Efficacy of perineal massage during the second stage of labor for the prevention of perineal injury: A systematic review and meta‐analysis

[EN] Background: Numerous interventions to reduce perineal trauma during childbirth have been studied in recent years, including perineal massage. Objective: To determine the efficacy of perineal massage during the second stage of labor to prevent perineal damage. Search Strategy: Systematic search in PubMed, Pedro, Scopus, Web of Science, ScienceDirect, BioMed, SpringerLink, EBSCOhost, CINAHL, and MEDLINE with the terms Massage, Second labor stage, Obstetric delivery, and Parturition. Selection Criteria: The articles must have been published in the last 10 years; the perineal massage was administered to the study sample; and the experimental design consisted of randomized controlled trial. Data Collection and Analysis: Tables were used to describe both the studies' characteristics and the extracted data. The PEDro and Jadad scales were used to assess the quality of studies. Main Results: Of the 1172 total results identified, nine were selected. Seven studies were included in the meta-analysis and indicated a statistically significant decreased number of episiotomies in perineal massage. Conclusions: Massage during the second stage of labor appears to be effective in preventing episiotomies and reducing the duration of the second stage of labor. However, it does not appear to be effective in reducing the incidence and severity of perineal tears.S

Clinical Diagnosis of Placenta Accreta and Clinicopathological Outcomes

Objective To investigate the association between the intraoperative diagnosis of placenta accreta at the time of cesarean hysterectomy and pathological diagnosis. Study Design This is a retrospective cohort study of all patients undergoing cesarean hysterectomy for suspected placenta accreta from 2000 to 2016 at Barnes-Jewish Hospital. The primary outcome was the presence of invasive placentation on the pathology report. We estimated predictive characteristics of clinical diagnosis of placenta accreta using pathological diagnosis as the correct diagnosis. Results There were 50 cesarean hysterectomies performed for suspected abnormal placentation from 2000 to 2016. Of these, 34 (68%) had a diagnosis of accreta preoperatively and 16 (32%) were diagnosed intraoperatively at the time of cesarean delivery. Two patients had no pathological evidence of invasion, corresponding to a false-positive rate of 4% (95% confidence interval [CI]: 0.5%, 13.8%) and a positive predictive value of 96% (95% CI: 86.3%, 99.5%). There were no differences in complications among patients diagnosed intraoperatively compared with those diagnosed preoperatively. Conclusion Most patients undergoing cesarean hysterectomy for placenta accreta do have this diagnosis confirmed on pathology. However, since the diagnosis of placenta accreta was made intraoperatively in nearly a third of cesarean hysterectomies, intraoperative vigilance is required as the need for cesarean hysterectomy may not be anticipated preoperatively

Quality of comprehensive emergency obstetric care through the lens of clinical documentation on admission to labour ward

Background: Clinical documentation gives a chronological order of procedures and activities that a patient is given during their management.Objective: To determine the level of quality of comprehensive emergency obstetric care, through the lens of clinical documentation of process indicators of selected emergency obstetric conditions that mostly cause maternal mortality on admission to labour wardDesign: Multi-site cross sectional survey.Setting: Twenty two Government Hospitals in Kenya with capacity to offer comprehensive emergency obstetric care.Subjects: Process variables were abstracted from patient’ case records with a diagnosis of normal vaginal delivery, obstetric haemorrhage, severe pre eclampsia/eclampsia and emergency cesarean section.Results: Availability of structure indicators were graded excellent and good except for long gloves, misoprostol, ergometrin and parenteral cefuroxime that were graded low. A total of 1,216 records were abstracted for process analysis. The median (IQR) for the: six variables of obstetric history was five (4-5); five variables of antenatal profile was four (1-5); five variables of vital signs documentation was three (2-4); five variables for obstetric exam was four (4-5); seven variables of vaginal examination one (0-2); ten variables for partograph was seven (2-9); five variables for obstetric hemorrhage was three (2-4) and eleven variables for severe pre-eclampsia/eclampsia was five (3-6). The median (IQR) from decision-to-operate to caesarean section was three (2-4) hours.Conclusion: Quality of emergency obstetric care based on documentation depicts inadequacy. There is an urgent need to objectively address the need for proper clinical documentation as an indicator of quality performance

Perinatal and newborn care in a two years retrospective study in a first level peripheral hospital in Sicily (Italy)

