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PubMed2006

Audit of severe maternal morbidity in Uganda--implications for quality of obstetric care.

BACKGROUND: For every maternal death, there are probably 100 or more morbidities, but the quality of health care for these women who survive has rarely been an issue. The purpose of this study is to explore audit of severe obstetric morbidity and the concept of near miss in four referral hospitals in Uganda. METHODS: This was an exploratory systematic enquiry into the care of a subset of women with severe morbidity designated as near miss cases by organ failure or dysfunction. Patient factors and environmental factors were also explored. Data were abstracted from clinical records and from interviews with patients, relatives, and health workers. RESULTS: Records of 685 women with severe maternal morbidity were examined and 229 cases fulfilled the criteria for near miss cases. Obstetric hemorrhage, rupture of the uterus, puerperal sepsis, and abortion complications were the major conditions leading to the near miss state in more than three quarters of the patients. Nearly half the cases were at home when the events occurred. More than half the cases delayed to seek care, because the patients were unwilling, or relatives were not helpful. Similar proportion also experienced substandard care in the hospitals. CONCLUSIONS: A systemic analysis found substandard care and records, and patient-related factors in more than half the cases of severe maternal morbidity. Audit of near miss cases might offer a non-threatening stimulus for improving the quality of obstetric care.

Adolescent↗
PubMedDate not supplied

The new obstetrics: strategic implications for hospitals.

In brief, Obstetrics, like many other medical specialties, is experiencing the convergence of a number of diverse medical, social and economic trends. As a result there is increasingly intense turmoil in how these services are clinically delivered and in how they are managed--with a profound shift from basically inpatient, institutional care to outpatient care. Hospital executives must be alert to these changes if they expect their clinics and inpatient facilities to remain competitive and to deliver the best possible care under a rapidly changing set of expectations. If executives fail to recognize these pressures and thereby fail to create timely strategic reactions, their organizations may subsequently experience poor long run performance. The issue in obstetrics is not merely one of determining how best to manage obstetrics-related clinics, programs or departments; although this is a significant hospital management problem, it is important to recognize the changes and prevalent patterns, and to begin devising responsive management strategies. See strategies below.

Ambulatory Care↗
PubMed1991

At the water's edge: where obstetrics and anesthesia meet.

Conflict exists between satisfying the parturient's desire for oral intake and traditional restrictive standards of obstetric and anesthesia departments. Surveys of institutions providing obstetric services reveal greatly varying oral intake policy. There is neither evidence of benefit in withholding fluids nor evidence of risk in allowing them. Prolonged fasting has potential liabilities. Maternal mortality is rare, and anesthesia-related causes are not among the common etiologies. Aspiration is not a significant factor in the modern era. Higher risk for anesthesia morbidity is associated with general anesthesia, particularly difficult intubation. Instead of implicating oral intake as a risk factor for pulmonary aspiration, the literature consistently emphasizes the critical role of properly trained and dedicated obstetric anesthesia personnel. Unless parturients are not candidates for regional anesthesia, a nonparticulate diet should be allowed. Liberal use of regional anesthesia as well as antacid prophylaxis is recommended.

Anesthesia, Obstetrical↗
PubMed2006

Adverse events detected by clinical surveillance on an obstetric service.

