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PubMed2006

Attitudes of obstetric and pediatric health care providers toward resuscitation of infants who are born at the margins of viability.

OBJECTIVES: The objective of this study was to determine the attitudes of a variety of health care providers toward the recommendations that should be made to parents regarding the resuscitation of infants who are born at the margins of viability. METHODS: A written questionnaire was distributed to the medical and nursing staff at 4 tertiary perinatal centers. For each of 5 weekly gestational age intervals from 22 weeks to 26 weeks, 6 days, the health care providers were asked to describe on a scale from 1 to 5 whether they would strongly discourage through strongly encourage resuscitation. They also were queried regarding their comfort with counseling regarding these issues. The attitudes of various groups of providers were compared across weekly intervals. RESULTS: A total of 204 physicians and 539 nurses completed the survey. The majority would strongly discourage, either discourage or strongly discourage, be neutral or recommend, recommend or strongly recommend, and strongly recommend resuscitation during the 23rd, 24th, 25th, 26th, and 27th weeks of gestation, respectively. Obstetric caregivers were slightly less likely than pediatric caregivers to strongly discourage resuscitation from 22 weeks to 22 weeks, 6 days and 23 weeks to 23 weeks, 6 days. There were no significant differences in the recommendations of obstetricians and pediatricians. Pediatric nurses were more likely to strongly recommend resuscitation from 26 weeks to 26 weeks, 6 days and more likely either to discourage or to strongly discourage resuscitation from 23 weeks to 23 weeks, 6 days and to strongly discourage resuscitation from the 22 weeks to 22 weeks, 6 days than their obstetric counterparts. Obstetric nurses were slightly less likely than obstetricians to strongly recommend resuscitation at 26 weeks to 26 weeks, 6 days and less likely to strongly discourage resuscitation from 22 weeks to 22 weeks, 6 days. CONCLUSIONS: The caregivers' recommendations seem to be based logically on the current literature regarding survival and morbidity that is experienced by infants who are born at the threshold of viability. Although there are minor differences, there was a relatively consistent approach among professional groups.

Attitude of Health Personnel↗
PubMedDate not supplied

[The current status of obstetric analgesia and anesthesia in Italy].

BACKGROUND: There is a more and more vivid interest regarding methods of obstetric analgesia and anesthesia while there is a lack of epidemiological data about the Italian reality. Aim of the study was to evaluate the current state of obstetric analgesia and anesthesia and create an interest for anesthesiologists in a professionally and scientifically interesting field. METHODS DESIGN: transversal study of clinical observation of the Italian situation based on questionnaires composed of 20 multiple choice and closed questions, addressed to chief anesthesiologists of 220 randomized Italian hospitals. SETTING: 220 Italian hospitals having a capacity of more than 100 beds. RESULTS: Out of the 220 questionnaires, 91 were returned. Merely 17 hospitals guaranteed a permanent peridural analgesic service. To improve this situation, anesthesiologists call for introducing chargeable services and increasing the medical staff. In spite of the widely documented advantages that regional anesthesia offers for maternal and fetal well-being, this technique is practised in only 26% of cesarean sections. This percentage is greatly higher than that obtained from a similar experience in 1991, where the use of regional anesthesia technique was of 3-4%. In 11 hospitals postoperative analgesia is not carried out on a regular basis. CONCLUSIONS: Even though the general opinion is showing a growing interest for obstetric analgesia and anesthesia, it has not yet reached the same dignity as in other countries.

Analgesia, Obstetrical↗
PubMed1999

[Evolution and quality of care during labor and delivery in primiparous patients who underwent early obstetrical analgesia].

