Social determinants and exposure to intimate partner violence in women with severe acute maternal morbidity in the intensive care unit: a systematic review.

BACKGROUND: Studying severe acute maternal morbidity in the intensive care unit improves our understanding of potential factors affecting maternal health. AIM: To review evidence on maternal exposure to intimate partner violence and social determinants of health in women with severe acute maternal morbidity in the intensive care unit. METHODS: The protocol for this review was registered in PROSPERO (registration number CRD42016037492). A systematic search was performed in MEDLINE, CINAHL, ProQuest, LILACS and SciELO using the search terms "intensive care unit", "intensive care", "critical care" and "critically ill" in combination with "intimate partner violence", "social determinants of health", "severe acute maternal morbidity", pregnancy, postpartum and other similar terms. Eligible studies were (i) quantitative, (ii) published in English and Spanish, (iii) from 2000 to 2021, (iv) with data related to intimate partner violence and/or social determinants of health, and (v) investigating severe acute maternal morbidity (maternity patients treated in the intensive care unit during pregnancy, childbirth or within 42 days of pregnancy termination). Of 52,866 studies initially identified, 1087 full texts were assessed and 156 studies included. Studies were independently assessed by two reviewers for screening, revision, quality assessment and abstracted data. Studies were categorised into high/middle/low-income countries and summarised data were presented using a narrative description, due to heterogenic data as: (i) exposure to intimate partner violence and (ii) social determinants of health. RESULTS: One study assessed intimate partner violence among mothers with severe acute maternal morbidity in the intensive care unit and found that women exposed to intimate partner violence before and during pregnancy had a nearly four-fold risk of severe acute maternal morbidity requiring ICU admission. Few social determinants of health other than age were reported in most studies. CONCLUSION: This review identified a significant gap in knowledge concerning intimate partner violence and social determinants of health in women with severe acute maternal morbidity in the intensive care unit, which is essential to better understand the complete picture of the maternal morbidity spectrum and reduce maternal mortality.

Primary postpartum haemorrhage adversely impacts breastfeeding initiation in Victoria, Australia.

PROBLEM: Breastfeeding has many important benefits for both mother and baby but sustained breastfeeding is sub-optimal. BACKGROUND: Identifying women who need increased support to establish breastfeeding has the potential to improve this. Analysis of the relationship between primary postpartum haemorrhage (PPH) and primary severe PPH and breastfeeding may prove informative as PPH has potentially negative impacts on breastfeeding. AIM: To determine the relationship between PPH and severe PPH and breastfeeding at postnatal discharge and formula use for breastfed babies in hospital. METHODS: Population-based retrospective cohort study using the Victorian Perinatal Data Collection for all liveborn singleton births at ≥ 37 weeks' gestation (n = 339,854) for 2009-13 in Victoria. Estimated blood loss was categorised as PPH ≥ 500 mL and severe PPH ≥ 1500 mL. Descriptive analysis was conducted and multivariable logistic regression was used to determine the adjusted odds ratio for the relationship between PPH/severe PPH and breastfeeding outcomes after adjustment for relevant confounders. FINDINGS: Overall, 94.9% of women initiated breastfeeding. Babies whose mother had a PPH or severe PPH were less likely than others to be exclusively breastfeeding at discharge (aOR 0.88; (95% CI 0.86, 0.90) and aOR 0.57; (95% CI 0.53, 0.61) respectively). Formula - given to 25.9% of all breastfed babies - was more likely for those whose mothers had a PPH or severe PPH (aOR 1.15; (95% CI 1.12, 1.17) and aOR 2.15; (95% CI 2.01, 2.29) respectively. CONCLUSIONS: Women have greater challenges establishing exclusive breastfeeding following PPH and severe PPH. Improving support in hospital for women following PPH may increase breastfeeding success.

Occupational Therapy Interventions for Clients with Ehlers-Danlos Syndrome (EDS) in the Presence of Postural Orthostatic Tachycardia Syndrome (POTS).

