Normal birth rates before and after the merging of mixed-risk and low-risk maternity wards in Iceland: A retrospective cohort study on the impact of inter-professional preventative measures.

BACKGROUND: In 2014, the National University Hospital of Iceland (NUHI) merged a mixed-risk birth unit and a midwifery-led low-risk unit into one mixed-risk unit. Interprofessional preventative and mitigating measures were implemented since there was a known threat of cultural contamination between mixed-risk and low-risk birth environments. The aim of the study was to assess whether the NUHI's goal of protecting the rates of birth without intervention had been achieved and to support further development of labor services. METHODS: A retrospective cohort study of all women who had singleton births at NUHI birth units in two 2-year periods, 2012-2013 and 2015-2016. The primary outcome variables, birth without intervention, with or without artificial rupture of membranes (AROM), were adjusted for confounding variables using logistic regression analysis. Secondary outcome variables (individual interventions and maternal and neonatal complications) were analyzed using descriptive statistics, t test, and Chi-square test. RESULTS: The rate of births without interventions, both with and without AROM, increased significantly after the unit merger and accompanying preventative measures. The rates of AROM, oxytocin augmentation, episiotomies, and epidural analgesia decreased significantly. The rate of induction increased significantly. There were no significant differences in maternal or neonatal complication rates. CONCLUSIONS: Interprofessional preventative measures, implemented alongside a mixed-risk and low-risk birth unit merger, can increase rates of births without interventions in a mixed-risk hospital setting. However, it is necessary to maintain awareness of the possible effects of a mixed-risk birth environment on the use of childbirth interventions and examine the long-term effects of preventative measures.

[Visual field loss in eyes undergoing minimally invasive glaucoma surgery in Iceland].

INTRODUCTION: Glaucoma is a degenerative disease of the optic nerve and is marked by visual field defects (VFD). The only approved treatment is IOP lowering, either with eye drops, laser or surgery. Minimally invasive glaucoma surgery (MIGS) has become an appealing treatment modality, offering IOP lowering effect without the complication rates of trabeculectomy or the patient adherence required for pharmacologic therapy. In this study we aim to describe the severity of VFD in patients undergoing their first MIGS surgery. METHODS: Retrospective study reviewing the medical records of all patients that underwent MIGS surgery at the University Hospital of Iceland from January 2019 to June 2020. Eyes with previous glaucoma surgeries and secondary glaucomas were excluded. The results were divided into two groups, MIGS with phacoemulsification and standalone MIGS. RESULTS: 112 eyes included in the study. Mean age 74.5 ± 10.6 years. The mean defect (MD) score was 8.8 ± 6.4 and the number of glaucoma medications 1.8 ± 1.0 for the group as a whole. Significant difference (p<0.01) was between the age, MD score and the number of glaucoma medications between the two groups. Looking at the eyes that did not undergo phacoemulsification a significant difference (p<0.05) was between the MD score of primary open angle glaucoma eyes, 11.2 ± 6.5 dB and pseudoexfoliation glaucoma, 6.0 ± 3.3 dB. CONCLUSION: Visual field defect and the number of glaucoma medications at referral to surgery was markedly less compared to a trabeculectomy study done in Iceland 3 years prior. Few comparable studies include MD score in their results, most focus on changes in intraocular pressure. Comparing the MD score to three studies from Germany and Austria the MD score seems to be similar. In our study a lower MD score for pseudoexfoliation glaucoma implies that Icelandic ophthalmologists send pseudoexfoliation eyes earlier for an operation.

[Medical management of glaucoma and interaction between glaucoma and systemic medications].

