The safety of obstetric services in small communities in northern Ontario.

The safety of the obstetric care system in the small hospitals of northern Ontario was assessed by analysing the outcomes of all obstetric cases over a 2-year period. Information was retrieved by place of residence rather than hospital of delivery so that the overall perinatal system, including the referral patterns, would be assessed. There was little difference in perinatal loss rate (stillbirths and neonatal deaths up to 28 days per 1000 births) for residents of areas served by different levels of obstetric care. Areas served by units where cesarean sections are done regularly but which do not have specialists in obstetrics or pediatrics had a perinatal loss rate of 10.43, whereas areas served by units staffed with two or more specialists in both obstetrics and pediatrics and handling more than 1000 deliveries per year had a perinatal loss rate of 12.13. Although many of the smaller hospitals did not have the minimum capabilities suggested for obstetric units relatively safe care was being provided. These results do not support the need for further centralization of obstetric services in northern Ontario.     

Obstetric flying squad service-a defence.

Eighty-one calls made by the obstetric flying squad in West Berkshire were assessed on the basis of a suggestion that patients would do as well, if not better, if they were brought straight to hospital by ambulance rather than await the arrival of the flying squad. Of the 81 calls, 36 were made to general-practitioner maternity units and 45 were made to patients'' homes. In both groups, the flying squad service was considered to be still of great value. Though slightly slower than an emergency ambulance call, it represents a much safer method of transporting an obstetric patient in an emergency.     

Adult respiratory distress syndrome during pregnancy and immediately postpartum.

From 1976 to 1983, the adult respiratory distress syndrome occurred in 14 patients during pregnancy or within a month postpartum. There were 8 survivors, giving a 43% mortality. All but 2 patients had obstetric-related precipitating events--labor problems, infections, eclampsia-toxemia, and obstetric hemorrhages. During emergency cesarean sections, 3 patients had respiratory problems that may have caused their respiratory distress syndrome. The average duration of mechanical ventilatory support was 16 days. Six patients had barotrauma with 1 patient sustaining an irreversible anoxic central nervous system injury. Infections were documented in 8 patients, 6 of whom had obstetric foci. There is a lack of information regarding the adult respiratory distress syndrome in this patient group. Though uncommon, it can cause substantial mortality and morbidity.     

Risk of schizophrenia in adults born after obstetric complications and their association with early onset of illness: a controlled study.

OBJECTIVE--To determine whether obstetric complications occur to excess in the early histories of individuals who go on to develop schizophrenia when compared with controls, and to seek clinical correlates of any such excess. DESIGN--Contemporaneous maternity hospital records were identified and extracted verbatim, and these extracts evaluated for obstetric complications by two independent assessors who were blind to subjects'' status. SUBJECTS--65 patients having an ICD-9 diagnosis of schizophrenia, the records of the previous same sex live birth being deemed to be those of a control subject. MAIN OUTCOME MEASURE--Presence of one or more obstetric complications recorded in maternity notes of patients and controls. RESULTS--When two recognised scales for specifying obstetric complications were used the patients with schizophrenia were significantly more likely than controls to have experienced at least one obstetric complication (odds ratio 2.44, 95% confidence interval 1.08 to 6.03). Patients also showed a greater number and severity of and total score for obstetric complications, fetal distress being the only complication to occur to significant individual excess (present in five (8%) patients, absent in controls). There was a marked sex effect, male patients being more vulnerable (odds ratio 4.24, 1.39 to 12.90) to such complications. Obstetric complications in patients were unrelated to family history or season of birth but were associated with a significantly younger age at onset of illness (mean difference--4.5 years,--1.2 to--7.8 years). CONCLUSIONS--Patients with schizophrenia, particularly males, have an excess of obstetric complications in their early developmental histories, and such complications are associated with a younger age at onset of their disease. Though the data are not conclusive, they also suggest that obstetric complications may be secondary to yet earlier events.     

Maternal Clinical Diagnoses and Hospital Variation in the Risk of Cesarean Delivery: Analyses of a National US Hospital Discharge Database

Background

Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women''s clinical diagnoses.

