Sacrospinous fixation: Review of relevant anatomy and surgical technique.

Apical support is an important component of pelvic floor reconstruction for pelvic organ prolapse. Sacrospinous ligament fixation is a recognized procedure for apical support. Complications from sacrospinous ligament fixation include pain (buttock and leg) and bleeding. There is some debate as to the optimal location for placement of the sacrospinous fixation sutures. This review summarizes the neuroanatomy of the coccygeus sacrospinous ligament as it pertains to the sacrospinous ligament fixation procedure. An appreciation of the neuroanatomy will lead to a better understanding of methods to reduce operative complications and improve suture placement. This paper also describes a technique for the sacrospinous fixation procedure to better assist clinicians in dissecting the connective tissue off the ligament. Removing or clearing the connective tissue off the ligament will allow critical landmarks to be easily palpated and hence a more accurate placement of sutures. This in turn may reduce the risk of perioperative complications.

Cesarean delivery in low- and middle-income countries: A review of quality of care metrics and targets for improvement.

Improving quality of care in low-and middle-income countries (LMICs) is a global priority, specifically around maternal and newborn care, where mortality and morbidity remain unacceptably high. Cesarean delivery is the most common procedure in women, thus evaluating quality around the provision of this intervention provides insight into overall quality of care around childbirth. In this review we provide an overview on the quality of care around cesarean delivery using the six domains of quality proposed by the Institute of Medicine: equity, effectiveness, efficiency, safety, timeliness and patient-centered care. We review evidence of potential quality gaps in each of these domains around cesarean delivery in LMICs, discuss opportunities for improvement and provide suggestions on metrics for tracking quality in each of these domains. As cesarean delivery rates increase globally, efforts to ensure quality will be essential to drive continued and sustained improvements in global maternal and newborn outcomes.

Toward a complete estimate of physical and psychosocial morbidity from prolonged obstructed labour: a modelling study based on clinician survey.

INTRODUCTION: Prolonged obstructed labour often results from lack of access to timely obstetrical care and affects millions of women. Current burden of disease estimates do not include all the physical and psychosocial sequelae from prolonged obstructed labour. This study aimed to estimate the prevalence of the full spectrum of maternal and newborn comorbidities, and create a more comprehensive burden of disease model. METHODS: This is a cross-sectional survey of clinicians and epidemiological modelling of the burden of disease. A survey to estimate prevalence of prolonged obstructed labour comorbidities was developed for prevalence estimates of 27 comorbidities across seven categories associated with prolonged obstructed labour. The survey was electronically distributed to clinicians caring for women who have suffered from prolonged obstructed labour in Asia and Africa. Prevalence estimates of the sequelae were used to calculate years lost to disability for reproductive age women (15 to 49 years) in 54 low- and middle-income countries that report any prevalence of obstetric fistula. RESULTS: Prevalence estimates were obtained from 132 participants. The median prevalence of reported sequelae within each category were: fistula (6.67% to 23.98%), pelvic floor (6.53% to 8.60%), genitourinary (5.74% to 9.57%), musculoskeletal (6.04% to 11.28%), infectious/inflammatory (5.33% to 9.62%), psychological (7.25% to 24.10%), neonatal (13.63% to 66.41%) and social (38.54% to 59.88%). The expanded methodology calculated a burden of morbidity associated with prolonged obstructed labour among women of reproductive age (15 to 49 years old) in 2017 that is 38% more than the previous estimates. CONCLUSIONS: This analysis provides estimates on the prevalence of physical and psychosocial consequences of prolonged obstructed labour. Our study suggests that the burden of disease resulting from prolonged obstructed labour is currently underestimated. Notably, women who suffer from prolonged obstructed labour have a high prevalence of psychosocial sequelae but these are often not included in burden of disease estimates. In addition to preventative and public health measures, high quality surgical and anaesthesia care are urgently needed to prevent prolonged obstructed labour and its sequelae.

Feasibility and acceptability of the menstrual cup for non-surgical management of vesicovaginal fistula among women at a health facility in Ghana.

