Epidemiology of occupational injuries among insured workers in Saudi Arabia between 2004 and 2016

This is a retrospective analysis of annual reports on occupational injuries issued by the national social insurance agency of the Kingdom of Saudi Arabia (KSA) for the years 2004 through 2016. For each criterion we calculated an index based on the equation N_Y/N_ref x100, where N_Y is the number of occupational injuries by a specific criterion in a specific year Y, and N_ref is the number of injuries in the corresponding criterion in the reference year, i.e. 2004. We also calculated the number of injuries to number of workers ratio (N_i/N_w) for different occupations and economic sectors to get a clearer idea of the injury trends per worker. In terms of occupational injury rates (with respect to 2004), we observed increases in construction, financing & real estate (economic sectors), among engineers and technicians (occupations), in infections and secondary contusions (injury type), for upper and lower limbs (affected body parts), over falls and “other” causes. Most injuries occurred on Fridays, which is a weekend day in Saudi Arabia. We also observed increased recovery without disability (injury status). However, if we look at the number of occupational injuries per worker, we can see a decreasing trend over time for all occupations and economic sectors, most likely thanks to improved labour law and safety at work practices for insured workers. Our findings are similar to reports from other Persian Gulf countries and reflect current labour health and safety issues in the area.

Low-pressure membrane technology for potable water filtration: true costs

The overall cost, expressed as the present value (PV), of the construction and operation of low-pressure membrane filtration of inland water for potable water supply has been determined for membrane installations across the UK. The analysis was based on 15 full-scale installations installed with hollow fibre and capillary tube polymeric membranes, for which cost and related data were available. The analysis encompassed labour, in addition to energy, chemicals and critical component replacement. PV data were presented as functions of flow capacity (i.e. as cost curves), delineated as capital (CAPEX), operating (OPEX) and total PV normalised against flow rate (PV') the CAPEX excluding the site-specific civil engineering costs. Captured CAPEX data revealed these to be lower than those previously reported, and with a reduced economy of scale. The OPEX PV exceeded the CAPEX by a factor of 3-6 based on a 20-year life cycle, the difference increasing with decreasing flow capacities. Costs associated with unplanned (or "reactive") maintenance, partly associated with the repair of breached membranes and/or permeability recovery following membrane clogging, were found to make up around half the labour costs. Labour costs as a proportion of the flow increased with decreasing flow, exceeding the CAPEX at flows below 30,000 m³/d. Outcomes indicate labour costs associated with process upsets to contribute significantly to the overall cost of the installation over its life cycle, particularly at flows below ~30,000 m³/d. A clear trade-off exists between supplementary capital investment to allay process upsets and the operational costs associated with such events.

Labour Market Dynamics in South Africa at the Onset of the COVID-19 Pandemic

This paper conducts an analysis of labour market dynamics in South Africa during the initial period of lockdown, from the end of March to the end of April 2020, using the first wave of the NIDS-CRAM (2020) survey. Within our sample of over 6,000 adults aged 18 to 59, we found that there was a very large decrease in employment. The fraction of the sample that was conventionally classified as employed decreased from 57% in February to 48% in April. If we further exclude temporarily absent workers, which we term "furloughed" employees, this fraction decreases further to 38%. Thus, about one out of every three employed people in our sample either lost their job or did not work and received no wages during April. This has extremely large implications for poverty and welfare. We further analyse the labour market by comparing across demographic groups as defined by race, by gender, by age groups, by geographic areas and by education levels. The over-arching finding from this analysis is that the job losses were not uniformly distributed amongst the different groups. In particular, groups who have always been more vulnerable - such as women, African/Blacks, youth and less educated groups - have been disproportionately negatively affected.

Evaluating the efficacy of outpatient use of isosorbide mononitrate on cervical ripening in pregnant women with unfavourable cervix

The aim of the present study was to evaluate the efficacy of outpatient administration of nitric oxide donor isosorbide mononitrate for cervical ripening. A randomised clinical trial was performed on term pregnant women with Bishop Score < 6. In the case group, Isosorbide-5-mononitrate capsule and in the control group, placebo was inserted in the posterior vaginal fornix for two consecutive days. The main outcomes were increases in Bishop Score after 48 hours of intervention, number of vaginal deliveries and interval from intervention to delivery.There was a significant increase of the mean Bishop score in the isosorbide group [3.57 ± 1.12 VS 1.54 ± 1.42 respectively (p = .001)]. The other outcome variables did not show a significant difference between the two groups except for headache which was significantly more in the case group. No cases of tachysystole were observed in the two groups. Additionally, haemoglobin levels after delivery did not show a significant difference between the two groups.Impact statement:What is already known on this subject? Cervical ripening in women with an unfavourable cervix and having an indication for induction of labour is an important issue in modern obstetrics. Different methods have been used for cervical ripening and induction of labour including mechanical (i.e. laminaria tents, Dilapan-S, foley catheter), medical (i.e. PGs) and supportive methods. There is no consensus on the best option for cervical ripeningWhat will the results of this study add to the current knowledge of this subject? Outpatient administration of nitric oxide could affect cervical ripening without a significant improvement in the duration of different stages of labour, intervention to delivery interval and number of vaginal deliveries.What are the implications of these findings for clinical practice and/or further research? Due to the contradictory results of various studies, more studies should be performed with greater sample size to evaluate nitric oxide donor isosorbide mononitrate effect on labour duration and reducing caesarean deliveries. Additional data is needed to assess the real impact of NO donors on different stages of labour and its implications.