Postural orthostatic tachycardia syndrome (POTS) is often seen in clients with Ehlers-Danlos syndrome (EDS), primarily hypermobile EDS. Research has shown clients with EDS and POTS may experience limitations affecting not only their physical function, but also their social, emotional, and mental well-being. Using a client-centered approach, occupational therapy practitioners assess health, well-being, symptomatology (fatigue, muscle pain, dizziness, etc.), participation and engagement in occupation, and provide interventions to improve quality of life. This paper will address occupational therapy interventions to treat common symptomatology for clients with EDS in the presence of POTS, including environmental modifications, use of adaptive equipment and orthoses, exercise and fall prevention, energy conservation and pacing, sleep hygiene, and routine and habit development to promote optimal engagement in meaningful occupations.

Implementation of an obstetric triage decision aid into a maternity assessment unit and emergency department.

BACKGROUND: The obstetric triage decision aid (OTDA) consists of 10 common pregnancy complaints with key signs and symptoms generating a triage score based on targeted questioning responses. It was developed to provide a standardised approach for obstetric triage conducted by midwives and emergency nurses as neither professional group are expert in the triage of pregnant and postpartum women. AIM: To evaluate implementation of the OTDA into an emergency department (ED) and maternity assessment unit (MAU). METHODS: The OTDA was introduced to the ED and MAU of a hospital in Australia. A range of implementation strategies were utilised and assessed by pre and post staff survey, and a three-month post-audit of unscheduled maternity presentations. The primary outcome was adoption rate of the OTDA. Secondary outcomes were staff confidence and waiting times. Analyses were undertaken using SPSS (v24). Paired analysis was conducted on staff surveys. RESULTS: There were a total of 2829 unscheduled presentations: ED (n=708) and MAU (n=2121), 88.1% were triaged using the OTDA, used more in the MAU than the ED (93.2% vs 72.7%; p<.001). In the MAU, women seen within 15min of arrival improved significantly from 42.0% to 78.0%. There was improvement in the self-rated confidence (p=.002) and competence (p=.004) by nurses and midwives to conduct obstetric triage. CONCLUSION: The introduction of the OTDA required different approaches to change practice. There were improvements in staff self-rated confidence and competence, a reduction in clinical risk associated with under-triage in the ED and improved prioritisation of care in the MAU.

Umbilical Cord Management at Term and Late Preterm Birth: A Meta-analysis.

CONTEXT: The International Liaison Committee on Resuscitation prioritized scientific review of umbilical cord management at term and late preterm birth. OBJECTIVE: To assess effects of umbilical cord management strategies (clamping timing and cord milking) in infants ≥34 weeks' gestational age. DATA SOURCES: Cochrane Central Register of Controlled Trials, Medline, PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and trial registries searched July 2019. STUDY SELECTION: Two authors independently assessed eligibility of randomized controlled trials. DATA EXTRACTION: Two authors independently extracted data and assessed evidence certainty (Grading of Recommendations Assessment, Development and Evaluations). RESULTS: We identified 46 studies (9159 women and their infants) investigating 7 comparisons. Compared with early cord clamping (ECC) <30 seconds, delayed cord clamping (DCC) ≥30 seconds (33 studies), intact-cord milking (1 study), and cut-cord milking (2 studies) probably improve hematologic measures but may not affect survival without neurodisability, anemia in early infancy, or maternal postpartum hemorrhage. No differences in major neonatal morbidities are seen in studies comparing methods of optimizing placental transfusion (DCC versus cut-cord milking [3 studies], longer delays in clamping [7 studies], or physiologic parameters [3 studies]). Strategies that promote increased placental transfusion may be associated with greater phototherapy use. Evidence for all outcomes was low or very low certainty. LIMITATIONS: Incompleteness and low certainty of findings limit applicability. CONCLUSIONS: Compared with ECC, DCC or cord milking increases hemoglobin and hematocrit immediately after birth in infants ≥34 weeks' gestational age. The uncertain effects of DCC and cord milking compared with ECC on major morbidities limit usefulness of available evidence for policy and practice.

Developing epilepsy training capacity for primary care providers using the project ECHO telementoring model.

