European Association of Perinatal Medicine (EAPM), European Board and College of Obstetricians and Gynaecologists (EBCOG), European Midwives Association (EMA). Joint position statement: Substandard and disrespectful care in labour - because words matter.

Substandard or disrespectful care during labour should be of serious concern for healthcare professionals, as it can affect one of the most important events in a woman's life. Substandard care refers to the use of interventions that are not considered best-practice, to the inadequate execution of interventions, to situations where best-practice interventions are withheld from patients, or there is lack of adequate informed consent. Disrespectful care refers to forms of verbal and non-verbal communication that affect patients' dignity, individuality, privacy, intimacy, or personal beliefs. There are many possible underlying causes for substandard and disrespectful care in labour, including difficulties in modifying behaviours, judgmental or paternalistic attitudes, personal interests and individualism, and a human tendency to make less arduous, less difficult, or less stressful clinical decisions. The term "obstetric violence" is used in some parts of the world to describe various forms of substandard and disrespectful care in labour, but suggests that it is mainly carried out by obstetricians and is a serious form of aggression, carried out with the intent to cause harm. We believe that this term should not be used, as it does not help to identify the underlying problem, its causes, or its correction. In addition, it is generally seen by obstetricians and other healthcare professionals as an unjust and offensive term, generating a defensive and less collaborative mindset. We reach out to all individuals and institutions sharing the common goal of improving women's experience during labour, to work together to address the underlying causes of substandard and disrespectful care, and to develop common strategies to deal with this problem, based on mutual comprehension, trust and respect.

Self-reported exposure to severe events on the labour ward among Swedish midwives and obstetricians: A cross-sectional retrospective study.

BACKGROUND: The process of delivery entails potentially traumatic events in which the mother or child becomes injured or dies. Midwives and obstetricians are sometimes responsible for these events and can be negatively affected by them as well as by the resulting investigation or complaints procedure (clinical negligence). OBJECTIVE: To assess the self-reported exposure rate of severe events among midwives and obstetricians on the delivery ward and the cumulative risk by professional years and subsequent investigations and complaints. DESIGN: Cross-sectional survey. PARTICIPANTS: Members of the Swedish Association of Midwives (SFB) and the Swedish Society of Obstetrics and Gynaecology (SFOG). METHODS: A questionnaire covering demographic characteristics, experiences of self-reported severe events on the delivery ward, and complaints of medical negligence was developed. Potential consequences of the complaint was not reported. A severe event was defined as: 1) the death of an infant due to delivery-related causes during childbirth or while on the neonatal ward; 2) an infant being severely asphyxiated or injured at delivery; 3) maternal death; 4) very severe or life threatening maternal morbidity; or 5) other stressful events during delivery, such as exposure to violence or aggression. RESULTS: The response rate was 39.9% (n=1459) for midwives and 47.1% (n=706) for obstetricians. Eighty-four percent of the obstetricians and almost 71% of responding midwives had experienced one or more self-reported severe obstetric event with detrimental consequences for the woman or the new-born. Fourteen percent of the midwives and 22.4% of the obstetricians had faced complaints of medical negligence from the patient or the family of the patient. CONCLUSIONS: A considerable proportion of midwives and obstetricians will, in the course of their working life, experience severe obstetric events in which the mother or the new-born is injured or dies. Preparedness for such exposure should be part of the training, as should managerial and peer support for those in need. This could prevent serious consequences for the health care professionals involved and their subsequent careers.

Analysis of malpractice claims with a focus on oxytocin use in labour.

BACKGROUND: The objective of this study was to analyse the motives behind disciplinary action in obstetric malpractice cases concerning delivery, and to evaluate the frequency of inappropriate oxytocin use in these cases. METHODS: An analysis of all malpractice claims resulting in disciplinary action against physicians and midwives during the period 1996-2003. Investigations and decisions made by the Board of Medical Responsibility were reviewed with special focus on the use of oxytocin. RESULTS: Of 77 cases, 60 regarded patients in labour. In the majority, there had been a normal pregnancy and spontaneous start of labour (78%). At the beginning of labour, 87% showed a normal fetal heart rate (FHR) pattern, indicating fetal well-being. In 70%, there was adverse fetal outcome with brain damage or death. The most common reason for disciplinary action was improper interpretation of fetal monitor tracings and corresponding failure to recognise fetal distress (76%). Injudicious use of oxytocin was common (68.5%), and was the primary reason for disciplinary action in 33% of the cases. CONCLUSION: In a Swedish setting, a few common clinical problems pervade; interpretation of FHR patterns and the use of oxytocin account for the majority of rulings of negligence in malpractice cases regarding delivery. Analysis of the cases suggests that the adverse fetal outcomes could possibly have been prevented.

