Antenatal detection of large-for-gestational-age fetuses following implementation of the Growth Assessment Protocol: secondary analysis of a randomised control trial

OBJECTIVE

To determine whether the Growth Assessment Protocol (GAP) affects the antenatal detection of large for gestational age (LGA) or maternal and perinatal outcomes amongst LGA babies.

DESIGN

Secondary analysis of a pragmatic open randomised cluster control trial comparing the GAP with standard care.

SETTING

Eleven UK maternity units.

POPULATION

Pregnant women and their LGA babies born at ≥36⁺⁰  weeks of gestation.

METHODS

Clusters were randomly allocated to GAP implementation or standard care. Data were collected from electronic patient records. Trial arms were compared using summary statistics, with unadjusted and adjusted (two-stage cluster summary approach) differences.

MAIN OUTCOME MEASURES

Rate of detection of LGA (estimated fetal weight on ultrasound scan above the 90th centile after 34⁺⁰  weeks of gestation, defined by either population or customised growth charts), maternal and perinatal outcomes (e.g. mode of birth, postpartum haemorrhage, severe perineal tears, birthweight and gestational age, neonatal unit admission, perinatal mortality, and neonatal morbidity and mortality).

RESULTS

A total of 506 LGA babies were exposed to GAP and 618 babies received standard care. There were no significant differences in the rate of LGA detection (GAP 38.0% vs standard care 48.0%; adjusted effect size -4.9%; 95% CI -20.5, 10.7; p = 0.54), nor in any of the maternal or perinatal outcomes.

CONCLUSIONS

The use of GAP did not change the rate of antenatal ultrasound detection of LGA when compared with standard care.

Characteristics associated with antenatally unidentified small-for-gestational-age fetuses: prospective cohort study nested within DESiGN randomized controlled trial

OBJECTIVE

To identify the clinical characteristics and patterns of ultrasound use amongst pregnancies with an antenatally unidentified small-for-gestational-age (SGA) fetus, compared with those in which SGA is identified, to understand how to design interventions that improve antenatal SGA identification.

METHODS

This was a prospective cohort study of singleton, non-anomalous SGA (birth weight < 10th centile) neonates born after 24 + 0 gestational weeks at 13 UK sites, recruited for the baseline period and control arm of the DESiGN trial. Pregnancy with antenatally unidentified SGA was defined if there was no scan or if the final scan showed estimated fetal weight (EFW) at the 10th centile or above. Identified SGA was defined if EFW was below the 10th centile at the last scan. Maternal and fetal sociodemographic and clinical characteristics were studied for associations with unidentified SGA using unadjusted and adjusted logistic regression models. Ultrasound parameters (gestational age at first growth scan, number and frequency of ultrasound scans) were described, stratified by presence of indication for serial ultrasound. Associations of unidentified SGA with absolute centile and percentage weight difference between the last scan and birth were also studied on unadjusted and adjusted logistic regression, according to time between the last scan and birth.

RESULTS

Of the 15 784 SGA babies included, SGA was not identified antenatally in 78.7% of cases. Of pregnancies with unidentified SGA, 47.1% had no recorded growth scan. Amongst 9410 pregnancies with complete data on key maternal comorbidities and antenatal complications, the risk of unidentified SGA was lower for women with any indication for serial scans (adjusted odds ratio (aOR), 0.56 (95% CI, 0.49-0.64)), for Asian compared with white women (aOR, 0.80 (95% CI, 0.69-0.93)) and for those with non-cephalic presentation at birth (aOR, 0.58 (95% CI, 0.46-0.73)). The risk of unidentified SGA was highest among women with a body mass index (BMI) of 25.0-29.9 kg/m2 (aOR, 1.15 (95% CI, 1.01-1.32)) and lowest in those with underweight BMI (aOR, 0.61 (95% CI, 0.48-0.76)) compared to women with BMI of 18.5-24.9 kg/m2 . Compared to women with identified SGA, those with unidentified SGA had fetuses of higher SGA birth-weight centile (adjusted odds for unidentified SGA increased by 1.21 (95% CI, 1.18-1.23) per one-centile increase between the 0th and 10th centiles). Duration between the last scan and birth increased with advancing gestation in pregnancies with unidentified SGA. SGA babies born within a week of the last growth scan had a mean difference between EFW and birth-weight centiles of 19.5 (SD, 13.8) centiles for the unidentified-SGA group and 0.2 (SD, 3.3) centiles for the identified-SGA group (adjusted mean difference between groups, 19.0 (95% CI, 17.8-20.1) centiles).