BACKGROUND: Primary care providers (PCPs) provide a large proportion of care for people with epilepsy (PWE) and need regular training for updates. However, PCPs treat patients in so many therapeutic areas that epilepsy often becomes a less important concern. We used an established telementoring program, Project ECHO (Extension for Community Healthcare Outcomes), and combined epilepsy education with general neurology topics to generate more interest among PCPs. METHODS: We offered 20 one-hour webinar sessions over a two-year period, each consisting of a panel of neurology experts, with a combination of case presentations, a 20-minute didactic presentation, and live, interactive question and answer. Attendees logged in from their own computers or phones, and all presentations were archived online for future viewing. Interviews with PCPs indicated a combination of epilepsy and general neurology topics would be better received, so epilepsy topics alternated monthly with general neurology topics (e.g., headache, stroke, and dementia). Session evaluation included participants' comfort in treating patients with neurological disorders and confidence in knowledge of the topic area. RESULTS: After the second session, mean attendance was 27.5 participants (range 15-38), with a total of 164 unique individual participants. Attendees were a mix of mostly regional, some out of state, and a few international learners, including practicing PCPs, trainees, and nurse practitioners. Archived presentations on our website were viewed 212 times; seizure topics were the most viewed. Mean evaluation scores for relevance, value, and increased knowledge were all in the "agree to strongly agree" range. Over 97% of respondents reported greater interest in improving care of patients with epilepsy or neurological disorders, and over 98% reported greater comfort and self-efficacy when treating patients with these conditions. Only eight cases were submitted for review prior to the sessions. CONCLUSIONS: We successfully piloted a telementoring program using Project ECHO methodology, which was effective in educating PCPs about epilepsy treatment. Combining epilepsy and other neurology topics was an effective strategy in garnering interest among PCPs, but additional methods are needed to encourage participants to present their own cases.

Talking testing: Impact of a training intervention on midwives' antenatal HIV, hepatitis B and hepatitis C screening practice.

BACKGROUND: Midwives play a critical role in ensuring that HIV, hepatitis B and hepatitis C screening occurs during early pregnancy, in accordance with national consensus guidelines and policies. Limited opportunities exist for midwives to gain the knowledge, skills and confidence required to initiate testing discussions at the first antenatal visit. AIM: To design, deliver and evaluate a workforce education intervention to build midwives' capacity to initiate testing for HIV and viral hepatitis. METHOD: Victorian midwives were invited to enrol in an intervention which comprised a pre-learning package and a one-day study day covering clinical, epidemiological and psychosocial aspects of HIV, hepatitis B and hepatitis C testing in early pregnancy. A pre-/post-test design, incorporating a survey with eight knowledge items and four confidence items, was used to measure impact. FINDINGS: Of the 69 participating midwives, 55 completed the pre-survey, 69 completed the post-survey and 19 completed a three-month follow up survey. Participant knowledge improved across all domains, with the most significant increases in the areas of HIV and viral hepatitis testing, transmission and treatment. Midwives' confidence levels increased following the intervention, and this was generally sustained among the smaller sample at the three-months. CONCLUSION: Our findings demonstrate that short educational interventions, designed and delivered by content experts, result in longer-term improvements in clinical practice which are crucial to ensuring women and their partners are given adequate information and recommendations about screening for HIV, hepatitis B and hepatitis C and during pregnancy.

Impact of a University-Wide Interdisciplinary Mind-Body Skills Program on Student Mental and Emotional Well-Being.

