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Butler SE, Wallace EM, Bisits A, Selvaratnam RJ, Davey MA. Induction of labor and cesarean birth in lower-risk nulliparous women at term: A retrospective cohort study. Birth 2024. [PMID: 38173333 DOI: 10.1111/birt.12806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 10/13/2023] [Accepted: 11/30/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVE To evaluate whether induction of labor (IOL) is associated with cesarean birth (CB) and perinatal mortality in uncomplicated first births at term compared with expectant management outside the confines of a randomized controlled trial. METHODS Population-based retrospective cohort study of all births in Victoria, Australia, from 2010 to 2018 (n = 640,191). Preliminary analysis compared IOL at 37 weeks with expectant management at that gestational age and beyond for uncomplicated pregnancies. Similar comparisons were made for IOL at 38, 39, 40, and 41 weeks of gestation and expectant management. The primary analysis repeated these comparisons, limiting the population to nulliparous women with uncomplicated pregnancies and excluding those with a medical indication for IOL. We compared perinatal mortality between groups using Chi-square tests and multivariable logistic regression for all other comparisons. Adjusted odds ratios and 99% confidence intervals were reported. p < 0.01 denoted statistical significance. RESULTS Among nulliparous, uncomplicated pregnancies at ≥37 weeks of gestation in Victoria, IOL increased from 24.6% in 2010 to 30.0% in 2018 (p < 0.001). In contrast to the preliminary analysis, the primary analysis showed that IOL in lower-risk nulliparous women was associated with increased odds of CB when performed at 38 (aOR 1.23(1.13-1.32)), 39 (aOR 1.31(1.23-1.40)), 40 (aOR 1.42(1.35-1.50)), and 41 weeks of gestation (aOR 1.43(1.35-1.51)). Perinatal mortality was rare in both groups and non-significantly lower in the induced group at most gestations. DISCUSSION For lower-risk nulliparous women, the odds of CB increased with IOL from 38 weeks of gestation, along with decreased odds of perinatal mortality at 41 weeks only.
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Affiliation(s)
- Sarah E Butler
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Euan M Wallace
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
- Department of Health, Melbourne, Victoria, Australia
| | - Andrew Bisits
- Department of Obstetrics and Gynaecology, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Roshan J Selvaratnam
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Mary-Ann Davey
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
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Selvaratnam RJ, Wallace EM, Rolnik DL, Mol BW, Butler SE, Bisits A, Lawson J, Davey MA. Elective induction of labour at full-term gestations and childhood school outcomes. J Paediatr Child Health 2023; 59:1028-1034. [PMID: 37294278 DOI: 10.1111/jpc.16449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 05/16/2023] [Accepted: 05/22/2023] [Indexed: 06/10/2023]
Abstract
AIM To explore the association between induction of labour at full-term gestations in low-risk nulliparous women and childhood school outcomes. METHODS A retrospective whole-of-population cohort study linking perinatal data to educational test scores at grades 3, 5 and 7 in Victoria, Australia. Low-risk nulliparous women with singleton pregnancies induced at 39 and 40 weeks without a medical indication were compared to those expectantly managed from that week of gestation. Multivariable logistic regressions were used as well as generalised estimating equations on longitudinal data. RESULTS At 39 weeks, there were 3687 and 103 164 infants in the induction and expectant arms, respectively. At 40 weeks' gestation, there were 7914 and 70 280 infants, respectively. Infants born to nulliparous women induced at 39 weeks' gestation had significantly poorer educational outcomes at grade 3 (adjusted odds ratio (aOR) = 1.39, 95% confidence interval (CI): 1.13-1.70) but not grades 5 (aOR = 1.05, 95% CI: 0.84-1.33) and 7 (aOR = 1.07, 95% CI: 0.81-1.40) compared to those expectantly managed. Infants born to nulliparous women induced at 40 weeks had comparable educational outcomes at grade 3 (aOR = 1.06, 95% CI: 0.90-1.25) but poorer educational outcomes at grades 5 (aOR = 1.23, 95% CI: 1.05-1.43) and 7 (aOR = 1.23, 95% CI: 1.03-1.47) compared to those expectantly managed. CONCLUSIONS There were inconsistent associations between elective induction of labour at full-term gestations in low-risk nulliparous women and impaired childhood school outcomes.
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Affiliation(s)
- Roshan J Selvaratnam
- The Ritchie Centre, Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
- Safer Care Victoria, Department of Health, Victorian Government, Melbourne, Victoria, Australia
| | - Euan M Wallace
- The Ritchie Centre, Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
- Department of Health, Victorian Government, Melbourne, Victoria, Australia
| | - Daniel L Rolnik
- The Ritchie Centre, Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Ben W Mol
- The Ritchie Centre, Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Sarah E Butler
- The Ritchie Centre, Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Andrew Bisits
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Obstetrics and Gynaecology, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Janna Lawson
- The Ritchie Centre, Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Mary-Ann Davey
- The Ritchie Centre, Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
- Safer Care Victoria, Department of Health, Victorian Government, Melbourne, Victoria, Australia
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Murphy VE, Jensen ME, Holliday EG, Giles WB, Barrett HL, Callaway LK, Bisits A, Peek MJ, Seeho SK, Abbott A, Robijn AL, Colditz PB, Searles A, Attia J, McCaffery K, Hensley MJ, Mattes J, Gibson PG. Effect of asthma management with exhaled nitric oxide versus usual care on perinatal outcomes. Eur Respir J 2022; 60:13993003.00298-2022. [PMID: 35777773 PMCID: PMC9669403 DOI: 10.1183/13993003.00298-2022] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/10/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Asthma exacerbations in pregnancy are associated with adverse perinatal outcomes. We aimed to determine whether fractional exhaled nitric oxide (F ENO)-based asthma management improves perinatal outcomes compared to usual care. METHODS The Breathing for Life Trial was a multicentre, parallel-group, randomised controlled trial conducted in six hospital antenatal clinics, which compared asthma management guided by F ENO (adjustment of asthma treatment according to exhaled nitric oxide and symptoms each 6-12 weeks) to usual care (no treatment adjustment as part of the trial). The primary outcome was a composite of adverse perinatal events (preterm birth, small for gestational age (SGA), perinatal mortality or neonatal hospitalisation) assessed using hospital records. Secondary outcomes included maternal asthma exacerbations. Concealed random allocation, stratified by study site and self-reported smoking status was used, with blinded outcome assessment and statistical analysis (intention to treat). RESULTS Pregnant women with current asthma were recruited; 599 to the control group (608 infants) and 601 to the intervention (615 infants). There were no significant group differences for the primary composite perinatal outcome (152 (25.6%) out of 594 control, 177 (29.4%) out of 603 intervention; OR 1.21, 95% CI 0.94-1.56; p=0.15), preterm birth (OR 1.14, 95% CI 0.78-1.68), SGA (OR 1.06, 95% CI 0.78-1.68), perinatal mortality (OR 3.62, 95% CI 0.80-16.5), neonatal hospitalisation (OR 1.24, 95% CI 0.89-1.72) or maternal asthma exacerbations requiring hospital admission or emergency department presentation (OR 1.19, 95% CI 0.69-2.05). CONCLUSION F ENO-guided asthma pharmacotherapy delivered by a nurse or midwife in the antenatal clinic setting did not improve perinatal outcomes.
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Affiliation(s)
- Vanessa E. Murphy
- Priority Research Centre Grow Up Well, University of Newcastle, and Hunter Medical Research Institute, Newcastle, Australia,School of Medicine and Public Health, Faculty of Health, University of Newcastle, and Hunter Medical Research Institute, Newcastle, Australia,Corresponding author: Vanessa E. Murphy ()
| | - Megan E. Jensen
- Priority Research Centre Grow Up Well, University of Newcastle, and Hunter Medical Research Institute, Newcastle, Australia,School of Medicine and Public Health, Faculty of Health, University of Newcastle, and Hunter Medical Research Institute, Newcastle, Australia
| | - Elizabeth G. Holliday
- School of Medicine and Public Health, Faculty of Health, University of Newcastle, and Hunter Medical Research Institute, Newcastle, Australia
| | - Warwick B. Giles
- Specialty of Obstetrics, Gynaecology and Neonatology, Sydney Medical School Northern, University of Sydney, Sydney, Australia
| | - Helen L. Barrett
- Queensland Diabetes and Endocrine Centre, Mater Health Services, South Brisbane, Australia,Mater Research Institute – The University of Queensland, St Lucia, Australia
| | - Leonie K. Callaway
- School of Medicine, University of Queensland, Brisbane, Australia,Obstetric Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Andrew Bisits
- Birthing Unit, Royal Hospital for Women Randwick, Randwick, Australia
| | - Michael J. Peek
- Australian National University Medical School, The Australian National University, Canberra, Australia,Department of Obstetrics and Gynaecology, Centenary Hospital for Women and Children, Canberra, Australia
| | - Sean K. Seeho
- Specialty of Obstetrics, Gynaecology and Neonatology, Sydney Medical School Northern, University of Sydney, Sydney, Australia
| | | | - Annelies L. Robijn
- Priority Research Centre Grow Up Well, University of Newcastle, and Hunter Medical Research Institute, Newcastle, Australia
| | - Paul B. Colditz
- Perinatal Research Centre, UQCCR, University of Queensland, Brisbane, Australia
| | | | - John Attia
- School of Medicine and Public Health, Faculty of Health, University of Newcastle, and Hunter Medical Research Institute, Newcastle, Australia
| | | | - Michael J. Hensley
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
| | - Joerg Mattes
- Priority Research Centre Grow Up Well, University of Newcastle, and Hunter Medical Research Institute, Newcastle, Australia,Paediatric Respiratory and Sleep Medicine Department, John Hunter Children's Hospital, Newcastle, Australia
| | - Peter G. Gibson
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia,Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
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Fox D, Coddington R, Scarf V, Bisits A, Lainchbury A, Woodworth R, Maude R, Foureur M, Sandall J. Harnessing technology to enable all women mobility in labour and birth: feasibility of implementing beltless non-invasive fetal ECG applying the NASSS framework. Pilot Feasibility Stud 2021; 7:214. [PMID: 34876233 PMCID: PMC8650358 DOI: 10.1186/s40814-021-00953-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 11/26/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND A new wireless and beltless monitoring device utilising fetal and maternal electrocardiography (ECG) and uterine electromyography, known as 'non-invasive fetal ECG' (NIFECG) was registered for clinical use in Australia in 2018. The safety and reliability of NIFECG has been demonstrated in controlled settings for short periods during labour. As far as we are aware, at the time our study commenced, this was globally the first trial of such a device in an authentic clinical setting for the entire duration of a woman's labour. METHODS This study aimed to assess the feasibility of using NIFECG fetal monitoring for women undergoing continuous electronic fetal monitoring during labour and birth. Women were eligible to participate in the study if they were at 36 weeks gestation or greater with a singleton pregnancy, planning to give birth vaginally and with obstetric indications as per local protocol (NSW Health Fetal Heart Rate Monitoring Guideline GL2018_025. 2018) for continuous intrapartum fetal monitoring. Written informed consent was received from participating women in antenatal clinic prior to the onset of labour. This single site clinical feasibility study took place between January and July 2020 at the Royal Hospital for Women in Sydney, Australia. Quantitative and qualitative data were collected to inform the analysis of results using the NASSS (Non-adoption, Abandonment, Scale up, Spread and Sustainability) framework, a validated tool for analysing the implementation of new health technologies into clinical settings. RESULTS Women responded positively about the comfort and freedom of movement afforded by the NIFECG. Midwives reported that when no loss of contact occurred, the device enabled them to focus less on the technology and more on supporting women's physical and emotional needs during labour. Midwives and obstetricians noticed the benefits for women but expressed a need for greater certainty about the reliability of the signal. CONCLUSION The NIFECG device enables freedom of movement and positioning for labouring women and was well received by women and the majority of clinicians. Whilst measurement of the uterine activity was reliable, there was uncertainty for clinicians in relation to loss of contact of the fetal heart rate. If this can be ameliorated the device shows potential to be used as routinely as cardiotocography (CTG) for fetal monitoring. This is the first time the NASSS framework has been used to synthesise the implementation needs of a health technology in the care of women during labour and birth. Our findings contribute new knowledge about the determinants for implementation of a complex technology in a maternity care setting. TRIAL REGISTRATION The Universal Trial Number is reU1111-1228-9845 and the Australian and New Zealand Clinical Trial Registration Number is 12619000293167p. Trial registration occurred on the 20 February, 2019. The trial protocol may be viewed at http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377027.
