Intrapartum care algorithms for liquor abnormalities: oligohydramnios, meconium, blood and purulent discharge.

AIM: To construct evidence-based algorithms for the assessment and management of common amniotic fluid abnormalities detected during labour. POPULATION: Low-risk singleton, term pregnant women in labour. SETTING: Birth facilities in low- and middle-income countries. SEARCH STRATEGY: We searched international guidelines published by the American College of Obstetricians and Gynecologists (ACOG), the National Institute for Health and Care Excellence (NICE), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Royal College of Obstetricians and Gynaecologists (RCOG), the Society of Obstetrics and Gynaecology (SOGC) and the World Health Organization (WHO). We also searched The Cochrane Library and MEDLINE up to 20 January 2020 using keywords for relevant systematic reviews and randomised trials. CASE SCENARIOS: We developed evidence-based intrapartum care algorithms for four case scenarios: oligohydramnios; meconium-stained amniotic fluid; bloody amniotic fluid or vaginal bleeding; and purulent amniotic fluid or discharge. These conditions may be associated with fetal and /or maternal morbidity. Differential diagnosis includes uteroplacental insufficiency, fetal growth restriction, fetal distress, abruption, placenta or vasa praevia, uterine rupture and intra-amniotic infection, respectively. Algorithms include how to assess for, diagnose and manage these conditions. CONCLUSIONS: Four algorithms are presented, to provide a systematic approach and guidance on the clinical management for the following amniotic fluid abnormalities: oligohydramnios; meconium-stained liquor; bloody amniotic fluid or vaginal bleeding; and purulent amniotic fluid or discharge. These algorithms may be beneficial in supporting clinical decision making, particularly in low-resource settings. TWEETABLE ABSTRACT: Evidence based algorithms for management of common amniotic fluid abnormalities seen during labour.

Constructing evidence-based clinical intrapartum care algorithms for decision-support tools.

AIM: To describe standardised iterative methods used by a multidisciplinary group to develop evidence-based clinical intrapartum care algorithms for the management of uneventful and complicated labours. POPULATION: Singleton, term pregnancies considered to be at low risk of developing complications at admission to the birthing facility. SETTING: Health facilities in low- and middle-income countries. SEARCH STRATEGY: Literature reviews were conducted to identify standardised methods for algorithm development and examples from other fields, and evidence and guidelines for intrapartum care. Searches for different algorithm topics were last updated between January and October 2020 and included a combination of terms such as 'labour', 'intrapartum', 'algorithms' and specific topic terms, using Cochrane Library and MEDLINE/PubMED, CINAHL, National Guidelines Clearinghouse and Google. CASE SCENARIOS: Nine algorithm topics were identified for monitoring and management of uncomplicated labour and childbirth, identification and management of abnormalities of fetal heart rate, liquor, uterine contractions, labour progress, maternal pulse and blood pressure, temperature, urine and complicated third stage of labour. Each topic included between two and four case scenarios covering most common deviations, severity of related complications or critical clinical outcomes. CONCLUSIONS: Intrapartum care algorithms provide a framework for monitoring women, and identifying and managing complications during labour and childbirth. These algorithms will support implementation of WHO recommendations and facilitate the development by stakeholders of evidence-based, up to date, paper-based or digital reminders and decision-support tools. The algorithms need to be field tested and may need to be adapted to specific contexts. TWEETABLE ABSTRACT: Evidence-based intrapartum care clinical algorithms for a safe and positive childbirth experience.

Disparity in utilization and expectation of community-based maternal health care services among women in Myanmar: a cross-sectional study.

BACKGROUND: Aim of this study is to assess women's utilization and expectation of community-based antenatal and delivery care services in Myanmar and determine associated factors for disparity of services received with services women expected to receive. METHODS: A cross-sectional survey was conducted among 6-month postpartum women in three townships of Myanmar during May-September 2016. Associated factors for the services with disparity were identified using multinomial logistic regression models. RESULTS: Of 1743 women, the percentages of antenatal care (ANC) attended by a skilled provider, at least four ANC visits, and early ANC were 89, 60 and 36%, respectively. The percentage of non-facility delivery was 65%. Many ANC services received and services expected to receive had lower than 80% coverage. Services with significant disparity included blood hemoglobin and urinary protein testing, and iron supplementation. Low access to ANC, women's socio-economic status, pregnancy and delivery complications, and out-of-pocket cost were associated with disparity of these services. CONCLUSION: Utilization and expectation of community-based ANC services and facility delivery is low in Myanmar. Disparities of the services received with the services women expected to receive were common in ANC. Improving women's expectations on essential services during pregnancy is needed as well as strengthening community participation.

