Planned mode of birth after previous caesarean section and special educational needs in childhood: a population-based record linkage cohort study.

OBJECTIVE: To investigate the association between planned mode of birth after previous caesarean section and a child's risk of having a record of special educational needs (SENs). DESIGN: Population-based cohort study. SETTING: Scotland. POPULATION: A cohort of 44 892 singleton children born at term in Scotland between 2002 and 2011 to women with one or more previous caesarean sections. METHODS: Linkage of Scottish national health and education data sets. MAIN OUTCOME MEASURES: Any SENs and specific types of SEN recorded when a child was aged 4-11 years and attending a Scottish primary or special school. RESULTS: Children born following planned vaginal birth after previous caesarean (VBAC) compared with elective repeat caesarean section (ERCS) had a similar risk of having a record of any SENs (19.24 versus 17.63%, adjusted risk ratio aRR 1.04, 95% CI 0.99-1.09) or specific types of SEN. There was also little evidence that planned VBAC with or without labour induction compared with ERCS was associated with a child's risk of having a record of any SENs (21.42 versus 17.63%, aRR 1.09, 95% CI 1.01-1.17 and 18.78 versus 17.63%, aRR 1.03, 95% CI 0.98-1.08, respectively) or most types of SEN. However, an increased risk of sensory impairment was seen for planned VBAC with labour induction compared with ERCS (1.18 versus 0.78%, risk difference 0.4%, adjusted odds ratio aOR 1.60, 95% CI 1.09-2.34). CONCLUSIONS: This study provides little evidence of an association between planned mode of birth after previous caesarean and SENs in childhood beyond a small absolute increased risk of sensory impairment seen for planned VBAC with labour induction. This finding may be the result of performing multiple comparisons or residual confounding. The findings provide valuable information to manage and counsel women with previous caesarean section concerning their future birth choices. TWEETABLE ABSTRACT: There is little evidence planned mode of birth after previous caesarean section is associated with special educational needs in childhood.

Pregnancy at very advanced maternal age: a UK population-based cohort study.

OBJECTIVES: To describe the characteristics, management and outcomes of women giving birth at advanced maternal age (≥48 years). DESIGN: Population-based cohort study using the UK Obstetric Surveillance System (UKOSS). SETTING: All UK hospitals with obstetrician-led maternity units. POPULATION: Women delivering at advanced maternal age (≥48 years) in the UK between July 2013 and June 2014 (n = 233) and 454 comparison women. METHODS: Cohort and comparison group identification through the UKOSS monthly mailing. MAIN OUTCOME MEASURES: Pregnancy complications. RESULTS: Older women were more likely than comparison women to be overweight (33% versus 23%, P = 0.0011) or obese (23% versus 19%, P = 0.0318), nulliparous (53% versus 44%, P = 0.0299), have pre-existing medical conditions (44% versus 28%, P < 0.0001), a multiple pregnancy (18% versus 2%, P < 0.0001), and conceived following assisted conception (78% versus 4%, P < 0.0001). Older women appeared more likely than comparison women to have pregnancy complications including gestational hypertensive disorders, gestational diabetes, postpartum haemorrhage, caesarean delivery, iatrogenic and spontaneous preterm delivery on univariable analysis and after adjustment for demographic and medical factors. However, adjustment for multiple pregnancy or use of assisted conception attenuated most effects, with significant associations remaining only with gestational diabetes (adjusted odds ratio [aOR] 4.81, 95% CI 1.93-12.00), caesarean delivery (aOR 2.78, 95% CI 1.44-5.37) and admission to an intensive care unit (aOR 33.53, 95% CI 2.73-412.24). CONCLUSIONS: Women giving birth at advanced maternal age have higher risks of a range of pregnancy complications. Many of the increased risks appear to be explained by multiple pregnancy or use of assisted conception. TWEETABLE ABSTRACT: The pregnancy complications in women giving birth aged 48 or over are mostly explained by multiple pregnancy.

Incidence, risk factors, management and outcomes of amniotic-fluid embolism: a population-based cohort and nested case-control study.

OBJECTIVE: To describe the incidence, risk factors, management and outcomes of amniotic-fluid embolism (AFE) over time. DESIGN: A population-based cohort and nested case-control study using the UK Obstetric Surveillance System (UKOSS). SETTING: All UK hospitals with obstetrician-led maternity units. POPULATION: All women diagnosed with AFE in the UK between February 2005 and January 2014 (n = 120) and 3839 control women. METHODS: Prospective case and control identification through UKOSS monthly mailing. MAIN OUTCOME MEASURES: Amniotic-fluid embolism, maternal death or permanent neurological injury. RESULTS: The total and fatal incidence of AFE, estimated as 1.7 and 0.3 per 100 000, respectively, showed no significant temporal trend over the study period and there was no notable temporal change in risk factors for AFE. Twenty-three women died (case fatality 19%) and seven (7%) of the surviving women had permanent neurological injury. Women who died or had permanent neurological injury were more likely to present with cardiac arrest (83% versus 33%, P < 0.001), be from ethnic-minority groups (adjusted odds ratio [OR] 2.85, 95% confidence interval [95% CI] 1.02-8.00), have had a hysterectomy (unadjusted OR 2.49, 95% CI 1.02-6.06), had a shorter time interval between the AFE event and when the hysterectomy was performed (median interval 77 minutes versus 248 minutes, P = 0.0315), and were less likely to receive cryoprecipitate (unadjusted OR 0.30, 95% CI 0.11-0.80). CONCLUSION: There is no evidence of a temporal change in the incidence of or risk factors for AFE. Further investigation is needed to establish whether earlier treatments can reverse the cascade of deterioration leading to severe outcomes.