OBJECTIVE: Adverse events are adverse patient outcomes resulting from medical care. We performed this study to estimate the rate of adverse events and potential adverse events-errors that have a high likelihood of causing patient harm-occurring during obstetric care. METHODS: This was a prospective cohort study of an obstetric unit in a teaching hospital. We included patients admitted consecutively to the hospital. A trained observer monitored patients for 72 triggers, which were predefined occurrences deemed likely to indicate an actual or potential adverse event. When a trigger occurred, the observer captured information describing it. A five-person multidisciplinary team, including the observer, three physicians, and a hospital risk manager, judged whether the trigger represented an adverse event or potential adverse event. Adverse events were further characterized as preventable. RESULTS: The cohort included 425 patients; 47% were in active labor. We identified 110 triggers. Nine were considered adverse events (risk 2%, 95% confidence interval [CI] 1-4%, rate 0.8 events per 100 patient days), and six were preventable (risk 1%, 95% CI 0-3%, rate 0.5 events per 100 patient days). The remaining triggers included 14 potential adverse events (risk 3%, 95% CI 2-5%, rate 1.3 events per 100 patient days). No adverse event resulted in permanent disability or death. Adverse events and potential adverse events were most commonly "system" problems, such as unavailable staff or operating rooms, or poor fetal outcomes, such as trauma to the newborn. CONCLUSION: Serious adverse events occur infrequently on an obstetric service. However, important quality problems are common and should be targeted for improvement. LEVEL OF EVIDENCE: II-2.

Adult↗
PubMed2005

Obstetric ectoscopy: an eye-opener for hospital-based clinicians.

Obstetricians show a disproportionately small or even insignificant interest in alarming maternal mortality and maternal ill health in underserved and impoverished countries. We keep silent or are indifferent in areas of our expertise instead of reminding politicians of the "scandal of our time", the maternal mortality. The historical roots of this fallacy is discussed. An outward-looking attitude ("ectoscopy") is needed in undergraduate and postgraduate training in obstetrics and gynecology, incorporating skills in auditing various aspects of quality care in community obstetrics. Programming to reduce maternal and perinatal ill-health should be given emphasis in specialist training in obstetrics and gynecology.

Attitude of Health Personnel↗
PubMed1988

Survey of the practice of epidural analgesia in a regional sample of obstetric units.

An investigation into practices of the epidural services in a regional sample of obstetric units was undertaken following recent reported disasters associated with epidural analgesia for labour pain. A questionnaire was completed by all 22 obstetric units in the region, which included six teaching, 14 district and two independent centres. In three units the epidural service was shared with the obstetricians. A continuous anaesthetic presence was provided in 16 of 22 units. There was considerable variation in the attendance upon epidural patients by the anaesthetists. Instructions to midwives for top-ups and subsequent care of patients followed no uniform pattern. Midwife in-service training in the initial management of serious epidural complications and in cardiopulmonary resuscitation was inconsistent. In some units, the avoidance of aortocaval compression was not emphasised in the management of serious complications such as severe maternal hypotension, total spinal blockade or cardiac arrest of the parturient. The results obtained in this survey suggest that there is a need to review the requirements in the provision of obstetric epidural services and consideration should be given to the establishment of a generally accepted standard of practice.

Anesthesia, Epidural↗
PubMed1992

Use of adrenaline in obstetric analgesia.

A questionnaire on the use of adrenaline in obstetric analgesia was completed by 87 obstetric anaesthetists: 71% of consultants in teaching hospitals were prepared to use adrenaline mixed with local anaesthetics compared with 33% of consultants in district hospitals; they had a similar duration of obstetric anaesthetic experience. Test doses containing adrenaline were not commonly used in labour, but were more often used prior to elective Caesarean section. Adrenaline was used with either lignocaine or bupivacaine; few consultants used both solutions. Contraindications to the use of adrenaline in the nonuser group were in decreasing order of rank: neurological damage, pregnancy-induced hypertension, stenotic valvular heart disease, sickle cell disease or trait of fetal distress. Overall, the contraindications related to the systemic absorption of adrenaline were most common.

Analgesia, Obstetrical↗
PubMed2005

Are rural adolescents necessarily at risk of poorer obstetric and birth outcomes?

