Intimate partner violence and severe acute maternal morbidity in the intensive care unit: A case-control study in Peru.

BACKGROUND: Intimate partner violence is a prevalent public health issue associated with all-cause maternal mortality. This study investigated the relationship between intimate partner violence, severe acute maternal morbidity in the intensive care unit (ICU), and neonatal outcomes. METHODS: This was a prospective case-control study in a hospital in Lima, Peru, with 109 cases (maternal ICU admissions) and 109 controls (obstetric patients not admitted to the ICU). Data were collected through face-to-face interviews and medical record review. Partner violence was assessed using the World Health Organization instrument. Multivariate logistic regression was used to model the association between intimate partner violence and severe acute maternal morbidity. RESULTS: There was a significantly higher rate of intimate partner violence both before and during pregnancy among cases (58.7%) than controls (27.5%). In multivariate analysis, intimate partner violence both before and during pregnancy (aOR 3.83 (95% CI: 1.99-7.37)), being married (3.86 (1.27-11.73)), having <8 antenatal care visits (2.78 (1.14-6.80)), and having previous abortions (miscarriage, therapeutic, or unsafe) (1.69 (1.13-2.51)) were significantly associated with severe acute maternal morbidity. The ICU admission rate was 18.8 (per 1000 live births), and ICU maternal mortality was 1.7%. The perinatal mortality rate was higher in cases (9.3%) than in controls (1.8%). CONCLUSIONS: Intimate partner violence was associated with an increased risk of severe acute maternal morbidity. This suggests a more severe impact of intimate partner violence on pregnancy than has been previously identified. Inquiring about intimate partner violence during prenatal visits may prevent further harm to the mother-baby dyad.

Incidence, trends and severity of primary postpartum haemorrhage in Australia: A population-based study using Victorian Perinatal Data Collection data for 764 244 births.

BACKGROUND: Increasing incidence and severity of postpartum haemorrhage, together with postpartum haemorrhage-associated morbidities, have been reported in many high-resource countries. In-depth analysis of such factors in Victorian births since 2002 was lacking. AIMS: Our aim was to determine the incidence and trends for primary postpartum haemorrhage (World Health Organization and International Classification of Diseases 10th revision, Australian Modification definitions) for all confinements in Victoria, Australia, for the years 2003-2013 and the incidence and trends for severe postpartum haemorrhage (≥1500 mL) for 2009-2013. MATERIALS AND METHODS: In this population-based cross-sectional study de-identified data from the Victorian Perinatal Data Collection were analysed for confinements (excluding terminations) from 2003 to 2013 (n = 764 244). Perinatal information for all births ≥20 weeks (or of at least 400 g birthweight if gestation was unknown) were prospectively collected. RESULTS: One in five women (21.8%) who gave birth between 2009 and 2013 experienced a primary postpartum haemorrhage and one in 71 women (1.4%) experienced a severe primary postpartum haemorrhage. The increasing trends in incidence of primary postpartum haemorrhage, severe primary postpartum haemorrhage, blood transfusion, admission to an intensive care or high dependency unit and peripartum hysterectomy were significant (P < 0.001). Women who had an unassisted vaginal birth had the lowest incidence of primary postpartum haemorrhage. The highest incidence was experienced by women who had an unplanned caesarean section birth. Women who had a forceps birth had the highest incidence of severe primary postpartum haemorrhage. CONCLUSIONS: The incidence of primary postpartum haemorrhage, severe primary postpartum haemorrhage and associated maternal morbidities have increased significantly over time in Victoria.

Accuracy of postpartum haemorrhage data in the 2011 Victorian Perinatal Data Collection: Results of a validation study.

BACKGROUND: The postpartum haemorrhage (PPH) rate in Victoria in 2009 for women having their first birth, based on information reported to the Victorian Perinatal Data Collection (VPDC), was 23.6% (primiparas). Prior to 2009 PPH was collected via a tick box item on the perinatal form. Estimated blood loss (EBL) volume is now collected and it is from this item the PPH rate is calculated. Periodic assessment of data accuracy is essential to inform clinicians and others who rely on these data of their quality and limitations. AIMS: This paper describes the results of a state-wide validation study of the accuracy of EBL volume and EBL-related data items reported to VPDC. MATERIALS AND METHODS: PPH data from a random sample of 1% of births in Victoria in 2011 were extracted from source medical records and compared with information submitted to the VPDC. Accuracy was determined, together with sensitivity, specificity, positive predictive value and negative predictive value for dichotomous items. RESULTS: Accuracy of reporting for EBL ≥ 500 mL was 97.2% and for EBL ≥ 1500 mL was 99.7%. Sensitivity for EBL ≥ 500 mL was 89.0% (CI 83.1-93.0) and for EBL ≥ 1500 mL was 71.4% (CI 35.9-91.8). Blood product transfusion, peripartum hysterectomy and procedures to control bleeding were all accurately reported in >99% of cases. CONCLUSIONS: Most PPH-related data items in the 2011 VPDC may be considered reliable. Our results suggest EBL ≥ 1500 mL is likely to be under-reported. Changes to policies and practices of recording blood loss could further increase accuracy of reporting.

