Postpartum care: evaluation and experience among care providers and care receivers.

INTRODUCTION: There have been substantial alterations in the structure of postpartum care over the last several decades. Our aim was to investigate the perceived quality of, and satisfaction with, postpartum care among caregivers and care receivers in the maternity ward of a community hospital in Norway with about 2600 births per year. METHODS: We conducted a cohort study of women giving birth and the caregiving staff in the maternity ward during a 7-month period. A questionnaire, with a Cronbach α coefficient above 0.8, was filled in anonymously, both by the staff in the ward and by the women. The questionnaire explored the respondents' evaluations of the information offered by the staff; the teaching of skills in child care and establishment of breastfeeding; assistance with practical tasks like making beds, serving meals, and keeping order in the room; visiting rules; level of noise in the ward; whether the pediatric service was adequate; length of the stay; and to what extent caregivers were able to respond to the individual needs of the mothers. Finally, the questionnaire explored the degree of kindliness communicated by the staff. Five extra questions in the women's questionnaire explored their personal experiences in the ward. RESULTS: The care receivers' evaluations of the maternity ward did not differ significantly from that of the caregivers in questions related to overall care and service. However, the mothers rated the importance of assistance with child care during the night significantly higher than did the staff. Responses to questions addressing noise in the ward demonstrated a higher tolerance among the mothers compared with the staff. In addition, mothers tended (but not a statistically significant result) to rate the quality of the teaching of child-care skills lower, compared with the staff's ratings. DISCUSSION: By exploring both the caregivers' and care receivers' evaluations and expectations of the actual services in the maternity ward, areas for enhancement of the quality of the ward and its services can be detected and carried out. The present study revealed 2 areas needing further focus: assistance with child care during the night and teaching of child-care skills during the stay. We believe that investigations that collect data from both caregivers and care receivers, by using adapted and validated questionnaires to gather information on quality and satisfaction with the maternity ward, are mandatory for improvement and continuous adaptation of health services.

Is oxytocin given during surgical termination of first trimester pregnancy useful? A randomized controlled trial.

OBJECTIVE: To compare the impact of 5 IU (international units) of oxytocin administered during surgical termination of first-trimester pregnancy compared to no oxytocin, on postoperative bleeding, pain and nausea. DESIGN: A randomized controlled single-blinded study. SETTING: A Norwegian community hospital with 1,064 consecutive legal abortions in the 20 months of study period. SAMPLE: A total of 378 women undergoing surgical termination of first-trimester pregnancy and willing to participate in the study. METHODS: Women were randomized into two groups: Group 1, receiving a standard procedure of 5 IU of oxytocin during the surgical procedure, or Group 2, receiving no oxytocic agent. All women had preoperative misoprostol. MAIN OUTCOME MEASURES: Vaginal bleeding, pain and nausea recorded by weighing pads immediately after the surgical procedure and counting pads during the three following days. RESULTS: No significant differences between the two groups could be demonstrated with regard to the recorded postoperative blood loss, pain and nausea. CONCLUSIONS: The standard routine of administering oxytocin during surgical termination of first-trimester pregnancy should be revised.

[Actinomycosis as a complication of intrauterine device use]. / Aktinomykose som komplikasjon til spiralbruk.

BACKGROUND: Infections in the female pelvis can present clinically in various ways and the causing agent can be difficult to trace. In this paper we present updated knowledge about infections caused by the bacterium Actinomycosis in relation to intrauterine device use. MATERIAL AND METHODS: The article is based on own clinical experience and literature identified through a non-systematic search in PubMed. RESULTS: Actinomycosis in the female pelvis is a rare disease and the pathogenesis is still obscure. The incidence in Scandinavia has not been established. The infection can cause tumor-like structures resulting in bowel and urinary obstruction. The bacteria can be difficult to detect. Preferably the agent should be demonstrated in a specimen from the infected area to ensure the correct diagnosis. However, Actinomyces is a normal inhabitant of the gastrointestinal tract and is also present in 5 % of cervical smears from healthy women. The optimal treatment of actinomycosis is long-term treatment with penicillin, alone or in addition to surgery. INTERPRETATION: To avoid unnecessary and potentially difficult surgical procedures, actinomycosis should be a differential diagnosis when women with a longstanding intrauterine device develop signs of infection in addition to a pelvic mass. Intrauterine devices should be replaced every fifth year and should be removed at menopause.

Anal sphincter tears at spontaneous delivery: a comparison of five hospitals in Norway.

