The utility of clinical care pathways in determining perinatal outcomes for women with one previous caesarean section; a retrospective service evaluation

<p>Abstract</p> <p>Background</p> <p>The rising rates of primary caesarean section have resulted in a larger obstetric population with scarred uteri. Subsequent pregnancies in these women are risk-prone and may complicate. Besides ensuring standardised management, care pathways could be used to evaluate for perinatal outcomes in these high risk pregnancies. We aim to demonstrate the use of a care pathway for vaginal birth after caesarean section as a service evaluation tool to determine perinatal outcomes.</p> <p>Methods</p> <p>A retrospective service evaluation by review of delivery case notes and records was undertaken at the Aga Khan University Hospital, Nairobi, Kenya between January 2008 and December 2009</p> <p>Women with ≥2 previous caesarean sections, previous classical caesarean section, multiple gestation, breech presentation, severe pre-eclampsia, transverse lie, placenta praevia, conditions requiring induction of labour and incomplete records were excluded. Outcome measures included the proportion of eligible women who opted for test of scar (ToS), success rate of vaginal birth after caesarean section (VBAC); proportion on women opting for elective repeat caesarean section (ERCS) and their perinatal outcomes.</p> <p>Results</p> <p>A total of 215 women with one previous caesarean section were followed up using a standard care pathway. The median parity (minimum-maximum) was 1.0<abbrgrp><abbr bid="B1">1</abbr><abbr bid="B2">2</abbr><abbr bid="B3">3</abbr><abbr bid="B4">4</abbr></abbrgrp>. The other demographic characteristics were comparable. Only 44.6% of eligible mothers opted to have a ToS. The success rate for VBAC was 49.4% with the commonest (31.8%) reason for failure being protracted active phase of labour. Maternal morbidity was comparable for the failed and successful VBAC group. The incidence of hemorrhage was 2.3% and 4.4% for the successful and failed VBAC groups respectively. The proportion of babies with acidotic arterial PH (< 7.10) was 3.1% and 22.2% among the successful and failed VBAC groups respectively. No perinatal mortality was reported.</p> <p>Conclusions</p> <p>Besides ensuring standardised management, care pathways could be objective audit and service evaluation tools for determining perinatal outcomes.</p

Interventions to reduce unnecessary caesarean sections in healthy women and babies

Optimising the use of caesarean section (CS) is of global concern. Underuse leads to maternal and perinatal mortality and morbidity. Conversely, overuse of CS has not shown benefits and can create harm. Worldwide, the frequency of CS continues to increase, and interventions to reduce unnecessary CSs have shown little success. Identifying the underlying factors for the continuing increase in CS use could improve the efficacy of interventions. In this Series paper, we describe the factors for CS use that are associated with women, families, health professionals, and health-care organisations and systems, and we examine behavioural, psychosocial, health system, and financial factors. We also outline the type and effects of interventions to reduce CS use that have been investigated. Clinical interventions, such as external cephalic version for breech delivery at term, vaginal breech delivery in appropriately selected women, and vaginal birth after CS, could reduce the frequency of CS use. Approaches such as labour companionship and midwife-led care have been associated with higher proportions of physiological births, safer outcomes, and lower health-care costs relative to control groups without these interventions, and with positive maternal experiences, in high-income countries. Such approaches need to be assessed in middle-income and low-income countries. Educational interventions for women should be complemented with meaningful dialogue with health professionals and effective emotional support for women and families. Investing in the training of health professionals, eliminating financial incentives for CS use, and reducing fear of litigation is fundamental. Safe, private, welcoming, and adequately resourced facilities are needed. At the country level, effective medical leadership is essential to ensure CS is used only when indicated. We conclude that interventions to reduce overuse must be multicomponent and locally tailored, addressing women’s and health professionals’ concerns, as well as health system and financial factors

Correlation between laparoscopic and histopathologic diagnosis of endometriosis

Objective: To review the histopathologic diagnosis of biopsies taken following visualization of endometriosis at laparoscopy and to correlate visual with microscopic diagnoses. Methods: A retrospective review was undertaken of medical charts with a diagnosis of endometriosis at Aga Khan University Hospital, Nairobi, Kenya, between January 2001 and October 2010. Eligibility included visual diagnosis of endometriosis at laparoscopy, with a clear record of site, size, morphology, and number of lesions. The histopathologic diagnosis of the biopsies sampled was sought. Correlation was undertaken using κ statistics for diagnostic variability. Results: Of the 204 relevant records, 152 (74.5%) met the eligibility criteria; from these cases, 239 specimens were submitted for histology. The most common symptom was chronic pelvic pain (108 [71.1%]). Most biopsies were obtained from the ovary and posterior cul-de-sac. Histopathologic diagnosis was confirmed in (152 [63.8%]) specimens and correlated with Asian race, multiparity, and chronic pelvic pain. Neither the site of the lesion nor the stage of disease influenced the histopathologic diagnosis. Conclusion: Laparoscopic visualization of endometriosis does not always correlate with histopathologic diagnosis; several other lesions may mimic endometriosis on histopathologic examination

Factors contributing to failure of vacuum delivery and associated maternal/neonatal morbidity

Objective: To determine factors contributing to the failure of vacuum delivery and to compare the neonatal and maternal morbidity associated with failed and successful procedures. Methods: A retrospective case– control study was undertaken at Aga Khan University Hospital, Nairobi, Kenya, by review of medical charts from the period of January 2007 to December 2010. In total, 31 cases of failed vacuum delivery were compared with 124 controls where extraction was successful. The primary outcome measure was fetal malposition. Secondary outcome measures included a composite score of maternal complications, a 5-minute Apgar score below 7, an umbilical arterial pH below 7.1, and a base excess below−12. Multiple logistic regression analysis was undertaken to identify factors associated with failure of vacuum delivery. Results: Demographic and labor characteristics were similar in both groups. Fetal malposition significantly contributed to the failure of vacuum delivery (odds ratio 12.7, 95% confidence interval 1.5–14.8). Failure of vacuum delivery was not associated with clinically important neonatal or maternal morbidity. Conclusions: Vacuum extraction is a safe mode of delivery where indicated, with minimal maternal and neonatal morbidity even in the event of procedural failure

External cephalic version in East, Central, and Southern Africa

Objective: To evaluate the views of maternity care providers in East, Central, and Southern Africa on external cephalic version (ECV), and its determinants, with the aim of drawing lessons for practice. Methods: In February 2009, a cross-sectional survey using self-administered semi-structured questionnaires was conducted among delegates attending a regional conference of obstetricians and gynecologists. Descriptive statistical analysis was undertaken, and comments were analyzed for themes. Results: Of the 70 questionnaires issued to eligible delegates, 64 were fully completed (response rate 91%). Seventy-nine percent of respondents did not offer ECV. Approximately a third (31%) of the practitioners offered elective vaginal breech delivery. Clinicians offering ECV did so at varying gestational ages. Clinicians not offering ECV gave various reasons including concerns about the procedure\u27s safety and lack of training and experience with it, policy restrictions, medico-legal concerns, clinician or client reluctance, and poor results with the procedure. Conclusion: Overall, ECV is not widely practiced in East, Central, and Southern Africa, mainly owing to concerns related to safety and policy. Efforts aimed at reviving ECV in these regions should address these concerns. A conceptual framework of such efforts is proposed herein