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Arslan E, Einerson BD, Zhang J, Zhang J, Branch DW. The Effect of "Off Hours" on Maternal and Perinatal Outcomes in a Diverse U.S. Cohort. Am J Perinatol 2024; 41:89-97. [PMID: 34856608 DOI: 10.1055/s-0041-1740119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study aimed to evaluate the "off-hour effect" on maternal and neonatal adverse events in a large cohort representing U.S. POPULATION STUDY DESIGN A secondary analysis of the Consortium on Safe Labor (CSL) dataset with 208,695 women and 229,385 deliveries was performed. The study included the deliveries of ≥23 gestational weeks from 19 hospitals in the United States from 2002 to 2008. Babies with congenital anomalies were excluded from neonatal outcomes. We compared maternal and neonatal outcomes of patients delivered during weekdays versus off hours (nights and weekends). The primary outcomes of the study were composite maternal and composite neonatal adverse events. The secondary outcomes were delivery type and individual maternal and neonatal adverse events including maternal death and perinatal mortality rate. Associations between off hours and all the outcomes were analyzed in bivariable and multivariable analyses. The same analyses were performed in strata by indication for admission (spontaneous labor or induction of labor). RESULTS Composite maternal adverse events (6.19 vs. 6.06%, p = 0.41) and maternal death (0.01 vs. 0.01%, p = 0.19) were not significantly different between off hours and weekday groups. In contrast, composite neonatal adverse events (6.91 vs. 5.84%, p < 0.001) and perinatal mortality rate (1.03 vs. 0.77%, p < 0.001) were higher in the off-hour group. After adjusting for confounding variables, only the composite neonatal outcome continued to be associated with off hours (adjusted odds ratio [aOR] = 1.10, 95% confidence interval [CI]: 1.04-1.16). Stratified analyses showed that the off-hour effect for the neonatal composite outcome was not present in those presenting in spontaneous labor (6.1 vs. 5.9%, p = 0.40). CONCLUSION Off-hour delivery was not associated with severe maternal morbidity and was only modestly associated with severe neonatal morbidity. This association was observed in women undergoing induction, not in those presenting in spontaneous labor. These data draw into question the existence of a clinically meaningful and correctable "off-hour effect" in obstetrics. KEY POINTS · The presence of a significant off-hour effect in obstetrics is still questionable.. · If the off-hour effect exists, it seems that not to be related with staffing issues.. · There is not a big difference for adverse events at off hours in spontaneously laboring patients..
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Affiliation(s)
- Erol Arslan
- Division of Maternal Fetal Medicine, University of Utah Health Sciences, Salt Lake City, Utah
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Health Sciences, Van Training and Research Hospital, Van/Turkey
| | - Brett D Einerson
- Division of Maternal Fetal Medicine, University of Utah Health Sciences, Salt Lake City, Utah
- Division of Maternal Fetal Medicine, Intermountain Health Care, Murray, Utah
| | - Jingwen Zhang
- Ministry of Education, Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Zhang
- Ministry of Education, Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - D Ware Branch
- Division of Maternal Fetal Medicine, University of Utah Health Sciences, Salt Lake City, Utah
- Division of Maternal Fetal Medicine, Intermountain Health Care, Murray, Utah
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Slade L, Digance G, Bradley A, Woodman R, Grivell R. Change in timing of induction protocol in nulliparous women to optimise timing of birth: results from a single centre study. BMC Pregnancy Childbirth 2022; 22:316. [PMID: 35418020 PMCID: PMC9008892 DOI: 10.1186/s12884-022-04663-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 03/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Induction of labour (IOL) is a common obstetric intervention. When planning IOL, especially in women at risk for complications at delivery, the aim should be for delivery to occur when senior staff are available to optimise safe care. METHODS A change in timing of IOL protocol at our institution was introduced in November 2018 aiming to increase births occurring "in-hours" defined as 08:00 to 20:00 h. This retrospective cohort study compares the odds of "in-hours" birth before and after the intervention and the association on birth outcomes. The study compared outcomes during the new IOL pathway period to a historical birth cohort from January to December 2017. Inclusion criteria were nulliparous women undergoing planned IOL at term with a cephalic singleton pregnancy. Logistic regression was used to compare odds of in-hours birth for the 2 periods with adjustment for maternal age at delivery, gestation, more than 2 cervical ripening agents required, undergoing IOL for post-dates pregnancy, mode of birth, whether or not IOL proceeded according to planned protocol and missing values using multiple imputation. RESULTS The rate of deliveries occurring in-hours were higher following the intervention; n = 118/285 (45.6%) pre-intervention versus n = 251/470 (53.4%) post-intervention; adjusted OR = 1.47, 95% CI = 1.07-2.01, p = 0.02). The percentage of caesarean sections (CS) occurring in-hours was significantly lower in the pre-intervention group n = 71/153 (28.3%) compared with the post intervention group = 35/132(46.4%) (p < 0.001)). The rate of CS was higher in the pre intervention n = 132/285(46.3%) compared with the post intervention group n = 153/470 (32.4%)). CONCLUSIONS The change in induction procedures was associated with a significantly higher rate of births occurring in-hours and a lower rate of overall of CS. This policy change led to a better pattern of timing of birth for nulliparous women undergoing IOL.
