Prevention and Management of Postpartum Hemorrhage

Postpartum hemorrhage (PPH) remains a major traumatic event that can occur after delivery. All expectant women are considered to be at risk of PPH and its effects. PPH is a preventable condition and primary interventions including active management of the 3rd stage of labor, use of uterotonics, and uterine massage. Analysis of the project site showed that PPH affected approximately 15% of all deliveries that occurred between 2014 and 2015. The overarching aim of the project was to determine how a nursing-focused educational intervention would affect staff nurse knowledge regarding PPH to decrease the incidence rate. The goal of the project was to develop an educational module for obstetric and postpartum nurses about prevention and management of PPH, decrease the PPH incidence rate from 15% to 10%, and evaluate the obstetric and postpartum nurses\u27 attitudes toward the Association of Women\u27s Health, Obstetric and Neonatal Nurses (AWHONN) guideline used to decrease the risk of PPH. Bandura\u27s social learning and self-efficacy theories were used to guide the development and implementation of the educational intervention. A paired t test was used to analyze the differences in the staff nurses\u27 knowledge of PPH before and after the educational intervention. The group\u27s mean score preintervention was 53.65% and 90% postintervention, representing a 36.35% increase in the knowledge scores. The PPH rate decreased from 15% to 0% after implementation of the project. Social change will occur through a better understanding of the physiology of PPH and the positive adaptation of the use of AWHONN guidelines in managing PPH as such, may decrease mortality

Prediction of preterm delivery in symptomatic women using PAMG‐1, fetal fibronectin and phIGFBP‐1 tests: systematic review and meta‐analysis

Objective To assess the accuracy of placental alpha microglobulin‐1 (PAMG‐1), fetal fibronectin (fFN) and phosphorylated insulin‐like growth factor‐binding protein‐1 (phIGFBP‐1) tests in predicting spontaneous preterm birth (sPTB) within 7 days of testing in women with symptoms of preterm labor, through a systematic review and meta‐analysis of the literature. The test performance of each biomarker was also assessed according to pretest probability of sPTB ≤ 7 days. Methods The Cochrane, MEDLINE, PubMed and ResearchGate bibliographic databases were searched from inception until October 2017. Cohort studies that reported on the predictive accuracy of PAMG‐1, fFN and phIGFBP‐1 for the prediction of sPTB within 7 days of testing in women with symptoms of preterm labor were included. Summary receiver–operating characteristics (ROC) curves and sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and positive (LR+) and negative (LR–) likelihood ratios were generated using indirect methods for the calculation of pooled effect sizes with a bivariate linear mixed model for the logit of sensitivity and specificity, with each diagnostic test as a covariate, as described by the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy. Results Bivariate mixed model pooled sensitivity of PAMG‐1, fFN and phIGFBP‐1 for the prediction of sPTB ≤ 7 days was 76% (95% CI, 57–89%), 58% (95% CI, 47–68%) and 93% (95% CI, 88–96%), respectively; pooled specificity was 97% (95% CI, 95–98%), 84% (95% CI, 81–87%) and 76% (95% CI, 70–80%) respectively; pooled PPV was 76.3% (95% CI, 69–84%) (P < 0.05), 34.1% (95% CI, 29–39%) and 35.2% (95% CI, 31–40%), respectively; pooled NPV was 96.6% (95% CI, 94–99%), 93.3% (95% CI, 92–95%) and 98.7% (95% CI, 98–99%), respectively; pooled LR+ was 22.51 (95% CI, 15.09–33.60) (P < 0.05), 3.63 (95% CI, 2.93–4.50) and 3.80 (95% CI, 3.11–4.66), respectively; and pooled LR– was 0.24 (95% CI, 0.12–0.48) (P < 0.05), 0.50 (95% CI, 0.39–0.64) and 0.09 (95% CI, 0.05–0.16), respectively. The areas under the ROC curves for PAMG‐1, fFN and phIGFBP‐1 for sPTB ≤ 7 days were 0.961, 0.874 and 0.801, respectively. Conclusions In the prediction of sPTB within 7 days of testing in women with signs and symptoms of PTL, the PPV of PAMG‐1 was significantly higher than that of phIGFBP‐1 or fFN. Other diagnostic accuracy measures did not differ between the three biomarker tests. As prevalence affects the predictive performance of a diagnostic test, use of a highly specific assay for a lower‐prevalence syndrome such as sPTB may optimize management