Epidural analgesia, intrapartum hyperthermia, and neonatal brain injury: a systematic review and meta-analysis

BACKGROUND

Epidural analgesia is associated with intrapartum hyperthermia, and chorioamnionitis is associated with neonatal brain injury. However, it is not known if epidural hyperthermia is associated with neonatal brain injury. This systematic review and meta-analysis investigated three questions: (1) does epidural analgesia cause intrapartum hyperthermia, (2) is intrapartum hyperthermia associated with neonatal brain injury, and (3) is epidural-induced hyperthermia associated with neonatal brain injury?

METHODS

PubMed, ISI Web of Knowledge, The Cochrane Library, and Embase were searched from inception to January 2020 using Medical Subject Headings (MeSH) terms relating to epidural analgesia, hyperthermia, labour, and neonatal brain injury. Studies were reviewed independently for inclusion and quality by two authors (Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach). Two meta-analyses were performed using the Mantel-Haenszel fixed effect method to generate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Forty-one studies were included for Question 1 (646 296 participants), 36 for Question 2 (11 866 021 participants), and two studies for Question 3 (297 113 participants). When the mode of analgesia was randomised, epidural analgesia was associated with intrapartum hyperthermia (OR: 4.21; 95% CI: 3.48-5.09). There was an association between intrapartum hyperthermia and neonatal brain injury (OR: 2.79; 95% CI: 2.54-2.3.06). It was not possible to quantify the association between epidural-induced hyperthermia and neonatal brain injury.

CONCLUSIONS

Epidural analgesia is a cause of intrapartum hyperthermia, and intrapartum hyperthermia of any cause is associated with neonatal brain injury. Further work is required to establish if epidural-induced hyperthermia is a cause of neonatal brain injury.

Obstetric anal sphincter injuries (OASIS) in multiparous women with the use of epidural anaesthesia: A retrospective cohort study

BACKGROUND

The use of epidural as a form of analgesia is increasingly common in labour, but this has shown to have been associated with increased rates of instrumental delivery, and prolonged second stage, resulting in increased rates of OASIS (Obstetric Anal Sphincter Injury).

AIMS

This study aimed to investigate the impact of epidural anaesthesia in multiparous women undergoing vaginal deliveries on OASIS and secondary maternal outcomes.

MATERIALS AND METHODS

A retrospective cohort study of multiparous women with singleton pregnancies delivering at term ≥37 weeks and the use of epidural analgesia in labour at a tertiary hospital in Melbourne, Victoria, Australia, the Royal Women's Hospital was undertaken between the period 2012-2018. Maternal outcomes were collated and dichotomised according to the presence of epidural use. Multiparous women with no prior history of a vaginal birth and non-cephalic presentation during labour were excluded.

RESULTS

There were 14 124 multiparous women who met the inclusion criteria; spontaneous labour is associated with an increased risk of OASIS at adjusted odds ratio (aOR) 1.46, P = 0.012. The overall rate of epidural use was 17%. Women with epidural use had significantly lower chances of sustaining OASIS in normal vaginal births and instrumental vaginal births. (1% vs 1.8%, aOR 0.49, P = 0.004). Epidural is associated with increased rates of prolonged second stage (8.5% vs 3.8%, P < 0.05), instrumental delivery (26.1% vs 4%, P < 0.05), and episiotomy use (23.8% vs 10.2%, P < 0.05).

CONCLUSION

The use of epidural analgesia in multiparous women is associated with a reduction in anal sphincter injuries.

Mixed-methods systematic review: Childbearing women's views, experiences, and decision-making related to epidural analgesia in labour

AIMS

To investigate childbearing women's views, experiences and decision-making related to epidural analgesia in labour.

DESIGN

Mixed-methods systematic review.

DATA SOURCES

A comprehensive literature search was implemented across Medline, CINAHL and EMBASE from 2000 to September 2018. The literature search was undertaken in January 2018 and updated in September 2018. Thirty papers were selected.

