Postpartum Setting Research Articles

BS3-2: Mammary Stroma as an NSAID Target; Implications for Pregnancy-Associated Breast Cancer.

Abstract Utilizing a young women's breast cancer cohort from the University of Colorado Cancer Center, we show that women diagnosed as late as five-ten years postpartum have worse prognosis than nulliparous women or women diagnosed during pregnancy, and represent ∼50% of all young women's breast cancer patients. We propose that breast involution following pregnancy accounts for this poor prognosis. Characterization of involution identifies tissue remodeling programs that share similarities with microenvironments known to promote metastasis. Using SHG imaging, we find fibrillar collagen bundles with radially-aligned fibers similar to those observed in invasive tumors deposited in the involuting gland. By immunohistochemistry and FACS we find macrophages with an M2-polarization-like profile similar to tumor-associated macrophages at abundant levels during involution. In three independent mouse models for postpartum breast cancer, we isolate postpartum mammary gland involution as a driving force for cancer progression. Mammary tumors arising in the mouse involuting microenvironment express COX-2 and isolated tumor cells are motile and invasive in a collagen-1/COX-2 dependent manner. Targeting involution-macrophages as likely mediators of tumor promotion was accomplished using a previously described mouse transgenic model. Macrophage depletion during involution had catastrophic effects on normal mammary gland involution. Conversely, inhibition of COX-2 with celecoxib, aspirin or ibuprofen did not interfere with postpartum lobular regression. COX-2 inhibition did decrease tumor growth, local tumor cell dispersion and lung metastasis. NSAID treatment also suppressed collagen and tenascin-C deposition in the involuting microenvironment, suggesting that modulation of extracellular matrix proteins may be a novel mechanism by which NSAIDs exhibit chemopreventive activity. Our studies indicate two distinct roles for COX-2 in the postpartum setting. COX-2 activity within the tumor cell is required for invasiveness and COX-2 activity in the host promotes collagen fibrillogenesis. Several correlative observations implicate the collagen/COX-2 pathway in postpartum breast cancer in women: involuting breast tissue has increased collagen with radially aligned fibers, analysis of 11 publically available microarray data sets shows high COL1A and COX-2 independently correlate with decreased relapse free-survival in young breast cancer patients, and COX-2 protein is observed in DCIS lesions in postpartum cases at higher levels than nulliparous cases. In summary, our studies suggest further research into COX-2 inhibitor use might provide a novel strategy to improve the prognosis of young women should they be diagnosed with postpartum breast cancer. The question of whether an NSAID based intervention study could be aimed at recently pregnant women at high risk for breast cancer also remains to be determined, but is an extremely desirable objective given that the ∼ 6 million pregnancies in the US per year. Supported by grants from DoD Synergistic Idea Awards BC060531 & BC10400/001, Komen Foundation KG090629, DoD Idea Award BC074970 to PJK, ACS New England Division Postdoctoral Fellowship Spin Odyssey PF-08-257-01-CSM to TRL and DoD Predoctoral Grants BC073482 to JO and BC100910 to HM. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr BS3-2.

Timely Discharge of Clinically Eligible Patients in the Postpartum Setting

Timely Discharge of Clinically Eligible Patients in the Postpartum Setting

The role of collagen and COX-2 in post-partum breast involution on the progression of pregnancy-associated breast cancer and its inhibition by NSAIDs.