Spontaneous Unexplained Preterm Labor with Intact Membrane: Finding Protein Biomarkers through Placenta Proteome

Spontaneous unexplained preterm labor with intact membrane (sPTL-IM) remains as an unresolved challenge in obstetrics due to the complex syndromes involved during preterm birth. Two dimensional-gel electrophoresis (2D-GE) coupled with matrix-assisted laser desorption/ionization-time of flight/time of flight (MALDI TOF/TOF) mass spectrometry has become an alternative in screening for potential novel protein-based biomarkers and revealing the pathophysiology of sPTL-IM. To achieve this objective, protein extracted from fetal and maternal sides of the placenta obtained from sPTL-IM (n = 5) and the respective control (n = 10) groups were separated and compared using 2D-gel electrophoresis. MALDI-TOF/TOF mass spectrometry was utilized to identify the differentially expressed proteins between both groups, and the molecular functions of these proteins were studied. A total of 12 proteins were significantly differentiated in sPTL-IM over the control. Differentially expressed proteins were identified to have involved in structural/cytoskeletal components, immune responses, fetal and placenta development, and anticoagulation cascade. More proteins were found to be differentially expressed in the fetal side compared to the maternal side of the placenta. This postulates that the influence of sPTL-IM from fetus is greater than that of the mother. Ultimately, these results might lead to further investigations in elucidating the potential of these proteins as biomarkers and/or drug targets

