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Michael C Klein

Publications and source records attributed to Michael C Klein.

At least 19 recordsLinked to original sources
PubMed2006

Epidural analgesia associated with low-dose oxytocin augmentation increases cesarean births: a critical look at the external validity of randomized trials.

OBJECTIVE: Randomized controlled trials suggest epidural analgesia (EA) does not increase the frequency of cesarean births compared with opioid analgesia. We analyzed trials comparing EA with opioid analgesia to determine their external validity in contemporary North American practice. STUDY DESIGN: Randomized controlled trials comparing EA with opioid analgesia were identified from the Cochrane database and Medline and included if they reported labor outcomes and management protocols. Labor management was then compared with current obstetric practice determined from surveys of North American teaching maternity units and clinical practice guidelines. RESULTS: Of 19 trials identified, 8 were included. Seven trials used Active Management of Labor protocols that used high-dose oxytocin; each demonstrated no epidural-related increase in cesarean births. One trial that used low-dose oxytocin demonstrated a marked increase in cesarean births. Most large North American obstetric units use low-dose oxytocin. CONCLUSION: Randomized trials showing no effect of EA on cesarean section (CS) rate lack external validity in much of North American practice. The limited data available suggest EA and low-dose oxytocin used together increase the CS rate. Early detection of dystocia and high-dose oxytocin augmentation should be considered for women receiving EA; those delivering in low-dose oxytocin settings should be advised of a probable increase in the likelihood of CS.

Analgesia, Epidural↗
PubMed2006

Why do women go along with this stuff?

PREFACE: Normal childbirth has become jeopardized by inexorably rising interventions around the world. In many countries and settings, cesarean surgery, labor induction, and epidural analgesia continue to increase beyond all precedent, and without convincing evidence that these actions result in improved outcomes (1,2). Use of electronic fetal monitoring is endemic, despite evidence of its ineffectiveness and consequences for most parturients (1,3); ultrasound examinations are too often done unnecessarily, redundantly, or for frivolous rather than indicated reasons (4); episiotomies are still routine in many settings despite clear evidence that this surgery results in more harm than good (5); and medical procedures, unphysiological positions, pubic shaving and enemas, intravenous lines, enforced fasting, drugs, and early mother-infant separation are used unnecessarily (1). Clinicians write and talk about the ideal of evidence-based obstetrics, but do not practice it consistently, if at all. Why do women go along with this stuff? In this Roundtable Discussion, Part 2, we asked some maternity care professionals and advocates to discuss this question.

Analgesia, Epidural↗
PubMed2005

A comparison of urinary and sexual outcomes in women experiencing vaginal and Caesarean births.

OBJECTIVE: To evaluate the urinary and sexual consequences of vaginal delivery compared with Caesarean section. METHODS: We performed a cohort analysis of data from a randomized controlled trial of episiotomy conducted in 3 Montreal hospitals in 1990-1991. Of the 999 trial participants for whom follow-up data were available, 135 delivered by Caesarean section (CS), and 864 had a vaginal birth (VB). After stratifying for parity, we compared rates of urinary incontinence (UI) and sexual functioning at 3 months postpartum in women who had a VB with the rates in women who had a CS. RESULTS: Primiparous women reported unspecified UI at 3 months postpartum more often (17.9%) in the VB group than in the CS group (6.4%). This difference remained significant whether or not there was a prior history of UI. Multiparous women showed no difference in rates of UI (VB 17.1% vs. CS 16.0%), whether there was a prior history of UI or not. Stress incontinence was greater among primiparous women in the VB group (VB 34.5% vs. CS 12.8%) regardless of prior UI history, but the proportion of women whose UI was severe enough to wear a pad was similar in primiparous women (VB 16.0%, CS 15.4%) and multiparous women (VB 23.8%, CS 25.0%). Women's sexual dissatisfaction was greater among primiparous women who had a vaginal birth (VB 70.1%, CS 54.5%), but in multiparous women, the rates of sexual dissatisfaction were similar (VB 64.2%, CS 71.4%). The frequency of dyspareunia for each mode of delivery was similar in primiparous women (VB 30.7%, CS 31.6%). Overall, both primiparous and multiparous women who had intact perineums after VB had less dyspareunia than those undergoing CS (VB 26.2, CS 40.7%). However, the proportion of women experiencing dyspareunia was greatest among those who had an episiotomy with or without forceps.