CONCLUSIONS

Unidentified SGA was more common amongst women without an indication for serial ultrasound, and in those with cephalic presentation at birth, BMI of 25.0-29.9 kg/m2 and less severe SGA. Ultrasound EFW was overestimated in women with unidentified SGA. This demonstrates the importance of improving the accuracy of SGA screening strategies in low-risk populations and continuing performance of ultrasound scans for term pregnancies. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Improving antenatal detection of small-for-gestational-age fetus: economic evaluation of Growth Assessment Protocol

OBJECTIVE

To determine whether the Growth Assessment Protocol (GAP), as implemented in the DESiGN trial, is cost-effective in terms of antenatal detection of small-for-gestational-age (SGA) neonate, when compared with standard care.

METHODS

This was an incremental cost-effectiveness analysis undertaken from the perspective of a UK National Health Service hospital provider. Thirteen maternity units from England, UK, were recruited to the DESiGN (DEtection of Small for GestatioNal age fetus) trial, a cluster randomized controlled trial. Singleton, non-anomalous pregnancies which delivered after 24 + 0 gestational weeks between November 2015 and February 2019 were analyzed. Probabilistic decision modeling using clinical trial data was undertaken. The main outcomes of the study were the expected incremental cost, the additional number of SGA neonates identified antenatally and the incremental cost-effectiveness ratio (ICER) (cost per additional SGA neonate identified) of implementing GAP. Secondary analysis focused on the ICER per infant quality-adjusted life year (QALY) gained.

RESULTS

The expected incremental cost (including hospital care and implementation costs) of GAP over standard care was £34 559 per 1000 births, with a 68% probability that implementation of GAP would be associated with increased costs to sustain program delivery. GAP identified an additional 1.77 SGA neonates per 1000 births (55% probability of it being more clinically effective). The ICER for GAP was £19 525 per additional SGA neonate identified, with a 44% probability that GAP would both increase cost and identify more SGA neonates compared with standard care. The probability of GAP being the dominant clinical strategy was low (11%). The expected incremental cost per infant QALY gained ranged from £68 242 to £545 940, depending on assumptions regarding the QALY value of detection of SGA.

CONCLUSION

The economic case for replacing standard care with GAP is weak based on the analysis reported in our study. However, this conclusion should be viewed taking into account that cost-effectiveness analyses are always limited by the assumptions made. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Effect of the Growth Assessment Protocol on the DEtection of Small for GestatioNal age fetus: process evaluation from the DESiGN cluster randomised trial

Background

Reducing the rate of stillbirth is an international priority. At least half of babies stillborn in high-income countries are small for gestational-age (SGA). The Growth Assessment Protocol (GAP), a complex antenatal intervention that aims to increase the rate of antenatal detection of SGA, was evaluated in the DESiGN type 2 hybrid effectiveness-implementation cluster randomised trial (n = 13 clusters). In this paper, we present the trial process evaluation.

Methods

A mixed-methods process evaluation was conducted. Clinical leads and frontline healthcare professionals were interviewed to inform understanding of context (implementing and standard care sites) and GAP implementation (implementing sites). Thematic analysis of interview text used the context and implementation of complex interventions framework to understand acceptability, feasibility, and the impact of context. A review of implementing cluster clinical guidelines, training and maternity records was conducted to assess fidelity, dose and reach.

Results

Interviews were conducted with 28 clinical leads and 27 frontline healthcare professionals across 11 sites. Staff at implementing sites generally found GAP to be acceptable but raised issues of feasibility, caused by conflicting demands on resource, and variable beliefs among clinical leaders regarding the intervention value. GAP was implemented with variable fidelity (concordance of local guidelines to GAP was high at two sites, moderate at two and low at one site), all sites achieved the target to train > 75% staff using face-to-face methods, but only one site trained > 75% staff using e-learning methods; a median of 84% (range 78–87%) of women were correctly risk stratified at the five implementing sites. Most sites achieved high scores for reach (median 94%, range 62–98% of women had a customised growth chart), but generally, low scores for dose (median 31%, range 8–53% of low-risk women and median 5%, range 0–17% of high-risk women) were monitored for SGA as recommended.