A quality improvement initiative to reduce central line infection in neonates using checklists.

Central line associated blood stream infections (CLABSI) are the most common complication of central catheters in neonates. These infections increase length of hospital stay, hospital costs and impact on mortality and morbidities. We performed a quasi-experimental study, over 24 months, utilising a pre-post design to determine the impact checklists had on central line infections. We introduced checklists for insertion, daily maintenance and procedural access based on the existing clinical guideline. Infections and compliance were monitored and reported back to the unit each month. We utilised the interrupted time series analysis to evaluate the impact of introduction of the checklists. Over the 24 months, 318 infants were included with a total of 509 central lines inserted. In the post intervention phase, definite CLABSI rates declined by 41%, from 13.8 definite CLABSIs per 1000 central-line days to 7.8 definite CLABSIs per 1000 central-line days. There was significant change in the mean levels in the post intervention phase (coefficient crude -0.01015; 95% CI -0.01980-0.00051, p value 0.039). Checklist compliance for insertion was 70%, and daily maintenance compliance overall mean was 66%. CONCLUSION: Our quality improvement initiative using checklists, supported with education and feedback, significantly reduced CLABSI in our neonatal unit. What is Known: • Central line associated blood stream infection (CLABSI) continue to cause mortality and morbidity in the neonatal population. • Bundles of intervention use quality improvement methodology to reduce CLABSI and checklists can assist with the introduction of these. What is New: • Checklists assist with reducing central line infection. • To ensure the success of checklists, robust education, leadership and continuous feedback are vital.

Antibiotic lock for the prevention of catheter-related infection in neonates.

BACKGROUND: Use of a central venous catheter (CVC) in neonates is associated with an increase in nosocomial infection. Numerous strategies exist to prevent catheter-related bloodstream infection (CRBSI); however, CRBSI continues to be a major problem. Antibiotic locking catheters is a new and promising treatment that potentially prevents this severe condition. OBJECTIVES: To assess the effectiveness of antibiotic lock versus no antibiotic lock or alternative antibiotic lock in the prevention of catheter-related infections in newborn infants of any gestational age during their initial stay in the neonatal unit and to study any relevant adverse effects from antibiotic lock therapy. SEARCH METHODS: Methods followed those of the Cochrane Neonatal Review Group (CNRG). We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014, Issue 5); MEDLINE (via PubMed); EMBASE (hosted by EBCHOST); CINAHL; abstracts from Pediatric Academic Societies, European Society for Paediatric Research and trials registries; and references cited in our short listed articles using keywords and MeSH headings, up to April 2015. SELECTION CRITERIA: We considered all trials utilising random or quasi-random participant allocation. Participants included all newborn infants of any postmenstrual age who required any type of CVC. We compared an antibiotic lock technique with no antibiotic lock or placebo, such as heparinised saline, for any duration of time. DATA COLLECTION AND ANALYSIS: We extracted data using the standard methods of the CNRG. Two review authors independently assessed the relevance and risk of bias of the retrieved records. We expressed our dichotomous results using risk ratio (RR) with their 95% confidence intervals (CIs). We assessed for heterogeneity using the I(2) statistic. MAIN RESULTS: We included three trials (271 infants) in this review. Two of the three included studies had an overall low risk of bias and the remaining study had high risk of selection and performance biases. The use of an antibiotic lock decreased the incidence of confirmed catheter-related infection (typical RR 0.15, 95% CI 0.06 to 0.40; 3 studies, 271 infants) (high-quality evidence). The typical absolute risk reduction (ARR) was 18.5% and the number needed to treat for an additional beneficial outcome (NNTB) was 5. The effect of use of an antibiotic lock on suspected catheter infection was imprecise (typical RR 0.65, 95% CI 0.22 to 1.92) (moderate quality evidence). Confirmed and suspect infection rates combined were lower in the antibiotic lock group (absolute rates, RR 0.25, 95% CI 0.12 to 0.49; rate per 1000 catheter days, RR 0.17, 95% CI 0.07 to 0.40). The ARR was 20.5% and the NNTB was 5. None of the studies report resistance to the antibiotic used during the lock treatment. There was no significant difference in the detectable serum levels of antibiotic. When the data from two studies were pooled, there were significantly fewer episodes of hypoglycaemia in the treatment arm (typical RR 0.51, 95% CI 0.28 to 0.92). There was no statistically significant difference for mortality due to sepsis between the control and intervention group. AUTHORS' CONCLUSIONS: Based on a small number of trials and neonates, antibiotic lock solution appeared to be effective in preventing CRBSI in the neonatal population. However, as each included study used a different antibiotics and antibiotic resistance could not be reliably assessed, the evidence to-date is insufficient to determine the effects of antibiotic lock on infections in neonates.

