Review: Targeted nutrition in gestating sows: opportunities to enhance sow performance and piglet vitality.

Birth weight is a key factor for piglet survival, and therefore, there is ongoing interest in how nutrition during gestation can influence birth weight. Interestingly, sows are generally fed one single diet throughout gestation. This paper reviews past attempts to increase foetal growth to term and discusses opportunities to target nutritional manipulations at specific windows of gestation where key developmental events occur. Birth weight limits chances to survive mainly in piglets with birth weight below 1 kg. These piglets represent around 16% of the population. Given the normal distribution of birth weight, the mean birth weight needs to be increased by at least 50-100 g to have a meaningful impact on this proportion of the population and on perinatal survival. Based on existing variation in reported mean birth weight across a number of studies, it is argued that it is unrealistic to expect an increase in mean birth weight of more than 100 g. Attempts in the past to increase birth weight have focussed on the last trimester of gestation, when foetal growth is accelerated. Increase in feed allowance or nutritional concepts that target placenta vascularisation have not been successful. It is argued that nutritional manipulations should rather focus on the middle of gestation, since in that period, placenta growth occurs and since placenta size limits the foetal size. Alternatively, nutritional manipulations can target placentation during the embryonic phase.

Effect of low colostrum intake on gastrointestinal development and uterine and cervical morphometrical architecture in the neonatal gilt.

To assess the importance of natural variation in colostrum intake on piglet gastrointestinal and reproductive development, two equally sized female piglets from each of 27 litters were selected, one with low (average 226 g) and one with high (average 401 g) colostrum intake. At weaning (23 d of age), piglets were euthanised to perform macromorphological measurements on ileum, colon, cervix and uterus tissues, and to obtain tissue samples from the cervix and uterus for histology. Sections of uterine and cervical preparations were analysed using digital image analysis. Despite being selected for the same birth weight (average 1.1 kg, standard deviation 0.18 kg), piglets with low colostrum intake weighed 5.91 ± 0.17 kg and piglets with high colostrum intake weighed 6.96 ± 0.19 kg at weaning (P < 0.05). Most of the micro- and macroscopic measures such as length and weight of ileum and colon, cervix and uterus, luminal size of cervix and uterus, number of cervical crypts and uterine glands, were greater in gilts with high colostrum intake. The histological architecture of the uterus and cervix in gilts with high colostrum intake showed more complexity, reflecting more advanced development in these piglets. In conclusion, these data demonstrate that independent of birth weight, natural variation in colostrum intake is related to the overall development of neonatal piglets, affecting body growth, as well as growth and development of the gut and reproductive tract.

[The Dutch Child Health Care guideline 'early detection of congenital heart disease in the age group 0-19 years']. / De standaard 'Vroegtijdige opsporing van aangeboren hartafwijkingen 0-19 jaar' van de jeugdgezondheidszorg.

The Dutch Child Health Care guideline on the early detection of congenital heart disease was developed according to the principles for evidence-based guideline development and contains recommendations for the conduct of the examination during routine check-ups and for referral criteria. Most congenital heart diseases can be detected in the first year of life if physicians and nurses work according to this guideline. Important early times for screening are the home visit to infants at the age of two weeks by the child health nurse and the routine check-up of infants at the age of four weeks by the child health care physician. A routine cardiac screening is carried out in every child by the nurse and the physician at times specified in the basic list of professional responsibilities. A more extensive examination is carried out when indicated. Routine cardiac check-ups are recommended until the age of four, after which they should be done only when indicated on medical grounds. A feasibility study showed that physicians and nurses can apply the guideline effectively, provided that they take part in prior specific training.

Do patients matter? Contribution of patient and care provider characteristics to the adherence of general practitioners and midwives to the Dutch national guidelines on imminent miscarriage.