Conclusions

Implementation of GAP was generally acceptable to staff but with issues of feasibility that are likely to have contributed to variation in implementation strength. Leadership and resourcing are fundamental to effective implementation of clinical service changes, even when such changes are well aligned to policy mandated service-change priorities.

Trial registration

Primary registry and trial identifying number: ISRCTN 67698474. Registered 02/11/16. 10.1186/ISRCTN67698474.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01228-1.

Is there a role for carbetocin in the prophylaxis of postpartum obstetric haemorrhage?

Postpartum haemorrhage is a common complication of pregnancy, most commonly due to uterine atony. Uterotonics have a vital role in preventing postpartum haemorrhage but the choice of the most effective agent with the fewest adverse effects is a subject of debate. Carbetocin, a synthetic analogue of oxytocin has been available in the UK since 2007 but is not currently widely used. It has a longer duration of action than oxytocin, which avoids the need for an infusion and as it is heat-stable it can be stored at room temperature. Current UK clinical guidelines, based on the results of older meta-analyses, do not recommend carbetocin as a first-line agent. A Cochrane review, published in 2018, ranked carbetocin in the top three drug regimens for preventing postpartum haemorrhage and an international consensus statement on uterotonic use for caesarean birth concluded that carbetocin may become the preferred drug for caesarean birth, by reducing the need for additional uterotonics. The higher cost of carbetocin when compared with oxytocin is a limiting factor, but the significant healthcare costs of a postpartum haemorrhage and the physiological impact of this event suggests it a reasonable alternative to consider, especially if ergometrine is contraindicated or in those who are undergoing a caesarean birth or are at high risk of bleeding.

The DESiGN trial (DEtection of Small for Gestational age Neonate), evaluating the effect of the Growth Assessment Protocol (GAP): study protocol for a randomised controlled trial

Background

Stillbirth rates in the United Kingdom (UK) are amongst the highest of all developed nations. The association between small-for-gestational-age (SGA) foetuses and stillbirth is well established, and observational studies suggest that improved antenatal detection of SGA babies may halve the stillbirth rate. The Growth Assessment Protocol (GAP) describes a complex intervention that includes risk assessment for SGA and screening using customised fundal-height growth charts. Increased detection of SGA from the use of GAP has been implicated in the reduction of stillbirth rates by 22%, in observational studies of UK regions where GAP uptake was high. This study will be the first randomised controlled trial examining the clinical efficacy, health economics and implementation of the GAP programme in the antenatal detection of SGA.

Methods/design

In this randomised controlled trial, clusters comprising a maternity unit (or National Health Service Trust) were randomised to either implementation of the GAP programme, or standard care. The primary outcome is the rate of antenatal ultrasound detection of SGA in infants found to be SGA at birth by both population and customised standards, as this is recognised as being the group with highest risk for perinatal morbidity and mortality. Secondary outcomes include antenatal detection of SGA by population centiles, antenatal detection of SGA by customised centiles, short-term maternal and neonatal outcomes, resource use and economic consequences, and a process evaluation of GAP implementation. Qualitative interviews will be performed to assess facilitators and barriers to implementation of GAP.

Discussion

This study will be the first to provide data and outcomes from a randomised controlled trial investigating the potential difference between the GAP programme compared to standard care for antenatal ultrasound detection of SGA infants. Accurate information on the performance and service provision requirements of the GAP protocol has the potential to inform national policy decisions on methods to reduce the rate of stillbirth.

Trial registration

Primary registry and trial identifying number: ISRCTN 67698474. Registered on 2 November 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3242-6) contains supplementary material, which is available to authorized users.

