Experiences of maternity care among women at increased risk of preterm birth receiving midwifery continuity of care compared to women receiving standard care: Results from the POPPIE pilot trial.

BACKGROUND: Midwifery continuity of care models for women at low and mixed risk of complications have been shown to improve women's experiences of care. However, there is limited research on care experiences among women at increased risk of preterm birth. We aimed to explore the experiences of care among women with risk factors for preterm birth participating in a pilot trial (POPPIE) of a midwifery continuity of care model which included a specialist obstetric clinic. METHODS: A total of 334 pregnant women identified at increased risk of preterm birth were randomly allocated to either midwifery continuity of care (POPPIE group) or standard maternity care. Women in both groups were followed up at six-to-eight weeks postpartum and were invited to complete a postnatal survey either online or by post. An equal status exploratory sequential mixed method design was chosen to collect and analyse the quantitative postnatal survey data and qualitative interviews data. The postnatal survey included measures of social support, trust, perceptions of safety, quality of care, control during childbirth, bonding and quality of life. Categorical data were analysed with chi-squared tests and continuous data were analysed with t-tests and/or Mann-Whitney U test to measure differences in measures scores among groups. The qualitative interview data were subjected to a thematic framework analysis. Data triangulation brought quantitative and qualitative data together at the interpretation stage. FINDINGS: A total of 166 women completed the survey and 30 women were interviewed (90 and 16 in POPPIE group; 76 and 14 in standard group). We found survey respondents in the POPPIE group, compared to respondents in the standard group, were significantly more likely to report greater trust in midwives (Mann-Whitney U, p<0.0001), greater perceptions of safety during the antenatal care (t-test, p = 0.0138), have a particular midwife to contact when they needed during their pregnancy (t-test, p<0.0001) and the postnatal period (chi-squared, p<0.0001). They reported increased involvement in decisions regarding antenatal, intrapartum and postnatal care (t-test, p = 0.002; p = 0.008; p = 0.006 respectively); and greater postnatal support and advice about: feeding the baby (chi-squared, p<0.0001), handling, settling and looking after the baby (chi-squared, p<0.0001), baby's health and progress (chi-squared, p = 0.039), their own health and recovery (chi-squared, p = 0.006) and who to contact about any emotional changes (chi-squared, p = 0.005). There were no significant differences between groups in the reporting of perceptions of safety during birth and the postnatal period, concerns raised during labour and birth taken seriously, being left alone during childbirth at a time of worries, control during labour, bonding, social support, and physical and mental health related quality of life after birth. Results from qualitative interviews provided insight and depth into many of these findings, with women in the POPPIE group reporting more positive experiences of bonding towards their babies and more positive physical health postnatally. CONCLUSIONS: Compared with standard maternity care, women at increased risk of PTB who received midwifery continuity of care were more likely to report increased perceptions of trust, safety and quality of care. TRIAL REGISTRATION: ISRCTN (Number: 37733900); UK CRN (ID: 31951).

Hereditary Cancer Risk Assessment and Genetic Testing in the Community-Practice Setting.

OBJECTIVE: To evaluate the feasibility and results of incorporating routine hereditary cancer risk assessment, counseling, and follow-up genetic testing in the community obstetrics and gynecology practice setting without referral to a genetic counselor. METHODS: This prospective process intervention study was conducted with two obstetrics and gynecology practice groups (five sites). The intervention included baseline process assessment, refinement of clinic-specific patient screening workflows and tools, and training in hereditary cancer risk screening and follow-up. Outcomes related to hereditary cancer assessment and testing were measured during an 8-week postintervention period. Patients and health care providers were surveyed about satisfaction with the process. Data also were collected during the 8 weeks before the intervention to assess the effects of screening process improvements. RESULTS: A total of 4,107 patients were seen during the postintervention period, and 92.8% (3,811) were assessed for hereditary cancer risk. Among those assessed, 906 of 3,811 (23.8%) women met National Comprehensive Cancer Network guidelines for genetic testing, and 813 of 906 (89.7%) eligible patients were offered genetic testing. A total of 165 of 4,107 (4.0%) women completed genetic testing and received a final test result. This represents a fourfold increase over genetic testing immediately before the intervention (1.1%) and an eightfold increase over the previous year (0.5%). Testing identified pathogenic variants in 9 of 165 (5.5%) tested women. All health care providers (15/15) reported that they will continue to use the established hereditary cancer risk assessment process. In addition, 98.8% (167/169) of patients who submitted a sample for genetic testing and completed a patient satisfaction survey stated that they were able to understand the information provided, and 97.6% (165/169) expressed satisfaction with the overall process. CONCLUSION: It is feasible to incorporate hereditary cancer risk assessment, education, and testing into community obstetrics and gynecology practices. As a result, multigene panel testing identified significant cancer risks that otherwise would not have been recognized.