Evaluations of labor and delivery progress and care quality in primiparous patients that receive obstetric analgesia by peridural way at the beginning of the active phase, was done. One-hundred-twenty-nine patients at the beginning of the active phase of the labor were randomized into two groups: Group I: Sixty-six patients that received obstetric analgesia by peridural way and Group II: Sixty-three patients did not receive analgesia by any way. Length of the cervical dilation and effacement, and expulsive period, cervical dilation rate per hour, delivery type, labor experience and perinatal outcomes were measured. The length means of the cervical dilation and effacement was 177.7 (SD +/- 89.0) and 296.0 (SD +/- 114.5) minutes to Group I and II respectively (p < 0.005). Cervical dilation rate was 2.74 and 1.6 centimeters per hour to Group I and II respectively (p < 0.05). The length of the expulsive period was 36.54 minutes (SD +/- 21.7) to Group I and 42.57 minutes (SD +/- 16.15) to Group II (p > 0.05). Labor experience was referred like very painful in the 9% and 100% to Group I and II respectively (p < 0.05). The perinatal outcomes and method of delivery were similar between two groups. Obstetric analgesia administered by peridural way at the beginning of the active phase of the labor significantly reduce the dilation and effacement period and whole labor, without modify the expulsive period length. It does not inhibit the uterine activity and improvement the care quality of the labor.

Adult↗
PubMedDate not supplied

[Motives for a revision of the physiology of labor and an updating of obstetric terminology].

During the second half of our century, revolutionary progress has been made in obstetrics in terms of care, prevention and technology, but curiously a number of doctrinal questions have been left unresolved which are more important in cultural and practical terms than is commonly thought. We refer in particular to the physiology of the mechanics of labour whose inveterate lacunae of interpretation and major conceptual inaccuracies would be easily resolved if tackled with sufficient interest. These are easy questions to resolve because the missing or incorrect aspects of the traditional model used to interpret the mechanics of labour are for the most part only caused by clashes with the basic principles of physical science. If the mechanics of labour are re-examined with a view to anchoring them rigorously and satisfactorily to the principles of physics, the traditional model of interpretation, which is currently in vogue, is completely invalidated and replaced by another based on a series of hydrodynamic phenomena of considerable obstetric interest. The advantages of these hydrodynamic phenomena are represented by the onset of the so-called "pelvic press", doubling the motor forces of labour during the release of the fetus, the constant maintenance of a balance of forces in the fetal environment, the rotary movements caused autonomously by a hydraulic and muscular system of fixing the womb during the release of the fetus, and above all by the equal interaction of the fetus in the mechanics of its own birth. Clearly, this new interpretative model calls for the use of partly updated and partly innovative obstetric terminology.

Female↗
PubMed1999

Predicting style-of-care preferences of obstetric patients. Medical vs. midwifery model.

OBJECTIVE: To identify patient populations preferring more medically oriented vs. more midwifery-oriented medical care in order to provide an institutional resourcing model. STUDY DESIGN: Questionnaires were distributed to pregnant women regarding possible concerns related to style of care and length of hospitalization for obstetric delivery. Responses from the 135 usable surveys were analyzed by cluster analysis to search for common demographic or ideologic concerns that might distinguish two or more groups of patients according to style-of-care preferences. RESULTS: Four clusters were identified and categorized based on the initial hypothesis as midwifery preference, medical preference, passive and wanting both. Cluster membership could not be predicted by any demographic or historical variable studied, and the most significant style-of-care discriminator was related to preferred length of postpartum hospital stay, with 80% of the midwifery preference cluster desiring a short (< 24 hour) stay as compared to a single patient (2%) in the medical preference cluster. CONCLUSION: While obstetric care is often offered in distinctly stylized packages according to the training of the provider, our study suggests that patient preferences are much more complex and may contain many elements of both midwifery and medical styles of care. Broadening access to obstetric care will involve moving from our own preconceived notions of appropriate packaging into a patient-based and multi-option setting for delivery of these services.

Attitude to Health↗
PubMedDate not supplied

[Development of obstetrics at Knin Hospital after liberation in 1995].

