A research agenda to improve incidence and outcomes of assisted vaginal birth.

Access to emergency obstetric care, including assisted vaginal birth and caesarean birth, is crucial for improving maternal and childbirth outcomes. However, although the proportion of births by caesarean section has increased during the last few decades, the use of assisted vaginal birth has declined. This is particularly the case in low- and middle-income countries, despite an assisted vaginal birth often being less risky than caesarean birth. We therefore conducted a three-step process to identify a research agenda necessary to increase the use of, or reintroduce, assisted vaginal birth: after conducting an evidence synthesis, which informed a consultation with technical experts who proposed an initial research agenda, we sought and incorporated the views of women's representatives of this agenda. This process has allowed us to identify a comprehensive research agenda, with topics categorized as: (i) the need to understand women's perceptions of assisted vaginal birth, and provide appropriate and reliable information; (ii) the importance of training health-care providers in clinical skills but also in respectful care, effective communication, shared decision-making and informed consent; and (iii) the barriers to and facilitators of implementation and sustainability. From women's feedback, we learned of the urgent need to recognize labour, childbirth and postpartum experiences as inherently physiological and dignified human processes, in which interventions should only be implemented if necessary. The promotion and/or reintroduction of assisted vaginal birth in low-resource settings requires governments, policy-makers and hospital administrators to support skilled health-care providers who can, in turn, respectfully support women in labour and childbirth.

L'accès aux soins obstétriques d'urgence, y compris l'accouchement vaginal assisté et la césarienne, est essentiel pour améliorer les effets de la maternité et de l'accouchement. Toutefois, bien que la proportion de césariennes ait augmenté ces dernières décennies, le recours à l'accouchement vaginal assisté a diminué. C'est particulièrement le cas dans les pays à revenu faible ou intermédiaire, bien que l'accouchement vaginal assisté soit souvent moins risqué qu'une césarienne. Nous avons donc mené un processus en trois étapes afin d'imaginer un programme de recherche qui permettrait d'augmenter le recours à l'accouchement vaginal assisté ou de le réintroduire. Après avoir réalisé une synthèse des données probantes, qui a servi de base à une consultation avec des experts techniques qui ont proposé un programme de recherche initial, nous avons sollicité et incorporé les avis des représentantes des femmes pour ce programme. Ce processus nous a permis d'imaginer un programme de recherche complet, avec des sujets classés comme suit: (i) la nécessité de comprendre la perception qu'ont les femmes de l'accouchement vaginal assisté et de fournir des informations appropriées et fiables; (ii) l'importance de la formation des prestataires de soins de santé en matière de compétences cliniques, mais aussi de respect dans les soins de santé, de communication efficace, de prise de décision partagée et de consentement éclairé; ou (iii) les obstacles à la mise en œuvre et à la durabilité et les facteurs qui les facilitent. Les réactions de femmes nous ont appris qu'il était urgent de reconnaître que l'accouchement, la naissance et le post-partum sont des processus humains intrinsèquement physiologiques et dignes au cours desquels les interventions ne devraient être mises en œuvre qu'en cas de nécessité. La promotion et/ou la réintroduction de l'accouchement vaginal assisté dans les régions à faibles ressources nécessitent que les pouvoirs publics, les décideurs politiques et les administrations d'hôpitaux soutiennent les prestataires de soins de santé qualifiés, qui pourront à leur tour soutenir respectueusement les femmes pendant l'accouchement.