A survey of central venous catheter practices in Australian and New Zealand tertiary neonatal units.

BACKGROUND: Infection is the most common problem with central venous catheters (CVCs) in neonates. There are two published guidelines, including the Centers for Disease Control and Prevention (CDC), for the prevention of intravascular catheter-related infection that describes evidence-based practice to reduce nosocomial infection. OBJECTIVE: Our aims were to survey current medical and nursing management of central venous catheters in tertiary neonatal intensive care units in Australia and New Zealand and to compare with the CDC evidence-based practice guideline. METHODS: A cross sectional survey was performed across 27 Australian and New Zealand neonatal units in September 2012. Two web-based questionnaires were distributed, one to medical directors related to the insertion of CVCs while CVC "maintenance" surveys were sent to nurse unit managers. RESULTS: Seventy percent (19/27) medical management and 59% (16/27) on nursing management surveys were completed. In all neonatal intensive care units (NICUs) there were guidelines for CVC maintenance and for 18 out of 19 there were guidelines for insertion. In the seven units using femoral lines, three had a guideline on insertion and four for maintenance. CVC insertion was restricted to credentialed staff in 57.9% of neonatal units. Only 26.5% used full maximal sterile barriers for insertion. Skin disinfection practices widely varied. Dressing use and dressing change regimens were standardised; all using a semi-permeable dressing. Duration of cleaning time of the access point varied significantly; however, the majority used a chlorhexidine with alcohol solution (68.8%). Line and fluid changes varied from daily to 96 h. The majority used sterile gloves and a sterile dressing pack to access the CVC (68.8%). In the majority of NICUs stopcocks were used (62.5%) with a needle-less access point attached (87.5%). In less than 50% of NICUs education was provided on insertion and maintenance. CONCLUSION: There is diversity of current practices and some aspects vary from the CDC guideline. There is a need to review NICU current practices to align with evidence based guidelines. The introduction of a common guideline may reduce variations in practice.

Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes.

BACKGROUND: Policies for timing of cord clamping vary, with early cord clamping generally carried out in the first 60 seconds after birth, whereas later cord clamping usually involves clamping the umbilical cord more than one minute after the birth or when cord pulsation has ceased. The benefits and potential harms of each policy are debated. OBJECTIVES: To determine the effects of early cord clamping compared with late cord clamping after birth on maternal and neonatal outcomes SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 February 2013). SELECTION CRITERIA: Randomised controlled trials comparing early and late cord clamping. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial eligibility and quality and extracted data. MAIN RESULTS: We included 15 trials involving a total of 3911 women and infant pairs. We judged the trials to have an overall moderate risk of bias. Maternal outcomes: No studies in this review reported on maternal death or on severe maternal morbidity. There were no significant differences between early versus late cord clamping groups for the primary outcome of severe postpartum haemorrhage (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.65 to 1.65; five trials with data for 2066 women with a late clamping event rate (LCER) of ~3.5%, I(2) 0%) or for postpartum haemorrhage of 500 mL or more (RR 1.17 95% CI 0.94 to 1.44; five trials, 2260 women with a LCER of ~12%, I(2) 0%). There were no significant differences between subgroups depending on the use of uterotonic drugs. Mean blood loss was reported in only two trials with data for 1345 women, with no significant differences seen between groups; or for maternal haemoglobin values (mean difference (MD) -0.12 g/dL; 95% CI -0.30 to 0.06, I(2) 0%) at 24 to 72 hours after the birth in three trials. Neonatal outcomes: There were no significant differences between early and late clamping for the primary outcome of neonatal mortality (RR 0.37, 95% CI 0.04 to 3.41, two trials, 381 infants with a LCER of ~1%), or for most other neonatal morbidity outcomes, such as Apgar score less than seven at five minutes or admission to the special care nursery or neonatal intensive care unit. Mean birthweight was significantly higher in the late, compared with early, cord clamping (101 g increase 95% CI 45 to 157, random-effects model, 12 trials, 3139 infants, I(2) 62%). Fewer infants in the early cord clamping group required phototherapy for jaundice than in the late cord clamping group (RR 0.62, 95% CI 0.41 to 0.96, data from seven trials, 2324 infants with a LCER of 4.36%, I(2) 0%). Haemoglobin concentration in infants at 24 to 48 hours was significantly lower in the early cord clamping group (MD -1.49 g/dL, 95% CI -1.78 to -1.21; 884 infants, I(2) 59%). This difference in haemoglobin concentration was not seen at subsequent assessments. However, improvement in iron stores appeared to persist, with infants in the early cord clamping over twice as likely to be iron deficient at three to six months compared with infants whose cord clamping was delayed (RR 2.65 95% CI 1.04 to 6.73, five trials, 1152 infants, I(2) 82%). In the only trial to report longer-term neurodevelopmental outcomes so far, no overall differences between early and late clamping were seen for Ages and Stages Questionnaire scores. AUTHORS' CONCLUSIONS: A more liberal approach to delaying clamping of the umbilical cord in healthy term infants appears to be warranted, particularly in light of growing evidence that delayed cord clamping increases early haemoglobin concentrations and iron stores in infants. Delayed cord clamping is likely to be beneficial as long as access to treatment for jaundice requiring phototherapy is available.