Shoulder dystocia: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF).

Shoulder dystocia (SD) is defined as a vaginal delivery in cephalic presentation that requires additional obstetric maneuvers to deliver the fetus after the head has delivered and gentle traction has failed. It complicates 0.5-1% of vaginal deliveries. Risks of brachial plexus birth injury (level of evidence [LE]3), clavicle and humeral fracture (LE3), perinatal asphyxia (LE2), hypoxic-ischemic encephalopathy (LE3) and perinatal mortality (LE2) increase with SD. Its main risk factors are previous SD and macrosomia, but both are poorly predictive; 50-70% of SD cases occur in their absence, and most deliveries when they are present do not result in SD. No study has proven that the correction of these risk factors (except gestational diabetes) would reduce the risk of SD. Physical activity is recommended before and during pregnancy to reduce the occurrence of some risk factors for SD (Grade C). In obese women, physical activity should be coupled with dietary measures to reduce fetal macrosomia and weight gain during pregnancy (Grade A). Women with gestational diabetes require diabetes care (diabetic diet, glucose monitoring, insulin if needed) (Grade A) because it reduces the risk of macrosomia and SD (LE1). Only two measures are proposed for avoiding SD and its complications. First, induction of labor is recommended in cases of impending macrosomia if the cervix is favorable at a gestational age of 39 weeks or more (professional consensus). Second, cesarean delivery is recommended before labor in three situations and during labor in one: (i) estimated fetal weight (EFW) >4500g if associated with maternal diabetes (Grade C), (ii) EFW >5000g in women without diabetes (Grade C), (iii) history of SD associated with severe neonatal or maternal complications (professional consensus), and finally during labor, (iv) in case of fetal macrosomia and failure to progress in the second stage, when the fetal head station is above +2 (Grade C). In cases of SD, it is recommended to avoid the following actions: excessive traction on the fetal head (Grade C), fundal pressure (Grade C), and inverse rotation of the fetal head (professional consensus). The McRoberts maneuver, with or without suprapubic pressure, is recommended first (Grade C). If it fails and the posterior shoulder is engaged, Wood's maneuver should be performed preferentially; if the posterior shoulder is not engaged, it is preferable to attempt to deliver the posterior arm next (professional consensus). It appears necessary to know at least two maneuvers to perform should the McRoberts maneuver fail (professional consensus). A pediatrician should be immediately informed of SD. The initial clinical examination should check for complications, such as brachial plexus injury or clavicle fracture (professional consensus). If no complications are observed, neonatal monitoring need not be modified (professional consensus). The implementation of practical training with simulation for all care providers in the delivery room is associated with a significant reduction in neonatal (LE3) but not maternal (LE3) injury. SD remains an unpredictable obstetric emergency. All physicians and midwives should know and perform obstetric maneuvers if needed, quickly but calmly.

A survey of prolapse practice in UK women's health physiotherapists: what has changed in the last decade?

