Optimising recovery after perineal trauma: Implementation of an evidence-based patient-centred care and clinical practice guideline.

BACKGROUND: Perineal trauma and pain can affect the quality of life of women who experience vaginal birth. AIM: To investigate the effect of perineal care and pain management on women's postpartum recovery. METHODS: This was a Quasi-experimental study. In Phase 1 women were treated using our old postnatal perineal care management guideline. In Phase 2 an updated guideline was introduced (regular administration of icepacks and analgesia during the first 24-48 h postpartum). During Phase 1, pregnant women planning a vaginal birth completed a baseline questionnaire. Those who sustained perineal trauma completed a survey at 24-48 h, seven days and 12 weeks after birth. In Phase 2 we continued recruiting participants, using the same procedure, and investigated the efficacy of pain relief approaches using the new guideline. RESULTS: In Phase 1, 111 women (Group 1), and Phase 2, 146 women (Group 2) were recruited. No statistically significant differences were found between the two groups in terms of the women's pain catastrophising, their partner's responses to pain behaviours, or birth outcomes. At 24-48 h and seven days postpartum, women in Group 2 were less likely than women in Group 1 to be bothered by back or perineal pain, headache, sleeping difficulties and dizziness (p < 0.05). More women in Group 2 received regular paracetamol and perineal icepacks during their hospital stay, with less use of oxycodone in Group 2 than Group 1. CONCLUSION: The implementation of the guideline's recommendations was associated with decrease back and perineal pain, headache, sleeping difficulties and dizziness during the first seven days postpartum.

Effects of the COVID-19 Pandemic on the Use of Telehealth for Antenatal Care.

Aims: To determine changes in the use of telehealth and face-to-face consultations for antenatal care (ANC) associated with the COVID-19 pandemic and to identify the groups of women most affected. Materials and Methods: Routine administrative data from three public hospitals in a Local Health District in New South Wales, Australia, were analyzed. Data from 19,171 women who gave birth before the pandemic started (January 2018-January 2020) were compared with data of 5,479 women who gave birth after the pandemic started (December 2020-June 2021). Results: One in eight antenatal services after the pandemic started was a telehealth consultation. The average number of telehealth consultations per woman increased by 0.6 (0.7-1.3, adjusted incidence rate ratio [IRR] = 1.71, p < 0.001), while face-to-face visits decreased by 1.4 (10.6-9.2, adjusted IRR = 0.87, p < 0.001), resulting in an overall reduction of 0.8 (11.3-10.5, p < 0.001) services (7.1%). The increase in telehealth consultations was evident in all groups, but was greatest among women attending the smallest hospital, younger women, and Indigenous women. Most groups of women experienced a reduction in the number of face-to-face and total consultations, but the greatest reductions were among women who attended the largest hospital, received shared care, were older than 35 years, or had conceived through in vitro fertilization. Conclusions: Use of telehealth accounted for a small proportion of total ANC services; its increase did not compensate for the reduction in face-to-face visits, which might have resulted from the lack of suitable equipment, access to facilities, and skills or willingness to engage in telehealth. Ultimately there was an overall reduction of service utilization, which was not uniform among different groups of women.

Clinical outcomes and cost-effectiveness of large-scale midwifery-led, paediatrician-overseen home phototherapy and neonatal jaundice surveillance: A retrospective cohort study.