Primary postpartum haemorrhage adversely impacts breastfeeding initiation in Victoria, Australia.

PROBLEM: Breastfeeding has many important benefits for both mother and baby but sustained breastfeeding is sub-optimal. BACKGROUND: Identifying women who need increased support to establish breastfeeding has the potential to improve this. Analysis of the relationship between primary postpartum haemorrhage (PPH) and primary severe PPH and breastfeeding may prove informative as PPH has potentially negative impacts on breastfeeding. AIM: To determine the relationship between PPH and severe PPH and breastfeeding at postnatal discharge and formula use for breastfed babies in hospital. METHODS: Population-based retrospective cohort study using the Victorian Perinatal Data Collection for all liveborn singleton births at ≥ 37 weeks' gestation (n = 339,854) for 2009-13 in Victoria. Estimated blood loss was categorised as PPH ≥ 500 mL and severe PPH ≥ 1500 mL. Descriptive analysis was conducted and multivariable logistic regression was used to determine the adjusted odds ratio for the relationship between PPH/severe PPH and breastfeeding outcomes after adjustment for relevant confounders. FINDINGS: Overall, 94.9% of women initiated breastfeeding. Babies whose mother had a PPH or severe PPH were less likely than others to be exclusively breastfeeding at discharge (aOR 0.88; (95% CI 0.86, 0.90) and aOR 0.57; (95% CI 0.53, 0.61) respectively). Formula - given to 25.9% of all breastfed babies - was more likely for those whose mothers had a PPH or severe PPH (aOR 1.15; (95% CI 1.12, 1.17) and aOR 2.15; (95% CI 2.01, 2.29) respectively. CONCLUSIONS: Women have greater challenges establishing exclusive breastfeeding following PPH and severe PPH. Improving support in hospital for women following PPH may increase breastfeeding success.

Implementation of an obstetric triage decision aid into a maternity assessment unit and emergency department.

BACKGROUND: The obstetric triage decision aid (OTDA) consists of 10 common pregnancy complaints with key signs and symptoms generating a triage score based on targeted questioning responses. It was developed to provide a standardised approach for obstetric triage conducted by midwives and emergency nurses as neither professional group are expert in the triage of pregnant and postpartum women. AIM: To evaluate implementation of the OTDA into an emergency department (ED) and maternity assessment unit (MAU). METHODS: The OTDA was introduced to the ED and MAU of a hospital in Australia. A range of implementation strategies were utilised and assessed by pre and post staff survey, and a three-month post-audit of unscheduled maternity presentations. The primary outcome was adoption rate of the OTDA. Secondary outcomes were staff confidence and waiting times. Analyses were undertaken using SPSS (v24). Paired analysis was conducted on staff surveys. RESULTS: There were a total of 2829 unscheduled presentations: ED (n=708) and MAU (n=2121), 88.1% were triaged using the OTDA, used more in the MAU than the ED (93.2% vs 72.7%; p<.001). In the MAU, women seen within 15min of arrival improved significantly from 42.0% to 78.0%. There was improvement in the self-rated confidence (p=.002) and competence (p=.004) by nurses and midwives to conduct obstetric triage. CONCLUSION: The introduction of the OTDA required different approaches to change practice. There were improvements in staff self-rated confidence and competence, a reduction in clinical risk associated with under-triage in the ED and improved prioritisation of care in the MAU.

Talking testing: Impact of a training intervention on midwives' antenatal HIV, hepatitis B and hepatitis C screening practice.

