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PubMed2001

Gynecology and obstetrical conditions requiring intensive care admission.

OBJECTIVE: Gynecological admissions to the surgical intensive care unit vary from the obstetrical cases. Pregnant women are of prime age and can tolerate the pregnancy and delivery well. There are certain rare conditions or complications, which make the pregnant women's life pass through a critical time. These are dealt with in a high dependency area, which is short of the intensive care unit. In King Khalid University Hospital there is no such arrangement, so the mildly affected and critically ill patients together are cared for in the surgical intensive care unit. The objective of this study is to study the gynecological and obstetrical conditions requiring intensive care admission in King Khalid University Hospital, surgical intensive care unit. METHODS: All obstetrical and gynecological patients who were admitted to the surgical intensive care unit were included. The demographic particulars, reason for admission, the course of the surgical intensive care unit stay and outcome were studied. RESULTS: During the study period of 3 years, there were 83, (100%) obstetrical and gynecological admissions to the surgical intensive care unit. Two (2%) cases were due to anesthesia complications. The majority of causes of admissions were due to obstetrical (n=63, 76%) complications or combination of medical and surgical conditions. Gynecological admissions comprised only 18 (22%) cases. There was no mortality in the group studied. CONCLUSION: Management of major obstetrical emergencies and gynaecological patients require an understanding of medical conditions' influence on the patients, and the physiological changes of normal and abnormal pregnancies. Intensive care unit management is an essential part in raising the level of patient care; health personnel training and continuing health care education may be improved.

Adult↗
PubMed2002

[Ultrasonography in primary health care--experiences within obstetrics 1983-99].

BACKGROUND: In 1983 ultrasound for obstetric purposes was introduced in a rural general practice in south-eastern Norway. We wanted to evaluate its systematic use in terms of pregnancy management and birth outcome. MATERIAL AND METHODS: Four sets of data were analysed: All obstetric ultrasound examinations done at the Sel Municipality Health Centre from 1 January 1998 to 28 February 1999; the database at the county hospital covering all obstetric patients and births in its catchment area, including those from the Sel community; all Medical Birth Registry reports on women from Sel from 1983 to 2000; a local register of pregnancy management and events in Sel from 1983 to 2000, organised by the local general practitioner. RESULTS: We found no difference in the accuracy of assessment of date of birth between the general practitioner in Sel and the Lillehammer outpatient obstetric department. The average number of ultrasound scans of individual women was also the same. Obstetric ultrasound in general practice successfully selected out patients who could be managed locally and those who needed referral. INTERPRETATION: Our results indicate true benefits and no definite hazards of obstetric ultrasound in rural general practice. As we have evaluated only one single practice, these results should be confirmed or negated in future studies.

Databases, Factual↗
PubMed2003

[Use of antibiotics in prevention and therapy in obstetrics and gynaecologic surgery].

BACKGROUND: The antibiotic treatments employed in 1999 in cases of gynaecologic and obstetric surgery in the first clinic of the Gynaecology and Obstetrics Department of the University of Turin have been evaluated. METHODS: 1131 gynaecological operations (major interventions, minor interventions, laparoscopies) and 492 laparotomic operations in obstetrics (mostly Cesareans) were assessed. Modalities of administration of chemoantibiotics (CAB) both at the prophylaxis stage and during the therapy stage were evaluated. RESULTS: A great application of chemoantibiotic prophylaxis (CABP) was noted as regards the gynaecological interventions (57.4% of cases) and low resort to chemoantibiotic therapy (CABT) (9%), thus highlighting the effectiveness of prophylaxis in reducing the incidence of infectious complications in the postoperative course in gynaecological surgery. As for obstetrics, the low percentage resort to CABP (36%) and the high resort to CABT (26%) were noted. It is proposed to obviate this fact by increasing the number of cases of CABP for obstetrics so as to reduce the massive recourse to CABT. CONCLUSIONS: Finally, some pharmacoeconomic remarks are offered regarding the rationalisation of the use of CABs in hospital surgical obstetrics and gynaecology.

Antibiotic Prophylaxis↗
PubMed1992

Obstetric care and cesarean birth rates: a program to monitor quality of care.

