Changes in induction methods have not influenced cesarean section rates among women with induced labor.

INTRODUCTION: Induction of labor has become more common in most countries during the last decade. We have compared methods and routines of labor induction as practiced in Norway in 2003 and 2013, and surveyed practices with regard to induction of labor without a medical indication in 2013. MATERIAL AND METHODS: A telephone interview with all delivery units in Norway was conducted in 2003. Data on preferred induction methods, use of prostaglandin, dosages, dose intervals and routes of administration were collected. In 2013, the same questionnaire was used, with additional questions on induction of labor without a medical indication. Data on overall cesarean section and induction rates were obtained from the Medical Birth Registry of Norway. RESULTS: From 2003 to 2013 the induction rate increased by 62% and the cesarean section rate by 6%. The cesarean section rate in women with induced labor remained stable at 17.1 and 17.4%, respectively. In 2003, 31 of 43 hospitals used dinoprostone for cervical ripening and induction. In 2013, 34 of 39 hospitals used misoprostol. A cervical balloon was used in three of 43 hospitals in 2003 compared with 31 of 39 in 2013. All but one hospital induced labor without a strict medical indication in 2013. CONCLUSION: The preferred methods for induction of labor changed within a decade to the use of misoprostol and cervical balloon. Induction of labor without strict medical indications is widely practiced. The changed induction methods have not influenced the cesarean section rates in women with induced labors.

A comprehensive obstetric patient safety program reduces liability claims and payments.

Begun in 2003, the Yale-New Haven Hospital comprehensive obstetric safety program consisted of measures to standardize care, improve teamwork and communication, and optimize oversight and quality review. Prior publications have demonstrated improvements in adverse outcomes and safety culture associated with this program. In this analysis, we aimed to assess the impact of this program on liability claims and payments at a single institution. We reviewed liability claims at a single, tertiary-care, teaching hospital for two 5-year periods (1998-2002 and 2003-2007), before and after implementing the safety program. Connecticut statute of limitations for professional malpractice is 36 months from injury. Claims/events were classified by event-year and payments were adjusted for inflation. We analyzed data for trends as well as differences between periods before and after implementation. Forty-four claims were filed during the 10-year study period. Annual cases per 1000 deliveries decreased significantly over the study period (P < .01). Claims (30 vs 14) and payments ($50.7 million vs $2.9 million) decreased in the 5-years after program inception. Compared with before program inception, median annual claims dropped from 1.31 to 0.64 (P = .02), and median annual payments per 1000 deliveries decreased from $1,141,638 to $63,470 (P < .01). Even estimating the monetary awards for the 2 remaining open cases using the median payments for the surrounding 5 years, a reduction in the median monetary amount per case resulting in payment to the claimant was also statistically significant ($632,262 vs $216,815, P = .046). In contrast, the Connecticut insurance market experienced a stable number of claims and markedly increased cost per claim during the same period. We conclude that an obstetric safety initiative can improve liability claims exposure and reduce liability payments.

Brief report: Availability of lipid emulsion in United States obstetric units.

BACKGROUND: Lipid emulsion is recommended in the guidelines for the management of local anesthetic systemic toxicity. In this study, we sought to identify the current level of lipid emulsion availability in U.S. obstetric units. METHODS: A survey was developed addressing lipid emulsion availability and sent to U.S. obstetric anesthesia directors in June 2011. Univariate statistics were used. RESULTS: The response rate was 69%. Lipid emulsion was available in 88% of the units (95% confidence interval, 73%-94%). At least 95% of respondents had lipid emulsion available in <30 minutes (100% of n=68). CONCLUSIONS: U.S. academic obstetric anesthesia units are equipped to administer lipid emulsion in the setting of local anesthetic systemic toxicity.

Trend in mode of delivery in Rajavithi Hospital: a ten-year analysis (2002-2011).

OBJECTIVE: To create trends in mode of delivery both public and private service at Rajavithi Hospital. MATERIAL AND METHOD: The medical records of singleton pregnant women delivered between January 1, 2002 and December 31, 2011 were retrospectively analyzed for mode of delivery, indication of operative obstetrics, and modality of services (public and private service). RESULTS: During the study period, total singleton deliveries gradually decreased from 9,418 to 6,023 while the spontaneous vaginal delivery rate fluctuated, and the cesarean delivery rate increased from 25.48% to 34.70%. Vaginal operative deliveries steadily declined such as, forceps extraction 3.83% to 0.95%, vacuum extraction, 1.72% to 0.85%, and vaginal breech delivery 0.92 to 0.28%. CONCLUSION: The cesarean delivery rate increased in contrast with the decline of the vaginal operative delivery rate.

