Informed consent in episiotomy: Co-analysis with midwives and distillation of best practice.

BACKGROUND: Performing an episiotomy where clinically indicated is a key intervention in the Obstetric Anal Sphincter Injury Care Bundle (OASI-CB) implemented across England and Wales to reduce the risk and increase the detection of severe perineal trauma after birth. Standards of consent provided to people in maternity care generally and for episiotomy specifically have been reported as suboptimal. Compromising birthing people's personal autonomy or sense of control has been linked to a dissatisfying birth experience, negative psychological sequelae, and litigation. METHODS: This study explored experienced midwives' practice of informed consent for episiotomy during a midwife-led birth. We sampled 43 midwives across eight NHS Trusts in England and Wales using online focus groups and telephone interviews about their experience of consent in episiotomy. Using qualitative content analysis and art-based co-analysis methods with eight midwives from across the research sites, we co-analyzed and co-constructed three themes and four practice recommendations from the data. RESULTS: Three themes were constructed from the data: Assent rather than consent, Change in culture to support best practice, and Standardized information. These themes informed the shaping of four recommendations for best practice in episiotomy informed consent. CONCLUSION: This study has shown how variations in midwifery practice and culture may impact birthing people's experience of informed consent in episiotomy. Midwives may not have the knowledge or skills to conduct a detailed consent conversation, leading to variation in practice and messages for birthing people. The use of antenatal discussion aids can offer women the opportunity to become informed and fully participate in the decision-making process.

Current practice in the introduction of solid foods for preterm infants.

OBJECTIVE: The present study compared the age of first solid foods in a cohort of preterm infants with term infants and identified factors influencing timing of solid food introduction. DESIGN: Structured interviews on infant feeding practices, growth and medical status at term equivalence and at 3, 6, 9 and 12 months corrected postnatal age. The age of solid food introduction was compared between term and preterm infants, and the influence of maternal, infant and milk feeding factors was assessed. SETTING: This prospective longitudinal study recruited primary carers of preterm and term infants from a regional metropolitan referral hospital in eastern Australia. PARTICIPANTS: One hundred and fifty infants (preterm, n 85; term, n 65). RESULTS: When corrected for prematurity, preterm infants received solid foods before the recommended age for the introduction of solid foods for term infants. Median introduction of solid foods for preterm infants was 14 weeks corrected age (range 12-17 weeks). This was significantly less than 19 weeks (range 17-21 weeks) for term infants (P < 0·001). Lower maternal education and male gender were associated with earlier introduction of solid foods among preterm infants. CONCLUSIONS: Preterm infants are introduced to solid foods earlier than recommended for term infants, taking account of their corrected age. Further research is needed to assess any risk or benefit associated with this pattern and thus to develop clear evidence-based feeding guidelines for preterm infants.

Red flags for episiotomy in a midwife-led birth: Using co-production with midwives to capture clinical experience.

BACKGROUND: One of four key points in the Obstetric Anal Sphincter Injury Care Bundle, first piloted in the UK in 2016, was the directive to perform episiotomy when clinically indicated. Midwives are the primary health care professional for straightforward births in the UK and there is very little published literature that relates to their practice in this area. AIM: The aim of the study was to explore experienced midwives' decision-making processes in their assessments for episiotomy during birth. METHODS: 43 midwives self-identifying as confident in performing episiotomy were sampled across 8 NHS Trusts in England and Wales. Data collection was via online focus groups and 1:1 interviews. Primary thematic analysis was undertaken by the research team. Preliminary themes were used to structure a co-production analysis workshop where eight experienced midwives undertook a secondary analysis of the data resulting in four overall themes. FINDINGS: Four themes were identified, 'Optimising Perineal Function', 'Red Flags to Stimulate Decision-Making', 'The Midwives' Episiotomy' and 'Infiltration as a Catalyst for Birth'. DISCUSSION: Midwives use a number of visual, auditory and touch cues to inform their assessments for episiotomy during birth. CONCLUSION: This study provides valuable insight into the cues that guide experienced midwives' decision-making in relation to episiotomy and contributes evidence related to performing episiotomy when clinically indicated in spontaneous vaginal birth.

Process evaluation of the Hunter Illawarra Kids Challenge Using Parent Support study: a multisite randomized controlled trial for the management of child obesity.

The purposes of this article are to (a) outline findings from secondary or process outcome data of the Hunter Illawarra Kids Challenge Using Parent Support (HIKCUPS) study and (b) inform the design and development of future research interventions and practice in the management of child obesity. Data were collected by means of facilitator evaluations, independent session observation, attendance records, and parent questionnaires. Internal validity and reliability of the program delivery were high. All parents reported positive changes in their children as a result of the physical activity program, the dietary modification program, or both. Most participants completed the home activities, but more than half reported that finding time to do them was problematic. Facilitator review indicated that future programs should specifically cater to children of similar age or same sex, allow adequate time for explanation of complex nutritional concepts, and use intrinsic motivators for participants. Recommendations for future interventions, specifically the implementation of subsequent HIKCUPS or other multisite effectiveness studies, are detailed.

Predictive validity of four bioelectrical impedance equations in determining percent fat mass in overweight and obese children.