OBJECTIVE: To study the quality of obstetric care in relation to rising cesarean rates, a Task Force was formed in New York state by the Department of Health and ACOG District II. The Task Force also included the Organization of Obstetric, Gynecologic, and Neonatal Nurses and the Hospital Association of New York State. The goals were to enhance hospitals' in-house review processes, standardize terminology, and improve the quality of care. A premise of the program was that if quality of care improved, cesarean rates would fall. METHODS: A Dictionary of Terms was developed to standardize clinical and diagnostic terminology. A two-tiered review process was instituted, using internal and external hospital reviews. A format for in-house review of obstetric care was developed and recommended to hospitals. External reviews were conducted at 24 hospitals during 1989-1990. Review teams, composed of obstetrician-gynecologists and obstetric nurses in active obstetric practice, assessed obstetric facilities, staffing, medical care, and the in-house review process. Contacts continued with the hospitals after site visits to follow up on implementation of recommendations. General recommendations to improve care, based on the overall program experience, were distributed to hospitals and physicians as part of educational efforts to improve quality of care. RESULTS: The state cesarean rate reversed. Statistics for 1989 and 1990 showed a stronger downward trend in reviewed hospitals than in non-reviewed hospitals. A survey of reviewed hospitals reported a positive response to the review process. CONCLUSION: A successful quality assurance program can be jointly developed by a state regulatory agency and a medical specialty society.

Cesarean Section↗
PubMed2005

Knowledge and perception of obstetric analgesia among prospective parturients at the Lagos University Teaching Hospital.

BACKGROUND: Natural labour is painful. Such pain has little value and is potentially harmful to the parturient and foetus. OBJECTIVE: To assess knowledge, perceptions and acceptance of obstetric analgesia among prospective parturients. The effect of age, educational status and parity on the above variables was evaluated. DESIGN AND SETTING: Prospective cross-sectional study between October 2002 and April 2003 at the Lagos University Teaching Hospital (LUTH). PATIENTS AND METHODS: Patients attending ante-natal clinics voluntarily responded to a structured questionnaire which enquired patient's age, educational status and parity; knowledge, perceptions and acceptance of obstetric analgesia. The association between the variables was determined with the Pearson's Chi square test. RESULT: Four hundred and fifty patients of varying educational levels were studied. Only 175 (38.9%) knew of obstetric analgesia. There was a significant association between educational status and knowledge of obstetric analgesia (p = 0.000). Two hundred and ninety four patients (65.3%) would accept analgesia during labour of which 179 (60.9%) would leave the choice to the doctor to give them the "best available". There was no association between age, educational status and parity with acceptance (p > 0.05). Reasons for rejection included labour being a 'natural process' in 15.1%, faith in divine intervention 6.0% and concerns about side effects 3.1%. CONCLUSION: This study has revealed a dearth of knowledge and gross misconception about obstetric analgesia. With proper education, many patients will accept some form of analgesia during labour. There is an urgent need to commence standard obstetric analgesia services in our tertiary hospitals.

Adolescent↗
PubMed1977

Post-operative wound sepsis following obstetrical and gynaecological laparotomies in Nigeria.

The results of a prospective survey of post-operative wound sepsis following obstetrical and gynaecological laparotomies at the University College Hospital, Ibadan, Nigeria are presented. The overall wound sepsis rate was 20.2 per cent, but the corresponding rates in the gynaecological, primary obstetrical and repeat obstetrical cases were 14.9 per cent, 7.0 per cent and 29.9 per cent respectively. Statistical tests indicate that these rates differ significantly. The rate among the gynaecological cases did not differ significantly from the primary obstetrical cases, but that of the repeat obstetrical cases was significantly higher than those of the other two groups. The poorer wound healing in the repeat obstetrical laparotomies is thought to be due to poor blood supply. The variables that correlated significantly with wound sepsis rate were: pre-operative anaemia, number of medical students in theatre, antibiotic chemoprophylaxis and excision of previous scar in repeat laparotomies. The commonest organism involved in the wound sepsis was staph pyogenes. The wound sepsis rate obtained in this survey was high and various preventive measures are discussed.

Abdomen↗
PubMed1996

[Estimation of need for obstetrical interventions in Morocco. An approach based on the spatial analysis of deficits].