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Affiliation(s)
- Laura Slade
- Flinders Medical Centre, Adelaide, SA, Australia.
| | | | | | - Richard Woodman
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA, Australia
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24 hour consultant obstetrician presence on the labour ward and intrapartum outcomes in a large unit in England: A time series analysis. PLoS One 2021; 16:e0249233. [PMID: 33788880 PMCID: PMC8011758 DOI: 10.1371/journal.pone.0249233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 03/15/2021] [Indexed: 11/19/2022] Open
Abstract
Objectives To explore the effect of introducing 24/7 resident labour ward consultant presence on neonatal and maternal outcomes in a large obstetric unit in England. Design Retrospective time sequence analysis of routinely collected data. Setting Obstetric unit of large teaching hospital in England. Participants Women and babies delivered between1 July 2011 and 30 June 2017. Births <24 weeks gestation or by planned caesarean section were excluded. Main outcome measures The primary composite outcome comprised intrapartum stillbirth, neonatal death, babies requiring therapeutic hypothermia, or admission to neonatal intensive care within three hours of birth. Secondary outcomes included markers of neonatal and maternal morbidity. Planned subgroup analyses investigated gestation (<34 weeks; 34–36 weeks; ≥37 weeks) and time of day. Results 17324 babies delivered before and 16110 after 24/7 consultant presence. The prevalence of the primary outcome increased by 0.65%, from 2.07% (359/17324) before 24/7 consultant presence to 2.72% (438/16110, P < 0.001) after 24/7 consultant presence which was consistent with an upward trend over time already well established before 24/7 consultant presence began (OR 1.09 p.a.; CI 1.04 to 1.13). Overall, there was no change in this trend associated with the transition to 24/7. However, in babies born ≥37 weeks gestation, the upward trend was reversed after implementation of 24/7 (OR 0.67 p.a.; CI 0.49 to 0.93; P = 0.017). No substantial differences were shown in other outcomes or subgroups. Conclusions Overall, resident consultant obstetrician presence 24/7 on labour ward was not associated with a change in a pre-existing trend of increasing adverse infant outcomes. However, 24/7 presence was associated with a reversal in increasing adverse outcomes for term babies.
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Rahim A, Lock G, Cotzias C. Incidence of second-stage (fully dilated) cesarean sections and how best to represent it: A multicenter analysis. Int J Gynaecol Obstet 2021; 156:119-123. [PMID: 33715159 DOI: 10.1002/ijgo.13672] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/23/2021] [Accepted: 03/11/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To gather multicenter data on the incidence of second-stage cesarean sections and suggest alternative methods by which the data can be represented. METHODS Retrospective, observational study over a 12-month study period. Numbers of term, singleton live births were collated from each of six maternity units. Data were separated by mode of delivery-unassisted vaginal birth, assisted (instrumental) vaginal delivery and elective, first-stage, and second-stage cesarean sections. Second-stage cesarean sections were expressed as a proportion of all deliveries, of all laboring women (i.e. excluding elective cesarean sections), and all women who reach full dilatation (i.e. excluding elective and first-stage cesarean sections). RESULTS Of the 28 867 deliveries included in the analysis, 493 of these were second-stage cesarean sections. This represented an incidence of 1.7% of all deliveries, 2.0% of all women in labor, and 2.5% of all women who reach full dilatation. CONCLUSION Second-stage cesarean sections continue to be common. Safe delivery of a deeply impacted fetal vertex is essential in modern obstetric practice.
