Compliance with clinical guidelines increases the safety of vacuum-assisted delivery.

BACKGROUND: Vacuum-assisted delivery (VAD) is a common and safe obstetric procedure. However, occasionally serious complications may occur. Clinical guidelines and College Statements have been developed to reduce the risk of serious adverse events. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) College Statement C-Obs 16 has not been evaluated to see if advice improves outcomes. AIM: The aim was to evaluate whether compliance with RANZCOG College Statement C-Obs 16 advice reduced the risk of serious adverse outcomes, specifically clinically significant subgaleal haemorrhage and major birth trauma. MATERIALS AND METHODS: Retrospective audit of VADs in a level five hospital (NSW Maternity and Neonatal capability framework) from January 2020 to 2021. RESULTS: There were 1960 women who delivered in the study period, of whom 252 (12.8%) delivered by vacuum, and complete data were available from 241 cases. Statement compliance was observed in 81%. The main deviation from Statement compliance was pulls exceeding three. Statement compliance was associated with a significant reduction in the incidence of subgaleal haemorrhage (0% vs 11%, P = 0.0002), major birth trauma (3% vs 22%, P = 0.0001), requirement for neonatal resuscitation (14% vs 35%, P = 0.0026) and Apgar scores at one minute less than six (5% vs 22% P = 0.0006). Statement compliance was associated with a significant reduction in maternal blood loss at delivery (388 mL vs 438 mL, P = 0.01). Noncompliance with Statement advice was observed significantly more often in pregnancy complicated by gestational diabetes (3% vs 15%, P = 0.02) and birth requiring instrument change (4% vs 13% P = 0.031). CONCLUSION: Compliance with a College Statement is associated with lower rates of subgaleal haemorrhage and major neonatal trauma. The main deviation from compliance was pulls in excess of three. Keyword: birth trauma, clinical guidelines, quality and safety in healthcare, subgaleal haemorrhage, vacuum delivery.

Economic cost of secondary postpartum haemorrhage: A case-control study at a tertiary hospital in Australia.

BACKGROUND: Secondary postpartum haemorrhage (PPH) is a condition which affects 0.2-3.0% of women. Despite its impact on maternal morbidity, there is a lack of understanding of the cost burden of disease. AIMS: To determine the economic cost of secondary PPH in the postpartum period, compared to the costs for women without this diagnosis. MATERIALS AND METHODS: Data were prospectively collected on a cohort of 97 women who presented with secondary PPH to the emergency department (ED) between July 2020 and February 2021. A case-control design was then used to compare postpartum cost data from these patients to a group of 97 controls who were matched to maternal demographics, and who did not present with secondary PPH. RESULTS: For women with secondary PPH, there were significantly more hospital attendances, and postpartum costs were higher for all cost subcategories across ED, admissions, and outpatient attendances (P < 0.0001), compared to controls. The total cost of postpartum care for 97 patients with secondary PPH was $254 377.62 with an average cost per patient of $2622.45, compared to $26 670.46 for 97 controls with an average cost of $274.95 per patient (P < 0.0001). This demonstrates a 9.5-fold increase in postpartum costs per woman with secondary PPH. CONCLUSIONS: Secondary PPH is an under-researched condition which presents a significant cost burden for the health system. Evidence-based guidelines addressing the prevention and management of secondary PPH may assist in minimising this cost burden for both the health service and the patient.

A Randomized Trial of Prenatal n-3 Fatty Acid Supplementation and Preterm Delivery.