El acceso a la atención obstétrica de emergencia, incluido el parto vaginal asistido y el parto por cesárea, es crucial para mejorar los resultados de la maternidad y el parto. No obstante, aunque el porcentaje de partos por cesárea ha aumentado en las últimas décadas, el uso del parto vaginal asistido ha disminuido. Esto ocurre especialmente en los países de ingresos bajos y medios, a pesar de que un parto vaginal asistido suele ser menos arriesgado que un parto por cesárea. Por lo tanto, llevamos a cabo un proceso de tres pasos para identificar un programa de investigación necesario para aumentar el uso del parto vaginal asistido o volver a incorporarlo: tras realizar una síntesis de la evidencia, que sirvió de base para una consulta con expertos técnicos que propusieron un programa de investigación inicial, buscamos e integramos las opiniones de las representantes de las mujeres sobre este programa. Este proceso nos ha permitido identificar un programa de investigación exhaustivo, con temas categorizados como: (i) la necesidad de comprender las percepciones de las mujeres sobre el parto vaginal asistido, y proporcionar información adecuada y fiable; (ii) la importancia de formar a los profesionales sanitarios en habilidades clínicas, pero también en atención respetuosa, comunicación efectiva, toma de decisiones compartida y consentimiento informado; o (iii) las barreras y los facilitadores de la implementación y la sostenibilidad. A partir de las opiniones de las mujeres, nos enteramos de la urgente necesidad de reconocer las experiencias del parto, el alumbramiento y el posparto como procesos humanos inherentemente fisiológicos y dignos, en los que las intervenciones solo deben aplicarse si son necesarias. La promoción o la reincoporación del parto vaginal asistido en regiones de escasos recursos exige que los gobiernos, los responsables de formular políticas y los administradores de hospitales apoyen a los profesionales sanitarios capacitados que, a su vez, pueden ayudar a las mujeres en el trabajo de parto y el alumbramiento de manera respetuosa.

"I hope to all the world they don't forget women of Afghanistan": An interrupted survey among doctors in Afghanistan.

OBJECTIVE: To assess current access to essential sexual and reproductive health (SRHR) services in Afghanistan and how access has changed with the transition of power. METHODS: This is a cross-sectional study based on data from an anonymous survey among doctors in Afghanistan in May 2022, analyzed using descriptive statistics. The survey recorded subjective estimates of access to SRHR services, barriers to access, extent of maternal mortality or near miss due to preventable factors, and the effect of the regime change on access. RESULTS: The data collection was interrupted after 60 responses. A majority of providers responded that their population went hungry often or always. According to our criteria for "access", that 75% or more of the population was estimated to have it, no respondents (0%) assessed that access existed for services for gender-based violence. The corresponding proportion responding that access existed was 3.4% for services after rape, 12.6% for legal abortion, 13.3% for antenatal care, and 20% for labor care. According to 41.7% of respondents, untreated postpartum hemorrhage accounted for a large or very large proportion of preventable maternal mortality or near miss. Almost half of respondents (47.4%) reported the same for lack of skilled providers, 66.2% reported it for the concept "too many pregnancies", and 55% reported it for malnutrition and poor health. According to 43.3% of respondents, the regime change had reduced access to labor care to a large extent, 33.9% of respondents said this in relation to access to contraceptives, and 43.1% for overall access for internally displaced persons. CONCLUSION: Interim data suggest that women in some settings in Afghanistan have no access to SRHR services, that preventable factors account for a large portion of maternal deaths or near miss, and that access has deteriorated since the transition of power.

Capture Sequencing to Explore and Map Rare Casein Variants in Goats.

Genetic variations in the four casein genes CSN1S1, CSN2, CSN1S2, and CSN3 have obtained substantial attention since they affect the milk protein yield, milk composition, cheese processing properties, and digestibility as well as tolerance in human nutrition. Furthermore, milk protein variants are used for breed characterization, biodiversity, and phylogenetic studies. The current study aimed at the identification of casein protein variants in five domestic goat breeds from Sudan (Nubian, Desert, Nilotic, Taggar, and Saanen) and three wild goat species [Capra aegagrus aegagrus (Bezoar ibex), Capra nubiana (Nubian ibex), and Capra ibex (Alpine ibex)]. High-density capture sequencing of 33 goats identified in total 22 non-synonymous and 13 synonymous single nucleotide polymorphisms (SNPs), of which nine non-synonymous and seven synonymous SNPs are new. In the CSN1S1 gene, the new non-synonymous SNP ss7213522403 segregated in Alpine ibex. In the CSN2 gene, the new non-synonymous SNPs ss7213522526, ss7213522558, and ss7213522487 were found exclusively in Nubian and Alpine ibex. In the CSN1S2 gene, the new non-synonymous SNPs ss7213522477, ss7213522549, and ss7213522575 were found in Nubian ibex only. In the CSN3 gene, the non-synonymous SNPs ss7213522604 and ss7213522610 were found in Alpine ibex. The identified DNA sequence variants led to the detection of nine new casein protein variants. New variants were detected for alpha S1 casein in Saanen goats (CSN1S1 ∗C1), Bezoar ibex (CSN1S1 ∗J), and Alpine ibex (CSN1S1 ∗K), for beta and kappa caseins in Alpine ibex (CSN2 ∗F and CSN3 ∗X), and for alpha S2 casein in all domesticated and wild goats (CSN1S2 ∗H), in Nubian and Desert goats (CSN1S2 ∗I), or in Nubian ibex only (CSN1S2 ∗J and CSN1S2 ∗K). The results show that most novel SNPs and protein variants occur in the critically endangered Nubian ibex. This highlights the importance of the preservation of this endangered breed. Furthermore, we suggest validating and further characterizing the new casein protein variants.