INTRODUCTION: Glaucoma used to be the most common cause for blindness in Iceland. As the incidence of glaucoma increases with age, the patients often have numerous comorbidities and use various medications. It is important to keep in mind interactions and side effects of glaucoma medications when deciding systemic medical treatment for these patients to ensure their safety and comfort. The goal of the study was to gather information about drug use of patients with severe glaucoma. METHODS: A retrospective study where data were collected from 100 consecutive patients who underwent a trabeculectomy as first glaucoma surgery at Landspitali National University Hospital of Iceland during 2013-2017. All systemic and ophthalmic medications during 6 months before and after the surgery, medical diagnoses, age and gender of the patients were registered. RESULTS: Of all 100 patients, 87 used systemic medication, averaging 5.3 drugs/patient. Mean number of glaucoma medication used was 3.0. Mean age at surgery was 75 years and 53 were women. The most common systemic drug class was anti-hypertensives, used by 57 patients where beta-blockers were the most common, used by 30 patients. Zopiclone was the most common single drug, used by 29 patients. CONCLUSION: It is evident that patients with glaucoma take various drugs for systemic illness that can affect their glaucoma and have interactions with glaucoma drugs. It is urgent that healthcare providers keep this in mind when deciding on systemic treatment for patients with glaucoma, with regards to possible interactions with glaucoma drugs and the effect on patient's overall health.

Perineal injuries and birth positions among 2992 women with a low risk pregnancy who opted for a homebirth.

BACKGROUND: Whether certain birth positions are associated with perineal injuries and severe perineal trauma (SPT) is still unclear. The objective of this study was to describe the prevalence of perineal injuries of different severity in a low-risk population of women who planned to give birth at home and to compare the prevalence of perineal injuries, SPT and episiotomy in different birth positions in four Nordic countries. METHODS: A population-based prospective cohort study of planned home births in four Nordic countries. To assess medical outcomes a questionnaire completed after birth by the attending midwife was used. Descriptive statistics, bivariate analysis and logistic regression were used to analyze the data. RESULTS: Two thousand nine hundred ninety-two women with planned home births, who birthed spontaneously at home or after transfer to hospital, between 2008 and 2013 were included. The prevalence of SPT was 0.7 % and the prevalence of episiotomy was 1.0 %. There were differences between the countries regarding all maternal characteristics. No association between flexible sacrum positions and sutured perineal injuries was found (OR 1.02; 95 % CI 0.86-1.21) or SPT (OR 0.68; CI 95 % 0.26-1.79). Flexible sacrum positions were associated with fewer episiotomies (OR 0.20; CI 95 % 0.10-0.54). CONCLUSION: A low prevalence of SPT and episiotomy was found among women opting for a home birth in four Nordic countries. Women used a variety of birth positions and a majority gave birth in flexible sacrum positions. No associations were found between flexible sacrum positions and SPT. Flexible sacrum positions were associated with fewer episiotomies.

Transfers to hospital in planned home birth in four Nordic countries - a prospective cohort study.

INTRODUCTION: Women planning a home birth are transferred to hospital in case of complications or elevated risk for adverse outcomes. The aim of the present study was to describe the indications for transfer to hospital in planned home births, and the proportion of cases in which this occurs. MATERIAL AND METHODS: Women in Norway, Sweden, Denmark and Iceland who had opted for, and were accepted for, home birth at the onset of labor, were included in the study. Data from 3068 women, 572 nulliparas and 2446 multiparas, were analyzed for proportion of transfers during labor and within 72 h after birth, indications for transfer, how long before or after birth the transfer started, time from birth to start of transfer, duration and mode of transfer, and whether the transfer was classified as potentially urgent. Analyses were stratified for nulliparity and multiparity. RESULTS: One-third (186/572) of the nulliparas were transferred to hospital, 137 (24.0%) during labor and 49 (8.6%) after the birth. Of the multiparas, 195/2446 (8.0%) were transferred, 118 (4.8%) during labor and 77 (3.2%) after birth. The most common indication for transfers during labor was slow progress. In transfers after birth, postpartum hemorrhage, tears and neonatal respiratory problems were the most common indications. A total of 116 of the 3068 women had transfers classified as potentially urgent. CONCLUSIONS: One-third of all nulliparous and 8.0% of multiparous women were transferred during labor or within 72 h of the birth. The proportion of potentially urgent transfers was 3.8%.

History of violence and subjective health of mother and child.