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Affiliation(s)
- Deborah Fox
- Centre for Midwifery Child and Family Health, University of Technology Sydney, Sydney, Australia.
| | - Rebecca Coddington
- Centre for Midwifery Child and Family Health, University of Technology Sydney, Sydney, Australia
| | - Vanessa Scarf
- Centre for Midwifery Child and Family Health, University of Technology Sydney, Sydney, Australia
| | - Andrew Bisits
- Royal Hospital for Women, NSW Health, Sydney, Australia
| | | | - Rachael Woodworth
- Centre for Midwifery Child and Family Health, University of Technology Sydney, Sydney, Australia
| | - Robyn Maude
- Victoria University of Wellington, Wellington, New Zealand
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Dahlen HG, Thornton C, Downe S, de Jonge A, Seijmonsbergen-Schermers A, Tracy S, Tracy M, Bisits A, Peters L. Intrapartum interventions and outcomes for women and children following induction of labour at term in uncomplicated pregnancies: a 16-year population-based linked data study. BMJ Open 2021; 11:e047040. [PMID: 34059509 PMCID: PMC8169493 DOI: 10.1136/bmjopen-2020-047040] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES We compared intrapartum interventions and outcomes for mothers, neonates and children up to 16 years, for induction of labour (IOL) versus spontaneous labour onset in uncomplicated term pregnancies with live births. DESIGN We used population linked data from New South Wales, Australia (2001-2016) for healthy women giving birth at 37+0 to 41+6 weeks. Descriptive statistics and logistic regression were performed for intrapartum interventions, postnatal maternal and neonatal outcomes, and long-term child outcomes adjusted for maternal age, country of birth, socioeconomic status, parity and gestational age. RESULTS Of 474 652 included births, 69 397 (15%) had an IOL for non-medical reasons. Primiparous women with IOL versus spontaneous onset differed significantly for: spontaneous vaginal birth (42.7% vs 62.3%), instrumental birth (28.0% vs 23.9%%), intrapartum caesarean section (29.3% vs 13.8%), epidural (71.0% vs 41.3%), episiotomy (41.2% vs 30.5%) and postpartum haemorrhage (2.4% vs 1.5%). There was a similar trend in outcomes for multiparous women, except for caesarean section which was lower (5.3% vs 6.2%). For both groups, third and fourth degree perineal tears were lower overall in the IOL group: primiparous women (4.2% vs 4.9%), multiparous women (0.7% vs 1.2%), though overall vaginal repair was higher (89.3% vs 84.3%). Following induction, incidences of neonatal birth trauma, resuscitation and respiratory disorders were higher, as were admissions to hospital for infections (ear, nose, throat, respiratory and sepsis) up to 16 years. There was no difference in hospitalisation for asthma or eczema, or for neonatal death (0.06% vs 0.08%), or in total deaths up to 16 years. CONCLUSION IOL for non-medical reasons was associated with higher birth interventions, particularly in primiparous women, and more adverse maternal, neonatal and child outcomes for most variables assessed. The size of effect varied by parity and gestational age, making these important considerations when informing women about the risks and benefits of IOL.
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Affiliation(s)
- Hannah G Dahlen
- School of Nursing and Midwifery, Western Sydney University, Penrith South, New South Wales, Australia
| | - Charlene Thornton
- School of Nursing and Midwifery, Western Sydney University, Penrith South, New South Wales, Australia
- College of Nursing and Health Sciences, Flinders University Faculty of Medicine Nursing and Health Sciences, Adelaide, South Australia, Australia
| | - Soo Downe
- School of Nursing and Midwifery, Western Sydney University, Penrith South, New South Wales, Australia
- Research in Childbirth and Health (ReaCH) Unit, University of Central Lancashire, Preston, Lancashire, UK
| | - Ank de Jonge
- School of Nursing and Midwifery, Western Sydney University, Penrith South, New South Wales, Australia
- Midwifery Science, AVAG, Amsterdam Public Health, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anna Seijmonsbergen-Schermers
- Midwifery Science, AVAG, Amsterdam Public Health, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Sally Tracy
- School of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Mark Tracy
- Westmead Newborn Intensive Care Unit, The University of Sydney Paediatrics and ChildHealth and WSLHD, Westmead, New South Wales, Australia
| | - Andrew Bisits
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Lilian Peters
- School of Nursing and Midwifery, Western Sydney University, Penrith South, New South Wales, Australia
- Midwifery Science, AVAG, Amsterdam Public Health, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Phipps H, Hyett JA, Kuah S, Pardey J, Matthews G, Ludlow J, Narayan R, Santiagu S, Earl R, Wilkinson C, Bisits A, Carseldine W, Tooher J, McGeechan K, de Vries B. Persistent occiput posterior position outcomes following manual rotation: a randomized controlled trial. Am J Obstet Gynecol MFM 2021; 3:100306. [PMID: 33418103 DOI: 10.1016/j.ajogmf.2021.100306] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 12/31/2020] [Accepted: 12/31/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Persistent occiput posterior position in labor is associated with adverse maternal and perinatal outcomes. Prophylactic manual rotation from the occiput posterior position to the occiput anterior position in the second stage of labor is considered a safe and easy to perform procedure that in observational studies has shown promise as a method for preventing operative deliveries. OBJECTIVE This study aimed to determine the efficacy of prophylactic manual rotation in the management of occiput posterior position for preventing operative delivery. The hypothesis was that among women who are at least 37 weeks pregnant and whose baby is in the occiput posterior position early in the second stage of labor, manual rotation will reduce the rate of operative delivery compared with the "sham" rotation. STUDY DESIGN A double-blinded, parallel, superiority, multicenter, randomized controlled clinical trial in 4 tertiary hospitals was conducted in Australia. A total of 254 nulliparous and parous women with a term pregnancy and a baby in the occiput posterior position in the second stage of labor were randomly assigned to receive either a prophylactic manual rotation (n=127) or a sham rotation (n=127). The primary outcome was operative delivery (cesarean, forceps, or vacuum delivery). Secondary outcomes were cesarean delivery, combined maternal mortality and serious morbidity, and combined perinatal mortality and serious morbidity. Analysis was by intention to treat. Proportions were compared using chi-square tests adjusted for stratification variables using the Mantel-Haenszel method or the Fisher exact test. Planned subgroup analyses by operator experience and by manual rotation technique (digital or whole-hand rotation) were performed. RESULTS Operative delivery occurred in 79 of 127 women (62%) assigned to prophylactic manual rotation and 90 of 127 women (71%) assigned to sham rotation (common risk difference, 12; 95% confidence interval, -1.7 to 26; P=.09). Among more experienced operators or investigators, operative delivery occurred in 46 of 74 women (62%) assigned to manual rotation and 52 of 71 women (73%) assigned to a sham rotation (common risk difference, 18; 95% confidence interval, -0.5 to 36; P=.07). Cesarean delivery occurred in 22 of 127 women (17%) in both groups. Instrumental delivery (forceps or vacuum) occurred in 57 of 127 women (45%) assigned to prophylactic manual rotation and 68 of 127 women (54%) assigned to sham rotation (common risk difference, 10; 95% confidence interval, -3.1 to 22; P=.14). There was no significant difference in the combined maternal and perinatal outcomes. CONCLUSION Prophylactic manual rotation did not result in a reduction in the rate of operative delivery. Given manual rotation was associated with a nonsignificant reduction in operative delivery, more randomized trials are needed, as our trial might have been underpowered. In addition, further research is required to further explore the potential impact of operator or investigator experience.
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Affiliation(s)
- Hala Phipps
- Sydney Institute for Women, Children and their Families, Sydney Local Health District, Sydney, New South Wales, Australia; Discipline of Obstetrics, Gynaecology and Neonatology, The University of Sydney, Sydney, New South Wales, Australia.
| | - Jon A Hyett
- Sydney Institute for Women, Children and their Families, Sydney Local Health District, Sydney, New South Wales, Australia; Royal Prince Alfred Hospital Women and Babies Ambulatory Care, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Sabrina Kuah
- Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - John Pardey
- Nepean Hospital, Penrith, New South Wales, Australia
| | - Geoff Matthews
- Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Joanne Ludlow
- Discipline of Obstetrics, Gynaecology and Neonatology, The University of Sydney, Sydney, New South Wales, Australia; Royal Prince Alfred Hospital Women and Babies Ambulatory Care, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Ultrasound Care, Sydney, New South Wales, Australia
| | - Rajit Narayan
- Royal Prince Alfred Hospital Women and Babies Ambulatory Care, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Stanley Santiagu
- Royal Prince Alfred Hospital Women and Babies Ambulatory Care, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Rachel Earl
- Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Chris Wilkinson
- Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Andrew Bisits
- Royal Hospital for Women, Sydney, New South Wales, Australia; Discipline of Obstetrics, Gynaecology and Neonatology, School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Wendy Carseldine
- Maternity and Gynaecology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Jane Tooher
- Sydney Institute for Women, Children and their Families, Sydney Local Health District, Sydney, New South Wales, Australia; Royal Prince Alfred Hospital Women and Babies Ambulatory Care, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kevin McGeechan
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Sydney, New South Wales, Australia
| | - Bradley de Vries
- Sydney Institute for Women, Children and their Families, Sydney Local Health District, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney School of Public Health, Sydney, New South Wales, Australia
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7
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Koh PR, Di Filippo D, Bisits A, Welsh AW. Bimanual examination for clot evacuation: a retrospective cohort study of women with postpartum haemorrhage after vaginal delivery. BMC Pregnancy Childbirth 2020; 20:245. [PMID: 32334562 PMCID: PMC7183670 DOI: 10.1186/s12884-020-02916-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 03/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bimanual clot evacuation (BCE) is a simple clinical manoeuvre that may reduce need for surgical intervention in the management of severe postpartum haemorrhage (PPH). We sought to determine whether performing BCE in cases of severe PPH after vaginal birth reduces the need for surgical intervention. METHODS A retrospective chart review of women who delivered vaginally with a severe PPH between January 1, 2011 and December 31, 2014 in a single tertiary women's hospital in Sydney, Australia was conducted. Severe PPH was classified as a blood loss ≥1000mls. The need for surgical management (including operating theatre uterine exploration or evacuation, intrauterine balloon tamponade, repair of significant trauma, uterine or internal iliac artery ligation, B-Lynch suture insertion or hysterectomy) was the primary outcome measure, as expressed by need for operating theatre utilisation. RESULTS From a cohort of 438, 149 women (34.0%) had BCE, of whom 29 (19.5%) required surgical management compared to 103 of 289 women with no BCE (35.6%); an odds ratio (OR) of 0.38 for BCE (confidence interval 0.20-0.72; p = 0.003). Early BCE (< 1 h of delivery) was associated with a further reduction in surgery (OR 0.24; confidence interval 0.08-0.70; p = 0.009) compared to late BCE (> 1 h of delivery). There was no reduction in estimated blood loss (p = 0.86) or blood transfusion (p = 0.71) with BCE. CONCLUSION Our study suggests BCE reduces theatre utilisation in the context of severe PPH following vaginal delivery. Prospective trials are needed to determine whether BCE should be endorsed as a treatment modality for PPH post-vaginal delivery.