Quantification of A. fumigatus-specific CD154+ T-cells-preanalytic considerations

Fungal specific CD154⁺ T-cells have been described as a biomarker in invasive aspergillosis. The influence of sample storage on the detection of these cells was assessed. Six-hour delay prior to PBMC isolation is associated with an 18% decrease of cell viability and alterations of the cellular composition of the sample. This results in 87% reduction of CD154⁺ A. fumigatus specific cells due to reduced assay sensitivity and increased background values in unstimulated samples. If prompt cell measurement is not feasible, isolated PBMCs can be frozen (at -20°C and -80°C) and processed later with comparable assay reliability (mean value fresh vs. thawing: 0.126, 0.133; Pearson-Coefficient: 0.962).

Large-aperture wide-bandwidth antireflection-coated silicon lenses for millimeter wavelengths

The increasing scale of cryogenic detector arrays for submillimeter and millimeter wavelength astrophysics has led to the need for large aperture, high index of refraction, low loss, cryogenic refracting optics. Silicon with n=3.4, low loss, and high thermal conductivity is a nearly optimal material for these purposes but requires an antireflection (AR) coating with broad bandwidth, low loss, low reflectance, and a matched coefficient of thermal expansion. We present an AR coating for curved silicon optics comprised of subwavelength features cut into the lens surface with a custom three-axis silicon dicing saw. These features constitute a metamaterial that behaves as a simple dielectric coating. We have fabricated silicon lenses as large as 33.4 cm in diameter with micromachined layers optimized for use between 125 and 165 GHz. Our design reduces average reflections to a few tenths of a percent for angles of incidence up to 30° with low cross polarization. We describe the design, tolerance, manufacture, and measurements of these coatings and present measurements of the optical properties of silicon at millimeter wavelengths at cryogenic and room temperatures. This coating and lens fabrication approach is applicable from centimeter to submillimeter wavelengths and can be used to fabricate coatings with greater than octave bandwidth.

PainDETECT: a suitable screening tool for neuropathic pain in patients with painful post-traumatic trigeminal nerve injuries?

The PainDETECT questionnaire (PD-Q), originally developed and validated in a multicentre study of neuropathic pain (NeP) patients with back pain, is increasingly being applied to other pain conditions. The present study assessed whether the PD-Q would be a suitable screening tool for detecting NeP in patients with post-traumatic inferior alveolar nerve injury (IANI) and lingual nerve injury (LNI). A prospective cohort of patients with clinically diagnosed neuropathy was given the PD-Q at their clinic appointment, or it was sent to them after their consultation. Eighty-nine patients (IANI = 56, LNI = 33) were included in the study, 75 of whom suffered from painful neuropathy. Of the patients who completed the questionnaire fully (n = 56), allowing a summary score to be calculated, 34% were classified as having 'likely NeP' according to the PD-Q; 41% of patients scored in the uncertain classification range and the remaining quarter in the 'likely nociceptive' classification. There was a significant association between PD-Q scores and pain intensity levels across the sample, with those classified as likely NeP reporting high levels of pain. The results suggest that the PD-Q in its current format is not a suitable screening tool for NeP associated with IANI or LNI.

Clinical and anatomical heterogeneity in autistic spectrum disorder: a structural MRI study

BACKGROUND

Autistic spectrum disorder (ASD) is characterized by stereotyped/obsessional behaviours and social and communicative deficits. However, there is significant variability in the clinical phenotype; for example, people with autism exhibit language delay whereas those with Asperger syndrome do not. It remains unclear whether localized differences in brain anatomy are associated with variation in the clinical phenotype.

METHOD

We used voxel-based morphometry (VBM) to investigate brain anatomy in adults with ASD. We included 65 adults diagnosed with ASD (39 with Asperger syndrome and 26 with autism) and 33 controls who did not differ significantly in age or gender.

RESULTS

VBM revealed that subjects with ASD had a significant reduction in grey-matter volume of medial temporal, fusiform and cerebellar regions, and in white matter of the brainstem and cerebellar regions. Furthermore, within the subjects with ASD, brain anatomy varied with clinical phenotype. Those with autism demonstrated an increase in grey matter in frontal and temporal lobe regions that was not present in those with Asperger syndrome.