BACKGROUND: Previous studies have suggested that maternal supplementation with n-3 long-chain polyunsaturated fatty acids may reduce the incidence of preterm delivery but may also prolong gestation beyond term; however, more data are needed regarding the role of n-3 long-chain polyunsaturated fatty acids in pregnancy. METHODS: We performed a multicenter, double-blind, randomized trial in which women who were pregnant with single or multiple fetuses were assigned to receive either fish-oil capsules that contained 900 mg of n-3 long-chain polyunsaturated fatty acids (n-3 group) or vegetable-oil capsules that contained trace n-3 long-chain polyunsaturated fatty acids (control group) daily, beginning before 20 weeks of gestation and continuing to 34 weeks of gestation or delivery, whichever occurred first. The primary outcome was early preterm delivery, defined as delivery before 34 completed weeks of gestation. Other pregnancy and neonatal outcomes were also assessed. RESULTS: A total of 5544 pregnancies in 5517 women were randomly assigned at six centers in Australia; 5486 pregnancies were included in the primary analysis. Early preterm delivery occurred in the case of 61 of 2734 pregnancies (2.2%) in the n-3 group and 55 of 2752 pregnancies (2.0%) in the control group; the between-group difference was not significant (adjusted relative risk, 1.13; 95% confidence interval [CI], 0.79 to 1.63; P = 0.50). There were no significant differences between the groups in the incidence of interventions in post-term (>41 weeks of gestation) deliveries, in adverse events, or in other pregnancy or neonatal outcomes, except that a higher percentage of infants born to women in the n-3 group than in the control group were very large for gestational age at birth (adjusted relative risk, 1.30; 95% CI, 1.02 to 1.65). Percentages of serious adverse events did not differ between the groups. Minor gastrointestinal disturbances were more commonly reported in the n-3 group than in the control group. CONCLUSIONS: Supplementation with n-3 long-chain polyunsaturated fatty acids from early pregnancy (<20 weeks of gestation) until 34 weeks of gestation did not result in a lower incidence of early preterm delivery or a higher incidence of interventions in post-term deliveries than control. (Funded by the Australian National Health and Medical Research Council and the Thyne Reid Foundation; ORIP Australian New Zealand Clinical Trials Registry number, ACTRN12613001142729.).

Is there an association between the vaginal microbiome and first trimester miscarriage? A prospective observational study.

AIM: To examine whether there are differences in the vaginal microbiome of women who miscarry compared to those who have normal pregnancy outcomes. METHODS: Prospective observational study conducted at the Canberra Hospital, Australia, with 24 participant women in the first trimester of pregnancy. The vaginal microbiomes of the 24 women were characterized using sequencing analysis of the V4 region of the 16S rRNA gene employing an Illumina MiSeq instrument with QIAGEN reagents. Vaginal microbiome data were correlated with pregnancy clinical metadata. RESULTS: Ordination plots showed differences in the composition of microbiomes of women who miscarried and controls. In nulliparous women, Lactobacillus crispatus was the dominant bacterium in 50% of women. Lactobacillus iners was the dominant bacterium in 50% of women with a history of prior miscarriage and a miscarriage in the study compared to 15% (p = 0.011) in those with no history of miscarriage and no miscarriage in the study. There were significant differences in the number of operational taxonomic units and the richness of the microbiomes of women who miscarried compared to those who delivered at term. Eight taxa were found in different relative abundances in both groups of women. CONCLUSIONS: The study indicated that the composition of the vaginal microbiome varies with pregnancy history. Also, there was a significant difference in the vaginal microbiomes between women who suffered miscarriage and those who continued to term delivery both in the overall microbiome populations and in the abundances of individual taxa.

Improving vaccination of pregnant women against seasonal influenza through use of a mandatory field in the obstetric electronic medical record.

BACKGROUND: The aim of the present study was to determine whether using a mandatory data field in an electronic health record would increase compliance with the recommendation to vaccinate pregnant women against influenza. METHODS: Two cohorts of women who delivered at the Centenary Hospital for Women and Children between 1-31 July 2015 and 1-31 July 2017 were compared for compliance with the national public health recommendation to vaccinate all pregnant women against influenza. The single change between audit periods was programming the electronic health record to include a mandatory field preventing clinicians from closing patient files unless they selected an answer to the question asking whether influenza vaccination had been performed. Data were audited and compliance rates were compared. RESULTS: A total of 275 and 299 women delivered in the two audit periods. There were no significant differences in maternal or neonatal characteristics between the two cohorts except for maternal age, which was younger in the second period (33.3 versus 31.5 years; P = 0.001). Vaccination rates doubled between audit periods (35.0% versus 79.8%, P < 0.0001). CONCLUSION: Introducing a mandatory data field into an electronic health record system may increase compliance with public health interventions, such as influenza vaccination in pregnant women.