RESULTS

Four overarching synthesized findings were identified: (a) choice; (b) pain management experience; (c) lack of information; and (d) information provision and consent.

REVIEW METHODS

Quality appraisal was conducted using JBI levels of evidence and other established tools. NVivo was used to independently dual code and thematically synthesize qualitative data. A narrative synthesis of the quantitative findings from the included studies was undertaken. The GRADE-CERQual approach was used to assess confidence in the review findings based on the qualitative data. A set of integrated mixed-methods synthesized findings was produced.

CONCLUSION

Recommendations for practice based on the systematic review findings are that midwives should dedicate time to discuss epidural with women and birth partners, ideally during the second or third trimester of pregnancy, asking women what coping strategies or pain relief they have been considering, if any. The factors which may influence the woman's choice of epidural, including pain threshold, ability to cope with pain, timing of epidural and length of labour should be continuously evaluated during labour. The midwife should remain with women after an epidural has been sited, demonstrating understanding of the woman's choice and providing an opportunity for discussion of plans for the remaining labour and birth.

IMPACT

The findings of this systematic review can inform both healthcare professionals and service users on various aspects of the decision-making process about the use of epidural analgesia in labour. Data can be transferable to similar settings in high-income countries.

Which technique is better to place a manoeuvrable vacuum extractor cup on the flexion point? Vacca vs. Bird technique

Objectives The purpose of this study is to compare the vacuum extractor cup application technique described by Bird vs. the technique described by Vacca on a simulation model. Methods Six obstetricians participated in the study. Each obstetrician performed eight vacuum assisted deliveries using the Bird technique and eight vacuum assisted deliveries using the Vacca 5-Steps technique. Results A total of 96 vacuum assisted deliveries were performed. The mean distance from the centre of the cup to the flexion point was 1.78±0.96 cm for the Bird technique and 1.05±0.60 cm for the Vacca technique (p<0.001). The lateral distance (over the parietal bone) was 1.16±0.69 cm for the Bird technique and 0.66±0.52 cm for the Vacca technique (p<0.001). The vertical distance (towards the frontal or occipital bone) was 1.12±1.02 cm for the Bird technique and 0.67±0.55 cm for the Vacca technique (p=0.009). In occipito anterior positions, there were no significant differences between both techniques. Conclusions The Vacca technique was better in transverse and posterior positions.

Individual, interpersonal and economic challenges of underemployment in the wake of COVID-19

BACKGROUND

COVID-19 has caused economic slowdown all across the globe. It results in job loss on the one hand and less wages, increased working hours, overqualified employees and part time jobs on the other hand. Low demand of labour and a huge availability of work force will put many in a disadvantageous position, where they will have to compromise with the circumstances by being underemployed. Cabinet decisions, by some Indian states like Uttar Pradesh, to suspend the labour laws related to minimum wage, bonus, working hours and other employee benefits will put workers in a highly disadvantageous position of being underemployed. This may lead to many socio-economic, psychological and health-related implications.

OBJECTIVE

The aim of this paper is to provide a comprehensive review on the concept of underemployment, its types and consequences.

METHODOLOGY

A critical and constructive analysis of the literature was performed.

RESULTS

The findings reveal that if employment does not provide workers with proper opportunities to use their education, time, skills and expertise, it can create stressful situations in workers' lives.

CONCLUSION

The problem needs both a diagnosis and robust treatment in order to have better outcomes at the individual, organisational and national levels.

The Jehovah's Witness obstetric patient - a literature review

The patient's right to refuse blood transfusion must be honoured in case of its clear expression. Some special pharmacologic and/or surgical procedures can be useful in a Jehovah Witness (JW) parturient. In case of excess blood loss the maintenance of peripheral tissue oxygenation is crucial. Only a few hospitals have equipment for blood salvage, and alternative oxygen carriers have potentially lethal side effects. Findings suggest that obstetric facilities should develop special algo-rithms of management in the case of the JW obstetric patient, with written declaration of which elements of blood are not acceptable for the patient, early diagnosis and intensive treatment of anaemia in pregnancy, administration of antifibrinolytic agents before surgery, use of electric surgical tools to restore haemostasis, early detection and aggressive treatment of excessive blood loss and, last but not least, close cooperation between obstetricians and anaesthesiologists, including sharing the information about the patient's refusal of blood transfusion.