CONCLUSIONS

Adults with ASD have significant differences from controls in the anatomy of brain regions implicated in behaviours characterizing the disorder, and this differs according to clinical subtype.

Virtual reality training for radiotherapy becomes a reality

A report in 2007 to the UK Government identified a crisis in England for training staff and students for the radiotherapy treatment of cancer. The Hull authors have developed an immersive life size virtual environment of a radiotherapy treatment room, known as VERT, to address this problem. VERT provides the trainee with models, simulation, enhanced visualization and training aids for treatment of virtual patients in a virtual treatment room. In 2007 immersive VERT systems for radiotherapy training were established for training purposes at the University Aarhus Hospital (Denmark) and the Birmingham City University (UK). This paper reports on early evaluations of VERT by these two institutions.

Optical design of the atacama cosmology telescope and the millimeter bolometric array camera

The Atacama Cosmology Telescope is a 6 m telescope designed to map the cosmic microwave background simultaneously at 145, 215, and 280 GHz with arcminute resolution. Each frequency will have a 32 by 32 element focal plane array of transition edge sensor bolometers. The telescope and the cold reimaging optics are optimized for millimeter-wave observations with these sensitive detectors. The design of each is described.

Immersive visualization with automated collision detection for radiotherapy treatment planning

Intensity modulated radiotherapy (IMRT) is a technique for treating cancer tumours using external delivery of radiation. To create a treatment plan the directions of the external radiation beams (typically 5 to 9) need to be specified. Normally the beams are all coplanar due to the added complexity of planning and patient set-up for non-coplanar beams. RTStar provides a virtual environment of a radiotherapy (RT) treatment room that provides a range of views and visualizations that aid a treatment planner to choose non-coplanar beam directions efficiently. RTStar also automatically warns the planner when a collision would occur during patient set-up. A study was conducted on 8 prostate IMRT cancer patients using RTStar to create RT plans using non-coplanar beams. The study demonstrated that these IMRT prostate plans with non-coplanar beams had a dosimetric advantage over their coplanar conterparts.

A role for GnRH in early brain regionalization and eye development in zebrafish

Gonadotropin-releasing hormone (GnRH) is a highly conserved peptide that is expressed early in brain development in vertebrates. In zebrafish, we detected GnRH mRNA within 2h post fertilization by RT-PCR. To determine if GnRH is involved in development, we used gene knockdown techniques to block translation of gnrh2 or gnrh3 mRNA after which the expression patterns for gene markers were examined at 24h post fertilization with in situ hybridization. First, loss of either GnRH2 or GnRH3 affected regionalization of the brain as shown by a change in expression of fgf8 or pax2.1 genes in the midbrain-hindbrain boundary or diencephalon-midbrain boundary. Second, lack of GnRH2 and/or GnRH3 altered gene markers expressed in the formation of the eye cup (pax2.1, pax6.1, mab21l2 and meis1.1) or eye stalk (fgf8 and pax2.1). Third, knockdown of GnRH2 affected the size and shape of the midbrain and expression of gene markers therein. Results from assays with the TUNEL method and caspase-3 and -9 activity showed the brain and eye changes were unlikely to result from secondary apoptotic cell death before 24h post fertilization. These experiments suggest that GnRH loss-of-function affects early brain and eye formation during development.

Are investigations anxiolytic or anxiogenic? A randomised controlled trial of neuroimaging to provide reassurance in chronic daily headache

OBJECTIVES

Aims were to investigate (a) whether neuroimaging in patients with chronic daily headache reassures patients or fails to reassure them and/or worsens outcome, impacting on service use, costs, health anxieties, and symptoms, and (b) whether this reassurance process occurs differentially in patients with different levels of psychological morbidity.

DESIGN

randomised controlled trial; setting: headache clinic in secondary care, South London; participants: 150 patients fulfilling criteria for chronic daily headache, stratified using the Hospital Anxiety and Depression Scale (HADS); intervention: treatment as usual or the offer of an MRI brain scan; main outcome measures: use of services, costs, and health anxiety.