One of the indicators of health system effectiveness with regard to maternal health is the maternal mortality ratio. Measuring this ratio in developing countries is, however, not an easy task since reliable information on mortality is rarely available. An alternative to the maternal mortality ratio measurement, as an indicator of effectiveness, is the assessment of the coverage of obstetrical intervention needs. The authors chose to restrict the notion of "needs" to the obstetrical interventions carried out in order to save a mother's life. Using data from a survey by the Ministry of Health of the Moroccan Kingdom on all the obstetrical interventions carried out in 1989, obstetrical intervention rates for "absolute maternal indications" are analysed according to the mother's origin, by province and urban/rural environment. The spatial analysis of these rates showed large variations in each of the environments (0 to 2.14 % of the expected births in urban areas and 0 to 1.25 % in rural areas) and a significative difference between the rural and urban distributions (median 0.80 % in urban areas versus 0.30 % in rural areas). Applying a reference rate of 1 %, deficits between the expected numbers of needed obstetrical interventions and the observed numbers were calculated for every province in both urban and rural areas. In the whole of Morocco, intervention rates are markedly below what is expected. The spatial analysis of the deficits helps to identify the provinces where the problem is the most prominent in terms of numbers of women whose intervention needs have to be covered. The authors discuss the validity of the reference rate and suggest several strategies to solve the problem. They conclude that the deficits map is a useful tool to decide on priorities for planning and monitoring of strategies to be implemented. The spatial analysis of obstetrical intervention deficits seems to be an instrument both cheaper and more relevant than a maternal mortality estimates survey.

Developing Countries↗
PubMed1998

Does successful completion of the Perinatal Education Programme result in improved obstetric practice?

OBJECTIVE: To determine whether successful completion of the Perinatal Education Programme (PEP) improves obstetric practice. METHOD: The three midwife obstetric units (MOUs) in a health district of Mpumalanga were included in the study. Two MOUs enrolled in the PEP and the third did not. A 'before-and-after' study design was used to assess any changes in practice, and to monitor whether any changes occurred in the district during the time of the study; data were also collected at the third MOU. Data were collected by scoring of the obstetric files after the patient had delivered. OUTCOME MEASURES: We ascertained whether the obstetric history, syphilis testing, blood group testing, haemoglobin measurement and uterine growth assessment were performed during antenatal care along with whether appropriate action was taken. For intrapartum care, estimation of fetal weight, the performance of pelvimetry, blood pressure monitoring, urine testing, evaluation of head above pelvis, fetal heart rate monitoring, monitoring of contractions and plotting of cervical dilatation, and whether the appropriate actions were taken, were assessed. RESULTS: Eight of the 13 midwives at the two MOUs completed the PEP and all demonstrated an improvement in knowledge. Case notes of 303 patients from the various clinics were studied. There was no change in the referral patterns of any of the clinics during the study period. The obstetric history was well documented, but in no group was there a satisfactory response to a detected problem; appropriate action was taken in between 0% and 12% of cases. Syphilis testing was performed in 56-82% of cases, with no difference between the groups. The haemoglobin level was measured in only 4-15% of patients, with no difference before or after completion of the PEP. Where a problem in uterine growth was detected, an appropriate response occurred in 0-8% of patients and no difference before or after completion of the PEP was ascertained. In all groups, estimation of fetal weight and pelvimetry were seldom performed, the urine and fetal heart rate documentation were moderately well done and the blood pressure monitoring, assessment of head above pelvis, monitoring of contractions and plotting of cervical dilatation were usually performed. No differences before or after the PEP were detected. Where problems were detected, appropriate actions taken during labour improved, but not significantly. CONCLUSION: Completion of the obstetric manual of the PEP improved the knowledge of the midwives but no alteration in practice was detected.

Africa↗
PubMed2002

[Obstetric analgesia and anesthesia in Switzerland in 1999].