Understanding staff views and experiences of a clinical practice change to reduce stillbirth in South Asian women: A cross-sectional survey.

BACKGROUND: In July 2017, Victoria's largest maternity service implemented a new clinical practice guideline to reduce the rates of term stillbirth in women of South Asian background. AIM: To capture the views and experiences of clinical staff following the implementation of the new clinical guideline. METHODS: Cross sectional survey of clinical staff providing maternity care in August 2018, 12 months post implementation. Staff were asked to provide their agreement with ten statements assessing: perceived need for the guideline, implementation processes, guideline clarity, and clinical application. Open-ended questions provided opportunities to express concerns and offer suggestions for improvement. The frequency of responses to each question were tabulated. Open ended responses were grouped together to identify themes. FINDINGS: A total of 120 staff completed the survey, most (n=89, 74%) of whom were midwives. Most staff thought the rationale (n=95, 79%), the criteria for whom they applied (83%, n=99), and the procedures and instructions within the guideline were clear (74%, n=89). Staff reported an increase in workload (72%, n=86) and expressed concerns related to rationale and evaluation of the guidelines, lack of education for both staff and pregnant South Asian women, increased workload and insufficient resources, patient safety and access to care. Challenges relating to shared decision making and communicating with women whose first language is not English were also identified. DISCUSSION: This study has identified key barriers to and opportunities for improving implementation and highlighted additional challenges relating to new clinical guidelines which focus on culturally and linguistically diverse women.

A concept analysis of obstetric violence in the United States of America.

The aim is to clarify the concept of "obstetric violence in the United States of America." Obstetric violence (OV) is a poorly defined and rarely applied concept in the United States that causes significant harm and requires recognition. The design is a concept analysis to examine the structure and function of OV in the United States. An English language literature review with no date restrictions was performed using CINAHL, PubMed, and Google search. The search was expanded to the related terms "birth rape" and "birth trauma." The concept analysis was conducted using the method outlined by Walker and Avant. The synthesized definition proposed is: Obstetric violence is abuse or mistreatment by a health care provider of a female who is engaged in fertility treatment, preconception care, pregnant, birthing, or postpartum; or the performance of any invasive or surgical procedure during the full span of the childbearing continuum without informed consent, that is coerced, or in violation of refusal. It is a sex-specific form of violence against women (VAW) that is a violation of human rights. A clear definition and understanding of OV in the United States will allow for its recognition. A conceptual basis for naming it can lead to better knowing its prevalence, further studies, and operationalizing the term to create pathways for accountability and restitution. Nurses are in a unique position to minimize OV risk and to promote individual and unit-based responses for zero-tolerance.

Midwives' experiences as preceptors and the development of good preceptorships in obstetric units.

OBJECTIVE: To study midwives' experience in their role as a preceptor and their perception on how to best support midwifery students in obstetrics units. Obstetric units are an important learning area for student midwives but knowledge on how to become a good midwife preceptor is limited. DESIGN: This qualitative study explores midwife preceptors' experience of supervising midwifery students in three obstetric units in Sweden. Following ethical approval seventeen midwife preceptors were interviewed and data were analysed thematically. FINDINGS: Thematic analysis of the interviews resulted in the identification of two themes and five subthemes: (1) self-efficacy in the preceptor role which involves (a) being confident in the professional position and (b) having the support of management and colleagues and (2) supporting the student to attain self-confidence and independence which entails (a) helping the student to grow, (b) facilitating reflection in learning situations, and (c) "taking a step back". KEY CONCLUSION: Good preceptorship occurs when midwives achieve full self-efficacy, when they master the preceptor role, and when they have enhanced their abilities to help, the student reach confidence and independence. IMPLICATIONS FOR PRACTICE: Health care organisations needs to develop and support midwifery preceptorships.

From the trenches: inpatient management of coronavirus disease 2019 in pregnancy.

The novel coronavirus disease 2019 caused by the severe acute respiratory syndrome coronavirus 2 has become a pandemic. It has quickly swept across the globe, leaving many clinicians to care for infected patients with limited information about the disease and best practices for care. Our goal is to share our experiences of caring for pregnant and postpartum women with novel coronavirus disease 2019 in New York, which is the coronavirus disease 2019 epicenter in the United States, and review current guidelines. We offer a guide, focusing on inpatient management, including testing policies, admission criteria, medical management, care for the decompensating patient, and practical tips for inpatient antepartum service management.

