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PubMed2005

Impact of 1996 Residency Review Committee Obstetrics-Gynecology primary care requirements on residency training and surgical procedures.

OBJECTIVE: This study evaluated the impact of required primary care rotations in obstetrics-gynecology residency training after 1996. STUDY DESIGN: A questionnaire was sent to the 1994 to 2003 graduates from 1 residency program, and records of surgical procedures completed during residency were analyzed. RESULTS: Thirty-nine of 46 graduates participated in the study (response rate 85%). Required primary care training was associated with increased confidence in providing primary care (81.5% versus 54.5%, P = .12) but less agreement that obstetrics-gynecology is a primary care specialty (21.4% versus 45.5%, P = .23). Abdominal hysterectomies and vaginal hysterectomies per resident did not decrease (127 versus 113, P = 0.149, and 55 versus 48, P = .06, respectively). Adjusted for temporal trends, cesarean sections per resident decreased (366 versus 321, P = .009). CONCLUSION: Residents maintained adequate rates of major inpatient surgical procedures after implementation of required primary care training. There was a tendency for residents who graduated after 1996 to have less favorable attitudes about primary care.

Adult↗
PubMed2006

The use of United States vital statistics in perinatal and obstetric research.

Vital statistics data have been used to track maternal and child health in the United States since the early 1900s. The breadth of information collected on birth and death certificates coupled with advances in computer processing have made possible critical perinatal and obstetric research. These enhancements also facilitate potentially problematic uses of the same data. This commentary explores characteristics of the United States Vital Statistics System and presents some thoughts with regard to the appropriate use of these data. The advantages of vital statistics include representativeness and the ability to examine subpopulations. Limitations include possible underreporting of medical conditions and procedures, lack of ability to ascertain clinical intent, and the well-known issues with gestational age reporting. Analyses based on vital statistics are important in informing future clinical research projects. However, respecting the limitations of vital statistics data enhance their appropriate role in obstetric and perinatal research.

Epidemiologic Research Design↗
PubMed2006

Burnout, depression, and career satisfaction: cross-sectional study of obstetrics and gynecology residents.

OBJECTIVE: This study was undertaken to measure career satisfaction among obstetrics and gynecology residents and assess its relationship to burnout, depression, and malpractice concerns. STUDY DESIGN: A 63-item, anonymous, self-administered survey was distributed to residents at 23 randomly selected obstetric and gynecologic residency programs in the United States. The outcome measures included the Maslach Burnout Inventory-Human Services Survey, the Center for Epidemiological Studies-Depression Scale, and perceptions of malpractice and career satisfaction. RESULTS: Eighty-three percent of the residents were either "very or somewhat satisfied" with their career choice. The majority (89.8%) showed evidence of moderate burnout and 34.2% were considered depressed. Ninety-six percent were concerned about malpractice with 35% pursuing fellowship solely because of malpractice concerns. Residents dissatisfied with their career choice were twice as likely to be depressed (30% vs 55%, P = .03). Both emotional exhaustion (P < .0001) and consideration of fellowship because of malpractice (P < .0001) were strongly predictive of diminishing career satisfaction. CONCLUSION: Resident career satisfaction was inversely correlated with burnout and depression, which were more prevalent than expected. Overall, residents were satisfied with their career choice, but also negatively influenced by malpractice concerns.

Attitude of Health Personnel↗
PubMed2004

[Labour epidural analgesia in Martinique: evaluation of quality and accessibility to epidural analgesia by the patients in level one obstetric clinic].

OBJECTIVES: The main aim of this study was to evaluate real-life experience and the quality of labor epidural analgesia (LEA) by the patients, from the anaesthesia consultation to leaving the clinic after childbirth. STUDY DESIGN: Descriptive study. PATIENTS AND METHODS: This study took place over a period of 8 weeks, at the level I obstetric clinic in Martinique. One hundred and thirty-four successive patients completed an anonymous questionnaire following childbirth. RESULTS: During the study period (134 patients completed the questionnaire, corresponding to 100% return) 127 women had asked for LEA (94%), which was possible in 94%, with a patient satisfaction level of 94% and an average mark for quality at 18/20. The quality of information given at the anaesthesia consultation was judged excellent for 97%, and 91% were reassured by the consultation. The delay between the demand and the LEA procedure was less than 15 min in 63%, and in 39% the procedure was done during the night. The procedure was painless in 63%, and 97% of women were ready to begin the same procedure again. CONCLUSION: This study seems to underline the fact that the needs and the acceptability of LEA are the same in Martinique as in mainland France. This study does not support the hypothesis of the cultural barrier to justify the low level of LEA in the Overseas Departments. An obvious result seems to be that good organization of anaesthesia and obstetric services results in a natural increase in LEA demand.