Vitamin B3 levels in women who experience first-trimester miscarriage.

Miscarriage is the most common complication in early pregnancy. It was recently reported in mice that miscarriage can be prevented through the administration of niacin. We conducted a prospective, exploratory pilot study involving 24 women who were less than 14 weeks pregnant. Neither niacin intake (P = 0.24) nor urinary vitamin B3 measured as the 1-methyl-5-carboxylamide-2-pyridone/N-1-methylnicotinamide (2-pyr/MNA) ratio (P = 1.00) predicted miscarriage. However, the difference in mean 2-pyr/MNA ratios between women who miscarried and controls suggests there may be a threshold niacin level protective in miscarriage prevention warranting further investigation.

Can a clinical senate enhance state-wide clinician engagement? A survey study.

Objective Clinician engagement correlates with quality, safety and efficacy outcomes. The aim of the present study was to explore whether a clinical senate model achieves clinical input into system manager and operational health service boards. Methods A mixed-methods survey was undertaken. Participants were current or immediate past members of the Clinical Senate of Western Australia (CS). For the 124 surveys sent out, the response rate was 60%. Results Respondents stated the CS played a role in clinician engagement (95%), contributed to healthcare reform (82%), knowledge of contemporary health issues (92%), feedback to decision makers (82%), clinician networking (94%), debate on important issues (93%), enabled clinicians to work on recommendations to improve health at a state level (87%), contributed to clinician thinking on health reform (88%) and enabled clinicians to share their knowledge (91%). Four major themes emerged in the qualitative analysis: (1) the need for a strong independent clinician forum and voice at a state level; (2) the need to strengthen clinician interactions with operational healthcare boards; (3) a strong belief that clinician engagement strengthened quality and safety outcomes at a state level; and (4) that membership was important and needed to be diverse, multidisciplinary and independent, but structurally representative of clinicians in the state. Conclusion A clinical senate model can facilitate state-wide clinician engagement. What is known about the topic? High levels of clinical engagement foster a culture within healthcare organisations that is associated with the delivery of sustained high-quality, safe and efficient services. This has led to a focus on strategies to optimise clinical engagement in healthcare planning and reform. However, there is limited data exploring how to achieve clinical engagement at a state, rather than local, level within the healthcare system. What does this paper add? This survey study evaluates the effectiveness of the Western Australian clinical senate model in achieving clinical engagement at a state level with regard to the outcomes of quality and safety, planning and reform. The survey findings suggest the clinical senate model is an effective strategy for state-based clinical engagement. What are the implications for practitioners? Clinical engagement is important. It is necessary to have in place strategies that address not only local engagement within a health service, but also system-wide engagement in order to promote quality and safety, planning and reform agendas at a state level.

Does cardiotocography have a role in the antenatal management of pregnancy complicated by gestational diabetes mellitus?

BACKGROUND: Controversy surrounds the role of fetal cardiotocography (CTG) in the antenatal management of pregnancy complicated with gestational diabetes mellitus (GDM). AIM: The aim was to investigate whether antenatal CTG aids management in pregnancy complicated by GDM. MATERIALS AND METHODS: A prospective audit of 1404 consecutive antenatal CTG in women diagnosed with GDM. Outcomes for all CTG were audited to determine whether CTG altered pregnancy management. RESULTS: In women requiring combination therapy (diet and medication), 43 CTG were required to change management of a pregnancy. In women managed by diet alone with a secondary pregnancy complication, 161 CTG were required to change management. In women managed by diet alone with no secondary pregnancy complication, CTG did not change management. CONCLUSIONS: Antenatal CTG is not recommended in women with GDM managed by diet alone with no secondary pregnancy complication. Antenatal CTG is recommended in women with GDM who require combination therapy (diet and medication). The role of CTG in women managed by diet alone with a secondary pregnancy complication should be based upon the nature of the complication.

