Global implications of evidence ‘biased’ practice: management of the third stage of labour

Increasing attention is being paid to the promotion of clinical and cost-effective care informed by the highest level of evidence to ensure health outcomes are optimised and access to health care is equitable. There are obvious advantages to these approaches, including increased awareness of the importance of rigorous methodology when conducting primary and secondary research, utilising methods which are systematic, robust, transparent and explicit. Evidence-based practice was introduced to replace the traditional approach of ‘this is how we have always done it’ as an underpinning for clinical practice. Ironically, however, the transition has not been straightforward and there have been criticisms of the way ‘evidence’ to support some areas of practice is perceived and applied in clinical settings. Anecdotally and based on personal experience, there are two main criticisms: 1. Acceptance of evidence without critique: Too much faith (or blind faith) in the process by which ‘evidence’ (authoritative or systematic) is produced. 2. Lack of holistic insight in the application of evidence: Employing ‘one size fits all’ policies ignoring individual needs for required care in conveyor-like processed care provision. To explore these criticisms, the example of management of the third stage of labour is used.</p

Gefitinib and Methotrexate to Treat Ectopic Pregnancies with a Pre-Treatment Serum hCG 1000–10,000 IU/L: Phase II Open Label, Single Arm Multi-Centre Trial

This work was supported by an NHMRC Grant (#1008276) to ST, TJ and EW, and an MRC Centenary Award (G0802808) to AH. The funders had no role study design, collection, analysis, and interpretation of data; in the writing of the report or in the decision to submit the paper.Peer reviewedPublisher PD

The impact of maternal BMI status on pregnancy outcomes with immediate short-term obstetric resource implications : a meta-analysis.

Obesity is rising in the obstetric population, yet there is an absence of services and guidance for the management of maternal obesity. This systematic review aimed to investigate relationships between obesity and impact on obstetric care. Literature was systematically searched for cohort studies of pregnant women with anthropometric measurements recorded within 16-weeks gestation, followed up for the term of the pregnancy, with at least one obese and one comparison group. Two researchers independently data-extracted and quality-assessed each included study. Outcome measures were those that directly or indirectly impacted on maternity resources. Primary outcomes included instrumental delivery, caesarean delivery, duration of hospital stay, neonatal intensive care, neonatal trauma, haemorrhage, infection and 3rd/4th degree tears. Meta-analysis shows a significant relationship between obesity and increased odds of caesarean and instrumental deliveries, haemorrhage, infection, longer duration of hospital stay and increased neonatal intensive care requirement. Maternal obesity significantly contributes to a poorer prognosis for mother and baby during delivery and in the immediate post-partum period. National clinical guidelines for management of obese pregnant women, and public health interventions to help safeguard the health of mothers and their babies are urgently required

'Me and my bump': an interpretative phenomenological analysis of the experiences of pregnancy for vulnerable women

Eight pregnant women, considered to be ‘vulnerable’ due to exposure to a number of underlying risk factors, participated in semi-structured interviews regarding their experiences of pregnancy and of Mellow Bumps, a 6-week targeted antenatal intervention. Interview transcripts were explored using interpretative phenomenological analysis. The analysis revealed five superordinate themes: pregnancy as a time of reflection; the body being taken over; pregnancy as an emotional rollercoaster; relationships as important; separating identities. Pre- and post-natal attachment theories were found to be useful in interpreting the data. Findings suggest that pregnancy may be ‘normalising’ and provide an important opportunity for building more positive representations of the self. Findings also provide clinical support for the assertion that the attachment relationship begins before birth. The Mellow Bumps intervention was uniformly seen as helpful. It appeared to nurture prenatal attachment relationships, playing a potentially protective role, by helping to establish the foundations for secure mother–infant relationships in the future. Meeting similar women and engaging in ordinary, supportive conversation during Mellow Bumps seemed to reduce feelings of isolation and stigma. Implications for clinical practice are considered

Antenatal breast expression in women with diabetes: outcomes from a retrospective cohort study