BACKGROUND: Two hundred seventy-five thousand maternal deaths, 2.7 million neonatal deaths, and 2.6 million stillbirths have been estimated in 2015 worldwide, almost all in low-income countries (LICs). Moreover, more than 20 million severe disabilities result from the complications of pregnancy, childbirth or its management each year. A significant decrease of mortality/morbidity rates could be achieved by providing effective perinatal and newborn care also in high-income countries (HICs), especially in peripheral hospitals and/or rural areas, where the number of childbirths per year is often under the minimal threshold recognized by the reference legislation. We report on a 2 years retrospective cohort study, conducted in a first level peripheral hospital in Cefalù, a small city in Sicily (Italy), to evaluate care provided and mortality/morbidity rates. The proposed goal is to improve the quality of care, and the services that peripheral centers can offer. METHODS: We collected data from maternity and neonatal records, over a 2-year period from January 2017 to December 2018. The informations analyzed were related to demographic features (age, ethnicity/origin area, residence, educational level, marital status), diagnosis at admission (attendance of birth training courses, parity, type of pregnancy, gestational age, fetal presentation), mode of delivery, obstetric complications, the weight of the newborns, their feeding and eventual transfer to II level hospitals, also through the Neonatal Emergency Transport Service, if the established criteria were present. RESULTS: Eight hundred sixteen women were included (age 18-48 years). 179 (22%) attended birth training courses. 763 (93%) were Italian, 53 foreign (7%). 175 (21%) came from outside the province of Palermo. Eight hundred ten were single pregnancies, 6 bigeminal; 783 were at term (96%), 33 preterm (4%, GA 30-41 WG); 434 vaginal deliveries (53%), 382 caesarean sections (47%). One maternal death and 28 (3%) obstetric complications occurred during the study period. The total number of children born to these women was 822, 3 of which stillbirths (3.6‰). 787 (96%) were born at term (>37WG), 35 preterm (4%), 31 of which late preterm. Twenty-one newborns (2.5%) were transferred to II level hospitals. Among them, 3 for moderate/severe prematurity, 18 for mild prematurity/other pathology. The outcome was favorable for all women (except 1 hysterectomy) and the newborns transferred, and no neonatal deaths occurred in the biennium under investigation. Of the remaining 798 newborns, 440 were breastfed at discharge (55%), 337 had a mixed feeding (breastfed/formula fed, 42%) and 21 were formula fed (3%). CONCLUSIONS: Although the minimal standard of adequate perinatal care in Italy is >500 childbirths/year, the aims of the Italian legislation concern the rationalization of birth centers as well as the structural, technological and organizational improvement of health facilities. Therefore, specific contexts and critical areas need to be identified and managed. Adequate resources and intervention strategies should be addressed not only to perinatal emergencies, but also to the management of mild prematurity/pathology, especially in vulnerable populations for social or orographic reasons. The increasing availability and spread of health care offers, even in HICs, cannot be separated from the goal of quality of care, which is an ethic and public health imperative

Non-pharmacological interventions to reduce anxiety in pregnancy, labour and postpartum: A systematic review

Background: The anxiety mothers experience during pregnancy is well known and may have negative consequences for the emotional, psychological, and social development of newborns. Anxiety must therefore be reduced using different strategies. Objective: To determine published non-pharmacological interventions to reduce anxiety during pregnancy, childbirth and postpartum. Methods: A systematic peer-review of experimental and quasi-experimental studies was conducted using the PubMed, Scopus, Web of Science (WOS), and CINAHL databases. The quality of the studies was assessed using the Spanish version of the PEDro scale. Two researchers participated independently in the data selection and extraction process. Findings: 587 articles were identified, of which 21 met the eligibility criteria. In eleven studies the intervention was performed during pregnancy, in three of them during labour, in four of them during the postpartum period, and in three of them during pregnancy and postpartum. During pregnancy, the most effective interventions were behavioural activation, cognitive behavioural therapy, yoga, music therapy, and relaxation; during childbirth: aromatherapy; during pregnancy and postpartum: antenatal training, massage by partners, and self-guided book reading with professional telephone assistance. Conclusion and Implications: The most effective interventions to reduce anxiety were performed either during pregnancy or during the postpartum period, not during labour. Most of the interventions were performed on the women, with few of them being performed on both partners. Non-pharmacological interventions may be applied by nurses and midwives to reduce anxiety during pregnancy, labour and postpartum

Achieving the Millennium Development Goal of reducing maternal mortality in rural Africa: an experience from Burundi.