Adult↗
PubMed2005

[Prevention of venous thromboembolism in surgery and obstetrics].

The French Society of anaesthesiology and intensive care has chosen a high level methodology to issue professional Recommendations on perioperative and obstetrical venous thromboembolism prophylaxis. In addition with a short review on mechanical and pharmacological prophylaxis, all surgical and obstetrical settings have been studied. The initiation and duration of prophylaxis have been particularly debated in close relation with the level of surgical risk. A large group of experts has been involved in this process. More than 150 other experts have participated in the reading process. Didactic tables have been added to help the prescription.

Delivery, Obstetric↗
PubMed2006

Hypoglossal nerve transfer in obstetric brachial plexus palsy.

A cost-benefit analysis was performed of hypoglossal nerve transfer in six patients with obstetric brachial palsy taking into account the factors donor site morbidity and extent of recovery. Hypoglossal nerve transfer was employed in four children for elbow flexion only; in two patients for elbow flexion as well as for elbow extension. The transfer was part of an extended brachial plexus reconstruction for treatment of obstetric brachial plexus palsy. After a mean post-operative interval of 52 months (SD+/-8.1), two professional speech therapists investigated late donor site morbidity by analyzing elementary and communicative functions. The functional result for the arm was assessed using the Mallet scale and by performing a physical examination. Following hypoglossal nerve transfer, early donor site morbidity was significant causing great anxiety in the parents. Late donor site morbidity consisted of serious oral problems in a number of the children. They also showed clear associated movements in the arm during mouth/tongue activity. Recovery of powerful volitional elbow flexion was achieved in four cases only. We do not believe that the sacrifice of such an important function as exerted by the hypoglossal nerve is balanced by the gain demonstrated in our series.

Brachial Plexus↗
PubMed2004

The role of the maternal-fetal medicine specialist in high-risk obstetric care.

The maternal-fetal medicine (MFM) specialist is a member of the health care team who possesses expertise in the management of the high-risk pregnancy. The MFM specialist has advanced knowledge of obstetric, medical, genetic, and surgical complications of pregnancy and the effects of complications on the mother, fetus, and newborn. The MFMspecialist may function as consultant, comanager, or direct care provider and may be equally comfortable in antepartum ambulatory, inpatient obstetric, and critical care settings. As the female population increases, the number of MFM specialists also is expected to grow.

Critical Care↗
PubMed2006

Trauma and the obstetric patient: collaboration in care.

Management of the obstetric patient who suffers a traumatic injury is critically dependent o well-coordinated, integrated care. The injured pregnant woman's first presentation usually is to the emergency room. Although the first priority is the stabilization of pregnancy and active involvement of the obstetric team within the trauma and critical care settings enhances patient care and potentiates optimal outcome for the mother and fetus.

Adult↗
PubMedDate not supplied

Obstetric complications in individuals diagnosed with autism and in healthy controls.

The aim of the present study was to investigate birth complications in Israeli autistic probands. We interviewed 206 mothers of autistic probands and 152 healthy control mothers with a structured tool encompassing prenatal, perinatal, and neonatal complications. Analysis of obstetric suboptimality, derived by summing all positive items of each of the 3 categories and dividing them by the number of patients analyzed, revealed no prenatal between-group difference. The controls had a somewhat elevated perinatal suboptimality score, whereas the autistic probands had a significantly greater neonatal suboptimality score. These differences in obstetric suboptimality were retained after controlling for the demographic parameters found different between the 2 groups (sex of participants and mothers' years of schooling). Our findings suggest that the presence of nonspecific neonatal factors, rather than the specific influence of individual severe insults, may account for the elevated neonatal suboptimality found in probands diagnosed with autism compared with healthy controls.

Adult↗
PubMed2005

Obstetric outcome of 6346 pregnancies with infants affected by congenital heart defects.

OBJECTIVE: To evaluate whether pregnancies with infants affected by congenital heart defects are associated with adverse obstetric and perinatal outcome. STUDY DESIGN: In a prospective population-based cohort study from Sweden (1992-2001), 6346 singleton pregnancies with infants affected by congenital heart defects were, after suitable adjustments, compared to all delivered women. RESULTS: The prevalence of cardiovascular defects was 9.1 per 1000 births. Among them, mothers of 6346 infants (71%) had information on maternal smoking habits and maternal height and weight in early pregnancy that enabled the calculation of BMI. All cases with known chromosomal abnormalities and/or maternal pre-existing diabetes were excluded. Eighty-four percent (n=5338) had an isolated cardiovascular defect. Severe types occurred in 21.7% (n=1378). In the group of pregnancies with infants affected by congenital heart defects as compared to all delivered women, there was an increased risk of the following outcomes (adjusted OR (95%CI)): pre-eclampsia (1.21 (1.06-1.37)), cesarean section (1.91 (1.79-2.03)), instrumental delivery (1.21 (1.10-1.34)), pre-term delivery (2.58 (2.39-2.79)), small-for gestational age (1.96 (1.77-2.16)), meconium aspiration (1.51 (1.28-1.77)), and fetal distress (1.38 (1.17-1.63)). CONCLUSIONS: Pregnancies with infants affected by congenital heart defects are associated with several obstetric and neonatal complications.