INTRODUCTION AND HYPOTHESIS: Prolapse is a common female problem, and conservative treatments such as pelvic floor muscle training (PFMT) are important options for women. Evidence supporting the effectiveness of PFMT for prolapse has grown over the last decade, and it was hypothesised that practice and practice guidelines would have developed in line with the evidence. To assess this, up-to-date information about the practice of physiotherapists working in women's health regarding their treatment of prolapse was required. METHODS: An online survey sent to members of the Association of Chartered Physiotherapists in Women's Health and the Chartered Physiotherapists Promoting Continence. Results were compared with those of an earlier survey undertaken in 2002. RESULTS: A 49 % response rate was achieved. The majority of respondents were senior physiotherapists (55 %) and had worked in women's health for more than 10 years. Respondents were treating significantly more women with prolapse than a decade before: 36 % vs 14 % treated more than 50 women per year in 2002 and 2013 respectively (p < 0.001). Individualised PFMT (93 %), lifestyle advice (92 %) and biofeedback-assisted PFMT (83 %) were the most common treatment elements, with four being the average number of appointments. Forty-eight percent had changed their practice as a result of recent research; however, scepticism amongst medics, the referral of women directly for surgery, and constraints on resources were thought to be barriers to wider implementation of the evidence of PFMT for prolapse. CONCLUSIONS: There has been uptake of evidence-based prolapse practice by UK specialist physiotherapists in the last decade. Further research targeting the implementation of this evidence would be valuable in addressing potential barriers, and in supporting the need for physiotherapy in the treatment of prolapse.

[The Application of Bryophyllum pinnatum Preparations in Obstetrics and Gynaecology ­ a Multicenter, Prospective Observational Study]. / Die Anwendung von Bryophyllum pinnatum-Präparaten in der Geburtshilfe und Gynäkologie - eine multizentrische prospektive Beobachtungsstudie

BACKGROUND: Bryophyllum pinnatum has been introduced in anthroposophic medicine in Europe and is nowadays also widely used in conventional medicine. The aim of this study was to assess the prescriptions in the field of gynaecology and obstetrics in Switzerland and to document potential effects and possible adverse events of B. pinnatum. PATIENTS AND METHODS: Private practices and clinics for obstetrics and gynaecology were asked to document each prescription of B. pinnatum for their female patients during 31 months with an online questionnaire. RESULTS: At the University Hospital Zurich, at the Cantonal Hospital Winterthur as well as at 2 private practices, a total of 174 women and 208 prescriptions of B. pinnatum were recorded (several prescriptions per patient were possible). Most of the patients were pregnant (87%). B. pinnatum was prescribed as a tocolytic agent to 83% of all patients and to 95% of all pregnant patients and showed a good or a very good effectiveness. Further, 14% of the patients received B. pinnatum for sedation against their restlessness during the day and 5% for sedation against sleep problems. A decrease of the restlessness was achieved for these 2 indications. 13% of the patients suffered from a hyperactive bladder and in two-thirds of them the effectiveness of the treatment with B. pinnatum was classified as very good. In 92% of the cases, Bryophyllum 50% chewable tablets were prescribed. CONCLUSIONS: In conventional gynaecology and obstetrics, B. pinnatum is predominantly prescribed for pregnant women in case of prematurel abour, against restlessness and for hyperactive bladder. B. pinnatum showed a good effectiveness with a high benefit in the treatment of hyperactivity-associated health problems.

Peripheral neuropathy in obstetrics: efficacy and safety of α-lipoic acid supplementation.

OBJECTIVE: Neuropathic pain during pregnancy is a common condition due to the physical changes and compression around pregnancy and childbirth that make pregnant women more prone to develop several medical conditions such as carpal tunnel syndrome, sciatica, meralgia paraesthetica and other nerve entrapment syndromes. Most of the treatments usually performed to counteract neuropathic pain are contraindicated in pregnancy so that, the management of these highly invalidating conditions remains an issue in the clinical practice. We aimed to review the efficacy and safety of alpha lipoic acid supplementation in the treatment of neuropathic pain. DISCUSSION: Lipoic acid is a co-factor essential in the regulation of mitochondrial energy. It has been demonstrated that lipoic acid supplementation is involved in several biochemical processes and actions, exerting important antioxidant and anti-inflammatory activity and significantly improving pain and paraesthesia in patients with sciatica, carpal tunnel syndrome and diabetic neuropathy. CONCLUSIONS: Efficacy of lipoic acid is combined with a high safety profile, making this molecule a novel candidate for the management of several diseases. Data reported so far are promising and dietary supplementation with lipoic acid seems a useful tool to contrast neuropathic pain during pregnancy.

An emerging model of maternity care: smartphone, midwife, doctor?

