Assessment of competence for caesarean section with global rating scale

Objective: To establish as reliable and valid the nine-point global rating scale for assessing residents\\u27 independent performance of Caesarean Section. Methods: The validation study was conducted at the Department of Obstetrics and Gynaecology, Aga Khan University Hospital, from April to December 2008, and comprised 15 residents during 40 Caesarean Sections over 9 months. Independently two evaluators rated each procedure and the difficulty of each case. Results: The observations per faculty ranged from 1-8 (mean 4.07± 2.56). The Year 4 residents were observed the most i.e. 32 (40%), followed by Year 3, 30 (37.5%); Year 2; 14 (17.5%); and Year 1, 4 (5%). Mean time required for observation of the surgery was 43.81±14.28 (range: 20-90) with a mode of 45 min. Mean aggregate rating on all items showed gradual progression with the year of residency. The assessment tool had an internal consistency reliability (Cronbach\\u27s alpha) of 0.9097 with low inter-rater reliability. Conclusion: The evaluation tool was found to be reliable and valid for evaluating a resident\\u27s competence for performing Caesarean Section. Training of the assessors is required for a better inter-rater agreement

Gestational diabetes mellitus--a forerunner of chronic disorders in mother and child

Gestational Diabetes Mellitus (GDM) can have serious immediate as well as long term consequences, both for the mother as well as the off-spring. It seems that women of south Asian origin are not only more likely to have GDM but also suffer more from the adverse consequences of the disorder. These consequences include the development of type 2 DM in women with a history of GDM and a higher risk of obesity and metabolic syndrome in the off-spring. Pakistani physicians should consider GDM seriously because the WHO states that rise in the prevalence of type 2 DM will mainly occur in developing countries such as ours. Since GDM can lead to development of type 2 DM, efforts should be made to prevent type 2 DM through lifestyle modification strategies in this high risk population. It is important that we develop some clear cut guidelines for prevention and treatment of GDM

Household chores as the main source of physical activity: Perspectives of pregnant Pakistani women

Objective: To understand the level of physical activity in pregnant women and to identify perceived facilitators and barriers faced by them. Methods: This cross-sectional study was conducted from January to June 2016 at Aga Khan Maternity and Child Care Centre, Hyderabad, Pakistan, and comprised pregnant women attending the antenatal clinics. They were administered the pregnancy physical activity questionnaire while additional questions were asked to assess perceived barriers and facilitators in pregnancy. SPSS 19 was used for data analysis.Results: Of the 455 subjects, 179(36%) were physically active. Their median metabolic equivalent of task hours per week was 14.65 (interquartile range=0-105.8). The overall mean age of subjects was 26±4.47 years, while the mean gestational age was 24±10 weeks. Household activity had a strong positive correlation with total activity (p\u3c0.05). Reported barriers included lack of energy and lack of information regarding benefits of physical activity, and facilitators included support from family and affordable facilities in the area of residence.Conclusion: Majority of the pregnant women failed to meet the daily recommendations for physical activity

A review related to midwifery led model of care

Background: Midwifery led care (MLC) is a model of care in which perinatal care is provided to women throughout different phases of childbirth by a midwife. Objective: This paper aims to provide a literature review on MLC. Methods: A variety of databases and reports were considered to do the literature review on MLC. The search was limited from 1991 to 2011 by using keywords. A total of 50 articles were critically appraised for this review. Findings: The main theme that emerged was women ’s satisfaction with MLC. Satisfaction was integrated with midwife ’s presence throughout childbirth, experience to enhance normality in childbirth, cost-effectiveness of MLC, and facilitation of women ’s choice and control during labor. Conclusion: The review concludes that MLC is women-friendly as it considers and respects women’s needs holistically during childbirth

Factor VII deficiency and pregnancy: a case report and review of literature

Factor VII deficiency is one of the \u27rare inherited disorders of coagulation.\u27 Few cases of Factor VII deficiency have been reported during pregnancy, a state which could potentially cause fatal haemorrhage. Here we report a case of a pregnant lady with a history of heavy menorrhagia and multiple first pregnancy failures. Delivery was carried out via Caesarean section due to non-reassuring foetal heart monitoring. Patient was treated with Fresh Frozen Plasma (FFPs) and Factor VII concentrates, however, the patient developed bleeding postoperatively. Literature indicates that whilst Factor VII levels rise during pregnancy in normal women, no increase is seen in homozygous cases, whereas there is a moderate rise in heterozygous individuals. History of heavy menorrhagia, multiple first pregnancy failures and a positive family history for bleeding disorders necessitate investigation and monitoring of Factor VII levels during pregnancy. Factor VII concentrates achieve adequate homeostasis in most cases. Recombinant Factor VIIa, however, is the treatment of choice and does not carry a risk of infection transmission or thrombus formation

Implementation of warning tool to improve maternal newborn health outcomes in a developing country