OBJECTIVE: To assess the relative contribution of patient and care provider characteristics to the adherence of general practitioners (GPs) and midwives to two specific recommendations in the Dutch national guidelines on imminent miscarriage. The study focused on performing physical examinations at the first contact and making a follow up appointment after 10 days because these are essential recommendations and there was much variation in adherence between different groups of providers. DESIGN: Prospective recording by GPs and midwives of care provided for patients with symptoms of imminent miscarriage. SETTING: General practices and midwifery practices in the Netherlands. SUBJECTS: 73 GPs and 38 midwives who agreed to adhere to the guidelines; 391 patients were recorded during a period of 12 months. MAIN MEASURES: Adherence to physical examinations and making a follow up appointment were measured as part of a larger prospective recording study on adherence to the guidelines on imminent miscarriage. Patient and care provider characteristics were obtained from case recordings and interviews, respectively. Multilevel analysis was performed to assess the contribution of several care provider and patient characteristics to adherence to two selected recommendations: the number of recommended physical examinations at the first contact and the number of days before a follow up appointment took place. RESULTS: In the multilevel model explaining variance in adherence to physical examinations, the care provider's acceptance of the recommendations was the most important factor. Severity of symptoms and referral to an obstetrician were significant factors at the patient level. In the model for follow up appointments the characteristics of the care provider were less important. Referral to an obstetrician and probability diagnosis were significant factors at the patient level. CONCLUSIONS: The study showed that characteristics of both the patient and care provider contribute to the variability in adherence. Furthermore, the contribution of the characteristics differed per recommendation. It is therefore advised that the contribution of both patient and care provider characteristics per recommendation should be carefully examined. If implementation is to be successful, strategies should be developed to address these specific contributions.

Adherence by midwives to the Dutch national guidelines on threatened miscarriage in general practice: a prospective study.

OBJECTIVE: To determine the feasibility for midwives to adhere to Dutch national guidelines on threatened miscarriage in general practice. DESIGN: Prospective recording of appointments by midwives who agreed to adhere to the guidelines on threatened miscarriage. Interviews with the midwives after they had recorded appointments for one year. SETTING: Midwifery practices in The Netherlands. SUBJECTS: 56 midwives who agreed to adhere to the guidelines; 43 midwives actually made records from 156 clients during a period of 12 months. MAIN OUTCOME MEASURES: Adherence to each recommendation and reasons for non-adherence. RESULTS: The recommendation that a physical examination should take place on the first and also on the follow up appointment was not always adhered to. Reasons for non-adherence were the midwives' criticism of this recommendation, their lack of knowledge or skills, and the specific client situation. Adherence to a follow up appointment after 10 days, a counselling consultation after six weeks, and not performing an ultrasound scan was low. Reasons for non-adherence were mainly based on the midwives' criticism of these recommendations and reluctance on the part of the client. Furthermore, many midwives did not give information and instructions to the client. It is noteworthy that in 13% of the cases the midwife's policy was overridden by the obstetrician taking control of the situation after the midwife had requested an ultrasound scan. CONCLUSIONS: Those recommendations in the guidelines on threatened miscarriage that are most often not adhered to should be reviewed. To reduce conflicts about ultrasound scans and referrals, agreement on the policy on threatened miscarriage should be mutually established between midwives and obstetricians.

[Does the '(Imminent) miscarriage standard of the Dutch College of Family Physicians correspond to the management by gynecologists?]. / Sluit de standaard '(Dreigende) miskraam' van het Nederlands Huisartsen Genootschap aan bij het beleid van gynaecologen?