QUESTION: This survey investigated the common practice of obstetric analgesia and anaesthesia in Swiss hospitals and evaluated the influence of the Swiss interest group for obstetric anaesthesia. METHODS: In March 1999 we submitted 145 questionnaires to all Swiss hospitals providing an obstetric service. RESULTS: The rate of epidural analgesia (EA) was higher in large hospitals (> 1,000 births/year) than in small services. EA was maintained by continuous infusion techniques in 53% of the responding hospitals. For elective caesarean section, spinal anaesthesia (SA) and EA were performed in 77% and 16% of the patients, respectively. General anaesthesia (5%) was only used in small hospitals (< 500 births/year). Emergency caesarean section was performed under SA in 75% of all hospitals and only in 25% was a general anaesthesia used. An already existing EA for labour analgesia was continued for anaesthesia for caesarean section in 63% of Swiss hospitals. CONCLUSIONS: Regional anaesthesia was most commonly used for obstetric anaesthesia in Swiss hospitals. Epidemiological studies, recommendations of the Swiss interest group for obstetric anaesthesia, as well as the expectations of pregnant women, increased the numbers of regional anaesthesia compared with the first survey in 1992.

Adult↗
PubMed1985

Survey of obstetric forceps training in North America in 1981.

In April, 1983, a questionnaire was sent to all 144 United States and Canadian members of the Association of Professors of Gynecology and Obstetrics to survey residency training and current use of obstetric forceps in 1981. One hundred five programs (73%), responsible for at least 283,000 births in 1981, were subsequently analyzed. All training programs used outlet forceps and all programs but one used midforceps for delivery. Hospitals with high cesarean birth rates did not perform significantly fewer midforceps operations. Hospitals with high midforceps rates did not also have high outlet forceps rates nor did these high rates closely reflect the personal attitude to obstetric forceps of the director of the obstetric training program. Simpson's forceps were most commonly used for outlet forceps and occipitoanterior midforceps operations, whereas Kielland's forceps were selected by 76% of programs for rotational midcavity deliveries. Staff obstetricians were the primary instructors of forceps technique in the delivery room in only 50% of United States programs; all Canadian respondents reported the staff obstetrician as the principal educator in obstetric residency forceps training.

Attitude of Health Personnel↗
PubMed2006

Simulation training in the obstetrics and gynecology clerkship.

OBJECTIVE: The purpose of this study was to determine the effectiveness of obstetrics simulator training for medical students by comparing measures of confidence in normal obstetrics skills of students with and without training. STUDY DESIGN: After a lecture on normal labor and delivery, 33 third-year students practiced their skills either on an obstetrics simulator (n = 17) or received no further formal instruction (n = 16). All students were asked to respond to surveys of their experience and confidence in performing obstetrics procedures. RESULTS: Students who practiced deliveries on the simulator were more likely to believe that they could perform most portions of a vaginal delivery with minimal supervision or independently than were students who did not receive simulator experience. Fifteen students (88%) who received simulator experience felt that they were ready to attempt a vaginal delivery independently or with minimal supervision compared with 2 students (12.5%) who received a lecture only (P < .001). CONCLUSION: Students who practiced deliveries on an obstetrics simulator report higher levels of confidence in their skills to perform vaginal deliveries.

Clinical Clerkship↗
PubMed2004

Complicated deliveries, critical care and quality in emergency obstetric care in Northern Tanzania.

Our objective was to determine the availability and quality of obstetric care to improve resource allocation in northern Tanzania. We surveyed all facilities providing delivery services (n=129) in six districts in northern Tanzania using the UN Guidelines for monitoring emergency obstetric care (EmOC). The three last questions in this audit outline are examined: Are the right women (those with obstetric complications) using emergency obstetric care facilities (Met Need)? Are sufficient quantities of critical services being provided (cesarean section rate (CSR))? Is the quality of the services adequate (case fatality rate (CFR))? Complications are calculated using Plan 3 of the UN Guidelines to assess the value of routine data for EmOC indicator monitoring. Nearly 60% of the expected complicated deliveries in the study population were conducted at EmOC qualified health facilities. 81.2% of the expected complicated deliveries are conducted in any facility (including facilities not qualifying as EmOC facilities). There is an inadequate level of critical services provided (CSR 4.6). Voluntary agencies provide most of these services in rural settings. All indicators show large variations with the setting (urban/rural location, level and ownership of facilities). Finally, there is large variation in the CFR with only one facility meeting the minimum accepted level. Utilization and quality of critical obstetric services at lower levels and in rural districts must be improved. The potential for improving the resource allocation within lower levels of the health care system is discussed. Given the small number of qualified facilities yet relatively high Met Need, we argue that it is neither the mothers' ignorance nor their lack of ability to get to a facility that is the main barrier to receiving quality care when needed, but rather the lack of quality care at the facility. Little can be concluded using the CFR to describe the quality of services provided.