Background: Women with diabetes are sometimes advised to express breast milk antenatally to prepare for breastfeeding and to store colostrum for infant feeding in preventing or treating hypoglycaemia after the birth. The acceptability, risks and benefits of this practice have not been evaluated. This was aimed to investigate the pattern of antenatal breast expression uptake and its relationship with birth outcomes in women with diabetes. Methods: This was part of a two year retrospective cohort study of pregnant women with diabetes (type 1, 2 and gestational diabetes) who gave birth during 2001–2003 in Derby Hospitals NHS Foundation Trust (n = 94). The information on the practice of antenatal breastfeeding expression and birth outcomes was collected via self-administered questionnaires and by examining maternity records. Results: Thirty-seven percent of women (35/94) recalled that they were advised to express antenatally and 17% did (16/94). The mean gestational age at birth for women who hand-expressed was lower than that for those who did not (mean difference (MD) (95% confidence intervals (CI)): -1.2 (−2.4 to 0.04), p = 0.06). A higher proportion of babies from the antenatal expression group were admitted to special care baby units (SCBU) (MD (95% CI): 21% (−3.9 to 46.3). Conclusions: Less than half the women who stated that they were advised to express, did so. There seems to be an indication that antenatal breast milk expression and lower gestational age at birth are associated. The trend of a higher rate of SCBU admission for babies from the breast milk expression group compared to those who did not express antenatally is of concern. An appropriately-powered randomised controlled trial is needed to determine the safety of this practice and its acceptability to women and health professionals before it can be recommended for implementation in practice. Keywords: Diabetes, Antenatal, Breast milk expression, Retrospective, Gestational age, Cohort, Gestation</p

Pregnancy in Diabetes: challenges and opportunities for improving pregnancy outcomes

Our aim was to review the data from the National Pregnancy in Diabetes (NPID) audit, and to identify the challenges and opportunities for improving pregnancy outcomes in women with diabetes. We reviewed three years of NPID data and relevant diabetes and obstetric literature, and found that there has been little change in pregnancy preparation or outcomes over the past 3 years, with substantial clinic-to clinic variations in care. Women with Type 2 diabetes remain less likely to take 5 mg preconception folic acid (22.8% vs. 41.8%; P < 0.05), and more likely to take potentially harmful medications (statin and/or ACE inhibitor 13.0% vs. 1.8%; P < 0.05) than women with Type 1 diabetes. However, women with Type 1 diabetes are less likely to achieve the recommended glucose control target of HbA1c < 48 mmol/mol (6.5%) (14.9% vs. 38.1%; P < 0.05). The following opportunities for improvement were identified. First, the need to integrate reproductive health into the diabetes care plans of all women with diabetes aged 15–50 years. Second, to develop more innovative approaches to improve uptake of pre-pregnancy care in women with Type 2 diabetes in primary care settings. Third, to integrate insulin pump, continuous glucose monitoring and automated insulin delivery technologies into the pre-pregnancy and antenatal care of women with Type 1 diabetes. Fourth, to improve postnatal care with personalized approaches targeting women with previous pregnancy loss, congenital anomaly and perinatal mortality. A nationwide commitment to delivering integrated reproductive and diabetes healthcare interventions is needed to improve the health outcomes of women with diabetes

Utilisation of Postnatal Care among Rural Women in Nepal

Background: Postnatal care is uncommon in Nepal, and where it is available the quality is often poor. Adequate utilisation of postnatal care can help reduce mortality and morbidity among mothers and their babies. Therefore, our study assessed the utilisation of postnatal care at a rural community level. Methods: A descriptive, cross-sectional study was carried out in two neighbouring villages in early 2006. A total of 150 women who had delivered in the previous 24 months were asked to participate in the study using a semi-structured questionnaire. Results: The proportion of women who had received postnatal care after delivery was low (34%). Less than one in five women (19%) received care within 48 hours of giving birth. Women in one village had less access to postnatal care than women in the neighbouring one. Lack of awareness was the main barrier to the utilisation of postnatal care. The woman's own occupation and ethnicity, the number of pregnancies and children and the husband's socio-economic status, occupation and education were significantly associated with the utilisation of postnatal care. Multivariate analysis showed that wealth as reflected in occupation and having attended antenatal are important factors associated with the uptake of postnatal care. In addition, women experiencing health problems appear strongly motivated to seek postnatal care. Conclusion: The postnatal care has a low uptake and is often regarded as inadequate in Nepal. This is an important message to both service providers and health-policy makers. Therefore, there is an urgent need to assess the actual quality of postnatal care provided. Also there appears to be a need for awareness-raising programmes highlighting the availability of current postnatal care where this is of sufficient quality