Domestic violence is a leading risk factor in default from colposcopy services.

AIM: Domestic violence is common in women and is associated with poorer health-care outcomes. However, no causal pathway has been identified to explain this observation. We have followed a cohort of women to determine whether poorer outcomes can be explained by high rates of default and loss to follow-up. MATERIAL AND METHODS: A prospective cohort study was performed. Institutional ethics approval was obtained. Participants were consecutive patients attending colposcopy clinics at a major metropolitan hospital in Australia. Following ascertainment of domestic violence status, appointment outcomes for colposcopy services were tracked for a 3-year period. Multivariate analysis was undertaken to determine demographic factors associated with default from care and loss to follow-up. RESULTS: Of 581 women approached, consent was obtained from 574 women (99%). Domestic violence status was obtained from 566 women, of whom 187 (33%) had a recent history of exposure. Women exposed to violence were more likely to default from colposcopy once (26.2% vs 7.4%; P < 0.0001), twice (11.2% vs 3.2%, P = 0.0001), or thrice (10.7% vs 2.4%, P < 0.0001). They were more likely to be lost to follow-up (8.0% vs 1.1%, P < 0.0001). In multivariate analysis, exposure to domestic violence remained significantly associated with default and loss to follow-up. CONCLUSION: Domestic violence is a risk factor for default from attendance and loss to follow-up at colposcopy services. This may explain the mechanism behind adverse health-care outcomes seen. Screening and targeted appointment intervention programs may improve clinical compliance.

Attitudes of pregnant women towards personally controlled electronic, hospital-held, and patient-held medical record systems: a survey study.

BACKGROUND: On July 1, 2012 the Australian Government launched the personally controlled electronic health record (PCEHR). This article surveys obstetric patients about their medical record preferences and identifies barriers to adoption of the PCEHR. MATERIALS AND METHODS: A survey study was conducted of antenatal patients attending a large Australian metropolitan hospital. Consecutive patients completed questionnaires during the launch phase of the PCEHR system. Quantitative and qualitative data were collected on demographics, computer access and familiarity, preference for medical record system, and perceived benefits and concerns. RESULTS: Of 528 women eligible to participate, 474 completed the survey (89.8%). Respondents had high levels of home access to a computer (90.5%) and the Internet (87.1%) and were familiar with using computers in daily life (median Likert scale of 9 out of 10). Despite this, respondents preferred hospital-held paper records, and only one-third preferred a PCEHR; the remainder preferred patient-held records. Compared with hospital-held paper records, respondents felt a PCEHR would reduce the risk of lost records (p<0.0001) and improve staff communication (p<0.0001). However, there were significant concerns about confidentiality and privacy of the PCEHR (p<0.0001) and lack of control (p<0.0001). CONCLUSIONS: Consumers see advantages and disadvantages with the PCEHR, although the majority still prefer existing record systems. To increase uptake, confidentiality, privacy, and control concerns need to be addressed.

Barriers to the 4-h rule: what causes delays for gynaecology patients in the emergency department?

OBJECTIVES: To explore factors that led to noncompliance with the 4-h rule for gynaecology patients in a general emergency department. METHODS: A cross-sectional cohort study was performed at a general emergency department. The files of all female patients aged from birth to 100 years presenting from 1 January 2009 to 31 December 2010 were screened. Those patient's files where a coded gynaecological diagnosis was made were reviewed. A time flow analysis was then undertaken of 580 consecutive files to evaluate barriers to admission or discharge of patients within the 4-h period. A further 300 files were audited to determine whether suboptimal management by emergency department staff contributed towards delays. RESULTS: There were 134 438 presentations to the emergency department, of which 2968 were gynaecology presentations (2.2%). The overall compliance with the 4-h rule was 66%. Patients with acute triage status, who were pregnant or who were eventually admitted, were more likely to be managed in compliance with the 4-h rule. The main barriers to compliance were incomplete examinations by emergency department staff; waiting for ultrasound examinations and blood test results; delays waiting for specialty review; and delays caused by initial review by surgical teams. CONCLUSION: Specific barriers to compliance with the 4-h rule can be identified in gynaecology patients. Strategies specific to overcome these barriers can be developed to improve compliance.