RESULTS

Seventy six patients were randomised to the offer of a brain scan and 74 patients to treatment as usual. One hundred and thirty seven (91%) primary care case notes were examined at 1 year, 103 (69%) patients completed questionnaires at 3 months and 96 (64%) at 1 year. Sixty six (44%) patients were HADS positive (scored >11 on either subscale). Patients offered a scan were less worried about a serious cause of the headaches at 3 months (p = 0.004), but this was not maintained at 1 year; other health anxiety measures did not differ by scan status. However, at 1 year HADS positive patients offered a scan cost significantly less, by 465 pounds Sterling (95% confidence interval (CI): -1028 pounds Sterling to -104 pounds Sterling), than such patients not offered a scan, due to lower utilisation of medical resources.

CONCLUSIONS

Neuroimaging significantly reduces costs for patients with high levels of psychiatric morbidity, possibly by changing subsequent referral patterns of the general practitioner.

Occupational health issues affecting the pharmaceutical sales force

BACKGROUND

The sales force forms a significant sub-population in the pharmaceutical industry workforce. Role and organizational characteristics, such as isolation, peripatetic working and car travel and the psychosocial and ergonomic hazards related to work tasks, present particular occupational health risks.

AIM

To review the occupational risks associated with peripatetic sales force work and evidence for the effectiveness of preventive interventions.

METHODS

We carried out a review of the available literature between 1990 and 2003.

RESULTS

The following hazards were identified as significant and worthy of further investigation for this occupational group: driving on company business; violence in the workplace; stress; ergonomic issues; and mobile phone use.

CONCLUSION

To ensure effective prevention and management of employee health problems, specific health management strategies and interventions must be developed to meet the occupational health needs of this group.

The humanization of birth

The humanization of birth conference drew more than 2000 people from 26 countries. This article summarizes the conference. In much of the world women have learned to fear birth; this fear is represented by the increase in cesarean section rates seen in many countries. The humanization of birth may reduce this fear. Yet humanization is difficult to achieve in technocratic societies. It is important to recognize that safety and self-fulfilling experiences are not contradictions, and that humanized birth is the safest approach.

Human resources for maternity care: the present system in Brazil, Japan, North America, Western Europe and New Zealand

This article describes the nature of the humanization of birth and the overlapping but distinct role of professionals within the maternity services with an emphasis on the role of the midwife. It describes the status of midwives in different parts of the world, and the common characteristics of work undertaken to restore the role of the midwife. Midwifery is seen as an essential component of effective maternity services. In addition it is important to recognize the important role that traditional birth attendants play in many parts of the world. An appropriate structure including primary and secondary and tertiary care services are important for professionals to play their full part.

Homotypic fusion of immature secretory granules during maturation requires syntaxin 6

Homotypic fusion of immature secretory granules (ISGs) gives rise to mature secretory granules (MSGs), the storage compartment in endocrine and neuroendocrine cells for hormones and neuropeptides. With the use of a cell-free fusion assay, we investigated which soluble N-ethylmaleimide-sensitive fusion protein attachment receptor (SNARE) molecules are involved in the homotypic fusion of ISGs. Interestingly, the SNARE molecules mediating the exocytosis of MSGs in neuroendocrine cells, syntaxin 1, SNAP-25, and VAMP2, were not involved in homotypic ISG fusion. Instead, we have identified syntaxin 6 as a component of the core machinery responsible for homotypic ISG fusion. Subcellular fractionation studies and indirect immunofluorescence microscopy show that syntaxin 6 is sorted away during the maturation of ISGs to MSGs. Although, syntaxin 6 on ISG membranes is associated with SNAP-25 and SNAP-29/GS32, we could not find evidence that these target (t)-SNARE molecules are involved in homotypic ISG fusion. Nor could we find any involvement for the vesicle (v)-SNARE VAMP4, which is known to be associated with syntaxin 6. Importantly, we have shown that homotypic fusion requires the function of syntaxin 6 on both donor as well as acceptor membranes, which suggests that t-t-SNARE interactions, either direct or indirect, may be required during fusion of ISG membranes.