Adult↗
PubMed2005

Maternity care by family physicians: characteristics of successful and sustainable models.

OBJECTIVE: To provide examples of sustainable and rewarding models of maternity care that can help reduce the attrition of family practitioners from intrapartum maternity care practice. METHODS: We surveyed a cohort of family physicians providing maternity care in primary care settings, using various models, to determine how each model handled the challenges of this practice. RESULTS: Different models of care are effective; there is no single best model of family practice maternity care. Successful models provide care for a substantial volume of patients, have call schedules that are appropriate for the volume of patients and number of participating physicians, have protocols for patient management, and have flexible and compatible clinic members. CONCLUSION: Structured sign-out models of care that incorporate innovative models for funding assist many family physicians in Canada in continuing to provide maternity care. Family medicine residents must be encouraged to incorporate these models of maternity care into their future practices.

Appointments and Schedules↗
PubMed2005

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

AIMS AND OBJECTIVES: 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. BACKGROUND: 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. DESIGN: A prospective cohort design comparing self-reported competencies prior to starting work in the single-room maternity care and six months after. METHODS: 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. RESULTS: Scores on the perinatal self-efficacy scale and the single-room maternity care competency tool were improved. These differences were statistically significant. CONCLUSIONS: 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. RELEVANCE TO CLINICAL PRACTICE: An education programme tailored to the learning needs of experienced clinical nurses contributes to improvements in nursing competencies and patient care.

Adult↗
PubMed2005

Obstetric maternal outcomes at Bella Coola General Hospital: 1940 to 2001.

OBJECTIVE: To describe obstetric procedures (episiotomy, forceps, vacuum extraction, caesarean section) and maternal outcomes for patients who gave birth in an isolated, rural hospital. DESIGN: A retrospective cohort study. STUDY POPULATION: Women beyond 20 weeks' gestation who gave birth between Mar. 7, 1940, and June 9, 2001, inclusive, at the Bella Coola General Hospital (BCGH). MAIN OUTCOME MEASURES: Data collected included maternal age, date of delivery, mode of delivery (vaginal delivery v. cesarean section), whether an episiotomy was performed or not, if forceps or vacuum extraction were used, whether analgesia, sedation or anesthesia was used, and maternal mortality. RESULTS: There were 2373 deliveries, including 12 sets of twins. There were no maternal mortalities. Cesarean sections were not routinely performed until the 1970s. Since then, there has been an increase in cesarean section rates to 11% of all deliveries in the 1990s. In the 1940s 28% of deliveries involved an episiotomy. This increased to 47% in the 1970s and was followed by a sharp decline to 4% in the 1990s. There was an increase, followed by a more gradual decrease in the use of forceps, and there was a recent increase in the use of vacuum extraction. The changes in procedure rates appear to reflect best practice guidelines of the times. In the case of episiotomies, the data suggest rural physicians are capable of rapid incorporation of recent recommendations. Rates for all procedures tended to be lower than those reported elsewhere in Canada and the United States. Narcotics, sedatives, inhalation agents and regional anesthetics were used to relieve the pain of labour and delivery throughout the study period. CONCLUSIONS: Women giving birth in the low technology environment of the BCGH experienced relatively low obstetric procedural rates with excellent maternal outcomes.

Anesthesia, Obstetrical↗
PubMed2005

Perinatal outcomes at Bella Coola General Hospital: 1940 to 2001.