OBJECTIVE: To determine if the '(Imminent) miscarriage' standard issued by the Dutch College of General Practitioners corresponds to the management by obstetricians. DESIGN: Postal questionnaire. SETTING: Research Centre Primary/Secondary Health Care, Free University Hospital Amsterdam. METHOD: A postal questionnaire was sent in 1994 to all partnerships of obstetricians (n = 122) in the Netherlands about their management in case of an imminent miscarriage. RESULTS: The response rate was 86% (n = 105). Nearly all partnerships (94%) had an agreement about their management in case of an imminent miscarriage, but the individual protocols varied. In case of a miscarriage or an imminent miscarriage 10% and 28% respectively of all partnerships said they would refer the woman to the GP or midwife. Furthermore, 21% of all partnerships said that the GP or midwife could not have an ultrasound scan made themselves, i.e. without referring to the obstetrician. Many respondent knowing the GP standard (64%) did not agree with the guidelines restricting ultrasound scans (39%) or advising expectative management (24%). They thought that an ultrasound scan was essential to diagnosis and that an expectative management would increase the risk of severe blood loss. On the other hand 15% agreed to all the guidelines. CONCLUSION: The management of obstetricians with respect to (imminent) miscarriage is diverse and does not correspond to the guidelines of the '(Imminent) miscarriage' GP standard, notably with respect to the advised expectative management.

[Cause for referral by family physicians and obstetricians in Amsterdam in (threatened) miscarriage as reflected in the guideline '(Threatened) abortion' of the Dutch Society for Family Physicians]. / Verwijsredenen van huisartsen en verloskundigen in Amsterdam bij (dreigende) miskraam gespiegeld aan de standaard '(Dreigende) miskraam' van het Nederlands Huisartsen Genootschap.

OBJECTIVE: To determine the reasons general practitioners (GPs) and midwives have for referring patients with symptoms of imminent miscarriage to hospital and the management in hospital. DESIGN: Prospective and descriptive. SETTING: Research Centre Primary/Secondary Health Care, University Hospital Free University, the "Onze Lieve Vrouwe Gasthuis' hospital, both in Amsterdam, the Netherlands. METHOD: During the period August 1994-February 1995 anamnesis, diagnostics, diagnosis and further management were recorded for all patients who visited the "Onze Lieve Vrouwe Gasthuis' hospital with blood loss and/or pain in the first 16 weeks of gestation. Patients revealed their wishes concerning referral by filling in questionnaires. Their GPs/midwives were asked about the referral motives in a telephone interview. RESULTS: In the hospital 105 patients were recorded; 34% came on their own initiative. In hospital none of the patients with the diagnosis "imminent miscarriage' was referred back to the GP/midwife. Only 59% of the GPs/midwives performed the physical examinations the (imminent) miscarriage guideline of the Dutch College of General Practitioners advises. In 56% of the 32 patients referred there was no reason for referral according to the (imminent) miscarriage guideline. CONCLUSION: The (imminent) miscarriage guideline issued by the Dutch College of General Practitioners was not always followed because patients went to the hospital on their own account, GPs/midwives did not agree with the guideline, patients wanted another policy and obstetricians kept patients in their own care.

Patients' and professionals' barriers and facilitators to external cephalic version for breech presentation at term, a qualitative analysis in the Netherlands.

OBJECTIVE: external cephalic version (ECV) is a relatively simple and safe manoeuvre and a proven effective approach in the reduction of breech presentation at term. There is professional consensus that ECV should be offered to all women with a fetus in breech presentation, but only up to 70% of women eligible for ECV undergo an ECV attempt. The aim of the study was to identify barriers and facilitators for ECV among professionals and women with a breech presentation at term. DESIGN: qualitative study with semi-structured interviews. SETTING: Dutch hospitals. PARTICIPANTS: pregnant women with a breech presentation who had decided on ECV, and midwives and gynaecologists treating women with a breech presentation. MEASUREMENTS: on the basis of national guidelines and expert opinions, we developed topic lists to guide the interviews and discuss barriers and facilitators in order to decide on ECV (pregnant women) or advice on ECV (midwives and gynaecologists). FINDINGS: among pregnant women the main barriers were fear, the preference to have a planned caesarean section (CS), incomplete information and having witnessed birth complications within the family or among friends. The main facilitators were the wish for a home birth, the wish for a vaginal delivery and confidence of the safety of ECV. Among professionals the main barriers were a lack of knowledge to fully inform and counsel patients on ECV, and the inability to counsel women who preferred a primary CS. The main facilitator was an unambiguous policy on (counselling for) ECV within the region. CONCLUSION: we identified several barriers and facilitators possibly explaining the suboptimal implementation of ECV for breech presentation in the Netherlands. This knowledge should be taken into account in designing implementation strategies for ECV to improve the uptake of ECV by professionals and patients.