Symptoms Of Menopause In Peri And Postmenopausal Women And Their Attitude Towards Them.

BACKGROUND: The climacteric or perimenopause is the transitional phase during which reproductive function ceases. The average age of the menopause is 51.4 years with a duration of two years. Symptomatology include: vasomotor, psychological, urogenital/sexual, skin, menstrual irregularities and others. The objective was to study the attitude of these women towards menopause. METHODS: In this cross-sectional study, 500 women were included. RESULTS: Palpitations and headaches were found in 30% and 32% respectively in perimenopausal women compared to 16% and 20% in postmenopausal women. Irritability, anxiety and lethargy affected every 3 in 10 women while 24% reported forgetfulness and 12% had loss of libido in the peri menopausal group. The incidence of the above symptoms was much lower in the postmenopausal group, irritability being on the top (16%) followed by forgetfulness (12%), lethargy in 10% and loss of libido in 3%. Dyspareunia was reported by 18% of perimenopasual and 8% of menopausal women. Urinary complaints were found in 9% and 3% of the perimenopausal and menopausal women respectively. About 2 in 10 complained of dryness of skin. Menstrual irregularities affected 3 in 10 women and the commonest form of abnormality was delayed cycles (23%). Concerning their attitude towards menopause 46% perimenopausal and 76% of the postmenopausal women did not perceive menopause as a medical condition and were found satisfied as they had accepted it as a natural ageing process. Some 20-40% of women who were worried or dreading menopause were those who linked impairment of vision with menopause. CONCLUSIONS: Attitude of women in our society was found positive towards menopause.

Replacement of dilation and curettage/evacuation by manual vacuum aspiration and medical abortion, and the introduction of postabortion contraception in Pakistan.

Manual vacuum aspiration (MVA) and medical abortion were introduced to replace dilation and curettage/evacuation for incomplete abortions, and postabortion contraception was provided in 5 selected public hospitals in Pakistan. In the largest hospital, an Ipas MVA training center since 2007, MVA use reached 21% in 2008. After the International Federation of Gynecology and Obstetrics (FIGO) and UNFPA provided MVA kits, MVA use increased dramatically to 70%-90% in 2010-2013. In 2 of the remaining 4 hospitals in which the Society of Obstetricians and Gynecologists of Pakistan trained doctors in May 2012 and January 2013, the target of having 50% of women managed by MVA and medical abortion (MA) was met; however, in the third hospital only 43% were treated with MVA and MA. In the fourth hospital, where misoprostol and electric vacuum aspiration use was 64% and 9%, respectively, before training, an MVA workshop introduced the technique. Postabortion contraception was provided to 9%-29% of women, far below the target of 60%.

Laparoscopic evaluation in infertility.