The objective of this study is to present the development of obstetrics in the Knin General Hospital after military action "Storm" and consecutive liberation in 1995. Delivery register was used as the source of data in the period from liberation, i.e. from August 1995 to December 31, 1998. The number of medical visits during pregnancy, number and methods of deliveries and perinatal outcome are presented. Along with the improved organization of the Obstetrics and Gynecology Department of the Knin General Hospital the number of visits during pregnancy increased from average 2.4 (0-4) in 1995 to 6.7 (2-13) in 1998. With return of the population, the number of deliveries increased from 18 in 1995 to 275 in 1998. Also, the number of Cesarean sections increased from 1 (5.6%) in 1995 to 18 (6.5%) in 1998, but the frequency is the same. Perinatal mortality was low, only one child died from twin pregnancy, as a fetal death because of cord prolapse. The results of the Department of Obstetrics and Gynecology from the Knin General Hospital are comparable with other modern centers which were not under war occupation, thanks to the great effort of the Ministry of Health and help of medical staff from Zagreb, Sisak, Sibenik, Bjelovar, Cakovec and the Knin General Hospital.

Croatia↗
PubMed2002

The AANA Foundation closed malpractice claims study: obstetric anesthesia.

The purpose of this study was to evaluate the anesthesia care provided during obstetric adverse events. Malpractice claims filed against nurse anesthetists for care involving obstetric anesthesia (n = 41) were extracted from the American Association of Nurse Anesthetists Foundation Closed Claim database. The events represented in the claims occurred from 1990 to 1996 and represented anesthetics provided by both anesthetists and anesthesiologists. Risk factors for adverse outcomes identified in this study included advanced maternal age, ethnicity, and obesity. Patients requiring emergency cesarean sections under general anesthesia were found to be at considerable risk for sentinel events. The most common adverse outcome in the obstetric closed claim database was neonatal death (n = 11 [27%]), followed by maternal death (n = 9 [22%]) and complications resulting from regional anesthesia (n = 8 [20%]). The leading cause of maternal death and brain damage was a failure to secure a patient airway. The mode of delivery in 95% (n = 19) of the 20 claims in which death was the outcome was surgical. In the claims representing maternal death, 89% (8) of the 9 claims represented surgical deliveries under general anesthesia. These maternal death cases were designated emergent in 56% (5) of the claims. The anesthetic care was deemed appropriate in 56% (23) of the claims. The median payment for appropriate care ($2,866.00) was less than for care determined to be inappropriate ($45,000.00).

Anesthesia, Obstetrical↗
PubMed2001

Outcomes in rural obstetrics, Atherton Hospital 1991-2000.

Analysis of annual obstetric audit data collected over the decade 1991-2000 from the Atherton Hospital in Far North Queensland provides ongoing evidence of safe obstetric practice provided by a group of non-specialist doctors in a rural community. During that period, there were 2997 deliveries; of these, 2400 (80.1%) were public patients and 596 (19.9%) were private patients. There were 16 perinatal deaths (perinatal mortality rate 5.3/1000). This is remarkably consistent with the outcome of the previous decade, 1981-90, when the total deliveries was 2883 with 15 perinatal deaths (perinatal mortality rate 5.2/1000). However, compared with 1981-90, the number of Caesarean sections rose from an overall rate of 13.0% (public 10.6%; private 18.3%) to an overall rate of 17.4% (public 16.7%; private 20.4%). In 1981-90, there were 909 private confinements (31.5% of total) and in 1991-2000 there were 597 (19.9% of total). This decline in the number of private obstetric cases may have significant implications for future models of care. There were no maternal deaths in the 20 years 1981-2000.

Delivery, Obstetric↗
PubMed1975

[Obstetric diagnosis and patterns of behavior in labor (author's transl)].

