Primary Obstetric Care Research Articles

The Fetal Alert Network: An Innovative Program of Access to Care,Surveillance, and Education for Birth Defects in Ontario

Optimal pregnancy outcomes rely on coordinated timely access to appropriate evidence-based clinical care. This is particularly true for pregnant women carrying fetuses diagnosed with birth defects. A systematic approach to prenatal care is ideal, but Ontario has traditionally lagged behind other regions in this regard. In 2004, in response to this challenge, the Fetal Alert Network (FAN) was established with funding support from the Ontario Ministry of Health and Long-Term Care. FAN is composed of five multidisciplinary regional health care teams of nurse coordinators working in close collaboration with primary obstetrical care providers, medical geneticists, specialists in maternal fetal medicine, and pediatric specialists. The teams facilitate access to subspecialists through patient triage and referral, provide outreach education, and act as local experts and change agents to improve care. A key objective is to go beyond a traditional surveillance system to the linkage of service provision with outcomes and effectiveness.FAN’s objectives are to ensure optimal health care access and delivery at all levels, to promote coordination and collaboration among providers, to provide timely and accurate information about health system utilization and clinical outcomes, and to educate patients and primary care providers about prenatal diagnosis. Program evaluation is currently underway. Preliminary analyses indicate that achievement of these objectives has resulted in seamless coordinated access to service for the targeted group of patients, as well as enhanced communication among providers; accessible education and information; and precise, accurate, and timely health care data and information.

Information on commonly asked questions about genetic evaluation and counseling for infertile couples

Information on commonly asked questions about genetic evaluation and counseling for infertile couples

The potential of midwives providing primary obstetric care to reduce perinatal deaths in a rural region

Objective: To determine the proportion of perinatal deaths that could be reduced by midwives providing primary obstetric services. Method: The study was conducted in a rural region of the Eastern Cape, South Africa. The primary obstetric and final causes of perinatal deaths and avoidable factors related to these deaths were determined in a large town and two small towns. Results: In the three towns 52 (48.6%) of the 107 avoidable factors were related to medical care while 20 (38.5%) of these had the potential to be prevented at the level of care rendered by midwives. In the large town 21 (20.6%) of 102 and in the smaller towns 15 (24.6%) of 61 perinatal deaths had potential for intervention by midwives. Conclusion: The 22.1% of perinatal deaths potentially preventable by midwives presupposes complete patient cooperation within an optimally functioning health system.

Primary care in obstetrics and gynecology resident education: a baseline survey of residents’ perceptions and experiences

Objective: To determine the perceptions and practices of American obstetrics and gynecology residents concerning primary care immediately before the institution of Residency Review Committee Special Requirements for Obstetrics and Gynecology. Methods: The Council on Resident Education in Obstetrics and Gynecology In-Service Examination in 1995, given to 4361 residents, who represented all programs in the country, included a questionnaire on whether obstetrics and gynecology was primary care and whether they planned to do primary care after residency. Primary care services were categorized by counseling and screening, as defined by the U.S. Preventive Health Services Task Force. Variables included gender, residency level (upper or lower), and type of residency (community or university based). Data were analyzed using the χ 2 text and multiple analyses of variance. Results: The response rate was 94% (4099 of 4361), representing a nationwide complement. Eighty-seven percent of the respondents believed that obstetrics and gynecology was primary care and 85% planned to practice accordingly after residency. Residents spend less than 25% of their time counseling on nongynecologic subjects and less than 25% of their time screening for nongynecologic entities, so their perception as primary care providers focused on traditional obstetric and gynecologic counseling and screening services. When assessments were made by gender, level of training, and type of residency, significant differences were found in many variables regarding counseling and screening practices. Conclusion: Our survey results suggest that most American obstetrics and gynecology residents consider obstetrics and gynecology primary care but that there were limitations in the educational venues for learning about nongynecologic primary care before the implementation of the Residency Review Committee Special Requirements. Improvement in nongynecologic primary care teaching is a reasonable expectation because residency programs have had 3 years to institute the mandated changes and provide it to residents.

Dutch midwives: relational care and birth location.