OBJECTIVE: To study the self-reported prevalence of experienced violence among a cohort of women about two years after giving birth, their health during pregnancy, pregnancy outcomes and their experience of their child's health. SETTING AND SUBJECTS: In 2011, a total of 657 women participated in phase III of the Childbirth and Health Cohort Study in Icelandic Primary Health Care, 18 to 24 months after delivery. The women had previously participated in phase I around pregnancy week 16 and phase II 5-6 months after delivery. Data were collected by postal questionnaires. MAIN OUTCOME MEASURES: Women's reported history of experienced violence, sociodemographic and obstetric background, self-perceived health, the use of medications and their child's perceived health. RESULTS: In phase III, 16% of women reported experiencing violence. These women felt less support from their current partner (p < 0.001), compared to those who did not report violence. Their pregnancies were more frequently unplanned (p < 0.001), deliveries more often by caesarean section (p < 0.05), and their self-perceived health was worse (p < 0.001). They reported more mental and somatic health complaints, and their use of antidepressant drugs was higher (p < 0.001). Furthermore, women with a history of violence considered their child's general health as worse (p = 0.008). CONCLUSIONS: Our study confirms that a history of violence is common among women. A history of violence is associated with various maternal health problems during and after pregnancy, a higher rate of caesarean sections and maternal reports of health problems in their child 18-24 months after birth. KEY POINTS Violence is a major concern worldwide. Understanding the impact of violence on human health and developing effective preventive measures are important elements of any public health agenda. • The reported prevalence of experiencing violence was 16% among women attending antenatal care in the primary health care setting in Iceland. • Women with a history of violence reported worse health in general during pregnancy and delivered more often by caesarean section, compared to women with no such history. • Mothers with a history of violence also evaluated the general health of their child as worse than women with no such history. • The findings of this study support the importance of recognizing and addressing experienced violence among women in primary care.

Outcome of planned home and hospital births among low-risk women in Iceland in 2005-2009: a retrospective cohort study.

BACKGROUND: At 2.2 percent in 2012, the home birth rate in Iceland is the highest in the Nordic countries and has been rising rapidly in the new millennium. The objective of this study was to compare the outcomes of planned home births and planned hospital births in comparable low-risk groups in Iceland. METHODS: The study is a retrospective cohort study comparing the total population of 307 planned home births in Iceland in 2005-2009 to a matched 1:3 sample of 921 planned hospital births. Regression analysis, adjusted for confounding variables, was performed for the primary outcome variables. RESULTS: The rate of oxytocin augmentation, epidural analgesia, and postpartum hemorrhage was significantly lower when labor started as a planned home birth. Differences in the rates of other primary outcome variables were not significant. The home birth group had lower rates of operative birth and obstetric anal sphincter injury. The rate of 5-minute Apgar score < 7 was the same in the home and hospital birth groups, but the home birth group had a higher rate of neonatal intensive care unit admission. Intervention and adverse outcome rates in both study groups, including transfer rates, were higher among primiparas than multiparas. Oxytocin augmentation, epidural analgesia, and postpartum hemorrhage rates were significantly interrelated. CONCLUSIONS: This study adds to the growing body of evidence that suggests that planned home birth for low-risk women is as safe as planned hospital birth.

How Long Is a Normal Labor? Contemporary Patterns of Labor and Birth in a Low-Risk Sample of 1,612 Women from Four Nordic Countries.

OBJECTIVE: Normal progress of labor is a subject for discussion among professionals. The aim of this study was to assess the duration of labor in women with a planned home birth and spontaneous onset who gave birth at home or in hospital after transfer. METHODS: This is a population-based study of home births in four Nordic countries (Denmark, Iceland, Norway, and Sweden). All midwives assisting at a home birth from 2008 to 2013 were asked to provide information about home births using a questionnaire. RESULTS: Birth data from 1,612 women, from Denmark (n = 1,170), Norway (n = 263), Sweden (n = 138), and Iceland (n = 41) were included. The total median duration from onset of labor until the birth of the baby was approximately 14 hours for primiparas and 7.25 hours for multiparas. The duration of the different phases varied between countries. Blood loss more than 1,000 mL and perineal ruptures that needed suturing were associated with a longer pushing phase and the latter with country of residence, parity, single status, and the baby's weight. CONCLUSION: In this population of healthy women with a low prevalence of interventions, the total duration of labor was fairly similar to what is described in the literature for multiparas, but longer for primiparas. Although the duration of the phases of labor differed among countries, it was to a minor extent associated with severe outcomes.