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Affiliation(s)
- Pui Ru Koh
- School of Women's and Children's Health, University of New South Wales, Randwick, NSW, Australia
| | - Daria Di Filippo
- School of Women's and Children's Health, University of New South Wales, Randwick, NSW, Australia
| | - Andrew Bisits
- Department of Obstetrics, Royal Hospital for Women, Sydney, NSW, Australia
| | - Alec W Welsh
- School of Women's and Children's Health, University of New South Wales, Randwick, NSW, Australia. .,Department of Maternal-Fetal Medicine, Royal Hospital for Women, Locked Bag 2000, Barker Street, Randwick, NSW, 2031, Australia.
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Chevreul K, Shand A, Korb D, LeRoux E, Nassar N, Sibony O, Bisits A, Alberti C. Variations in the use of caesarean section: a Comparison between France and Australia. Eur J Public Health 2019. [DOI: 10.1093/eurpub/ckz185.203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
There has been a rise in obstetric intervention during labour and birth including rates of caesarean section around the world. The rates of caesarean section are lower in France (20%) than Australia (34%). Both countries have universal health care systems. Australia has a well-established program of obstetric benchmarking and national data collection for comparing maternal and perinatal outcomes taking into account maternity units and maternal characteristics. Although the optimal caesarean section rate is not known, variation in caesarean section rates raise questions about what is driving variation in practice and whether the right care is being delivered. The World Health Organisation has recently released non-clinical recommendations aiming to reduce unnecessary caesarean sections, including that births are classified by Robson classification for easier comparison.
Methods
We aim to compare rates of mode of birth in 2 tertiary hospitals- one in France and one in Australia using Robson classification. This project will investigate differences in patient casemix, and obstetric management that may lead to differences in outcome. In addition, we will try to explore differences in the health systems including clinical activity, induction rates, staffing (number, type (medical, nursing, midwifery)), and models of care.
Outcomes
Caesarean section is one of the most common operations performed in hospitals. Important variations of surgical rates raise question regarding whether access to this procedure is optimized. Determining current practice and outcomes of women in two different settings will provide important data to inform hospital practice and further research. In addition, this research may inform national guidelines about indications for caesarean section.
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Affiliation(s)
- K Chevreul
- AP-HP, Hospital Universitaire Robert-Debré, CIC-EC 1426, Obstetrics Department, Paris, France
- Université de Paris, UMR 1123 ECEVE, INSERM, Paris, France
| | - A Shand
- The University of Sydney, Sydney, Australia
- Royal Hospital for Women, Sydney, Australia
| | - D Korb
- AP-HP, Hospital Universitaire Robert-Debré, CIC-EC 1426, Obstetrics Department, Paris, France
- Université de Paris, INSERM U1153, EPOPé, INSERM, Paris, France
| | - E LeRoux
- AP-HP, Hospital Universitaire Robert-Debré, CIC-EC 1426, Obstetrics Department, Paris, France
- Université de Paris, UMR 1123 ECEVE, INSERM, Paris, France
| | - N Nassar
- The University of Sydney, Sydney, Australia
| | - O Sibony
- AP-HP, Hospital Universitaire Robert-Debré, CIC-EC 1426, Obstetrics Department, Paris, France
| | - A Bisits
- Royal Hospital for Women, Sydney, Australia
| | - C Alberti
- AP-HP, Hospital Universitaire Robert-Debré, CIC-EC 1426, Obstetrics Department, Paris, France
- Université de Paris, UMR 1123 ECEVE, INSERM, Paris, France
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9
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Affiliation(s)
- Brendon W H Lee
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Department of Obstetrics and Gynaecology, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Bronwyn Devine
- Department of Obstetrics and Gynaecology, Royal Hospital for Women, Sydney, New South Wales, Australia.,Department of Obstetrics and Gynaecology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Andrew Bisits
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Department of Obstetrics and Gynaecology, Royal Hospital for Women, Sydney, New South Wales, Australia.,Department of Maternity, Royal Hospital for Women, Sydney, New South Wales, Australia
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Abstract
Our primary objective was to compare neonatal and maternal outcomes in women with twin pregnancies, beyond 32 weeks, having a planned vaginal birth or a planned caesarean section (CS). This was a retrospective cohort study from a single tertiary centre over nine years. 534 sets of twins ≥32 + 0 weeks of gestation were included. 401 sets were planned vaginally and 133 sets were planned by CS. We compared a composite adverse perinatal outcome (perinatal mortality or serious neonatal morbidity; five minute APGAR score ≤4, neurological abnormality and need for intubation) and a composite maternal adverse outcome (major haemorrhage, trauma or infection) between the groups. There were no significant differences. Given the similarity of these results with several other larger studies of twin birth, we sought to look at reasons why there is still a rising rate of CS for twin births. We further make suggestions for keeping this rate to a sensible minimum. Impact statement What is already known on this subject? The largest randomised controlled study comparing planned vaginal birth with planned CSs for lower risk twins between 32 and 39 weeks of gestation, showed no added safety from planned CS. However, in most of the Western countries this conclusion has failed to increase the number of planned vaginal births for lower risk twins. What do the results of this study add? This observational study from a single tertiary centre provides external validation of the twin trial results in a practical day-to-day setting. It also provides insights as to how planned vaginal birth can be developed and maintained, with a key focus on safety and maternal participation in decision making. It does focus on consent and providing accurate data. What are the implications of these findings for clinical practice and/or further research? There are good grounds to encourage vaginal birth for low-risk twin pregnancies. The trend of rising caesarean rates in low-risk twin pregnancies worldwide will erode important skills for the conduct of vaginal births without any clear benefit for mothers or babies. The current situation demands careful thought about implementing innovative training opportunities for younger obstetricians. Finally, we need intelligent responses to many non-evidence-based factors which can drive clinical practice.
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Affiliation(s)
- A Reitter
- a Department of Obstetrics and Gynaecology , University Hospital Frankfurt, Goethe-University , Frankfurt , Germany
| | - B A Daviss
- b Department of Obstetrics and Gynaecology, Midwifery Division , Montfort Hospital , Ottawa , Canada
| | - M J Krimphove
- a Department of Obstetrics and Gynaecology , University Hospital Frankfurt, Goethe-University , Frankfurt , Germany
| | - K C Johnson
- c Department of Epidemiology and Community Medicine , University of Ottawa , Ottawa , Canada
| | - R Schlößer
- d Department of Pediatrics, Division Neonatology , University Hospital Frankfurt, Goethe-University , Frankfurt , Germany
| | - F Louwen
- a Department of Obstetrics and Gynaecology , University Hospital Frankfurt, Goethe-University , Frankfurt , Germany
| | - A Bisits
- e Department of Obstetrics and Gynecology, Royal Hospital for Women , University of New South Wales , Randwick , Australia
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11
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Bisits A. Response to 'Term breech delivery: Is recommending vaginal birth a breach of best practice?'. Aust N Z J Obstet Gynaecol 2017; 57:479. [PMID: 28766710 DOI: 10.1111/ajo.12668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 06/06/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Andrew Bisits
- Department of Maternity, Royal Hospital for Women, Sydney, New South Wales, Australia
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12
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Bisits A. There is a place in current obstetric practice for planned vaginal breech birth. Aust N Z J Obstet Gynaecol 2017; 57:372-374. [DOI: 10.1111/ajo.12643] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 04/17/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Andrew Bisits
- Department of Maternity; Royal Hospital for Women; Sydney New South Wales Australia
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13
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Affiliation(s)
- Andrew Bisits
- Director of Obstetrics and Gynaecology, Royal Hospital for Women, Randwick, New South Wales, Australia.
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14
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Abstract
OBJECTIVE The aim of this study was to explore the experiences of women who planned a vaginal breech birth. METHOD An online survey was developed consisting of questions regarding women's experiences surrounding planned vaginal breech birth. The survey was distributed between April 2014 and January 2015 to closed membership Facebook groups that had a consumer focus on vaginal breech birth. RESULTS In total, 204 unique responses to the survey were obtained from women who had sought the option of a vaginal breech birth in a previous pregnancy. Most women (80.8%) stated that they were happy with the birth choices they made, and a significant proportion (89.4%) would attempt a vaginal breech birth in subsequent pregnancies. Less than half of women were formally referred to a clinician skilled in vaginal breech birth when their baby was diagnosed breech (41.8%), while the remainder sourced a clinician themselves. Half of the women felt supported by their care provider (56.7%) and less than half (42.3%) felt supported by family and friends. CONCLUSION The women who responded to this international survey sought the option of a vaginal breech birth, were subsequently happy with this decision, and would attempt a vaginal breech birth in their next pregnancy. Access to vaginal breech birth is important for some women; however, this choice may be challenging to achieve. Consistent information and support from clinicians is important to assist decision-making.
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Affiliation(s)
| | | | | | - Andrew Bisits
- University of Technology Sydney, Sydney, NSW, Australia.,Director of Obstetrics at the Royal Hospital for Women, Randwick, NSW, Australia
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15
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Petrovska K, Watts N, Sheehan A, Bisits A, Homer C. How do social discourses of risk impact on women’s choices for vaginal breech birth? A qualitative study of women’s experiences. Health, Risk & Society 2016. [DOI: 10.1080/13698575.2016.1256378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Karolina Petrovska
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Nicole Watts
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Athena Sheehan
- School of Nursing and Midwifery, Western Sydney University, Penrith, Australia
| | - Andrew Bisits
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
- Department of Obstetrics and Gynaecology, Royal Hospital for Women, Randwick, Australia
| | - Caroline Homer
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
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16
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Coxon K, Homer C, Bisits A, Sandall J, Bick D. Erratum to 'Reconceptualising Risk in Childbirth' [Midwifery 38 (2016) 1-5]. Midwifery 2016; 42:101. [PMID: 27662699 DOI: 10.1016/j.midw.2016.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 09/02/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Kirstie Coxon
- King's College London, Florence Nightingale Faculty of Nursing and Midwifery, UK.
| | | | - Andrew Bisits
- Royal Hospital for Women, Barker St. Randwick, NSW 2031, Australia
| | - Jane Sandall
- King's College London, Division of Women's Health, School of Medicine, UK
| | - Debra Bick
- King's College London, Florence Nightingale Faculty of Nursing and Midwifery, UK
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17
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Watts NP, Petrovska K, Bisits A, Catling C, Homer CSE. This baby is not for turning: Women's experiences of attempted external cephalic version. BMC Pregnancy Childbirth 2016; 16:248. [PMID: 27561416 PMCID: PMC5000477 DOI: 10.1186/s12884-016-1038-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 08/11/2016] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Existing studies regarding women's experiences surrounding an External Cephalic Version (ECV) report on women who have a persistent breech post ECV and give birth by caesarean section, or on women who had successful ECVs and plan for a vaginal birth. There is a paucity of understanding about the experience of women who attempt an ECV then plan a vaginal breech birth when their baby remains breech. The aim of this study was to examine women's experience of an ECV which resulted in a persistent breech presentation. METHODS A qualitative descriptive exploratory design was undertaken. In-depth semi-structured interviews were conducted and analysed thematically. RESULTS Twenty two (n = 22) women who attempted an ECV and subsequently planned a vaginal breech birth participated. Twelve women had a vaginal breech birth (55 %) and 10 (45 %) gave birth by caesarean section. In relation to the ECV, there were five main themes identified: 'seeking an alternative', 'needing information', 'recounting the ECV experience', 'reacting to the unsuccessful ECV' and, 'reflecting on the value of an ECV'. CONCLUSIONS ECV should form part of a range of options provided to women, rather than a default procedure for management of the term breech. For motivated women who fit the safe criteria for vaginal breech birth, not being subjected to a painful experience (ECV) may be optimal. Women should be supported to access services that support vaginal breech birth if this is their choice, and continuity of care should be standard practice.