The management and outcomes of placenta accreta, increta, and percreta in the UK: a population-based descriptive study.

OBJECTIVE: To describe the management and outcomes of placenta accreta, increta, and percreta in the UK. DESIGN: A population-based descriptive study using the UK Obstetric Surveillance System (UKOSS). SETTING: All 221 UK hospitals with obstetrician-led maternity units. POPULATION: All women diagnosed with placenta accreta, increta, and percreta in the UK between May 2010 and April 2011. METHODS: Prospective case identification through the monthly mailing of UKOSS. MAIN OUTCOME MEASURES: Median estimated blood loss, transfusion requirements. RESULTS: A cohort of 134 women were identified with placenta accreta, increta, or percreta: 50% (66/133) were suspected to have this condition antenatally. In women with a final diagnosis of placenta increta or percreta, antenatal diagnosis was associated with reduced levels of haemorrhage (median estimated blood loss 2750 versus 6100 ml, P = 0.008) and a reduced need for blood transfusion (59 versus 94%, P = 0.014), possibly because antenatally diagnosed women were more likely to have preventative therapies for haemorrhage (74 versus 52%, P = 0.007), and were less likely to have an attempt made to remove their placenta (59 versus 93%, P < 0.001). Making no attempt to remove any of the placenta, in an attempt to conserve the uterus or prior to hysterectomy, was associated with reduced levels of haemorrhage (median estimated blood loss 1750 versus 3700 ml, P = 0.001) and a reduced need for blood transfusion (57 versus 86%, P < 0.001). CONCLUSIONS: Women with placenta accreta, increta, or percreta who have no attempt to remove any of their placenta, with the aim of conserving their uterus, or prior to hysterectomy, have reduced levels of haemorrhage and a reduced need for blood transfusion, supporting the recommendation of this practice.

Control of the preovulatory gonadotropin surge in the ewe.

The aims of this study were to determine the effect of ovariectomy on the release of LH and FSH during the preovulatory gonadotropin surge and to ascertain, by the use of sodium pentobarbitone (NaPb), if the secretion of these pituitary hormones requires continuous stimulation from the hypothalamus. Sheep were treated with NaPb for 2 h beginning 1) immediately before the gonadotropin surge, 2) during the ascending limb of the gonadotropin surge, and 3) during the descending limb of the gonadotropin surge. Ewes were ovariectomized (ovx) at each of the time periods listed above, and intact ewes included were at times 2 and 3. A group of intact ewes was given 100 microgram gonadotropin-releasing hormone (GnRH) in addition to NaPb at time 2, NaPb given during the ascending limb of the gonadotropin surge caused a transient fall in peripheral LH and FSH; however, the release of gonadotropins was reinitiated and the surge continued when the ewes recovered from anesthesia. Treatment with NaPb after the apex of the gonadotropin surge did not affect circulating levels of LH and FSH. Ewes given NaPb and ovx before the initiation of the gonadotropin surge released significantly less LH and FSH during the surge than the other treatment groups. The total amounts of LH and FSH released in intact and ovx ewes treated with NaPb after the surge was initiated were not different than those levels in the saline-treated controls. Intact ewes treated with 100 micrograms GnRH also released an amount of LH similar to that in the control group. We conclude that gonadotropin release from the pituitary gland requires the continual presence of GnRH during the ascending limb of the preovulatory gonadotropin surge, and that once the surge has been triggered, the ovaries do not appear to be required for further hypothalamic stimulation.

An integer linear programming model of staff retention and termination based on multiattribute utility theory.

An integer linear programming formulation was used to model several staffing alternatives available to the director of a recreation therapy department. The utility function of the decision maker was assessed using two attributes of effectiveness: performance and experience. Two utility approximations were obtained for each staff member based upon the average performance rating and number of years of experience both as a recreation therapist and at the facility. The utility obtained was viewed as a proxy for, and a comparative measure of, effectiveness, which considers the criteria of training and experience. The individuals who comprise the most effective combination of therapists, given staff reductions, were obtained by maximizing the sum of staff values. The first constraint set involved a budgetary constraint, coverage constraints, and an EEOC policy restriction. The coverage restriction and the budget were varied to reflect changes in the department resources. The model was validated with the department supervisor for the case of a one-position, 10% budget decrease.

Determination of an optimal forecast model for ambulance demand using goal programming.

A multistep approach to determining the optimal parameters of an exponential smoothing model was used to forecast emergency medical service (E.M.S.) demand for four counties of South Carolina. Daily emergency and routine (non-emergency) demand data were obtained and forecast statistics generated for each county sampled, using Winters' exponential smoothing model. A goal programme was formulated to combine forecast results for emergency calls with routine call forecasts. The goal programme gave a higher priority to accurate forecasting of emergency demand. The forecast model generated implicitly weights demand by severity and provides a reliable estimate of demand overall. The optimal parameter values for the smoothing model were obtained by minimizing the objective function value of the goal programming problem. The parameter values obtained were used to forecast demand for E.M.S. in the selected counties. The results of the model were compared to those using a multiple linear regression model and a single-objective-based exponential smoothing model for 2 months of data. When compared with two single-objective forecast models, the multiple-objective approach yielded more accurate forecasts and, therefore, was more cost-effective for the planner. The model presents and demonstrates a theoretical approach to improving the accuracy of ambulance demand forecasts. The possible impact of this approach on planning efficiency is discussed.