Optimal continuous support accompanying labor - the midwives' and laboring women's point of view.

BACKGROUND: Women who have continuous intrapartum support are more likely to have a shorter labor and spontaneous vaginal birth, and are less likely to need intrapartum analgesia than women who receive usual care without support. We aimed to determine what women in labor and midwives regard as the optimal number of labor supporters and whether they should be present during medical interventions. METHODS: A questionnaire was distributed to midwives participating in a national midwifery conference in June 2015. In addition, an anonymized questionnaire concerning the preferred number and type of supporters was distributed to laboring women at the beginning of labor and repeated post-partum in the maternity unit of a single tertiary medical center between March 2017 and January 2018. RESULTS: Of 124 midwives from 18 hospitals throughout Israel attending the conference, 92 (74%) completed the questionnaire. Eighty-three percent of the midwives who responded felt that more than two supporters interferes with their work. Eighty percent of the midwives work in obstetrical units that allow up to two labor supporters, and 82% of them felt that one or two supporters is optimal. Similarly, of the 140 laboring women surveyed, 84% preferred one or two supporters. There was no difference in the preferred number of supporters between the maternal pre- and post-partum questionnaires. The laboring women and midwives had differing opinions regarding supporter presence during vacuum extraction and perineal suture. Sixty-four percent of the midwives preferred that the supporter not be present during vacuum extraction, and 45% of them preferred that the supporter not be present during perineal suture. In contrast, among the laboring women, 78% preferred supporter presence during vacuum extraction, 76% during perineal suture and 74% during vaginal examination. Interestingly, even among the midwives, 82% preferred that the supporter remain during vaginal examination and 84% preferred the supporter remain during medical rounds. CONCLUSIONS: Serious consideration should be given to restricting the number of labor supporters to two, as both laboring woman and midwives consider that to be the optimal number. In light of the difference of opinion regarding presence of supporters during certain medical procedures, additional surveys concerning the points of view of obstetricians and laboring women in additional hospitals should be considered before establishing a national policy.

Development of a simple menstrual migraine screening tool for obstetric and gynecology clinics: the menstrual migraine assessment tool.

OBJECTIVE: To develop and validate a brief questionnaire to screen for menstrual migraine (MM), and to estimate MM prevalence in an obstetrics and gynecology (OB/GYN) setting in a pilot study. METHODS: Patients with unknown MM status from a headache clinic completed a 9-item questionnaire. The attributes of each question were compared with a validated headache calendar to develop a 3-item MM questionnaire. The headache calendar and questionnaire were then administered to nonpregnant/nonmenopausal OB/GYN patients. A diagnosis was assigned by a blinded specialist using the headache calendar, and MM prevalence was determined. RESULTS: The analysis yielded 3 relevant questions administered to 250 women for our tool, called the Menstrual Migraine Assessment Tool (MMAT): (1) "Do you have headaches that are related to your period (ie, occur between 2 days before the onset of your period, until the third day of your period) most months?" (2) "When my headaches are related to my period, they eventually become severe"; (3) "When my headaches are related to my period, light bothers me more than when I don't have a headache." If question 1 was positive, questions 2 and 3 were answered. Among women responding positively to question 1 and > or =1 other question, the sensitivity and specificity were 0.94 and 0.74, respectively. Of 610 randomly chosen OB/GYN patients, 12.1% had pure MM (ie, migraine exclusively between days +2 and -3 of menses), 10.1% had menstrually related migraine (ie, MM and attacks at other times), and 14.1% had migraine without relation to their menses. CONCLUSION: The MM screener MMAT exhibits sufficient sensitivity and specificity to assess this frequently disabling condition presenting at the OB/GYN office.

The maternity ward of a teaching hospital: reconfiguration of maternal-child nursing care.

OBJECTIVE: to analyze the strategies used by nurses and nurse professors for a better position in the maternity ward of the teaching hospital of the Universidade Federal do Espírito Santo. METHOD: this is a social-historical study with a qualitative approach. The primary sources were written documents, such as official letters, memos, ordinances, standards and routines of the hospital; photographic material; and oral testimonies from seven participants. The interviews were performed using a semi-structured questionnaire, with questions regarding the adaptation from a sanatorium to a teaching hospital, the challenges faced, and the strategies adopted by the nursing department. RESULTS: the results allowed us to understand the close link between the maternity ward and the nursing course of the Universidade Federal do Espírito Santo, which created a differentiated nursing care that integrated training and care with a broader and humanized look. FINAL CONSIDERATIONS: the actions of the nurses were recognized and gave them professional visibility, influencing a new form of care in the maternity ward.

