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PubMedDate not supplied

Obstetric fistula: a preventable tragedy.

Obstetric fistula disables millions of women and girls in developing countries, primarily in sub-Saharan Africa and South Asia. The United Nations Population Fund (UNFPA) recently launched a global campaign to end fistula, labeling this condition a preventable and treatable tragedy. Obstetric fistula overwhelmingly results from obstructed labor, which occurs in cases of cephalopelvic disproportion and malpresentation. Cephalopelvic disproportion often complicates deliveries in young, primiparous women of low gynecologic age. Social factors, including young age at marriage and malnutrition of girl children, can also contribute to cephalopelvic disproportion. These social etiologies must be addressed by prevention campaigns. Direct prevention of fistula can occur during delivery when skilled providers identify women and girls at risk for obstetric fistula and link them with innovative interventions, such as Fistula Prevention Centers, through which they can more readily access emergency obstetric care, and by setting strict time limits for laboring at home without progress. Community-based programs, such as the Tostan program in West Africa, use social education to prevent fistula. Moreover, effective surgical techniques for fistula repair are available in some settings and should be expanded to reach those in need. Midwives can play a key role in the prevention and treatment of this tragic obstetric complication.

Adolescent↗
PubMed1997

Improving the quality of obstetric care at the teaching hospital, Zaria, Nigeria.

PRELIMINARY STUDIES: Research at Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria, showed delay in treating women with obstetric complications and highlighted multiple contributing factors. INTERVENTIONS: In response, a surgical theater was restored to working order, the maternity ward renovated, resident physicians trained in obstetrics and an emergency drug pack system instituted. A system of blood donation from families of women attending antenatal clinics was introduced. Later, community interventions focused on improving access and reducing delay in seeking care. RESULTS: Mean admission-to-treatment interval was reduced by 57%, from 3.7 h in 1990 to 1.6 h in 1995. The proportion of women treated in less than 30 min increased from 39% in mid-1993 to 87% in late 1995. Case fatality rate (CFR) among women with major obstetric complications fell from 14% in 1990 to 11% in 1995. The annual number of women with complications seen, however, declined from 326 in 1990 to 65 in 1995. COSTS: Cost of material improvements was approximately US$135,000, of which 65% was provided by government. An additional $8000 per year in new staff salaries was paid by the government. CONCLUSIONS: Hospital obstetric services can be improved and government can be mobilized to contribute. Treatment delay and obstetric CFR can be reduced. Deteriorating economic conditions, however, may diminish utilization of services despite improvements.

Community Networks↗
PubMed1997

Improving obstetric care at the district hospital, Ekpoma, Nigeria. The Benin PMM Team.

PRELIMINARY STUDIES: Facility reviews and focus group discussions revealed several factors at the district hospital contributing to maternal deaths in Ekpoma District, Nigeria. INTERVENTIONS: In response, the necessary equipment for the operating theater, labor suite and laboratory were repaired or purchased. A blood bank and standby generator were repaired. Drugs and consumable material were purchased and a revolving fund established. Refresher courses were held for medical officers, nursing staff and laboratory technicians. At a later stage, community interventions focused on improving access and reducing delay in seeking care. RESULTS: The number of cesarean sections performed increased from zero in 1990-1991 to between seven and 13/year in the period 1992-1995. The number of women with major obstetric complications seen at the hospital increased from seven in 1990 (5% of obstetric admissions) to a high of 29 (20% of obstetric admissions) in 1993. These gains were not sustained, however. In 1995, only 12 women with complications (9% of obstetric admissions) were seen. COSTS: The cost of improvements was approximately US $12,800, of which 41% was paid by the government and the rest by the project. CONCLUSIONS: Improving obstetric care at the district hospital can increase use by women with complications. However, sociopolitical and economic problems can hamper success.

Emergencies↗
PubMed2003

Simulation laboratories for training in obstetrics and gynecology.