Obstetricians, so far mainly interested in mechanics, have lately understood that innervation and interplay of the propelling and retaining structures also depend on the affects and impulses acting during delivery. There is normal and pathologic obstetric behavior. The obstetric situations demanding action from the obstetrician are not rarely correlated or due to pathologic behavior at birth. This disturbed or disturbance-producing behavior at birth, however, is by no means always directly related to anxiety, in the sense of the generally accepted anxiety-tension-pain syndrome. Disturbed behavior at birth may also be related to many other affects which often, but not always, are secondary to anxiety or designed to defend against it: retentive, annoyed, perfectionistic, poor in contact, worried, inactive or confused behavior at birth. In practice knowledge of such affect-constellations aids the preventive efforts of the obstetrician. Theoretically the origin of this subgroup of functional disturbances of birth is interesting. Interpersonal psychiatry after Harry Stack Sulivan sees in the non-organic psychic disturbances and symptoms an interpersonal process and not any more characteristics of an isolated individual. Since the functional disturbances of obstetric physiology are in part related to, in part due to, affect-constellations and behavior, they confirm this concept of interpersonal psychiatry. Medicine likes to study physiologic processes as if they represented a closed system within the limits of an isolated organism. In fact, the course of many physiologic processes is determined by simultaneously active affects i.e. the concrete interpersonal situation. This view, increasingly accepted for the physiology of libido and functional sexual disturbances, also applies to part of the functional disturbances of birth.

Anger↗
PubMed2003

Ureteric injuries during obstetric and gynecologic procedures.

OBJECTIVE: To review the ureteric injuries resulting from obstetric and gynecologic procedures with a comparative analysis of current pertinent literature. METHODS: From January 1994 -December 1997, the medical records of all patients who sustained ureteric injuries as a result of obstetric or gynecologic procedures and managed at the Princess Basma Teaching Hospital, North of Jordan were reviewed. The clinical presentations, investigations, features of injury and treatment modalities were studied. RESULTS: There were 17 patients with 19 ureteric injuries incurred during obstetric or gynecologic procedures during the study period. Patients were relatively young and presented with loin pain. The left lower ureter was injured in 11 cases. Hysterectomy, alone, accounted for 13 injuries mainly in association with malignancy. Deliveries, in general, were associated with very low rate of injury. Ureteric ligation was the most common mechanism of injury (47%). Injuries were intraoperatively recognized in 41.2% (7/17) of cases. Patients were treated by either endourological or formal surgical repair. The overall success rate after an average of 32.3 months of follow-up was achieved in 89.5% (17/19). This outcome was not significantly altered by either the features of injury or by the treatment schedules. CONCLUSION: Iatrogenic ureteric injury is still a major cause of harm and concern. The time taken to detect the injury remains the most important morbidity-related factor. Recent trends towards earlier intervention and the use of various endourological means of repair deserve support and promotion.

Adolescent↗
PubMed1992

[Centralization of obstetric care and perinatal mortality in Norwegian counties 1986-90. Analysis based on public statistics from the medical birth registry].

The relationship between centralization of obstetric care and perinatal mortality was studied in 19 Norwegian counties for the period 1986-90. No significant trend was found. However, during the period 1988-1990 prenatal mortality was significantly higher, with a relative risk of 1.21 (95% confidence interval 1.00-1.45), in the three counties with only one obstetric department than it was in all other counties. The analysis did not support the notion that greater centralization of obstetric care would decrease perinatal mortality.

Centralized Hospital Services↗
PubMed2003

A systematic review of training in acute obstetric emergencies.

