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M W Enkin

Publications and source records attributed to M W Enkin.

32 records · Page 2Linked to original sources
PubMed1991

Obstetrical attitudes and practices before and after the Canadian Consensus Conference Statement on Cesarean Birth.

This paper describes one aspect of a research program aimed at reducing the incidence of cesarean section in Ontario for women with a previous cesarean section or a breech presentation. Using data from multiple sources--surveys of obstetricians, and hospital administrators, and hospital record statistics, the authors attempt to assess the response of obstetricians to pressure to change their practice. This pressure comes principally from the Canadian Consensus Conference Statement on Cesarean Birth, released in June 1986 and subsequently endorsed by a number of professional organizations. The Statement provides clear guidelines for the management of labour in women with previous cesarean section or a breech presentation. The findings present a number of interpretive challenges. Based on their response to hypothetical cases obstetricians are favourably disposed to considering a trial of labour for women with previous cesarean section and breech presentation. However, both their reported practices, as well as hospital statistics indicate the continued high prevalence of cesarean section, though there is a small decline in cesareans for previous cesarean section. There was no evidence that hospitals lacked appropriate facilities for a trial of labour or had unduly restricted formal policies. Furthermore, although awareness of and agreement with the Consensus Statement recommendations was high, when questioned on the actual details of the recommendations, obstetrician's recall was surprisingly low. Respondents tended to err in the direction of choosing more conservative measures than those recommended by the Statement.(ABSTRACT TRUNCATED AT 250 WORDS)

Attitude of Health Personnel↗
PubMed1990

Cesarean section in Ontario: practice patterns and responses to hypothetical cases.

A 40% random sample of Ontario's obstetricians were asked to respond to hypothetical scenarios for previous cesarean section, breech presentation and dystocia, and to describe their practice patterns. Their responses confirmed findings from other studies, which reported differences between physicians' responses to hypothetical cases and their actual practice. In this study, 18% chose a cesarean section for the hypothetical case of a patient who had previously undergone cesarean section and 2% chose a cesarean section for the hypothetical case of breech presentation. However, in practice, the obstetricians reported that they do cesarean section on 71% of their previous section patients and on 57% of their breech patients. Physicians in teaching hospitals were less likely than those in community hospitals to choose cesarean section for a woman who had previously undergone cesarean section both hypothetically and in practice. For breech presentation, no difference was found. The discrepancy between responses to the hypothetical cases and practice patterns could not be attributed to the absence of anesthesia services or to restrictive hospital policies.

Anesthesia Department, Hospital↗
PubMed1989

Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians.

Guidelines for medical practice can contribute to improved care only if they succeed in moving actual practice closer to the behaviors the guidelines recommend. To assess the effect of such guidelines, we surveyed hospitals and obstetricians in Ontario before and after the release of a widely distributed and nationally endorsed consensus statement recommending decreases in the use of cesarean sections. These surveys, along with discharge data from hospitals reflecting actual practice, revealed that most obstetricians (87 to 94 percent) were aware of the guidelines and that most (82.5 to 85 percent) agreed with them. Attitudes toward the use of cesarean section were congruent with the recommendations even before their release. One third of the hospitals and obstetricians reported changing their practice as a consequence of the guidelines, and obstetricians reported rates of cesarean section in women with a previous cesarean section that were significantly reduced, in keeping with the recommendations (from 72.2 percent to 61.1 percent; P less than 0.01). The surveys also showed, however, that knowledge of the content of the recommendations was poor (67 percent correct responses). Furthermore, data on actual practice after the publication of the guidelines showed that the rates of cesarean section were 15 to 49 percent higher than the rates reported by obstetricians, and they showed only a slight change from the previous upward trend. We conclude that guidelines for practice may predispose physicians to consider changing their behavior, but that unless there are other incentives or the removal of disincentives, guidelines may be unlikely to effect rapid change in actual practice. We believe that incentives should operate at the local level, although they may include system-wide economic changes.

Cesarean Section↗
PubMed1985

Six myths about controlled trials in perinatal medicine.