Safety and efficacy of intensive intraoperative glycaemic control in cardiopulmonary bypass surgery: a randomised trial.

BACKGROUND: This study aimed to determine the safety and efficacy of intraoperative intensive glycaemic treatment with modified glucose-insulin-potassium solution by hyperinsulinemic normoglycaemic clamp in cardiopulmonary bypass surgery patients. We hypothesised that the treatment would reduce infection rates in this group of patients. METHODS: A prospective, randomised, double-blind trial was conducted in cardiopulmonary bypass surgery patients. A total of 199 adult patients (out of a planned 400) were randomly allocated to intensive or conventional treatment with target glucose levels of 4.4-8.3 mmol/l and < 13.8 mmol/l, respectively. The primary outcomes were clinical infection and cytokine levels, including interleukin (IL)-6 and IL-10. The secondary outcomes were morbidity and mortality. RESULTS: The study was terminated early because of safety concerns (hypoglycaemia). The clinical post-operative infection rate was 17% in the intensive group and 13% in the conventional group (P = 0.53). The proportion of patients with hypoglycaemia was significantly higher in the intensive group (23%) compared with the conventional group (3%) (P < 0.001). Morbidity and mortality rates were similar for both groups. Anaesthetic duration > 2 h (vs. ≤ 2 h), pre-operative IL-6 level > 15 pg/ml (vs. ≤ 15 pg/ml) and post-operative IL-6 level 56-110 pg/ml (vs. ≤ 55 pg/ml) were independent predictors for post-operative infection. CONCLUSIONS: Intraoperative intensive glycaemic treatment significantly increased the risk of hypoglycaemia, but its effect on post-operative infection by clinical assessment could not be determined. Anaesthetic duration, pre-operative and post-operative IL-6 levels can independently predict post-operative infection.

Treatment success among Myanmar migrants with TB in Thailand.

SETTING: Two facilities, one providing clinic-based care and another providing residential care to Myanmar migrants with TB, in a Thailand-Myanmar border area.OBJECTIVE: To determine the effects of health insurance, total delay and the model of care on treatment success of TB.METHODS: A prospective study was conducted among adult Myanmar migrants under treatment for newly diagnosed TB. Effects of health insurance, total delay and model of care on treatment success at completion of 6-month treatment were analysed using multiple logistic regression models.RESULTS: Of 191 Myanmar migrants with TB, 167 (87.4%) had treatment success. Median time delays from symptom onset to treatment initiation among migrants with health insurance receiving clinic-based care were significantly shorter than those without health insurance. Those who received residential care had higher odds of treatment success than those under clinic-based care (aOR 6.0, 95% CI 1.5-23.3); having health insurance (aOR 1.0, 95% CI 0.3-2.9) and total delay (aOR 1.7, 95% CI 0.7-4.2) were not significantly associated with treatment success.CONCLUSIONS: A high treatment success rate was associated with receiving residential care among Myanmar migrants with TB on the Thai-Myanmar border. The residential care model, implemented under a non-governmental organisation, was feasible and effective for the migrant population.

Prediction of outpatient visits and expenditure under the Universal Coverage Scheme in Bangkok using subscriber's attributes: A random forest analysis.

Objectives: There is limited evidence on methods to allocate budgets to healthcare providers under capitation schemes. The objective of this study was to construct and test models that predict outpatient visits and expenditure for each healthcare facility using subscriber data from the preceding year. Study design: We used the database of the Universal Coverage Scheme in Bangkok, Thailand that stores subscriber information and healthcare service utilization data. One-percent and ten-percent random samples of subscribers were selected as training and testing groups, respectively. Methods: Using data of the training group, we constructed a model using a random forest algorithm to predict outpatient visits and expenditure in 2017 from the 2016 data. The model was applied to the testing group and facility-level predicted number of visits and expenditure were compared with actual data. Results: The identically-structured training and testing groups consisted of 37,259 and 371,650 subscribers, respectively. Approximately 25% of subscribers utilized outpatient services. The R2 for models predicting facility-level utilization rate (visits/subscribers) and expenditure per subscriber in 2017 were 0.85 and 0.75, respectively. Conclusions: The model to predict outpatient visits and expenditure performed well. Such a prediction model may be useful for allocating budgets to healthcare facilities under capitation systems.

Effect of Global Fund financial support for patients with multidrug-resistant tuberculosis.