OBJECTIVE: To describe models used for the training of labour ward personnel in acute obstetric emergencies and to describe how these models have been evaluated and compared. DESIGN: A systematic review of the following databases: Medline, the Cumulative Index of Nursing and Allied Health Literature, Embase, PsycLit, Allied and Alternative Medicine, Education Resources Information Center and the Cochrane Library using a structured search strategy. SETTING: Labour ward. POPULATION OR SAMPLE: Labour ward personnel. INCLUSION CRITERIA: All papers that described or evaluated any form of drill or training in acute obstetric emergencies involving any personnel in a labour ward environment were included. Descriptions of training in developing countries were excluded. METHODS: Papers were classified as editorials or commentaries, papers describing a training programme or papers evaluating a training method. A data collection form was used to extract relevant information by two investigators independently. MAIN OUTCOME MEASURE: Description of training models. RESULTS: Of 44 relevant papers, 22 were classed as editorials or commentaries. Six descriptions of training programmes were found and four papers involved an evaluation of such programmes. All evaluations involved the use of questionnaires to course participants. No studies comparing one form of training with another were found. CONCLUSIONS: With regard to training in acute obstetric emergencies, few training programmes have been described, and even fewer have been evaluated. Training methods need to be developed, described and evaluated; further well-conducted research for this important intervention is urgently required.

Acute Disease↗
PubMed2003

[A watershed in Norwegian obstetrics].

BACKGROUND: Professional obstetrics in Norway developed during the 19th century. This paper analyses the development through the second half of the 19th century at the Maternity Clinic in Christiania (now Oslo). MATERIAL AND METHODS: All patient files from the years 1852, 1872 and 1892, a total of 1231 records, were analysed. Socio-demographic and gynaecologic data were registered as well as data about the delivery and the child. RESULTS: The number of deliveries increased nearly five times during the period. The proportion of married women increased from less than 20% to nearly 50%. Maternal mortality decreased from above 3% to below 1%, mostly because childbed fever became infrequent. The number of operative deliveries increased substantially, particularly the use of the obstetric forceps, in 1892 utilised in 6 % of deliveries. In the reviews published in those days, eclampsia and reduced contractions were the most frequently cited indications for the use of the obstetric forceps. Problems with the heart sound of the fetus were not mentioned. However, patient files demonstrate that a weak or missing heart sound of the fetus was also an important indication for the use of the forceps. INTERPRETATION: Giving birth at the clinic was gradually becoming an alternative for other than poor women, because it was safer than before and in some cases the obstetricians could offer effective help. However, at the end of the 19th century, not more than about 15% of all deliveries took place at the clinic. This paper demonstrates the importance of scrutinising patient files as a supplement to register data, as is the case today, too.

Adult↗
PubMed2005

[Obstetrical and anesthetic management of pregnant women who smoke].

Is the obstetrical and anesthetic management of pregnant women who smoke different from that for a pregnant women who does not smoke? This was the question the experts were asked during the first "Tobacco and pregnancy" Consensus Conference. To address these two questions a Medline and Embase search was carried out. The review of the literature confirmed the limited number of reported studies directly concerned, from the obstetrical or anesthesia point of view, with the problems of the management of women who smoke. Consequently, we are not able to suggest detailed recommendations. However, during the perinatal period, the correlation between tobacco and some obstetrical or surgical complications have been established. On this basis, studies must be undertaken in order to propose an optimal attitude for pregnant smokers.

Anesthesia, Obstetrical↗
PubMedDate not supplied

The obstetric performance of United Kingdom asylum seekers from Somalia: a case-control study and literature review.

BACKGROUND: Little published research exists regarding obstetric performance of immigrant women in the United Kingdom. The aim of this study was to evaluate the obstetric performance and fetal outcomes of Somalian women who received prenatal care and requested to deliver at a teaching hospital in North London. METHOD: This is a case-control study in which consecutive Somalian women were identified as index cases and the subsequent British-born Caucasian women listed in the delivery book served as controls. RESULTS: 69 index and 69 control cases were analyzed. Fifty-five percent of the Somalian women spoke little or no English. Half (50%) had undergone circumcision, the majority being type I WHO classification of female genital circumcision, which did not require significant surgical intervention prior to labor; 13% had cesarean sections, 13% instrumental vaginal deliveries, and 74% had vaginal deliveries. The Somalian women had higher parity (2.35 vs. 1.18) and were more likely to be grand multiparous (9/69 vs. 1/69) compared to controls. Epidural use was less frequent in Somalian women, but otherwise there were no significant differences between the two groups with regard to maternal age, rates of induction of labor, cesarean sections, duration of labor, premature deliveries, instrumental deliveries, and birth weights. CONCLUSIONS: The demographic characteristics of the Somalian female population appear to exert minimal effect on obstetric and fetal outcomes. This may be due to the increased vigilance exercised by health professionals as well as to the fact that recent arrivals are from more urban and westernized areas in Somalia.