e11117 Background: Prognosis of young women’s breast cancer is influenced by reproductive history with worse prognosis when diagnosis is within five years postpartum. We propose that breast involution accounts for the poor prognosis of postpartum breast cancers (BC), as involution is identified by tissue remodeling programs that share similarities with tumor promoting microenvironments including elevated fibrillar collagen deposition and COX-2 expression. Methods: We developed murine models of postpartum BC. To determine if targeting COX-2 may decrease progression of postpartum BC, mice were treated with NSAID ibuprofen for two weeks during the window of involution. Further, the collagen/COX-2 pathway in human postpartum BC was investigated in breast tissue and DCIS from young women. Results: The normal murine involuting gland showed high levels of radiating collagen fibers organized similar to collagen from invasive tumors. Mammary tumors arising in this collagen-rich microenvironment have increased levels of COX-2. In vitro, tumor cells isolated from PABCs are motile and invasive in a collagen and COX-2 dependent manner. Surprisingly inhibition of COX-2 during involution decreased collagen levels and frequency of radial fibers. Ibuprofen treatment reduced tumor size, collagen architecture, COX-2 expression, and lung cell seeding. In humans, comparison of breast tissue from nulliparous women to involution shows increased levels of collagen and >2x the frequency of radially aligned fibers. In our DCIS study, analysis of COX-2 expression reveals a trend towards increased COX-2 expression in the postpartum DCIS lesions. Conclusions: Our results confirm involution as a driver of postpartum BC and indicate two roles for COX-2 in tumor cell invasion in the postpartum setting: 1) COX-2 activity in the tumor is required for motility and 2) COX-2 activity in the host promotes collagen fibrillogenesis, which promotes metastasis. The human correlative results implicate collagen and COX-2 in the poor prognosis of postpartum BC. Our data preliminarily support the idea of an NSAID intervention study for recently pregnant women at high risk for breast cancer.

Abstract 1590: A preclinical mammary intraductal model to study early stage human breast cancer

Abstract Our goal is to develop a murine intraductal mammary model to examine the progression of early stage human breast cancer. Current models include injection of human mammary epithelial cell lines into the mammary fat pad (MFP) of immunocompromised mice or intraductal injection via cleaved nipple. With the MFP model, these cells are injected into the correct anatomical location for primary invasive tumors but do not form in the location of initiation, i.e., the mammary ducts. Intraductal models allow direct study of tumor cell formation and dissemination from mammary ducts; however, surgical manipulations performed to expose the teat canal are confounded by wound healing and inflammatory programs that are reported to be tumor promotional in other contexts. Our intraductal model of human breast cancer delivers human mammary tumor cells directly through the mouse teat into the correct anatomical location for ductal in situ carcinoma (DCIS) without surgical manipulations. Further, our model provides co-evolution of tumor progression with stromal changes versus the MFP model where the stroma responds to tumor cells at time of injection. Using the bi-potential progenitor MCF10ADCIS.com cell line and harvesting tissue 4 weeks post-injection, we corroborate reported studies showing DCIS lesions with distinct characteristics of the main human subtypes and progression to invasive disease. Immunohistochemical (IHC) analysis shows that these cells incorporate into the mouse mammary ducts and form E-cadherin-based junctional complexes with neighboring cells, including other human tumor cells or normal mouse epithelial cells. Although these cells have been characterized as estrogen receptor (ER) negative both in vitro and in vivo, IHC revealed that some tumors developed within our model were ER positive according to the Allred scoring method. Our model permits a rigorous evaluation of the effects that physiologic-induced changes in mammary tissue remodeling (i.e. postpartum involution) has on tumor progression. We investigated tumor incidence and burden in the postpartum involution setting and found much greater increases in the involution group compared to the respective nulliparous control group. Interestingly, the Ki67 proliferative index is lower in the involution compared to the respective nulliparous control, suggesting a mechanism other than proliferation is driving tumor promotion in the postpartum setting. In summary, our murine intraductal model of human breast cancer provides a rigorous approach to studying early stage tumor progression. This model is particularly suited to studying host effects on tumor progression and future studies will determine the effects of physiological endocrine status on tumor cell dissemination from mammary ducts. Since mammary ducts are the primary sites of occult tumors in women, we propose that this teat injection model will be a more relevant model for all stages of human disease. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 1590. doi:10.1158/1538-7445.AM2011-1590

Abstract CN10-03: Stromal signals from the involuting microenvironment that are important in postpartum breast cancer