AIM: To evaluate a large midwifery-led, paediatrician-overseen home jaundice surveillance and home phototherapy (HPT) programme. METHODS: We conducted a retrospective cohort study over 2019. Included were all infants with birth gestation ≥35 weeks, discharged at 4-96 h and receiving care from midwifery-at-home (a 12-h daily, 365-days hospital-based outreach service, supported by hospital paediatricians). Phototherapy was delivered via BiliSoft blanket with treatment thresholds determined by standard nomograms. The main outcomes of interest were unplanned readmissions, and cost-effectiveness based on hospital finance department actual costs. Also examined were parental compliance, device issues and safety. RESULTS: During 2019, 4308 infants received home jaundice surveillance with 86% hospital-discharged before 72 h, 82% exclusively breastfed and 69% having overseas-born mothers. Four hundred infants received HPT, comprising 101 continuing from inpatient phototherapy (IPT), 56 rebounding after IPT, and 243 home-diagnosed as needing phototherapy and triaged to HPT. Only 1 of 400 (0.25%) HPT infants required readmission. Additionally, there were 80 home-diagnosed jaundiced infants triaged to immediate readmission for IPT. Maximal serum bilirubin was 454 µmol/L. No exchange transfusion, encephalopathy or HPT-device problems occurred. An early 2019 bilirubin analyser upgrade resulted in higher bilirubin readings and some unintended subthreshold phototherapy. Supported by midwives, most parents managed HPT with ease. HPT cost $640/day compared to $2100/day for infant IPT readmission and $1000/day for a longer birth-admission stay. Up to 2 weeks' midwifery-at-home care for the whole cohort cost $2 m less than a 2-day longer birth-admission stay. CONCLUSION: Large-scale, midwifery-led, paediatrician-overseen jaundice surveillance and HPT can achieve very low unplanned readmission rates and be cost-effective.

Comparing JM-105 and MBJ-20 Transcutaneous Bilirubinometers According to the Area Tested in Ethnically Diverse Late-Preterm and Term Neonates.

This study aims to evaluate the correlation between the results of transcutaneous bilirubin (TcB) levels measured by the 2 transcutaneous bilirubinometers according to the area tested and to compare the TcB measurements and the serum bilirubin (SBR) levels. We screened 78 neonates born at more than 35 weeks of gestation and aged less than 168 hours for jaundice. We used JM-105 and MBJ-20 to measure the TcB at the forehead and the chest. For newborns who had high TcB measurements, we obtained blood samples during the subsequent 30 minutes. There was a strong correlation between the TcB measurements by JM-105 and MBJ-20 and this correlation was stronger when they were used on the sternum. The mean differences between the TcB measurements on the forehead and the sternum and the SBR levels were similar for the JM-105 and the MBJ-20. There was a strong correlation between SBR and the measurements using the 2 devices on the sternum (JM-105: r = 0.805; MBJ-20: r = 0.801), unlike measurements taken on the forehead by each device (r = 0.777 and r = 0.751, respectively). Both devices had high sensitivity and negative predictive values at SBR level of less than 230 µmol/L (<13.4 mg/dL) and high specificity and positive predictive values at SBR level of 230 µmol/L and greater (>13.4mg/dL). Both devices equally overestimated the actual SBR and had more reliable results if used on the sternum.

Risk of preterm birth in the subsequent pregnancy following caesarean section at full cervical dilatation compared with mid-cavity instrumental delivery.

BACKGROUND: Expediting delivery in the second stage of labour often involves a choice between a caesarean section at full dilatation or mid-cavity instrumental delivery. Accumulating evidence suggests that the mode of delivery may influence the risk of preterm birth in the subsequent pregnancy. AIMS: To directly compare first birth caesarean section at full dilatation with mid-cavity instrumental delivery for the risk of preterm birth in the subsequent pregnancy (second birth). A further aim was to identify predictive factors associated with these index modes of delivery. MATERIALS AND METHODS: This is a retrospective cohort study involving three maternity hospitals in western Sydney over the period of 2006-2017. Inclusion criteria were nulliparous women with a singleton term cephalic first birth delivered by caesarean section at full dilatation or mid-cavity instrumental delivery, and whose second birth also occurred under our care. Data were analysed separately for first and second births. RESULTS: There were 425 caesarean section at full dilatation and 874 mid-cavity instrumental cases which met inclusion criteria. The risk of preterm birth in the second birth was 5.7% compared to 3.2%, respectively (risk ratio 1.76; 95% CI 1.04-3.00; P = 0.035). After excluding causes of preterm birth not related to previous mode of delivery, the risk of spontaneous preterm birth was 4.3% compared to 2.0%, respectively (risk ratio 2.18; 1.14-4.19; P = 0.019). CONCLUSION: Caesarean section at full dilatation is associated with a significantly higher rate of preterm birth in the subsequent pregnancy compared to a mid-cavity instrumental delivery. This should be considered in second-stage mid-cavity decision-making.

