Policies for care during the third stage of labour: a survey of maternity units in Syria

<p>Abstract</p> <p>Background</p> <p>Care for women during the third stage aims to reduce the risk of major haemorrhage, but is very variable. The current World Health Organisation (WHO) recommendation is that care should include administration of a uterotonic (oxytocin, if it is available) soon after birth of the baby, delayed cord clamping, and delivery of the placenta by controlled cord traction.</p> <p>Methods</p> <p>To ascertain care policies used during the third stage of labour in maternity units in Syria, we conducted a survey of 69 maternity units in obstetric and general public hospitals. A brief questionnaire was administered by face to face interview or telephone with senior obstetricians and midwives. Outcome measures were the use of prophylactic uterotonic drugs, timing of cord clamping, use of controlled cord traction, and treatment for postpartum haemorrhage. Obstetricians were asked about both vaginal and caesarean births, midwives only about vaginal births.</p> <p>Results</p> <p>Responses were obtained for 66 (96%) hospitals: a midwife and an obstetrician were interviewed in 40; an obstetrician only in 20; a midwife only in 6. Responses were similar, although midwives were more likely to report that the umbilical cord was clamped after 1-3 minutes or after cessation of pulsation (2/40 obstetricians and 9/40 midwives). Responses have therefore been combined.</p> <p>One hospital reported never using a prophylactic uterotonic drug. The uterotonic was Syntometrine^®(oxytocin and ergometrine) in two thirds of hospitals; given after delivery of the placenta in 60 (91%) for vaginal births, and in 47 (78%) for caesarean births. Cord clamping was within 20 seconds at 42 hospitals 64%) for vaginal births and 45 (75%) for caesarean births. Controlled cord traction was never used in a quarter (17/66) of hospitals for vaginal births and a half (32/60) for caesarean births.</p> <p>68% of respondents (45/66) thought there was a need for more randomised trials of interventions during the third stage of labour.</p> <p>Conclusion</p> <p>Most maternity units report using Syntometrine^®, usually given after delivery of the placenta, clamping the cord within 20 seconds, and using controlled cord traction.</p

Volvulus of the ileal pouch-anal anastomosis: A meta-narrative systematic review of frequency, diagnosis, and treatment outcomes

Background: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for medically refractory ulcerative colitis and familial adenomatous polyposis. While rare, a pouch volvulus can occur. We aimed to determine the frequency, presentation, and management approach of pouch volvulus in patients with IPAA. Methods: A systematic search of published literature was performed by a medical reference librarian on 10 August 2018 and two independent reviewers identified relevant publications, extracted data, and assessed the methodological quality based on a validated tool. A retrospective review of the Mayo Clinic electronic medical records identified one case of pouch volvulus between January 2008 and August 2018. Results: The frequency of pouch volvulus from one large published study reporting long-term outcomes of IPAA was 0.18% (3/1,700). A total of 22 patients (18 ulcerative colitis) were included (median age 32 years, 73% females). Median time to volvulus after IPAA was 36 months while median interval to volvulus diagnosis from symptom onset was 24 hours. Abdominal pain was the most commonly reported symptom (76%). The diagnosis was made primarily by abdominal computed tomography (13/17 patients, 76%). Endoscopic treatment was successful in 1 of 11 patients (9%). Surgery was performed in 20 patients and pouch-pexy and pouch excision were the most frequent surgical operations. A redo IPAA was performed in five patients (25%). Conclusion: Pouch volvulus is a rare but serious complication of IPAA and should be suspected even in the absence of obstruction symptoms. Endoscopic treatment often fails and surgery is effective when performed early