Characterizing the peak in the cosmic microwave background angular power spectrum

A peak has been unambiguously detected in the cosmic microwave background angular spectrum. Here we characterize its properties with fits to phenomenological models. We find that the TOCO and BOOM/NA data determine the peak location to be in the range 175-243 and 151-259, respectively (at 95% confidence) and determine the peak amplitude to be between approximately 70 and 90 &mgr;K. The peak shape is consistent with inflation-inspired flat, cold dark matter plus cosmological constant models of structure formation with adiabatic, nearly scale invariant initial conditions. It is inconsistent with open models and presents a great challenge to defect models.

Clinical interventions and outcomes of One-to-One midwifery practice

BACKGROUND

Changing Childbirth became policy for the maternity services in England in 1994 and remains policy. One-to-One midwifery was implemented to achieve the targets set. It was the first time such a service had been implemented in the Health Service. An evaluation was undertaken to compare its performance with conventional maternity care.

METHODS

This was a prospective comparative study of women receiving One-to-One care and women receiving the system of care that One-to-One replaced (conventional care) to compare achievement of continuity of carer and clinical outcomes. The evaluation took place in The Hammersmith Hospitals NHS Trust, the Queen Charlotte's and Hammersmith Hospitals. This was part of a larger study, which included the evaluation of women's responses, cost implications, and clinical standards and staff reactions. The participants were all those receiving One-to-One midwifery practice (728 women), which was confined to two postal districts, and all women receiving care in the system that One-to-One replaced, in two adjacent postal districts (675 women), and expecting to give birth between 15 August 1994 and 14 August 1995. Main outcome measures were achievement of continuity of care, rates of interventions in labour, length of labour, maternal and infant morbidity, and breastfeeding rates.

RESULTS

A high degree of continuity was achieved through the whole process of maternity care. One-to-One women saw fewer staff at each stage of their care, knew more of the staff who they did see, and had a high level of constant support in labour. One-to-One practice was associated with a significant reduction in the use of epidural anaesthesia (odds ratio (OR) 95 per cent confidence interval (CI) = 0.59 (0.44, 0.80)), with lower rates of episiotomy and perineal lacerations (OR 95 per cent CI = 0.70 (0.50, 0.98)), and with shorter second stage labour (median 40 min vs 48 min). There were no statistically significant differences in operative and assisted delivery or breastfeeding rates.

CONCLUSIONS

This study confirms that One-to-One midwifery practice can provide a high degree of continuity of carer, and is associated with a reduction in the rate of a number of interventions, without compromising safety of care. It should be extended locally and replicated in other services under continuing evaluation.

Developmental characterization of the gene for laminin alpha-chain in sea urchin embryos

We describe the isolation and characterization of a cDNA clone encoding a region of the carboxy terminal globular domain (G domain) of the alpha-1 chain of laminin from the sea urchin, Strongylocentrotus purpuratus. Sequence analysis indicates that the 1.3 kb cDNA (spLAM-alpha) encodes the complete G2 and G3 subdomains of sea urchin a-laminin. The 11 kb spLAM-alpha mRNA is present in the egg and declines slightly in abundance during development to the pluteus larva. The spLAM-alpha gene is also expressed in a variety of adult tissues. Whole mount in situ hybridization of gastrula stage embryos indicates that ectodermal and endodermal epithelia and mesenchyme cells contain the spLAM-alpha mRNA. Immunoprecipitation experiments using an antibody made to a recombinant fusion protein indicates spLAM-alpha protein is synthesized continuously from fertilization as a 420 kDa protein which accumulates from low levels in the egg to elevated levels in the pluteus larva. Light and electron microscopy identify spLAM-alpha as a component of the basal lamina. Blastocoelic microinjection of an antibody to recombinant spLAM-alpha perturbs gastrulation and skeleton formation by primary mesenchyme cells suggesting an important role for laminin in endodermal and mesodermal morphogenesis.

Evaluation of one-to-one midwifery: women's responses to care

BACKGROUND

One-to-one midwifery was a demonstration project introduced into a London-based maternity service in 1993 to put into practice the new government policy for maternity services in England. Evaluation was integral to the development of the project.

METHODS

The evaluation of women's responses was conducted between August 1994 and August 1995 based on a longitudinal, self-completion questionnaire, interviews, and focus groups. Women in the study group (n = 728) received the new service and women in the control group (n = 675) received conventional care. The study design integrated quantitative and qualitative methods and went beyond a simple estimation of satisfaction with care.