Accessing Occupational Health Services in the Southern African Development Community Region

Only 15% of the global population has access to occupational safety and health services. In Africa, only 5% of employees working from major establishments have access to occupational health services (OHS). Access to primary health care (PHC) services is addressed in many settings and inclusion of OHS in these facilities might increase efficiency in preventing occupational diseases. A cross-sectional study was conducted in four Southern African Development Community (SADC) countries aiming at assessing the availability of OHS at PHC facilities and the organization of OHS. We conducted a literature review to assess the provision and organization of OHS services. In addition to the review, a total of 23 doctors from Zambia were interviewed using questionnaires in order to determine the availability of OHS and training. Consultations with heads of ministries were done in four SADC countries. Results showed that in the SADC region, OHS are fragmented and lack a comprehensive approach. In addition, out of 23 PHC facilities, only two (13%) provided occupational health and PHC. However, OHS provided at PHC facilities were limited to TB screening and audiometric testing. Our study showed a huge inadequacy of trained occupational health practitioners. This study supports the World Health Organization’s advocacy to integrate OHS at the PHC level.

Situation of labour room documentation at secondary level public health facilities of Cuttack district, Odisha, India - A SWOT analysis

Background:

Poor documentation practices in labour rooms have been a challenge especially in resource limited countries. This hinders the efforts towards improving quality of maternal healthcare services. Little effort has been made on this regard in many countries including India. SWOT analysis on labour room documentation would be the first step in understanding the situation, barriers and to formulate strategies for improvement.

Materials and Methods:

Facility based cross-sectional study was carried out in five secondary health facilities of Cuttack district, Odisha, India. A qualitative method using in-depth interviews among 26 healthcare providers was adopted for data collection and inductive content analysis approach for analysis. Strategies like pioneering, positive, conservative and resistive were formulated under each of the three major components identified.

Results:

Three major components emerged were i) Adherence and completeness of labour room records and reports, ii) Status of the monitoring and supervision and iii) Utilization of labour room data. Improving knowledge and skill through training and supportive supervision, adopting computer-based application for data management, better coordination among supervisors and labour room staff, infrastructural strengthening for documentation and its security, making documentation a priority, more accountability would improve the documentation. Ensuring data analysis and interpretation, discussion in review meetings and regular monitoring and supervision will improve performance.

Conclusion:

Ensuring documentation of labour room records, regular quality monitoring and supervision, and analysis and interpretation of data are critical to improve labour room performance. Making it a priority and adopting the strategies will achieve the same, thereby better labour outcome.

Raising awareness about chronic pain and dyspareunia among women - a Swedish survey 8 months after childbirth

Background and aims Although several studies have been conducted, knowledge about chronic pain and dyspareunia after childbirth is still limited. The aim of this study was to explore the prevalence of chronic pain 8 months after childbirth in a cohort of Swedish women. The characteristics of chronic pain, such as, pain intensity, localization and frequency as well as pain interference with daily activities were examined. An additional aim was to describe the prevalence and intensity of dyspareunia. Methods Data were obtained through two self-administered questionnaires and the patient record system, Obstetrix. The first questionnaire was distributed on the maternity ward, 24-36 h after labour, to Swedish-speaking women who had given birth to a living child (n = 1,507). The second questionnaire was sent by post 8 months after childbirth. We collected data about demographic and social characteristics, pain presence and its onset, as well as pain intensity, frequency, bodily localization and pain interference with activities of women's daily life. Results In total, 1,171 (77.7%) responded to both questionnaires and were included in the analysis. Eight months after giving birth, totally 16.7% (195/1,171) of the women reported chronic pain related to childbirth. Of these, 9.1% (106/1,171) of women reported chronic pain with onset during pregnancy, 4.5% (53/1,171) experienced chronic pain with onset following labour and 3.1% (36/1,171) of women had both chronic pain with onset during pregnancy and chronic pain with onset following labour (each participant could only appear in one of the groups). Women reported a lower prevalence of chronic pain after vaginal delivery than caesarean section (61/916, 6.7% vs. 28/255, 11%, p = 0.021, OR 1.73, 95% CI 1.1-2.8). Moreover, 19.2% (211/1,098) of women experienced dyspareunia. There was no difference regarding prevalence of dyspareunia and the mode of delivery. Of those women who had a vaginal delivery, 19.5% (167/858) experienced pain during intercourse and the corresponding number for women after caesarean section was 18.3% (44/240) (p = 0.694, OR 0.929, CI 0.6-1.3). Approximately 80% of women with chronic pain, and 60% of women that experienced dyspareunia, rated their worst pain as moderate or severe (NRS 4-10). The corresponding number regarding average chronic pain was between 50 and 70%. More than 35% of the women with chronic pain scored pain interference with daily activities as ≥4 on a 0-10 NRS. Conclusions In our study, chronic pain 8 months after childbirth was reported by one in six women and one in five of the women experienced dyspareunia. The intensity of both chronic pain and dyspareunia was reported as moderate to severe in a significant proportion of women and chronic pain interfered considerably with daily activities. Implications There is a need to raise awareness among healthcare providers of this clinical problem as well as to revise and upgrade education regarding pain after childbirth to prevent potential long-term health problems, women's suffering and increased need for health care. The development of strategies for prevention, follow-up and treatment of pain is warranted. More research, including women's experiences of pain as well as intervention studies, are also needed.

