Change in prevalence of gestational diabetes and obstetric complications when applying IADPSG screening criteria in a Belgian French speaking University Hospital. A retrospective cohort study.

BACKGROUND: In April 2012 our institution chose to switch from a two- step criteria for Gestational Diabetes Mellitus (GDM) screening, to the International Association of Diabetes in Pregnancy Study Group (IADSPG) criteria. This shift led to an increased prevalence of GDM in our pregnant population. We designed a study in order to estimate the magnitude of the increase in GDM prevalence before and after the switch in screening strategy. As a secondary objective we wanted to evaluate if there was a significant difference between the two periods in the percentage of maternal and neonatal complications such as gestational hypertensive disorders (GHD), primary cesarean section (pCS), preterm birth, large for gestational age (LGA) newborns, macrosomia, shoulder dystocia, 5' Apgar score less than to 7 at birth, neonatal intensive care unit (NICU) transfer and neonatal hypoglycemia. METHODS: We selected retrospectively 3496 patients who delivered between January 2009 and December 2011 who were screened with the two-step criteria (group A), and compared them to 2555 patients who delivered between January 2013 and December 2014 and who were screened with IADPSG criteria (Group B). We checked patients' electronic files to establish GDM status, baseline characteristics (age, body mass index, nationality, parity) and the presence of maternal and neonatal complications. RESULTS: GDM prevalence increased significantly from group A (3.4%; 95%CI 2.8-4.06%) to group B (16.28%; 95%CI 14.8 -17.7%). In group B there were significantly more non-Belgian and primiparous patients. There was no statistically significant difference in maternal and neonatal complications between the two groups, even after adjustment for nationality and parity. There was a non-significant reduction of the proportion of macrosomic and of LGA babies. CONCLUSIONS: In our population the introduction of IADPSG screening criteria has increased the prevalence of GDM without having a statistically significant impact on pregnancy outcomes.

Assessment of an urgency classification for assisted vaginal delivery.

We performed a prospective observational audit to evaluate the application of the Lucas caesarean section urgency classification to assisted vaginal delivery in the operating theatre. We collected data from 400 women having category 1-3 delivery in the operating theatre. Twenty percent of the caesarean sections and 4% of the vaginal deliveries were category 1. The median (IQR) decision-delivery interval was 25 (19.5-37) min for category 1 caesarean section and 19.5 (15-29) min for category 1 vaginal delivery, and 43.5 (36-57) min and 45 (32-57) for category 2 caesarean section and vaginal delivery, respectively. Sixty-three percent of category 1 caesarean section and 75% of category 1 vaginal delivery were performed in ≤30 min. Antenatal or intrapartum risk factors were present before the decision for delivery in 82% of caesarean sections and 80% of vaginal deliveries. The application of the Lucas urgency classification to assisted vaginal delivery merits further evaluation.

[Collective memories of women who have experienced maternal near miss: health needs and human rights]. / Memórias coletivas de mulheres que vivenciaram o near miss materno: necessidades de saúde e direitos humanos.

The collective memories of women that have experienced maternal near miss can help elucidate serious obstetric events, like maternal death. Their experience is authentic and representative, with the construction of a common identity. This identity lends quality to a group's memory, and such memory is thus a social phenomenon. The study analyzed the experience of twelve women who nearly died during the gestational and postpartum cycle. The thematic oral history method was used, from the perspective of health needs and human rights. Six collective memories comprised the discourses: unmet health needs; healthcare deficiencies; denial of contact with the newborn child; violation of rights; absence of demand for rights; and compensation for unmet rights and needs. To understand these women's health needs is to acknowledge the women as bearers of rights and to individualize care, respecting their autonomy, guaranteeing access to technologies, and establishing an effective bond with health professionals.

Memórias coletivas de mulheres que vivenciaram o near miss materno: necessidades de saúde e direitos humanos / Collective memories of women who have experienced maternal near miss: health needs and human rights / Memorias colectivas de mujeres que experimentaron el near miss materno: necesidades de salud y derechos humanos

Resumo: Mulheres que vivenciaram o near miss materno podem, por meio de suas memórias coletivas, ajudar na compreensão dos eventos obstétricos graves, como a morte materna. A experiência das pessoas é autêntica e representativa do todo com a construção de uma identidade comum. É a identidade que dá qualidade à memória de um grupo. Assim, cada memória é um fenômeno social. Analisou-se a experiência de 12 mulheres que quase morreram em função do estado gravídico-puerperal. O método da história oral temática foi utilizado, na perspectiva das necessidades de saúde e direitos humanos. Seis memórias coletivas compuseram os discursos: necessidades de saúde não atendidas; deficiências assistenciais; privação do contato com o filho; violação de direitos; ausência de reivindicação dos direitos; e compensações dos direitos e necessidades não atendidos. Compreender as necessidades de saúde dessas mulheres é reconhecê-las como sujeitos de direitos; é individualizar a assistência, respeitando sua autonomia, garantindo o acesso às tecnologias e estabelecendo vínculo (a)efetivo com o profissional de saúde.

Abstract: The collective memories of women that have experienced maternal near miss can help elucidate serious obstetric events, like maternal death. Their experience is authentic and representative, with the construction of a common identity. This identity lends quality to a group's memory, and such memory is thus a social phenomenon. The study analyzed the experience of twelve women who nearly died during the gestational and postpartum cycle. The thematic oral history method was used, from the perspective of health needs and human rights. Six collective memories comprised the discourses: unmet health needs; healthcare deficiencies; denial of contact with the newborn child; violation of rights; absence of demand for rights; and compensation for unmet rights and needs. To understand these women's health needs is to acknowledge the women as bearers of rights and to individualize care, respecting their autonomy, guaranteeing access to technologies, and establishing an effective bond with health professionals.

