PRISM study-Pre-natal iron deficiency screening and management within an Australian regional centre.

INTRODUCTION: Current Australian guidelines differ in their recommendations on optimal iron deficiency anaemia screening and management during pregnancy. A more active approach to screening and treatment of iron deficiency in pregnancy has been beneficial within a tertiary population. However, this approach has not been evaluated within a regional healthcare setting. OBJECTIVE: To evaluate the clinical impact of standardised screening and management for iron deficiency in pregnancy within a regional Australian centre. DESIGN: Single centre, retrospective cohort observational study that audited medical records pre and post implementation of standardised screening and management for antenatal iron deficiency. We compared rates of anaemia at birth, rates of peripartum blood transfusions and rates of peripartum iron infusions. FINDINGS: There were 2773 participants with 1372 participants in the pre-implementation group and 1401 in the post-implementation group. Participant demographics were similar. Anaemia at admission for birth decreased from 35% to 30% (RR 0.87, 95% CI (0.75, 1.00), p 0.043) Fewer blood transfusions were required (16 (1.2%) pre-implementation, 6 (0.4%) post-implementation, RR 0.40, 95% CI(0.16, 0.99), p 0.048). Antenatal iron infusions increased from 12% to 18% of participants post implementation (RR 1.47, 95% CI(1.22, 1.76), p 〈0.001).We audited compliance with the guidelines and found improvements post implementation. DISCUSSION: This is the first study to show clinically useful and statistically significant reduction in rates of anaemia and blood transfusions, post implementation of routine ferritin screening and management within a regional Australian population. CONCLUSION: The results of this study suggest there is benefit to implementation of standardised ferritin screening and management packages in Australian antenatal care. It also encourages RANZCOG to review current recommendations on screening for iron deficiency anaemia during pregnancy.

The effect of intraperitoneal ropivacaine on post-operative pain and recovery after diagnostic laparoscopy and hysteroscopy: A randomised double-blind placebo-controlled trial.

BACKGROUND: Intraperitoneal local anaesthetic has shown benefit in operative laparoscopy; however, no randomised controlled trial has been reported with patients having diagnostic laparoscopy. AIMS: To determine the effect of intraperitoneal ropivacaine on post-operative analgesic requirements, pain, nausea scores and recovery following gynaecological diagnostic laparoscopy and hysteroscopy. MATERIALS AND METHODS: Randomised double-blind placebo-controlled trial. Well women aged 18-50 years, undergoing day case hysteroscopy and diagnostic laparoscopy for gynaecological indications were randomised to 20 mL of 150 mg intraperitoneal ropivacaine diluted in saline, or 20 mL normal saline instillation (placebo) at the end of the procedure. Women were followed up until eight hours post-discharge. RESULTS: Slower than anticipated recruitment meant that the study was finished before the sample size of 100 patients was achieved. Fifty-nine patients were included for analysis. Thirty-one patients were randomised to ropivacaine and 28 patients to control. Sixty-one percent of patients in both arms required opioid medication in recovery. The total median equivalent morphine dose was significantly higher in the patients randomised to control (11.7 mg) vs ropivacaine (6.7 mg), P = 0.03. Time to discharge was 20 min faster in patients randomised to ropivacaine, but this finding did not reach significance. Overall pain and nausea scores in the first eight hours showed no significant differences. CONCLUSION: There was significantly reduced opioid use in recovery when using intraperitoneal ropivacaine compared to placebo, in this randomised placebo-controlled trial on women undergoing day case diagnostic laparoscopy and hysteroscopy.

Accessing and engaging with antenatal care: an interview study of teenage women.

BACKGROUND: Pregnant teenagers in rural and regional areas experience distinct disadvantages, that are not simply a function of their age, and these have a substantial impact on their health and that of their baby. Studies demonstrate that antenatal care improves pregnancy outcomes amongst pregnant women, especially adolescents. Understanding teenager's views and experiences of pregnancy and motherhood is important to ensure antenatal care meets young women's needs. This study explored teenage women's experiences and perceptions of barriers and facilitators to engaging in pregnancy care in rural and regional Victoria, Australia. METHODS: Between February-October 2017, pregnant women aged ≤19 years were purposively recruited from one regional and two rural health services in Victoria. Semi-structured, face-to-face interviews guided by naturalistic inquiry were conducted and an inductive approach to analysis was applied. RESULTS: Four key themes emerged from the analysis of the transcripts of 16 interviews: Valuing pregnancy care, Interactions with Maternity Service, Woman-centred care, and Support systems. Teenage women primary motivation to attend care was to ensure their baby's wellbeing and lack of engagement occurred when the relevance of antenatal care was not understood. Appointment flexibility and an accessible location was important; most participants were reliant on others for transport. Continuity of carer and respectful, non-judgement communication by staff was highly valued. Many young women had fractured families with pregnancy diminishing their social world, yet having a baby gave them purpose in their lives. CONCLUSION: Maternity services and health professionals that provide flexible, adaptable women-centred care and support through pregnancy and early motherhood will assist young women's engagement in antenatal care.