Methods and Findings

Using data from the 2009 and 2010 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project—a 20% sample of US hospitals—we analyzed data for 1,475,457 births in 1,373 hospitals. We fitted multilevel logistic regression models (patients nested in hospitals). The outcome was cesarean (versus vaginal) delivery. Covariates included diagnosis of diabetes in pregnancy, hypertension in pregnancy, hemorrhage during pregnancy or placental complications, fetal distress, and fetal disproportion or obstructed labor; maternal age, race/ethnicity, and insurance status; and hospital size and location/teaching status.The cesarean section prevalence was 22.0% (95% confidence interval 22.0% to 22.1%) among women with no prior cesareans. In unadjusted models, the between-hospital variation in the individual risk of primary cesarean section was 0.14 (95% credible interval 0.12 to 0.15). The difference in the probability of having a cesarean delivery between hospitals was 25 percentage points. Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics (0.16 [95% credible interval 0.14 to 0.18]). A limitation is that these data, while nationally representative, did not contain information on parity or gestational age.

Conclusions

Variability across hospitals in the individual risk of cesarean section is not decreased by accounting for differences in maternal diagnoses. These findings highlight the need for more comprehensive or linked data including parity and gestational age as well as examination of other factors—such as hospital policies, practices, and culture—in determining cesarean section use. Please see later in the article for the Editors'' Summary     

Recent trends in cesarean section use in California.

Cesarean section use in the United States has increased to 24.7% of deliveries in 1988 and is the most common hospital surgical procedure. California cesarean section rates were examined to measure recent trends in obstetric practices and to project future patterns of cesarean section use. Using discharge abstracts from 1983 to 1987 California hospital deliveries, total cesarean section rates were found to increase from nearly 22% in 1983 to 25% in 1987, an increase of 15%. Using a series of least-squares regression models, time trends in the distribution of indications associated with cesarean section among all deliveries and indication-specific cesarean section rates were evaluated. Increases in the number of women with previous cesarean section and fetal distress contributed to rising cesarean section rates. In addition, indication-specific cesarean section rates increased for breech presentation and dystocia. These trends were counterbalanced, in part, by declining rates of repeat cesarean sections. Trends noted for July 1985 through 1987 did not differ substantially from those observed for January 1983 to June 1985, suggesting that recent policy attempts to alter cesarean section use have not had a measurable effect on existing trends. Projections suggest that California cesarean section rates will rise to a level of 34% by the year 2000.     

Hospital factors associated with maternal and neonatal outcomes of deliveries to patients with a previous cesarean delivery: an ecological study

Background:Recommendations for deliveries of pregnant patients with a previous cesarean delivery and the type of hospitals deemed safe for these deliveries have evolved in recent years, although no studies have examined hospital factors and associated safety. We sought to evaluate maternal and neonatal outcomes among patients with a previous cesarean delivery by hospital tier and volume.Methods:We carried out an ecological study of singleton live births delivered at term gestation to patients with a previous cesarean delivery in all Canadian hospitals (excluding Quebec), 2013–2019. We obtained data from the Discharge Abstract Database of the Canadian Institute for Health Information. The primary outcomes were severe maternal morbidity or mortality (SMMM), and serious neonatal morbidity or mortality (SNMM). We used regression modelling to examine hospital tier (tier 4 hospitals being those that provide the highest level of care) and volume; we also identified hospitals with high rates of SMMM and SNMM using within-tier comparisons and comparisons with the overall rate.Results:We included 235 442 deliveries to patients with a previous cesarean delivery; SMMM and SNMM rates were 14.6 per 1000 deliveries and 4.6 per 1000 live births, respectively. Among patients with a parity of 1, SMMM rates were lower in tier 1 hospitals (adjusted incidence rate ratio [IRR] 0.68, 95% confidence interval [CI] 0.52–0.89) and higher in tier 4 hospitals (adjusted IRR 1.41, 95% CI 1.05–1.91) than in tier 2 hospitals; SNMM rates did not differ by hospital tier. Rates of SNMM increased with increasing hospital volume (adjusted IRR 1.02, 95% CI 1.00–1.04) and increasing rates of vaginal birth after cesarean delivery (adjusted IRR 1.02, 95% CI 1.01–1.04). Most hospitals had relatively low SMMM and SNMM rates, although a few hospitals in each tier and volume category had significantly higher rates than others.Interpretation:Adverse maternal and neonatal outcomes among patients with a previous cesarean delivery showed no clear pattern of decreasing SMMM and SNMM with increasing tiers of service and hospital volume. All hospitals, irrespective of tier or size, should continually review their rates of adverse maternal and neonatal outcomes.