SETTING: The Global Fund provides financial support for patients with multidrug-resistant tuberculosis (MDR-TB), patients' families and hospitals providing services for these patients in Thailand, but the impact of this support has not been evaluated.OBJECTIVE: To assess the impact of Global Fund financial support on drug adherence, out-of-pocket (OOP) payments, sputum culture conversion and the perception of the usefulness of this support.DESIGN: A retrospective cohort study was conducted in eight provincial hospitals with and without financial support in four regions of Thailand. MDR-TB patients aged ≥15 years registered in 2015-2016 who received treatment at these hospitals for at least 6 months were included.RESULTS: There was no significant difference in drug adherence rates. The OOP payments during treatment were significantly lower in patients who received financial support (P < 0.001). Although the supported group had higher positive culture rates at the beginning of treatment, sputum converted at a faster rate than for the unsupported group (P = 0.034). More than 80% of both groups perceived financial support as being useful, leading to faster diagnosis and improving follow-up compliance.CONCLUSION: Financial support for MDR-TB patients has a positive impact on treatment and should be continued.

Under- and over-consumption intermittent TB treatment among rural TB patients in south-west China.

OBJECTIVE: To assess adherence to intermittent directly observed treatment (DOT) during the 2-month intensive phase of tuberculosis (TB) treatment in south-west rural China. DESIGN: A cross-sectional study was conducted in Simao Prefecture, Yunnan Province, China. One hundred and thirty new TB patients registered under DOTS and treated during the 2-month intensive phase and their observers were separately interviewed at their homes using structured questionnaires. Numbers of packs of TB drugs were checked on the spot. RESULTS: Of 130 visits, the same percentage (3.1%) of patients and their observers reported missing > or =2 consecutive weeks of treatment (prevalence-adjusted kappa = 0.94). The percentages who missed > or =20% of the packs, as reported by patients and observers, were 3.8 and 2.3, respectively (prevalence-adjusted kappa = 0.969). According to the pill count, nine patients (7%) had missed > or =20% of the packs, 10 had over-consumed TB drugs and two had lost respectively five and six packs. Eight of the 10 who had over-consumed had done so due to confusion in the days of the month, and two because they wanted a quicker recovery. CONCLUSIONS: Intermittent regimens in China need to be more carefully monitored to avoid over-consumption of anti-tuberculosis drugs in addition to non-adherence due to under-consumption.

Prophylactic use of ergot alkaloids in the third stage of labour.

BACKGROUND: Previous research has shown that the prophylactic use of uterotonic agents in the third stage of labour reduces postpartum blood loss and moderate to severe postpartum haemorrhage. This is one of a series of systematic reviews assessing the effects of prophylactic use of uterotonic drugs - here, prophylactic ergot alkaloids compared with no uterotonic agents, and different regimens of administration of ergot alkaloids. OBJECTIVES: To determine the effectiveness and safety of prophylactic use of ergot alkaloids in the third stage of labour compared with no uterotonic agents, as well as with different routes or timing of administration for prevention of postpartum haemorrhage. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 December 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4) and MEDLINE (1966 to December 2006). SELECTION CRITERIA: All randomised or quasi-randomised controlled trials comparing prophylactic ergot alkaloids with no uterotonic agents or comparing different routes or timings of administration of ergot alkaloids in the third stage of labour among women giving birth vaginally. DATA COLLECTION AND ANALYSIS: We systematically reviewed the potential studies, considered eligible studies, assessed the validity of each included study and extracted data independently. MAIN RESULTS: We included six studies comparing ergot alkaloids with no uterotonic agents, with a total of 1996 women in ergot alkaloids group and 1945 women in placebo or no treatment group. The use of injected ergot alkaloids in the third stage of labour significantly decreased mean blood loss (weighted mean difference -83.03 ml, 95% confidence interval (CI) -99.39 to -66.66 ml) and postpartum haemorrhage of at least 500 ml (relative risk (RR) 0.38, 95% CI 0.21 to 0.69). The risk of retained placenta or manual removal of the placenta, or both, were inconsistent. Ergot alkaloids increased the risk of vomiting (RR 11.81, 95% CI 1.78 to 78.28), elevation of blood pressure (RR 2.60, 95% CI 1.03 to 6.57) and pain after birth requiring analgesia (RR 2.53, 95% CI 1.34 to 4.78). One study compared oral ergometrine with placebo and showed no significant benefit of ergometrine over placebo. No maternal adverse effects were reported. There were no included trials that compared different administration regimens of ergot alkaloids. AUTHORS' CONCLUSIONS: Prophylactic intramuscular or intravenous injections of ergot alkaloids are effective in reducing blood loss and postpartum haemorrhage, but adverse effects include vomiting, elevation of blood pressure and pain after birth requiring analgesia, particularly with the intravenous route of administration.