Efficacy of surgical excision and sub-dermal injection of triamcinolone acetonide for treatment of keloid scars after caesarean section: a single blind randomised controlled trial protocol.

BACKGROUND: One of the first-line options to treat keloid scars is corticosteroid injection after excision of the existing scar. A thorough literature search has shown a lack of research on the injection of corticosteroid injection immediately after the excision of the existing caesarean section keloid scars. Therefore, in the proposed study, we aim to investigate the effect of surgical excision and corticosteroid (triamcinolone acetonide) injection immediately after surgical removal of old caesarean section keloid scars on the recurrence of the scars. This is a protocol for a randomised controlled trial. METHODS/DESIGN: Pregnant women (n = 150), who attend antenatal clinics at Westmead Hospital in New South Wales, Australia, have a keloid scar from a previous caesarean section, meet the inclusion criteria and sign the consent form, will be randomised to either the control or the intervention group. The control group will receive surgical excision of the keloid scar at the beginning of the procedure during skin incision. The baby will be delivered according to normal procedures, and routine wound closure will be performed in accordance with National Institute for Health and Care Excellence guidelines. The intervention group will receive surgical excision of the keloid scar after the delivery of the baby, and closure of the uterus layers, rectus sheath and the fat layer will be completed as explained above. Then, triamcinolone acetone will be injected sub-dermally at the time of wound closure. Two ampules of triamcinolone acetonide will be administered at a single dose; each ampule contains 10 mg/1 ml active medication. The surgeon will inject one ampule along the entire length of the upper edge of the skin incision and one ampule along the entire length of the lower edge of the skin incision, using a 25 G needle. After the procedure is completed, the surgeon will fill in the post-operation survey. The participants will be followed up post-operation, daily on the ward and then at 6 weeks, 6 months and 12 months post-partum. Main outcomes are (1) keloid formation after caesarean section and (2) changes in the appearance and specification of the keloid scar after the intervention. DISCUSSION: We anticipate that surgical excision and steroid injection will be a safe, lasting and cost-effective treatment in the management of caesarean keloid scars which will be useful for patients unable to undergo cosmetic surgery due to clinical or financial reasons. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12618000984291 . Registered on 12 June 2018.

Foley catheter silicone versus latex for term outpatient induction of labour: A randomised trial.

BACKGROUND: Both silicone and latex single-balloon Foley catheters are available for cervical ripening but no literature exists to compare them. Local experience suggested more frequent insertion-related accidental rupture of the membranes (acROM) with silicone. AIMS: To compare the performance of silicone versus latex catheters with respect to acROM and other outcomes. MATERIALS AND METHODS: Women undergoing outpatient Foley catheter cervical ripening were randomised to a silicone or latex catheter. Data were collected on the primary outcome, acROM, and secondary outcomes including catheter insertion failure, unplanned hospital admission and patient-reported discomfort, together with intrapartum fever and antibiotics for suspected chorioamnionitis along with general obstetric and neonatal outcomes. RESULTS: Among 534 recruited women, acROM was significantly more common with a silicone compared to a latex catheter at 7.2% (19/265) versus 1.5% (4/269) (relative risk (RR) 4.8; 95% CI 1.7-14.0). Insertion failure was significantly less common with silicone than latex at 2.6% (7/265) versus 9.3% (25/269) (RR 0.3; 95% CI 0.1-0.6). However, when the alternative catheter was subsequently tried, the final failure rates were 1.9% silicone (5/265) versus 2.6% latex (7/269). Insertion-related hospital admission was higher with silicone at 9.4% (25/265) than latex at 4.8% (13/269) (RR 2.1; 95% CI 1.1-4.1). All other obstetric outcomes were similar between the groups. CONCLUSION: When used for cervical ripening, a silicone Foley catheter is associated with a higher rate of acROM than a latex catheter but a lower rate of insertion failure. It may, therefore, be reasonable to attempt insertion with a latex catheter initially and manage insertion failures with a silicone catheter.