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Affiliation(s)
- N P Watts
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - K Petrovska
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - A Bisits
- Royal Hospital for Women, Sydney, Australia
| | - C Catling
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - C S E Homer
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Sydney, Australia.
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18
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Murphy VE, Jensen ME, Mattes J, Hensley MJ, Giles WB, Peek MJ, Bisits A, Callaway LK, McCaffery K, Barrett HL, Colditz PB, Seeho SK, Attia J, Searles A, Doran C, Powell H, Gibson PG. The Breathing for Life Trial: a randomised controlled trial of fractional exhaled nitric oxide (FENO)-based management of asthma during pregnancy and its impact on perinatal outcomes and infant and childhood respiratory health. BMC Pregnancy Childbirth 2016; 16:111. [PMID: 27189595 PMCID: PMC4869189 DOI: 10.1186/s12884-016-0890-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 04/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Asthma exacerbations are common during pregnancy and associated with an increased risk of adverse perinatal outcomes. Adjusting asthma treatment based on airway inflammation rather than symptoms reduces the exacerbation rate by 50 %. The Breathing for Life Trial (BLT) will test whether this approach also improves perinatal outcomes. METHODS/DESIGN BLT is a multicentre, parallel group, randomised controlled trial of asthma management guided by fractional exhaled nitric oxide (FENO, a marker of eosinophilic airway inflammation) compared to usual care, with prospective infant follow-up. Women with physician-diagnosed asthma, asthma symptoms and/or medication use in the previous 12 months, who are 12-22 weeks gestation, will be eligible for inclusion. Women randomised to the control group will have one clinical assessment of their asthma, including self-management education. Any treatment changes will be made by their general practitioner. Women randomised to the intervention group will have clinical assessments every 3-6 weeks during pregnancy, and asthma treatments will be adjusted every second visit based on an algorithm which uses FENO to adjust inhaled corticosteroid (ICS) dose (increase in dose when FENO >29 parts per billion (ppb), decrease in dose when FENO <19 ppb, and no change when FENO is between 19 and 29 ppb). A long acting beta agonist (LABA) will be added when symptoms remain uncontrolled. Both the control and intervention groups will report on exacerbations at a postpartum phone interview. The primary outcome is adverse perinatal outcome (a composite measure including preterm birth, intrauterine growth restriction, neonatal hospitalisation at birth or perinatal mortality), assessed from hospital records. Secondary outcomes will be each component of the primary outcome, maternal exacerbations requiring medical intervention during pregnancy (both smokers and non-smokers), and hospitalisation and emergency department presentation for wheeze, bronchiolitis or croup in the first 12 months of infancy. Outcome assessment and statistical analysis of the primary outcome will be blinded. To detect a reduction in adverse perinatal outcomes from 35 % to 26 %, 600 pregnant women with asthma per group are required. DISCUSSION This trial will provide evidence for the effectiveness of a FENO-based management strategy in improving perinatal outcomes in pregnant women with asthma. If successful, this would improve the management of pregnant women with asthma worldwide. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12613000202763 .
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Affiliation(s)
- Vanessa E Murphy
- Priority Research Centre GrowUpWell, University of Newcastle and Hunter Medical Research Institute, Level 2, West Wing, University Drive, Newcastle, NSW, 2308, Australia.
| | - Megan E Jensen
- Priority Research Centre GrowUpWell, University of Newcastle and Hunter Medical Research Institute, Level 2, West Wing, University Drive, Newcastle, NSW, 2308, Australia
| | - Joerg Mattes
- Priority Research Centre GrowUpWell, University of Newcastle and Hunter Medical Research Institute, Level 2, West Wing, University Drive, Newcastle, NSW, 2308, Australia.,Paediatric Respiratory and Sleep Medicine Department, John Hunter Children's Hospital, Newcastle, NSW, Australia
| | - Michael J Hensley
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW, 2305, Australia
| | - Warwick B Giles
- Department of Obstetrics and Gynaecology, Sydney Medical School Northern, University of Sydney, Royal North Shore Hospital, St Leonards, Sydney, NSW, 2065, Australia
| | - Michael J Peek
- Sydney Medical School Nepean, University of Sydney, Nepean Hospital, PO Box 63, Penrith, NSW, 2751, Australia
| | - Andrew Bisits
- Birthing Unit, Royal Hospital for Women Randwick, Barker St, Randwick, NSW, 2031, Australia
| | - Leonie K Callaway
- School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Obstetric Medicine, Royal Brisbane and Women's Hospital, UQ Health Sciences Building, Butterfield St, Herston, Brisbane, QLD, 4029, Australia
| | - Kirsten McCaffery
- Sydney School of Public Health, University of Sydney, Room 301F, Edward Ford Building A27, Sydney, NSW, 2006, Australia
| | - Helen L Barrett
- School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Obstetric Medicine, Royal Brisbane and Women's Hospital, UQ Health Sciences Building, Butterfield St, Herston, Brisbane, QLD, 4029, Australia
| | - Paul B Colditz
- Perinatal Research Centre, UQCCR, University of Queensland, Butterfield St, Herston, Brisbane, QLD, 4029, Australia
| | - Sean K Seeho
- Department of Obstetrics and Gynaecology, Sydney Medical School Northern, University of Sydney, Royal North Shore Hospital, St Leonards, Sydney, NSW, 2065, Australia
| | - John Attia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Andrew Searles
- Hunter Medical Research Institute, Kookaburra Circuit, New Lambton, Newcastle, NSW, Australia
| | - Christopher Doran
- Hunter Medical Research Institute, Kookaburra Circuit, New Lambton, Newcastle, NSW, Australia
| | - Heather Powell
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW, 2305, Australia.,Department of Obstetrics and Gynaecology, Sydney Medical School Northern, University of Sydney, Royal North Shore Hospital, St Leonards, Sydney, NSW, 2065, Australia.,Priority Research Centre for Healthy Lungs, University of Newcastle and Hunter Medical Research Institute, Level 2, West Wing, University Drive, Newcastle, NSW, 2308, Australia
| | - Peter G Gibson
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW, 2305, Australia.,Department of Obstetrics and Gynaecology, Sydney Medical School Northern, University of Sydney, Royal North Shore Hospital, St Leonards, Sydney, NSW, 2065, Australia.,Priority Research Centre for Healthy Lungs, University of Newcastle and Hunter Medical Research Institute, Level 2, West Wing, University Drive, Newcastle, NSW, 2308, Australia
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19
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Catling C, Petrovska K, Watts N, Bisits A, Homer C. Barriers and facilitators for vaginal breech births in Australia: Clinician's experiences. Women Birth 2016; 29:138-43. [DOI: 10.1016/j.wombi.2015.09.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 09/14/2015] [Accepted: 09/21/2015] [Indexed: 11/27/2022]
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20
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Catling C, Petrovska K, Watts N, Bisits A, Homer C. Care during the decision-making phase for women who want a vaginal breech birth: Experiences from the field. Midwifery 2016; 34:111-116. [DOI: 10.1016/j.midw.2015.12.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 12/09/2015] [Accepted: 12/20/2015] [Indexed: 10/22/2022]
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Homer CS, Watts NP, Petrovska K, Sjostedt CM, Bisits A. Women's experiences of planning a vaginal breech birth in Australia. BMC Pregnancy Childbirth 2015; 15:89. [PMID: 25885035 PMCID: PMC4396595 DOI: 10.1186/s12884-015-0521-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 03/30/2015] [Indexed: 11/10/2022] Open
Abstract
Background In many countries, planned vaginal breech birth (VBB) is a rare event. After the Term Breech Trial in 2000, VBB reduced and caesarean section for breech presentation increased. Despite this, women still request VBB. The objective of this study was to explore the experiences and decision-making processes of women who had sought a VBB. Methods A qualitative study using descriptive exploratory design was undertaken. Twenty-two (n = 22) women who planned a VBB, regardless of eventual mode of birth were recruited. The women had given birth at one of two maternity hospitals in Australia that supported VBB. In-depth, semi-structured interviews using an interview guide were conducted. Interviews were analysed thematically. Results Twenty two women were interviewed; three quarters were primiparous (n = 16; 73%). Nine (41%) were already attending a hospital that supported VBB with the remaining women moving hospitals. All women actively sought a vaginal breech birth because the baby remained breech after an external cephalic version – 12 had a vaginal birth (55%) and 10 (45%) a caesarean section after labour commenced. There were four main themes: Reacting to a loss of choice and control, Wanting information that was trustworthy, Fighting the system and seeking support for VBB and The importance of ‘having a go’ at VBB. Conclusions Women seeking a VBB value clear, consistent and relevant information in deciding about mode of birth. Women desire autonomy to choose vaginal breech birth and to be supported in their choice with high quality care.
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Affiliation(s)
- Caroline Se Homer
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Level 7, 235 Jones St, Ultimo NSW 2007, PO Box 123, Sydney, Australia.
| | - Nicole P Watts
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Level 7, 235 Jones St, Ultimo NSW 2007, PO Box 123, Sydney, Australia.
| | - Karolina Petrovska
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Level 7, 235 Jones St, Ultimo NSW 2007, PO Box 123, Sydney, Australia.
| | - Chauncey M Sjostedt
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Level 7, 235 Jones St, Ultimo NSW 2007, PO Box 123, Sydney, Australia.
| | - Andrew Bisits
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Level 7, 235 Jones St, Ultimo NSW 2007, PO Box 123, Sydney, Australia. .,Royal Hospital for Women, Barker St, Randwick, NSW 2031, Australia.
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22
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Phipps H, Hyett JA, Kuah S, Pardey J, Ludlow J, Bisits A, Park F, Kowalski D, de Vries B. Persistent Occiput Posterior position - OUTcomes following manual rotation (POP-OUT): study protocol for a randomised controlled trial. Trials 2015; 16:96. [PMID: 25872776 PMCID: PMC4436169 DOI: 10.1186/s13063-015-0603-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 02/12/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Occiput posterior position is the most common malpresentation in labour, contributes to about 18% of emergency caesarean sections and is associated with a high risk of assisted delivery. Caesarean section is now a major contributing factor to maternal mortality and morbidity following childbirth in developed countries. Obstetric intervention by forceps and ventouse delivery is associated with complications to the maternal genital tract and to the neonate, respectively. There is level 2 evidence that prophylactic manual rotation reduces the caesarean section rate and assisted vaginal delivery. But there has been no adequately powered randomised controlled trial. This is a protocol for a double-blinded, multicentre, randomised controlled clinical trial to define whether this intervention decreases the operative delivery (caesarean section, forceps or vacuum delivery) rate. METHODS/DESIGN Eligible participants will be (greater than or equal to) 37 weeks' with a singleton pregnancy and a cephalic presentation in the occiput posterior position on transabdominal ultrasound early in the second stage of labour. Based on a background risk of operative delivery of 68%, then for a reduction to 50%, an alpha value of 0.05 and a beta value of 0.2, 254 participants will need to be enrolled. This study has been approved by the Ethics Review Committee (RPAH Zone) of the Sydney Local Health District, Sydney, Australia, and protocol number X110410. Participants with written consent will be randomised to either prophylactic manual rotation or a sham procedure. The primary outcome will be operative delivery (defined as vacuum, forceps and/or caesarean section deliveries). Secondary outcomes will be caesarean section, significant maternal mortality/morbidity and significant perinatal mortality/morbidity. Analysis will be by intention-to-treat. Primary and secondary outcomes will be compared using a chi-squared test. A logistic regression for the primary outcome will be undertaken to account for potential confounders. The results of the trial will be presented at one or more medical conferences. The trial will be submitted to peer review journals for consideration for publication. There will be potential to incorporate the results into professional guidelines for obstetricians and midwives. TRIAL REGISTRATION The Australian New Zealand Clinical Trials Registry ACTRN12612001312831 . Trial registered 12 December 2012.