Intrauterine versus external tocodynamometry in monitoring labour: a randomised controlled clinical trial

OBJECTIVE

To investigate whether the use of intrauterine tocodynamometry versus external tocodynamometry (IT versus ET) during labour reduces operative deliveries and improves newborn outcome. As IT provides more accurate information on labour contractions, the hypothesis was that it may more appropriately guide oxytocin use than ET.

DESIGN

Randomised controlled trial.

SETTING

Two labour wards, in a university tertiary hospital and a central hospital.

POPULATION

A total of 1504 parturients with singleton pregnancies, gestational age ≥37 weeks and fetus in cephalic position: 269 women with uterine scars, 889 nulliparas and 346 parous women with oxytocin augmentation.

METHODS

Participants underwent IT (n = 736) or ET (n = 768) during the active first stage of labour.

MAIN OUTCOME MEASURES

Primary outcome: rate of operative deliveries.

SECONDARY OUTCOMES

duration of labour, amount of oxytocin given, adverse neonatal outcomes.

RESULTS

Operative delivery rates were 26.9% (IT) and 25.9% (ET) (odds ratio 1.05, 95% CI 0.84-1.32, P = 0.663). The ET to IT conversion rate was 31%. We found no differences in secondary outcomes (IT versus ET). IT reduced oxytocin use during labours with signs of fetal distress, and trial of labour after caesarean section.

CONCLUSIONS

IT did not reduce the rate of operative deliveries, use of oxytocin, or adverse neonatal outcomes, and it did not shorten labour duration.

TWEETABLE ABSTRACT

IT (versus ET) reduced oxytocin use in high-risk labours but did not influence operative delivery rate or adverse neonatal outcomes.

Effects of flexible sacrum positions during the second stage of labour on maternal and neonatal outcomes: A systematic review and meta-analysis

AIMS AND OBJECTIVES

To assess the effects of flexible sacrum positions on mode of delivery, duration of the second stage of labour, perineal trauma, postpartum haemorrhage, maternal pain, abnormal foetal heart rate patterns and Apgar scores based on published literature.

BACKGROUND

Maternal positions served as a nonmedical intervention may facilitate optimal maternal and neonatal outcomes during labour. Flexible sacrum positions are conducive to expanding pelvic outlet. Whether flexible sacrum positions have positive effects on maternal and neonatal well-being is a controversial issue under heated discussion.

DESIGN

We performed a systematic review and meta-analysis based on PRISMA guidelines.

METHODS

Randomised controlled trials (RCTs) comparing any flexible sacrum position with non-flexible sacrum position in the second stage of labour were included. PubMed, EMBASE, Cochrane Library, CINAHL, CNKI (China National Knowledge Infrastructure), SinoMed and Wanfang databases were searched from inception to 11 March 2019 for published RCTs. Risk of bias was assessed by the Cochrane criteria, and random-effects meta-analyses were conducted by RevMan 5.3.

RESULTS

Sixteen studies (3,397 women) published in English were included. Flexible sacrum positions in the second stage of labour could reduce the incidence of operative delivery, instrumental vaginal delivery, caesarean section, episiotomy, severe perineal trauma, severe pain and shorten the duration of active pushing phase in the second stage of labour. However, flexible sacrum positions may increase the incidence of mild perineal trauma. There was no significant difference in the duration of the second stage of labour, maternal satisfaction and other outcomes.

CONCLUSIONS

Flexible sacrum positions are superior in promoting maternal well-being during childbirth. However, several results require careful interpretation. More rigorous original studies are needed to further explore their effects.

RELEVANCE TO CLINICAL PRACTICE

The results support the use of flexible sacrum positions. Flexible sacrum positions are recommended to apply flexibly or tailor to individual woman's labour progress.

Programmed intermittent epidural bolus vs. patient-controlled epidural analgesia for maintenance of labour analgesia: a two-centre, double-blind, randomised study†