Simulations have been used by the military, airline industry, and our colleagues in other medical specialties to educate, evaluate, and prepare for rare but life-threatening scenarios. Work hour limits for residents in obstetrics and gynecology and decreased patient availability for teaching of students and residents require us to think creatively and practically on how to optimize their education. Medical simulations may address scenarios in clinical practice that are considered important to know or understand. Simulations can take many forms, including computer programs, models or mannequins, virtual reality data immersion caves, and a combination of formats. The purpose of this commentary is to call attention to a potential role for medical simulation in obstetrics and gynecology. We briefly describe an example of how simulation may be incorporated into obstetric and gynecologic residency training. It is our contention that educators in obstetrics and gynecology should be aware of the potential for simulation in education. We hope this commentary will stimulate interest in the field, lead to validation studies, and improve training in and the practice of obstetrics and gynecology.

Clinical Competence↗
PubMed2006

Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries.

BACKGROUND: Reliable evidence about the effect of female genital mutilation (FGM) on obstetric outcome is scarce. This study examines the effect of different types of FGM on obstetric outcome. METHODS: 28 393 women attending for singleton delivery between November, 2001, and March, 2003, at 28 obstetric centres in Burkina Faso, Ghana, Kenya, Nigeria, Senegal, and Sudan were examined before delivery to ascertain whether or not they had undergone FGM, and were classified according to the WHO system: FGM I, removal of the prepuce or clitoris, or both; FGM II, removal of clitoris and labia minora; and FGM III, removal of part or all of the external genitalia with stitching or narrowing of the vaginal opening. Prospective information on demographic, health, and reproductive factors was gathered. Participants and their infants were followed up until maternal discharge from hospital. FINDINGS: Compared with women without FGM, the adjusted relative risks of certain obstetric complications were, in women with FGM I, II, and III, respectively: caesarean section 1.03 (95% CI 0.88-1.21), 1.29 (1.09-1.52), 1.31 (1.01-1.70); postpartum haemorrhage 1.03 (0.87-1.21), 1.21 (1.01-1.43), 1.69 (1.34-2.12); extended maternal hospital stay 1.15 (0.97-1.35), 1.51 (1.29-1.76), 1.98 (1.54-2.54); infant resuscitation 1.11 (0.95-1.28), 1.28 (1.10-1.49), 1.66 (1.31-2.10), stillbirth or early neonatal death 1.15 (0.94-1.41), 1.32 (1.08-1.62), 1.55 (1.12-2.16), and low birthweight 0.94 (0.82-1.07), 1.03 (0.89-1.18), 0.91 (0.74-1.11). Parity did not significantly affect these relative risks. FGM is estimated to lead to an extra one to two perinatal deaths per 100 deliveries. INTERPRETATION: Women with FGM are significantly more likely than those without FGM to have adverse obstetric outcomes. Risks seem to be greater with more extensive FGM.

Adult↗
PubMed1996

Obstetric care: competition or co-operation.

OBJECTIVE: The aim of this study was to determine the feasibility of co-operation within maternity and obstetric care between midwives, general practitioners (GPs) and obstetricians. DESIGN: descriptive correlational study. SETTING: The Netherlands. Policy is towards more co-operation between primary and secondary health care. However, in Dutch health care midwives, GPs and obstetricians may also have conflicts of interests. PARTICIPANTS: members of obstetric co-operation groups (91 midwives, 53 GPs, 31 obstetricians) completed a questionnaire. MEASUREMENTS AND FINDINGS: in the questionnaire information was collected on what members of obstetric co-operative groups expect from co-operation. Findings indicated that consensus existed about experienced advantages and disadvantages of co-operation, tasks that should be achieved, and how obstetric co-operative groups could be set up. Nevertheless, there was evidence of competition and there were also conflicting ideas about co-operation. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: it is concluded that the findings have implications for the organisation of an obstetric co-operative group. If professionals want to start such a group it is preferable to start with topics that benefit all participants (win-win situation) and motivate them to participate actively. A second step may be an attempt to reach agreement about how to communicate with each other in the case of referrals and consultations. During this phase mutual trust and respect may grow, so that finally more difficult problems can be discussed (mixed-motives situation).

Attitude of Health Personnel↗
PubMed2002

The gynaecological-obstetrical practice of the renaissance physician Amatus Lusitanus (Dubrovnik, 1555-1557).