The approach to delivery for patients with a previous cesarean delivery has undergone substantial changes over the last few decades in Canada, the United States and elsewhere. Rates of vaginal birth after cesarean delivery (VBAC) in Canada increased rapidly, from less than 5% of deliveries in the late 1970s to peak at more than 35% in the mid-1990s.^1–4 However, this trend reversed sharply after studies in the mid-1990s showed that attempted VBAC (as opposed to elective repeat cesarean delivery) was associated with higher rates of severe maternal morbidity and of fetal and infant morbidity and mortality.^5–9 The decline has partly reversed after the release of a guideline from the Society of Obstetricians and Gynaecologists of Canada (SOGC) in 2005, and the National Institutes of Health Consensus Development Conference in 2010, which affirmed that patients with 1 previous transverse lower-segment cesarean section and no contraindications could be offered a trial of labour with appropriate discussion of risks and benefits.^10,11Recommendations regarding hospitals deemed safe for delivering patients with a previous cesarean delivery have also evolved. The 1998 and 1999 guidelines of the American College of Obstetricians and Gynecologists (ACOG) required hospitals attempting trials of labour to have “ready availability of emergency care” or “immediate availability of emergency care.”^12,13 After the publication of these guidelines, about 30% of hospitals in the US stopped offering trial-of-labour services to patients with a previous cesarean delivery because they could not provide immediate surgical and anesthesia services, which compelled many patients who had opted for a trial of labour to travel to hospitals far from their homes and families.^14–16 More recently, guidelines have attempted to balance clinical safety with the challenges associated with such social disruption. The current ACOG guideline states that a trial of labour can be attempted in a level 1 maternity care facility (i.e., a hospital providing basic obstetric services), which has “the ability to begin emergency cesarean delivery within a time interval that best incorporates maternal and fetal risks and benefits.”¹⁷ Similarly, the current SOGC guideline states that hospitals providing trial-of-labour services should have “the resources to perform an emergency cesarean section.”¹⁸ This change in recommendations has led to an increase in the number of hospitals that offer trials of labour, though concerns about inadequate access to such delivery options persist.^19,20Although clinical guidelines regarding hospitals deemed safe for delivering patients with a previous cesarean delivery have changed in recent years, to our knowledge, no studies have evaluated hospital factors and associated safety issues. We sought to evaluate maternal and infant outcomes of deliveries to patients with a previous cesarean delivery by tier of obstetric service and hospital delivery volume.     