Cost-effectiveness of a new strategy to detect pulmonary tuberculosis in household contacts in Myanmar.

SETTING: Guidelines regarding household contact tracing for pulmonary tuberculosis (TB) in different countries vary according to case detection methods. OBJECTIVE: To compare costs spent on detecting one TB case among household contacts between different contact tracing strategies in Mandalay City, Myanmar. METHODS: Cost estimation of case detection and diagnostic procedures using two different strategies were calculated. A modified conventional model included screening for TB signs and symptoms, sputum examination for those with positive signs and symptoms and chest X-ray (CXR) for those with negative sputum results. An interventional model included CXR, sputum examination if CXR was abnormal and Xpert® MTB/RIF assay for those with negative sputum results. Estimated costs in each model were stratified by age <15 and 15 years. RESULTS: The additional cost per TB case detected using the interventional model was US$35.41 compared to the modified conventional model. The probability that the interventional model was cost-effective using a threshold of US$100 per case detected was 81% (83% for those aged 15 years and 65% for those aged <15 years). CONCLUSIONS: The interventional model was more cost-effective in detecting one more pulmonary TB case among household contacts than the modified conventional model.

Rural Health Care Workers and Local Residents Health Status in Yulong County of Yunnan Province China and Hat Yai City of Songkhla Mansion Thailand.

INTRODUCTION: To compare health status between Hat Yai city of Songkhla Province in Thailand and Yulong county of Yunnan province in China about rural health care workers and local residents, analyzing of both differences, learning from the advanced experience and practice of Thailand, adjusting policy, especially for the implementation of measures to improve the lack of human resources construction of Yulong County rural health, promote the level of rural health service of Lijiang. METHODS: A qualitative study consisting of focus group discussions and individual in-depth interviews were conducted in Rural Health Care Workers and Local Residents Health Status in Yulong County of Yunnan Province China and Hat Yai City of Songkhla Mansion Thailand from. RESULTS: Compared to 41(100%) bachelor's degree of medical staffs in Hat Yai, this accounted only 94 (42%) bachelor's degree of medical staffs in Yulong county hospital, and 31 (12%)in townships hospitals. For medical workers in Hat Yai, they have at least one time on-job training per year, but for Yulong county, only 144 (29%)of the medical personnel participated in the training per year. Health expenditures of Yulong county was mainly borne by the local government, and medical insurance coverage rate is 217,107 (99%). Insurance average awareness of Hat Yai is 4449 (66.4%), Yulong County is 62,501 (28.5%), P<0.001, there are statistically significant differences between two cities. CONCLUSIONS: Thailand has good experience in training, well-paid, motivating and retaining talent for rural health human resources; multi-pronged, mechanism innovation, establish and perfect the system of human resources for health, is the essential way to solve the problem.

Antibiotic prophylaxis for operative vaginal delivery.

BACKGROUND: Vacuum and forceps assisted vaginal deliveries are reported to increase the incidence of postpartum infections and maternal readmission to hospital compared to spontaneous vaginal delivery. Prophylactic antibiotics are prescribed to prevent these infections. However, the benefit of antibiotic prophylaxis for operative vaginal deliveries is still unclear. OBJECTIVES: To assess the effectiveness and safety of antibiotic prophylaxis in reducing infectious puerperal morbidities in women undergoing operative vaginal deliveries including vacuum and/or forceps deliveries. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register (November 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2003) and MEDLINE (1966 to November 2003). SELECTION CRITERIA: All randomised trials comparing any prophylactic antibiotic regimens with placebo or no treatment in women undergoing vacuum or forceps deliveries were eligible. Participants were all pregnant women without evidence of infections or other indications for antibiotics of any gestational age undergoing vacuum or forceps delivery for any indications. Interventions were any antibiotic prophylaxis (any dosage regimen, any route of administration or at any time during delivery or the puerperium) compared with either placebo or no treatment. DATA COLLECTION AND ANALYSIS: Four reviewers assessed trial eligibility and methodological quality. Two reviewers extracted the data independently using prepared data extraction forms. Any discrepancies were resolved by discussion and a consensus reached through discussion with all reviewers. We assessed methodological quality of the included trial using the standard Cochrane criteria and the CONSORT statement of randomised controlled trials. We calculated the relative risks using a fixed effect model and all the reviewers interpreted and discussed the results. MAIN RESULTS: One trial, involving 393 women undergoing either vacuum or forceps deliveries, was included. This trial identified only two out of the nine outcomes specified in this review. It reported seven women with endomyometritis in the group given no antibiotic and none in prophylactic antibiotic group. This difference did not reach statistical significance, but the relative risk reduction was 93% (relative risks 0.07; 95% confidence interval (CI) 0.00 to 1.21). There was no difference in the length of hospital stay between the two groups (weighted mean difference 0.09 days; 95% CI -0.23 to 0.41). REVIEWERS' CONCLUSIONS: The data were too few and of insufficient quality to make any recommendations for practice. Future research on antibiotic prophylaxis for operative vaginal delivery is needed to conclude whether it is useful for reducing postpartum morbidity.