The objective of this study was to investigate whether midwives' care is influenced by their work setting, i.e. place of birth: at home or in the hospital. The design was a random sample survey, the setting was primary obstetrical care in the Netherlands. Some 150 independently practising midwives were interviewed as the subjects for the study. And variables of behaviour of midwives towards labouring women were covered by a questionnaire consisting of 19 relevant elements of that behaviour; behaviour which shapes their relational care. Results show that all midwives indicate differences in their behaviour according to the place where they provide the relational care towards the labouring woman; at home or in the hospital. However, the amount in which they indicate their functioning is affected by their work setting is not the same. The most striking findings are that midwives say to be more relaxed whilst providing care in a home situation, they take on a more informal approach and the interaction with the birthing woman is easier. Home birth is more time consuming than hospital birth: more visits and longer presence. During a home birth more activity of the expectant parents is to be expected regarding small domestic jobs than at a hospital birth. This study confirms that the location of a delivery has consequences for the professional functioning of midwives in case of home births. Their relational care is more intense and woman-centred.

Book Reviews

Book reviewed in this article: Basic Sciences for Obstetrics and Gynaecology Fifth Edition. Edited by: Tim Chard, Richard Lilford. Published by Springer Primary Care in Obstetrics and Gynaecology: A Handbook for Clinicians. Edited by: Joseph S. Sanfilippo and Roger P. Smith. Published by Springer Problems in Early Pregnancy: Advances in Diagnosis and Management. Edited by J.G. Grudsinskas and P.M.S. O'Brien. Published by RCOG Press. Critical Care Obstetrics, 3rd Edition. Edited by Steven L. Clark MD, David B. Cotton MD, Gary D.V. Hankins MD, Jeffrey P. Phelan MD. Published by Blackwell Scientific‐Publications Sports Gynaecology: Problems and Care of the Athletic Female. Edited by Michelle P. Warren, Mona M. Shangold. Published by Blackwell Science Inc Practical Procedures for the Gynaecological Oncologist. Edited by A. Peter, M. Henitx and David G. Allen. Published by Elsevier Science BV 1998 Endometrium and Endometriosis. Edited by Michael P. Diamond and Kevin G. Osteen. Published by Blackwell Science 1997 A Clinician's Guide to Menopause. Edited by Donna E. Stewart, Gail Erlick Robinson. Published by Health Press International Hysterectomy and HRT. Edited by John Studd and Linda Edwards. Published by RCOG Press The Yearbook of the Royal College of Obstetricians and Gynaecologists 1996. John Studd. Published by RCOG Press Obstetric Intensive Care. M.R. Foley, T.H. Strong. Published by Harcourt Brace & Co Australia Chromosome Abnormalities and Genetic Counselling. R.J.M. Gardner and G.R. Sutherland. Published by Oxford University Press Atlas of Gynecologic Surgery‐3rd Edition. H.A. Hirsch, O. Kaser, F.A. Lkle. Published by Georg Thieme Verlag Practical Manual of Operative Laparoscopy and Hysteroscopy. Ricardo Azziz, Ana Alvarez Murphy. Published by Springer‐Verlag GmbH & Co Kg Invasive Outpatient Procedures in Reproductive Medicine. Mark I. Evans, Mark P. Johnson and Kamran S. Moghissi. Published by MacLennan & Petty Neonatology for the MRCOG. Peter Dear and Simon Newell. Published by RCOG Press

Carpal tunnel syndrome in pregnancy: Frequency, severity, and prognosis

Objective: To determine the frequency, severity, prognosis, and patterns of carpal tunnel syndrome (CTS) in pregnancy. Design: Descriptive retrospective chart review using the Rochester Epidemiology Project medical record diagnostic indexing system to identify patients with new CTS occurring during pregnancy from 1987 to 1992 at our institution. Setting: Obstetrical practice, where two thirds of pregnant women in the county receive primary obstetrical care. Patients: Women pregnant during 1987 to 1992 who had a new diagnosis of CTS. Women with pregnancies at other dates or women who had CTS with onset before or after pregnancy were excluded. Outcome Measures: Age, underlying medical problems, gestation interval, weight gain, number of pregnancies, presenting symptoms, onset and duration of symptoms before diagnosis, trimester of CTS diagnosis, treatment and response, and results of electrophysiologic studies are described. Results: Of 10,873 pregnant patients receiving antenatal care for 14,579 pregnancies, 50 (.34%) fulfilled the inclusion criteria. Their mean age was 30.5 ± 4.0yrs. Twelve patients (24%) were primigravid. Mean weight gain was 12.1 ± 5.7kg. CTS was diagnosed most frequently during the third trimester ( n = 25, 50%). Symptom onset, when recorded, occurred with even distribution during each trimester: first, n = 11 (32%); second, n = 11 (32%); third, n = 12 (35%). For 37 patients in whom symptom duration was recorded, duration before diagnosis was 9.3 ± 9.0 weeks. Paresthesia (88%) was most often bilateral (68%), and 67% of patients had pain. The Tinel sign was present over the median nerve at the wrist in 95%. Only nine patients had nerve conduction studies performed. During pregnancy, 37 women were treated nonsurgically with wrist orthoses, steroid injections, or both. Of treated patients for whom follow-up data were available, 25 of 26 improved, and 4 of 26 required surgery. Thirteen women had no treatment during pregnancy; three underwent surgery in the postpartum period. All 7 women in whom conservative treatment failed who underwent surgery had resolution of symptoms. Conclusion: These results represent the frequency and patterns of clinically significant CTS in a large population of pregnant women. CTS severe enough to warrant treatment occurs infrequently in pregnancy and generally resolves spontaneously postpartum or responds to conservative treatment.