Cohort Studies↗
PubMed2005

The incidence of Sheehan's syndrome after obstetric hemorrhage.

OBJECTIVE: To estimate the incidence of Sheehan's syndrome in a well-described cohort of patients with obstetric hemorrhage. DESIGN: Retrospective cohort study. SETTING: Tertiary care center. PATIENT(S): Two hundred patients. INTERVENTION(S): Questionnaires were sent to study and comparison patients asking about menstrual dysfunction, lactation difficulty, cold intolerance, fatigue, axillary and pubic hair loss, and secondary infertility. MAIN OUTCOME MEASURE(S): Women who experienced two or more symptoms were referred for hormone testing of insulin-like growth factor 1 (IGF-1), T4, PRL, and early morning cortisol (F) levels. RESULT(S): A total of 109 patients responded to the survey, a 55% response rate. Fourteen of 55 (25%) patients in the hemorrhage group identified themselves as suffering from two or more symptoms on the questionnaire. Eight of the 14 patients were tested, but none had hormonal evidence of hypopituitarism. Four of 54 (7%) comparison patients also identified themselves as suffering from two or more symptoms, but neither of the two tested had hormonal evidence of hypopituitarism. CONCLUSION(S): Among women with postpartum hemorrhage, subsequent development of clinical symptoms does not correlate well with laboratory evidence of hypopituitarism. Clinically significant Sheehan syndrome is an uncommon consequence of obstetric hemorrhage in today's environment.

Adult↗
PubMed2006

[Proposition of a simplified investigation model for adverse outcomes in obstetrics and gynaecology].

Investigation of adverse outcomes in obstetrics and gynaecology requires a systematic and systemically oriented approach. The main objective of these assessments is to decrease their incidence. Lethal complications in obstetrics and gynaecological surgery have become so rare in developed countries that we have to grapple mainly with severe morbidities. A model for such investigation is presented, based on answers to 3 questions: What? How? and Why? These questions correspond to 3 components of quality assurance: Outcome, Process, and Structure, respectively. Aspects of Reason's model of accidents are also included, in the form of "active failures" and "latent conditions." The latter are divided into basic contributory factors, 4 of which are derived from a model of human factors influencing behaviour in anaesthesia or flight-crew environments. To illustrate its basic nature, the model is applied to anonymized cases of surgical complications. Application of the model to the reactive investigation of close calls is discussed, as is application to the proactive interrogation of the care system for the presence and nature of hazards that pose threats to safety.

Adult↗
PubMed2006

Measuring progress towards the MDG for maternal health: including a measure of the health system's capacity to treat obstetric complications.

OBJECTIVE: This paper argues for an additional indicator for measuring progress of the Millennium Development Goal for maternal health-the availability of emergency obstetric care. METHODS: MDG monitoring will be based on two indicators: the maternal mortality ratio and the proportion of births attended by skilled personnel. Strengths and weaknesses of a third indicator are discussed RESULTS: The availability of EmOC measures the capacity of the health system to respond to direct obstetric complications. Benefits to using this additional indicator are its usefulness in determining an adequate distribution of services and showing management at all levels what life-saving interventions are not being provided, and stimulate thought as to why. It can reflect programmatic changes over a relatively short period of time and data requirements are not onerous. CONCLUSION: A measure of strength of the health system is important since many interventions depend on the health system for their implementation.

Emergency Medical Services↗
PubMed2006

Effects of gestational weight gain and body mass index on obstetric outcome in Sweden.

OBJECTIVE: The objective of this study was to estimate the effects of low and high gestational weight gain, in different maternal Body Mass Index (BMI) classes, on obstetric and neonatal outcomes. METHOD: A prospective population-based cohort study of 245,526 singleton term pregnancies. Women were grouped in five categories of BMI and in three gestational weight gain categories; < 8 kg (low weight gain), 8-16 kg and >16 kg (high weight gain). Obstetric and neonatal outcomes were evaluated after adjustments for maternal age, parity, smoking, year of birth. RESULT: Obese women with low gestational weight gain had a decreased risk for the following outcomes (adjusted odds ratio; 95% confidence interval): preeclampsia (0.52; 0.42-0.62), cesarean section (0.81; 0.73-0.90), instrumental delivery (0.75; 0.63-0.88), and LGA births (0.66; 0.59-0.75). There was a 2-fold increased risk for preeclampsia and LGA infants among average and overweight women with excessive weight gain. High gestational weight gain increased the risk for cesarean delivery in all maternal BMI classes. CONCLUSION: The effects of high or low gestational weight gain differ depending on maternal BMI and the outcome variable studied. Obese women may benefit from a low weight gain during pregnancy.