急诊危重孕产妇5分钟紧急剖宫产的临床效果及新生儿不良结局的危险因素分析

摘要 目的：探讨急诊危重孕产妇5分钟紧急剖宫产的临床效果,并分析新生儿不良结局的危险因素。方法：回顾性分析2018年1月~2022年6月在河北省儿童医院妇产科收治的急诊危重孕产妇139例的临床资料。根据急诊剖宫产流程分为对照组（n=68,常规紧急剖宫产流程下进行手术）及观察组（n=71,5分钟紧急剖宫产）。观察两组孕产妇的手术情况、手术反应时间、孕产妇并发症、新生儿不良结局发生率。采用多因素Logistic回归模型分析新生儿不良结局的危险因素。结果：两组住院时间、术中出血量、术中输血情况组间对比,未见统计学差异（P>0.05）。与对照组相比,观察组进手术室至手术开始时间、决定手术至胎儿娩出的时间间隔（DDI）、决定手术至进手术室时间、手术开始至胎儿娩出时间均更短,新生儿不良结局发生率、并发症发生率更低（P<0.05）。根据新生儿不良结局将孕产妇分为不良组（n=38）、良好组（n=101）。单因素分析结果显示：新生儿不良结局与受教育程度、新生儿体重、孕周、剖宫产类型、DDI、妊娠合并症、采用辅助生殖技术有关（P<0.05）。多因素Logistic回归分析结果显示,受教育程度为小学及其以下、新生儿体重偏低、剖宫产类型为I类剖宫产、孕周偏短、DDI偏长均是新生儿不良结局的危险因素（P<0.05）。结论：急诊危重孕产妇5分钟紧急剖宫产可缩短各项手术反应时间,降低孕产妇并发症和新生儿不良结局发生率。此外,新生儿不良结局的发生与受教育程度、新生儿体重、剖宫产类型、孕周、DDI等因素有关。     

急性冠脉综合征患者急诊PCI术后心力衰竭的危险因素分析及护理干预

目的:探讨急性冠脉综合征(ACS)患者行急诊直接经皮冠状动脉介入治疗(PCI)后住院期间发生心力衰竭(HF)的危险因素分析及护理干预策略。方法:选取278例在我院接受急诊PCI手术患者为研究对象,按照术后住院期间是否出现心力衰竭分为两组:心力衰竭组(n=54例)和非心力衰竭组(n=224例),比较两组患者一般临床资料、实验室检查指标及相关治疗情况的差异,用Logistic回归分析探讨影响术后心力衰竭发生的危险因素,并制定相关护理策略。结果:278例老年患者中有54例PCI术后出现心力衰竭(发生率19.4%);两组患者在年龄、高血压、糖尿病、入院收缩压(SBP)、发病至PCI时间、入院血糖、入院NT-pro BNP、肌酸激酶同工酶(CK-MB)峰值、肌酐蛋白I(c Tn I)峰值、左室射血分数(LVEF)、左室舒张末内径(LVEDd)、术后TIMI血流、使用他汀类药物、β-受体阻滞剂方面存在统计学差异(P0.05);发病至PCI时间、高血压、入院时血糖、NT-pro BNP、c Tn I峰值是术后心力衰竭发生的独立危险因素(P0.05);而术后TIMI血流、使用β-受体阻滞剂治疗是保护性因素。结论:ACS患者行急诊PCI治疗后HF的发生受到多种因素的影响,应当积极制定相关护理干预策略以降低术后HF的发生率。     

Obstetric Care and Method of Delivery in Mexico: Results from the 2012 National Health and Nutrition Survey

Objective

To identify the current clinical, socio-demographic and obstetric factors associated with the various types of delivery strategies in Mexico.

Materials and Methods

This is a cross-sectional study based on the 2012 National Health and Nutrition Survey (ENSANUT) of 6,736 women aged 12 to 49 years. Delivery types discussed in this paper include vaginal delivery, emergency cesarean section and planned cesarean section. Using bivariate analyses, sub-population group differences were identified. Logistic regression models were applied, including both binary and multinomial outcome variables from the survey. The logistic regression results identify those covariates associated with the type of delivery.

Results

53.1% of institutional births in the period 2006 through 2012 were vaginal deliveries, 46.9% were either a planned or emergency cesarean sections. The highest rates of this procedure were among women who reported a complication during delivery (OR: 4.21; 95%CI: 3.66–4.84), between the ages of 35 and 49 at the time of their last child birth (OR: 2.54; 95%CI: 2.02–3.20) and women receiving care through private healthcare providers during delivery (OR: 2.36; 95%CI: 1.84–3.03).