The quality of the discharge planning process: the effect of a liaison nurse.

A project employing a liaison nurse has been started in the Dutch Zaandam region. The liaison project will focus on the experience of problems in preparing for hospital discharge and on continuity between hospital and home care. This article discusses the effect of the liaison nurse on the quality of the discharge planning process. The investigation included a pre-test and a main test for which data were collected using questionnaires. These were sent to patients who had received after-care on being discharged from hospital. To measure the quality of the discharge process and after-care continuity, use was made of explicit quality criteria, targeting discharge planning. The results show that discharge planning in hospitals has improved. No significant improvement was detected with respect to continuity of care. It may be concluded that the discharge process requires more attention. The quality criteria used here could function as points of departure.

Care for the imminent miscarriage by midwives and GPs.

A postal questionnaire was sent to a random sample of 495 Dutch general practitioners (GPs) and 278 midwives to evaluate the use of the 'imminent miscarriage' standard used by the Dutch College of General Practitioners. The response rates were 63 and 87% respectively. The first questions asked related to the respondents' routine management of an imminent miscarriage. The second part of the questionnaire addressed the respondents' attitude to the 17 most important guidelines in the standard. Finally, the respondents were invited to describe problems arising in adhering to the standard. Midwives and GPs differed in their management of an imminent miscarriage. Midwives used more 'technology' such as ultrasound scans or a doptone to trace complications or see if the fetus was still viable, whereas the GPs more often carried out vaginal and speculum examinations. Midwives also paid more attention to care following a miscarriage. The guidelines that many respondents did not adhere to involved the period of 10 days for the follow-up appointment and counselling after 6 weeks. Guidelines restricting ultrasound scans and the decision only to refer the patients to an obstetrician after three consecutive miscarriages were also not accepted by all respondents. Respondents mentioned several practical problems or obstacles in adhering to the standard, including women's requests for ultrasound scans or referrals and also the attitude of obstetricians who sometimes simply assumed control. The results will serve as a starting point for updating the standard.

Does the care given by general practitioners and midwives to patients with (imminent) miscarriage meet the wishes and expectations of the patients?

OBJECTIVE: In 1989 a Dutch national guideline on (imminent) miscarriage was developed for use in general practice. A prospective recording study was carried out to determine how the patients evaluated the care they received from general practitioners (GPs) and midwives who agreed to adhere to this (imminent) miscarriage guideline and to determine the aspects that influence this evaluation. SETTING: GP practices and midwifery practices in The Netherlands. DESIGN: Prospective recording of appointments during 4 consecutive weeks in a diary by patients who contacted their GP or midwife with symptoms of (imminent) miscarriage. STUDY PARTICIPANTS: Over a period of 12 months, 75 GPs and 43 midwives recorded all patients (n = 407) showing symptoms of (imminent) miscarriage. In total 265 patients had completed at least the first contact in the diary; 200 patients actually recorded all contacts. RESULTS: Most patients gave their GP or midwife a high evaluation score (8.2 or 8.7 respectively). Yet, 20% thought that the care could be improved if the GP or midwife gave more information, was more empathetic and carried out an ultrasound scan. In determining the aspects that have most influence on the patients' evaluation, empathy and support came first, followed by involvement of the patient in decision making, putting her at ease, and the total duration of the contacts. Although patients who wanted a referral gave a lower score, this seems to be of less importance than the above mentioned aspects. Expecting and getting an ultrasound scan did not influence the patient's evaluation.