Insights into the Genital Microbiota of Women Who Experienced Fetal Death in Utero.

The aim of this work was to achieve a better understanding of the bacterial pathogens associated with stillbirths that would serve to inform clinical interventions directed at reducing this adverse pregnancy outcome. A prospective observational study was conducted with the participation of 22 women from northern Peru, of whom 11 experienced fetal death in utero and 11 delivered preterm births. Swabs were taken from the vagina, placenta, amniotic fluid and axilla of the infant at birth by Caesarean section. The bacterial populations in the vagina and the amniotic space of each participant were determined by employing the amplicon sequencing of the V4 region of the 16S rRNA genes. The sequence data were analysed using bioinformatics tools. The work showed differences in the composition of the genital microbiomes of women who experienced preterm birth or fetal death in utero. There were no differences in the alpha diversity between the genital microbiotas of both groups of women, but there were more different taxa in the vagina and amniotic space of the preterm participants. Lactobacillus spp. was less abundant in the stillbirth cases. E. coli/Shigella, Staphylococcus, Gardnerella, Listeria and Bacteroides taxa were associated with the stillbirths. In each woman, there was a minimal concordance between the bacterial populations in the vagina and amniotic space.

The impact of molar pregnancy on the male partner.

BACKGROUND: Molar pregnancy is a complication of 1 in 200-2000 pregnancies whereby abnormal placental tissue proliferates in the absence of a fetus and may lead to metastases. The disease origin lies in dispermy or dual fertilisation of the egg. The aim of this study was to explore the impact of molar pregnancy upon the male partner. METHODS: Institutional ethics committee approval and individual consent were obtained. All women listed on the state molar pregnancy database who were receiving active follow-up (n = 102) and a random sample of women who had been registered in the previous 30 years (n = 56) were sent a postal survey outlining the purpose of the study and an invitation for their partner to participate. Sixty-six women gave permission for their partner to participate in the study. Questionnaires included the Hospital Anxiety and Depression Scale, Satisfaction with Life Scale and Sexual History Form 12. Responding partners were also invited to make comments about any aspect of particular concern. A reminder mail out was issued after 6 weeks. RESULTS: The response rate was 62% (N = 41). The key findings were that 32.5% and 12.5% of men met the case criteria for anxiety and depressive disorder, respectively. These figures represent a doubling of usual community rates for anxiety disorder. However, overall quality of life and sexual functioning outcomes were consistent with community samples. The presence of children played a protective role and was associated with significantly better psychological function and quality of life in univariate and multivariate analysis. Qualitative results complemented the quantitative data, with anxiety as the dominant emotional theme. CONCLUSION: There are high persisting levels of anxiety in male partners of women with molar pregnancy. Partners may benefit from therapy where anxiety disorders are detected.

Prevalence and associations of domestic violence at an Australian colposcopy clinic.

OBJECTIVE: Domestic violence is associated with significant mortality and morbidity including gynecological morbidity. We report the prevalence and associations of domestic violence in an Australian colposcopy service. MATERIALS AND METHODS: A prospective study was performed from consecutive patients attending colposcopy clinics at a major metropolitan hospital in Australia. Key outcomes were the prevalence of intimate partner violence and its key demographic associations. RESULTS: Consent was obtained from 574 and domestic violence status was ascertained in 566 of 581 women approached. Overall, 33% of responders reported violence within 12 months. In 14.5%, the female reported being sole recipient of violence; in a further 16.6%, violence was bidirectional, and in 1.9% of cases, a woman was the sole perpetrator. Key associations of violence were younger age at presentation (32 vs 35 y; p = .01), higher rates of smoking (51.3% vs 38.2%; p = .0004), higher rates of housing instability (32.2% vs 12.2%; p < .0001), a positive Beck Depression Inventory screen (50.0% vs 24.6%; p < .0001), and higher rates of default to initial attendance (15.5% vs 4.7%, p < .0001). CONCLUSIONS: Domestic violence is common in women presenting to colposcopy services and may be associated with poor housing stability and higher default rates.