Abstract Prognosis of young women's breast cancer is influenced by pregnancy. Women diagnosed within 5 years of childbirth have worse prognosis than age-matched nulliparous women or women diagnosed while pregnant. These data indicate that pregnancy-associated breast cancer (PABC) exists as two subtypes, with poor prognosis associated with cases diagnosed in the postpartum setting rather than during pregnancy. We propose that breast involution following pregnancy accounts for the poor prognosis of breast cancers diagnosed within 5 years of childbirth. Characterization of the involuting mammary gland has identified tissue remodeling programs associated with wound healing and inflammatory responses that share similarities with cancer microenvironments known to be tumor promotional. Based on these results, we proposed the Involution Hypothesis, which states that the physiologically normal microenvironment of the postpartum involuting gland is tumor promotional. We estimate a high proportion of young women with breast cancer actually have a “recent” pregnancy as a negative prognostic feature. Specifically, with an upper limit of 40 years of age for reproductive potential and a recent pregnancy defined as within 5 years of diagnosis, an estimated 20,000 cases of breast cancer per year in the U.S. may qualify as postpartum. Targeting the postpartum window with interventions designed to reduce the tumor promotional attributes of involution is highly attractive, as this window of risk is restricted in time and the population is readily identifiable. Testing the Involution Hypothesis has been limited by lack of preclinical models. We describe here a mouse xenograft model of PABC that isolates postpartum mammary gland involution as a driving force for breast cancer progression and metastasis. In this model, human mammary MCFDCIS.com tumor cells injected into the postpartum, involuting mammary gland form more proliferative and invasive tumors than tumor cells injected into the nulliparous gland. The involuting gland is characterized by high levels of radiating collagen fibers organized similar to collagen associated with invasive tumors across species. In our model of postpartum breast cancer, fibrillar collagen is identified as a primary mediator of tumor progression. Mammary tumors arising in the collagen-rich, involuting microenvironment are invasive and have increased levels of COX-2. In vitro, primary tumor cells isolated from PABC tumors are motile and invasive in a COX-2 dependent manner. Evidence that COX-2 induced motility is dependent on collagen signaling is demonstrated with functional blocking antibodies against β1-integrin, 2β1-integrin, and integrin associated protein CD47. These data suggest that treatment targeting COX-2 during postpartum involution may decrease progression of postpartum breast cancer. To test this hypothesis, mice were treated with the NSAID ibuprofen for two weeks coinciding with postpartum mammary gland involution. NSAID treatment was found to reduce tumor size, COX-2 expression, and lung cell seeding in this model. These antitumor effects were observed without blocking apoptosis of secretory mammary epithelial cells, which is required to remodel the gland to a nonsecretory state, and is a requisite for advancing this strategy to clinical trial. The question of whether an NSAID based intervention study could be aimed at recently pregnant women at high risk for breast cancer remains to be determined, but is an extremely desirable objective given that there are more than 6 million pregnancies in the U.S. per year. Citation Information: Cancer Prev Res 2010;3(12 Suppl):CN10-03.