OBJECTIVE: To describe the different causes of infertility based on findings of diagnostic laparoscopy and their comparative frequency in primary and secondary infertility. STUDY DESIGN: A cross-sectional study. PLACE AND DURATION OF STUDY: Obstetrics and Gynaecology Unit of Hayatabad Medical Complex, Peshawar, from January to December 2005. METHODOLOGY: All patients undergoing diagnostic laparoscopy for primary or secondary infertility were included. Male factor infertility cases was excluded. Frequency of the causes and finding was determined. RESULTS: One hundred and thirty six (70.46%) patients with primary and 57 (29.54%) with secondary infertility underwent diagnostic laparoscopy. Seventy (51.47%) with primary and 26 (45.51%) with secondary infertility had no visible abnormality. Bilateral tubal blockage was found in 32 (23.53%) primary and 16 (28.07%) cases of secondary infertility. Dense pelvic adhesions forming adnexal mass were found in 9 (6.61%) and 6 (10.5%) of primary and secondary respectively. Two cases each of bicornuate uterus and double uterus in primary infertility patients. Ovarian pathology was found in 18 (13.23%) primary and 4 (7.01%) cases of secondary infertility. PCO (polycystic ovaries) were detected in 12 (8.82%) and 2 (3.5%) cases of primary and secondary infertility respectively. Endometriotic cysts and deposits were found in 15 (10.29%) cases of primary and 3 (5.26%) cases of secondary infertility. CONCLUSION: Tubal disease is a common factor responsible for infertility and diagnostic laparoscopy is a valuable technique for complete assessment of female infertility and making treatment decisions according to the cause.

Postpartum haemorrhage: a preventable cause of maternal mortality.

OBJECTIVE: To assess the preventable predictors of severe postpartum haemorrhage and the adverse outcome associated with it. DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Obstetrics and Gynaecology, Hayatabad Medical Complex, PGMI, Peshawar, form January to December 2001. PATIENTS AND METHODS: All the admitted patients who developed severe postpartum haemorrhage (>1500 ml) were included in the study. Clinical and sociodemographic data was obtained along with results of investigations to categorize the complications encountered. Odds ratio (OR) and 95% confidence intervals were determined. RESULTS: During the study period, 75 out of 4683 obstetrical admissions, developed severe postpartum haemorrhage (1.6 %). About 65% of the patients were admitted with some other complications including obstructed labour, antepartum haemorrhage and eclampsia. The risk factors were grand multiparity (OR=3.4), pre-eclampsia (OR=2.75), antepartum haemorrhage (OR=13.35), active labour of more than 10 hours (OR=46.92), twin delivery (OR=3.25), instrumental delivery (OR=8.62) and caesarean section (OR=9.74). Maternal mortality in these cases was 2.66% and residual morbidity being 40%. Birth attendant other than doctor and delivery outside the study unit were significantly associated with the adverse outcome in these patients. CONCLUSION: Maternal outcome associated with postpartum haemorrhage is a function of care given during labour and postnatal period with early diagnosis and management of the complication and its risk factors, being the key of good maternal outcome.

External cephalic version for breech presentation at term.

OBJECTIVE: To assess the success rate of External Cephalic Version (ECV) at term and its effects on measures of pregnancy outcome. DESIGN: A quasi-experimental study. PLACE AND DURATION OF STUDY: The study was conducted at Hayatabad Medical Complex, Peshawar, from December 2003 to January 2005. PATIENTS AND METHODS: A total of 40 patients were offered ECV over a period of fourteen months. All singleton breech presentations with an otherwise normal antenatal course between 36-41 weeks of gestation were included in the study. Exclusion criteria included contraindications to ECV i.e. multiple pregnancy, oligohydramnios, growth retardation, antepartum hemorrhage, rupture of membranes toxemias of pregnancy, non-reassuring fetal monitoring pattern, previous uterine scar, bad obstetric history, any contraindication to vaginal delivery, labour and patient wishes after thorough counseling. Overall success rate of the procedure and its effect on maternal and fetal outcome was determined. Significance of results was determined using Chi-square test. RESULTS: A total of 40 patients were recruited for the trial. Overall success rate was 67.5% with only 30% being primi-gravida (p < 0.05). Multi-gravida showed higher success rate of 80%. Following successful ECV, spontaneous vaginal delivery was attained in 77.7% (n=21), while caesarean section was performed due to various indications in about 6 cases (p < 0.05). Following failed version, 61.5% (n=8) had elective C/S and only 5 delivered vaginally. Route of delivery did not affect the perinatal outcome except for congenital abnormalities. Following successful ECV, there was only one stillbirth. Overall live births associated with successful version was 96.2% (p < 0.05), while in failed version, there were no fetal deaths. CONCLUSION: ECV at term appears to be a useful procedure to reduce the number and associated complications of term breech presentation. It is safe for the mother and the fetus and helps to avoid a significant number of caesarean sections.