Comparison of the effect of caseload midwifery program and standard midwifery-led care on primiparous birth outcomes: A retrospective cohort matching study.

BACKGROUND: The effectiveness of continuity of care during the perinatal period is well documented, but implementing continuity of care model to practice requires evaluation. AIM: To evaluate the effect of a caseload midwifery program (CMP) on birth outcomes and rates of perinatal interventions at a metropolitan tertiary hospital in Australia, compared with standard midwifery-led care (SMC). METHODS: This was a retrospective, matched-cohort study. We extracted the data of 1000 nulliparous women from records of 19,001 women who gave birth at the hospital from 2011 to 2014. We used basic statistical tests to compare baseline demographic data, and logistic regression to calculate odds ratios, to evaluate maternal and neonatal outcomes. RESULTS: Adjusted regression analysis for the primary outcome showed that compared with women who received SMC, women who received care through CMP had an increased rate of normal vaginal birth (69% vs. 50%, OR = 1.79, 95%, CI = 1.38-2.32). Assessment of secondary outcomes showed that the women in CMP group had decreased rates of instrumental birth (15% vs. 26%, OR = 0.48, 95% CI = 0.35-0.66), episiotomy (23% vs. 40%, OR = 0.43, 95% CI = 0.33-0.57), epidural analgesia (33% vs. 43%, OR = 0.64, 95% CI = 0.50-0.83) and amniotomy (35% vs. 50%, OR = 0.56, 95% CI = 0.43-0.72). The CMP group also had greater rates of water immersion (54% vs. 22%, OR = 4.18, 95% CI = 3.17-5.5), physiological 3rd stage (7% vs. 1%, OR = 11.71, 95% CI = 3.56-38.43) and 2nd degree tear (34% vs. 24%, OR = 1.60, 95% CI = 1.21-2.11). There were no significant differences between the two groups for rates of other secondary outcomes including Caesarean section, cervical ripening procedures, third- and fourth-degree tears, postpartum haemorrhage and neonatal outcomes. CONCLUSION: CMP care is associated with increased rate of normal vaginal birth which supports wider implementation of the model. In addition, using routinely collected data and a cohort matching design can be an effective approach to evaluate maternal and neonatal outcomes.

Validation of the accuracy of postpartum haemorrhage data in the ObstetriX database: A retrospective cohort study.

BACKGROUND: Data related to postpartum haemorrhage (PPH) are important clinical parameters which can be applied to all places of birth, and their recording can be missed by busy clinicians providing critical care to women. We compared the accuracy of electronic ObstetriX records to the paper-based medical records of the women who sustained PPH. METHODS: In this retrospective cohort study over a period of one month, 363 electronic records were compared to the paper-based medical records. The volume of blood loss for each patient and interventions for PPH were compared across birth unit, operating theatre and postpartum ward. The kappa statistic for agreement between the two types of recording methods was calculated. RESULTS: There was substantial agreement between the ObstetriX records and medical records for the volume of blood loss at birth (kappa = 0.74), but poor agreement between records for the cumulative total volume of blood loss (kappa = 0.18). More women who experienced PPH and delivered in the operating theatre had errors in their ObstetriX records compared to women who had PPH with births in the birth unit (50% vs 16%; n = 73, P = 0.005). Interventions for PPH were found to be poorly recorded in ObstetriX, with 84% (n = 64/76) of women who experienced PPH having none of the interventions they received recorded. CONCLUSIONS: The ObstetriX database was not a generally reliable source of data relating to PPH. However, some data were recorded reliably, in particular, the volume of blood loss at birth.