OBJECTIVE: The purpose of the present study were to describe the sociodemographic and clinical characteristics of adolescent women giving birth at Wagga Wagga Base Hospital, and compare these with those with all adolescents in New South Wales. DESIGN: An investigative approach. MAIN OUTCOME MEASURES: Obstetric complications, delivery intervention and adverse infant outcomes. SETTING: Wagga Wagga Base Hospital. PARTICIPANTS: One hundred and sixteen adolescents aged 15-19 years. RESULTS: In relation to obstetric complications and infants with complications, the study sample was found to be representative of New South Wales adolescents. However, for type of delivery there was a higher rate of forceps delivery (12.3% (15) vs 4.7% (415) P = 0.0001), forceps rotation (4.1% (5) vs 0.9% (80) P = 0.004) and fewer normal vaginal deliveries (67.2% (82) vs 80.8% (7108) P = 0.006) at Wagga Wagga Base Hospital. CONCLUSION: These findings suggest that rural adolescents are at risk of delivery complications and are less likely to have a normal vaginal delivery. More research is required into obstetric and birth outcomes for the rural adolescent population.

Adolescent↗
PubMed1993

A national survey to assess current use of computerised information systems in obstetrics.

OBJECTIVE: To ascertain the number and type of obstetric computer systems (OCS) in Great Britain, and to ascertain user satisfaction with these systems. DESIGN: A postal questionnaire was circulated to every consultant obstetrician in Great Britain at the beginning of 1992. MAIN OUTCOME MEASURES: Information was sought on the hardware, software and uses of obstetric computer systems. Satisfaction with, benefits and problems of the system were also assessed. RESULTS: There was an 87.5% response rate. Of the 264 units questioned, 100 units reported that they had a computer system. Sixty-five units used terminals connected to a mainframe or minicomputer and 17 used stand-alone personal computers (PCs). Local area networks (LANs) were used in 19 units and wide area network (WANs) in 22 units. Software varied from commercial turnkey systems to in-house systems. The quoted annual running cost ranged from 50 pounds to 48,000 pounds. Most units were satisfied with their system. Problems included slow operating times, unreliability, user unfriendliness, deficiencies in training and inadequate customer support services. CONCLUSIONS: Obstetric computer systems are now coming into widespread use. Despite problems, the use of such systems is likely to increase. This survey establishes a database for those units who are considering acquiring or changing their computer system for the purpose of audit or research.

Attitude to Computers↗
PubMed2005

Acute obstetric emergency drill in England and Wales: a survey of practice.

Multidisciplinary training for obstetric emergencies is an issue of current interest and debate in the UK. This paper presents a survey of current practice in obstetric emergency drill training in England and Wales. A wide range of training methods and opinions about these methods are demonstrated in this survey. There is much interest in improving the management of obstetric emergencies and this is to be encouraged. However, reliable methods to assess and thereby optimise methods are urgently required in order that women and their babies can realise the maximum benefit from these complex interventions.

Clinical Competence↗
PubMed1971

Obstetric anaesthesia services in the United Kingdom.

In a survey of obstetric anaesthetic services in the United Kingdom questionnaires were sent to 398 hospital maternity units and 347 general-practitioner maternity units, of which 344 and 272 respectively were returned. Many hospitals were unable to provide an anaesthetist for obstetric surgery only, and few consultant anaesthetist sessions were allocated to obstetric surgery, particularly in regional hospitals in England and Wales. Constant supervision of junior anaesthetic staff with under 12 months' experience was lacking in several hospitals. Endotracheal intubation is widely used throughout the United Kingdom. Though regional analgesic techniques are used by most anaesthetists it is impossible to provide a 24-hour regional analgesic service in all but a few hospitals.

Anesthesia, Conduction↗
PubMed1979

Extended role for general practitioners in obstetrics? A medical audit.

A study was designed to evaluate provision of services, process of medical care, and outcome in four general-practitioner obstetric units in isolated areas (Berwick, Whitby, Guernsey, and Brecon). All units were equipped to induce labour; to perform instrumental vaginal delivery and selected breech deliveries; and to remove placentas manually. All had some fetal monitoring equipment. Caesarean sections could not be performed at Berwick and Whitby. Proportions of normal deliveries during 1976-7 varied from 75% to 93%. Perinatal mortality was acceptably low, as were transfer rates for neonates and mothers in labour. With specialist help and particular attention to training and broadening local doctors' experience of abnormal obstetrics, such units should be able to provide an excellent obstetric service.