Effects of copper on CYP1A activity and epithelial barrier properties in the rainbow trout gill.

The effects of copper on beta-naphthoflavone (betaNF)-induced ethoxyresorufin O-deethylase (EROD) activity were studied in rainbow trout (Oncorhynchus mykiss) gill filaments (after in vivo exposure) and in gill cells cultured as both primary cultures and as polarised epithelia, i.e. with water in the apical compartment and culture medium in the basolateral compartment. In the in vivo study betaNF and copper were added to the water, in primary cultures both chemicals were added to the culture medium and in cultured epithelia copper was added to the apical water whilst betaNF was added to the basolateral culture medium. In primary cultures this investigation was repeated with and without foetal bovine serum (FBS) supplementation of the culture media. Gill barrier properties, specifically polyethylene glycol (PEG-4000) permeability (i.e. paracellular permeability), sodium efflux and transepithelial electrical resistance (TER) were also investigated in cultured gill cell epithelia after apical treatment with copper. Two micromolar copper had no effect on EROD activity in gill filaments in vivo irrespective of whether EROD was induced by 0.01, 0.1 or 1.0 microM betaNF. Similarly, 0.5-100 microM copper had no effect on EROD induction in cultured epithelia. In primary cultures copper did reduce EROD induction but the effective concentration was dependent on whether the cells were supplemented with FBS, i.e. EROD activity was reduced by all copper concentrations of 5 and above if FBS was included, but only by 1000 microM if FBS was omitted. In cultured epithelia PEG-4000 permeability increased, whilst sodium efflux and TER were unaffected following treatment with 75 microM copper. Based on these results we conclude that the branchial monooxygenase system is a less sensitive target for copper than the barrier properties of the gill. Indeed, these data suggest the apical membrane of the gill epithelial cells minimises the uptake of waterborne copper and therefore protects the intracellular environment, including the CYP1A system. This could enable the freshwater fish gill to retain their potential of first-pass metabolism of waterborne organic compounds whilst simultaneously being exposed to waterborne copper.

Treatment of log yard run-off by irrigation of grass and willows.

Log yard run-off is a potential environmental risk, among other things because it creates an oxygen deficiency in receiving watercourses. This study was conducted to investigate the purification efficiency of soil-plant systems with couchgrass (Elymus repens) and willows (Salix sp.) when intensively irrigated with run-off from an open sprinkling system at a Norway spruce (Picea abies) log yard. The purification efficiency was determined both at the field scale (couchgrass) and in 68-L lysimeters (couchgrass and willows). Groundwater in the field and drainage water from the lysimeters were analysed for Total Organic Carbon (TOC), distillable phenols, total P, and total N. Retention of TOC, phenols and P occurred but no difference between couchgrass and willows was observed. The system had better purification capacity at the field scale than in the lysimeters.

Clarithromycin treatment selects for persistent macrolide-resistant bacteria in throat commensal flora.

The aim of the study was to determine the effect of clarithromycin treatment on resistance development in the commensal throat flora. Alpha-haemolytic streptococci and Neisseria spp. were isolated from patients receiving clarithromycin for eradication of Helicobacter pylori. The treatment resulted in an immediate increase in the number of macrolide-resistant streptococci, which remained for one year after treatment, but declined to background level three years later. The most prevalent resistance gene was mef(A). Neisseria spp. were less affected by the treatment: the number of resistant isolates increased in only in one case during treatment. In conclusion, a one-week standard therapy with clarithromycin selects for an increased prevalence of macrolide-resistant streptococci that persisted for more than one year.

Effects of soil type, irrigation volume and plant species on treatment of log yard run-off in lysimeters.

Wet storage of timber and pulpwood produces large quantities of run-off water. A study was conducted to determine the purification efficiency of soil-plant systems for log yard run-off. Sixteen 1200-l lysimeters (1.2 m deep soil columns) with clay or sand soil were planted with willow (Salix sp.) or alder (Alnus glutinosa), and irrigated with run-off from a Norway spruce (Picea abies) log yard. Drainage water was analysed for total organic carbon (TOC), phenols, total P and total N in order to determine concentrations and levels of retention. High retention of TOC, phenols and P occurred in the lysimeters, but no clear differences between willows and alder or clay and sand were identified. Lysimeters with high levels of irrigation showed greater retention than those with low levels. Soil-plant systems using willow and alder could provide an alternative for log yard run-off purification: the key requirement is to optimise irrigation rather than manipulate the plants or soils.