk antenatal clinics were present in 50 (47%) hospitals. The majority of hospitals provide written patient information in multiple languages for discussing obstetric anaesthesia options (77, 82%). Seventy-three hospitals (69%) use point-of-care testing to estimate haemoglobin concentration. Labour epidural analgesia is most commonly delivered via patient-controlled epidural analgesia in 80 (76%) hospitals, and the incidence of post-dural puncture headaches was recorded by 80 (76%) hospitals. Conclusions These results demonstrate variation in the provision of staffing, facilities, clinical practices, and outcome measurements across the UK. To deliver safe and equitable care across the UK, there needs to be standardisation of anaesthetic peripartum care based on national recommendations and the benchmarking and measurement of appropriate markers of quality.

Cost minimisation analyses of birth care in low-risk women in Norway: a comparison between planned home birth and birth in a standard obstetric unit

BackgroundEvidence exists that planned home births for low-risk women in settings in which they have access to hospital transfer if needed are safe. The costs of planned home births, compared to low-risk births in obstetric units, are not clear. The aim of this study was to compare costs associated with hospital births versus home births under different home birth organizations.MethodsWe performed a cost minimisation analysis (CMA) based on decision-analytic modelling while assuming that health outcomes were not affected by place of birth. Estimations of resource use were mainly based on three existing Norwegian datasets: (1) women with planned home births (n = 354), (2) women with planned home births (n = 482) of which 63 were transferred to a hospital, and (3) women with planned births in a hospital (n = 1550).ResultsPlanned home birth costs 45.9% (credibility interval [CrI] 39.1–54.2) of a low-risk birth at a hospital. For planned home birth, the birth was the costliest activity (32.1%). The costs for planned home birth were estimated to be €1872 (CrI 1694–2071) and included hospitalisations for some. Costs for only those with actual home birth was €1353 (CrI 1244–1469). Costs of a birth, including possible birth-related complications, in low-risk women in a hospital was €4077 (CrI 3575–4615).When including the costs of being on call for one woman at a time, a planned home birth costs €5,531 (CrI 5,171–5,906), which is 135.7% (CrI 117.7–156.8) of low-risk births at a hospital. When organizing midwives in the on call teams for multiple women at a time, a planned home birth costs € 2,842 (CrI 2,647–3,053), which is 69.7% (CrI 60.3–80.9) of a low-risk birth in a hospital.ConclusionsHome birth can be cost-effective if the midwives who facilitate home births are organised into larger groups, or they work for hospitals that also facilitate home births. A model in which midwives work separately or in pairs to assist with a home birth and are on call for one birth at a time may not be cost-effective.

Regional anaesthetic techniques in 14 Slovenian obstetric units between 2013 and 2021: where are we and where are we going?

Background: The use of regional anaesthetic techniques for caesarean section and labour analgesia is necessary for quality-driven obstetric anaesthesia as required by European minimum standards for obstetric analgesia and anaesthesia departments, which were issued by the European Society of Anaesthesiology and Intensive Therapy in 2020. The aim of this article is to evaluate the rate of caesarean sections performed using regional anaesthetic techniques and the rates of epidural, remifentanil-PCA, and meperidine analgesia for managing labour pain across the 14 Slovenian obstetric units, respectively. Methods: Data from the Slovenian National Perinatal Information System (NPIS) from 2013 to 2021 were analysed. Results: Spinal anaesthesia was used as a primary anaesthetic method (&gt; 50% of elective caesarean sections) in a half of Slovenian obstetric units. For emergency caesarean sections, regional anaesthetic methods (spinal and epidural) were used in &gt; 50% parturients in 3 obstetric units. Eight obstetric units had an epidural rate of &gt;10%. The use of epidural analgesia has progressively increased in 9 of 14 obstetric units. Remifentanil has been routinely used in 6 obstetric units. Accordingly, the consumption of meperidine has dropped in all but one obstetric unit in Slovenia. Conclusion: In the past decade, considerable progress has been observed in obstetric anaesthesia practice in Slovenia. This is evident from the increased use of regional anaesthesia for caesarean section and labour analgesia. However, there are considerable discrepancies in anaesthetic practices between different obstetric units in Slovenia, a situation the parturients should be informed of well in advance to be able to choose the obstetric unit according to their labour and delivery preferences. In order to avoid the differences in the quality and accessibility of anaesthetic practice between units, it is necessary to increase the number of anaesthesiologists involved in obstetric anaesthesia to ensure 24/7 service of labour analgesia to be able to fulfill minimum European standards for obstetric analgesia and anaesthesia departments.