Autonomy in place of birth: a concept analysis.

This article examines one of the relevant concepts in the current debate on home birth-autonomy in place of birth-and its uses in general language, ethics, and childbirth health care literature. International discussion on childbirth services. A concept analysis guided by the model of Walker and Avant. The authors suggest that autonomy in the context of choosing place of birth is defined by three main attributes: information, capacity and freedom; given the antecedent of not harming others, and the consequences of accountability for the outcome. Model, borderline and contrary cases of autonomy in place of birth are presented. A woman choosing place of birth is autonomous if she receives all relevant information on available choices, risks and benefits, is capable of understanding and processing the information and choosing place of birth in the absence of coercion, provided she intends no harm to others and is accountable for the outcome. The attributes of the definition can serve as a useful tool for pregnant women, midwives, and other health professionals in contemplating their moral status and discussing place of birth.

A variant associated with nicotine dependence, lung cancer and peripheral arterial disease.

Smoking is a leading cause of preventable death, causing about 5 million premature deaths worldwide each year. Evidence for genetic influence on smoking behaviour and nicotine dependence (ND) has prompted a search for susceptibility genes. Furthermore, assessing the impact of sequence variants on smoking-related diseases is important to public health. Smoking is the major risk factor for lung cancer (LC) and is one of the main risk factors for peripheral arterial disease (PAD). Here we identify a common variant in the nicotinic acetylcholine receptor gene cluster on chromosome 15q24 with an effect on smoking quantity, ND and the risk of two smoking-related diseases in populations of European descent. The variant has an effect on the number of cigarettes smoked per day in our sample of smokers. The same variant was associated with ND in a previous genome-wide association study that used low-quantity smokers as controls, and with a similar approach we observe a highly significant association with ND. A comparison of cases of LC and PAD with population controls each showed that the variant confers risk of LC and PAD. The findings provide a case study of a gene-environment interaction, highlighting the role of nicotine addiction in the pathology of other serious diseases.

Attitudes of Registered and Licensed Practical Nurses About the Importance of Families in Surgical Hospital Units: Findings From the Landspitali University Hospital Family Nursing Implementation Project.

The purpose of this study was to examine attitudes of registered nurses and licensed practical nurses about the importance of the family in surgical hospital units before (T1) and after (T2) implementation of a Family Systems Nursing educational intervention based on the Calgary Family Assessment and Intervention Models. This study was part of the Landspitali University Hospital Family Nursing Implementation Project and used a nonrandomized, quasi-experimental design with nonequivalent group before and after and without a control group. There were 181 participants at T1 and 130 at T2. No difference was found in nurses' attitudes as measured by the Families Importance in Nursing Care-Nurses' Attitudes (FINC-NA) questionnaire, before and after the educational intervention. Attitudes toward families were favorable at both times. Analysis of demographic variables showed that age, work experience, and workplace (inpatient vs. outpatient units) had an effect on the nurses' attitudes toward families. The influence of work experience on attitudes toward family care warrants further exploration.

Implementation of a midwifery model of woman-centered care in practice: Impact on oxytocin use and childbirth experiences.

INTRODUCTION: Theoretical models for midwifery have been developed in different countries, but few have been evaluated. This study evaluated the implementation of a midwifery model of woman-centered care (MiMo) in practice. METHODS: A mixed method study based on an implementation of MiMo was carried out in a labor ward at a university hospital in Sweden, with another labor ward as a reference. The qualitative core component was a secondary analysis of focus groups with midwives after the implementation. The supplemental quantitative components were oxytocin use for augmentation of labor and women's childbirth experiences before and after the implementation. RESULTS: The midwives viewed MiMo as a useful tool for comprehending the birthing woman holistically, and for identifying what might disturb the birth process. Hindering factors were a lack of organizational stability and time, and midwives' unwillingness to understand the model. Oxytocin use decreased significantly only in the implementation ward (p=0.002) and a significant difference was found between wards in the post-implementation period (p=0.004). However, logistic regression analyses showed that the interaction between ward and time period, controlling for age, epidural use, and birth outcome, was not significant (p=0.304), indicating that the decrease was not significantly related to the implementation. Childbirth experience did not differ before and after the implementation. CONCLUSIONS: By using MiMo in practice, midwives have a tool for comprehending the woman holistically and identifying disturbing factors during the birth. However, more research is needed for further implementation that should focus on the potential as well as hindering factors.