BACKGROUND: Positive effects of mind-body skills programs on participant well-being have been reported in health professions students. The success seen with medical students at this university led to great interest in expanding the mind-body skills program so students in other disciplines could benefit from the program. OBJECTIVE: The purpose of this study was to assess the effects of a 9-week mind-body skills program on the mental and emotional well-being of multidisciplinary students compared to controls. We also sought to determine if the program's effects were sustained at 1-year follow-up. METHODS: A cross-sectional pre-post survey was administered online via SurveyMonkey to participants of a 9-week mind-body skills program and a control group of students from 7 colleges at a public university from 2017-2019. Students were assessed on validated measures of stress, positive/negative affect, resilience, depression, anxiety, fatigue, sleep disturbance, mindfulness, empathy, and burnout. Scores were analyzed between-groups and within-groups using bivariate and multivariate analyses. A 1-year follow-up was completed on a subset of participants and controls. RESULTS: 279 participants and 247 controls completed the pre-survey and post-survey (79% response rate; 71% female, 68% white, mean age = 25 years). Participants showed significant decreases in stress, negative affect, depression, anxiety, sleep disturbance, and burnout, while positive affect, resilience, mindfulness, and empathy increased significantly (P < .05). Only sleep disturbance showed a significant decrease in the control group. Follow-up in a subset of participants showed that only mindfulness remained elevated at 1-year (P < .05), whereas the significant changes in other well-being measures were not sustained. CONCLUSION: Participation in a 9-week mind-body skills program led to significant improvement in indicators of well-being in multidisciplinary students. A pilot 1-year follow-up suggests that effects are only sustained for mindfulness, but not other parameters. Future programming should focus on implementing mind-body skills booster sessions to help sustain the well-being benefits.

Feasibility and Acceptability of a Community-Based Modified Mindfulness-Based Stress Reduction Program for the Under- and Unemployed.

BACKGROUND: Mindfulness-Based Stress Reduction (MBSR) often improves health outcomes, though literature primarily focuses on middle-class, employed individuals. With an estimated average of six million unemployed over the past year, and the recent uptick in unemployment due to the COVID-19 pandemic, it is important to identify methods to mitigate and reduce the negative health outcomes often associated with under- and unemployment. OBJECTIVES: We aimed to 1) outline the process of partnering with a community organization to implement a modified MBSR program for under- and unemployed individuals, and 2) present pilot data on preliminary results. METHODS: The modified MBSR program was implemented in two phases within a job training program for under- and unemployed individuals. In Phase I, group one received an eight-week program. Based on feedback, the MBSR program was reduced to six weeks and implemented for groups two and three (Phase II). Feasibility and acceptability were evaluated utilizing a mixed-methods approach. Changes in mindfulness, perceived stress, pain interference, anxiety, depression, and sleep disturbance were assessed pre-post the modified MBSR program. RESULTS: Thirty-three participants completed the program with twenty-nine post-survey responses. The modified MBSR program was feasible and acceptable as evidenced by the enrollment rate (96%), retention rate (72%), and qualitative feedback. Fifty-percent of participants self-reported weekly home practice compliance. Perceived stress and mindfulness demonstrated significant moderate improvements (d = .69, p = .005; d = .46, p = .001). Depression, anxiety, and pain interference results suggested small non-significant effect size improvements (d = .27, p = .19; d = .23, p = .31; d = .25, p = .07). Effects on fatigue and sleep disturbance were negligible. CONCLUSION: The modified MBSR program was feasible and acceptable to the organization and participants. Small to moderate improvements in mental health and pain interference outcomes were observed. Research using larger sample sizes and randomized designs is warranted.

Security from above and below: A critical ethnography of the health response to violence against women in Timor-Leste.

International advocacy and evidence have been critical for shifting the pervasive issue of violence against women onto the health agenda. Guidelines and training packages, however, can be underpinned by Western principles of responding to individual survivors of violence and availability of specialist referral services, which may not be available in many countries. As Timor-Leste and other nations begin to build their health system response to violence against women, it is important to understand the current practices of health providers and the broader sociocultural context of providing care to survivors of violence. During 11 months in the field (February-December 2016), we conducted qualitative interviews with 48 midwives and community leaders in three municipalities in Timor-Leste. The findings reveal that midwives engage at both the individual and collective levels, providing medical care, advice and moral support to survivors of violence as well as gathering support for women within families and communities. Midwives therefore navigate both formal and informal spaces as they respond to domestic and sexual violence. In doing so, they are influenced by their own experiences as women, as health providers imbued with authoritative knowledge, and as part of the wider sociocultural system. We argue that while much progress has been made in frameworks for health systems responding to survivors of violence, more work needs to be done to understand how to support health providers in low- and middle-income countries as they engage with perpetrators, families and communities. There is a need for further discussion of how health systems can address the issue of domestic and sexual violence as a collective social problem, while foregrounding the needs and rights of those experiencing violence. This research has implications for the content of guidelines and training, and importantly, for developing mechanisms to deal with complex social issues within local health services.