Serum Lipid Profile in Preeclamptic and Eclamptic Patients in North-Central Nigeria

Abstract Context: Preeclampsia and eclampsia contribute to 13% of maternal mortality. Central to its etiology are abnormal placentation and endothelial dysfunction. Studies of the maternal spiral arteries of these patients have revealed severe atherosis, extensive widespread endothelial dysfunction, and suspicion of abnormal lipid metabolism. Aim: This study was designed to determine the serum lipid profile in preeclamptic/eclamptic patients and compare it with normotensive controls. Materials and Methods: It was a comparative cross-sectional study, conducted in the Obstetrics and Gynecology unit, University of Ilorin Teaching Hospital. The study population was a total of 192 women comprising 96 pregnant women with preeclampsia/eclampsia and an equal number of normotensive pregnant women who were matched for age, gestational age, and body mass index, as controls. Total serum cholesterol, triglycerides, low-density cholesterol, and high-density cholesterol were determined. Results: The mean total cholesterol among the subjects was 4.79 ± 1.46 mmol/l, compared with the controls which was 4.69 ± 2.05 mmol/l (P = 0.673). The mean high-density lipoproteins (HDL) in the subjects were 1.27 ± 0.71 mmol/l, compared to the control which was 1.73 ± 0.73 mmol/l (P = 0.013). The mean triglyceride in the subjects was 2.41 ± 0.92 mmol/l, and that of the controls was 2.74 ± 0.92 mmol/l (P = 0.001). Mean low-density lipoproteins (LDL) were 2.85 ± 1.32 mmol/l in the subjects and 2.83 ± 1.48 mmol/l in the controls (P = 0.917). There was no relationship between lipid levels and the severity of the disease. Eclampsia was however associated with a higher total serum cholesterol, while intrauterine fetal demise was associated with significantly lower mean triglycerides. Conclusion: HDL and triglycerides are significantly lower in preeclamptic and eclamptic patients.

A time/space bubble: Expectant parents’ experience of birth after termination of pregnancy due to fetal anomaly in a midwifery-led, obstetric unit for prenatal loss

Termination of pregnancy due to a fetal anomaly is a challenging and mentally stressful experience, associated with trauma-related stress, depression and symptoms of complicated grief. It differs from other types of pregnancy loss because of the role of active decision-making. Expectant parents depend on caring and experienced staff to guide them during a time full of ambiguity and contrasting emotions.This study examines how expectant parents experience the process of birth with termination of pregnancy due to fetal anomaly at a specialised unit for prenatal loss.Data was generated from semi-structured interviews with 11 women and 9 male partners, one to five months after termination of pregnancy.Three themes were identified 1) Suspended time/space bubble; the unit for prenatal loss was described as a time-space bubble, that promoted a sense of meaning, a feeling of togetherness and an awareness of parallel worlds, 2) The midwife matters; participants emphasised midwives’ 'invisible', chronological and individualised practice, making it possible to be present and in the process, and 3) Meeting and spending time with the fetus/baby; participants’ responses and relation to the fetus were very different, with most of them embracing the fetus as a baby, grateful for the opportunity to have time together.The findings from this study suggest a need for specialised midwives dedicated to prenatal loss, in units designed as private and protected spaces to accommodate the requirements of parents undergoing termination of pregnancy due to fetal anomaly.

Inferred attractiveness gravity-based models for estimating realized access at rural hospitals

Operating obstetric units in rural America is financially challenging in part due to low birth volume. Birth volume at a hospital decreases when birthers bypass it to go to a farther hospital. Beyond financial considerations, it is important from a healthcare equity perspective for hospitals to know whether certain subgroups of birthers avoid utilizing the hospital’s services. This can better inform resource allocation decisions targeting those subgroups. In this paper, we use a nonlinear programming optimization model, inferred attractiveness gravity-based model (GBM), to estimate realized access to obstetric care at hospitals in Montana. We compare three variations of GBM and benchmark our results to a regression-based conditional logit model. Results indicate that hospital attractiveness varies across the level of obstetric care provided and depends on the subgroup of birthers considered. While all GBMs produced smaller errors for hospitals with higher birth volumes, our novel variant was more accurate for low-volume hospitals. Bootstrapping analyses and resolving the models for population subgroups indicated large variations in hospital attractiveness. Research findings contribute to new knowledge about equity in access to obstetric care, the importance of considering population heterogeneity in GBMs, and the benefit of using hospital demand-based thresholds for GBMs in rural settings.

Level of Knowledge of Staff Nurses on Breastfeeding Practices: A Descriptive Correlational Study

Background: Breastfeeding is recognized as the optimal approach to provide essential nutrients and promote the health of infants. Aim: This study aims to assess the nurses’ knowledge in the obstetric unit regarding breastfeeding practices in KFGH. Methods: A descriptive research approach, utilizing a questionnaire to evaluate nurses’ knowledge of breastfeeding best practices was used in this study among nurses who are working at KFGH. Results: Of the total 64 nurses, and majority (39.5%) of them are aged from 26 to 30 years. Most of them (98.4%) were female and 45.3% worked in the Obstetrics and Gynecology department, also, the majority (73.4%) held a Bachelor of Nursing degree. The results showed the attitude among nurses toward the breastfeeding management level was moderate with a mean score of 1.72 while the practice among nurses toward the breastfeeding management level was high with a mean score of 2.66, also, the knowledge among nurses toward the breastfeeding management level was high with mean score 2.36. The results showed there was a significant difference in the attitude level according to nationality (P-value = 0.007), but there was no significant difference according to the other demographic characteristics (age, marital status, department, education, experience, position, Course in obstetrics and Gynecology, and self-experience about breastfeeding). Conclusion: This study's findings gave insights into the current knowledge level of nurses in the obstetric unit regarding breastfeeding practices in KFGH and may contribute to the development of targeted interventions and educational programs to improve breastfeeding support and promotion in the hospital setting.