Stroke: Highlights of Selected Articles

HomeStrokeVol. 41, No. 11Stroke: Highlights of Selected Articles Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBStroke: Highlights of Selected Articles Originally published1 Nov 2010https://doi.org/10.1161/STROKEAHA.110.603795Stroke. 2010;41:2457Hemorrhagic Manifestations of Reversible Cerebral Vasoconstriction Syndrome: Frequency, Features, and Risk FactorsReversible cerebral vasoconstriction syndrome (RCVS) is characterized by severe headaches, focal deficits, seizures, and multifocal constriction of intracerebral arteries that resolves spontaneously in 3 months. It may be associated with both ischemic and hemorrhagic strokes. More than half of the cases of RCVS occur in the postpartum setting or in association with sympathomimetic or serotoninergic agents. The authors prospectively analyzed 89 consecutive patients with RCVS. Thirty-four percent of patients (n=30) developed at least 1 type of intracranial hemorrhage. Subarachnoid hemorrhage was the most frequent (n=27), followed by intracerebral hemorrhage (n=11), and then subdural hemorrhage (n=2). This study revealed that women and migrainers are at higher risk of intracranial hemorrhage. History of hypertension and blood pressure surges during the acute phase of RCVS were not associated with hemorrhage risk. Patients with hemorrhage had a greater risk of persistent focal deficits and were more likely to not be able to return to work at 6 months. RCVS should be considered in the differential diagnosis of patients with spontaneous intracranial hemorrhage. Women and migrainers are at high risk of intracranial hemorrhage with RCVS.See p 2505.Intravenous Alteplase for Stroke in Those Older Than 80 Years OldTreating stroke patients older than 80 with intravenous tissue plasminogen activator (tPA) remains controversial. In this issue of Stroke, Ford and colleagues present the outcomes and complications seen in tPA-treated patients >80 years (n=1831) versus ≤80 years (n=19 411) in the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Register (SITS-ISTR) database. The unadjusted symptomatic intracerebral hemorrhage (sICH) rate did not differ significantly between patients >80 years versus ≤80 years with the SITS-MOST definition but was significantly increased in the >80 years group using the National Institute of Neurological Disorders and Stroke definition. Fatal sICH (SITS-MOST definition) rate was similar in both age groups. After adjustment for baseline variables, there was no statistically significant difference in sICH rates between the 2 age groups, regardless of the used definition. The odds ratio for mortality in the >80 years group was higher (30% versus 12%) and for functional independence (mRS 0 to 2) lower (35% versus 57%) at 3 months. Compared to baseline, National Institutes of Health Stroke Scale scores improved to a similar extent in both age groups at 2 hours, 24 hours, and 7 days. Lastly, analysis of the age ranges <60, 61–70, 71–80, 81–90, and >90 years indicated no age-related increase in sICH (SITS-MOST definition). Though a progressive increase in mortality was observed, functional dependence (mRS 3 to 5) was similar across assessed age ranges. This study is important because it provides robust and reliable data that tPA-treated patients >80 years (1) do not have a higher risk for clinically significant sICH; (2) have early clinical improvement similar to younger patients; and (3) have poor outcomes related to increased mortality rather than to an increased rate of functional dependence.See p 2568.Impact of Microalbuminuria on Incident Stroke: A Meta-AnalysisIdentifying risk factors underlying atherosclerotic disease may help optimize patient care. Microalbuminuria, which is traditionally seen as a sign of early kidney disease, has also been increasingly recognized as a marker of endothelial dysfunction. In this issue of Stroke, Meng Lee and colleagues present data from a meta-analysis of 12 prospective cohort studies (total 48 596 participants and 1263 stroke events) to assess the association of microalbuminuria and the risk of stroke. Included studies were derived from general as well as type 2 diabetes mellitus and stroke history populations. The majority of studies were from a white-dominant population. Follow-up duration ranged from 1.1 years to 13.4 years, and the reported prevalence of microalbuminuria ranged from 12% to 40% in the included studies. After adjustment for established cardiovascular risk factors, presence of microalbuminuria was associated with greater subsequent stroke risk. The association was highest with ischemic stroke risk and essentially neutral for hemorrhagic stroke risk. Patients with microalbuminuria had an overall risk of future stroke that was approximately 90% greater than in those without microalbuminuria, and the impact of microalbuminuria was greatest in the population with a history of stroke. Nevertheless, the authors caution that potential publication bias may have resulted in an overestimation of the association between microalbuminuria and future stroke risk. Furthermore, given that this meta-analysis was based on observational studies, a causal relationship between ischemic stroke and microalbuminuria could not be proven. Nevertheless, the presented analysis supports the notion that microalbuminuria is an independent, and potentially modifiable, ischemic stroke risk factor.See p 2625.Footnotes Previous Back to top Next FiguresReferencesRelatedDetails November 2010Vol 41, Issue 11 Advertisement Article InformationMetrics https://doi.org/10.1161/STROKEAHA.110.603795 Originally publishedNovember 1, 2010 PDF download Advertisement

The Lived Experience of Pregnancy Complications in Single Older Women

To explore the lived experience of single older women (35 years or older at time of birth) who experienced complications in their planned pregnancy. Phenomenology, using semistructured interviews with 11 women between the ages of 35 to 48 years. Six themes emerged: (a) motherhood now or never, (b) the known and unknown, (c) importance of support, (d) the stigma of single motherhood, (e) changing priorities, and (f) long-term concerns for themselves and child/children. Nurses who work with pregnant women should understand as much as possible about the issues affecting older single women who choose pregnancy; this offers the best opportunity to provide comprehensive care. These women can be at increased risk for many pregnancy complications, and should receive counseling about their risks for both fetal and maternal complications. Nurses should also conduct a thorough psychosocial assessment to determine what support systems are in place and what resources are available if complications arise. In the intrapartum and postpartum settings, nurses can offer not only appropriate physical caregiving but also a supportive and caring attitude with women in this circumstance. Helping women maintain a sense of control by helping them to participate in their care planning is essential.

Factors associated with choosing a long acting reversible contraceptive method amongst postpartum women in an urban teaching hospital

Long acting reversible contraceptive (LARC) methods are highly effective, safe with breastfeeding, and permit child-spacing. Therefore, they may be ideal in the postpartum setting. We investigated factors associated with selection of LARC methods (intrauterine device or implant) among postpartum women at an urban hospital.