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Affiliation(s)
- Hala Phipps
- RPA Women & Babies, Royal Prince Alfred Hospital, Sydney, NSW, Australia. .,Discipline of Obstetrics, Gynaecology and Neonatology, University of Sydney, Sydney, NSW, Australia.
| | - Jon A Hyett
- RPA Women & Babies, Royal Prince Alfred Hospital, Sydney, NSW, Australia. .,Discipline of Obstetrics, Gynaecology and Neonatology, University of Sydney, Sydney, NSW, Australia.
| | - Sabrina Kuah
- Women's and Children's Hospital, Adelaide, SA, Australia.
| | | | - Joanne Ludlow
- RPA Women & Babies, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
| | | | - Felicity Park
- The John Hunter Hospital, Newcastle, NSW, Australia.
| | | | - Bradley de Vries
- RPA Women & Babies, Royal Prince Alfred Hospital, Sydney, NSW, Australia. .,Discipline of Obstetrics, Gynaecology and Neonatology, University of Sydney, Sydney, NSW, Australia.
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23
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Affiliation(s)
- Andrew Bisits
- Medical Co Director of Maternity Royal, Hospital for Women, Randwick, NSW, Australia.
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24
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Affiliation(s)
- Kirstie Coxon
- Division of Women׳s Health, King׳s College London, UK; Florence Nightingale Faculty of Nursing and Midwifery, King׳s College London, UK.
| | - Andrew Bisits
- Royal Hospital for Women, Barker st. Randwick, NSW 2031, Australia
| | - Jane Sandall
- King׳s College London, Division of Women׳s Health, School of Medicine, King׳s College London, 10th Floor, North Wing, St. Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
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25
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Reitter A, Daviss BA, Bisits A, Schollenberger A, Vogl T, Herrmann E, Louwen F, Zangos S. Does pregnancy and/or shifting positions create more room in a woman's pelvis? Am J Obstet Gynecol 2014; 211:662.e1-9. [PMID: 24949546 DOI: 10.1016/j.ajog.2014.06.029] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 05/21/2014] [Accepted: 06/13/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the impact of different positions on pelvic diameters by comparing pregnant and nonpregnant women who assumed a dorsal supine and kneeling squat position. STUDY DESIGN In this cohort study from a tertiary referral center in Germany, we enrolled 50 pregnant women and 50 nonpregnant women. Pelvic measurements were obtained with obstetric magnetic resonance imaging pelvimetry with the use of a 1.5-T scanner. We compared measurements of the depth (anteroposterior (AP) and width (transverse diameters) of the pelvis between the 2 positions. RESULTS The most striking finding was a significant 0.9-1.9 cm increase (7-15%) in the average transverse diameters in the kneeling squat position in both pregnant and nonpregnant groups. The average bispinous diameter in the pregnant group increased from 12.6 cm ± 0.65 cm in the supine dorsal to 14.5 cm ± 0.64 cm (P < .0001) in the kneeling squat; in the nonpregnant group the increase was from 12 cm ± 0.76 cm to 13.9 cm ± 1.04 cm (P < .0001). The average bituberous diameter in the pregnant group increased from 13.6 cm ± 0.93 cm in the supine dorsal to 14.5 cm ± 0.83 cm (P < .0001) in the kneeling squat position; in the nonpregnant women the increase was from 12.6 cm ± 0.92 cm to 13.5 cm ± 0.88 cm (P < .0001). CONCLUSION A kneeling squat position significantly increases the bony transverse and anteroposterior dimension in the mid pelvic plane and the pelvic outlet. Because this indicates that pelvic diameters change when women change positions, the potential for facilitation of delivery of the fetal head suggests further research that will compare maternal delivery positions is warranted.
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Affiliation(s)
- Anke Reitter
- Department of Obstetrics and Gynecology, Goethe University, Frankfurt, Germany.
| | - Betty-Anne Daviss
- Midwifery Division, Department of Obstetrics and Gynecology, Montfort Hospital, Ottawa, ON, Canada
| | - Andrew Bisits
- Royal Hospital for Women, University of New South Wales, Randwick, NSW, Australia
| | | | - Thomas Vogl
- Department of Radiology, Goethe University, Frankfurt, Germany
| | - Eva Herrmann
- Department of Biostatistic and Mathematic Modeling, Goethe University, Frankfurt, Germany
| | - Frank Louwen
- Department of Obstetrics and Gynecology, Goethe University, Frankfurt, Germany
| | - Stephan Zangos
- Department of Radiology, Goethe University, Frankfurt, Germany
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Dahlen HG, Tracy S, Tracy M, Bisits A, Brown C, Thornton C. Rates of obstetric intervention and associated perinatal mortality and morbidity among low-risk women giving birth in private and public hospitals in NSW (2000-2008): a linked data population-based cohort study. BMJ Open 2014; 4:e004551. [PMID: 24848087 PMCID: PMC4039844 DOI: 10.1136/bmjopen-2013-004551] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To examine the rates of obstetric intervention and associated perinatal mortality and morbidity in the first 28 days among low-risk women giving birth in private and public hospitals in NSW (2000-2008). DESIGN Linked data population-based retrospective cohort study involving five data sets. SETTING New South Wales, Australia. PARTICIPANTS 691 738 women giving birth to a singleton baby during the period 2000-2008. MAIN OUTCOME MEASURES Rates of neonatal resuscitation, perinatal mortality, neonatal admission following birth and readmission to hospital in the first 28 days of life in public and private obstetric units. RESULTS Rates of obstetric intervention among low-risk women were higher in private hospitals, with primiparous women 20% less likely to have a normal vaginal birth compared to the public sector. Neonates born in private hospitals were more likely to be less than 40 weeks; more likely to have some form of resuscitation; less likely to have an Apgar <7 at 5 min. Neonates born in private hospitals to low-risk mothers were more likely to have a morbidity attached to the birth admission and to be readmitted to hospital in the first 28 days for birth trauma (5% vs 3.6%); hypoxia (1.7% vs 1.2%); jaundice (4.8% vs 3%); feeding difficulties (4% vs 2.4%) ; sleep/behavioural issues (0.2% vs 0.1%); respiratory conditions (1.2% vs 0.8%) and circumcision (5.6 vs 0.3%) but they were less likely to be admitted for prophylactic antibiotics (0.2% vs 0.6%) and for socioeconomic circumstances (0.1% vs 0.7%). Rates of perinatal mortality were not statistically different between the two groups. CONCLUSIONS For low-risk women, care in a private hospital, which includes higher rates of intervention, appears to be associated with higher rates of morbidity seen in the neonate and no evidence of a reduction in perinatal mortality.
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Affiliation(s)
- Hannah G Dahlen
- Family and Community Health Research Group, School of Nursing and Midwifery, University of Western Sydney, Penrith, New South Wales, Australia
| | - Sally Tracy
- Royal Hospital for Women, University of Sydney, Sydney, Australia
| | - Mark Tracy
- Centre for Newborn Care, Westmead Hospital, Westmead, New South Wales, Australia
- School of Medicine, University of Sydney, Camperdown, New South Wales, Australia
| | - Andrew Bisits
- Royal Hospital for Women, Randwick, New South Wales, Australia
- School of Women and Children's Health, University of NSW, Randwick, New South Wales, Australia
| | - Chris Brown
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Charlene Thornton
- Family and Community Health Research Group, School of Nursing and Midwifery, University of Western Sydney, Penrith, New South Wales, Australia
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Borbolla Foster A, Bagust A, Bisits A, Holland M, Welsh A. Lessons to be learnt in managing the breech presentation at term: An 11-year single-centre retrospective study. Aust N Z J Obstet Gynaecol 2014; 54:333-9. [DOI: 10.1111/ajo.12208] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 03/08/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Ailsa Borbolla Foster
- Department of Obstetrics and Gynaecology; John Hunter Hospital; New Lambton New South Wales Australia
| | - Annalise Bagust
- Faculty of Medicine; University of New South Wales; Sydney New South Wales Australia
| | - Andrew Bisits
- Faculty of Medicine; University of New South Wales; Sydney New South Wales Australia
- Department of Obstetrics & Gynaecology; Royal Hospital for Women; Randwick Sydney New South Wales Australia
| | - Matthew Holland
- Department of Obstetrics and Gynaecology; John Hunter Hospital; New Lambton New South Wales Australia
| | - Alec Welsh
- Faculty of Medicine; University of New South Wales; Sydney New South Wales Australia
- Department of Obstetrics & Gynaecology; Royal Hospital for Women; Randwick Sydney New South Wales Australia
- Australian Centre for Perinatal Science; University of New South Wales; Sydney New South Wales Australia
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Tracy SK, Welsh A, Hall B, Hartz D, Lainchbury A, Bisits A, White J, Tracy MB. Caseload midwifery compared to standard or private obstetric care for first time mothers in a public teaching hospital in Australia: a cross sectional study of cost and birth outcomes. BMC Pregnancy Childbirth 2014; 14:46. [PMID: 24456576 PMCID: PMC3903023 DOI: 10.1186/1471-2393-14-46] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 01/14/2014] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In many countries midwives act as the main providers of care for women throughout pregnancy, labour and birth. In our large public teaching hospital in Australia we restructured the way midwifery care is offered and introduced caseload midwifery for one third of women booked at the hospital. We then compared the costs and birth outcomes associated with caseload midwifery compared to the two existing models of care, standard hospital care and private obstetric care. METHODS We undertook a cross sectional study examining the risk profile, birth outcomes and cost of care for women booked into one of the three available models of care in a tertiary teaching hospital in Australia between July 1st 2009 December 31st 2010. To control for differences in population or case mix we described the outcomes for a cohort of low risk first time mothers known as the 'standard primipara'. RESULTS Amongst the 1,379 women defined as 'standard primipara' there were significant differences in birth outcome. These first time 'low risk' mothers who received caseload care were more likely to have a spontaneous onset of labour and an unassisted vaginal birth 58.5% in MGP compared to 48.2% for Standard hospital care and 30.8% with Private obstetric care (p < 0.001). They were also significantly less likely to have an elective caesarean section 1.6% with MGP versus 5.3% with Standard care and 17.2% with private obstetric care (p < 0.001). From the public hospital perspective, over one financial year the average cost of care for the standard primipara in MGP was $3903.78 per woman. This was $1375.45 less per woman than those receiving Private obstetric care and $1590.91 less than Standard hospital care per woman (p < 0.001). Similar differences in cost were found in favour of MGP for all women in the study who received caseload care. CONCLUSIONS Cost reduction appears to be achieved through reorganising the way care is delivered in the public hospital system with the introduction of Midwifery Group Practice or caseload care. The study also highlights the unexplained clinical variation that exists between the three models of care in Australia.