Who decides to have sex? Exploring the perceptions of Timorese women and men through a reproductive justice lens.

Despite national policies to support sexual rights, Timorese women are constrained when making sexual and reproductive health decisions. Contextual understanding of sexual decision making is vital for effective engagement by sexual and reproductive health service providers with communities. An intersectional reproductive justice approach broadens the sexual rights lens allowing for an examination of multi-system factors impacting on sexual rights and health. Using the Matrix of Domination as a conceptual framework, we explored Timorese perceptions around decisions to have sex, and examined intersecting systems of oppression impacting on these decisions. Our study adopted a critical medical anthropological approach using ethnographic methods. A decolonising methodology aimed to make Timorese worldviews central to the analysis. Nine focus group discussions with 80 men and 17 individual reproductive history interviews with women were held in 4 of Timor-Leste's 13 municipalities during October 2015. Findings suggest that decisions to have sex are framed in terms of wishes and rights; however, it was the perceived entitlements of men that were prioritised and predominantly men who made these decisions. Violence, coercion and unwanted pregnancies were linked to decisions about sex, and identified as potential consequences for women, impacting on women's health and sexual rights.

Intimate partner violence and severe acute maternal morbidity in the intensive care unit: A case-control study in Peru.

BACKGROUND: Intimate partner violence is a prevalent public health issue associated with all-cause maternal mortality. This study investigated the relationship between intimate partner violence, severe acute maternal morbidity in the intensive care unit (ICU), and neonatal outcomes. METHODS: This was a prospective case-control study in a hospital in Lima, Peru, with 109 cases (maternal ICU admissions) and 109 controls (obstetric patients not admitted to the ICU). Data were collected through face-to-face interviews and medical record review. Partner violence was assessed using the World Health Organization instrument. Multivariate logistic regression was used to model the association between intimate partner violence and severe acute maternal morbidity. RESULTS: There was a significantly higher rate of intimate partner violence both before and during pregnancy among cases (58.7%) than controls (27.5%). In multivariate analysis, intimate partner violence both before and during pregnancy (aOR 3.83 (95% CI: 1.99-7.37)), being married (3.86 (1.27-11.73)), having <8 antenatal care visits (2.78 (1.14-6.80)), and having previous abortions (miscarriage, therapeutic, or unsafe) (1.69 (1.13-2.51)) were significantly associated with severe acute maternal morbidity. The ICU admission rate was 18.8 (per 1000 live births), and ICU maternal mortality was 1.7%. The perinatal mortality rate was higher in cases (9.3%) than in controls (1.8%). CONCLUSIONS: Intimate partner violence was associated with an increased risk of severe acute maternal morbidity. This suggests a more severe impact of intimate partner violence on pregnancy than has been previously identified. Inquiring about intimate partner violence during prenatal visits may prevent further harm to the mother-baby dyad.

Clinical outcomes post transition to adult services in young adults with perinatally acquired HIV infection: mortality, retention in care and viral suppression.