The programmed intermittent epidural bolus technique has shown superiority to continuous epidural infusion techniques, with or without patient-controlled epidural analgesia for pain relief, reduced motor block and patient satisfaction. Many institutions still use patient-controlled epidural analgesia without a background infusion, and a comparative study between programmed intermittent epidural bolus and patient-controlled epidural analgesia without a background infusion has not yet been performed. We performed a randomised, two-centre, double-blind, controlled trial of these two techniques. The primary outcome was the incidence of breakthrough pain requiring a top-up dose by an anaesthetist. Secondary outcomes included: motor block; pain scores; patient satisfaction; local anaesthetic consumption; and obstetric and neonatal outcomes. We recruited 130 nulliparous women who received initial spinal analgesia, and then epidural analgesia was initiated and maintained with either programmed intermittent epidural bolus or patient-controlled epidural analgesia using ropivacaine 0.12% with sufentanil 0.75 µg·ml^-1 . The programmed intermittent epidural bolus group had a programmed bolus of 10 ml every hour, with on-demand patient-controlled epidural analgesia boluses of 5 ml with a 20 min lockout, and the patient-controlled epidural analgesia group had a 5 ml bolus with a 12 min lockout interval; the potential maximum volume per hour was the same in both groups. The patients in the programmed intermittent epidural bolus group had less frequent breakthrough pain compared with the patient-controlled epidural analgesia group, 7 (10.9%) vs. 38 (62.3%; p < 0.0001), respectively. There was a significant difference in motor block (modified Bromage score ≤ 4) frequency between groups, programmed intermittent epidural bolus group 1 (1.6%) vs. patient-controlled epidural analgesia group 8 (13.1%); p = 0.015. The programmed intermittent epidural bolus group had greater local anaesthetic consumption with fewer patient-controlled epidural analgesia boluses. Patient satisfaction scores and obstetric or neonatal outcomes were not different between groups. In conclusion, we found that a programmed intermittent epidural bolus technique using 10 ml programmed boluses and 5 ml patient-controlled epidural analgesia boluses was superior to a patient-controlled epidural analgesia technique using 5 ml boluses and no background infusion.

Informed consent in obstetrics - a survey of pregnant women to set a new standard for consent in emergency obstetric interventions

Informed consent is necessary for all medical, surgical and obstetric interventions. Whilst informed consent can be obtained for elective procedures, it is much more challenging to obtain for emergency interventions. It can be difficult for women to understand the need for emergency intervention when pregnancy has been low risk. This can lead to problems with psychological trauma from the delivery being foremost in their minds in the postnatal period and in future pregnancies. The Montgomery ruling of 2015 encouraged informing women about risks and benefits of interventions and letting the women take responsibility for their own decision-making. Here, a patient-focused survey collected information on pregnant women's knowledge and wishes regarding emergency interventions. The responses were analysed in relation to local and Scottish national delivery data. We have initiated a novel programme to ensure all of our pregnant women are empowered to give informed consent for emergency interventions.IMPACT STATEMENTWhat is already known on this subject? There has been very little published on this subject to date and what has been published has involved focus groups or very small numbers of women.What do the results of this study add? This study adds significantly to our understanding of current Scottish and Highland regional delivery statistics to help foster realistic delivery expectations in our pregnant women. This study is the first to report on pregnant women's understanding of the possibility of requiring emergency intervention in labour and the relevant risks. It also highlights the fact that women prefer to get their information from community midwives, friends and family rather than their obstetricians or GPs. This study is also the first to report women's actual preferences and comments with regard to information provision, labour and delivery experiences and their wishes for the future.What are the implications of these findings for clinical practice and/or further research? The findings from this study have allowed us to develop and implement a novel means of obtaining informed consent in emergency obstetrics and the success of this programme will be reported following future analysis of patient experiences.

Women's epidural decision-making in labour: A Townsville perspective

BACKGROUND

Despite being an efficacious means of pain relief, there is a broad range of usage rates of epidural analgesia among countries worldwide. Australia sits between common usage in North America and more conservative usage in the UK. The reason for this is unclear, raising the question of whether there is a difference between Australia and other Western countries in pregnant women's attitudes toward epidural use, or the hospital context.

AIM

To explore predictors for epidural analgesia request among pregnant women in Townsville, Australia.

MATERIALS AND METHODS

A three-phase mixed methods exploratory study design, with Phase One involving 12 one-on-one interviews with pregnant and post-partum women regarding attitudes toward labour analgesia decision-making and epidural preferences. Interview data were analysed thematically to develop a survey distributed to 265 third-trimester women in Phase Two. Phase Three involved a chart review of survey participants to record delivery mode, epidural request and indication. Bivariate and logistic regression analysis of Phases Two and Three data were used to develop predictive models for epidural decision-making.

RESULTS

Interviews revealed several themes influencing analgesia preferences in Townsville women: concerns regarding personal safety, trust in health professionals, and previous experiences with labour. The logistic regression identified epidural request in labour to be predicted by: primiparity, epidural experience, induction or augmentation of labour, and perceived sense of control associated with epidural use.

CONCLUSIONS

This study suggests that the most significant influencers on Townsville women's epidural decision-making were parity, induction or augmentation of labour, previous experience of epidurals and attitude toward epidurals.