Despite a historical commitment to evaluation of the results of practice, obstetrics has missed many opportunities to assess new therapies adequately prior to their widespread use. Although randomized controlled trials are generally recognized as the best method of evaluating therapy, a number of myths about these trials have impeded both their performance and the implementation of their results. The unscientific nature of these myths is discussed, and examples from the perinatal literature are presented.

Clinical Trials as Topic↗
PubMed1983

The outcome of prolonged labor as defined by partography and the use of oxytocin: a descriptive study.

A descriptive study of 300 consecutive spontaneous labors in primigravid patients whose pregnancies were of 37 or more weeks' gestation with a singleton fetus in the vertex presentation, showed a cesarean section rate of 13%, a forceps delivery rate of 49%, and a spontaneous delivery rate of 38%. Oxytocin was used in 17% and epidural analgesia was used in 75% of the patients. The median rate for cervical dilatation for those women with spontaneous deliveries was 2 cm/hr (interquartile range = 1.5 to 3.3 cm/hr) and for those delivered with forceps, 1.2 cm/hr (interquartile range = 0.9 to 1.8 cm/hr). When labor was prolonged by 4 hours or more, the cesarean section rate rose to 34%. Oxytocin was used in only 41% of these patients. Of 23 women delivered by cesarean section for dystocia/disproportion, only nine received oxytocin. From the low incidence of low Apgar scores in all labor groups from this series, there would not appear to be a fetal advantage to earlier intervention. Although the suggestion from this study is that oxytocin administration when labor is prolonged by 4 hours will reduce the need for cesarean section, the true value of such an intervention can be tested only by a randomized controlled trial.

Adolescent↗
PubMed1981

Observations on the behavioral state of newborn infants during the first hour of life. A comparison of infants delivered by the Leboyer and conventional methods.

Minute-by-minute observations are reported on the behavioral state during the first hour of life of 18 term infants delivered by the Leboyer (L) method and 18 by the conventional (C) method. The mothers were unmedicated and only two women in each group received epidural anesthetics. All deliveries were spontaneous and the infants were healthy. The behavioural states of both groups of infants were very similar, with the infants spending approximately 60% of the first hour in the quiet-alert state (median time: L = 41.5 C = 35.0 minutes) and only 10% of the time in the irritable-crying state. ALthough there were some individual differences, both groups of infants spent the second 30 minutes of the first hour predominantly in the quiet-alert state. The clinical relevance of these observations is that the first hour of life can be used to advantage in promoting parent-infant interaction.

Adult↗
PubMed1980

A randomized clinical trial of the Leboyer approach to childbirth.

To examine the effects of the Leboyer method of delivery, we randomly assigned 56 women to either a Leboyer or a conventional delivery and used a variety of clinical and behavioral measures to assess the outcome in mother and child. No differences were noted in maternal or newborn morbidity, in infant behavior in the first hour of life, at 24 or 72 hours post partum, or at eight months of age; or in maternal perceptions of her infant and the experience of giving birth, except that eight months after delivery, mothers who had used the Leboyer method were more likely to say that the event had influenced their child's behavior (P = 0.05). Women who expected a Leboyer delivery had shorter active labors (P = 0.03), suggesting that psychologic factors (expectations) influence physical outcomes in perinatal medicine. Our results suggest that the Leboyer procedure has no advantage over a gentle, conventional delivery in influencing infant and maternal outcomes.

Behavior↗
PubMed1980

Proportion of fetal hemoglobin synthesis decreases during erythroid cell maturation.

Peripheral blood mononuclear cells from pregnant and postpartum women were cultured in vitro with erythropoietin. Burst-forming unit (BFU-E)-derived erythroid colonies composed of immature erythroblasts with low hemoglobin contents were observed by day 8 of culture. By day 12 of culture, numerous BFU-E-derived erythroid colonies with high hemoglobin contents were present. The gamma/(gamma + beta) globin synthetic ratio was approximately 12% in the early cultures and 6% in the late cultures, indicating that the proportion of fetal hemoglobin synthesis decreases during erythroid cell maturation. These studies also reveal that the capacity fof fetal hemoglobin production by peripheral blood BFU-E in vitro is not altered during pregnancy.

Cells, Cultured↗