Prenatal diagnosis of thalassemia in Songklanagarind Hospital in southern Thailand.

A thalassemia screening program for pregnant women has been established in Songklanagarind Hospital since 1992. After genetic counseling, a total of 5078 pregnant women accepted entry into a screening program for thalassemia. Couples at risk who should receive prenatal diagnosis were 2.8%. Total cases who accepted prenatal diagnosis were 135. Total clinical cases were 40 (29.6%) with achievement by prenatal diagnosis of 33 cases (82.5%). Genetic amniocentesis is the most acceptable method for prenatal diagnosis. Five cases (12.5%) were misdiagnosed due to contamination of maternal blood cells in amniotic fluid cases. Questionable results were reported in 2 cases (5%). Abortion occurred in one case (0.7%). Improvement of surgical technic in prenatal diagnosis reduced the complications and contamination of maternal cells. This program shows the feasibility of prevention and control of thalassemia disease in southern Thailand.

Cohort study of depressive moods in Thai women during late pregnancy and 6-8 weeks of postpartum using the Edinburgh Postnatal Depression Scale (EPDS).

OBJECTIVE: To identify depressive moods as measured by the Edinburgh Postnatal Depression Scale in late pregnancy and postpartum, explore associated factors and assess changes in depressive moods. METHODS: A cohort study of 610 pregnant Thai women was conducted. The self-reporting EPDS was completed at 36-40 weeks and at 6-8 weeks postpartum. RESULT: The prevalence of depressive moods (scores of 10 or more on the EPDS) was 20.5% during pregnancy and 16.8% at postpartum. Factors related to depressive moods in late pregnancy included marital status, evidence of irritable moods before menstruation, and attitudes towards this pregnancy. Unmarried women, women having irritable moods before menstruation or women having negative attitudes towards this pregnancy had double risk. Related factors during the postpartum period included religion, evidence of irritable moods before menstruation, perception of pregnancy complications and attitudes towards this pregnancy (p < 0.01). Women who perceived of having complications during this pregnancy, those who had irritable moods before menstruation or had negative attitudes towards this pregnancy had also double risk. The depressive moods were significantly reduced postnatally. CONCLUSION: One-fifth of pregnant and postpartum women experienced depressive moods but the severity declined at postpartum.

Serial translabial sonographic measurement of cervical dimensions between 24 and 34 weeks' gestation in pregnant Thai women.

OBJECTIVE: To assess serial changes of cervical dimensions in pregnant Thai women between 24 and 34 weeks' gestation by translabial sonography. METHODS: A longitudinal study of cervical dimensions obtained by translabial sonography at 24, 28, 30, 32, and 34 weeks' gestation in 144 women was conducted. The gestational age at labor was recorded and women were defined as having preterm labor or term labor according to whether there was onset of true labor pain before or after 37 completed weeks, respectively. Cervical changes over time were analyzed by repeated ANOVA. The associations between cervical dimensions and gestational age, parity and prepregnancy body mass index were calculated by multiple linear regression analysis. RESULTS: Cervical length decreased whereas cervical width increased as gestational age advanced. Cervical length and width in women with term labor, but only cervical length in women with preterm labor, changed significantly throughout the period of 24-34 weeks' gestation (P < 0.01). The cervix was significantly longer in parous women and in women with a body mass index of more than 26 kg/m2, but was shorter in women of advanced gestational age. The cervix was significantly wider in parous women and in those of advanced gestational age. Weekly crude rate, adjusted for parity and prepregnancy body mass index, of both cervical length shortening and cervical width widening was 0.4 mm in women with term labor. Women with preterm labor had cervical shortening of 0.5 mm per week. CONCLUSIONS: Gestational age, parity and prepregnancy body mass index are significantly associated with the dynamic changes of cervical length and width in Thai women. These factors should be considered when assessing normal values of cervical dimensions and for predicting the risk of preterm delivery.