Women's experiences of preeclampsia: a prospective survey of preeclamptic women at a single tertiary centre.

Preeclampsia (PE) can suddenly disrupt a normal pregnancy experience. This project aimed to see how PE was experienced close to the time of birth, in a group of hospital patients. Women with PE who gave birth at The Royal Women's Hospital, Melbourne, Australia, from October 2010 to May 2012 were asked to complete a survey designed with consumer input. There was a 74% response rate. Regarding diagnosis, 90% experienced PE, 2.5% experienced eclampsia and 7.5% experienced HELLP. For 60% of women, their baby was born earlier than expected. Although 67.5% of women knew little about PE prior to pregnancy and diagnosis, 67.5% believed PE was serious or life threatening. Fifty-five percent were afraid that their baby might die. The women in the study identified the need to obtain more information about PE (97.5%), and 60% indicated that their PE experience would either delay or contribute to the decision to not undertake a future pregnancy. This project details that PE can have a substantial psychological effect on patients around the time of birth. Maternity caregivers can direct counselling to address the specific vulnerabilities raised in PE and thus improve the care of women with PE.Impact StatementWhat is already known on this subject? Qualitative research from New Zealand showed that women experiencing preeclampsia (PE) can have a number of psychological issues with their pregnancy experience, including feeling no longer in control of their pregnancy, dealing with an unexpected medicalised preterm birth, and feeling fear for themselves and their baby's life, even if no formal psychiatric issues are identified. A PE support group surveyed their own members and found that these psychological issues are present in most of their members who had PE.What the results of this study add? This study was a survey of 40 women experiencing PE around the time of birth in a tertiary hospital in Melbourne, Australia, to see if these themes could be applied to a general hospital group. There was a 74% response rate. For 60% of women, the baby was born earlier than expected. Although most women knew little about PE prior to diagnosis, 67.5% believed PE was serious or life threatening at diagnosis. More than half (55%) were afraid their baby might die and 47.5% of women identified that separation from their baby impaired their ability to bond. Most women planned to obtain more information about PE (97.5%) and 50% indicated that their PE experience meant they would either delay or not undertake future pregnancy.What the implications are of these findings for clinical practice and/or further clinical research? This study demonstrates the significance of psychological factors in the care of women with pre-eclampsia or eclampsia and offers a range of issues that the health care provider can use in discussions with women in the early postnatal period, in the inter-pregnancy interval and in subsequent pregnancies. Further research would ideally involve a large sample in a range of hospital settings (primary through tertiary) to further consider the prevalence and enduring nature of themes identified in the present study.

Implementing an intervention to promote normal labour and birth: A study of clinicians' perceptions.

OBJECTIVE: Prior to implementation of a Normal Labour and Birth Bundle (NLBB) at a regional maternity service in Victoria, Australia, this study aimed to understand clinician factors that may influence the uptake, acceptance and use of the NLBB. DESIGN: This was a mixed methods study in which The Theory of Planned Behaviour (TPB) provided the framework for the conduct and analysis of the staff survey and focus groups. Descriptive and multiple regression were used to analyse the survey data and thematic analysis was used for the focus group data. PARTICIPANTS: Participants for the survey and focus groups included clinicians providing publicly funded care and management of labour for women birthing at the health service. Maternity care clinicians were invited to participate in both the survey and the focus groups. FINDINGS: Seventy-six clinicians (88.8%) responded to the survey. Mean scores for TPB constructs were well above the mid-scale score of 4, indicating strong positive attitudes, high levels of self-efficacy and positive social pressure to use the NLBB and strong intentions to use it in the future. Self-efficacy was the strongest independent predictor (ß = 0.45, p < 0.001) of intention to use the NLBB (overall model R2=0.38). A valued consequence of implementing standardised and objective guidelines, highlighted in the focus groups, was the positive impact on clinicians' confidence in their decision-making. KEY CONCLUSIONS: This study found that midwives and obstetricians were in favour of using a normal labour and birth care bundle and perceived the bundle to align with the expectations of work colleagues and the women they care for. The findings of this study show that clinicians at the health service had strong intentions to use the normal labour and birth care bundle in the future. IMPLICATIONS FOR PRACTICE: Implementation science is important in embedding and sustaining practice change. Understanding staff perceptions is an essential first step of this process.