OBJECTIVE: A gynaecological-obstetrical causation review in Dubrovnik from 1555 to 1557. Extract from the book "Curationum Medicinalium Centuriae V et VI" Amatus Lusitanus. METHOD: A thorough life and work archive study of Amatus Lusitanus has been made and, for this review, extracted his gynaecological-obstetrical causation observations and annotations. RESULTS: Amatus Lusitanus was an undisputed, reputable and respected medical figure during the mid 16th century. He decisively focused on intern medicine, incorporating the gynaecological-obstetrical field. His work and skill, most assuredly, contributed to the better comprehension, acknowledgement and reputation of the gynaecological-obstetrical practice, thus leaving repute and respect in medical history latitude. CONCLUSION: All these cases occurred in Dubrovnik during 1555-1557 and Amatus is assuredly an excellent observer and exactist, extracting the "relevant from the non-relevant" even in Dubrovnik's gynaecological-obstetrical daily happenings. He thoughtfully concludes his inability to remedy a malignant, advanced illness of the uterus, presumes an utero-vesico-intestinal fistula and openly speaks of medical ineptness of this causation. Proud of his invention in treating "contracted nipples"; correct in his advice and recommendations of "long and difficult births". Impartial in his perception of puerperal sepsis and its unfavourable pathology outcome. His description of "hormone insufficiency" is concise and precise; the preferred procedure in an "abortus in tractu" is purposeful and meaningful. He closely works with other physicians living and working in Dubrovnik; conscientiously directing surgeons in procedures of stillborn child births. He explains and treats pyschosexual disturbances "without fault" and in concurrence with, not only, the contemporary knowledge of such sexual disturbances, but also in concurrence with contemporary psychiatric procedures that, even today, are applied in such pathology treatment.

Croatia↗
PubMed2002

Perceived proficiency in endoscopic techniques among senior obstetrics and gynecology residents.

STUDY OBJECTIVES: To assess current training methods in laparoscopic surgery employed in United States obstetrics and gynecology residency programs, level of proficiency in various minimally invasive surgery procedures amongst senior obstetrics and gynecology residents, and ways in which training in minimally invasive surgery can be improved. DESIGN: Survey (Canadian Task Force classification III). SETTING: Accredited obstetrics and gynecology programs in the United States. SUBJECTS: All fourth-year residents in accredited obstetrics and gynecology programs in the United States. INTERVENTION: Residents received a survey regarding their perceived proficiency performing various laparoscopic procedures and the type of training they received in these techniques. MEASUREMENTS AND MAIN RESULTS: Responses were received from 133 programs (52.4%) and 295 residents (26.8%). Of these, 67% of residents thought emphasis on laparoscopic surgery training should be increased or greatly increased; 87% thought laparoscopic skills were important for building a successful practice. Formal teaching methods were clearly associated with improved perception of proficiency, and those with higher perception of proficiency expected to perform more laparoscopic procedures after graduation. Residents lacked perceived competency in most advanced laparoscopic procedures. CONCLUSION: Residents seem to benefit significantly from a formal curriculum in minimally invasive surgery, but they do not feel competent performing some advanced procedures on graduation. In our opinion, more emphasis should be placed on training in laparoscopic surgery in United States obstetrics and gynecology programs.

Curriculum↗
PubMed2004

Managing obstetrical patients during severe acute respiratory syndrome outbreak.

Severe Acute Respiratory Syndrome (SARS) is a newly described infectious disease caused by a coronavirus. Two outbreaks occurred in Toronto in the spring of 2003, resulting in the closure of 3 hospitals, including 2 obstetrical units. Strategies, devised using information about the coronavirus available at the time, as well as epidemiologic and infectious disease containment measures, were initiated to protect obstetrical patients and staff. In the first outbreak, the obstetrical unit of an affected Toronto hospital was kept open while other clinical services were closed. In the second outbreak, the obstetrical unit was closed along with all other clinical activities. This report details the stepwise processes used to make decisions during the SARS outbreaks and the implementation of the decisions made. It is recommended that these or similar protocols be used when an obstetrical unit is confronted with a large-scale nosocomial infectious outbreak that has a mechanism of transmission similar to that of SARS.