Critical Care↗
PubMed2004

Admission pattern and outcome in critical care obstetric patients.

We undertook a six-year retrospective study to determine the pattern of admission and outcome for obstetric patients admitted to the intensive care unit of the University of Nigeria Teaching Hospital, Enugu. The hospital records (case notes and intensive care unit records) were used to extract the necessary data. A total of 816 patients were admitted to the intensive care unit during the period under review. Eighteen (2.2%) were obstetric patients. Nine (50%) were preeclamptic and eclamptic patients. Four patients (22.2%) had obstetric haemorrhage. Five others presented with the following: asthma, postoperative respiratory distress, cervical incompetence, gestational diabetes and hypertension, and caesarean section for terminal carcinoma of the breast. There were six deaths (mortality rate 33.3%). Preeclampsia/eclampsia accounted for four deaths (44% mortality rate amongst preeclamptics/eclamptics), while two deaths accounted for a 50% mortality rate in the obstetric haemorrhage group. This study confirmed similar reports from the advanced nations and Asia that preeclampsia/eclampsia and obstetric haemorrhage are the leading causes of admission to the intensive care unit. The mortality rate in this study is however higher.

Adolescent↗
PubMedDate not supplied

Effectiveness of lifesaving skills training and improving institutional emergency obstetric care readiness in Lam Dong, Vietnam.

Essential obstetric care is promoted as the prime strategy to save women's lives in developing countries. We measured the effect of improving lifesaving skills (LSS) capacity in Vietnam, a country in which most women deliver in health facilities. A quasi-experimental study was implemented to assess the impact of LSS training and readiness (availability of essential obstetric equipment, supplies, and medication) on the diagnosis of life-threatening obstetric conditions and appropriate management of labor and birth. The intervention (LSS training and readiness) was provided to all clinics and hospitals from 1 of 3 demographically similar districts in southcentral Vietnam, to hospitals only in another district, with the third district serving as the comparison group. Detection of life-threatening obstetric conditions increased in both experimental clinics and hospitals, but the intervention only improved the management of these conditions in hospitals. Management of life-threatening obstetric conditions is most effective in hospitals. The intervention did not clearly benefit women delivering in clinics.

Adolescent↗
PubMed2000

Equipment for the difficult airway in obstetric units in Germany.

STUDY OBJECTIVE: To examine the availability of specialized equipment for the difficult airway management in obstetric units of German departments of anesthesiology. DESIGN AND SETTING: An anonymous questionnaire survey was mailed to the directors of 993 German departments of anesthesiology. Completed replies were grouped by number of deliveries performed each year. MAIN RESULTS: 55.5% of the hospitals responded. Data of 449 answers were evaluated for this investigation. A difficult airway cart was available in 99.3% of the departments. More detailed investigation revealed that different shaped laryngoscope blades (74.9% of the departments), laryngeal masks (91.0%), a fiberoptic bronchoscope (85.9%), and transtracheal puncture devices (59.9%) were available in the majority of the units. However, only a minority of the departments had these devices directly available in their obstetric operating rooms (OR; laryngeal masks 36.2%, fiberoptic bronchoscope 23.9%, transtracheal puncture set 22.0%). Larger units with more than 1,000 deliveries per year provided their equipment more often directly in the obstetric OR or the facility housing the obstetric unit than did smaller units with less than 1,000 deliveries per year (p< 0.001). CONCLUSIONS: The survey of German departments of anesthesia revealed that specialized equipment for the difficult airway management often is not directly available in the obstetric OR. Anesthesiologists must familiarize themselves as to which difficult airway equipment is available in their unit and where it is stored.

Anesthesia Department, Hospital↗
PubMed2005

Are most patients on the labour floor in active labour? A descriptive study of a Canadian obstetrical unit.