Apgar Score↗
PubMed2006

Eliminating obstetric fistula: progress in partnerships.

Obstetric fistula persists in the developing world due to poor access to obstetric care. It has been overlooked in the past, as the women suffering from fistula often live on the fringe of society due to their poverty and the stigma surrounding the condition. A global Campaign to End Fistula is bringing a variety of actors together to raise awareness and support to prevent fistula and provide comprehensive treatment for women living with fistula. This paper describes the strategies and progress of the campaign since it began in 2003.

Africa↗
PubMed2005

Obstetric epidural test doses: a survey of UK practice.

BACKGROUND: With the advent of low-dose epidural analgesia in labour, the content of the test dose has once again become the subject of debate. METHOD: A postal survey of 500 members of the Obstetric Anaesthetists' Association was conducted in 1999-2000, assessing the use of test doses during epidurals in labour and for caesarean section. RESULTS: There was a 67% response rate. Test doses are used in labour, at elective caesarean section and before epidural top-up for emergency caesarean section, by 90%, 93% and 37%, respectively. There was large variation in both drugs and doses. During labour, doses of bupivacaine range from 3 to 20 mg and of lidocaine 15 to 90 mg. There has been a three-fold increase in the use of low-dose local anaesthetic test doses since a previous national survey in 1997. The size of local anaesthetic test doses used at caesarean section is also variable. Epinephrine is used in 5% of labour, 14% of elective and 34% of emergency caesarean sections. Signs and symptoms that are commonly sought after test doses include somatic motor block, blood pressure change, sensory effect and symptoms from systemic local anaesthetic. The effect of the test dose is usually assessed after 5 min. CONCLUSION: There is no consensus about the nature of the ideal test dose in obstetric anaesthesia. There is a trend to use less concentrated test doses during labour. Doses that risk a high block if given spinally are still used. Epinephrine, aspiration testing and cardiovascular monitoring are uncommon.

Analgesia, Epidural↗
PubMed2005

A parturient with neurofibromatosis type 2: anesthetic and obstetric considerations for delivery.

Neurofibromatosis type 2 is an extremely rare form of neurofibromatosis characterized by central nervous system involvement with bilateral vestibular schwannomas and spinal tumors. Anesthetic management of a parturient with neurofibromatosis type 2 has not been fully reported, and the condition is challenging to obstetric anesthesiologists due to the presence of intracranial and intraspinal canal neurofibromas. We present a case of neurofibromatosis type 2 referred for delivery. Because of central neuraxial involvement, regional anesthesia was avoided, and the patient delivered by cesarean section under general anesthesia. The importance of pre-operative diagnosis and multidisciplinary management for neurofibromatosis type 2 is emphasized and anesthetic and obstetric considerations for delivery are presented.

Adult↗
PubMed2006

Obstetric regional blocks for women with multiple sclerosis: a survey of UK experience.

BACKGROUND: There has been a reluctance to use regional blocks for women with multiple sclerosis as effects on the course of the disease are unclear. We assessed the views of UK consultant obstetric anaesthetists regarding management of women with multiple sclerosis. METHODS: Following Obstetric Anaesthetists' Association approval a questionnaire was sent to UK consultant members. Opinions were sought on antenatal assessment, labour analgesia, anaesthesia for elective and emergency caesarean section, and modification in technique for those with multiple sclerosis. Enquiries were made of postnatal problems ascribed to regional blocks. RESULTS: Of the 592 replies analysed, 91% of respondents had seen fewer than 10 cases of multiple sclerosis in the past 10 years. Antenatal assessment was recommended by many with postnatal relapse most commonly discussed (64%). Many highlighted the need for informed consent and minimising local anaesthetic dose. For labour analgesia 79% would perform a regional block; a further 20% would do so in certain circumstances. For elective caesarean section, epidural rather than spinal anaesthesia was preferred by 4%; 2% would not use a regional block, preferring general anaesthesia. For emergency caesarean section with time only for single-shot spinal, 3% would give a general anaesthetic. Deterioration of symptoms after delivery were reported by 20% with 3% attributing symptoms such as prolonged block, leg weakness, bladder dysfunction and postnatal relapse to regional blocks. CONCLUSION: Most UK anaesthetists would perform regional blocks for labour and caesarean section in multiple sclerosis, although the experience of each anaesthetist is limited. Many emphasised the need for thorough pre-assessment and informed consent.

Adult↗