BACKGROUND: Mobile technology in the form of the smartphone is widely used, particularly in pregnancy and they are an increasing and influential source of information. AIM: To describe the diverse nature of pregnancy related applications (apps) for the smartphone and to flag that these apps can potentially affect maternity care and should be considered in future planning of care provision. METHODS: The 2 smartphone platforms, Apple and Android, were searched for pregnancy related apps and reviewed for their purpose and popularity. FINDINGS: iTunes and Google Play returned 1059 and 497 pregnancy related apps respectively. Forty percent of the apps were informative, 13% interactive, 19% had features of a medical tool and 11% were social media apps. By far the most popular apps, calculated as the number of reviews multiplied by average reviewer rating, were those with interactive features. DISCUSSION: The popularity of pregnancy-related apps could indicate a shift towards patient empowerment within maternity care provision. The traditional model of 'shared maternity care' needs to accommodate electronic devices into its functioning. Reliance on healthcare professionals may be reduced by the availability of interactive and personalised information delivered via a smartphone. This combined with the fact that smartphones are widely used by many women of childbearing age, has the potential to modify maternity care and experiences of pregnancy. Therefore it is important that healthcare professionals and policy-makers are more aware of these new developments, which are likely to influence healthcare and alter health-seeking behaviour. In addition healthcare professionals need to consider whether to discuss the use of apps in pregnancy with the women in their care.

Planned home birth in the United States and professionalism: a critical assessment.

Planned home birth has been considered by some to be consistent with professional responsibility in patient care. This article critically assesses the ethical and scientific justification for this view and shows it to be unjustified. We critically assess recent statements by professional associations of obstetricians, one that sanctions and one that endorses planned home birth. We base our critical appraisal on the professional responsibility model of obstetric ethics, which is based on the ethical concept of medicine from the Scottish and English Enlightenments of the 18th century. Our critical assessment supports the following conclusions. Because of its significantly increased, preventable perinatal risks, planned home birth in the United States is not clinically or ethically benign. Attending planned home birth, no matter one's training or experience, is not acting in a professional capacity, because this role preventably results in clinically unnecessary and therefore clinically unacceptable perinatal risk. It is therefore not consistent with the ethical concept of medicine as a profession for any attendant to planned home birth to represent himself or herself as a "professional." Obstetric healthcare associations should neither sanction nor endorse planned home birth. Instead, these associations should recommend against planned home birth. Obstetric healthcare professionals should respond to expressions of interest in planned home birth by pregnant women by informing them that it incurs significantly increased, preventable perinatal risks, by recommending strongly against planned home birth, and by recommending strongly for planned hospital birth. Obstetric healthcare professionals should routinely provide excellent obstetric care to all women transferred to the hospital from a planned home birth.The professional responsibility model of obstetric ethics requires obstetricians to address and remedy legitimate dissatisfaction with some hospital settings and address patients' concerns about excessive interventions. Creating a sustained culture of comprehensive safety, which cannot be achieved in planned home birth, informed by compassionate and respectful treatment of pregnant women, should be a primary focus of professional obstetric responsibility.

The electronic health record as a healthcare management strategy and implications for obstetrics and gynecologic practice.

PURPOSE OF REVIEW: To review the current trends, utilities, impacts and strategy for electronic health records (EHRs) as related to obstetrics and gynecology. RECENT FINDINGS: Adoption and utilization of EHRs are increasing rapidly but variably, given pressures of financial incentives, policy and technological advancement. Adoption is outpacing published evidence, but there is a growing body of descriptive literature regarding incentives, benefits, risks and costs of adoption and utilization. Further, there is a rising body of evidence that EHRs can bring benefits to processes and outcomes, and that their implementation can be considered as a healthcare management strategy. Obstetrics and gynecology practices have specific needs, which must be addressed in the adoption of such technology. Specialty specific literature is sparse but should be considered as part of any strategy aimed at achieving quality improvement and practice behavior change. SUMMARY: Obstetrics and gynecologic practice presents unique challenges to the effective adoption and use of EHR technologies, but there is promise as the technologies, integration and usability are rapidly improving. This technology will have an increasing impact on the practice of obstetrics and gynecology in the coming years.

Obstetric care in the Netherlands: relic or example?