OBJECTIVE: Adolescence is the only age group globally where HIV-associated mortality is rising, with poorer outcomes at all stages of the care cascade compared with adults. We examined post transition outcomes for young adults living with perinatal HIV. DESIGN: Retrospective cohort analysis. SETTING: A tertiary Youth Friendly Service London, UK. PARTICIPANTS: A total of 180 young adults living with perinatal HIV registered between 1 January 2006 and 31 December 2017 contributed 921 person-years of follow-up post transition to adult services. INTERVENTION: Youth Friendly Service with multidisciplinary care and walk-in access. MAIN OUTCOME MEASURES: Mortality, morbidity, retention in care, antiretroviral therapy (ART) uptake and HIV-viral load suppression. Crude incidence rates are reported per 1000 person-years. RESULTS: Of 180 youth registered, four (2.2%) died, 14 (7.8%) transferred care and four (2.2%) were lost to follow-up. For the 158 retained in care, the median age was 22.9 years [interquartile ranges (IQR) 20.3-25.4], 56% were female, 85% Black African, with a median length of follow-up in adult care of 5.5 years (IQR 2.9-7.3). 157 (99.4%) ever received an ART prescription, 127/157 (81%) with a latest HIV-viral load less than 200 copies RNA/ml, median CD4 cell count of 626 cells/µl (IQR 441-820). The all-cause mortality was 4.3/1000 person-years [95% confidence interval (CI) 1.2-11.1], 10 fold the aged-matched UK HIV-negative population [0.43/1000 person-years (95% CI 0.41-0.44)]. Post transition, 17/180 (9.4%) developed a new AIDS diagnosis; crude incidence rates 18.5/1000 person-years (95% CI 10.8-29.6). CONCLUSION: While this youth-friendly multidisciplinary service achieved high engagement and coverage of suppressive ART, mortality remains markedly increased compared with the general UK population.

Safety of retigabine in adults with partial-onset seizures after long-term exposure: focus on unexpected ophthalmological and dermatological events.

BACKGROUND: Retigabine is an antiepileptic drug developed for the adjunctive treatment of adults with epilepsy and partial-onset seizures (POS). Following its approval in 2011, reports of ophthalmological/dermatological pigmentation/discoloration led to a restriction of the indication in 2013, and in 2017, retigabine was voluntarily withdrawn from the market because of its limited usage. Here, data are reported from four open-label extension studies focusing on long-term safety with particular emphasis on ophthalmological and dermatological events. METHODS: Studies 113413 (NCT01336621), 114873 (NCT01777139), 115097 (NCT00310388), and 115098 (NCT00310375) were multicenter, open-label extension studies of retigabine (300-1200 mg/day) for the adjunctive treatment of adults with POS. Safety assessments included monitoring treatment-emergent adverse events (TEAEs) and serious adverse events (SAEs). When new safety issues were identified, protocols were amended to include additional on-treatment safety evaluations, including ophthalmological and dermatological examinations. Patients who had abnormal retinal pigmentation, unexplained vision change, pigmentation of nonretinal ocular tissue, or abnormal discoloration of skin, lips, nails, and/or mucosa at the end of the treatment phase were asked to enter a safety follow-up continuation phase comprising 6-monthly ophthalmological/dermatological assessments. RESULTS: The safety population (patients receiving ≥1 dose of retigabine in the open-label phase) comprised 98, 30, 376, and 181 patients for studies 113413, 114873, 115097, and 115098, respectively. Mean (standard deviation) treatment exposure ranged from 529 (424) to 1129 (999) days. In total, 68%-96% and 4%-27% of patients across the studies experienced TEAEs and TE SAEs, respectively. There were seven on-treatment deaths and two after discontinuation. Overall, 14%-73% of patients had an on-treatment eye examination, of whom 8/53, 4/22, 17/54, and 14/36 had abnormal retinal pigmentation and 15/53, 7/22, 15/54, and 11/36 had nonretinal ocular pigmentation in studies 113413, 114873, 115097, and 115098, respectively. Four patients had confirmed acquired vitelliform maculopathy. In patients with unresolved events at discontinuation and ≥1 posttreatment follow-up, retinal pigmentation resolved completely in 1/3, 0/3, 0/10, and 1/7 patients and nonretinal ocular pigmentation in 1/4, 0/3, 8/10, and 4/6 patients, respectively. Overall, 12%-83% of patients had an on-treatment dermatological examination, of whom 11/58, 0/25, 23/46, and 23/37 had any-tissue discoloration, respectively. In patients with unresolved events at discontinuation and ≥1 posttreatment follow-up, discoloration of skin, lips, nails, and/or mucosa resolved completely in 2/3, 0/0, 7/13, and 1/11 patients, respectively. CONCLUSIONS: The safety profile of retigabine in adults with POS across four open-label studies was generally consistent with data from previous placebo-controlled studies. Discoloration of various tissues occurred in a proportion of patients treated with retigabine and resolved completely in a small number of these patients following treatment discontinuation. In addition, comprehensive eye examination identified a new adverse reaction of acquired vitelliform maculopathy in a limited number of patients.