Prediction of Spontaneous Preterm Birth

Preterm birth is a leading cause of neonatal morbidity and mortality. It is a major goal in obstetrics to lower the incidence of spontaneous preterm birth (SPB) and related neonatal morbidity and mortality. One of the principal objectives is to discover early markers that would allow us to identify subgroups of patients at high risk of SPB and, secondly, to manage those patients with an appropriate and effective strategy. The purpose of this thesis was to provide data on prediction of spontaneous preterm birth. The studies described in this thesis aim to evaluate (1) which predictive tests are appropriate to use to identify women at risk for SPB; (2) what factors influence the predictive value of a diagnostic test in general and of cervical length assessment in particular; and (3) what strategies are used regarding threatened SPB in the specific Dutch obstetric care. In chapter 2 we described the mechanisms contributing to SPB, which - mainly - have been identified during the past decade. SPB may result from one of the four primary pathogenic mechanisms, or from a combination: (1) activation of the maternal or fetal HPA axis; (2) inflammation (of ascending genital tract, systemic or chorion/decidual); (3) decidual hemorrhage and (4) pathologic distention of the uterus. The review in the second part of chapter 2 describes the usefulness of new biochemical fluid markers to identify women at risk for SPB. There are no current data to support the use of salivary estriol, home uterine monitoring and for other biochemical markers (e.g., corticotropin-releasing hormone (CRH), maternal serum ?-fetoprotein (MSAFP), interleukine-6 (Il-6) and granulocyte colony-stimulating factor (G-CSF)) larger studies are needed. In the general population no other risk factors than the obstetric history has proven to be effective. In the population at risk transvaginal ultrasonography to determine cervical length and fetal fibronectin testing, or a combination of both is likely to be useful in determining women at high risk for preterm labor. However, their clinical usefulness may rest primarily with their high negative predictive value, thereby avoiding unnecessary intervention. Only treatment with oral antibiotics of women with BV who are at risk for SPB has resulted in a reduction of SPB. Prophylactic treatment in women at risk for SPB, but without BV is not indicated. In chapter 3 we described a study regarding the usefulness of possible novel markers matrix metalloproteinase (MMP)-1 and MMP-9 in the prediction of SPB. MMP-1 levels in cervicovaginal secretions were low and did not change during either preterm or term labor. MMP-9 levels increased during term and preterm labor, with highest values in laboring patients with ruptured membranes, MMP-9 is not a useful predictor of preterm birth, but does play an important role in membrane rupture. In chapter 4 and 5 we described the association of socio-demographic factors on the change of cervical length All women had a slight decrease of cervical length across gestation. Women who were African-American, under stress, or working as skilled manual laborers demonstrated significant shortening of the cervix during gestation. African-Americans delivered on average earlier (38.4 weeks) than the other race groups. All pregnancies displayed progressive cervical shortening except Asians. African-American women had shorter cervices across all 3 gestational age intervals even after controlling for preterm delivery. It suggests that shortening of the cervix is particularly a risk indicator for preterm birth in African-American women, since they already have shorter cervices to begin with. Measuring cervical length before 25 weeks gestation might not be of substantial contribution to the prediction of preterm birth in other ethnical groups. In chapter 6 we evaluated the role of transvaginal ultrasonographic cervical length measurements for women with cervical incompetence. We determined that there was an increase in cervical length after cerclage. However, the degree of lengthening after cerclage was not predictive of term delivery.We alsoshowed that serial cervical length measurement in the late second or early third trimester predicted preterm birth. Since we were interested how predictors of SPB are implemented in the Dutch obstetric care. We developed a questionnaire to study opinions and management regarding threatened preterm birth, mutual co-operation and the VIL between first line obstetrical practitioners (midwives and general practitioners practicing obstetrics) and gynecologists (Chapter 7). There appeared to be consensus among the three professional groups about the way that risk selection takes place. In chapter 8 we assessed the use of modern diagnostic methods such as transvaginal sonographic measurements of cervical length, examination of bacterial vaginosis (BV) and fetal fibronectin (FFN) by Dutch gynecologists. Cervical length measurements are used by most of the Dutch gynecologists, even as testing and treating for BV. Fetal fibronectin testing - according to literature the best marker available now - is seldomly been used. Gynecologists in general hospitals without residency programs prescribe tocolytics and repeat corticosteroid treatment more often compared to the gynecologists in hospitals with residency programs. They prescribe less antibiotics for women with threatened preterm birth. Apparently 40% of Dutch gynecologists treat preterm premature rupture of membranes (PPROM) with tocolytics while there are no contractions.On some points the disciplines involved in obstetric care should adopt their guidelines to use the evidence from the literature. Use of FFN in the Dutch setting should be evaluated in the future

Having an Elective Cesarean Section: Doing What\u27s Best

The purpose of this study was to discover a theory on how women decide to deliver their babies by cesarean section instead of experiencing a trial of labor and expected vaginal delivery when it is appropriate. The specific goals are to answer the research questions: What is the decision-making process by which healthy, low-risk women choose to deliver their babies by cesarean delivery in the absence of medical indications? What antecedents occur to influence a pregant woman\u27s decision to undergo a maternal request cesaren section? Seven women from the surrounding Knoxville area underwent in-depth interviews. To qualify for the study, the women had to be healthy and low-risk, had an elective cesarean section within the last two years, be 18 years or older and reside in the East Tennessee area. Symbolic interactionism and feminism were utilized to provide a theoretical framework for the study. The grounded theory methodology by Strauss and Corbin (1990) was used to develop the core category, context, antecedents, intervening factors and consequences. From the data, a substantive theory was identified, Having an elective c-section: Doing what\u27s best. The antecedents of the women\u27s decision were being scared and perceiving a cesarean section as an easier way to give birth. Women made this choice after gathering information and seeking support from health care providers, friends and family within the context of progressing through the pregnancy. Once the decision was made and the cesarean section was performed, the women voiced happiness with their decision and in having a good outcome. The findings of this study may assist office nurses, public health nurses, midwives, advanced practice nurses, childbirth educators and other women\u27s health nurses to educate women on their childbirth options and hopefully to reduce the rate of maternal request cesarean deliveries