Topical noninvasive retinal drug delivery of a tyrosine kinase inhibitor: 3% cediranib maleate cyclodextrin nanoparticle eye drops in the rabbit eye.

PURPOSE: Tyrosine kinase inhibitors inhibit VEGF receptors. If delivered to the retina, they might inhibit oedema and neovascularization such as in age-related macular degeneration and diabetic retinopathy. The aim of this study was to formulate cediranib maleate, a potent VEGF inhibitor, as γ-cyclodextrin nanoparticle eye drops and measure the retinal delivery and overall ocular pharmacokinetics after a single-dose administration in rabbits. METHODS: A novel formulation technology with 3% cediranib maleate as γ-cyclodextrin micro-suspension was prepared by autoclaving method. Suitable stabilizers were tested for heat-stable eye drops. The ophthalmic formulation was topically applied to one eye in rabbits. The pharmacokinetics in ocular tissues, tear film and blood samples were studied at 1, 3 and 6 hr after administration. RESULTS: γ-cyclodextrin formed complex with cediranib maleate. The formation of γ-cyclodextrin nanoparticles occurred in concentrated complexing media. Combined stabilizers prevented the degradation of drug during the autoclaving process. Three hours after administration of the eye drops, treated eyes showed cediranib levels of 737 ± 460 nM (mean ± SD) in the retina and 10 ± 6 nM in the vitreous humour. CONCLUSIONS: Cediranib maleate in γ-cyclodextrin nanoparticles were stable to heat in presence of stabilizers. The drug as eye drops reached the retina in concentrations that are more than 100 times higher than the 0.4 nM IC50 value reported for the VEGF type-II receptor and thus, presumably, above therapeutic level. These results suggest that γ-cyclodextrin-based cediranib maleate eye drops deliver effective drug concentrations to the retina in rabbits after a single-dose administration.

Being in charge in an encounter with extremes. A survey study on how women experience and work with labour pain in a Nordic home birth setting.

PROBLEM: There is a knowledge gap regarding women's experiences of coping with labour pain when not soliciting or not having access to pharmacological pain relief. BACKGROUND: How women manage labour pain is complex, multifaceted and only the woman giving birth can assess the experienced pain. Women in the Nordic countries planning for a homebirth have little or no access to pharmacologic pain relief during labour. AIM: The aim of this study was to explore how women experience and work with labour pain when giving birth in their own home. METHODS: Quantitative and qualitative data was prospectively collected and altogether 1649 women with a planned homebirth answered closed and open-ended questions about labour pain and birth experience. RESULTS: While labour pain was often experienced as positive or very positive, the intensity was experienced as severe or the worst imaginable pain. Two main themes arose from the womens´ descriptions of their birth experience regarding labour pain: An encounter with extremes and Being in charge at home. DISCUSSION: Women perceived labour pain as severe but manageable and were dedicated to completing the birth at home. Being at home enabled the women to exercise autonomy and work with labour pain on their own terms, together with the midwife and support persons. CONCLUSIONS: This study provides knowledge about women's experiences of labour pain in a home birth setting who used varying strategies to work with labour pain. This is a subject that should be explored further since results could also apply to facility-based birth settings.

Automatic fundus image quality assessment on a continuous scale.

Fundus photography is commonly used for screening, diagnosis, and monitoring of various diseases affecting the eye. In addition, it has shown promise in the diagnosis of brain diseases and evaluation of cardiovascular risk factors. Good image quality is important if diagnosis is to be accurate and timely. Here, we propose a method that automatically grades image quality on a continuous scale which is more flexible than binary quality classification. The method utilizes random forest regression models trained on image features discovered automatically by combining basic image filters using simulated annealing as well as features extracted with the discrete Fourier transform. The method was developed and tested on images from two different fundus camera models. The quality of those images was rated on a continuous scale from 0.0 to 1.0 by five experts. In addition, the method was tested on DRIMDB, a publicly available dataset with binary quality ratings. On the DRIMDB dataset the method achieves an accuracy of 0.981, sensitivity of 0.993 and specificity of 0.958 which is consistent with the state of the art. When evaluating image quality on a continuous scale the method outperforms human raters.