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Affiliation(s)
- Sally K Tracy
- Midwifery and Women’s Health Research Unit, Royal Hospital for Women, Barker Street, Randwick, New South Wales 2031, Australia
- University of Sydney, Sydney, New South Wales 2006, Australia
| | - Alec Welsh
- Department of Maternal Fetal Medicine, University of New South Wales, Randwick, New South Wales 2031, Australia
| | - Bev Hall
- Midwifery and Women’s Health Research Unit, Royal Hospital for Women, Barker Street, Randwick, New South Wales 2031, Australia
- University of Sydney, Sydney, New South Wales 2006, Australia
| | - Donna Hartz
- Midwifery and Women’s Health Research Unit, Royal Hospital for Women, Barker Street, Randwick, New South Wales 2031, Australia
- University of Sydney, Sydney, New South Wales 2006, Australia
| | - Anne Lainchbury
- Royal Hospital for Women, Barker Street, Randwick, New South Wales 2031, Australia
| | - Andrew Bisits
- Royal Hospital for Women, Barker Street, Randwick, New South Wales 2031, Australia
| | - Jan White
- Royal Hospital for Women, Barker Street, Randwick, New South Wales 2031, Australia
| | - Mark B Tracy
- Centre for Newborn Care, Westmead Hospital, Cnr Hawkesbury & Darcy Roads, Westmead, New South Wales 2145, Australia
- University of Sydney, Sydney, New South Wales 2006, Australia
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Tracy SK, Hartz DL, Tracy MB, Allen J, Forti A, Hall B, White J, Lainchbury A, Stapleton H, Beckmann M, Bisits A, Homer C, Foureur M, Welsh A, Kildea S. Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial. Lancet 2013; 382:1723-32. [PMID: 24050808 DOI: 10.1016/s0140-6736(13)61406-3] [Citation(s) in RCA: 199] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Women at low risk of pregnancy complications benefit from continuity of midwifery care, but no trial evidence exists for women with identified risk factors. We aimed to assess the clinical and cost outcomes of caseload midwifery care for women irrespective of risk factors. METHODS In this unblinded, randomised, controlled, parallel-group trial, pregnant women at two metropolitan teaching hospitals in Australia were randomly assigned to either caseload midwifery care or standard maternity care by a telephone-based computer randomisation service. Women aged 18 years and older were eligible if they were less than 24 weeks pregnant at the first booking visit. Those who booked with another care provider, had a multiple pregnancy, or planned to have an elective caesarean section were excluded. Women allocated to caseload care received antenatal, intrapartum, and postnatal care from a named caseload midwife (or back-up caseload midwife). Controls received standard care with rostered midwives in discrete wards or clinics. The participant and the clinician were not masked to assignment. The main primary outcome was the proportion of women who had a caesarean section. The other primary maternal outcomes were the proportions who had an instrumental or unassisted vaginal birth, and the proportion who had epidural analgesia during labour. Primary neonatal outcomes were Apgar scores, preterm birth, and admission to neonatal intensive care. We analysed all outcomes by intention to treat. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000349246. FINDINGS Publicly insured women were screened at the participating hospitals between Dec 8, 2008, and May 31, 2011. 1748 pregnant women were randomly assigned, 871 to caseload and 877 to standard care. The proportion of caesarean sections did not differ between the groups (183 [21%] in the caseload group vs 204 [23%] in the standard care group; odds ratio [OR] 0·88, 95% CI 0·70-1·10; p=0·26). The proportion of women who had elective caesarean sections (before onset of labour) differed significantly between caseload and standard care (69 [8%] vs 94 [11%]; OR 0·72, 95% CI 0·52-0·99; p=0·05). Proportions of instrumental birth were similar (172 [20%] vs 171 [19%]; p=0·90), as were the proportions of unassisted vaginal births (487 [56%] vs 454 [52%]; p=0·08) and epidural use (314 [36%] vs 304 [35%]; p=0·54). Neonatal outcomes did not differ between the groups. Total cost of care per woman was AUS$566·74 (95% 106·17-1027·30; p=0·02) less for caseload midwifery than for standard maternity care. INTERPRETATION Our results show that for women of any risk, caseload midwifery is safe and cost effective. FUNDING National Health and Medical Research Council (Australia).
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Affiliation(s)
- Sally K Tracy
- Midwifery and Women's Health Research Unit, University of Sydney, Royal Hospital for Women, Randwick, NSW, Australia.
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Welsh A, Clements S, Henry A, Bisits A. Elective birth at 37 weeks of gestation versus standard care for women with an uncomplicated twin pregnancy at term: the Twins Timing of Birth Randomised Trial. BJOG 2013; 119:1675-6; author reply 1676-7. [PMID: 23164120 DOI: 10.1111/1471-0528.12001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Dahlen HG, Tracy S, Tracy M, Bisits A, Brown C, Thornton C. Rates of obstetric intervention among low-risk women giving birth in private and public hospitals in NSW: a population-based descriptive study. BMJ Open 2012; 2:bmjopen-2012-001723. [PMID: 22964120 PMCID: PMC3467614 DOI: 10.1136/bmjopen-2012-001723] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To compare the risk profile of women giving birth in private and public hospitals and the rate of obstetric intervention during birth compared with previous published rates from a decade ago. DESIGN Population-based descriptive study. SETTING New South Wales, Australia. PARTICIPANTS 691 738 women giving birth to a singleton baby during the period 2000 to 2008. MAIN OUTCOME MEASURES Risk profile of women giving birth in public and private hospitals, intervention rates and changes in these rates over the past decade. RESULTS Among low-risk women rates of obstetric intervention were highest in private hospitals and lowest in public hospitals. Low-risk primiparous women giving birth in a private hospital compared to a public hospital had higher rates of induction (31% vs 23%); instrumental birth (29% vs 18%); caesarean section (27% vs 18%), epidural (53% vs 32%) and episiotomy (28% vs 12%) and lower normal vaginal birth rates (44% vs 64%). Low-risk multiparous women had higher rates of instrumental birth (7% vs 3%), caesarean section (27% vs 16%), epidural (35% vs 12%) and episiotomy (8% vs 2%) and lower normal vaginal birth rates (66% vs 81%). As interventions were introduced during labour, the rate of interventions in birth increased. Over the past decade these interventions have increased by 5% for women in public hospitals and by over 10% for women in private hospitals. Among low-risk primiparous women giving birth in private hospitals 15 per 100 women had a vaginal birth with no obstetric intervention compared to 35 per 100 women giving birth in a public hospital. CONCLUSIONS Low-risk primiparous women giving birth in private hospitals have more chance of a surgical birth than a normal vaginal birth and this phenomenon has increased markedly in the past decade.
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Affiliation(s)
- Hannah Grace Dahlen
- School of Nursing and Midwifery, Family and Community Health Research Group, University of Western Sydney, Sydney, New South Wales
| | - Sally Tracy
- Department of Nursing and Midwifery, University of Sydney, Sydney, New South Wales, Australia
| | - Mark Tracy
- Centre for Newborn Care, Westmead Hospital, Sydney, New South Wales, Australia
| | - Andrew Bisits
- Department of Maternity, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Chris Brown
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Charlene Thornton
- School of Nursing and Midwifery, Family and Community Health Research Group, University of Western Sydney, Sydney, New South Wales
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Mitchell C, Johnson R, Bisits A, Hirst J, Zakar T. PTGS2 (prostaglandin endoperoxide synthase-2) expression in term human amnion in vivo involves rapid mRNA turnover, polymerase-II 5'-pausing, and glucocorticoid transrepression. Endocrinology 2011; 152:2113-22. [PMID: 21385935 DOI: 10.1210/en.2010-1327] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The in vivo role of glucocorticoids in controlling prostaglandin endoperoxide synthase-2 (PTGS2) expression in the human amnion is unclear despite extensive studies using in vitro models. We addressed this issue by determining PTGS2 mRNA levels and gene transcriptional activity, RNA polymerase-II (pol-II) binding, pol-II C-terminal domain (CTD) phosphorylation, histone acetylation, and histone methylation at the PTGS2 gene in fresh amnion and in amnion explants incubated with dexamethasone for 24 h after delivery, when adaptation from in vivo to in vitro conditions occurred. PTGS2 mRNA turnover changed during incubation involving the initial rapid decrease and subsequent rebound of the transcription rate and stabilization of mRNA. pol-II accumulated in the 5'-region of the gene, which indicated postinitiation pausing. pol-II binding, 5'-accumulation, C-terminal domain Ser-5 and Ser-2 phosphorylation, and histone acetylation decreased rapidly and did not reverse during the transcriptional rebound, suggesting that the transcriptional mechanism altered in vitro. Dexamethasone decreased PTGS2 gene activity and mRNA levels. Glucocorticoid receptor-α (GRα) was bound to the PTGS2 promoter but did not affect pol-II recruitment, pausing, or the epigenetic marks. GRα binding, however, decreased initiating (Ser-5) and elongating (Ser-2) pol-II phosphorylation. The ability of the PTGS2 promoter to bind GRα in response to dexamethasone diminished during incubation. We conclude that PTGS2 mRNA turnover is accelerated in vivo, but the underlying mechanisms are not sustained beyond 24 h in explants. Glucocorticoids chronically transrepress PTGS2 gene activity in vivo in part by interfering with transcription initiation and elongation. Glucocorticoid transrepression of PTGS2 may be important for pregnancy maintenance and the timing of parturition.
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Affiliation(s)
- Carolyn Mitchell
- Mothers and Babies Research Centre, Hunter Medical Research Institute, Newcastle, New South Wales 2305, Australia
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Cooke H, Foureur M, Kinnear A, Bisits A, Giles W. The development and initiation of the NSW Department of Health interprofessional Fetal welfare Obstetric emergency Neonatal resuscitation Training project. Aust N Z J Obstet Gynaecol 2010; 50:334-9. [PMID: 20716260 DOI: 10.1111/j.1479-828x.2010.01167.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Fetal Welfare Obstetric emergency Neonatal resuscitation Training (FONT) project was initiated on a background of rising notifications of adverse events in NSW maternity units, the significant proportion of which were related to fetal welfare assessment. AIMS The aim of the study is to describe the development and introduction of the NSW state-wide interprofessional FONT project. METHODS Following development and risk assessment, FONT was launched in February 2008. The project consists of an online component and two face-to-face training days to be completed each 3 years; the first day for fetal welfare assessment and the second for obstetric and newborn emergencies. Eight, 2-day training sessions were conducted throughout NSW for FONT trainers. Each trainer underwent pre- and post-testing for changes in knowledge of fetal welfare assessment. The 2005-2008 NSW adverse event report numbers were assessed. RESULTS From 20 February to 17 April 2008, 240 trainers had been trained in fetal welfare assessment, and by the end of 2008 these trainers had trained 954 clinicians. There were significant improvements in the interpretation and management planning of electronic fetal heart rate patterns following training. Analysis of Severity Assessment Codes 1 and 2 showed no significant trend in the number of notifications for adverse events related to fetal welfare assessment. CONCLUSIONS In the first 11 months, 25% of the state's maternity practitioners had received training in the first stage of the FONT project. The FONT project has shown short-term improvements in learning and communication skills and in the participants of the project.