Outpatient cervical ripening: discomfort/pain during speculum and Foley catheter insertion.

OBJECTIVE: To examine discomfort/pain associated with the Foley catheter insertion process and explore factors affecting discomfort/pain. DESIGN: This cohort study conducted in the context of larger randomised clinical trial comparing silicone and latex Foley catheters. SETTING: A tertiary hospital in Western Sydney. PARTICIPANTS: Outpatient pregnant women (eligible participants in the main study). INTERVENTIONS: We asked about the discomfort/pain expectations and experience during the digital vaginal examination and insertion of the speculum, insertion of the Foley catheter and while the catheter was in situ. MEASUREMENTS: We used visual analog scale and a purposefully designed questionnaire to measure outcomes. FINDINGS: We found digital vaginal examination and speculum insertion (mean pain score = 4.6-4.7/10) to be significantly more uncomfortable than Foley catheter insertion (mean pain score = 3/10), while having the catheter in situ for a median of 14 h was mid-way in discomfort (mean pain score = 3.7/10). Only 12-13% of women experienced no discomfort during digital vaginal examination and speculum insertion, while about 40% experienced no discomfort during Foley catheter insertion. We identified no factors that influenced the experience of discomfort during speculum insertion. However, being overseas-born (odds ratio = 1.91, 95% = 1.10, 3.33) and experiencing discomfort during the speculum insertion (odds ratio = 8.15, 95% = 3.19, 20.79) increased the chance of discomfort on catheter insertion. Women's discomfort was not influenced by inserter designation or experience. KEY CONCLUSIONS: Digital vaginal examination and speculum insertion were moderately uncomfortable while insertion of a Foley catheter and having the catheter in situ for several hours were less uncomfortable procedures. IMPLICATIONS FOR PRACTICE: Only 8% of insertions were rated as difficult by staff while 70% were rated easy. This, together with the fact that the inserter's level of experience had no influence on women's discomfort, are reassuring for midwives who wish to teach and learn this common procedure.

Intravenous iron vs blood for acute post-partum anaemia (IIBAPPA): a prospective randomised trial.

BACKGROUND: Acute post-partum anaemia can be associated with significant morbidity including a predisposition for postnatal depression. Lack of clear practice guidelines means a number of women are treated with multiple blood transfusions. Intravenous iron has the potential to limit the need for multiple blood transfusions but its role in the post-partum setting is unclear. METHODS/DESIGN: IIBAPPA is a multi-centre randomised non-inferiority trial. Women with a primary post-partum haemorrhage (PPH) >1000 mL and resultant haemoglobin (Hb) 5.5-8.0 g/dL after resuscitation with ongoing symptomatic anaemia who are otherwise stable (no active bleeding) are eligible to participate. Patients with sepsis or conditions necessitating rapid Hb restoration are excluded. Eligible participants are randomised to receive a blood transfusion or a single dose of intravenous iron polymaltose calculated using the Ganzoni formula. Primary outcome measures include Hb, Ferritin and C-Reactive Protein levels on Day 7. Secondary outcomes evaluate (i) Hb, Ferritin and CRP levels on Day 14, 28, (ii) anaemia symptoms on Day 0, 7, 14 and 28 using structured health related quality of life questionnaires, (iii) treatment safety by assessing adverse reactions and infection endpoints and (iv) the quantitative impact of anaemia on breast feeding quality using a hospital designed questionnaire. DISCUSSION: If equivalence in Hb and ferritin levels, symptom scores and safety endpoints is demonstrated, intravenous iron may become the preferred treatment for women with acute post-partum anaemia to minimise transfusion reactions and costs. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry: ACTRN12615001370594 on 16th December, 2015 (prospective approval).