A study to investigate the relationship between obstetric brachial plexus palsies and cephalopelvic disproporation (including fetal macrosomia)

Thesis (M.Sc.)-University of Durban-Westville, 2002.In view of the lifelong impact of Obstetrical Brachial Plexus Palsies (OBPP), prevention of OBPP would be of great significance. Despite contemporary advances in antenatal planning and assessment, OBPP remains an unfortunate consequence after difficult childbirth. Permanent brachial plexus palsy is a leading cause of litigation related to birth trauma. Objectives: To determine the incidence of Obstetrical Brachial Plexus Palsy (OBPP), Cephalopelvic Disproportion (CPD) and macrosomia in KwaZulu-Natal. As well as to investigate the relationship between OBPP and CPD, and the relationship between OBPP and macrosomia. The study also aimed to determine whether antenatal risk factors could identify those prone to OBPP. Study design: This was a case control study that included all deliveries from 1997 to 2000 from four provincial hospitals (Addington, King Edward VIII, Prince Mshiyeni Memorial and RK Khan hospital). The outcome variable was OBPP. Results were analyzed using Statistical Program for Social Sciences (SPSS). Results: A total of 60 infants of 76 352 deliveries sustained OBPP. The incidence of OBPP was found to be 0.72 per 1000 deliveries. The incidence of CPD was found to be 33.5 per 1000 deliveries and the incidence of macrosomia was found to be 16.7 per 1000 deliveries. Race, Maternal height> 150 cm, gravida >3, parity >4, history of a previous big baby, normal vaginal delivery, delivery by a midwife, difficult labour, inadequate or doubtful pelvic capacity, birth weight of >3700 g and gestation period> 34 weeks were significant risk factors. Logistic regression analysis showed that race, parity> 4, normal vaginal delivery and gestation period> 35 weeks were the variables most associated with OBPP. Using linear regression model was obtained for the calculation of predictive risk scores. Conclusion: Using standard statistical formulae the probability of OBPP can be calculated in women with significant risk factors from the logistic regression formula. This would need to be validated and could provide a useful tool for screening for OBPP thus contributing to preventing this devastating complication of birth trauma. The risk assessment profile would contribute greatly to the prediction of OBPP and the subsequent prevention of this debilitating birth injury

Maternal, obstetric, biochemical and ultrasonic associations of normal and abnormal human pregnancy