Resumen: Las mujeres que experimentaron un near miss materno pueden, mediante sus memorias colectivas, ayudar a la comprensión de eventos obstétricos graves como la muerte materna. La experiencia de las personas es auténtica y representativa del todo con la construcción de una identidad común. Es la identidad la que da calidad a la memoria de un grupo. Así, cada memoria es un fenómeno social. Se analizó la experiencia de 12 mujeres que casi murieron en función del estado de embarazo-puerperio. Se utilizó el método de la historia oral temática, desde la perspectiva de las necesidades de salud y derechos humanos. Seis memorias colectivas compusieron los discursos: necesidades de salud no atendidas; deficiencias asistenciales; privación del contacto con el hijo; violación de derechos; ausencia de reivindicación de los derechos; y compensaciones de los derechos y necesidades no atendidas. Comprender las necesidades de salud de esas mujeres es reconocerlas como sujetos de derechos; es individualizar la asistencia, respetando su autonomía, garantizando el acceso a las tecnologías y estableciendo vínculo (a)efectivo con el profesional de salud.

Assessment of a modified four-category classification of urgency of caesarean section.

A four-category urgency classification for caesarean section (CS) based on clinical definitions was introduced in 2000. However, clinical application remains inconsistent. We proposed that modification of the wording of these definitions might improve consistency of assignment of urgency. A total of 349 maternity professionals applied an urgency category to 10 hypothetical cases of CS, using either the original or a modified classification. There was a supplementary question relating to urgency category in relation to the 30 minute decision-to-delivery time standard. The commonest urgency categories applied to the cases by the respondents were: Category 1: cord prolapse, significant placental abruption, maternal cardiorespiratory distress; Category 2: late fetal heart rate decelerations, CS pre-booked to avoid vaginal delivery but woman presents in advanced labour, bleeding placenta praevia without hypovolaemia, failed instrumental delivery with no fetal compromise; Category 3: deteriorating but compensated maternal medical condition; Category 4: operation at short notice but no clinical urgency. Consistency of responses in individual cases varied from 0.92 down to 0.55. Some 66% of respondents believe that only Category 1 cases should be included in a 30 minute decision-to-delivery time standard, whereas 34% would include Category 2 as well as Category 1 in this standard. The consistency of responses did not differ between the original and modified urgency classifications. Inter-rater reliability was better when comparing the answers from obstetricians compared with anaesthetists or midwives. This study found that the proposed modifications did not improve the consistency of application, and that any changes to the current classification should not be introduced without thorough investigation.

An evaluation of the quality of obstetric morbidity coding using an objective assessment tool, the Performance Indicators For Coding Quality (PICQ).

The Performance Indicators for Coding Quality (PICQ) is a data quality assessment tool developed by Australia's National Centre for Classification in Health (NCCH). PICQ consists of a number of indicators covering all ICD-10-AM disease chapters, some procedure chapters from the Australian Classification of Health Intervention (ACHI) and some Australian Coding Standards (ACS). The indicators can be used to assess the coding quality of hospital morbidity data by monitoring compliance of coding conventions and ACS; this enables the identification of particular records that may be incorrectly coded, thus providing a measure of data quality. There are 31 obstetric indicators available for the ICD-10-AM Fourth Edition. Twenty of these 31 indicators were classified as Fatal, nine as Warning and two Relative. These indicators were used to examine coding quality of obstetric records in the 2004-2005 financial year Australian national hospital morbidity dataset. Records with obstetric disease or procedure codes listed anywhere in the code string were extracted and exported from the SPSS source file. Data were then imported into a Microsoft Access database table as per PICQ instructions, and run against all Fatal and Warning and Relative (N=31) obstetric PICQ 2006 Fourth Edition Indicators v.5 for the ICD-10- AM Fourth Edition. There were 689,905 gynaecological and obstetric records in the 2004-2005 financial year, of which 1.14% were found to have triggered Fatal degree errors, 3.78% Warning degree errors and 8.35% Relative degree errors. The types of errors include completeness, redundancy, specificity and sequencing problems. It was found that PICQ is a useful initial screening tool for the assessment of ICD-10-AM/ACHI coding quality. The overall quality of codes assigned to obstetric records in the 2004- 2005 Australian national morbidity dataset is of fair quality.

Complex obstetric fistulas.

Obstetric fistulas are rarely simple. Most patients in sub-Saharan Africa and parts of Asia are carriers of complex fistulas or complicated fistulas requiring expert skills for evaluation and management. A fistula is predictably complex when it is greater than 4 cm and involves the continence mechanism (the urethra is partially absent, the bladder capacity is reduced, or both); is associated with moderately severe scarring of the trigone and urethrovesical junction; and/or has multiple openings. A fistula is even more complicated when it is more than 6 cm in its largest dimension, particularly when it is associated with severe scarring and the absence of the urethra, and/or when it is combined with a recto-vaginal fistula. The present article reviews the evaluation methods and main surgical techniques used in the management of complex fistulas. The severity of the neurovascular alterations associated with these lesions, as well as inescapable limitations in staff, health facilities, and supplies, make their optimal management very challenging.