Cross Infection↗
PubMed2004

Difficult airway equipment in obstetric units in the republic of Ireland: results of a national survey.

BACKGROUND AND OBJECTIVE: Difficult intubation in obstetric units has been identified as a major contributory factor to anaesthesia related maternal morbidity and mortality. Availability of equipment for management of a difficult airway is associated with reduced maternal complications. The purpose of our survey was to describe the availability of difficult airway equipment in Irish Obstetric Units. METHODS: A telephone survey was conducted in which all respondents were asked whether they housed basic airway equipment, alternative ventilation and alternative intubation equipment within or close to their obstetric unit. RESULTS: The most important finding of this study is that all the obstetric units in Ireland hold at least one alternative device for both ventilation and intubation. The most common alternative ventilation device was the laryngeal mask airway and the most common alternative intubating device was the surgical airway device. CONCLUSIONS: Irish Obstetric Units are well equipped according to the international guidelines for difficult intubation equipment. However, we believe that this situation could be further improved by training inexperienced anaesthetists in the use of the Intubating Laryngeal Mask and by the increased use of portable trolleys.

Equipment and Supplies, Hospital↗
PubMed2002

[Obstetrics and gynecology--retrospect of 125 years in Basel].

The development of the discipline Obstetrics and Gynecology is reflected by the medical history at the University of Basel. At the very beginning of academic obstetrics, the cantonal government realised the need of a more practical teaching completing the tradition of theoretical lecturing (1865). Obstetrics was (and still is) a typical example for the turn from theoretical to hands-on-teaching in medicine. At the time, when the independent chair of obstetrics at the University of Basel was founded (1867, Bischoff [1841-1892]), the fight against puerperal fever was the most urgent aim. The battle against puerperal fever was ultimately won around the turn of the 19th to the 20th century (von Herff [1856-1916]) but not much earlier. Step by step the gynecology grew out of the classical surgery where it has been located previously. Surgically skilled obstetricians like Fehling [1847-1925] and Bumm [1868-1925] have enhanced that development. Clinical research started with better information about the lying-in patients (Fehling, Bumm, Labhardt). Bacteriology in close connection with obstetrics was seen important (Bumm). Some decades later, clinical laboratories (clinical chemistry) were founded accompanying the diagnostic approach to various disorders of pregnancy (Labhardt [1874-1949]). Exfoliative cytology became mandatory since 1950 and this was the start to screening programs for early diagnosis of cervical cancer (Koller [1899-1985]). The family planning exploded in the years from 1965 on as the pill has been available, replacing sterilisation-procedures (Labhardt). Endocrinology of pregnancy and cycle needed new biochemical methods. The laboratories were installed. Responding to the demands of a growing discipline, the building was enlarged and adapted in three major steps: 1896 new "Frauenspital", 1928 first enlargement, 1956-1968 constructing of two more storeys, of new surgical theatres and an entire tract for routine and scientific laboratories filling now the area between Klingelberg-, Schanzen- and Spitalstrasse. The hospital harboured in its peak time (1968-1970) more than 300 beds. In 1959 the hospital staff took care of 5000 deliveries (Koller). Fetal monitoring was introduced 1962, being the starting point for the development of "fetal medicine" in Basel. At that time, Otto Käser [1899-1995] was chairman. He was appreciated as one of the most brilliant pelvic surgeons in Europe. Soon, the surgery for breast cancer was added to the classical gynecologic surgery. At the same time, ultrasound started to dramatically influence diagnostic procedures in pregnancy. In the eighties, in-vitro-fertilization and embryo-transfer improved the possibilities to overcome unwanted childlessness (Ludwig [*1929]) and supplemented endocrinology. The scientific spectre spread heavily to reproductive medicine since then, in particular to the molecular biology and research on stem-cells, which was introduced by the present chairman (Holzgreve [*1955]). He has founded several research groups concentrating on the retrieval of floating fetal cells from cord and maternal blood, on other topics in fetal cell research, prenatal diagnosis and in ultrasound.

Female↗
PubMed1998

Monitoring unmet obstetric need at district level in Morocco.