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Affiliation(s)
- Asad Rahim
- St Mary's Hospital, Imperial College NHS Trust, London, UK
| | - Gareth Lock
- West Middlesex Hospital, Chelsea and Westminster NHS Trust, London, UK
| | - Christina Cotzias
- West Middlesex Hospital, Chelsea and Westminster NHS Trust, London, UK
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Davis G, Ludlow J. Delivery in the second stage in theatre: Does consultant presence make a difference? A pilot study. Aust N Z J Obstet Gynaecol 2019; 59:730-733. [DOI: 10.1111/ajo.13026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 05/29/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Georgina Davis
- Department of Women's Health and Neonatology Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - Joanne Ludlow
- Department of Women's Health and Neonatology Royal Prince Alfred Hospital Sydney New South Wales Australia
- Discipline of Obstetrics, Gynaecology and Neonatology University of Sydney Sydney New South Wales Australia
- Ultrasound Care Sydney New South Wales Australia
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Skills training for operative vaginal birth. Best Pract Res Clin Obstet Gynaecol 2019; 56:11-22. [DOI: 10.1016/j.bpobgyn.2018.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 09/21/2018] [Accepted: 10/05/2018] [Indexed: 11/19/2022]
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Reid HE, Wittkowski A, Vause S, Heazell AEP. 'Just an extra pair of hands'? A qualitative study of obstetric service users' and professionals' views towards 24/7 consultant presence on a single UK tertiary maternity unit. BMJ Open 2018; 8:e019977. [PMID: 29511017 PMCID: PMC5855205 DOI: 10.1136/bmjopen-2017-019977] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To explore the views of maternity service users and professionals towards obstetric consultant presence 24 hours a day, 7 days a week. DESIGN Semistructured interviews conducted face to face with maternity service users and professionals in March and April 2016. All responses were analysed together (ie, both service users' and professionals' responses) using an inductive thematic analysis. SETTING A large tertiary maternity unit in the North West of England that has implemented 24/7 obstetric consultant presence. PARTICIPANTS Antenatal and postnatal inpatient service users (n=10), midwives, obstetrics and gynaecology specialty trainees and consultant obstetricians (n=10). RESULTS Five themes were developed: (1) 'Just an extra pair of hands?' (the consultant's role), (2) the context, (3) the team, (4) training and (5) change for the consultant. Respondents acknowledged that obstetrics is an acute specialty, and consultants resolve intrapartum complications. However, variability in consultant experience and behaviour altered perception of its impact. Service users were generally positive towards 24/7 consultant presence but were not aware that it was not standard practice across the UK. Professionals were more pragmatic and discussed how the implementation of 24/7 working had affected their work, development of trainees and potential impacts on future consultants. CONCLUSIONS The findings raised several issues that should be considered by practitioners and policymakers when making decisions about the implementation of 24/7 consultant presence in other maternity units, including attributes of the consultants, the needs of maternity units, the team hierarchy, trainee development, consultants' other duties and consultant absences.
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Affiliation(s)
- Holly E Reid
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St. Mary's Hospital, Manchester, UK
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust, Department of Clinical Psychology, Wythenshawe Hospital, Manchester, UK
| | - Anja Wittkowski
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust, Department of Clinical Psychology, Wythenshawe Hospital, Manchester, UK
| | - Sarah Vause
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St. Mary's Hospital, Manchester, UK
- Manchester University NHS Foundation Trust, St. Mary's Hospital, Manchester, UK
| | - Alexander E P Heazell
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St. Mary's Hospital, Manchester, UK
- Manchester University NHS Foundation Trust, St. Mary's Hospital, Manchester, UK
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O'Dwyer S. Re: The effect of senior obstetric presence on maternal and neonatal outcomes in UK NHS maternity units: a systematic review and meta-analysis: Time to re-consider Safer Childbirth's 168-hours recommendation. BJOG 2017; 124:1909-1910. [PMID: 28791788 DOI: 10.1111/1471-0528.14799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Sabrina O'Dwyer
- Department of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Imperial Healthcare NHS Trust, London, UK
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Reid HE, Hayes DJ, Wittkowski A, Vause S, Heazell AE. Authors' reply re: The effect of senior obstetric presence on maternal and neonatal outcomes in UK NHS maternity units: a systematic review and meta-analysis. BJOG 2017; 124:1910-1911. [PMID: 28791764 DOI: 10.1111/1471-0528.14800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Holly E Reid
- Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, Maternal and Fetal Health Research Centre, School of Medical Sciences, University of Manchester, Manchester, UK.,Greater Manchester Mental Health NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Dexter Jl Hayes
- Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, Maternal and Fetal Health Research Centre, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Anja Wittkowski
- Greater Manchester Mental Health NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK.,Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, School of Health Sciences, University of Manchester, Manchester, UK
| | - Sarah Vause
- Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, Maternal and Fetal Health Research Centre, School of Medical Sciences, University of Manchester, Manchester, UK.,Central Manchester University Hospitals NHS Foundation Trust, St Mary's Hospital, Manchester, UK
| | - Alexander Ep Heazell
- Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, Maternal and Fetal Health Research Centre, School of Medical Sciences, University of Manchester, Manchester, UK.,Central Manchester University Hospitals NHS Foundation Trust, St Mary's Hospital, Manchester, UK
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