Implementation of hysteroscopic surgery in The Netherlands.

OBJECTIVE: This study was conducted to assess the degree of diffusion of hysteroscopic surgery in gynaecological practice in The Netherlands in order to guide further implementation. The diffusion was objectified by defining the percentage of hospitals performing hysteroscopic procedures and the number of different procedures performed per gynaecologist. STUDY DESIGN: In 2003 all Departments of Gynaecology (n=102) in The Netherlands were sent a questionnaire. The questionnaire addressed the number and type of all hysteroscopic procedures that were performed in each hospital in 2002. Data from this study were compared to previously published data from 1997. RESULTS: Responses were received from 80% of all gynaecological departments in The Netherlands. Diagnostic hysteroscopy was performed in almost all hospitals in both 1997 and 2002. The percentage of hospitals that adopted polypectomy, myomectomy and endometrial ablation increased to more than 90% in 2002. The number of teaching hospitals that integrated diagnostic hysteroscopy, polypectomy and myomectomy (procedures required for graduation) into their operative spectrum increased to 100%. CONCLUSION: This survey indicates a growing trend of the diffusion of diagnostic and "basic" therapeutic hysteroscopic procedures in The Netherlands. However, figures upon more advanced hysteroscopic surgery are less optimistic.

[Evolution of the hospital institutions of Brussels and the progressive individualization of the departments of obstetrics]. / L'évolution des institutions hospitalères bruxelloises et l'individualisation progressive des services d'obstétrique.

The origin of Brussels hospitals goes back to the XIIth century when several institutions created by the Church were only aimed at lodging poor pilgrims. The evolution from ecclesiastic management to municipal direction ended up in the establishment of two main public hospitals devoted to health care : Saint-Jean and Saint-Pierre. The latter, founded under Austrian rule and associated from the start with clinical teaching, gained therefore a prominent position. In 1834, it became a university hospital thanks to an agreement between the recently founded Free University of Brussels and the municipal health authorities. Finally, the administration of the main university clinical infrastructure was totally taken over by the University and moved to the newly erected Erasmus Hospital together with all faculty buildings. Development of the Brussels Maternity occurred rather slowly and underwent several location changes because of varying general politics as well as for sanitary reasons of hygiene. It was not before the XXth century that obstetrical practice progressively shifted from the private domiciliary sphere at the hands of midwives, to the hospital environment and medical control as is the case today.

Robot chores: machines make the decisions on mock maternity ward.

Robots could be used to make decisions on wards, American scientists have claimed.

Implementation of a health care policy: an analysis of barriers and facilitators to practice change.

BACKGROUND: Governments often create policies that rely on implementation by arms length organizations and require practice changes on the part of different segments of the health care system without understanding the differences in and complexities of these agencies. In 2000, in response to publicity about the shortening length of postpartum hospital stay, the Ontario government created a universal program offering up to a 60-hour postpartum stay and a public health follow-up to mothers and newborn infants. The purpose of this paper is to examine how a health policy initiative was implemented in two different parts of a health care system and to analyze the barriers and facilitators to achieving practice change. METHODS: The data reported came from two studies of postpartum health and service use in Ontario Canada. Data were collected from newly delivered mothers who had uncomplicated vaginal deliveries. The study samples were drawn from the same five purposefully selected hospitals for both studies. Questionnaires prior to discharge and structured telephone interviews at 4-weeks post discharge were used to collect data before and after policy implementation. Qualitative data were collected using focus groups with hospital and community-based health care practitioners and administrators at each site. RESULTS: In both studies, the respondents reflected a population of women who experienced an "average" or non-eventful hospital-based, singleton vaginal delivery. The findings of the second study demonstrated wide variance in implementation of the offer of a 60-hour stay among the sites and focus groups revealed that none of the hospitals acknowledged the 60-hour stay as an official policy. The uptake of the offer of a 60-hour stay was unrelated to the rate of offer. The percentage of women with a hospital stay of less than 25 hours and the number with the guideline that the call be within 48 hours of hospital discharge. Public health telephone contact was high although variable in relation to compliance the guideline that the call be within 48 hours of hospital discharge. Home visits were offered at consistently high rates. CONCLUSION: Policy enactment is sometimes inadequate to stimulate practice changes in health care. Policy as a tool for practice change must thoughtfully address the organizational, professional, and social contexts within which the policy is to be implemented. These contexts can either facilitate or block implementation. Our examination of Ontario's universal postpartum program provides an example of differential implementation of a common policy intended to change post-natal care practices that reflects the differential influence of context on implementation.