Unmet obstetric need was assessed in Taounate province (Morocco) during the year 1995 by monitoring rates of major obstetric intervention for absolute maternal indications. We report results in terms of spatial distribution of the failures of the health care system to provide women with essential emergency obstetric care. An estimated 135 women with life-threatening conditions did not benefit from the obstetric interventions they required. The paper documents the effects of the monitoring process on the way the provincial team changed their way of dealing with deliveries. Assessment of unmet obstetric need in Taounate province proved feasible and affordable without external budgetary inputs. It provided the team with information on the magnitude of a previously ignored problem. The results were so dramatic as to lead the team to look for causes and solutions. These were clearly not merely technical but systemic in nature.

Female↗
PubMed2006

Obstetric anal sphincter rupture in older primiparous women: a case-control study.

OBJECTIVE: To determine if maternal age (35 years of age or older) in primiparous women is a risk factor for the development of obstetric anal sphincter rupture (OASR) and to identify obstetric factors associated with it. MATERIAL AND METHODS: This is a retrospective case-control study. The study population was made up of the 5,345 primiparous women aged 24-45 years who delivered vaginally with singleton live-born neonates during 1990-99 at the Department of Obstetrics and Gynecology, Linköping University Hospital, Sweden. As cases the 327 primiparous women aged 35-45 years at delivery were selected. For each case two primiparous controls ten years younger were selected, matched for gestational age and year of delivery, in all 654 controls. Maternal, obstetrical, and neonatal data were obtained from the delivery records. Obstetric factors for the development of OASR were assessed with multivariate logistic regression analysis. RESULTS: No significant association was found between the primiparous age category and OASR. Vacuum extraction, forceps delivery, and the head circumference of the neonate were found to be independent risk factors for OASR, while the use of mediolateral episiotomy or epidural analgesia were independent protective factors for developing OASR. CONCLUSIONS: Primiparous women, 35 years of age or older, do not seem to have a greater risk of OASR than younger primiparous women. Risk factors for OASR are instrumental vaginal delivery and the size of the neonate. Mediolateral episiotomy and epidural analgesia seem to reduce the risk for OASR.

Adult↗
PubMed2005

Maternal mortality in health institutions with emergency obstetric care facilities in Enugu State, Nigeria.

In order to assess the current level of maternal mortality in health institutions with comprehensive emergency obstetric care in Enugu State, South Eastern Nigeria, a retrospective analysis of maternal deaths for the years 1999-2003 was carried out to establish the maternal mortality ratios in the eligible health institutions. Each maternal death was studied in detail to establish the socio-demographic characteristics of the women who died; their referral sources, type of delay (if any), medical causes of death and their preventability. In-depth interviews of the service providers were carried out to throw more light on the maternal mortality situation in the state. Five out of seven eligible health institutions were studied. Within the 5-year period (1999-2003), there were 141 maternal deaths and 18,257 live births giving a maternal mortality ratio of 772 maternal deaths per 100,000. The folders of 89 out of the 141 women who died were retrieved. Of these 89 maternal deaths, 51.7% of them were unemployed, 52.4% were referred from private hospitals; type 3 delay was the commonest type of delay encountered in the care of the women. Referral delay was the main cause of delay accounting for 46.4% of all cases of type 3 delay. The leading causes of maternal deaths among the women were obstetric haemorrhage (19.1%), sepsis (18.0%), prolonged obstructed labour/ruptured uterus (16.9%) and pre-eclampsia/eclampsia (16.9%). The in-depth interviews corroborated the high maternal mortality ratio recorded and the type 3 delays in tackling obstetric emergencies. It also showed some discrepancies between reality and the health providers' perception of the magnitude of maternal mortality situation in the state. It was concluded that in health institutions in Enugu State with comprehensive emergency obstetric care facilities, the maternal mortality ratio remains high due to type 3 delays. Most of the referrals come from private hospitals, hence the need to retrain the private practitioners in emergency obstetric care.

Emergency Medical Services↗
PubMed2006

Should obstetrics and gynaecology be separate specialities? A survey of Yorkshire trainees.