This review assesses the rise and fall of the unique Dutch system of obstetric care. Why did home deliveries continue in the Netherlands when they almost completely disappeared in the rest of the Western world? Why is the Dutch system currently under so much pressure? Did the participants continue for too long with too conservative an approach? Which of the good things of the past have been lost?

Recent trends in clinicians providing care to pregnant women in the United States.

INTRODUCTION: Health care needs of pregnant women are met by a variety of clinicians in a changing policy and practice environment. This study documents recent trends in types of clinicians providing care to pregnant women in the United States. METHODS: We used a repeat cross-sectional design and data from the Integrated Health Interview Series (2000-2009), a nationally representative data set, for respondents who reported being pregnant at the time of the survey (N = 3204). Using longitudinal logistic regression models, we analyzed changes over time in pregnant women's reported use of care from 1) obstetrician-gynecologists; 2) midwives, nurse practitioners (NPs), or physician assistants (PAs); or 3) both an obstetrician-gynecologist and a midwife, NP, or PA. RESULTS: The percentage of pregnant women who reported seeing an obstetrician-gynecologist (87%) remained steady from 2000 through 2009. After controlling for demographic and clinical variables, the percentage who reported receiving care from a midwife, NP, or PA increased 4% annually (yearly adjusted odds ratio [AOR] 1.04; P < .001), indicating a cumulative increase of 48% over the decade. The percentage of pregnant women who received care from both an obstetrician-gynecologist and a midwife, NP, or PA also increased (AOR 1.027; P < .001), for a cumulative increase of 30%. DISCUSSION: The increasing role of midwives, NPs, and PAs in the provision of maternity care suggests changes in the perinatal workforce and practice models that may promote collaborative care and quality improvement. However, better data collection is required to gather detailed information on specific provider types, these trends, and their implications.

[Changing trends in obstetrics in the last decade]. / Az elmúlt évtized változóban lévo szülészeti trendjei.

The author (who has four decades of clinical and managerial practice) analyses the changing trends in obstetrics that occurred in the last decade. He focuses on the main points where the most significant professional developments have happened (prenatal care, new professional guidelines, and integrated services). This work covers the principles of prevention and the advanced diagnostics in the field of prenatal and obstetrical care. Finally, the author describes the need for structural and functional reorganization in obstetrics.

Web-based news reports on midwives compared with obstetricians: a prospective analysis.

BACKGROUND: The media both creates and reflects public opinion. The way in which health professionals are depicted in the media is likely to influence views held by and about different health professions. The aim of this study was to examine how midwives and obstetricians are reported in English language web-based news reports from around the world. METHODS: News alerts from the Internet search engine Google were created to search for the terms "midwife,""midwives,""midwifery,""obstetrics," and "obstetricians." These alerts were received over a 12-month period (May 1, 2006-April 31, 2007), downloaded, and analyzed using quantitative content analysis. RESULTS: A total of 522 web-based news reports for midwifery and 564 for obstetrics (n = 1,086) were found. Dominant categories for midwives were: "mainstreaming midwives" (models of care/rise of midwifery) (28%); "the Cinderella of the maternity care" (workforce/industrial) (27%); "delivering the baby with your hands tied" (funding, insurance, and legislation) (21%); "ask the expert" (education, research, and health advice) (8%), "recognizing midwives" (awards and announcements) (7%), "unsafe midwives" (litigation) (6%); and "the art of birth" (books, film, and photographs) (2%). Dominant categories for obstetricians were: "ask the expert" (research and advice) (26%); "doctors are heroes amongst us" (awards and announcements) (19%); "obstetric workforce woes" (workforce/industrial) (19%); "new frontiers" (trends in care and new technology) (17%); "the disappearing obstetrician" (insurance and litigation) (10%); and "human-interest news reports" (9%). Obstetricians were more likely to be recognized as experts on pregnancy and birth and receive public recognition compared with midwives. Midwives were more likely to be depicted as struggling to be a mainstream option while being hampered by lack of funding, insurance, and legislative barriers. CONCLUSIONS: Although midwives have rising acceptance, they still struggle with recognition. Obstetricians have both acceptance and recognition. Countries where midwifery is a mainstream option have more news reports related to midwifery than obstetrics. Different issues appear more dominant in some countries, such as work force in the United Kingdom and funding, insurance, and legislation in the United States.