Pertussis and Patient Safety: Implementing Tdap Vaccine Recommendations in Hospitals

Despite the availability of pediatric vaccines against pertussis ("whooping cough"), the disease is poorly controlled. Adolescents and adults with waning immunity, especially immediate family members, are responsible for 76%-83% of pertussis transmission to infants. Adolescent/adult tetanus, diphtheria, and acellular pertussis (Tdap) booster vaccines were licensed in the United States in 2005, but their use has been low and hospitals' implementation of immunization recommendations suboptimal. Efforts were implemented at two hospitals in Chicago to increase postpartum use of Tdap vaccine and to replace the tetanus and diphtheria toxoids (Td) booster with Tdap vaccine in emergency department (ED) settings. Postpartum Pertussis Vaccination Program at Prentice Women's Hospital: In the program's first 18 months (June 2008-November 2009) 9,540 doses of Tdap vaccine were administered to 78.87% of the postpartum patients. Children's Memorial Hospital: Tdap Use in Emergency Settings: In 2007, uptake of Tdap was slow. During 2008, of 43 ED patients receiving a tetanus toxoid-containing vaccine as part of wound management, 10 were given Tdap (20 had previously received a dose of Tdap vaccine). Hospital-based Tdap initiatives in postpartum and ED settings can be successfully implemented, provided that support is obtained not only from key decision makers at the hospital but also the health care providers who will be directly involved in implementing those initiatives. It is imperative that hospitals implement programs that increase the use of Tdap vaccine among postpartum women, in emergency settings, and among health care personnel.

Alternatively Activated Macrophages and Collagen Remodeling Characterize the Postpartum Involuting Mammary Gland across Species

Recent pregnancy correlates with decreased survival for breast cancer patients compared with non-pregnancy-associated breast cancer. We hypothesize that postpartum mammary involution induces metastasis through wound-healing programs known to promote cancer. It is unknown whether alternatively activated M2 macrophages, immune cells important in wound-healing and experimental tumorigenesis that also predict poor prognosis for breast cancer patients, are recruited to the normal involuting gland. Macrophage markers CD68, CSF-1R, and F4/80 were examined across the pregnancy and involution cycle in rodent and human mammary tissues. Quantitative immunohistochemistry revealed up to an eightfold increase in macrophage number during involution, which returned to nulliparous levels with full regression. The involution macrophages exhibit an M2 phenotype as determined by high arginase-1 and low inducible nitric oxide synthase staining in rodent tissue, and by mannose receptor expression in human breast tissue. M2 cytokines IL-4 and IL-13 also peaked during involution. Extracellular matrix (ECM) isolated from involuting rat mammary glands was chemotactic for macrophages compared with nulliparous mammary ECM. Fibrillar collagen levels and proteolysis increased dramatically during involution, and denatured collagen I acted as a strong chemoattractant for macrophages in cell culture, suggesting proteolyzed fibrillar collagen as a candidate ECM mediator of macrophage recruitment. M2 macrophages, IL-4, IL-13, fibrillar collagen accumulation, and proteolysis of collagen are all components of tumor promotional microenvironments, and thus may mediate promotion of breast cancers arising in the postpartum setting.

Bedside Shift Report Enhances Patient Satisfaction for Hispanic and Public Insurance Patients and Improves Visibility of Leadership in Obstetric and Postpartum Settings

Bedside Shift Report Enhances Patient Satisfaction for Hispanic and Public Insurance Patients and Improves Visibility of Leadership in Obstetric and Postpartum Settings

Cauda equina syndrome post‐caesarean section

Cauda equina syndrome is rarely associated with pregnancy, with few cases reported in the literature. The majority of cases describe antenatal presentations, with only one case manifesting post-partum, three weeks after a normal vaginal delivery. We outline a case of cauda equina syndrome following caesarean section in a patient with known lumbar disc disease, and discuss the contribution of the mode of delivery and anaesthesia as precipitants of disc herniation causing cauda equina compression. We conclude that vigilance, particularly in the post-partum setting, be attributed towards the neurological surveillance of women with known disc disease.

