The nature of labour pain: An updated review of the literature

BACKGROUND

The pain experience associated with labour is complex. Literature indicates psychosocial and environmental determinants of labour pain, and yet methods to support women usually target physiological attributes via pharmacological interventions.

AIM

To provide an update of our understanding of labour pain based on modern pain science. The review aims to help explain why women can experience labour pain so differently - why some cope well, whilst others experience great suffering. This understanding is pertinent to providing optimal support to women in labour.

METHOD

A literature search was conducted in databases Medline, Cumulative Index to Nursing and Allied Health Literature and PsycINFO, using search terms labor/labour, childbirth, pain, experience and perception. Thirty-one papers were selected for inclusion.

FINDINGS

Labour pain is a highly individual experience. It is a challenging, emotional and meaningful pain and is very different from other types of pain. Key determinants and influences of labour pain were identified and grouped into cognitive, social and environmental factors.

CONCLUSION

If a woman can sustain the belief that her pain is purposeful (i.e. her body working to birth her baby), if she interprets her pain as productive (i.e. taking her through a process to a desired goal) and the birthing environment is safe and supportive, it would be expected she would experience the pain as a non-threatening, transformative life event. Changing the conceptualisation of labour pain to a purposeful and productive pain may be one step to improving women's experiences of it, and reducing their need for pain interventions.

Pregnancy-induced hypertension and neonatal outcomes: a systematic review and meta-analysis

OBJECTIVE

Pregnancy-induced hypertension (PIH) is associated with preterm delivery but its independent impact on neonatal outcomes remains unclear. We sought to systematically review and meta-analyze clinical outcomes of preterm infants <37 weeks' gestation born to mothers with and without PIH.

STUDY DESIGN

Medline, Embase, PsychINFO and CINAHL were searched from January 2000 to October 2016. Studies with low-moderate risk of bias reporting neonatal outcomes based on PIH as primary exposure variable were included. Data were extracted independently by two co-authors.

RESULTS

PIH was associated with lower mortality (3 studies; adjusted odds ratio (aOR) 0.65; 95% confidence interval (CI) 0.54 to 0.79), lower severe retinopathy of prematurity (ROP) (2 studies; aOR 0.83; 0.72 to 0.96) and lower severe brain injury (2 studies; unadjusted OR (uOR) 0.57; 0.49 to 0.66). No association between PIH and short-term respiratory outcomes, bronchopulmonary dysplasia (BPD) or necrotizing enterocolitis (NEC) was identified. In subgroup analysis among infants <29 weeks' gestation, BPD odds were higher (3 studies; aOR 1.15; 1.06 to 1.26), whereas mortality lower (2 studies; aOR 0.73; 0.69 to 0.77). In subgroup analysis limited to severe PIH, odds of mortality (3 studies; uOR 2.36; 1.07 to 5.22) and invasive ventilation (3 studies; uOR 3.26; 1.11 to 9.61) were higher. In subgroup analysis limited to preeclampsia, odds of BPD (3 studies; uOR 1.21; 95% CI:1.03 to 1.43) and NEC were higher (3 studies; uOR 2.79; 95% CI:1.57 to 4.96).

CONCLUSION

PIH was associated with reduced odds of mortality and ROP (all infants), but higher odds for BPD (<29 weeks' gestation). The paradoxical reduction in mortality may be due to survival bias and deserves further exploration in future studies.

A review of atypical subtrochanteric femoral fractures in Northern Ireland between 2010 and 2014

The term atypical femoral fractures most commonly occur in the subtrochanteric area. Concerns exist regarding the role of bisphosphonate treatment in their aetiology. Which surgical intervention provides the best outcome remains contentious. We reviewed all atypical subtrochanteric femoral fractures treated in Northern Ireland over 5 years, specifically investigating incidence, prodromal symptoms, association with bisphosphonates and optimal fixation methods. All subtrochanteric fractures treated in the region were identified and reviewed for atypical features. Case notes and imaging were then reviewed for each patient. A total of 364 subtrochanteric femoral fractures were identified during the 5-year study period. Twenty-six of these met the criteria for an atypical fracture (7%). Thirteen patients (50%) had presented with prodromal symptoms prior to complete fracture, six of which had radiological evidence of an incomplete fracture of the lateral cortex. Thirteen patients had a history of bisphosphonate treatment. All were treated operatively, with twenty-five cephalomedullary nails and one dynamic hip screw. Twenty-one patients had follow-up for greater than 2 months, nine of which (42.9%) achieved radiological union with a mean time to union of 297 days. Dynamically locked nails had a higher union rate than statically locked (80% versus 33.3%). Four patients required major revision surgery (15.4%). The quality of reduction was statistically significant in predicting need for revision. Atypical fractures often present with prodromal symptoms. Complete fractures are difficult to successfully manage with longer than expected times to union. Treatment with a dynamically locked, cephalomedullary with a good reduction provided the best results.