OBJECTIVES: To estimate the reduction in maternal mortality associated with the emergency obstetric care provided by Médecins Sans Frontières (MSF) and to compare this to the fifth Millennium Development Goal of reducing maternal mortality. METHODS: The impact of MSF's intervention was approximated by estimating how many deaths were averted among women transferred to and treated at MSF's emergency obstetric care facility in Kabezi, Burundi, with a severe acute maternal morbidity. Using this estimate, the resulting theoretical maternal mortality ratio in Kabezi was calculated and compared to the Millennium Development Goal for Burundi. RESULTS: In 2011, 1385 women from Kabezi were transferred to the MSF facility, of whom 55% had a severe acute maternal morbidity. We estimated that the MSF intervention averted 74% (range 55-99%) of maternal deaths in Kabezi district, equating to a district maternal mortality rate of 208 (range 8-360) deaths/100 000 live births. This lies very near to the 2015 MDG 5 target for Burundi (285 deaths/100 000 live births). CONCLUSION: Provision of quality emergency obstetric care combined with a functional patient transfer system can be associated with a rapid and substantial reduction in maternal mortality, and may thus be a possible way to achieve Millennium Development Goal 5 in rural Africa

The effectiveness of mHealth interventions for maternal, newborn and child health in low- and middle-income countries:Protocol for a systematic review and meta-analysis

Rates of maternal, newborn and child (MNCH) mortality and morbidity are vastly greater in low– than in high–income countries and represent a major source of global health inequity. A host of systemic, economic, geopolitical and sociocultural factors have been implicated. Mobile information and communication technologies hold potential to ameliorate several of these challenges by supporting coordinated and evidence–based care, facilitating community based health services and enabling citizens to access health information and support. mHealth has attracted considerable attention as a means of supporting maternal, newborn and child health in developing countries and research to assess the impacts of mHealth interventions is increasing. While a number of expert reviews have attempted to summarise this literature, there remains a need for a fully systematic review employing gold standard methods of evidence capture, critical appraisal and meta–analysis, in order to comprehensively map, quality assess and synthesise this body of knowledge

Study of obstetric and fetal outcome of twin pregnancy in a tertiary care centre

Background: The past two decades have witnessed a sharp rise in the incidence of twin and higher order gestations. The progress and developments in assisted reproductive technology, availability and widespread use of ovulation inducing drugs and delayed childbearing are thought to be the causes responsible for the rise. Twin pregnancy is associated with increased maternal and perinatal morbidity and mortality as well as healthcare costs. Maternal complications like hypertensive disorders, anemia, gestational diabetes mellitus (GDM), preterm labour, preterm premature rupture of membranes (PPROM) and placental abruption increases. It is also responsible for repeated antenatal admissions, longer hospital stay, blood transfusions and increase in operative vaginal or cesarean delivery, post-partum hemorrhage and Hysterectomy. Twins have an increased risk of intraventricular hemorrhage, sepsis, necrotizing enterocolitis, respiratory distress syndrome and neonatal death. The objective of the study was to study the maternal and fetal outcome of twin pregnancy.Methods: Retrospective analytical review of all twin deliveries at the teaching hospital medical college of Central India, over a period of 3 years between January 2010 and December 2012.There were 55 twin deliveries, data analysis regarding maternal age, parity, presentation, gestational age at delivery, obstetric complication mode of delivery, birth weights, and perinatal morbidity & mortality was analyzed.Results: Majority of patients 44 (80%) were in age group of 20-30 years. 55% patients were booked and 62% were from urban area. 18 (32%) patients could reach beyond 37 weeks, there were 21 (38%) cases between 34 to 37 weeks and 16 (29%) between 30 to 34 weeks of gestation. Preterm delivery was the commonest complication occurring in 67% of the cases. Cephalic presentation of both the babies occurred in 36% of the cases. 50% of the twins needed admission to NICU for various indications like prematurity, birth asphyxia, low birth weight, meconium staining of liquor & delivery by caesarean section. In our study among the 55 twin births there were 16 (29 %) perinatal deaths and one maternal mortality.Conclusions: Twin pregnancies are high risk pregnancies with more maternal and fetal complications. The use of antenatal care services, identification and anticipation of complications, intrapartum management and good NICU facilities will help to improve maternal and neonatal outcome in twin pregnancies

Les facteurs influençant les motivations et les représentations des femmes qui choisissent d'accoucher sous anesthésie péridurale: Travail de Bachelor