Preoperative Multidisciplinary Team Huddle Improves Communication and Safety for Unscheduled Cesarean Deliveries: A System Redesign Using Improvement Science.

Optimal communication between care teams is a critical component in providing safe, timely, and appropriate patient care. Labor and delivery (L&D) units experience rapidly changing clinical scenarios often requiring escalation in care and unplanned cesarean deliveries (CDs). The University of Cincinnati Medical Center (UCMC) is a 550-bed academic level 4 maternal care center with a 13-bed L&D unit in Cincinnati, OH. There are approximately 2500 deliveries/y with a CD rate of 33%. The L&D unit is staffed with dedicated anesthesia personnel 24 hours a day. In our L&D unit, there was widespread dissatisfaction with multidisciplinary communication surrounding unscheduled CD. Near-miss safety events in our obstetric unit were attributed to preoperative communication failures. Initial surveys identified challenges in preoperative communication among nursing, anesthesiology, and obstetric teams leading to potential risk for compromised care. Using the UC Health Performance Improvement Way, we first sought to understand the process leading up to unscheduled CD. Change ideas were developed based on observed failures in communication. Interventions were tested and refined through iterative plan-do-study-act (PDSA) cycles. One key intervention was the introduction of a bedside, multidisciplinary, patient-centered, pre-CD huddle attended by nursing, anesthesia, and obstetrics representatives using a standard checklist for critical information. Qualitative patient feedback was elicited to inform change efforts. We compared patient and procedure characteristics from the baseline and huddle implementation phases. Our primary outcome measure was the satisfaction of care team members with communication around unscheduled CD. A secondary outcome was the general anesthesia (GA) rate for unscheduled CD. Our key process measure was adherence to the preoperative huddle. We tracked decision-to-incision interval (DTI) as a balancing measure. Huddle adherence reached 96% for unscheduled CD within 6 months of testing and implementation. A combined survey of anesthesia, nursing, and obstetrics showed that satisfaction scores related to unscheduled CD communication improved from 3.3/5 to 4.7/5 after huddle implementation. The rate of GA use and the median DTI remained unchanged. Patients felt more engaged and reported positive experiences by being a part of the huddle discussion. In an academic obstetric unit, communication failures surrounding unscheduled CD were identified as a contributor to staff dissatisfaction and perception of safety risk. Implementation of a bedside multidisciplinary pre-CD huddle improved communication between teams and contributed to creating a culture of safety without causing significant delays in care.

Ethnic, geographical and altitude considerations and maternal mortality associated with HELLP syndrome in Ecuador: a population-based cohort study

BackgroundEclampsia and pre-eclampsia rank as the third leading causes of maternal death in Ecuador, following pre-existing chronic diseases and postpartum haemorrhage, as reported by the Ecuadorian National Institute of Statistics and Census (INEC). In contrast, HELLP (Haemolysis, Elevated Liver enzymes, Low Platelet count) syndrome remains underexplored epidemiologically, not only in Latin America but globally. This study marks the first population-based investigation into HELLP syndrome incidence and mortality in Ecuador, examining geographical variations, altitude influences and ethnic backgrounds.MethodsConducted as a retrospective population-based cohort study from 2015 to 2017, this research delves into the incidence, risk factors and maternal mortality associated with HELLP syndrome in Ecuador. Utilising data from INEC and the Ecuadorian Ministry of Health, we identified HELLP syndrome cases through ICD-10 (International Classification of Diseases, tenth revision) coding in hospitalised individuals. Logistic regression analysis was employed to explore association, whilst geospatial statistical analysis focused on cantons to identify significant spatial clusters. Primary outcome measures include HELLP syndrome incidence and maternal mortality, supplying crucial insights into the syndrome’s impact on maternal health in Ecuador.ResultsThe incidence of HELLP syndrome is 0.76 (0.69–0.84)/ 1000 deliveries. Afro-Ecuadorian communities have a higher risk (Odds Ratio (OR) = 2.18 (1.03–4.63)) compared to Indigenous Ecuadorian communities. Living at mid-level or high altitude is a significant risk factor OR of 2.79 (2.19–3.55) and an OR 3.61 (2.58–5.03), respectively. Being an older mother was also identified as a risk factor. Women living more than 20 km from the obstetric unit have an OR of 2.55 (2.05–3.18). Moreover, we found that cantons with higher crude HELLP syndrome incidence also have lower numbers of physicians (R = 0.503, p-value < 0.001). The mortality incidence of women with HELLP syndrome is 21.22 (12.05–20.59)/1000 deliveries with HELLP syndrome diagnoses.ConclusionsHigh altitude, advanced maternal age and geographical distance between residence and health centres are risk factors for HELLP syndrome. Maternal mortality in women with HELLP syndrome is higher than pre-eclampsia and eclampsia but comparable with previous reports in other countries.