Decision-to-Delivery Interval After Implementation of a Specific Protocol for Emergency Cesarean Delivery Because of Category III Fetal Heart Rate Tracings.

OBJECTIVE: To assess the frequency of emergency cesarean deliveries with decision-to-delivery intervals (DDIs) of less than 30 minutes after implementation of a code blue protocol following National Institute of Child Health and Human Development (NICHD) category III fetal heart rate (FHR) tracings. The secondary aim was to compare differences in pregnancy outcomes for deliveries completed before and after the 30-minute threshold. METHODS: All women undergoing a code blue emergency cesarean delivery between July 2015 and December 2021 were included. Information from electronic medical records, including baseline demographics, clinical characteristics, and pregnancy outcomes were retrospectively reviewed. RESULTS: Among 254 code blue cesarean deliveries, 246 (96.9%) had a DDI of ≤30 minutes. The median DDI was 17 (14.3-20.0) minutes. No significant differences in adverse maternal and neonatal outcomes were detected between deliveries with DDIs greater than and less than 30 minutes. The incidence of stillbirth was higher in the >30 minute-DDI group than in the ≤30 minute-DDI group (12.5% vs. 2%; P = 0.176). CONCLUSIONS: After implementation of a code blue protocol for emergency cesarean delivery, a DDI within 30 minutes was achieved in 97% of cases with category III FHR tracings. The incidence of stillbirth was dramatically higher in the >30 minutes-DDI group. We encourage all obstetric units to consider every factor that could reduce the DDI by developing specific, local protocols.

Intravenous carbetocin versus intravenous oxytocin for preventing atonic postpartum hemorrhage after normal vaginal delivery in high-risk singleton pregnancies: a triple-blind randomized controlled trial.

PURPOSE: To compare the effectiveness of intravenous carbetocin to that of intravenous oxytocin for prevention of atonic postpartum hemorrhage (PPH) after vaginal delivery in high-risk singleton pregnancies. METHODS: This triple-blind randomized controlled trial included singleton pregnant women who delivered at Siriraj Hospital between August 2016 and January 2017 and who were 20 years or older, had a gestational age of at least 34 weeks, had a vaginal delivery, and had at least one risk factor for atonic postpartum hemorrhage. Immediately after vaginal delivery, participants were randomly assigned to receive either 5 U of oxytocin or 100 mcg of carbetocin intravenously. Postpartum blood loss was measured objectively in mL using a postpartum drape with a calibrated bag. RESULTS: A total of 174 and 176 participants constituted the oxytocin and carbetocin groups, respectively. The baseline characteristics were comparable between the groups. The carbetocin group had less postpartum blood loss (146.7 ± 90.4 vs. 195.1 ± 146.2 mL; p < 0.01), a lower incidence of atonic PPH (0 vs. 6.3%; p < 0.01), less usage of additional uterotonic drugs (9.1 vs. 27.6%; p < 0.01), and a lower incidence of postpartum anemia (Hb ≤ 10 g/dL) (9.1 vs. 18.4%; p < 0.05) than the oxytocin group. No significant differences regarding side effects were evident between the groups. CONCLUSIONS: Intravenous carbetocin is more effective than intravenous oxytocin for the prevention of atonic PPH among singleton pregnancies with at least one risk factor for PPH. CLINICAL TRIAL REGISTRATION: TCTR20160715004.

Enhancing the competencies of obstetrical nurses and midwives in high-risk pregnancy management through simulation-based training in Lao people's democratic republic: A pilot study.

BACKGROUND: Simulation-based training has been widely used as a valuable strategy for learning and evaluating clinical skills at different levels of nursing and midwifery education. The impact of simulation training on intensive management for high-risk pregnancy in a low-resource setting has been limited. AIM: To examine the effect of simulation-based training with low-fidelity mannequins on obstetrical nurses and midwives' knowledge, attitude, and skills for high-risk pregnancy management in a low-resource setting. METHOD: During September 2023, twenty-five obstetrical nurses or midwives who worked in five tertiary public hospitals in Vientiane Prefecture participated in the three-day training workshops for intensive management in high-risk pregnant women and newborns that used a simulation-based training approach integrating problem-based learning. The evaluated criteria of knowledge, attitudes, and skills pre- and post-test scores were statistically compared. FINDINGS: Workshop trainees demonstrated an increase significantly in knowledge for high-risk pregnancy management (p = 0.012), attitude toward high-risk pregnancy management (p = 0.000), and attitude toward simulation-based training design (p = 0.002). The clinical skills were used on the simulation performance checklist, and the pre-posttest gain in overall performance scores had a statistically significant difference (p = 0.000). The mean score of postpartum hemorrhage management skills was 11.48±2.23, which increased the highest score among all skills. CONCLUSIONS: The simulation-based training in high-risk pregnancy management improves the knowledge, attitude, and skills of nurses and midwives in low-resource settings. Next steps include direct observation of trainees in the clinical setting to assess their competence in ensuring patient safety, achieving positive pregnancy outcomes, and enhancing satisfaction.

Indications and outcomes of neonatal intubation: A single-center, prospective study in a middle-income country.

BACKGROUND: This study assessed the success rate and associated complications of hospital-wide neonatal endotracheal intubations by pediatric residents and neonatal fellows using direct laryngoscopy. Secondary objectives were to identify characteristics and indications for the procedure in a tertiary-care center. METHODS: A cross-sectional observational study was conducted. We prospectively collected performance and infant outcome data after neonatal intubation between March 1, 2019 and February 29, 2020. RESULTS: 171 intubations were observed in 105 infants. The median infant gestational age was 31.0 weeks (interquartile range [IQR]: 27.5-36.0 weeks). Fifty infants (48%) were very low birth weight (VLBW, <1500 g; median 1640 g [IQR: 870-2420 g]). The most common indication for intubation was respiratory failure (65%). Pediatric residents and neonatal fellows had overall success rates of 66% and 98%, respectively. The success rate for the first intubation attempt was higher with more advanced pediatric residency training (P < 0.001). The median attempts for each intubation were 1 (IQR: 1-2) for both VLBW and non-VLBW infants (P = 0.48). The adverse outcome rates were 5% and 3% for VLBW and non-VLBW infants, respectively (P = 0.53). More than 2 intubation attempts was the only significant independent risk factor for adverse outcomes (adjusted odds ratio 6.7; 95% CI 1.3-33.6; P = 0.02). CONCLUSIONS: The success rate of pediatric residents for neonatal intubation was similar for VLBW and non-VLBW infants. The main indication was respiratory failure, and nearly half were infants with VLBW. To minimize adverse sequelae, written guidelines limiting the number of intubation attempts by junior trainees are warranted.