The Israel perinatal census

Obstetric anesthesia services in Israel snapshot (OASIS) study: a 72 hour cross-sectional observational study of workforce supply and demand

Background

We planned an observational study to assess obstetric anesthesia services nationwide. We aimed to assess the effect of the anesthesia workload/workforce ratio on quality and safety outcomes of obstetric anesthesia care.

Methods

Observers prospectively collected data from labor units over 72 h (Wednesday, Thursday and Friday). Independent variables were workload (WL) and workforce (WF). WL was assessed by the Obstetric Anesthesia Activity Index (OAAI), which is the estimated time in a 24-h period spent on epidurals and all cesarean deliveries. Workforce (WF) was assessed by the number of anesthesiologists dedicated to the labor ward per week. Dependent variables were the time until anesthesiologist arrival for epidural (quality measure) and the occurrence of general anesthesia for urgent Cesarean section, CS, (safety measure). This census included vaginal deliveries and unscheduled (but not elective) CS.

Results

Data on 575 deliveries are from 12 maternity units only, primarily because a major hospital chain chose not to participate; eight other hospitals lacked institutional review board approval. The epidural response rate was 94.4%; 321 of 340 parturients who requested epidural analgesia (EA) received it. Of the 19 women who requested EA but gave birth without it, 14 (77%) were due to late arrival of the anesthesiologist. Median waiting times for anesthesiologist arrival ranged from 5 to 28 min. The OAAI varied from 4.6 to 25.1 and WF ranged from 0 to 2 per shift. Request rates for EA in hospitals serving predominantly orthodox Jewish communities and in peripheral hospitals were similar to those of the entire sample. More than a fifth (13/62; 21%) of the unscheduled CS received general anesthesia, and of these almost a quarter (3/13; 23%) were attributed to delayed anesthesiologist arrival.

Conclusions

Inadequate WF allocations may impair quality and safety outcomes in obstetric anesthesia services. OAAI is a better predictor of WL than delivery numbers alone, especially concerning WF shortage. To assess the quality and safety of anesthetic services to labor units nationally, observational data on workforce, workload, and clinical outcomes should be collected prospectively in all labor units in Israel.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13584-021-00460-2.

Collecting population-based perinatal data efficiently: the example of the Lebanese National Perinatal Survey

We describe the methodology and the main results of the Lebanese perinatal health survey. The survey was carried out during two consecutive weeks in autumn 1999 and spring 2000, with the aim of obtaining a minimum data set on all births occurring during a short period of time. All live births and stillbirths occurring during these periods in medical settings were recorded. The sample included 5231 women and 5333 newborns. Data were obtained from medical records and by interviewing the women in hospital after delivery. All maternity units and birth centres agreed to participate. Maternal characteristics, medical care during pregnancy and delivery, and pregnancy outcome were similar for the two study periods. However, gestational age distribution differed between the two periods. In total, 9.0% of infants were born < 37 weeks of gestation and 7.0% weighed < 2500 g at birth. Wide regional variations were observed for many indicators of health, care and risk factors. For instance, the caesarean section rate varied from 16.2% in the North Region to 28.0% in Beirut. The survey protocol was successfully applied in Lebanon and may be useful in other countries that have a relatively well-developed healthcare system, but few sources of reliable population-based statistics on health and medical care. This type of survey may also be an appropriate instrument for collecting additional data for health policy evaluations.

Vaginal birth following two cesarean deliveries--are the risks exaggerated?

BACKGROUND

Prior to 1996, most women who had undergone two previous cesarean deliveries were offered only cesarean delivery at Al-Hasa Health Centre. A policy of trial of labor was instituted in 1996. We compared the outcome of trial of labor versus cesarean delivery in women with a history of two previous cesarean deliveries who delivered between 1997 and 2002.

PATIENTS AND METHODS

All patients with a history of two previous lower segment cesarean deliveries were included in the study. Those considered suitable were permitted a trial of labor that was neither induced nor augmented at any stage.

RESULTS

Of the 205 patients in the study, 66 delivered vaginally (32.2%), 68 had an emergency cesarean delivery (33.2%), and 71 an elective cesarean delivery (34.6%). No scar dehiscence was observed, nor was hysterectomy performed in either group. The rate of complications was lower in the vaginal delivery group (4.5%) than in the cesarean delivery group (19.4%).

CONCLUSION

Trial of labor in women with a history of two cesarean deliveries is a reasonable consideration, and when carried out without the use of oxytocics or prostaglandins, is associated with reduced maternal morbidity with no difference in perinatal morbidity.

Thickness of the lower uterine segment: its influence in the management of patients with previous cesarean sections

OBJECTIVE

To determine how ultrasound measurement of the lower uterine segment affects the decision about delivery for patients with previous cesarean sections (CS) and what are the consequences on cesarean section rates and uterine rupture or dehiscence.

DESIGN

Prospective open study.

PATIENTS

198 patients: all women with a previous CS who gave birth in our department during 1995 and 1996 to an infant with a gestational age of at least 36 weeks and who underwent ultrasound measurement of their lower uterine segment (95-96 study group), compared with a similar population from 1989 to 1994 whose measurements were not provided to the treating obstetrician.

RESULTS

Among the patients with one previous CS, the vaginal delivery rate did not differ significantly during the two periods (70.3% for the 89-94 study period vs. 67.9% for the 95-96 study period, P=0.53), but the 95-96 study group experienced a significant increase in the rate of elective CS, compensated by a reduction in the rate of emergency CS (6.3% and 23.4%, respectively, for the 89-94 study period vs. 11.9% and 20.1% for the 95-96 study period, P=0.01). There was a very significant increase in the rate of vaginal delivery for the 95-96 study period among patients with two previous CS (26.7% vs. 8.0% for the 89-95 study period, P=0.01). The lower uterine segment was significantly thicker among women with a trial of labor than among those with an elective CS (4.5+/-1.4 mm compared with 3.8 +/- 1.5 mm; P=0.006); and the trial of labor group contained significantly fewer women with a lower uterine segment measurement less than 3.5 mm than did the elective CS group (24.0% compared with 56.6%; P<0.001). Two patients (0.8%) were found to have a defect of the uterine scar, a rate significantly lower than that observed in the early group (3.9%, P=0.03).

CONCLUSIONS

Ultrasound measurement of the lower uterine segment can increase the safe use of trial of labor, because it provides an additional element for assessing the risk of uterine rupture.

Management of breech presentation: the 1993 Israeli census

OBJECTIVES

To investigate current attitudes to management of labor and delivery in pregnancies complicated by breech presentation.

STUDY DESIGN

A questionnaire was sent to the directors of 23 units of maternal-fetal medicine, all members of the Israel Society of Perinatal Obstetricians. The survey included 69,072 deliveries in the year 1993. Current world literature on the topics included in the survey was also reviewed.

RESULTS

The overall response rate was 83% (19/23). The overall breech presentation rate was 3.4%, and overall caesarean section rate was 11.2%. In breech presentation, the caesarean section rate was 63.6%.

CONCLUSIONS

A rational approach allows vaginal breech delivery to be practiced in almost half of carefully selected cases. These results again emphasize the longstanding need for prospective randomized studies regarding the different aspects associated with the delivery of the fetus in breech presentation.