BACKGROUND: Midwives play a critical role in ensuring that HIV, hepatitis B and hepatitis C screening occurs during early pregnancy, in accordance with national consensus guidelines and policies. Limited opportunities exist for midwives to gain the knowledge, skills and confidence required to initiate testing discussions at the first antenatal visit. AIM: To design, deliver and evaluate a workforce education intervention to build midwives' capacity to initiate testing for HIV and viral hepatitis. METHOD: Victorian midwives were invited to enrol in an intervention which comprised a pre-learning package and a one-day study day covering clinical, epidemiological and psychosocial aspects of HIV, hepatitis B and hepatitis C testing in early pregnancy. A pre-/post-test design, incorporating a survey with eight knowledge items and four confidence items, was used to measure impact. FINDINGS: Of the 69 participating midwives, 55 completed the pre-survey, 69 completed the post-survey and 19 completed a three-month follow up survey. Participant knowledge improved across all domains, with the most significant increases in the areas of HIV and viral hepatitis testing, transmission and treatment. Midwives' confidence levels increased following the intervention, and this was generally sustained among the smaller sample at the three-months. CONCLUSION: Our findings demonstrate that short educational interventions, designed and delivered by content experts, result in longer-term improvements in clinical practice which are crucial to ensuring women and their partners are given adequate information and recommendations about screening for HIV, hepatitis B and hepatitis C and during pregnancy.

Umbilical Cord Management at Term and Late Preterm Birth: A Meta-analysis.

CONTEXT: The International Liaison Committee on Resuscitation prioritized scientific review of umbilical cord management at term and late preterm birth. OBJECTIVE: To assess effects of umbilical cord management strategies (clamping timing and cord milking) in infants ≥34 weeks' gestational age. DATA SOURCES: Cochrane Central Register of Controlled Trials, Medline, PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and trial registries searched July 2019. STUDY SELECTION: Two authors independently assessed eligibility of randomized controlled trials. DATA EXTRACTION: Two authors independently extracted data and assessed evidence certainty (Grading of Recommendations Assessment, Development and Evaluations). RESULTS: We identified 46 studies (9159 women and their infants) investigating 7 comparisons. Compared with early cord clamping (ECC) <30 seconds, delayed cord clamping (DCC) ≥30 seconds (33 studies), intact-cord milking (1 study), and cut-cord milking (2 studies) probably improve hematologic measures but may not affect survival without neurodisability, anemia in early infancy, or maternal postpartum hemorrhage. No differences in major neonatal morbidities are seen in studies comparing methods of optimizing placental transfusion (DCC versus cut-cord milking [3 studies], longer delays in clamping [7 studies], or physiologic parameters [3 studies]). Strategies that promote increased placental transfusion may be associated with greater phototherapy use. Evidence for all outcomes was low or very low certainty. LIMITATIONS: Incompleteness and low certainty of findings limit applicability. CONCLUSIONS: Compared with ECC, DCC or cord milking increases hemoglobin and hematocrit immediately after birth in infants ≥34 weeks' gestational age. The uncertain effects of DCC and cord milking compared with ECC on major morbidities limit usefulness of available evidence for policy and practice.

Active versus expectant management for women in the third stage of labour.

BACKGROUND: Active management of the third stage of labour involves giving a prophylactic uterotonic, early cord clamping and controlled cord traction to deliver the placenta. With expectant management, signs of placental separation are awaited and the placenta is delivered spontaneously. Active management was introduced to try to reduce haemorrhage, a major contributor to maternal mortality in low-income countries. OBJECTIVES: To compare the effectiveness of active versus expectant management of the third stage of labour. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (May 2010). SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing active versus expectant management of the third stage of labour. DATA COLLECTION AND ANALYSIS: Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. MAIN RESULTS: We included five studies (6486 women), all undertaken in hospitals in high-income countries. Four compared active versus expectant management, and one compared active versus a mixture of managements. Analysis used random-effects because of clinical heterogeneity. Active management reduced the average risk of maternal primary haemorrhage (more than 1000 ml) (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.14 to 0.87, three studies, 4636 women) and of maternal haemoglobin less than 9 g/dl following birth (RR 0.50, 95% CI 0.30 to 0.83, two studies, 1572 women) for women irrespective of their risk of bleeding. We identified no difference in Apgar scores less than seven at five minutes. Active management showed significant increases in maternal diastolic blood pressure, after-pains, use of analgesia and more women returning to hospital with bleeding. There was also a decrease in the baby's birthweight with active management, reflecting the lower blood volume from interference with placental transfusion. There were similar findings for women at low risk of bleeding except there was no significant difference identified for severe haemorrhage. Hypertension and interference with placental transfusion might be avoided by using modifications to the active management package, e.g. omitting ergot and deferring cord clamping, but we have no direct evidence of this here. AUTHORS' CONCLUSIONS: Active management of third stage reduced the risk of haemorrhage greater than 1000 ml in an unselected population, but adverse effects are identified. Women should be given information on the benefits and harms to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third stage management. Data are also required from low-income countries.

WITHDRAWN: Active versus expectant management in the third stage of labour.