A qualitative study of Western Australian women's perceptions of using a Snoezelen room for breastfeeding during their postpartum hospital stay.

BackgroundThere is limited evidence on the use of the Snoezelen concept for maternity clients. Snoezelen, a Dutch concept, initiated in the 1970s as a leisure activity for severely disabled people, involves creating an indoor environment using controllable stimuli to enhance comfort and relaxation. These specially designed rooms expose the user to multiple sensory stimulations combining vision, touch, sounds and aromas. The aim of this study was to provide insight into breastfeeding women's experience of using a Snoezelen room during hospitalisation.MethodsA qualitative exploratory design was chosen to reveal women's perceptions of using the Snoezelen room. Osborne Park Hospital, the study setting is the second largest public provider of obstetric services in Western Australia. A purposive sample was drawn from breastfeeding women who used the Snoezelen room during their postpartum stay from March 2006 to March 2007. Saturation was achieved after eleven breastfeeding women were interviewed six weeks post discharge. Data analysis involved the constant comparison method.ResultsParticipants entered the room feeling tired and emotional with an unsettled baby and breastfeeding issues aggravated by maternal stress and anxiety. All women indicated they were able to achieve relaxation while in the room and would recommend its use to other breastfeeding mothers. Two key themes revealed how the Snoezelen room facilitated maternal relaxation, which ultimately enhanced the breastfeeding experience. The first theme, "Finding Relaxation for the Breastfeeding Mother" incorporates three subthemes: 'Time out' for mother; Control in own personal space; and a Quiet/calm environment with homelike atmosphere. The second theme, "Enabling Focus on Breastfeeding", occurred after relaxation was achieved and involved four subthemes: Able to get one-on-one attention; Not physically exposed to others; Away from prying, judgemental eyes and Able to safely attempt breastfeeding alone knowing help is nearby.ConclusionInsight into how the Snoezelen room promoted relaxation also highlights what contributes to maternal anxiety during breastfeeding experiences in hospital. The findings offer health professionals the opportunity to consider adopting strategies such as a Snoezelen room in their hospital or being innovative in modifying the postpartum setting to promote relaxation for breastfeeding women.

Acute promyelocytic leukemia: an unusual cause of fatal secondary postpartum hemorrhage

Postpartum haemorrhage can rarely be associated with an underlying coagulation or haematological disorder. We wish to discuss a case of acute promyelocytic leukemia (APL) presenting as secondary postpartum hemorrhage (PPH), its clinical and pathological features and maternal outcome. We describe a 28-year-old woman who presented with secondary PPH accompanied by bleeding from gums, marked pallor, hematemesis, ecchymotic and purpuric spots all over the body, 8 days post-partum. Investigations revealed her to be having APL, a diagnosis not suspected by the referring clinic. She was given supportive therapy but died before chemotherapy could be started. The case emphasizes the importance of suspecting, investigating and energetically treating uncommon causes such as acute leukemia when an unusually severe clinical picture in a postpartum setting suggests such a possibility. This may prove to be life saving, particularly if the leukemia happens to be APL, a cancer with a very high cure rate.

Postpartum contraception: the New Mexico Pregnancy Risk Assessment Monitoring System

Objective To examine factors associated with postpartum contraception, including the relationship between ethnicity and postpartum contraceptive use. Methods We used data from the New Mexico Pregnancy Risk Assessment Monitoring System, which monitors selected maternal events occurring before, during and after pregnancy. Results Our findings in 4096 women revealed that women who are aged ≥35 years, unmarried and lacking a postpartum visit have increased risk of no postpartum contraception. The odds of postpartum contraception were over three times greater in women with a postpartum visit [adjusted odds ratio (OR)=3.06, 95% confidence interval (CI): 2.17–4.31) and over 50% greater in married women (adjusted OR=1.57, 95% CI: 1.16–2.11). Hispanic women were more likely than were Native Americans to use postpartum contraception (OR=1.25, 95% CI: 0.95–1.64). Conclusion Focused contraception counseling, especially in the postpartum setting, is important to help ensure the well-being of women and children.