The changing face of fractures of the hip in Northern Ireland: a 15-year review

AIMS

We reviewed all patients who sustained a fracture of the hip and were treated in Northern Ireland over a period of 15 years to identify trends in incidence, the demographics of the patients, the rates of mortality, the configuration of the fracture and the choice of implant.

PATIENTS AND METHODS

Since 01 January 2001 data about every fracture of the hip sustained in an adult have been collected centrally in Northern Ireland. All adults with such a fracture between 2000 and 2015 were included in the study. Temporal changes in their demographics, the mode of treatment, and outcomes including mortality were analysed.

RESULTS

The incidence of fractures of the hip, in Northern Ireland, rose from 54 in 100 000 in 2000 to 86 in 100 000 in 2015. If these trends continue, we predict this rising to 128 in 100 000 in 2030. We found that these patients are becoming older and increasingly frail, as assessed by the American Association of Anesthesiology grade. Complex extracapsular fractures have become more common since 2009, which may explain the increased use of cephalomedullary nails. Despite increasing frailty, the 30-day and 12-month rates of mortality fell significantly (p = 0.002 and 0.001, respectively).

CONCLUSION

Fractures of the hip are becoming more common and more complex in an aging, increasingly frail population. We expect these trends to continue. This will place an increasing economic and clinical strain on healthcare systems. Forward planning is essential to put systems in place that can deal with the increasing demand. Cite this article: Bone Joint J 2017;99-B:1223-31.

Fitness adjusted racial disparities in central adiposity among women in the USA using quantile regression

OBJECTIVE

This study comprehensively explores racial/ethnic disparities in waist circumference (WC) after adjusting for cardiorespiratory fitness (CRF), among both adult and adolescent women, across WC percentiles.

METHODS

Analysis was conducted using data from the 1999 to 2004 National Health and Nutrition Examination Survey. Female participants (n = 3,977) aged 12-49 years with complete data on CRF, height, weight and WC were included. Quantile regression models, stratified by age groups (12-15, 16-19 and 20-49 years), were used to assess the association between WC and race/ethnicity adjusting for CRF, height and age across WC percentiles (10th, 25th, 50th, 75th, 90th and 95th).

RESULTS

For non-Hispanic (NH) Black, in both the 16-19 and 20-49 years age groups, estimated WC was significantly greater than for NH White across percentiles above the median with estimates ranging from 5.2 to 11.5 cm. For Mexican Americans, in all age groups, estimated WC tended to be significantly greater than for NH White particularly for middle percentiles (50th and 75th) with point estimates ranging from 1.9 to 8.4 cm.

CONCLUSIONS

Significant disparities in WC between NH Black and Mexican women, as compared to NH White, remain even after adjustment for CRF. The magnitude of the disparities associated with race/ethnicity differs across WC percentiles and age groups.

Transition to adult services - a positive step

Following the success of antiretroviral therapy, an expanding cohort of adolescents with perinatally acquired HIV (PaHIV) is transitioning into adult care. Dedicated multidisciplinary transitional care HIV services have been established in the UK. However, published data on patient satisfaction with such services are sparse. A single centre survey of patient satisfaction was conducted in January 2014, and results compared to a previous similar survey in 2009. Patients were asked to complete a questionnaire regarding views of their care using a 7-point Likert scale. 51/96 attended within the time period and all completed the survey, compared with 21 in 2009. Ninety-two percent were satisfied with the care provided by the clinic, compared to 100% in 2009. The proportion who felt moving to their current service had a positive effect on their health increased from 68% in 2009 to 81% in 2014. Ninety-two percent were satisfied with the overall care provided by the clinic, compared to 100% in 2009. Ninety-four percent agreed that staff knew how to talk and listen to young people, 96% agreed staff were able to explain their treatments and problems clearly in a way that they could understand. Ninety-six percent felt that a clinic specifically for young people was useful. Despite a marked increase in clinic attendees and unchanged levels of service provision, patient satisfaction remained high. Patients strongly value the provision of dedicated services for young people.

Social determinants and maternal exposure to intimate partner violence of obstetric patients with severe maternal morbidity in the intensive care unit: a systematic review protocol

INTRODUCTION

Maternal mortality is a potentially preventable public health issue. Maternal morbidity is increasingly of interest to aid the reduction of maternal mortality. Obstetric patients admitted to the intensive care unit (ICU) are an important part of the global burden of maternal morbidity. Social determinants influence health outcomes of pregnant women. Additionally, intimate partner violence has a great negative impact on women's health and pregnancy outcome. However, little is known about the contextual and social aspects of obstetric patients treated in the ICU. This study aimed to conduct a systematic review of the social determinants and exposure to intimate partner violence of obstetric patients admitted to an ICU.