BACKGROUND: Expectant management of the third stage of labour involves allowing the placenta to deliver spontaneously or aiding by gravity or nipple stimulation. Active management involves administration of a prophylactic oxytocic before delivery of the placenta, and usually early cord clamping and cutting, and controlled cord traction of the umbilical cord. OBJECTIVES: The objective of this review was to assess the effects of active versus expectant management on blood loss, post partum haemorrhage and other maternal and perinatal complications of the third stage of labour. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Randomised trials comparing active and expectant management of the third stage of labour in women who were expecting a vaginal delivery. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by the reviewers. MAIN RESULTS: Five studies were included. Four of the trials were of good quality. Compared to expectant management, active management (in the setting of a maternity hospital) was associated with the following reduced risks: maternal blood loss (weighted mean difference -79.33 millilitres, 95% confidence interval -94.29 to -64.37); post partum haemorrhage of more than 500 millilitres (relative risk 0.38, 95% confidence interval 0.32 to 0.46); prolonged third stage of labour (weighted mean difference -9.77 minutes, 95% confidence interval -10.00 to -9.53). Active management was associated with an increased risk of maternal nausea (relative risk 1.83, 95% confidence interval 1.51 to 2.23), vomiting and raised blood pressure (probably due to the use of ergometrine). No advantages or disadvantages were apparent for the baby. AUTHORS' CONCLUSIONS: Routine 'active management' is superior to 'expectant management' in terms of blood loss, post partum haemorrhage and other serious complications of the third stage of labour. Active management is, however, associated with an increased risk of unpleasant side effects (eg nausea and vomiting), and hypertension, where ergometrine is used. Active management should be the routine management of choice for women expecting to deliver a baby by vaginal delivery in a maternity hospital. The implications are less clear for other settings including domiciliary practice (in developing and industrialised countries).

Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes.

BACKGROUND: Policies for timing of cord clamping vary, with early cord clamping generally carried out in the first 60 seconds after birth, whereas later cord clamping usually involves clamping the umbilical cord greater than one minute after the birth or when cord pulsation has ceased. OBJECTIVES: To determine the effects of different policies of timing of cord clamping at delivery of the placenta on maternal and neonatal outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2007). SELECTION CRITERIA: Randomised controlled trials comparing early and late cord clamping. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial eligibility and quality and extracted data. MAIN RESULTS: We included 11 trials of 2989 mothers and their babies. No significant differences between early and late cord clamping were seen for postpartum haemorrhage or severe postpartum haemorrhage in any of the five trials (2236 women) which measured this outcome (relative risk (RR) for postpartum haemorrhage 500 mls or more 1.22, 95% confidence interval (CI) 0.96 to 1.55). For neonatal outcomes, our review showed both benefits and harms for late cord clamping. Following birth, there was a significant increase in infants needing phototherapy for jaundice (RR 0.59, 95% CI 0.38 to 0.92; five trials of 1762 infants) in the late compared with early clamping group. This was accompanied by significant increases in newborn haemoglobin levels in the late cord clamping group compared with early cord clamping (weighted mean difference 2.17 g/dL; 95% CI 0.28 to 4.06; three trials of 671 infants), although this effect did not persist past six months. Infant ferritin levels remained higher in the late clamping group than the early clamping group at six months. AUTHORS' CONCLUSIONS: One definition of active management includes directions to administer an uterotonic with birth of the anterior shoulder of the baby and to clamp the umbilical cord within 30-60 seconds of birth of the baby (which is not always feasible in practice). In this review delaying clamping of the cord for at least two to three minutes seems not to increase the risk of postpartum haemorrhage. In addition, late cord clamping can be advantageous for the infant by improving iron status which may be of clinical value particularly in infants where access to good nutrition is poor, although delaying clamping increases the risk of jaundice requiring phototherapy.

Monitoring postpartum haemorrhage in Australia: Opportunities to improve reporting.

PROBLEM: The rate and severity of postpartum haemorrhage (PPH) are increasing, according to research reports and clinical anecdote, causing a significant health burden for Australian women giving birth. However, reporting a national Australian rate is not possible due to inconsistent reporting of PPH. BACKGROUND: Clinician concerns about the incidence and severity of PPH are growing. Midwives contribute perinatal data on every birth, yet published population-based data on PPH seems to be limited. What PPH information is contributed? What data are publicly available? Do published data reflect the PPH concerns of clinicians? AIM: To examine routine public reporting on PPH across Australia. METHODS: We systematically analysed routine, publicly reported data on PPH published in the most recent perinatal data for each state, territory and national report (up to and including October 2016). We extracted PPH data on definitions, type and method of data recorded, markers of severity, whether any analyses were done and whether any trends or concerns were noted. FINDINGS: PPH data are collected by all Australian states and territories however, definitions, identification method and documentation of data items vary. Not all states and territories published PPH rates; those that did ranged from 3.3% to 26.5% and were accompanied by minimal reporting of severity and possible risk factors. Whilst there are plans to include PPH as a mandatory reporting item, the timeline is uncertain. CONCLUSIONS: Routinely published PPH data lack nationally consistent definitions and detail. All states and territories are urged to prioritise the adoption of nationally recommended PPH items.