But : L’objectif de ce travail est de mettre en évidence les facteurs influençant les représentations et les motivations des femmes, les dirigeant vers le choix d’une anesthésie péridurale pour leur accouchement. Méthode : Nous avons effectué une revue de littérature basée sur une analyse descriptive et critique de cinq articles sélectionnés à travers les moteurs de recherche « Pubmed » et « Lissa ». Résultats : Les représentations et les motivations des femmes face au recours à une péridurale sont multiples. Les différences de perceptions et d’évaluations de la douleur ainsi que le déroulement de l’accouchement ont un impact sur la demande d’une péridurale. L’accompagnement des professionnels de la santé a un rôle important dans le choix final des femmes. Un certain nombre d’entres elles modifient leur requête initiale au cours de la grossesse et/ou au moment de l’accouchement. La présence ou non d’un anesthésiste dans la structure peut également jouer un rôle déterminant et peut modifier la prédilection des femmes face à une péridurale. Pour les professionnels de la santé, la péridurale peut permettre d’être moins présent auprès du couple mais aussi d’anticiper d’éventuelles interventions ultérieures dans le déroulement du travail d’accouchement. Conclusion : La péridurale est un moyen précieux qui a permis de diminuer le taux de mortalité en périnatalité. Elle permet également aux femmes de vivre un accouchement avec une diminution de la douleur. Les sages-femmes jouent un rôle primordial dans l’accompagnement des femmes concernant le choix de recourir à une anesthésie péridurale pour leur accouchement. Les divers professionnels de la santé tels que les sages-femmes, les gynécologues et les anesthésistes doivent prendre en compte les multiples facteurs influençant le choix des femmes et les accompagner selon leurs souhaits et leurs besoins

Planned delivery at 37 weeks gestation versus expectant management for non-severe chronic hypertension, a systematic review.

Background: Chronic hypertension is independently associated with an increased incidence of adverse maternal and perinatal outcomes. Delayed delivery carries maternal risks, while early delivery increases fetal risk, so appropriate timing is important. The optimal timing of delivery for women with this condition has not been adequately addressed by the available literature. Objective: To review the literature that assesses the benefits and risks of a policy of planned delivery versus expectant management in pregnant women with non-severe chronic hypertension at 37 weeks gestation. Our primary outcomes were composite maternal outcome (super-imposed pre-eclampsia, placental abruption, maternal admission to intensive care unit and composite perinatal outcome (stillbirth, admission to neonatal intensive care unit). Secondary outcomes were superimposed pre-eclampsia, placental abruption, maternal admission to the intensive care unit, stillbirth, and admission to the neonatal intensive care unit. Research Design and Search Methods: A systematic review with a narrative synthesis. We carried out an electronic search of different databases including CENTRAL, MEDLINE, and EMBASE. We set out to include randomized trials and cohort studies comparing planned early delivery and expectant management at 37 weeks gestation. We conducted a risk of bias assessment for each of the outcomes of interest. The quality of the evidence for the specified outcomes was assessed using the GRADE approach. Results: We screened a total of 8830 titles and abstracts and 15 articles were selected for full text review. We found one study that was eligible for inclusion. This was a randomized controlled trial with 76 participants with similar baseline clinical characteristics. Half of them were assigned to planned delivery at 37 weeks of gestation while the other half was assigned to expectant management up to 41 weeks of gestation. There was no significant difference in the rate of super-imposed pre-eclampsia between the two groups (OR =0.9 (95% CI 0.2 to 2.3) p-value 0.9). Similarly, no significant difference in the rate of placental abruption was observed between the two groups. (OR =1.0 (95% CI 0.2 to 5.2) p-value 1.0). For these two outcomes, the risk of bias was high and the findings were based on a low degree of certainty of the evidence. The rate of admission to the neonatal intensive care unit was higher in the planned delivery compared to the expectant management group (OR = 5.4 (95% CI 1.4 to 21.0); p-value 0.01.). There were some concerns about the risk of bias for this outcome and these findings were based on a moderate degree of the certainty of the evidence. Conclusion: In women with non-severe chronic hypertension in pregnancy, a policy of expectant management up to 41 weeks gestation was more favorable than planned delivery at 37 weeks gestation. There was no significant difference in the rates of super-imposed pre-eclampsia, or placental abruption though this finding was based on a low degree of certainty of the evidence. Additionally, expectant management was associated with lower rates of admission to the neonatal intensive care unit, and this finding is based on a moderate level of certainty of the evidence