OBJECTIVE: To assess the feasibility of the menstrual cup for short-term management of urinary leakage among women with vesicovaginal fistula (VVF). METHODS: A repeated measures design compared volume of leakage with and without the cup via a 2-hr pad test among women with VVF seeking surgical repair at a health facility in Ghana. Subsequently a gynecological exam was administered to assess safety outcomes, followed by a questionnaire to assess acceptability and perceived efficacy. A paired t-test was used to analyze reduction of leakage in ml, and percent reduction was reported. Study limitations include observer bias while evaluating adverse outcomes and the possibility of social desirability bias during questionnaire administration that might overestimate the effect of the cup and women's acceptability. RESULTS: Of the 32 patients screened, 11 were eligible (100% consent rate). At baseline, mean (±SD) leakage in ml was 63.2 (±49.2) (95% CI: 30.2-96.3) over two hours, while the mean leakage over two hours of use of the cup was 16.8 (±16.5) (95% CI: 5.7-27.9). The mean difference of 46.4 (±52.1) ml with use of the cup (95% CI: 11.4-81.4) was statistically significant (p = 0.02). With the cup, women experienced an average 61.0% (±37.4) (95% CI: 35.9-86.2) leakage reduction, a difference 10/11 users (91.0%) perceived in reduced leakage. One participant, reporting four previous surgical attempts, experienced a 78.7% leakage reduction. Acceptability was high-women could easily insert (8/11), remove (8/11), and comfortably wear (11/11) the cup and most (10/11) would recommend it. No adverse effects attributable to the intervention were observed on exam, although some women perceived difficulties with insertion and removal. Data collection tools were appropriate with slight modification advised. CONCLUSION: A larger trial is warranted for a more robust evaluation of the menstrual cup for management of urinary leakage due to VVF among women who have not yet accessed surgery or for whom surgery was not successful.

The long-term effects of adolescent pregnancies in a community in Northern Ghana on subsequent pregnancies and births of the young mothers.

BACKGROUND: In Ghana, adolescents represent 22% of the total population. The rates of adolescent pregnancies are high. Of all births registered in the country in 2014, 30% were by adolescents, and 14% of adolescents aged between 15 and 19 years had begun childbearing. Pregnancies and deliveries of adolescents are accompanied by more risks as compared to older women. The aim of the study was to explore the long-term effects of adolescent pregnancies on subsequent pregnancies and births and on the socioeconomic status of the women. METHOD: A cross-sectional interviewer-performed survey of a purposive sample of 400 women in one community of Northern Ghana was conducted. Relationships between the age at first pregnancy and complications such as cesarean section, preterm or stillbirth and others were explored in 143 patients using the statistical program SPSS (Statistical Package for the Social Sciences). RESULT: Results show that adolescent women (<19 years at their first pregnancy) have an 80% higher risk for a cesarean section for the first and subsequent births as compared to older women (≥ 19 years). Furthermore, younger mothers have a 45% higher risk of stillbirths and a 30% increased risk of losing their baby within the first 6 weeks after birth. There was no difference in the socioeconomic status between the two age groups. CONCLUSION: Adolescent pregnancies are risk factors for the outcome of subsequent pregnancies of these mothers. This study, for the first time, shows that not only the first pregnancy and birth of very young women are negatively influenced by the early pregnancy but also subsequent pregnancies and births. While this study is of a purposive sample of women in one community, the clinical relevance of this study should not only be interesting for healthcare practitioners in Northern Ghana and other African regions but also for prevention campaigns in these regions.

A 6-year (2004-2009) review of maternal mortality at the Eastern Regional Hospital, Koforidua, Ghana.

A 6-year (2004-2009) review of maternal deaths is presented to establish particular trends at the eastern regional hospital (1 of 10 regional hospitals in Ghana). There were a total of 191 maternal deaths over the period, with a total of 19,965 live births, giving a maternal mortality ratio of 957 per 100,000 live births. The main causes of maternal deaths were postpartum hemorrhage (22.5%), abortion-related causes (19.3%), hypertensive disorders in pregnancy (17.8%), and puerperal sepsis (8.9%). The study revealed that the highest number of deaths was recorded in the period following termination of pregnancy (abortion or delivery). Timely referral of patients to this hospital could help reduce preventable maternal deaths.