Epidural analgesia during labour and stress markers in the newborn

Labour and modes of delivery can influence the plasma levels of stress hormones and cytokines involved in pathophysiologic cascade, potentially damaging brain development of the newborn. This prospective observational, single-centre, case-control, non-profit study aimed to detect potential differences in foetal well-being such as stress neuroendocrine responses. Quantitative determinations of the stress markers interleukin (IL)-1β, IL-8, and β-endorphin were compared between the control group and the epidural analgesia group. We found higher IL1-β levels but lower IL-8 and β-endorphin levels in the epidural analgesia group than in the control group. No significant inter-group differences were observed for any parameters. Our findings demonstrate that epidural analgesia for pain relief during labour does not result in significant differences in blood stress response markers.IMPACT STATEMENTWhat is already known on this subject? We already know that plasma levels of stress hormones and cytokines are influenced by labour and delivery modes. This has a deep impact on the newborn in terms of brain damage, immune system deficits, and altered hypothalamic-pituitary axis responses. We also know that epidural analgesia is a widespread practice that offers pain relief to the woman in labour, but there are few studies on the potentially negative effects of epidural labour analgesia on the unborn child.What do the results of this study add? This study found no significative differences in blood stress response markers between the epidural analgesia group and the control group. Under this study circumstances we found out that epidural analgesia does not significantly influence the newborn's well-being during labour and delivery.What are the implications of these findings for clinical practice and/or further research? These findings must be confirmed by further studies to verify whether epidural analgesia is safe for the newborn's development.

Oxycodone for pain management in the latent phase of labour - A pragmatic trial

BACKGROUND

Parenteral opioids are used for pain relief in labour but there are little data for oxycodone in this context. The aim of this study was to evaluate the efficacy, foetal exposure and safety of subcutaneous oxycodone in the latent phase of labour.

METHODS

This pragmatic trial included 76 parturients, who received subcutaneous oxycodone for pain relief in the latent phase of labour according to the hospital protocol: an initial dose 0.1 mg/kg, and a second dose, 0.05 mg/kg, could be administered four hours later. Pain intensity and pain relief were assessed using a numerical rating scale of 0-10. After delivery, blood samples from the maternal and umbilical veins were collected, and plasma concentrations of oxycodone and its main metabolites were quantified using UPLC-MS/MS. The Apgar scores and maternal and neonatal adverse effects were recorded.

RESULTS

The foetal exposure at birth was low, the median oxycodone and oxymorphone umbilical vein plasma concentrations were 1.2 ng/mL (range 0.21-7.8) and 0.14 ng/mL (0-0.26), respectively. Pain scores decreased substantially, from a median pain score of 7/10 before oxycodone to median scores of 5/10 at 30 minutes after administration, 5/10 at 60 minutes and 6/10 at 120 minutes. The median Apgar score was 9 (range 2-10) at 1 minute and 9 (6-10) at 5 minutes. Maternal adverse effects were mild, and there were no oxycodone-related neonatal adverse effects.

CONCLUSION

Subcutaneous oxycodone provided effective analgesia during the latent phase of labour. Newborn exposure at birth was low, and oxycodone was well-tolerated.

Sharpey-Schafer Lecture 2019: From retroviruses to human birth

NEW FINDINGS

What is the topic of this review? The timing of birth is an important determinant of future health and well-being. This review examines the role of endogenous retroviruses as upstream regulators of key biological functions of the placenta, including cell-cell fusion, modulation of the maternal immune system, and the production of key pregnancy hormones. What advances does it highlight? Endogenous retroviruses are an obligate requirement for successful human reproduction. The products of retroviral elements, incorporated into the germline millions of years ago, have been co-opted to serve vital biological roles within the placenta that ultimately dictate the length of human pregnancy and therefore well-being trajectories.

ABSTRACT

Gestational length at the time of birth is an important determinant of future health and well-being, yet the physiological regulation of the onset of labour in humans remains obscure. The evolution of egg formation and internal fertilisation in amniotes required a mechanism to suppress the contractile activity of the oviduct that is provided by progesterone. Delivery of the egg is then associated with the withdrawal of progesterone and a return of contractile activity to the reproductive tract. In mammals, the process of pregnancy is complicated further by the need to protect the fetus from potential attack by the maternal immune system. There is increasing evidence that retroviruses incorporated into the mammalian germline in the evolutionary past play a key role in suppressing the maternal immune reaction to the developing conceptus, organising the development of the placenta and perhaps, in humans, modulating the action of progesterone, determining gestational length and the onset of labour. It seems that the presence of an endogenous retrovirus is an obligate requirement for human reproduction.