METHODS AND ANALYSIS

A systematic search will be conducted in MEDLINE, CINAHL, ProQuest, LILACS and SciELO from 2000 to 2016. Studies published in English and Spanish will be identified in relation to data reporting on social determinants of health and/or exposure to intimate partner violence of obstetric women, treated in the ICU during pregnancy, childbirth or within 42 days of the end of pregnancy. Two reviewers will independently screen for study eligibility and data extraction. Risk of bias and assessment of the quality of the included studies will be performed by using the Critical Appraisal Skills Programme (CASP) checklist. Data will be analysed and summarised using a narrative description of the available evidence across studies. This systematic review protocol will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines.

ETHICS AND DISSEMINATION

Since this systematic review will be based on published studies, ethical approval is not required. Findings will be presented at La Trobe University, in Conferences and Congresses, and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

CRD42016037492.

Is there any place for the variable angle proximal femoral plate? A case matched cohort study against the Dynamic Hip Screw system

INTRODUCTION

The Variable angle Martin Plate (MP) is designed to offer patient-specific adaption for the treatment of intertrochanteric hip fractures. Its proposed benefits include optimization of lag screw placement, plate shaft congruence and reduced risk of failure. Often its use has been criticized as representing a poor reduction of the fracture. The purpose of this study was to assess for a poorer quality of reduction, and compare functional outcomes and mortality, using a MP to that of a fixed angle Dynamic Hip Screw (DHS) in a matched cohort of patients.

METHODS

A retrospective review of a prospective fracture database system was undertaken between 1st January 2004 to 31st December 2013. MP patients were matched to a cohort of DHS patients. Outcomes measure were a quality of procedure score(QPS), 1-year mortality rates, reoperation rates, and Barthel Index functional outcome. Minimum follow up was 12 months.

RESULTS

A total of 77 Martin Plate patients were identified and case matched. The mean pre- and post-op Neck Shaft Angle (NSA) in the MPs was significantly different (132.97±7.78 Vs 126±8.62; p<0.0001). Conversely, the mean pre op DHS NSA and the mean post op NSA was not (p=0.397). Mean Tip-Apex Distance (TAD) was significantly different between groups; MP mean 26.51±9.09mm vs DHS 23.50±8.14mm (p=0.023). The QPS consisted of 4 variables. A significant inverse relationship between QPS and the incidence of construct related complications exists. TAD>25mm, and a change in AP NSA of >5°conveyed the greatest risk of complications. No difference occurred in complications, nor 12-month mortality.

CONCLUSIONS

No statistical difference was found in the quality of reduction between MP and DHS in this group of matched patients. QPS demonstrated a significant inverse correlation with implant-related complications. No significant difference was noted in the incidence of complications, Barthel Index functional scores, or 12-month mortality between implants. A rationale exists regarding the use of MPs, particularly in patients with varus NSA. However, planning and adequate reduction are essential regardless of implant choice.

Comparison of Hand Range of Motion During the Use of Normal and Adaptive (Built-Up) Silverware

Date Presented 4/9/2016

The objective of this study was to establish the normal range of motion (ROM) of a healthy hand using built-up spoons with electrogoniometry. Statistical analysis of the data found significant differences in ROM between joints and spoon size and confirmed the hypothesis that less ROM is required to grip the utensils.

Primary Author and Speaker: Susan McDonald

Additional Author and Speaker: David Levine

Contributing Author: Lauren Aguilar

Seeking Justice

In October 1999, Congress authorized the creation of the U.S. Department of Defense Task Force on Domestic Violence (DTFDV) as a 3-year effort to assist the secretary of defense in developing domestic violence prevention programs and interventions. The DTFDV began meeting in April 2000 and submitted its first report to the secretary of defense on February 28, 2001. This report included 68 recommendations addressing victim safety, offender accountability, education and training, and community collaboration. In February 2002, the DTFDV submitted its second report addressing these issues in greater detail and making an additional 86 recommendations. The National Network to End Domestic Violence reviewed the second report and addressed several key issues comments to the Department of Defense. The weaknesses of the report include its overall analysis of battering and its focus on clinical approaches to treatment and intervention. In contrast, the report has relatively strong recommendations for victim safety and confidentiality. This review examines both the strengths and weaknesses in these critical areas.