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Affiliation(s)
- Helen Cooke
- NSW Department of Health, New South Wales, Australia
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Abstract
This chapter discusses the tocolytic agents currently in use for the treatment of preterm labour and considers them in light of the evidence base. These agents are the beta2 sympathomimetic agonists, magnesium sulphate (MgSO(4)), indomethacin, nifedipine and atosiban. The available evidence for these agents shows that the beta2 agents are effective but have significant maternal side effects and no effect on perinatal outcome. MgSO(4) and glyceryl trinitrate are clearly ineffective. Nifedipine is effective with a low maternal side effect profile and is associated with improved perinatal outcomes. Meta-analyses of the several randomized controlled trials of atosiban show that it is no more effective than other tocolytic therapies. Possible directions for the future will be discussed.
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Affiliation(s)
- Warwick Giles
- Faculty of Health, University of Newcastle, Australia.
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Clifton VL, Bisits A, Zarzycki PK. Characterization of human fetal cord blood steroid profiles in relation to fetal sex and mode of delivery using temperature-dependent inclusion chromatography and principal component analysis (PCA). J Chromatogr B Analyt Technol Biomed Life Sci 2007; 855:249-54. [PMID: 17625993 DOI: 10.1016/j.jchromb.2007.05.041] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Revised: 03/28/2007] [Accepted: 05/11/2007] [Indexed: 11/30/2022]
Abstract
In the present work, human male and female fetal cord blood samples were purified, selectively extracted and separated to examine a fraction of steroids ranging from polar estetrol to relatively non-polar progesterone using solid phase extraction based on C-18 tubes and beta-cyclodextrin driven temperature dependent inclusion chromatography. Resulting UV diode array chromatographic patterns revealed the presence of 27 peaks. Chromatographic patterns of UV detected steroids were analyzed using principal components analysis which revealed differences between male/female and labour/not-in-labour clusters. Quantitative analysis of nine identified steroids including: estetrol, 17beta-estradiol, estrone, estriol, cortisol, cortisone, progesterone, 20 alpha-hydroxyprogesterone and 17 alpha-hydroxyprogesterone were not significantly different between males and females. Significant differences between male and female fetuses were related to as yet unidentified compounds. Four peaks were significantly different with labour which corresponded with cortisol, cortisone and two unidentified compounds. This protocol may distinguish significant differences between clinical groups that are not readily identifiable using univariate measurements of single steroids or different low molecular mass biomarkers. Moreover, we have provided new evidence that despite the absence of testosterone there are number of steroids and low molecular mass compounds that differ between male and female fetuses.
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Affiliation(s)
- Vicki L Clifton
- Mothers and Babies Research Centre, Hunter Medical Research Institute, University of Newcastle, NSW, Australia.
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Brown O, Bisits A. Re: Obstetric-induced incontinence: a black hole of preventable morbidity. Aust N Z J Obstet Gynaecol 2007; 47:152; author reply 153-4. [PMID: 17355309 DOI: 10.1111/j.1479-828x.2007.00704.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Gill A, Madsen G, Knox M, Bisits A, Giles W, Tudehope D, Rogers Y, Smith R. Neonatal neurodevelopmental outcomes following tocolysis with glycerol trinitrate patches. Am J Obstet Gynecol 2006; 195:484-7. [PMID: 16707077 DOI: 10.1016/j.ajog.2006.01.103] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2005] [Revised: 01/17/2006] [Accepted: 01/27/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The object of this study was to determine the effects of maternal tocolysis with glycerol trinitrate (GTN) patches on the neurodevelopment of infants. STUDY DESIGN This was a randomized, multicenter, controlled trial comparing the efficacy of GTN patches with standard beta2 agonist as tocolytic therapy. The previously reported outcomes of this study indicated no difference in neonatal mortality or morbidity to hospital discharge. One hundred fifty-six surviving infants from 2 Australian centers were psychometrically assessed using the Griffiths Mental development Scales (revised) at 18 months of age. RESULTS There was no difference in psychometric performance between those infants enrolled in either the GTN (81 infants) or beta2 agonist (75 infants) arm of the study. CONCLUSION This randomized trial supports no significant difference between GTN patches in comparison with standard beta2 agonist for tocolytic therapy. The results underscore the association between premature labor and adverse infant outcomes.
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Affiliation(s)
- Andrew Gill
- Mothers and Babies Research Centre, University of Newcastle, Newcastle, Australia
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Johnson RF, Mitchell CM, Giles WB, Bisits A, Zakar T. Mechanisms regulating prostaglandin H2 synthase-2 mRNA level in the amnion and chorion during pregnancy. J Endocrinol 2006; 188:603-10. [PMID: 16522739 DOI: 10.1677/joe.1.06488] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Increasing prostaglandin H(2) synthase (PGHS)-2 expression in the fetal membranes is implicated in the production of prostaglandins (PGs) that stimulate labour. We have determined the activity of the PGHS-2 gene in the amnion and chorion throughout gestation and defined the contribution of transcriptional and post-transcriptional mechanisms to the increase of PGHS-2 mRNA levels. We also measured PGHS-1 mRNA abundance to assess the participation of the two isoenzymes in fetal membrane PG-production during pregnancy. Amnion and chorion were collected from non-labouring women at 10-19 weeks (early), at 28-36 weeks (preterm) and at term (37-41 weeks). We determined PGHS-1 and -2 mRNA abundance and assessed PGHS-2 gene activity by measuring PGHS-2 heterogeneous nuclear RNA levels using real-time RT-PCR. PGHS-2 gene activity and mRNA levels were up-regulated in both tissues with advancing gestation. Path analysis demonstrated that the PGHS-2 mRNA up-regulation involved both transcriptional and post-transcriptional components. PGHS-2 mRNA abundance increased 9-11 fold between the early (10-19 weeks) and preterm (28-36 weeks) groups and remained high at term. The underlying mechanism was predominantly transcriptional in the amnion and post-transcriptional in the chorion. PGHS-1 mRNA expression precipitously decreased between early gestation and term. Thus, PGHS-2 mRNA abundance is up-regulated well in advance of term and is not a trigger for labour. There is a switch in PGHS mRNA expression during pregnancy with PGHS-1 dominating in the early period and PGHS-2 dominating at term.
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Affiliation(s)
- Renée F Johnson
- Division of Obstetrics and Gynaecology, John Hunter Hospital, Newcastle, New South Wales, Australia
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Abstract
We present a case of renal abscess with perinephric and paranephric extension. Ultrasonography showed an intrarenal lesion. The extension into the perinephric and paranephric space was better defined on MRI.
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Affiliation(s)
- M Puvaneswary
- Department of Medical Imaging, John Hunter Hospital, Newcastle, New South Wales, Australia.
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Bisits A, Madsen G, Knox M, Gill A, Smith R, Yeo G, Kwek K, Daniel M, Leung TN, Cheung K, Chung T, Jones I, Toohill J, Tudehope D, Giles W. The Randomized Nitric Oxide Tocolysis Trial (RNOTT) for the treatment of preterm labor. Am J Obstet Gynecol 2004; 191:683-90. [PMID: 15467526 DOI: 10.1016/j.ajog.2004.02.019] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This study was undertaken to assess the effectiveness of glyceryl trinitrate (GTN) patches in comparison with beta2 sympathomimetics (beta2) for the treatment of preterm labor. STUDY DESIGN A multicenter, multinational, randomized controlled trial was conducted in tertiary referral teaching hospitals. Women in threatened preterm labor with positive fetal fibronectin or ruptured membranes between 24 and 35 weeks' gestation were recruited and randomly assigned to either beta2 or GTN with rescue beta2 tocolysis if moderate-to-strong contractions persisted at 2 hours. Obstetric and neonatal outcomes were assessed. RESULTS Two hundred thirty-eight women were recruited and randomly assigned, 117 to beta2 and 121 to GTN. On a strict intention-to-treat basis, there was no significant difference in the time to delivery using Kaplan-Meier curves (P = .451). At 2 hours, 27% of women receiving beta2 had moderate or stronger contractions compared with 53% in the GTN group (P < .001). This led to 35% of women in the GTN group receiving rescue treatment. If delivery or requirement for beta2 rescue are regarded as treatment failure, then a significant difference was observed between the 2 arms (P = .0032). There were no significant differences in neonatal outcomes. CONCLUSION GTN is a less efficacious tocolytic compared with ss2 sympathomimetics.
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Affiliation(s)
- A Bisits
- The Mothers and Babies Research Centre, Faculty of Medicine and Health Sciences, The University of Newcastle, Australia
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Harris G, Connor L, Bisits A, Higginbotham N. "Seeing the baby": pleasures and dilemmas of ultrasound technologies for primiparous Australian women. Med Anthropol Q 2004; 18:23-47. [PMID: 15098426 DOI: 10.1525/maq.2004.18.1.23] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The practice of obstetric ultrasound scans has undergone significant expansion in the last two decades and is now a standard part of many women's antenatal care in Australia as elsewhere. This article reviews recent evidence about the value of obstetric ultrasound, summarizing debates and contradictions in research literature and practitioner guidelines. Pregnant women's interpretations of the significance of ultrasound are examined through multiple interviews with 34 study participants. We find that ultrasound has become an integral part of women's embodied experience of pregnancy, with its own pleasures and dilemmas. The increasing use of the technology has augmented the role of scientific biomedicine in the government of pregnancy. This must be understood in the light of trends toward individualized risk management in which the pregnant woman increasingly takes responsibility for the successful outcome of the pregnancy, in a context where pregnancy is discursively constructed as a risky domain of gendered experience in contemporary Australian society.
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Giles W, Bisits A, O'Callaghan S, Gill A. The Doppler Assessment in multiple pregnancy randomised controlled trial of ultrasound biometry versus umbilical artery Doppler ultrasound and biometry in twin pregnancy. BJOG 2003. [DOI: 10.1046/j.1471-0528.2003.02066.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Giles W, Bisits A, O'Callaghan S, Gill A. The Doppler assessment in multiple pregnancy randomised controlled trial of ultrasound biometry versus umbilical artery Doppler ultrasound and biometry in twin pregnancy. BJOG 2003; 110:593-7. [PMID: 12798478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
OBJECTIVE To assess the addition value of umbilical artery Doppler ultrasound added to standard ultrasound biometry measurements in the management of twin pregnancies. DESIGN A prospective randomised controlled multicentre trial of women with twin pregnancies. SETTING Tertiary level referral hospitals in Australia, New Zealand and Southeast Asia. POPULATION Pregnant women with twin pregnancies. METHODS Women were randomised at 25 weeks of gestation to receive either standard ultrasound biometric assessment or standard assessment plus Doppler ultrasound umbilical artery flow velocity waveform analysis. The studies were repeated at 30 and 35 weeks unless otherwise indicated. Physicians were advised to institute close fetal surveillance in the presence of an abnormal umbilical artery Doppler study or with biometry indicators of fetal compromise. MAIN OUTCOME MEASURES Standard obstetric (mode of delivery, perinatal mortality, hypertension, antenatal admissions and gestation at delivery) and neonatal (5 minute Apgar scores <5, admissions to neonatal nursery and requirements for ventilation) outcomes and statistical analysis was on intention-to-treat. There were no significant differences between the two groups with respect to demography, antenatal, peripartum and neonatal outcomes. There was no difference in the perinatal mortality rate in the no Doppler group (n = 264), which was 11/1000 live births, and the Doppler group (n = 262), which was 9/1000 live births. There were three unexplained intrauterine deaths in the no Doppler group and none in the Doppler group (OR 0.14, 95% CI 0.01-1.31). Two intrauterine deaths in the Doppler group were due to cord prolapse in labour and a fetomaternal haemorrhage, both very unlikely to be influenced by Doppler surveillance. CONCLUSIONS In this study, close surveillance in twin pregnancy resulted in a lower than expected fetal mortality from 25 weeks of gestation in both the no Doppler and Doppler groups. The lower rate of unexplained fetal death in the no Doppler group was not significantly different from the Doppler group.