Conclusions

The existence of different socio-demographic and obstetric profiles among women who receive care for vaginal or cesarean delivery, are supported by the findings of the present study. The frequency of vaginal delivery is higher in indigenous women, when the care provider is public and, in women with two or more children at time of the most recent child birth. Planned cesarean deliveries are positively associated with years of schooling, a higher socioeconomic level, and higher age. The occurrence of emergency cesarean sections is elevated in women with a diagnosis of a health issue during pregnancy or delivery, and it is reduced in highly marginalized settings.     

Northern obstetrics: a 5-year review of delivery among Inuit women.

There are over 18,000 Inuit in the Northwest Territories. As a group they have the highest birth rate, the lowest cesarean section rate and one of the highest perinatal death rates in Canada. We reviewed the obstetric experience of 512 Inuit women who either gave birth at Stanton Yellowknife Hospital or were referred from Yellowknife and gave birth at a southern facility between January 1981 and December 1985. Our experience is consistent with that documented in earlier reviews, which concluded that Inuit women tend to have efficient uterine action, to endure labour well and to rarely have dystocia. During the periods covered by these reviews delivery was frequently in the settlements; now hospital delivery is the norm. Substantial improvements in perinatal outcome are evident, but there remains a considerable gap between the northern and southern experience. Those attempting further progress must recognize that the need for obstetric care away from the home community is not fully appreciated by Inuit women, their families or their communities.     

Alternative, cost-effective fungus-staining method for control slides in cytology and histopathology

OBJECTIVE: To develop a cost-effective, reliable and safe method of providing fungal control slides for routine use in pathology laboratories. STUDY DESIGN: A set of easily available, low-cost material was tested to obtain fungal colonies on substrate adequate for paraffin-embedded sections or smears. RESULTS: Such material as cheese is a simple, inexpensive and practical culture medium for silver-positive fungi. A batch of paraffin blocks can be prepared to maintain a stock of control material in the laboratory. CONCLUSION: It is useful to maintain fungal colonies to produce staining control specimens using small pieces of refrigerated cheese to easily produce silver-staining control specimens or smears embedded in paraffin, reducing the risk of accidental exposure to potentially infective pathogens in the laboratory. This method might also be a good alternative for conserving routine surgical specimens, considering the currently decreasing numbers of necropsy and large specimens, particularly from immunosuppressed and infected patients.     

Cesarean section: trends and morbidity.

A review of 1683 cesarean sections performed at one hospital in a 3-year period (1977-79) showed that the cesarean section rate had trebled since 1967-79, the rates being 16.9% and 5.8%. The main indications for cesarean section responsible for this rise were dystocia, breech presentation and a previous cesarean section. AFter the operation 23.3% of received antibiotics. If the cesarean section rate is to fall, the biggest impact can be made by planning vaginal delivery in selected patients with a previous cesarean section and by improving the management of nonprogressive labour.     

Inducing labour with vaginally administered prostaglandin E2.

In 50 consecutive pregnant women at a 125-bed community hospital with 1000 deliveries annually, labour was induced with prostaglandin E2 administered intravaginally. There were no stillbirths or neonatal deaths, and complications in the mothers were few. In nine women (18%) oxytocin was subsequently administered because of a failure of labour to progress; in spite of this, cesarean section was required in two (4%) of the patients. The overall cesarean section rate was 6%. Prostaglandins have been used routinely to induce labour in the United Kingdom for several years. This noninvasive method is safe, effective and well received by women in a community hospital setting, including those wanting "natural childbirth".     

Pre-operative respiratory evaluation and management of patients for upper abdominal surgery.

Patients presenting for surgery, be it on an elective or emergency basis, do so in the hope that the anesthetic will be without risk. Yet complications which arise are not always due to anesthesia. More often, the surgical process and factors intrinsic to the patient are major determinants of outcome. Pre-operative assessment allows review of the patient and the proposed surgery, and formation of a plan of management for the pre-, intra-, and post-operative anesthetic care. This paper provides an overview of the pre-operative assessment and management of patients who are to undergo upper abdominal surgery, with the aim of minimizing their risk of post-operative pulmonary complications. In particular, factors which contribute to the development of post-operative respiratory problems are described.     