OBJECTIVE: To describe perinatal outcomes (mortality, weight, condition at birth) at an isolated, rural hospital. DESIGN: A retrospective cohort study. STUDY POPULATION: Neonates born to women beyond 20 weeks' gestation who delivered in the Bella Coola General Hospital (BCGH) between Mar. 7, 1940, and June 9, 2001, inclusive. MAIN OUTCOME MEASURES: Information collected from the labour and delivery case room record book includes Aboriginal status, date of delivery, birth weight, newborn mortality, and newborn condition at birth. RESULTS: There were 2373 deliveries, including 12 sets of twins. Total newborn mortality rates declined from approximately 4.7% in the 1940-1954 time period to 0.7% in the 1970-1984 time period and have remained near that level ever since. From 1940-1960 BCGH's perinatal mortality rate was higher than Canada's; it was lower than Canada's in the 1970s, higher in the 1980s and about the same for the 1990s. The condition of the vast majority (approximately 90%) of newborns was described as being "good" at birth. Approximately 5% of newborns had birth weights < 2500 g, and this has not changed much over the years. In the 1951-1962 time period Aboriginal women had a higher percentage (8%) of infants with birth weight < 2500 g compared with non-Aboriginal women (5%), but this percentage has declined over time to the point where the rate for both groups is now around 5%. CONCLUSIONS: Women giving birth in the low technology environment of the BCGH experienced acceptable neonatal outcomes. Trends in perinatal mortality, morbidity and low-birth-weight rates mirror those recorded for Canada.

Apgar Score↗
PubMed2004

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 dollars vs. 2377 dollars). 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.

Adult↗
PubMed2004

The effect of family physician timing of maternal admission on procedures in labour and maternal and infant morbidity.

OBJECTIVE: To determine if a family physician practice pattern of early admission is associated with increased rates of intervention in labour and delivery, and/or adverse maternal and newborn outcomes. METHOD: A retrospective cohort study compared women under the care of family physicians having 50% or more of their patients admitted to the labour and delivery unit "early" (defined as a cervical dilatation of < or =3 cm) to women under the care of family physicians having less than 50% of their patients admitted "early." Outcome measures included labour intervention rates and maternal and neonatal morbidity. RESULTS: After adjusting for maternal characteristics, care by family physicians with a practice of early admission was associated with increased rates of electronic fetal monitoring (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.27-1.89), epidural analgesia (OR, 1.34; 95% CI, 1.15-1.55), and Caesarean section (OR, 1.33; 95% CI, 1.00-1.65) compared to family physicians with a practice pattern of late admission. Malposition in labour was associated with more interventions in labour than was family physician practice pattern. CONCLUSION: Women under the care of family physicians with a practice pattern of early admission were more likely to receive electronic fetal monitoring, epidural analgesia, and Caesarean section than women under the care of family physicians with a practice pattern of late admission. Malposition in labour had a greater effect on procedure use than any other variable in our model.

Adult↗
PubMed2004

Guidelines for operative vaginal birth.

OBJECTIVE: To provide guidelines for operative vaginal birth in the management of the second stage of labour. OPTIONS: Non-operative techniques, episiotomy, and Caesarean section are compared to operative vaginal birth. outcome: Reduced fetal and maternal morbidity and mortality. EVIDENCE: MEDLINE and Cochrane databases were searched using the key words 'vacuum' and 'birth' as well as 'forceps' and 'birth' for literature published in English from January 1970 to June 2004. The level of evidence and quality of recommendations made are described using the Evaluation of Evidence from the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS: 1. Non-operative interventions such as one-to-one support, partogram use, oxytocin use, and delayed pushing in women using epidurals will decrease need for operative birth. (I-A) 2. Manual rotation may be used alone or in conjunction with instrumental birth with little or no increased risk to the pregnant woman or to the fetus. (III-B) 3. Routine episiotomy is not necessary for an assisted vaginal birth. (II-1E) 4. When operative intervention in the second stage of labour is required, the options, risks, and benefits of vacuum, forceps, and Caesarean section must be considered. The choice of intervention needs to be individualized, as one is not clearly safer or more effective than the other. (II-B) 5. Failure of the chosen method, vacuum and/or forceps, to achieve delivery of the fetus in a reasonable time should be considered an indication for abandonment of the method. (III-C) 6. Adequate clinical experience and appropriate training of the operator are essential to the safe performance of operative deliveries. Hospital credentialing boards should grant privileges for performing these techniques only to an appropriately trained individual who demonstrates adequate skills. (III-C). VALIDATION: The Clinical Practice Obstetrics Committee and Executive and Council of the Society of Obstetricians and Gynaecologists of Canada approved these guidelines.

Canada↗