Opinions of Non-English Speaking Fathers in the Antenatal and Delivery Room.

This study investigated the demographic differences, newborn outcomes, and psychological experiences of English speaking (ES) and non-English speaking (NES) fathers in antenatal and delivery rooms. One thousand fathers completed antenatal and delivery questionnaires. Thirty-three percent of NES fathers were smokers, compared to 26% of ES fathers. NES fathers also reported significantly lower elective cesarean surgery rates. However, intrauterine growth restriction was significantly higher amongst the NES newborn cohort. Further, nursery admission of newborns born to NES fathers was more than double that of ES fathers. NES fathers self-reported more psychological symptoms after delivery than ES fathers (31% vs 19%). This study highlights the dual need for more research into NES perinatal experiences and change in pregnancy management for NES families.

Unsettled infant behaviour and health service use: a cross-sectional community survey in Melbourne, Australia.

AIMS: To investigate factors associated with health service use by women and their infants in Victoria, Australia. METHODS: Cross-sectional screening survey of 875 women with 4-month-old infants attending immunisation clinics in five local government areas in Melbourne between May 2007 and August 2008. The self-report instrument assessed socio-demographic characteristics, unsettled infant behaviour, maternal mood (Edinburgh Postnatal Depression Scale) and, the outcome, health service use during the first 4 months post-partum. RESULTS: Mothers and their infants used on average 2.8 different health services in the first 4 months post-partum (range 0-8). After adjustment for other factors, high health service use (defined as >3 different services) was more common in mothers whose infants were unsettled with persistent crying, resistance to soothing and poor sleep. A one-point increase on the unsettled infant behaviour measure was associated with an 8% (2-14%) increase in the use of >3 services, 9% (3-16%) in use of emergency departments, 7% (2-13%) in use of telephone helplines and 9% (3-14%) of parenting services. Poorer maternal mental health was also implicated with a one-point increase on the Edinburgh Postnatal Depression Scale associated with a 4% (0.4-8%) increase in the likelihood of using more than three services. CONCLUSIONS: Unsettled infant behaviour is associated with increased use of multiple health services. The high use of emergency departments by families with unsettled infants found in this study suggests that enhancement of primary health-care capacity might be required.

A randomised trial of a four-step multidisciplinary approach to the antenatal care of obese pregnant women.

BACKGROUND: Obesity is common in pregnancy and results in morbidity to mother and newborn. AIM: To evaluate whether a four-step multidisciplinary protocol of antenatal care for overweight and obese women would reduce the incidence of gestational diabetes. METHODS: Pregnant women were approached at their first antenatal visit, and body mass index (BMI) was calculated to determine whether they were overweight or obese (BMI > 25). Eligible women were randomised to standard obstetric antenatal care or four-step multidisciplinary antenatal care. Clinic protocol included (i) continuity of obstetric provider; (ii) weighing on arrival at each visit; (iii) a five brief minute intervention by a food technologist who asked about the women's eating habits of the previous day, provided information on reading food labels, shopping lists of affordable foods available from local shops and recipes for a healthy pregnancy diet; and (iv) clinical psychology management to assess symptoms of depression and anxiety, stressful life events and determine whether psychological factors were involved in eating patterns. Labour and delivery data were audited from the medical records to determine the final incidence of gestational diabetes. The primary outcomes were gestational diabetes and weight gain. RESULTS: The intervention was associated with a significant reduction in the incidence of gestational diabetes (6 versus 29%, OR 0.17 95% CI 0.03-0.95, P = 0.04). It was also associated with reduced weight gain in pregnancy (7.0 versus 13.8 kg, P < 0.0001). Despite this, birthweight of newborns was similar [3.5 (0.1) kg versus 3.4 (0.1) kg P = 0.16]. CONCLUSION: A four-step management plan adopted with obese women reduces the incidence of gestational diabetes.