Partner Experiences of “Near-Miss” Events in Pregnancy and Childbirth in the UK: A Qualitative Study

Objective

Severe life-threatening complications in pregnancy that require urgent medical intervention are commonly known as “near-miss” events. Although these complications are rare (1 in 100 births), there are potentially 8,000 women and their families in the UK each year who live through a life-threatening emergency and its aftermath. Near-miss obstetric emergencies can be traumatic and frightening for women, and their impact can last for years. There is little research that has explored how these events impact on partners. The objective of this interview study was to explore the impact of a near-miss obstetric emergency, focusing particularly on partners.

Design

Qualitative study based on narrative interviews, video and audio recorded and transcribed for analysis. A qualitative interpretative approach was taken, combining thematic analysis with constant comparison. The analysis presented here focuses on the experiences of partners.

Participants

Maximum variation sample included 35 women, 10 male partners, and one lesbian partner who had experienced a life-threatening obstetric emergency.

Setting

Interviews were conducted in participants’ own homes.

Results

In the hospital, partner experiences were characterized by powerlessness and exclusion. Partners often found witnessing the emergency shocking and distressing. Support (from family or staff) was very important, and clear, honest communication from medical staff highly valued. The long-term emotional effects for some were profound; some experienced depression, flashbacks and post-traumatic stress disorder months and years after the emergency. These, in turn, affected the whole family. Little support was felt to be available, nor acknowledgement of their ongoing distress.

Conclusion

Partners, as well as women giving birth, can be shocked to experience a life-threatening illness in childbirth. While medical staff may view a near-miss as a positive outcome for a woman and her baby, there can be long-term mental health consequences that can have profound impacts on the individual, but also their families.     

E-PASS评分系统用于评估老龄患者消化道手术后并发症和转归的临床价值研究

目的:评价日常活动和手术应激评估(Estimation of physiologic ability and surgical stress,E-PASS)系统用于评估老龄患者消化道手术后并发症和转归的临床价值。方法:回顾性分析2011年7月至2013年7月西京医院消化外科所有65岁以上的患者的临床资料,计算其中行消化道手术者的E-PASS评分,并记录这些患者术后并发症的发生情况和患者术后的住院时间。分析E-PASS评分和几项该评分未涉及的因素与老龄患者消化道手术后并发症的发病率、死亡率、住院时间的相关性。结果:研究共纳入1236例老龄行消化道手术的患者,其中521例发生术后并发症(42.15%),8例死亡(0.65%)。患者术前E-PASS评分系统中,三项评分均与术后住院时间相关,术前风险评分(Preoperative risk score,PRS)和综合风险评分(Comprehensive risk score,CRS)与术后并发症的发病率和死亡率显著相关(P均0.05)。E-PASS评分系统未包含的指标中,麻醉方法与术后并发症发生和住院时间无关,术后入ICU、术中使用血管活性药物和急诊手术与术后发病率、死亡率和住院时间相关(P均0.05)。结论:E-PASS评分系统可用于预测老龄患者行消化道手术后并发症的发生情况和转归,纳入术后入ICU、术中使用血管活性药物和急诊手术三项指标可能进一步提高E-PASS评分系统的预测准确性。     

The new role of the hospital emergency department

The volume of medical services delivered within hospital emergency departments in the City of Saskatoon is increasing rapidly. These probably are not “new” medical services but rather represent a transfer of “old” services to the emergency departments from other sites where they were previously rendered. The visit to the emergency department is initiated more often by the patient than the doctor and once there the patient is treated in a relatively short period of time. The illnesses so managed do not have a diagnostic, therapeutic or prognostic uniformity but rather are characterized by their acute and totally unexpected onset. This acute and non-programmable nature of the illness makes it difficult to deliver the service in a physician''s office where the appointment system prevails and efficiently deals with the great majority of his patients. Data to determine whether or not this is a desirable development have not yet been obtained but it is clear that in its present usage the emergency department must be thought of as a facility which not only provides exceptional diagnostic and therapeutic equipment but as one which also provides a treatment facility without prior appointment available at any hour of the day or night.