Automation improves repeatability of retinal oximetry measurements.

PURPOSE: Retinal oximetry is a technique based on spectrophotometry where images are analyzed with software capable of calculating vessel oxygen saturation and vessel diameter. In this study, the effect of automation of measurements of retinal vessel oxygen saturation and vessel diameter is explored. METHODS: Until now, operators have had to choose each vessel segment to be measured explicitly. A new, automatic version of the software automatically selects the vessels once the operator defines a measurement area. Five operators analyzed image pairs from the right eye of 23 healthy subjects with semiautomated retinal oximetry analysis software, Oxymap Analyzer (v2.5.1), and an automated version (v3.0). Inter- and intra-operator variability was investigated using the intraclass correlation coefficient (ICC) between oxygen saturation measurements of vessel segments in the same area of the retina. RESULTS: For semiautomated saturation measurements, the inter-rater ICC was 0.80 for arterioles and venules. For automated saturation measurements, the inter-rater ICC was 0.97 for arterioles and 0.96 for venules. For semiautomated diameter measurements, the inter-rater ICC was 0.71 for arterioles and venules. For automated diameter measurements the inter-rater ICC was 0.97 for arterioles and 0.95 for venules. The inter-rater ICCs were different (p < 0.01) between the semiautomated and automated version in all instances. CONCLUSION: Automated measurements of retinal oximetry values are more repeatable compared to measurements where vessels are selected manually.

Angiotensin Receptor Blockers in cyclodextrin nanoparticle eye drops: Ocular pharmacokinetics and pharmacologic effect on intraocular pressure.

PURPOSE: Orally administered angiotensin II receptor blockers (ARBs) decrease intraocular pressure (IOP). Topical administration may reduce systemic side effects and result in a useful glaucoma drug. The aim of this study is to test the ocular delivery and pharmacologic effect of nanoparticle eye drops containing ARBs (e.g. irbesartan and candesartan). METHODS: 1.5% irbesartan and 0.15% candesartan eye drops were applied to rabbits. The pharmacokinetics in cornea and aqueous humour after single eye drop application were studied in 49 rabbits. The effect of the eye drops on IOP was studied in 10 rabbits using an iCare (® TonoVet Plus, iCare, Finland) tonometer and compared with 0.5% timolol eye drops. RESULTS: Candesartan lowered IOP from 24.6 ± 5.1 mmHg at baseline to 19.0 ± 2.9 mmHg (mean ± SD, p = 0.030, n = 10) 4 hr after application. Irbesartan lowered IOP from 24.2 ± 1.7 mmHg to 20.2 ± 0.9 mmHg (p = 0.14, n = 10). Timolol decreased the IOP from 24.9 ± 4.2 mmHg to 20.4 ± 4.8 mmHg (mean ± SD, p = 0.036, n = 10). The pharmacokinetics data show that both formulations deliver effective amounts of drug into the intraocular tissues, with irbesartan and candesartan reaching concentrations of 121 ± 69 and 30.43 ± 13.93 ng/g (mean ± SD), respectively, in the aqueous humour 3 hr after a single-dose administration. CONCLUSIONS: Topical application of irbesartan and candesartan eye drops delivers effective drug concentrations to the anterior segment of the eye in rabbits, achieving drug concentrations 100 times above the IC50 for angiotensin II receptor and showing an IOP-lowering effect. Angiotensin receptor blocker (ARB) eye drops have potential as a new class of glaucoma drugs.

Health professionals' perceptions of a midwifery model of woman-centred care implemented on a hospital labour ward.