Perinatal nursing education for single‐room maternity care: an evaluation of a competency‐based model

To evaluate the success of a competency-based nursing orientation programme for a single-room maternity care unit by measuring improvement in self-reported competency after six months. Single-room maternity care has challenged obstetrical nurses to provide comprehensive nursing care during all phases of the in-hospital birth experience. In this model, nurses provide intrapartum, postpartum and newborn care in one room. To date, an evaluation of nursing education for single-room maternity care has not been published. A prospective cohort design comparing self-reported competencies prior to starting work in the single-room maternity care and six months after. Nurses completed a competency-based education programme in which they could select from a menu of learning methods and content areas according to their individual needs. Learning methods included classroom lectures, self-paced learning packages, and preceptorships in the clinical area. Competencies were measured by a standardized perinatal self-efficacy tool and a tool developed by the authors for this study, the Single-Room Maternity Care Competency Tool. A paired analysis was undertaken to take into account the paired (before and after) nature of the design. Scores on the perinatal self-efficacy scale and the single-room maternity care competency tool were improved. These differences were statistically significant. Improvements in perinatal and single-room maternity care-specific competencies suggest that our education programme was successful in preparing nurses for their new role in the single-room maternity care setting. This conclusion is supported by reported increases in nursing and patient satisfaction in the single-room maternity care compared with the traditional labour/delivery and postpartum settings. An education programme tailored to the learning needs of experienced clinical nurses contributes to improvements in nursing competencies and patient care.

Single Room Maternity Care: Perinatal Outcomes, Economic Costs, and Physician Preferences

Objectives: (1) To compare perinatal outcomes and costs of care among women giving birth in a single room maternity care (SRMC) setting versus a traditional delivery suite or postpartum setting; and (2) to report on physicians’ responses to the SRMC environment.Methods: Among women who were determined to be at "low risk" for intrapartum complications through the use of a triage tool, the outcomes of those receiving care in the new SRMC unit were compared to the outcomes of those cared for in the traditional delivery suite and postpartum modules. Total costs of the entire maternity service before and after implementation of SRMC were also compared. Physicians were surveyed about the adequacy of the physical environment.Results: Rates of intrapartum interventions and adverse outcomes were similar in both groups, with the exception of less frequent electronic fetal monitoring in the SRMC setting. Caesarean section rates were lower than expected in both groups. Length of stay was significantly shorter in the SRMC group (55.1 ± 26.5 days vs. 61.0 ± 24.3 days; < .001). Staff positions in the hospital were reduced from 206 to 193.7. Direct costs for women of similar acuity (resource intensity weightings) were reduced by 24% ($1809 vs. $2377). The proportion of physicians preferring SRMC to the traditional setting increased from 45.8% at 6 months to 78.7% at 12 months after implementation of the SRMC model (P = .003).Conclusion: SRMC is a model of obstetric care for women at low risk for intrapartum complications, offering cost savings without affecting perinatal outcomes, and is well accepted by physicians.