OBJECTIVE: To analyze circumstances relating to severe anal sphincter tears occurring at spontaneous delivery, in view of reported differences in practice regarding manual perineal protection during delivery. DESIGN: Cohort study of midwife-conducted non-operative vaginal deliveries. SETTING: Five Norwegian hospitals with 12,438 consecutive deliveries during a 12-month period. METHODS: Data from 357 women sustaining third and fourth grade anal sphincter tears (2.9%) were analyzed. MAIN OUTCOME MEASURES: Different incidence of major perineal tears. RESULTS: Sphincter tear incidence varied significantly between the five hospitals, from 1.3 to 4.7% (p<0.001, RR=3.14 (CI: 2.38-5.56)). There was no significant difference between the five hospitals when other risk variables were compared. Use of oxytocin in the second phase of labor and of epidural analgesia was significantly more often applied in the hospital with the lowest rate of sphincter tears. The midwives' perception of having applied perineal support was not significantly different between the two hospitals with the highest and the lowest incidence of sphincter tear. CONCLUSION: The observed difference in incidence of sphincter tear between the hospitals remains unexplained, but could be due to different perineal protection handling techniques.

[A woman in the second trimester of pregnancy with acute abdominal pain]. / En kvinne, gravid i annet trimester, med akutte magesmerter.

A 42-year-old pregnant (22 weeks) woman with a history of peptic ulcer 20 years earlier, was presented to our gynaecological clinic with acute abdominal pain in 2005. She was para-1, had delivered a healthy child two years earlier and now she had an uncomplicated pregnancy. Upon admittance she was pale, hyperventilating and complained of epigastric pain and nausea. There was no vaginal bleeding and no uterine contractions. Ultrasound examination revealed a single fetus with normal cardiac activity. During the examination blood pressure suddenly dropped and the patient was considered to be in a state of pre-shock. Intraabdominal hemorrhage was suspected and she underwent immediate exploratory laparotomy. Uterine rupture with an intact gestational sac extruding through the laceration in the middle of the fundal region of the uterus was found. A sub-total hysterectomy was performed. The physio-pathology leading to the uterine rupture is discussed. An interstitial pregnancy close to the ostium internum (cornual pregnancy) may have lead to the thinning and rupture of the uterine wall in the fundal part. Alternatively, the placenta's location in the upper uterine cavity (possibly caused by a 3 cm myoma that seemed to divide the uterine cavity into two compartments) may have caused thinning and rupture of the uterine wall in the fundal part. The literature describing uterine rupture in the second trimester is reviewed.

Does oral magnesium substitution relieve pregnancy-induced leg cramps?

OBJECTIVE: Our aim was to assess the effect of 360mg magnesium oral substitution daily among pregnant women suffering from leg cramps in pregnancy, defined as painful cramps different from restless legs symptoms. STUDY DESIGN: In a double blind randomised controlled trial healthy pregnant women between 18 and 36 weeks of pregnancy suffering from painful leg cramps, at least twice a week, were invited to participate. Forty-five women were enrolled initially, 38 completed the treatment and were treated during 2 weeks with either magnesium (360mg=15mmol magnesium lactate and magnesium citrate, Nycoplus Magnesium), or placebo tablets. Serum magnesium and calcium were investigated together with urine magnesium and magnesium-creatinin ratio on day 1 and day 15. Frequency and intensity of leg cramps were recorded. The study was powered to detect a 50% reduction in leg cramps. RESULTS: Registration of pain frequency and intensity during the two study weeks demonstrated no significant differences between the two groups. Mean number and intensity of cramps were 9.5 (S.D. 5.1) and 13.2 (S.D. 6.5) in the magnesium group, compared to 7.7 (S.D. 4.7) and 11.4 (S.D. 8.5) in the placebo group. Baseline magnesium levels were 0.77 and 0.74mmol/L in the magnesium group and the placebo group, respectively No significant differences between the two groups, or within the groups, were found when comparing serum values of serum magnesium and total calcium at inclusion time and at the end of the treatment. There was a statistically significant increase in magnesium excretion in the magnesium treatment group (p<0.01). The number of dropouts was two in the treatment group and five in the control group. CONCLUSIONS: No significant effect on frequency or intensity of leg cramps in pregnant women of magnesium treatment with 360mg daily could be detected in this trial.

Post-cesarean surgical site infections according to CDC standards: rates and risk factors. A prospective cohort study.