Eclampsia--management and outcome with magnesium sulphate as the anticonvulsant.

OBJECTIVE: To study the maternal outcome in terms of morbidity and mortality with the use of magnesium sulphate in eclampsia for seizure control and prophylaxis. DESIGN: A quasi experimental study. PLACE AND DURATION OF STUDY: This study was conducted in Obstetrics and Gynaecology Unit of Hayatabad Medical Complex, Peshawar, from 1st September 2002 to 31st December 2003. PATIENTS AND METHODS: All the patients admitted with eclampsia during this period were included in the study. A detailed history and clinical examination were recorded. Patients were monitored for number of fits, rise in blood pressure (BP), dose of magnesium sulphate administered and its side effects, development of complications of eclampsia, duration of labour, mode of delivery and use of other medications as well as maternal and perinatal outcome. RESULTS: During this period, 52 patients were admitted with eclampsia. Majority were unbooked. Primigravida were 31 (59.6%). Common age group was between 21 and 30 years having 34 (65.4%) patients while 16 (30.7%) patients were 20 years or less than 20 years of age. Thirty-three (63.4%) patients had antenatal fits, 9 (17.3%) intrapartum fits and 11 (19.2%) had postpartum eclampsia. Twenty-six patients had term pregnancy, 22 patients with 28-36 weeks gestation while 4 patients developing eclampsia before 28 weeks gestation. Eighteen patients had spontaneous vaginal delivery; labour was induced in 21 patients while 6 patients underwent cesarean section. Maternal complications included pulmonary oedema, tongue bites, HELLP syndrome, placental abruption and coagulopathy. Side effects of magnesium sulphate were low. There were 4 (7.6%) maternal deaths due to eclampsia. Perinatal outcome was good with 33 (63.4%) live births, 3 IUDs and 10 still births, mostly due to prematurity. CONCLUSION: Magnesium sulphate was found to be an effective anti-convulsant both for control and prophylaxis of seizures in eclampsia and improved maternal and fetal outcome.

Management of gestational trophoblastic tumours: a five-year clinical experience.

OBJECTIVE: An analysis of a 5-year clinical experience in the management of gestational trophoblastic tumours in a tertiary care hospital. DESIGN: A prospective cohort follow-up study. PLACE AND DURATION OF STUDY: The study was conducted at Hayatabad Medical Complex, Peshawar from 1998 to 2003. PATIENTS AND METHODS: A total of 30 cases were managed and a detailed analysis of these patients was done. Of these 13 followed Hydatidiform Mole, 10 after abortion and 7 after a term pregnancy. RESULTS: Out of 30 cases of gestational trophoblastic tumour, 63.3% were between 21 and 38 years of age. Ninety percent of the patients presented with vaginal bleeding, while life-threatening hemorrhage occurred in 23.3%of the cases.43.3% of the patients had hydatidiform mole as an antecedent pregnancy and 36.7% of the patients presented within four months of the antecedent pregnancy. Blood groups O and B were most frequently encountered i.e. in 40% and 33.3% of the cases. Metastatic disease was present in 46.6% of the cases, of which 8 were high risk and one was of medium risk group. Major sites of metastasis were lungs (33.3%) and vagina (30%). Serum BHCG of 40,000 miu / ml and above was present in 53.3% of the cases (P=0.016) and number of metastasis >8 were found in 16.7% cases (P=0.001). Prior chemotherapy was given in only 2 patients and both of them died due to resistance. Chemotherapy was given to 100% of patients; survival was 100% in low-risk group and 50% in high-risk group (P=0.004). Overall mortality was 20% i.e. 6 patients died of the disease. Major side effects of chemotherapy were stomatitis (66.6%), alopecia (56.6%), low hemoglobin (60%), weight loss and recurrent infection. CONCLUSION: Late diagnosis, previously failed chemotherapy and high WHO prognostic scores are major risk factors affecting outcome in these patients. Hence every female in reproductive age group with unexplained bleeding per vaginum should be investigated with serum BHCG (Beta human chorionic gonadotrophin).