Appointments and Schedules↗
PubMed1989

Increased obstetric activity: a new meaning to "induced labour"?

This study examines the possible reasons for increased obstetric activity in Denmark over the past 25 years. Since 1960 there has been a substantial increase in the average number of hospital admissions (from 10 to 32 per 100 deliveries), in deliveries diagnosed as complicated (from 15 to 49%), and above all in major interventions at delivery (from 4 to 22%). In spite of this increase in activity there is no evidence that the postwar trend of decreasing perinatal mortality has been further improved during the period of study. It seems possible that the rising level of activity is the result of increasing availability of new technology, decreasing numbers of deliveries and unchanged obstetric staffing levels, with an increased tendency to diagnose and intervene in "at risk" pregnancies. There is a need to determine how the current level of obstetric activity has arisen. Since there is evidence for an increased expectation of intervention by pregnant women, the theory of supplier induced demand may be among the leading contenders to be tested.

Adult↗
PubMed1998

Childbirth as a biological model for stress? Associations with endocrine and obstetric factors.

OBJECTIVE: The aims of this investigation were to measure corticotropin-releasing hormone (CRH), corticotropin (ACTH) and cortisol before, during and after delivery searching for an endocrine intercorrelation of the hypothalamic-pituitary-adrenal (HPA) axis and to correlate these findings with obstetrical variables. METHODS: Blood was sampled from 50 women with singleton pregnancies at term without uterine contractions, during delivery (after full cervical dilatation) and on the 4th postnatal day. Hormones were measured by radioimmunoassay (RIA). The correlation between obstetric variables, sociodemographic and endocrine data were evaluated using the Spearman rank coefficient. Group comparisons for continuous variables were calculated using the Mann-Whitney U test and Kruskal-Wallis test. RESULTS: Maternal plasma ACTH and cortisol increased significantly during labor, declining toward the 4th postnatal day (p < 0.001) and showing a significant intercorrelation (p < 0.01). Compared to women without uterine contractions CRH rose during labor (p < 0.05) and decreased rapidly to the 4th postnatal day (p < 0.001). No correlations between CRH and ACTH or cortisol were observed. None of the obstetrical variables (parity, newborn's weight, duration of delivery) revealed any significant correlation with ACTH. Analgetic medication (pethidine hydrochloride) was not able to influence the endocrine response to labor stress. CONCLUSIONS: Stressful experience during childbirth has an impact on endocrine response. However, this is not fully evident along the HPA axis in a simple biological model with monocausal dependencies. This 'biological stress model' is not sensitive enough to detect different childbirth conditions and the hormones in the maternal compartment have partially fetal (placental) origin.

Adrenocorticotropic Hormone↗
PubMed2004

[Gentle obstetrical management for very early preterm deliveries].