Objective: To improve health outcomes through the implementation of national early warning sign tool for babies delivered through emergency caesarean section in off-work hours. Methods: This comparative clinical study was conducted at the Aga Khan Hospital for Women and Children, Karachi, from April to August 2014, and comprised women who had an emergency caesarean section. Maternal and perinatal outcomes were compared of patients in Group A and Group B which represented individuals before and after the implementation of the national early warning score respectively. Results: Of the 200 participants, there were 100(50%) in each group. The overall mean age was 26.79±5.10 years. The mean age was 26.3±5 years in Group A, and 27.2±5 years in Group B (p=0.25). The two groups were also comparable in terms of parity (p=0.77) and co-morbidities (p =0.51). There was no stillbirth or maternal death, but decline in complications due to post-partum haemorrhage (p=0.00) was observed due to early recognition and timely management. None of the women required referral to higher facility. Conclusion: National early warning score was found to be a practical early warning tool for obstetric population

What method of contact works best for recruiting participants in a study: lessons for health care researchers?

Objectives: To assess the various recruitment strategies used by medical researchers and their response rates. Methods: The observational study, part of a larger retrospective cohort, was done at the Aga Khan University Hospital, Karachi, Pakistan, from May 2008-December 2010, covering a period from 1999 to 2005. We used a multi-mode contact approach for including participants in the study. This comprised an invitational letter that described the study sent along with a mail-back, postage-paid envelope and multiple phone calls for recruitment of participants. The response to each mode was noted and described as frequency and percentage. Results: There were 1335 participants eligible for recruitment in the study. Of them, 1247 (93.4%) were sent mailouts to which only 84 (6.7%) responded. Besides, 1133 participants,whose phone numbers were available, were called. Overall, the number of people that we were able to contact was low. The response to postage paid mail was very poor whereas the majority of participants were contacted via phone calls. Out of such participants, 257 (19.25%) agreed to participate at the very first call and our results suggest that more than three calls made very little contribution to the consent rate. CONCLUSION: Recruiting subjects from contact information available in the medical records may not be the best method. Multiple and innovative approaches are required for approaching potential participants and requesting them to participate in a study

Adolescent food insecurity in rural Sindh, Pakistan: A cross-sectional survey

Background: Food insecurity (FI) is alarmingly high in developing countries including Pakistan. A quarter of Pakistan\u27s population consists of adolescents yet there is no information on their experience of FI. FI at adolescent age have long term effect on mental and physical health hence we aimed to determine the prevalence of food insecurity (FI) among adolescents and compare it with household FI, and assess social determinants of adolescent FI.Methods: A cross-sectional survey on 799 households with unmarried adolescents was conducted from September 2015 to June 2016 in three union councils of Hyderabad, Pakistan. Unmarried 10-19 years old girls and boys were interviewed regarding their FI status using Household Food Insecurity Assessment Scale (HFIAS). Household-level FI was also assessed by interviewing mothers of adolescents, and it was compared with adolescent\u27s FI. Association of adolescent\u27s FI with socio-demographic determinants was explored through Cox regression using STATA version 14.0. and prevalence ratios were estimated.Results: FI was found among 52.4% of the adolescents compared to 39% of the households. Thirty percent of the adolescents were food insecure within the food secure households. Female adolescents were found to be less food insecure (Adjusted Prevalence Ratio (APR) 0.4 95% CI [0.3, 0.5]) compared to males. Social determinants like socioeconomic status (SES), crowding index or education of parents were not associated with adolescents\u27 FI.Conclusion: Half of the adolescents were found to be food insecure which raises concerns regarding their health in the long run. Gender is an important social determinant of FI among adolescents which suggests an in-depth exploration of social dynamics of adolescent FI. We recommend the mixed-methods study to develop contextually relevant interventions to reduce FI among this group and improve their health status

Obstetric patients in intensive care unit: Perspective from a teaching hospital in Pakistan

Objective: Review of obstetric cases admitted to the intensive care unit.Design: Ten year retrospective review of individual patients\u27 medical records.Participants: Records of obstetric patients admitted from 2005-2014.Setting: Aga Khan University Hospital Karachi.Main outcome Measures: Diagnosis at the time of admission, associated risk factors, and intervention required aspects of management and rate of mortality.Findings: A total of 194 obstetric patients were admitted out of which 86.2% of patients had ventilator support. Mortality was not seen to be significantly associated with parity and antenatal/postnatal status. The median age of patients was 34 years, minimum length of stay was 24 hours and maximum stay was 53 days. Sixty one percent of patients were admitted to with organ system failure. The overall mortality rate was 21.64% (42/194). The mortality rate was five times more likely in patients who had gastro-intestinal complication {Odds Ratio=4.87; 95%CI: 1.65-14.36}. The largest group of patients {28.4%} presented with hematological diagnosis.Conclusion: When the intensive care unit admission became essential, primary diagnosis included: postpartum hemorrhage, hypertensive disorders, sepsis and infectious diseases. An increased vigilance of high-risk pregnant women and a stabilization of their condition before intervention is administered, improves the outcome of these women