Adult↗
PubMed2006

Obstetric anal sphincter injury: how to avoid, how to repair: a literature review.

Avoiding obstetrical injury to the anal sphincter is the single biggest factor in preventing anal incontinence among women. Any form of instrument delivery has consistently been noted to increase the risk of obstetric anal sphincter injury and altered fecal continence by between 2- and 7-fold. Routine episiotomy is not recommended. Episiotomy use should be restricted to situations where it directly facilitates an urgent delivery. A mediolateral incision, instead of a midline, should be considered for persons at otherwise high risk of obstetric anal sphincter injury. The internal anal sphincter needs to be separately repaired if torn. Women with injuries to the internal anal sphincter or rectal mucosa have a worse prognosis for future continence problems. All women, particularly those with risk factors for injury, should be surveyed for symptoms of anal incontinence at postpartum follow-up.

Anal Canal↗
PubMed1992

Changing obstetric practice and 2-year outcome of the fetus of birth weight under 1000 g.

The aim of this study was to assess the outcome up to 2 years of age for the fetus of birth weight 500-999 g, over time and in association with changes in obstetric care. Two consecutive cohorts of infants of birth weight 500-999 g were compared from two eras, 1977-1982 and 1985-1987, and their outcome up to 2 years of age was determined with particular emphasis on the effect of various obstetric interventions at the time of birth, such as cesarean delivery, electronic fetal monitoring, antenatal steroid therapy, and tocolytic therapy. The outcome to 2 years was analyzed by logistic function regression to adjust for imbalances in confounding perinatal variables. In the latter era, the survival rate to 2 years increased significantly by almost 50%, and only 7% of the survivors were severely disabled. The rates of delivery by cesarean and of electronic fetal monitoring both increased significantly in the latter era, but neither was associated with the improved outcome. The only variable associated with an improved outcome that was amenable to obstetric intervention at the time of birth was antenatal steroid therapy, which was used equally in both eras. The obstetrician may aid the fetus of birth weight 500-999 g by giving the mother steroids to accelerate fetal lung maturity, but cesarean cannot be recommended as the routine mode of delivery unless there are recognized maternal or fetal indications.

Delivery, Obstetric↗
PubMed1990

Quality assurance in obstetrics: a model.

Since 1985, a computerized data base has been used for the entry of information relevant to each of the 2500 deliveries performed at Danbury Hospital each year. This data base consists of 73 fields and codes for approximately 490 potential diagnoses and pieces of information spanning the patient's medical, surgical, and obstetric history; current antepartum, labor, delivery, and postpartum course; and neonatal course and outcome. With the publication of the Joint Commission on Accreditation of Healthcare Organizations Potential Obstetrical Care Clinical Indicators and, more recently, The American College of Obstetricians and Gynecologists (ACOG) Obstetric Clinical Indicators, information has been extracted from this data base and is being used as part of the quality assurance program of the department. The report generated from this extracted data base provides information regarding 22 of the 24 relevant ACOG indicators. The records thus identified are then subjected to an initial screen. Those records that do not pass the initial screen are reviewed by the departmental Patient Care Review Committee, which examines each record for suitability of management and has the ability to request clarification of that management from the responsible attending physician and/or to refer the record to the departmental chairman for further discussion with the attending physician. Topics for departmental educational programs can be based on deficiencies highlighted by the quality assurance program.

Cesarean Section↗