The work in this thesis describes a series of studies utilising diverse data sources which were analysed using a number of regression methods (logistic, linear, Cox, Poisson), to address the factors associated with normal and abnormal pregnancy outcome. A series of maternal characteristics were related to adverse pregnancy outcome. Teenage pregnancy was not associated with an increased risk of any adverse outcome among first births, but was strongly associated with adverse outcome among second births [8]. Parity also interacted with body mass index: maternal obesity was associated with an increased risk of preterm birth among nulliparous but not multiparous women. This was explained by higher rates of elective preterm deliveries among obese nullipara [31]. There was a linear relationship between maternal age and the duration of labour, and the risk of operative vaginal and caesarean delivery [37]. It was hypothesised that age-related deterioration in obstetric performance was due to prolonged hormonal stimulation prior to the first birth. This hypothesis was supported by the observation that later menarche was independently associated with a decreased risk of operative delivery [38]. A short inter-pregnancy interval was associated with an increased risk of spontaneous preterm birth, but not stillbirth or intra-uterine growth restriction [16]. The risk of unexplained stillbirth at term was increased among nulliparous women [5] and nulliparous women also had slightly longer pregnancies [7]. A U-shaped relationship between birth weight and caesarean risk was observed at term. There was an interaction between fetal sex and caesarean risk: small boys were at increased risk of emergency caesarean [3]. The same interaction was observed for antepartum stillbirth [4]. Previous pregnancy outcome was predictive of the outcome of subsequent pregnancies. Women who were delivered by caesarean section in their first pregnancy had an increased risk of unexplained stillbirth in their second [17]. This finding was confirmed in a separate cohort and associations were also observed between previous complicated livebirths and the subsequent risk of unexplained stillbirth [32]. Some specific situations were also studied (vaginal birth after caesarean section (VBAC) and twins). Among women attempting VBAC, the absolute risk of delivery-related perinatal death was comparable to primiparous women but was significantly higher than women delivered by elective caesarean section [11]. The risk of perinatal death associated with uterine rupture was increased in low throughput obstetric units and among women induced with prostaglandins [19]. Using simple maternal characteristics, approximately 50% of women attempting VBAC could be classified into having a high (>40%) or low (<10%) risk of emergency caesarean [24]. This was better discrimination than could be achieved using similar characteristics among nulliparous women being induced at term [21]. The risk of delivery related perinatal death was increased among second twins, although this was only evident among births at term [13]. The association was observed among sex discordant twins, but was not observed among twins delivered by elective caesarean section [23]. The association between birth order and the risk of death due to anoxia was confirmed in data from England and Wales [33]. Ultrasonic measurements of the fetus were related to eventual birth weight. The range of error associated with such estimates was quantified and abdominal circumference on its own was as predictive as models using abdominal circumference and femur length [1]. Estimating fetal weight using ultrasound was not found to be a better measure of human fetal blood volume than simply using gestational age [10]. A series of ultrasonic measurements in the first and second trimester were predictive of pregnancy outcome, including smaller than expected crown rump length and intra-uterine growth restriction, preterm birth and low birth weight [2]; a long cervix in mid gestation and caesarean section [36]; and, high resistance patterns of uterine artery Doppler flow velocimetry and stillbirth [30]. Biochemical measurements performed in early pregnancy were also predictive of later adverse outcome: low maternal levels of pregnancy-associated plasma protein A (PAPP-A) were associated with an increased of pre-eclampsia, preterm birth and growth restriction [9]; low PAPP-A prior to 13 weeks was associated with birth weight at term in healthy pregnancies [12] and with a dramatically increased risk of stillbirth due to placental dysfunction [22]. Low first trimester levels of placenta growth factor were associated with increased risks of pre-eclampsia and growth restriction, whereas there was no association between elevated levels of the soluble fms-like receptor and adverse outcome [35]. Measurements of biochemical variables in the second trimester were also predictive of outcome, with elevated maternal serum alphafetoprotein (AFP) being associated with an increased risk of stillbirth [34] and spontaneous preterm birth [29]. Women with the combination of low first trimester PAPP-A and high second trimester AFP were at particularly high risk of complications, reflecting the synergistic predictive ability of the two measures [27]. Given proposed similarities between stillbirth and sudden infant death syndrome (SIDS), this outcome was also studied. Elevated second trimester levels of AFP were also associated with an increased subsequent risk of SIDS [20]. Women with a pregnancy resulting ultimately in SIDS were found to be more likely to have had complications in past and future pregnancies [25]. The risk of SIDS declined with advancing gestational age at term following spontaneous, but not elective birth [15]. Obstetric characteristics were used to generate a predictive model for SIDS [26]. Pregnancy outcome was also predictive of other aspects of child health, specifically, respiratory morbidity following birth at term was associated with an increased risk of hospital admission for asthma [18]. Pregnancy complications were also related to long term maternal health. Elective caesarean delivery for breech presentation did not appear to have an independent effect on fertility [28]. However, pregnancy complications were associated with the mother’s subsequent experience of cardiovascular disease. Women experiencing growth restriction, preterm birth or pre-eclampsia were at increased risk of subsequent ischaemic heart disease (IHD) [6] and the risk of this was also related to the number of miscarriages experienced prior to the first birth [14]. The parents of women who had experienced pregnancy complications or recurrent miscarriage had an increased incidence of IHD [39 & 40, respectively]