Risk factors for perineal injury during delivery

Objective: We sought to identify risk factors for anal sphincter injury during vaginal delivery. Study Design: This was a retrospective, case-control study. We reviewed 2078 records of vaginal deliveries within a 2-year period from May 1, 1999, through April 30, 2001. Cases (n = 91) during the study period were defined as parturients who had documentation of greater than a second-degree perineal injury. Control subjects (n = 176), who were identified with the use of a blinded protocol, included women who were delivered vaginally with less than or equal to a second-degree perineal injury. For each patient, we reviewed medical and obstetrics records for the following characteristics: maternal age, race, weight, gestational age, parity, tobacco use, duration of first and second stages of labor, use of oxytocin, use of forceps or vacuum, infant birth weight, epidural use, and episiotomy use. Results: Of the 2078 deliveries that were reviewed, we discovered 91 cases (4.4%) of documented anal sphincter injury. The mean maternal age of our sample was 24.9 ± 5.9 years). Nearly two thirds (63.2%) were white; 26.7% were black, and 10.1% were of other racial backgrounds. Forceps were used in 51.6% of deliveries that resulted in tears (cases), compared to 8.6% of deliveries without significant tears (control subjects, P <.05). Using cases and control subjects with complete data (cases, 82; control subjects, 144), delivery with forceps was associated with a 10-fold increased risk of perineal injury (odds ratio, 10.8; 95% CI, 5.2-22.3) compared to noninstrumented deliveries. The association was similar after adjustment for age, race, parity, mode of delivery, tobacco use, episiotomy, duration of labor (stages 1 and 2), infant birth weight, epidural, and oxytocin use (odds ratio, 11.9; 95% CI, 4.7-30.4). Nulliparous women were at increased risk for tears (adjusted odds ratio, 10.0; 95% CI, 3.0-33.3) compared with multiparous patients, but parity did not reduce the association between forceps-assisted deliveries and anal sphincter injuries. Increasing fetal weight was also a risk factor in both unadjusted and adjusted analyses. The performance of a midline episiotomy was associated with an increased risk of anal sphincter tear compared with delivery without an episiotomy in the univariate analysis (odds ratio, 4.9; 95% CI, 2.5-9.6), but this association was reduced in the adjusted analysis (odds ratio, 2.5; 95% CI, 1.0-6.0). The increased duration of both the first and second stages of labor increased injury risk in the unadjusted, but not adjusted, analysis. No significant association was observed between case status and the use of oxytocin or epidural anesthesia. Greater, but not significant, increased risk was associated with maternal indications for operative delivery compared with fetal indications. Conclusion: Our results are consistent with recent reports that identify forceps delivery and nulliparity as risk factors for recognized anal sphincter injury at the time of vaginal delivery. Further investigation should focus on the determination of whether the association of injury to instrumentation is causal or, in fact, modifiable. Because of the established association between sphincteric muscular damage and anal incontinence, patients should be counseled about the risk of anal sphincter injury when operative vaginal delivery is contemplated. Such patients should be followed closely in the postpartum setting to assess for the development of potential anorectal complaints. (Am J Obstet Gynecol 2003;189:255-60.)

Migrant fathers and their attitudes to potential male hormonal contraceptives

The purpose of this study was to assess potential uptake of male hormonal contraception (MHC) in migrant fathers in a post-partum setting, and to compare them to Australian-born fathers. It was a cross-sectional study of a convenience sample from the post-natal ward of a tertiary level obstetric hospital. Seventy-six English-speaking fathers born in South-East Asia or on the Indian subcontinent were surveyed and their responses compared with those provided by 118 Australian-born participants from a previous study. The main outcome measures were acceptability of potential male hormonal contraception on a 5-point scale, and preferred mode of administration. Information on past and future intended contraceptive use, including existing male forms of contraception, was also compared with data collected from the group of Australian-born men. Only 13.6% (95%CI: 5.8–21.4) of migrant fathers would definitely or probably consider trying MHC compared with 47.5% (95%CI: 38.5–56.5) of Australian-born fathers (chi-square, p < 0.001). There were significant differences in desired mode of administration in potential ‘triers’ from both groups, as well as in attitudes to existing contraception. Two-yearly injection was the most popular method of administration in migrants, with 38.3% of ‘triers’ listing it as their first choice (compared with 21.4% in published data on Australian-born men; chi-square, p = 0.038). We conclude that migrant groups are less enthusiastic about novel potential MHC. The influence of education on acceptance of this contraceptive possibility needs to be assessed.

Introducing domestic violence assessment in a postpartum clinical setting.

Attempts to introduce assessment for exposure to domestic violence in health care settings have met with limited success, in spite of widespread knowledge of the prevalence of spousal abuse and its implications for women's health. We assessed the utility of Rogers' model of institutional change for the implementation of a universal screening program for domestic violence in postpartum clinical settings. We adapted Rogers' innovation-diffusion model to develop and implement a protocol for domestic violence assessment among 300 nurses working in two hospitals that together provide obstetrical care to the City of Vancouver, British Columbia, Canada. Our education sessions introduced new knowledge and addressed attitudes and beliefs. They were followed by "hands-on" demonstration and supervision of assessments. Our "Let's Talk" visual aids program added visibility to our initiative and provided cues as to how to undertake screening and response. Screening rates were monitored along with a process evaluation based on anecdotal reporting by nursing staff. Following the initiation of educational sessions and supervision of assessment, the screening rate was 42%. Within 6 months, the screening rate had climbed to 60% and was sustained at that level. Major barriers to screening include difficulty in finding the opportunity to screen in privacy and overcoming language barriers. Application of Rogers' principles of diffusion of innovation in the implementation of a universal program for a domestic violence in two obstetrical care settings resulted in a screening rate of 60% which has been sustained for the first 18 months of the program.