Risk factors for severe postpartum haemorrhage: A population-based retrospective cohort study.

BACKGROUND: Severe postpartum haemorrhage (PPH) is a serious clinical problem that is increasing in incidence. AIM: To identify risk factors for severe PPH. MATERIALS AND METHODS: Population-based retrospective cohort study of all women who gave birth in Victoria in 2009-2013 using the validated Victorian Perinatal Data Collection. Three multivariable logistic regression models estimated the adjusted risk of severe PPH. Adjusted odds ratios (aOR) and their 95% confidence intervals are reported. The primary outcome was severe PPH (estimated blood loss of ≥1500 mL). RESULTS: Severe PPH occurred in 1.4% of all births (n = 5122). Maternal characteristics significantly associated with severe PPH included: multiple pregnancy; older maternal age; overweight/obesity; first births. Other risk factors included placental complications, macrosomia, instrumental vaginal birth, third and fourth degree perineal lacerations, in-labour caesarean section, birth at a gestation other than 37-41 weeks, duration of labour 12 to <24 h, and use of oxytocin infusions in labour. Planned pre-labour caesarean section was associated with reduced odds of severe PPH. Severe PPH also occurred in 0.7% (n = 104) of women with none of the identified risk factors. CONCLUSIONS: Numerous risk factors for severe PPH are identified but some cases are not modifiable or predictable. Limiting use of oxytocin infusions in labour to cases with clear indications, and strategies to prevent severe perineal lacerations would prevent some severe PPHs. Close surveillance of all women in the hours immediately following birth is crucial to detect and manage excessive blood loss and reduce severe PPH and associated morbidity.

Informing the development midwifery standards for practice: A literature review for policy development.

AIM: To critically appraise and synthesise the literature regarding the role and scope of midwifery practice, specifically to inform the evidence based development of standards for practice for all midwives in Australia. DESIGN: A structured scoping review of the literature DATA SOURCES: CINAHL Complete, MEDLINE Complete and Cochrane Libraries databases, online and grey literature databases REVIEW METHODS: Comprehensive searches of databases used key words and controlled vocabulary for each database to search for publications 2006-2016. Studies were not restricted by research method. FINDINGS: There is no substantive body of literature on midwifery competency standards or standards for practice. From 1648 papers screened, twenty-eight papers were identified to inform this review. Eight studies including systematic reviews were annotated with three research papers further assessed as having direct application to this review. To inform the development of Midwife standards for practice, the comprehensive role of the midwife across multiple settings was seen to include: woman centred and primary health care; safe supportive and collaborative practice; clinical knowledge and skills with interpersonal and cultural competence. KEY CONCLUSIONS: Midwifery practice is not restricted to the provision of direct clinical care and extends to any role where the midwife uses midwifery skills and knowledge. This practice includes working in clinical and non-clinical relationships with the woman and other clients as well as working in management, administration, education, research, advisory, regulatory, and policy development roles. IMPLICATIONS FOR PRACTICE: This review articulates the definition, role and scope of midwifery practice to inform the development of contemporary standards for practice for the Australian midwife.

Survival of Staphylococcus aureus on therapeutic ultrasound heads.

Therapeutic ultrasound (US) is commonly used in the rehabilitation of soft tissue injuries including wounds. US heads and coupling gel come into direct contact with patient skin, increasing the risk for health care-associated infections owing to cross contamination. In this study, nearly 80% of Staphylococcus aureus placed on US heads in gel survived for 1 hour, with survival of 3 days possible in other types of organic matter.

The nature of labour pain: An updated review of the literature.