OBJECTIVES: The aim of this study was to document the true incidence of post-cesarean surgical site infections (SSI), according to the definition of the US Centers for Disease Control and Prevention (CDC), and to identify independent risk factors for infection. DESIGN: Prospective population-based cohort study in Norway. Setting. Sykehuset Asker og Baerum HF, a secondary community hospital, associated with the University of Oslo (UiO), Norway, accounting for 2,000 deliveries per year. Participants. All cesarean deliveries during a 12-month period from September 2003. Main outcome measures. Rate and risk factors for SSI. RESULTS: The total rate of SSI was 8.9%, with an observation period of 30 days post-operatively, compared to 1.8% registered at hospital discharge. The total response rate was 100%. There was no significant difference in SSI rate in elective or emergency cesarean section (CS), respectively. All SSI were superficial. We found 2 significant independent risk factors: operating time > or =38 min and body mass index (BMI) >30. CONCLUSION: The rate of SSI is underestimated if the observation time is limited to the hospital stay. Operating time exceeding 38 min substantially increases the risk of SSI. The finding of no significant difference in SSI rate between elective and emergency CS should lead to a different approach concerning the use of antibiotics: subgroup at risk (operating time > or =38 min and BMI >30) may benefit from antibiotics in relation to the operation, whether the CS is an emergency or elective operation.

Genital prolapse: a follow-up study assessing subjective and objective results five years or more after surgical intervention.

BACKGROUND: With few reports in the field, we wanted to assess the long-term outcome of vaginal repair by objective and subjective measures. METHODS: One hundred and sixty-seven women underwent surgical repair during a five-year period from 1990. Five years or more after surgery, 93 women were interviewed and underwent a physical examination to evaluate the post-operative results. RESULTS: Sixty-eight women (72%) stated that they were satisfied with the operative result. Five women (5.4%) had undergone relapse surgery. The examination revealed relapse in seven women (7.5%). Persistent sensation of vaginal pressure and heaviness was the most frequent symptom among those who were not satisfied with the operative result. The mean age was 67.8 years. The frequency of "de novo" urinary leakage post-operatively does not seem to exceed the expected development of leakage attributable to ageing in the population. CONCLUSIONS: The results in this study reveals that the need for relapse surgery is twice the reported figure when thorough anatomical examination is performed. There is also a discrepancy between the anatomical findings and the subjective symptoms reported by the patient.

[Anal sphincter rupture during vaginal delivery]. / Sfinkterskade ved vaginal forløsning.

BACKGROUND: Rupture of the anal sphincter during childbirth is a major cause of faecal incontinence among women, a condition with considerable psychosocial consequences. The reported incidences show large variations, from 0.36% to 24%. Definitions and classifications vary as much. Also, reports on the persisting subjective problems of the women afflicted demonstrate diversity. MATERIAL AND METHODS: Over a 2(1/2) year period from January 2000, all women with partial or total rupture of the anal sphincter during delivery were invited to a follow up consultation after 6 months and interviewed about their subjective discomfort. RESULTS: Over the period in question we registered 147 ruptures of the anal sphincter among 6124 vaginal deliveries (2.4%); 109 (1.7%) were partial ruptures, 38 (0.7%) total ruptures. Among the 137 women who came in for a consultation 6 months after delivery, 92 (67%) had no complaints at all. Five women (4%) had some degree of leakage for liquid stools. None of them had incontinence for solid stools. INTERPRETATION: The reported incidence is in keeping with most of the previous registrations in the Nordic countries, but not with those giving the lowest figures. Improved delivery technique might reduce the incidence. The incidence of discomfort and complaints we found at 6 months was lower than expected on the basis of previous reports.

Depression and smoking during pregnancy.

This study examined the relationship between depression and smoking during a woman's pregnancy. It surveyed 487 pregnant women (aged 17-44) during routine ultrasound examinations at the 18th week of gestation. A multiple regression analysis showed that depression is a significant predictor of smoking during pregnancy, after controlling for other factors such as the desirability of the pregnancy and the presence of other smokers in the household. Both current smokers and former smokers were significantly more likely to report depressive symptoms (using Centers for Epidemiological Studies Depression Scale, CES-D) than never smokers; the rates are 12.9%, 25.1%, and 37.5% for never, former, and current smokers, respectively. Among current smokers, the depressed were significantly less confident about quitting than the nondepressed, although both felt the need to quit. These results suggest that interventions to help pregnant women quit smoking may need to take a more comprehensive approach to be effective.