BACKGROUND: Theoretical models as a basis for midwives' care have been developed over recent decades. Although there are similarities between these models, their usefulness in practice needs to be researched in specific cultural contexts. AIM: To explore whether, when adopted by midwives on labour wards, a midwifery model of woman-centred care (MiMo) was useful in practice from the viewpoint of a variety of health professionals. METHODS: Data were collected from a variety of health professionals before and after an intervention of implementating MiMo at a hospital-based labour ward in Sweden, using nine focus group interviews with a total of 43 participants: midwives (n=16), obstetricians (n=8), assistant nurses (n=11) and managers (n=8). The text from interviews was analysed using content analysis. FINDINGS: From expressing no explicit need of a midwifery model of woman-centred care before the intervention, there was a shift in midwives, obstetricians and managers perceptions towards identifying advantages of using the MiMo as it gives words to woman-centred midwifery care. Such shift in perception was not found among the assistant nurses. DISCUSSION: Clarification of the various roles of health professionals is needed to develop the model. Heavy workloads and stress were barriers to implementing the model. Thus, more support is needed from organisational management. CONCLUSIONS: The model was useful for all professional groups, except for assistant nurses. Further studies are needed in order to clarify the various professional roles and interdisciplinary collaborations in making the MiMo more useful in daily maternity care.

Midwives' care on a labour ward prior to the introduction of a midwifery model of care: a field of tension.

PURPOSE: There is a need to deepen knowledge about midwives' care in obstetric-led labour wards in which midwives are responsible for normal births. This ethnographic study explores the content and meaning of midwives' care of women in a hospital-based labour ward in Sweden prior to the introduction of a theoretical midwifery model of care. METHODS: Data were gathered through participant observation, analysed through interpretation grounded in reflexivity discussions and are presented in the form of ethnographic descriptions. RESULTS: The midwives' care was provided in a field of tension in which they had to balance contrasting models of care, described in the themes: The birthing rooms and the office-Different rooms of care, Women giving birth or being delivered-Midwives' expectations and relationships with women, Old and new caring roles of the midwife-Women giving birth in a "new age", Being and doing-Different approaches to caring, and Holistic and reductionist care-Guided by contrasting models and guidelines. The midwives' freedom to act as autonomous professionals was hindered by medical and institutional models of care and this led to uncertainty regarding their roles as midwives. CONCLUSIONS: Midwives having to balance their activities in a field of tension require midwifery models that can guide their practice.

Retinal oximetry: Metabolic imaging for diseases of the retina and brain.

Retinal oximetry imaging of retinal blood vessels measures oxygen saturation of hemoglobin. The imaging technology is non-invasive and reproducible with remarkably low variability on test-retest studies and in healthy cohorts. Pathophysiological principles and novel biomarkers in several retinal diseases have been discovered, as well as possible applications for systemic and brain disease. In diabetic retinopathy, retinal venous oxygen saturation is elevated and arteriovenous difference progressively reduced in advanced stages of retinopathy compared with healthy persons. This correlates with pathophysiology of diabetic retinopathy where hypoxia stimulates VEGF production. Laser treatment and vitrectomy both improve retinal oximetry values, which correlate with clinical outcome. The oximetry biomarker may allow automatic measurement of severity of diabetic retinopathy and predict its response to treatment. Central retinal vein occlusion is characterized by retinal hypoxia, which is evident in retinal oximetry. The retinal hypoxia seen on oximetry correlates with the extent of peripheral ischemia, visual acuity and thickness of macular edema. This biomarker may help diagnose and measure severity of vein occlusion and degree of retinal ischemia. Glaucomatous retinal atrophy is associated with reduced oxygen consumption resulting in reduced arteriovenous difference and higher retinal venous saturation. The oximetry findings correlate with worse visual field, thinner nerve fiber layer and smaller optic disc rim. This provides an objective biomarker for glaucomatous damage. In retinitis pigmentosa, an association exists between advanced atrophy, worse visual field and higher retinal venous oxygen saturation, lower arteriovenous difference. This biomarker may allow measurement of severity and progression of retinitis pigmentosa and other atrophic retinal diseases. Retinal oximetry offers visible light imaging of systemic and central nervous system vessels. It senses hypoxia in cardiac and pulmonary diseases. Oximetry biomarkers have been discovered in Alzheimer's disease and multiple sclerosis and oxygen levels in the retina correspond well with brain.