RESULTS

Satisfaction with antenatal and birth care was generally high, but study group women showed more positive responses overall. Both groups showed a preference for continuity of caregiver, but expectations were higher in the study group (72% of the study group and 42% of the control group preferred to see one caregiver). Both groups had less satisfied responses to hospital postnatal care (50% study and 54% control group were very satisfied). Study group women showed greater preparedness for birth than control group women (18% vs 12% "very well prepared") and for the time after the baby's birth (26% vs 15% "very prepared").

CONCLUSIONS

The study demonstrated that women were more satisfied with the one-to-one model of care. Taken together with the results of clinical and economic audit and professional responses, the evaluation suggests that this model should be developed and evaluated further to gain a greater understanding of women's needs of the maternity service.

The use of clinical audit in evaluating maternity services reform: a critical reflection

The clinical evaluation described here, using a casenote study, was part of a larger study evaluating the changes made to part of the maternity services in one NHS Trust, in response to the recommendations of Changing Childbirth (Department of Health 1993a). Results of the audit showed no evidence of a lowering of clinical standards within the study group and provided reassurance that a radical change in the model of care, with greatly enhanced continuity of career, an emphasis on community-based and midwifery-led care, and some reductions in labour interventions, could be implemented without compromising safety of care. The audit process raised a number of methodological problems which will need to be addressed in developing audit approaches which are able to reflect quality of care. It is important to recognize that the record of care is not a direct mirror of the care provided but a secondary source, kept for different purposes and designed to cover a different set of priorities from those which audit may seek to capture. The audit approach used in this study will be modified in continuing evaluation of the service as it moves from a pilot stage towards providing a mainstream service. Additional methods, including direct observation of care, will be employed in a sample of cases in order to assist in interpretation of audit findings.

Bladder augmentation can be problematic with renal failure and transplantation

Ten consecutive patients with failure of urinary bladder augmentation (UBA) performed either prior to or after reaching end-stage renal disease (ESRD) were studied. Seven patients developed increased hydroureteronephrosis, infectious complications, and advanced to ESRD after UBA. The mean time to development of ESRD in patients who had UBA performed with moderate chronic renal failure (CRF) was 1.8 years. The UBAs in all seven patients were taken down prior to transplantation. Subsequently, five of these UBA-takedown patients have received kidney grafts and all have stable, good renal function. Three patients had their UBA performed after they reached ESRD, in preparation for renal transplantation. All three of these patients experienced recurrent urosepsis following transplantation, resulting in death in one patient and loss of graft in another. The third patient will undergo takedown of the UBA. This study suggests that UBA may possibly not be the best option for patients with moderate CRF and those awaiting transplantation.

Change and power in midwifery

Midwives are experiencing problems in playing their full part in the maternity services and the communities in which they practice. Mothers, babies, and families require greater care from these caregivers for healthier pregnancy and birth outcomes. Change to renew the power, skills, and knowledge of midwives is evident in many parts of the world. Processes of change require an examination of the purpose of midwifery. The starting point of change is an awareness of the meaning of birth to individuals and society, and of the role of midwives in supporting families around the time of birth. Midwives should use their power to resolve the considerable problems facing childbearing families, and to enrich the event.

Quantitative cell line based bioassays for human cytokines

Research in cytokine biology is ever increasing and it is clear that cytokines are involved in a wide range of pathological and physiological processes. The validity of such research relies heavily on the appropriate measurement of levels of cytokines in various biological samples. Amongst the currently available methods for measuring cytokine levels, it is only the biological assay of samples that can directly provide estimates of biologically active cytokines present in test samples. Of the several bioassay systems available for detecting cytokines, cell line based bioassays are the easiest to perform and provide the most precise and accurate data. The suitability of any cell line for bioassaying a particular cytokine depends on several criteria such as sensitivity, ease of growth maintenance, and cytokine specificity. The design and analysis of cell line bioassays is also important in providing valid estimates of cytokine levels. We review the most useful cell lines currently available for bioassaying cytokines and discuss the design advantages and limitations of cytokine bioassays.