INTRODUCTION: In its guideline on intrapartum fetal surveillance, the Society of Obstetricians and Gynaecologists of Canada (SOGC) recommended the availability of 1:1 nursing care (1 nurse to 1 patient) for women in active labour. The common perception is that the majority of women in labour and delivery units are in active labour. Identifying the proportion of women in active labour versus those who are not in active labour is crucial for the allocation of nursing care resources. OBJECTIVES: We sought to obtain a quantitative description of our obstetrical population to determine the distribution of women in the labour and delivery (L&D) unit, the obstetrical triage unit, and the labour, delivery, recovery, and postpartum (LDRP) unit and to determine the proportion of women in active labour who were receiving 1:1 nursing care. METHODS: We randomly sampled and surveyed nursing care activities and patient distribution in a 1-hour period each day over a period of 4 months; each hour of the day was assessed on 5 separate occasions. The 3 units (L&D, LDRP, and obstetrical triage) were surveyed simultaneously. RESULTS: In the L&D unit, 31% of women were in active labour; of those, 92% received 1:1 nursing care. The remaining women (69%) were either in the early phase of labour, had significant obstetrical complications, were undergoing Caesarean section, or had just delivered. In the LDRP unit, 13% of women were in active labour, and 87% were postpartum. Almost one-half the women (45%) in the obstetrical triage unit were being assessed for possible labour or possible rupture of membranes, while the remainder were being assessed for other pregnancy-related problems. CONCLUSION: Contrary to common perception, the majority of women in the L&D unit were admitted for reasons other than active labour but required care in that unit. The concept of providing 1:1 nursing care solely to women in active labour would leave the labour units understaffed. We recommend that institutions use a more precise classification system, rather than the presence or absence of labour, to determine individual patient risk and the appropriate nursing resource requirements.

Cesarean Section↗
PubMed1999

Current obstetrical practice and umbilical cord prolapse.

The aim of this study was to assess the contribution of current obstetrical practice to the occurrence and complications of umbilical cord prolapse. Maternal and neonatal charts of 87 pregnancies complicated by true umbilical cord prolapse during a 5-year period were reviewed. Twin gestation and noncephalic presentations were common features (14 and 41%, respectively). Eighty-nine percent (77) of infants were delivered by cesarean section of which 29% were classical and 88% were primary. The mean gestational age at delivery was 34.0 +/- 6.0 weeks, and the mean birth weight was 2318 +/- 1159 g. Obstetrical intervention preceded 41 (47%) cases (the obstetrical intervention group): amniotomy (9), scalp electrode application (4), intrauterine pressure catheter insertion (6), attempted external cephalic version (7), expectant management of preterm premature rupture of membranes (14), manual rotation of the fetal head (1), and amnioreduction (1). There were 11 perinatal deaths. Thirty-three percent of the infants (32) had a 5-min Apgar score < 7 and 34% had a cord pH < 7.20. Neonatal seizures, intracerebral hemorrhage, necrotizing enterocolitis, hyaline membrane disease, persistent fetal circulation, sepsis, assisted ventilation, and perinatal mortality were comparable in the "obstetrical intervention" and "no-intervention" groups. Most of the neonatal complications occurred in infants < 32 weeks' gestation. We conclude that obstetrical intervention contributes to 47% of umbilical cord prolapse cases; however, it does not increase the associated perinatal morbidity and mortality.

Cesarean Section↗
PubMed1978

Obstetric anesthesia.

In this article, we have presented an overview of obstetric analgesia and anesthesia. If one central theme could be developed, it shoud be that analgesia either for labor and delivery or cesarean section must be chosen and performed with absolute exactness and safety. There is no margin for error. The ultimate goal should be delivery of obstetric anesthesia in such a way that the best qualified professional is responsible for establishing the services in the hospital. Such service must provide contiguous around-the-clock coverage for tertiary hospital centers. On the one hand, most anesthesiologists are not well suited to many of the special demands of the obstetric suite, and, on the other hand, many obstetricians lack the full understanding and capabilities that the anesthesiologists possess. One solution for this dilemma might be to encourage obstetric colleagues to seek anesthesia training in order to organize obstetric anesthesia coverage.

Analgesia↗