A questionnaire was given to trainees attending the Yorkshire Modular training programme to determine their views on separating obstetrics and gynaecology. A total of 73 questionnaires were collected; 34% of participants were junior grade (SHO), 65% were middle grade (SpR, LAT, SSHO) and 30% of participants were male. A total of 42% of participants wanted to work in gynaecology only; 28% of participants wanted to work in obstetrics only; and only 23% wanted a combined practice. The primary reasons to prefer gynaecology was more job satisfaction than in obstetrics and better social hours of work (100%). All of the 28% of participants who wanted to work in obstetrics only, thought it is more rewarding and 100% enjoyed the challenge. In conclusion, perhaps separating obstetrics and gynaecology will make both specialties more attractive, as individuals would not be compelled to practice both. There is a possibility that this might result in better recruitment and retention in both specialities.

Adult↗
PubMed1994

Strategies for establishing a critical care obstetric service.

Critical care obstetrics is gaining increased recognition as a subspecialty of perinatal medicine. As the specialty continues to expand, many institutions may consider establishing a critical care obstetric service. However, implementing such a service is not feasible for every institution because of space limitations, budgetary constraints, lack of necessary resources, and/or a limited number of critically ill obstetric patients. This article explores strategies for examining the feasibility of establishing a critical care obstetric service, suggests methods of implementation, and offers an alternative when establishing a critical care obstetric service is not feasible.

Feasibility Studies↗
PubMedDate not supplied

Obstetrical brachial plexus palsy.

Since the days of Hippocrates, scripts have included descriptions of infants who were unable to move their arms. However, it was not until the mid-1700s that an obstetric cause for the paralysis was considered. In 1872, the term obstetrical brachial plexus palsy was coined when a correlation was made between excessive traction on the brachial plexus during delivery and the clinical finding of arm paralysis. Surgical intervention became the norm in the beginning of the 19th century and continued until 1930. Poor outcomes and spontaneous resolution of obstetrical brachial plexus palsy prompted a 40-year span of conservative treatment. By the late 1960s, advances in technology and microsurgical techniques revived interest in surgical intervention in the management of obstetrical brachial plexus palsy. This article focuses on obstetrically caused brachial plexus injury, including risk factors, clinical presentation, and treatment options and outcomes. An understanding of current medical practices and their outcomes also provides a basis on which to develop sound support strategies to help parents who face this dilemma.

Brachial Plexus Neuropathies↗
PubMed2002

Surgical strategy for improving forearm and hand function in late obstetric brachial plexus palsy.

For the purpose of treatment, obstetric brachial plexus palsy can be subdivided into two distinct phases: initial obstetric brachial plexus palsy, and late obstetric brachial plexus palsy. In the latter, nerve surgery is no longer practical, and treatment often requires palliative surgery to improve function of the shoulder, elbow, forearm, and hand. Late obstetric brachial plexus palsy in the forearm and hand includes weakness or absence of wrist or metacarpophalangeal or interphalangeal joint extension; weakness or absence of finger flexion; forearm supination, or less commonly pronation contracture; ulnar deviation of the wrist; dislocation of the radial or ulnar head; thumb instability; or sensory disturbance of the hand. Palliative reconstruction for these forearm and hand manifestations is more difficult than for the shoulder or elbow because of the lack of powerful regional muscles for transfer. This report reviews the authors' experience performing more than 100 surgical procedures in 54 patients over a 9-year period (between 1988 and 1997) with a minimum of 2 years' follow-up. Surgical treatment is highly individualized, but the optimal age for forearm and hand reconstruction is usually later than for shoulder and elbow reconstruction because of the requirement for a preoperative exercise program. Multiple procedures for forearm and hand function were often performed on any given patient. Frequently, these were done simultaneously with reconstructive procedures for improving shoulder and/or elbow function. Traditional tendon transfer techniques do not provide satisfactory reconstruction for those deformities. Many of the authors' patients required more complex techniques such as nerve transfer and functioning free-muscle transplantation to augment traditional techniques of tendon and/or bone management. Sensory disturbance of the forearm and hand in late obstetric brachial plexus palsy seems a minor problem and further sensory reconstruction is unnecessary.

Adolescent↗