Bioelectrical impedance equations are frequently used by food and nutrition professionals to estimate percent fat mass in overweight and obese children. However, it is not known whether they are accurate for such children, as they have been primarily developed for children of varying body weights. The aim of this cross-sectional study was to evaluate the predictive validity of four previously published prediction equations developed for the pediatric population, among a sample of overweight and obese children. Thirty overweight or obese children (mean age=7.57+/-1.28 years) underwent measurement of fat mass, percent fat mass, and fat-free mass using dual-energy x-ray absorptiometry (DEXA) and bioelectrical impedance analysis (BIA). Impedance values from the BIA were entered into the four prediction equations and Pearson correlations used to determine the significance of associations between each of the BIA prediction equations and DEXA for percent fat mass, fat mass, and fat-free mass. For percent fat mass, paired t tests were used to assess differences between the methods and the technique of Bland and Altman was used to determine bias and error. Results showed that the mean percent fat mass as determined by DEXA for this age group was 40.79%. In comparison with other BIA prediction equations, the Schaefer equation had the closest mean value of 41.98%, and was the only equation not to significantly differ from the DEXA (P=0.121). This study suggests that the Schaefer equation is the only accurate BIA prediction equation for assessing percent fat mass in this sample of overweight and obese children from primarily white backgrounds.

The HIKCUPS trial: a multi-site randomized controlled trial of a combined physical activity skill-development and dietary modification program in overweight and obese children.

BACKGROUND: Childhood obesity is one of the most pressing health issues of our time. Key health organizations have recommended research be conducted on the effectiveness of well-designed interventions to combat childhood obesity that can be translated into a variety of settings. This paper describes the design and methods used in the Hunter Illawarra Kids Challenge Using Parent Support (HIKCUPS) trial, an ongoing multi-site randomized controlled trial, in overweight/obese children comparing the efficacy of three interventions: 1) a parent-centered dietary modification program; 2) a child-centered physical activity skill-development program; and 3) a program combining both 1 and 2 above. METHODS/DESIGN: Each intervention consists of three components: i) 10-weekly face-to-face group sessions; ii) a weekly homework component, completed between each face-to-face session and iii) three telephone calls at monthly intervals following completion of the 10-week program. Details of the programs' methodological aspects of recruitment, randomization and statistical analyses are described here a priori. DISCUSSION: Importantly this paper describes how HIKCUPS addresses some of the short falls in the current literature pertaining to the efficacy of child obesity interventions. The HIKCUPS trial is funded by the National Medical Research Council, Australia.

Pregnancy and Glycemic Index Outcomes study: effects of low glycemic index compared with conventional dietary advice on selected pregnancy outcomes.

BACKGROUND: Eating carbohydrate foods with a high glycemic index (GI) has been postulated to result in fetoplacental overgrowth and higher infant body fat. A diet with a low glycemic index (LGI) has been shown to reduce birth percentiles and the ponderal index (PI). OBJECTIVES: We investigated whether offering LGI dietary advice at the first antenatal visit would result in a lower fetal birth weight, birth percentile, and PI than providing healthy eating (HE) advice. This advice had to be presented within the resources of routine antenatal care. DESIGN: The Pregnancy and Glycemic Index Outcomes study was a 2-arm, parallel-design, randomized, controlled trial that compared the effects of LGI dietary advice with HE advice on pregnancy outcomes. Eligible volunteers who attended for routine antenatal care at <20 wk of gestation were randomly assigned to either group. RESULTS: A total of 691 women were enrolled, and 576 women had final data considered. In the LGI group, the GI was reduced from a mean (± SEM) of 56 ± 0.3 at enrollment to 52 ± 0.3 (P < 0.001) at the final assessment. There were no significant differences in primary outcomes of fetal birth weight, birth percentile, or PI. In a multivariate regression analysis, the glycemic load was the only significant dietary predictor (P = 0.046) of primary outcomes but explained <1% of all variation. CONCLUSION: A low-intensity dietary intervention with an LGI diet compared with an HE diet in pregnancy did not result in any significant differences in birth weight, fetal percentile, or PI.

Does a low glycaemic index (GI) diet cost more during pregnancy?

 The aim of this study was to examine the monetary cost of dietary change among pregnant women before and after receiving low glycaemic index (GI) dietary advice. The pregnant women in this study were a subgroup of participants in the Pregnancy and Glycaemic Index Outcomes (PREGGIO) study. Twenty women from the low GI dietary advice group, who had completed their pregnancies, were randomly chosen. All these women had completed three day food records at 12–16 weeks and again around 36 weeks of gestation. Consumer food prices were applied to recorded dietary intake data. The mean ± SD GI of the diet reduced from 55.1 ± 4.3 to 51.6 ± 3.9 (p = 0.003). The daily cost of the diet (AUD) was 9.1 ± 2.7 at enrolment and 9.5 ± 2.1 prior to delivery was not significantly different (p = 0.52). There were also no significant differences in the daily energy intake (p = 0.2) or the daily cost per MJ (p = 0.16). Women were able to follow low GI dietary advice during pregnancy with no significant increase in the daily costs.