Impact of violence against women on severe acute maternal morbidity in the intensive care unit, including neonatal outcomes: a case-control study protocol in a tertiary healthcare facility in Lima, Peru.

INTRODUCTION: Preventing and reducing violence against women (VAW) and maternal mortality are Sustainable Development Goals. Worldwide, the maternal mortality ratio has fallen about 44% in the last 25 years, and for one maternal death there are many women affected by severe acute maternal morbidity (SAMM) requiring management in the intensive care unit (ICU). These women represent the most critically ill obstetric patients of the maternal morbidity spectrum and should be studied to complement the review of maternal mortality. VAW has been associated with all-cause maternal deaths, and since many women (30%) endure violence usually exerted by their intimate partners and this abuse can be severe during pregnancy, it is important to determine whether it impacts SAMM. Thus, this study aims to investigate the impact of VAW on SAMM in the ICU. METHODS AND ANALYSIS: This will be a prospective case-control study undertaken in a tertiary healthcare facility in Lima-Peru, with a sample size of 109 cases (obstetric patients admitted to the ICU) and 109 controls (obstetric patients not admitted to the ICU selected by systematic random sampling). Data on social determinants, medical and obstetric characteristics, VAW, pregnancy and neonatal outcome will be collected through interviews and by extracting information from the medical records using a pretested form. Main outcome will be VAW rate and neonatal mortality rate between cases and controls. VAW will be assessed by using the WHO instrument. Binary logistic followed by stepwise multivariate regression and goodness of fit test will assess any association between VAW and SAMM. ETHICS AND DISSEMINATION: Ethical approval has been granted by the La Trobe University, Melbourne-Australia and the tertiary healthcare facility in Lima-Peru. This research follows the WHO ethical and safety recommendations for research on VAW. Findings will be presented at conferences and published in peer-reviewed journals.

Data accuracy in the Victorian Perinatal Data Collection: Results of a validation study of 2011 data.

OBJECTIVE: Public health data sets such as the Victorian Perinatal Data Collection (VPDC) provide an important source for health planning, monitoring, policy, research and reporting purposes. Data quality is paramount, requiring periodic assessment of data accuracy. This article describes the conduct and findings of a validation study of data on births in 2011 extracted from the VPDC. METHOD: Data from a random sample of one percent of births in Victoria in 2011 were extracted from original medical records at the birth hospital and compared with data held in the VPDC. Accuracy was determined for 93 variables. Sensitivity, specificity, positive predictive value and negative predictive value were calculated for dichotomous items. RESULTS: Accuracy of 17 data items was 99% or more, the majority being neonatal and intrapartum items, and 95% or more for 46 items. Episodes of care with the highest proportion of items with accuracy of 95% or more were neonatal and postnatal items at 80 and 64%, respectively. Accuracy was below 80% for nine items introduced in 2009. Agreement between medical records and VPDC data ranged from 48% to 100%, the exception being two highly inaccurate smoking-related items. Reasons for discrepancies between VPDC data and medical records included miscoding, missing and inconsistent information. CONCLUSION: This study found high levels of accuracy for data reported to the VPDC for births in 2011; however, some data items introduced in 2009 and not previously validated were less accurate. Data may be used with confidence overall and with awareness of limitations for some new items.

Prevention of central venous catheter-related infection in the neonatal unit: a literature review.

Central venous catheter infections are the leading cause of healthcare-associated bloodstream infections and contribute significantly to mortality and morbidity in neonatal intensive care units. Moreover, infection poses significant economic consequence which increased hospital costs and increased length of hospital stay. Prevention strategies are detailed in guidelines published by the Centers for Disease Control and Prevention (CDC) in the United States; nevertheless, recent surveys in neonatal units in the United States, and Australia and New Zealand demonstrate these are not always followed. This review discusses the numerous evidence-based strategies to prevent catheter infections including hand hygiene, maximal sterile barriers during insertion, skin disinfection, selection of insertion site, dressings, aseptic non-touch technique, disinfection of catheter hubs/ports, administration set management, prompt removal of catheter, antibiotic locks, systemic antibiotic prophylaxis and chlorhexidine bathing. Furthermore, it will describe different strategies that can be implemented into clinical practice to reduce infection rates. These include the use of care bundles including checklists, education and the use of CVC teams.

Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes.