Impact of bromide on halogen incorporation into organic moieties in chlorinated drinking water treatment and distribution systems

The impact of elevated bromide concentrations (399 to 750 μg/L) on the formation of halogenated disinfection by-products (DBPs), namely trihalomethanes, haloacetic acids, haloacetonitriles, and adsorbable organic halogen (AOX), in two drinking water systems was investigated. Bromine was the main halogen incorporated into all of the DBP classes and into organic carbon, even though chlorine was present in large excess to maintain a disinfectant residual. Due to the higher reactivity of bromine compared to chlorine, brominated DBPs were rapidly formed, followed by a slower increase in chlorinated DBPs. Higher bromine substitution and incorporation factors for individual DBP classes were observed for the chlorinated water from the groundwater source (lower concentration of dissolved organic carbon (DOC)), which contained a higher concentration of bromide, than for the surface water source (higher DOC). The molar distribution of adsorbable organic bromine to chlorine (AOBr/AOCl) for AOX in the groundwater distribution system was 1.5:1 and almost 1:1 for the surface water system. The measured (regulated) DBPs only accounted for 16 to 33% of the total organic halogen, demonstrating that AOX measurements are essential to provide a full understanding of the formation of halogenated DBPs in drinking waters. In addition, the study demonstrated that a significant proportion (up to 94%) of the bromide in source waters can be converted AOBr. An evaluation of AOBr and AOCl through a second groundwater treatment plant that uses conventional treatment processes for DOC removal produced 70% of AOX as AOBr, with 69% of the initial source water bromide converted to AOBr. Exposure to organobromine compounds is suspected to result in greater adverse health consequences than their chlorinated analogues. Therefore, this study highlights the need for improved methods to selectively reduce the bromide content in source waters.

Placental Insufficiency in Fetuses That Slow in Growth but Are Born Appropriate for Gestational Age: A Prospective Longitudinal Study

OBJECTIVES

To determine whether fetuses that slow in growth but are then born appropriate for gestational age (AGA, birthweight >10th centile) demonstrate ultrasound and clinical evidence of placental insufficiency.

METHODS

Prospective longitudinal study of 48 pregnancies reaching term and a birthweight >10th centile. We estimated fetal weight by ultrasound at 28 and 36 weeks, and recorded birthweight to determine the relative change in customised weight across two timepoints: 28-36 weeks and 28 weeks-birth. The relative change in weight centiles were correlated with fetoplacental Doppler findings performed at 36 weeks. We also examined whether a decline in growth trajectory in fetuses born AGA was associated with operative deliveries performed for suspected intrapartum compromise.

RESULTS

The middle cerebral artery pulsatility index (MCA-PI) showed a linear association with fetal growth trajectory. Lower MCA-PI readings (reflecting greater diversion of blood supply to the brain) were significantly associated with a decline in fetal growth, both between 28-36 weeks (p = 0.02), and 28 weeks-birth (p = 0.0002). The MCA-PI at 36 weeks was significantly higher among those with a relative weight centile fall <20%, compared to those with a moderate centile fall of 20-30% (mean MCA-PI 1.94 vs 1.61; p<0.05), or severe centile fall of >30% (mean MCA-PI 1.94 vs 1.56; p<0.01). Of 43 who labored, operative delivery for suspected intrapartum fetal compromise was required in 12 cases; 9/18 (50%) cases where growth slowed, and 3/25 (12%) where growth trajectory was maintained (p = 0.01).

CONCLUSIONS

Slowing in growth across the third trimester among fetuses subsequently born AGA was associated with ultrasound and clinical features of placental insufficiency. Such fetuses may represent an under-recognised cohort at increased risk of stillbirth.

Estimating cut points: A simple method for new wearables

Wearable technology is readily available for continuous assessment due to a growing number of commercial devices with increased data capture capabilities. However, many commercial devices fail to support suitable parameters (cut points) derived from the literature to help quantify physical activity (PA) due to differences in manufacturing. A simple metric to estimate cut points for new wearables is needed to aid data analysis.

OBJECTIVE

The purpose of this pilot study was to investigate a simple methodology to determine cut points based on ratios between sedentary behaviour (SB) and PA intensities for a new wrist worn device (PRO-Diary™) by comparing its output to a validated and well characterised 'gold standard' (ActiGraph™).

STUDY DESIGN

Twelve participants completed a semi-structured (four-phase) treadmill protocol encompassing SB and three PA intensity levels (light, moderate, vigorous). The outputs of the devices were compared accounting for relative intensity.

RESULTS

Count ratios (6.31, 7.68, 4.63, 3.96) were calculated to successfully determine cut-points for the new wrist worn wearable technology during SB (0-426) as well as light (427-803), moderate (804-2085) and vigorous (≥ 2086) activities, respectively.

CONCLUSION

Our findings should be utilised as a primary reference for investigations seeking to use new (wrist worn) wearable technology similar to that used here (i.e., PRO-Diary™) for the purposes of quantifying SB and PA intensities. The utility of count ratios may be useful in comparing devices or SB/PA values estimated across different studies. However, a more robust examination is required for different devices, attachment locations and on larger/diverse cohorts.