BACKGROUND: The pain experience associated with labour is complex. Literature indicates psychosocial and environmental determinants of labour pain, and yet methods to support women usually target physiological attributes via pharmacological interventions. AIM: To provide an update of our understanding of labour pain based on modern pain science. The review aims to help explain why women can experience labour pain so differently - why some cope well, whilst others experience great suffering. This understanding is pertinent to providing optimal support to women in labour. METHOD: A literature search was conducted in databases Medline, Cumulative Index to Nursing and Allied Health Literature and PsycINFO, using search terms labor/labour, childbirth, pain, experience and perception. Thirty-one papers were selected for inclusion. FINDINGS: Labour pain is a highly individual experience. It is a challenging, emotional and meaningful pain and is very different from other types of pain. Key determinants and influences of labour pain were identified and grouped into cognitive, social and environmental factors. CONCLUSION: If a woman can sustain the belief that her pain is purposeful (i.e. her body working to birth her baby), if she interprets her pain as productive (i.e. taking her through a process to a desired goal) and the birthing environment is safe and supportive, it would be expected she would experience the pain as a non-threatening, transformative life event. Changing the conceptualisation of labour pain to a purposeful and productive pain may be one step to improving women's experiences of it, and reducing their need for pain interventions.

Incidence, trends and severity of primary postpartum haemorrhage in Australia: A population-based study using Victorian Perinatal Data Collection data for 764 244 births.

BACKGROUND: Increasing incidence and severity of postpartum haemorrhage, together with postpartum haemorrhage-associated morbidities, have been reported in many high-resource countries. In-depth analysis of such factors in Victorian births since 2002 was lacking. AIMS: Our aim was to determine the incidence and trends for primary postpartum haemorrhage (World Health Organization and International Classification of Diseases 10th revision, Australian Modification definitions) for all confinements in Victoria, Australia, for the years 2003-2013 and the incidence and trends for severe postpartum haemorrhage (≥1500 mL) for 2009-2013. MATERIALS AND METHODS: In this population-based cross-sectional study de-identified data from the Victorian Perinatal Data Collection were analysed for confinements (excluding terminations) from 2003 to 2013 (n = 764 244). Perinatal information for all births ≥20 weeks (or of at least 400 g birthweight if gestation was unknown) were prospectively collected. RESULTS: One in five women (21.8%) who gave birth between 2009 and 2013 experienced a primary postpartum haemorrhage and one in 71 women (1.4%) experienced a severe primary postpartum haemorrhage. The increasing trends in incidence of primary postpartum haemorrhage, severe primary postpartum haemorrhage, blood transfusion, admission to an intensive care or high dependency unit and peripartum hysterectomy were significant (P < 0.001). Women who had an unassisted vaginal birth had the lowest incidence of primary postpartum haemorrhage. The highest incidence was experienced by women who had an unplanned caesarean section birth. Women who had a forceps birth had the highest incidence of severe primary postpartum haemorrhage. CONCLUSIONS: The incidence of primary postpartum haemorrhage, severe primary postpartum haemorrhage and associated maternal morbidities have increased significantly over time in Victoria.

Responding to violence against women: A qualitative study with midwives in Timor-Leste.

PROBLEM: The health sector is a critical partner in the response to violence against women, but little is known about how to translate international guidelines and sustainable good practice in remote and under-resourced health systems. AIM: This research explores the barriers and enablers that midwives report in responding to domestic and sexual violence in Timor-Leste, a country with a very high rate of violence against women. The aim is to inform a systems approach to health provider training and engagement applicable to Timor-Leste and other low-resource settings. METHODS: In 2016 we conducted qualitative interviews and group discussions with 36 midwives from rural health settings, community health centres and hospitals in three municipalities of Timor-Leste. FINDINGS: A range of individual, health system and societal factors shape midwives' practice. While training provided the foundation for knowing how to respond to cases of violence, midwives still faced significant health system barriers such as lack of time, privacy and a supportive environment. Key enablers were support from colleagues and health centre managers. CONCLUSION: Health provider training to address violence against women is important but tends to focus on individual knowledge and skills. There is a need to shift toward systems-based approaches that engage all staff and managers within a health facility, work creatively to overcome barriers to implementation, and link them with wider community-based resources.