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Affiliation(s)
- Warwick Giles
- Discipline of Reproductive Medicine and Mothers and Babies Research Centre, Faculty of Medicine and Health Sciences, University of Newcastle, New South Wales 2308, Callaghan, Australia
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Giles W, O'Callaghan S, Cole S, Bisits A. Triplet pregnancy complicated by feto-feto-fetal transfusion with very rapid deterioration and fetal demise in all three triplets. Aust N Z J Obstet Gynaecol 2002; 42:408-9. [PMID: 12403292 DOI: 10.1111/j.0004-8666.2002.409_2.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Warwick Giles
- Division of Obstetrics and Gynaecology, John Hunter Hospital, Newcastle, New South Wales, Australia
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McGrath S, McLean M, Smith D, Bisits A, Giles W, Smith R. Maternal plasma corticotropin-releasing hormone trajectories vary depending on the cause of preterm delivery. Am J Obstet Gynecol 2002; 186:257-60. [PMID: 11854646 DOI: 10.1067/mob.2002.119635] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Although second trimester maternal plasma corticotropin-releasing hormone concentrations are elevated in women who are destined to deliver preterm, the sensitivity and positive predictive value of an individual test of corticotropin-releasing hormone concentration is low. This poor screening performance may be due in part to the observation that the causes of preterm delivery are heterogenous, with potentially different effects on corticotropin-releasing hormone production. We have reanalyzed data from a previous cohort of women with multiple samplings to determine whether the trajectory of increase of placental corticotropin-releasing hormone provided more information than did a single sample. STUDY DESIGN In this cohort, where 2 to 4 samples that had been assayed for corticotropin-releasing hormone were available on 305 women, the general form of the exponential equation y = ae(bt) was fitted to the corticotropin-releasing hormone data of each individual by the Gauss-Newton nonlinear least squares method, which generated the parameters, y-intercept and rate of rise, in corticotropin-releasing hormone concentration for each woman. Nonparametric statistical techniques, including bootstrapping, were applied to compare the results for the group of women who delivered at term with the group of women who delivered spontaneously preterm and the group of women who were delivered preterm by induction or cesarean delivery because of obstetric indication. RESULTS The 3 clinically defined groups have significantly different parameters, y-intercept and rate of rise, which describe the corticotropin-releasing hormone trajectory. The group that delivered preterm because of obstetric indications had a similar mean y-intercept but significantly greater mean rate of rise in corticotropin-releasing hormone concentration than the term group (0.3491 vs 0.1788; 95% CI, 0.2331-0.4615 vs 0.1394-0.2330). The group that delivered spontaneously preterm had a significantly greater mean y-intercept than the group that delivered preterm because of obstetric indication (17.08 vs 1.83; 95% CI, 5.89-28.43 vs 0.03-5.19) but a similar mean rate of rise to the group that delivered at term. CONCLUSION These data suggest that spontaneous preterm delivery is associated with an abnormal setting of the production of corticotropin-releasing hormone that is present from very early in pregnancy, although women who experience an induced preterm delivery are characterized by rapidly rising placental corticotropin-releasing hormone concentrations. These data further suggest that clinical abnormalities that are associated with preterm delivery by induction or cesarean delivery are associated with abnormalities that lead to a rapidly increasing corticotropin-releasing hormone concentrations. Trajectories for corticotropin-releasing hormone provide information beyond that obtained from a single sample.
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Affiliation(s)
- Shaun McGrath
- Mothers and Babies Research Centre, John Hunter Hospital, Newcastle, NSW, Australia
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Affiliation(s)
- S Cole
- Maternal-Fetal Medicine Unit, John Hunter Hospital, Newcastle, NSW, Australia.
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Giles W, Bisits A, Knox M, Madsen G, Smith R. The effect of fetal fibronectin testing on admissions to a tertiary maternal-fetal medicine unit and cost savings. Am J Obstet Gynecol 2000; 182:439-42. [PMID: 10694349 DOI: 10.1016/s0002-9378(00)70236-5] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Fetal fibronectin bedside testing has been proposed as a diagnostic tool for the accurate diagnosis of preterm labor. The study objective was to determine whether the introduction of routine fetal fibronectin bedside testing affected costs and transfer rates from referral district hospitals to a tertiary obstetric hospital, as well as direct admissions to a tertiary referral hospital. STUDY DESIGN We performed an 18-month prospective audit of fetal fibronectin use in 9 referral hospitals and one university maternal-fetal medicine unit. Data collected were delivery details and cervical dilatation at admission. Cost savings in terms of transport costs for patients with a negative fetal fibronectin result who were not transferred or admitted to the tertiary center were calculated for interhospital transfer (road ambulance or fixed-wing retrieval). RESULTS One hundred fifty-one patients had a presumptive diagnosis of threatened preterm labor. Forty-five patients had a positive fetal fibronectin result and 106 had a negative fetal fibronectin result (3 with cervical dilatation >/=3 cm). Eleven (24%) patients with a positive fetal fibronectin result were delivered within 7 days, and 5 (5%) with a negative fetal fibronectin result were delivered within 7 days. One patient was delivered at 34 weeks, and the remaining patients were delivered at or after 36 weeks' gestation. All 3 patients with negative fetal fibronectin results with cervical dilatation of >/=3 cm were delivered within 5 days, leaving 2 (1.9%) patients (with closed cervices and negative fetal fibronectin results) being delivered 5 days after the fetal fibronectin testing. Ninety percent of the patients admitted to a referral hospital with threatened preterm labor who had a negative fetal fibronectin result were not transferred; thus an unnecessary transfer was avoided, with cost savings ranging from $30,297 for road and fixed-wing transport. CONCLUSION A negative fetal fibronectin result is not helpful if cervical dilatation is present, and these patients should be treated as having a high risk of preterm delivery. The use of a fetal fibronectin test was associated with a 90% reduction in maternal transfer and can substantially reduce the costs and inconvenience associated with unnecessary transfer.
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Affiliation(s)
- W Giles
- Discipline of Reproductive Medicine and The Mothers' and Babies' Research Centre, Faculty of Medicine and Health Sciences, University of Newcastle, Callaghan, New South Wales, Australia
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McLean M, Bisits A, Davies J, Walters W, Hackshaw A, De Voss K, Smith R. Predicting risk of preterm delivery by second-trimester measurement of maternal plasma corticotropin-releasing hormone and alpha-fetoprotein concentrations. Am J Obstet Gynecol 1999; 181:207-15. [PMID: 10411821 DOI: 10.1016/s0002-9378(99)70461-8] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Many women who have preterm labor have abnormally high plasma concentrations of the placental peptide corticotropin-releasing hormone and the fetal product alpha-fetoprotein in early pregnancy. This study was designed to evaluate the ability of these biochemical tests and a clinical risk factor score to prospectively discriminate pregnancies at high risk for preterm delivery. STUDY DESIGN Eight hundred sixty women were studied prospectively from the early second trimester until delivery. A risk factor score for preterm delivery was calculated from the clinical history and maternal plasma corticotropin-releasing hormone and alpha-fetoprotein concentrations were measured by radioimmunoassay between 17 and 30 weeks' gestation. The risk factor score, corticotropin-releasing hormone concentration, and alpha-fetoprotein concentration for each woman were expressed as individual odds or likelihood ratios for preterm delivery and as a combined risk estimate derived from the 3 tests. RESULTS Sixty women had preterm deliveries (n = 37 spontaneous labor, n = 23 planned deliveries), and these women had significantly higher concentrations of corticotropin-releasing hormone (median 1.92 multiples of the median) and alpha-fetoprotein (median 1.32 multiples of the median) than did women with term deliveries (median 1.00 multiples of the median, P <.001 for both tests), with these abnormalities being evident from early in the second trimester. The risk factor score was >/=10 in 28% of women with preterm delivery and 7% of women with term delivery. The combination of all 3 markers resulted in a higher detection rate and a higher positive predictive value than the risk factor score, corticotropin-releasing hormone concentration, or alpha-fetoprotein concentration alone, correctly discriminating 37% of women who would have preterm deliveries with a false-positive rate of 5%. The positive predictive value was also 37% (odds of being affected given a positive result were 1:1.7). CONCLUSIONS The combination of measurement of maternal plasma corticotropin-releasing hormone and alpha-fetoprotein concentrations in the second trimester with risk factor scoring provides a more accurate indicator of the risk of preterm delivery than does risk factor scoring alone. This method of risk assessment may therefore be of use in targeting prevention strategies.
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Affiliation(s)
- M McLean
- Maternal Health Research Centre, John Hunter Hospital and University of Newcastle, Australia
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Abstract
The use of single-dose intramuscular methotrexate for the primary treatment of ectopic pregnancy is increasing in frequency in many countries. We performed a systematic review of all available studies and case reports of intramuscular methotrexate to examine the therapeutic efficacy, side-effects and complication rates of this new treatment approach. The pooled data show a successful resolution rate of 71% (95% confidence interval 58% to 81%) after a single dose of intramuscular methotrexate and 84% (95% confidence interval 77% to 90%) after 1 or 2 doses. Side-effects were experienced by 24% (95% confidence interval 9% to 47%) of patients and 10% (95% confidence interval 7% to 14%) had a ruptured ectopic pregnancy. The pooled data show that single-dose intramuscular methotrexate is associated with a high failure rate. Follow-up is prolonged and there is a significant incidence of minor side-effects. Serious complications and side-effects have occurred. The use of intramuscular methotrexate should be confined to clinical trials until more evidence is obtained to support its more widespread use.
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Affiliation(s)
- J Parker
- Division of Obstetrics and Gynaecology, John Hunter Hospital, Newcastle, New South Wales
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Bisits A, Madsen G, McLean M, O'Callaghan S, Smith R, Giles W. Corticotropin-releasing hormone: a biochemical predictor of preterm delivery in a pilot randomized trial of the treatment of preterm labor. Am J Obstet Gynecol 1998; 178:862-6. [PMID: 9579457 DOI: 10.1016/s0002-9378(98)60503-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We assessed the ability of maternal plasma corticotropin-releasing hormone measurements to predict preterm delivery in the setting of a pilot study comparing transdermal glyceryl trinitrate with standard beta-mimetic therapy for preterm labor and to determine the effect of these tocolytics on maternal plasma corticotropin-releasing hormone concentrations. STUDY DESIGN Twenty-six consecutive patients with preterm labor were randomized to tocolytic treatment with transdermal glyceryl trinitrate (n=13) or intravenous albuterol (n=13). RESULTS Plasma corticotropin-releasing hormone immunoreactivity levels were higher in women who were delivered within 7 days (41.4+/-13.5 pmol/L) than in those continuing to term (14.2+/-2.4 pmol/L, p=0.011) and were not altered by treatment. Two women in each of the treatment groups delivered within 7 days of the initiation of treatment, two women in the glyceryl trinitrate group were changed to albuterol because of persistence of contractions. Glyceryl trinitrate treatment was associated with significantly fewer maternal side effects. Neither treatment altered umbilical artery Doppler ultrasonographic findings. CONCLUSION Transdermal glyceryl trinitrate is better tolerated than intravenous albuterol but may be no more efficacious than albuterol for the treatment of preterm labor. Biologic markers such as plasma corticotropin-releasing hormone levels may be an important method of identifying women at high risk of preterm delivery.
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Affiliation(s)
- A Bisits
- Maternal Health Research Centre and Division of Obstetrics, John Hunter Hospital, Newcastle, New South Wales, Australia
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