OBJECTIVE: In view of the general improvement in survival of very early preterm newborns the contribution of the obstetrical management to this development has been studied. METHODS: A comprehensive literature search was performed concentrating on prospective randomised clinical trials, meta-analyses and review articles dealing with different aspects of the obstetrical management of very early preterm deliveries which were published during the last 10 years. RESULTS: The benefit of antepartal administration of glucocorticoids to the mother for stimulation of pulmonary maturity of the fetus and the overall clinical condition of the preterm newborn at birth has been proven by several prospective randomised studies. In contrast, there is only indirect evidence for the benefit of an early transfer of these pregnancies to a perinatal centre. The benefit of a short-term prolongation of pregnancy by the administration of tocolytics is evident in the context of glucocorticoid administration for pulmonary maturity. There is no clear evidence for the benefit of long-term tocolytic treatment of preterm labour. Various prospective randomised trials comparing delivery by primary or elective caesarean section with vaginal birth combined with selective section as indicated by a deterioration of the condition of the fetus or the mother during the first or second stage of labour have clearly shown increased maternal morbidity in the elective caesarean section group. The expected advantage for the condition of the newborn could not be shown. In a meta-analysis of 6 such trials, the problem of recruiting participants was stressed. All 6 trials had to be terminated before the calculated number of study participants had been recruited. CONCLUSION: For planned early preterm delivery a transfer of the mother into perinatal centre is recommended for pregnancies beyond 22 0/7 weeks. Starting at 24 0/7 weeks, glucocorticoids should be administered. Between 24 0/7 and 24 6/7 weeks, survival chances remain clearly at less than 50%, and up to 50% of those surviving develop moderate to severe handicaps. Obstetrical management, in particular a decision for caesarean section due to fetal indication, must be individualised taking into account the wishes of the parents. Beyond 25 0/7 weeks, newborn survival should be given priority, and although clear evidence for the optimal mode of delivery is missing in cases of spontaneous labour leading to rapid dilatation of the cervix, with a normal singleton cephalic fetus, a vaginal delivery may be attempted. If under close supervision of labour there are signs of fetal or maternal deterioration, a caesarean section should be performed without delay. With breech presentation as well as twins or multiple fetuses there is a general trend towards primary caesarean section. In the absence of spontaneous labour and with an unripe cervix, elective caesarean section is considered as the method of choice for the delivery of the early preterm fetus.

Cesarean Section↗
PubMed1986

Cesarean section: a controversial feature of modern obstetric practice.

Cesarean section (CS) has been an integral part of modern obstetrics during the last decades. As safety has increased, so too has the range of problems that CS is used to solve, to a degree that it must cause medical concern. There is a great danger in the blind faith that CS is the only way out in every difficult obstetric situation. The problem can always be easily solved by CS in an acute difficult obstetrical situation. However, CS is a major abdominal surgery and it may present any complication that besets major surgery including severe intraoperative and postoperative complications, a much greater risk for maternal death compared to vaginal delivery and also late complications, i.e. secondary involuntary infertility. Therefore, CS should never be undertaken lightly and without serious consideration of the justifications, preparations and all ancillary support.

Abortion, Induced↗
PubMed1997

Obstetric and gynaecological patients in an intensive care unit: a 1 year review.

Management of the critically ill patient forms a significant proportion of obstetric and gynaecological (O & G) practice. There have however, been very few reports on the management of such patients in intensive care units (ICU). We review all O & G patients admitted to the surgical ICU at King Edward VIII Hospital, Durban, South Africa, and make recommendations regarding management of such patients. The medical records of all O & G patients admitted to the surgical ICU between the period January-December 1992 were analysed. Of all admissions to the ICU 13.6% (n = 122) were O & G patients. Eclampsia was the most common diagnosis accounting for 66% of all obstetric admissions. Of all eclamptics in the study period 24% were admitted to the ICU. The overall maternal mortality was 21%. O & G patients form a major workload of surgical ICUs and the majority of these patients are women with eclampsia. Management of such patients requires an understanding of the physiological changes of normal and abnormal pregnancies. Therefore, all large obstetrical units in developing countries should establish their own ICU in order that patient care, health personnel training and continuing health care education may be improved.

Adolescent↗
PubMed1988

Psychiatric consultation-liaison services to an obstetrics and gynecology department.

This paper describes the psychiatric consultation-liaison services provided to an Obstetrics and Gynecology Department. Clinical services are provided both by program consultation and by individual inpatient and outpatient referral. Clinical problems in obstetrics and gynecology that result in psychiatric referral are discussed. Research interests which play an important role in the program are described. Educational activities are directed toward ward and clinic staff, undergraduate medical students, residents and the practising specialist. The combination of well articulated consumer requests, interested gynecologists and obstetricians, broadened gynecology residency training objectives, and greater involvement of consultation-liaison psychiatrists suggests a promising future for psychosomatic obstetrics and gynecology.

Female↗