Comparison of cross-legged sitting position with the traditional sitting position for the ease of insertion of an epidural catheter in parturient for providing labour analgesia: A randomised control trial

Background and Aims:

The patient's position during the insertion of the epidural catheter plays a major role in the success of labour analgesia. In our study, we compared the ease of insertion of the epidural catheter in either traditional sitting position (TSP) or crossed-legged sitting position (CLSP). The primary objective was to compare the number of successful first attempts at epidural placement between the groups. Secondary objective included patient comfort, ease of landmark palpation and the number of needle-bone contacts.

Methods:

The prospective non-blinded randomised control study was conducted on 50 parturient with uncomplicated pregnancy during active labour. Patients were randomly assigned into two groups using a computer-generated random sequence of numbers by closed envelope technique. Group TSP received epidural in a traditional sitting position and group CLSP received an epidural in a crossed-legged sitting position with knee and hip flexed.

Results:

The parturient in both groups were comparable with respect to the distribution of age, height, weight and parity. The baseline visual analogue score (VAS) and VAS scores at 15 min were comparable between groups. Percentage of a parturient with successful epidural placement in the first attempt was higher in CLSP group than in TSP group (88% versus 44%, P = 0.004). The landmark, needle-bone contact and comfort during positioning were comparable between the two groups.

Conclusion:

Cross-legged sitting position is a better position than the traditional sitting position for the ease of insertion of labour epidural catheter.

Birth preparation acupuncture for normalising birth: An analysis of NHS service routine data and proof of concept

A number of studies show that acupuncture may help with labour and delivery. An NHS maternity acupuncture service providing birth preparation acupuncture has assessed its routine hospital maternity annual data from 2014 to 2016 to see what effect it had on labour and delivery outcomes. The data from this service was analysed and women who had birth preparation acupuncture were compared with those who did not receive it. Maternal age, parity and socio-economic status were considered confounders and were adjusted for in the analysis. Women who received acupuncture had more normal births (less surgical births) [OR 0.76 (0.64, 0.91)], required less intrapartum analgesia [OR 0.74 (0.63, 0.86)], fewer components of an induction of labour [OR 0.74 (0.61, 0.91)] and a reduced length of a hospital stay [OR 0.91 (0.87, 0.95)]. The patients highly valued the availability of acupuncture within the maternity service as it enhanced their patient journey.Impact statementWhat is already known on this subject? Numerous studies provide evidence for the effects of acupuncture in normalising pregnancy and birth. These effects include musculoskeletal preparation of the pelvis, cervical ripening, enhancing endogenous oxytocin release, and analgesic properties.What do the results of this study add? Our analysis shows that women who received birth preparation acupuncture had fewer surgical births, required less intrapartum analgesia, less components of induction of labour and had a reduced length of hospital stay, supporting the use of maternity acupuncture in normalising birth outcomes.What are the implications of these findings for clinical practice and/or further research? The findings show that acupuncture, by potentially normalising birth, may lead to reductions in costs of service. Further, additional research is required to see whether acupuncture is cost effective and could have an adjunctive role as a complementary therapy for improving birth outcomes and a woman's experience of childbirth.

Variation in competent and respectful delivery care in Kenya and Malawi: a retrospective analysis of national facility surveys

Objective

Although substantial progress has been made in increasing access to care during childbirth, reductions in maternal and neonatal mortality have been slower. Poor‐quality care may be to blame. In this study, we measure the quality of labour and delivery services in Kenya and Malawi using data from observations of deliveries and explore factors associated with levels of competent and respectful care.

Methods

We used data from nationally representative health facility assessment surveys. A total of 1100 deliveries in 392 facilities across Kenya and Malawi were observed and quality was assessed using two indices: the quality of the process of intrapartum and immediate postpartum care (QoPIIPC) index and a previously validated index of respectful maternity care. Data from standardised observations of care were analysed using descriptive statistics and multivariable random‐intercept regression models to examine factors associated with variation in quality of care. We also quantified the variance in quality explained by each domain of covariates (patient‐, provider‐ and facility‐level and subnational divisions).

Results

Only 61–66% of basic elements of competent and respectful care were performed. In adjusted models, better‐staffed facilities, private hospitals and morning deliveries were associated with higher levels of competent and respectful care. In Malawi, younger, primipara and HIV‐positive women received higher‐quality care. Quality also differed substantially across regions in Kenya, with a 25 percentage‐point gap between Nairobi and the Coast region. Quality was also higher in higher‐volume facilities and those with caesarean section capacity. Most of the explained variance in quality was due to regions in Kenya and to facility, and patient‐level characteristics in Malawi.

Conclusions

Our findings suggest considerable scope for improvement in quality. Increasing staffing and shifting births to higher‐volume facilities – along with promotion of respectful care in these facilities – should be considered in sub‐Saharan Africa to improve outcomes for mothers and newborns.