BACKGROUND: Policies for timing of cord clamping vary, with early cord clamping generally carried out in the first 60 seconds after birth, whereas later cord clamping usually involves clamping the umbilical cord more than one minute after the birth or when cord pulsation has ceased. The benefits and potential harms of each policy are debated. OBJECTIVES: To determine the effects of early cord clamping compared with late cord clamping after birth on maternal and neonatal outcomes SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 February 2013). SELECTION CRITERIA: Randomised controlled trials comparing early and late cord clamping. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial eligibility and quality and extracted data. MAIN RESULTS: We included 15 trials involving a total of 3911 women and infant pairs. We judged the trials to have an overall moderate risk of bias. MATERNAL OUTCOMES: No studies in this review reported on maternal death or on severe maternal morbidity. There were no significant differences between early versus late cord clamping groups for the primary outcome of severe postpartum haemorrhage (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.65 to 1.65; five trials with data for 2066 women with a late clamping event rate (LCER) of ~3.5%, I(2) 0%) or for postpartum haemorrhage of 500 mL or more (RR 1.17 95% CI 0.94 to 1.44; five trials, 2260 women with a LCER of ~12%, I(2) 0%). There were no significant differences between subgroups depending on the use of uterotonic drugs. Mean blood loss was reported in only two trials with data for 1345 women, with no significant differences seen between groups; or for maternal haemoglobin values (mean difference (MD) -0.12 g/dL; 95% CI -0.30 to 0.06, I(2) 0%) at 24 to 72 hours after the birth in three trials. NEONATAL OUTCOMES: There were no significant differences between early and late clamping for the primary outcome of neonatal mortality (RR 0.37, 95% CI 0.04 to 3.41, two trials, 381 infants with a LCER of ~1%), or for most other neonatal morbidity outcomes, such as Apgar score less than seven at five minutes or admission to the special care nursery or neonatal intensive care unit. Mean birthweight was significantly higher in the late, compared with early, cord clamping (101 g increase 95% CI 45 to 157, random-effects model, 12 trials, 3139 infants, I(2) 62%). Fewer infants in the early cord clamping group required phototherapy for jaundice than in the late cord clamping group (RR 0.62, 95% CI 0.41 to 0.96, data from seven trials, 2324 infants with a LCER of 4.36%, I(2) 0%). Haemoglobin concentration in infants at 24 to 48 hours was significantly lower in the early cord clamping group (MD -1.49 g/dL, 95% CI -1.78 to -1.21; 884 infants, I(2) 59%). This difference in haemoglobin concentration was not seen at subsequent assessments. However, improvement in iron stores appeared to persist, with infants in the early cord clamping over twice as likely to be iron deficient at three to six months compared with infants whose cord clamping was delayed (RR 2.65 95% CI 1.04 to 6.73, five trials, 1152 infants, I(2) 82%). In the only trial to report longer-term neurodevelopmental outcomes so far, no overall differences between early and late clamping were seen for Ages and Stages Questionnaire scores. AUTHORS' CONCLUSIONS: A more liberal approach to delaying clamping of the umbilical cord in healthy term infants appears to be warranted, particularly in light of growing evidence that delayed cord clamping increases early haemoglobin concentrations and iron stores in infants. Delayed cord clamping is likely to be beneficial as long as access to treatment for jaundice requiring phototherapy is available.

Effect of an extended midwifery postnatal support programme on the duration of breast feeding: a randomised controlled trial.

OBJECTIVE: to evaluate the effects of an extended midwifery support (EMS) programme on the proportion of women who breast feed fully to six months. DESIGN: randomised controlled trial. SETTING: large public teaching hospital in Australia. PARTICIPANTS: 849 women who had given birth to a healthy, term, singleton baby and who wished to breast feed. INTERVENTION: participants were allocated at random to EMS, in which they were offered a one-to-one postnatal educational session and weekly home visits with additional telephone contact by a midwife until their baby was six weeks old; or standard postnatal midwifery support (SMS). Participants were stratified for parity and tertiary education. MEASUREMENTS: the main outcome measures were prevalence of full and any breast feeding at six months postpartum. FINDINGS: there was no difference between the groups at six months postpartum for either full breast feeding [EMS 43.3% versus SMS 42.5%, relative risk (RR) 1.02, 95% confidence interval (CI) 0.87-1.19] or any breast feeding (EMS 63.9% versus SMS 67.9%, RR 0.94, 95%CI 0.85-1.04). CONCLUSIONS: the EMS programme did not succeed in improving breast-feeding rates in a setting where there was high initiation of breast feeding. Breast-feeding rates were high but still fell short of national goals. IMPLICATIONS FOR PRACTICE: continuing research of programmes designed to promote breast feeding is required in view of the advantages of breast feeding for all mothers and babies.