Primary Care in Obstetrics and Gynecology

Primary Care in Obstetrics and Gynecology

Failure to detect vertical transmission of hepatitis C virus.

To search for transmission of hepatitis C virus (HCV) from infected mothers to their infants. Prospective clinical, serologic, and molecular biologic follow-up (at least 3 months) of the infants of mothers with anti-HCV antibody. A county hospital providing primary and referral care in high-risk obstetrics (perinatology). Twenty-three mothers with anti-HCV antibody and their 24 infants. An enzyme-linked immunosorbent assay (EIA) and a four-antigen recombinant immunoblot assay (RIBA) were used to test for anti-HCV antibody; serum HCV RNA was measured in two independent laboratories by reverse transcription and polymerase chain reaction (PCR) using nested primers in the 5'-noncoding region. Infant samples were tested for HCV RNA by PCR at delivery and after 3 to 6 months of follow-up. Each sample was tested at least four times in two independent laboratories. Twenty-nine of 648 mothers (4.5%; 95% Cl, 3.0% to 6.4%) had anti-HCV antibody; these women had 30 babies. Twenty-three mothers and their 24 babies were followed at least 3 months (mean follow-up, 52 weeks). Of the 23 mothers, 21 (91%; Cl, 72% to 99%) had a reactive RIBA; one woman had an indeterminate RIBA and was positive for HCV RNA by PCR. In 16 of 23 mothers (70%; Cl, 47% to 87%), PCR yielded a positive result in both laboratories. The mean maternal alanine aminotransferase (ALT) level was 1.6 times the normal value. All the babies had anti-HCV antibody in cord-blood samples, but antibody disappeared or diminished in strength in interval samples, and no infant had evidence of active production of anti-HCV antibody. Only 1 of 24 (4%; Cl, 0.1% to 21%) cord-blood samples was HCV RNA positive, and none of 24 (0%; Cl, 0% to 14%) follow-up samples was positive for HCV RNA by PCR in either laboratory. Four mothers and one baby had antibody to HIV. Infant anti-HCV antibody is most likely acquired passively in utero, and vertical transmission of HCV is uncommon.

Organizing for Primary Care in Obstetrics

Organizing for Primary Care in Obstetrics

Problem-Orientated Antenatal Notekeeping: A Useful Primary Health Care Tool

It has recently been demonstrated that about 56 percent of patients delivering in a rural obstetric unit had significant risk factors, and that 85 percent of these could have been detected by meticulous antenatal screening before the onset of labour. These figures show that the average rural obstetric unit in South Africa is dealing with a large percentage of high risk patients. In this work, it is hampered by: 1. Communications problems: i.e. bad roads, long distances. and unpredictable telephones. 2. A serious shortage of medical staff resulting in primary obstetric care being delivered by midwives with minimal medical supervision.

Obstetric care in a family health-oriented university associated neighborhood health center.

The structure, staffing, and planning methods of the obstetric component of a family-oriented University Hospital associated family health care facility are briefly described. The interviews and screening procedures are outlined necessary to develop a broad data base for total health care planning. The roles of the members of the multiprofessional team employed are described with particular emphasis on the use of a nurse midwife as the primary obstetric care professional. Management procedures are referred to as well as the educational component present within such a program. The program is evaluated in terms of clinical outcome, patient and professional acceptance, and cost.

The Case of the New Family Physician and the Practicing Pediatrician in Delivery of Health Care for Children in Canada

The College of Family Physicians of Canada has evolved a firm philosophy of its new image. The medical school graduate of the future will enter a two-year program partly hospital-based and partly community clinic-or private office-based to develop the adequate skills necessary to render primary care in internal medicine, pediatrics, obstetrics and gynecology, psychiatry, and trauma, with a continual infusion of knowledge related to the psychosocial dynamics of family life. This new physician will require the services of the social worker, the public health nurse, the school nurse, the psychologist, the family counsellor and the psychiatrist.