Induction of labour survey questions.

ObjectivesTo explore local induction of labour pathways in the UK National Health Service to provide insight into current practice.DesignNational survey.SettingHospital maternity services in all four nations of the UK.SampleConvenience sample of 71 UK maternity units.MethodsAn online cross-sectional survey was disseminated and completed via a national network of obstetrics and gynaecology specialist trainees (October 2021-March 2022). Results were analysed descriptively, with associations explored using Fisher’s Exact and ANOVA.Main outcome measuresInduction rates, criteria, processes, delays, incidents, safety concerns.Results54/71 units responded (76%, 35% of UK units). Induction rate range 19.2%-53.4%, median 36.3%. 72% (39/54) had agreed induction criteria: these varied widely and were not all in national guidance. Multidisciplinary booking decision-making was not reported by 38/54 (70%). Delays reported ‘often/always’ in hospital admission for induction (19%, 10/54) and Delivery Suite transfer once induction in progress (63%, 34/54). Staffing was frequently reported cause of delay (76%, 41/54 ‘often/always’). Delays triggered incident reports in 36/54 (67%) and resulted in harm in 3/54 (6%). Induction was an area of concern (44%, 24/54); 61% (33/54) reported induction-focused quality improvement work.ConclusionsThere is substantial variation in induction rates, processes and policies across UK maternity services. Delays appear to be common and are a cause of safety concerns. With induction rates likely to increase, improved guidance and pathways are critically needed to improve safety and experience of care.</div

Induction rates according to maternity unit size (number of births per year).

Induction rates according to maternity unit size (number of births per year).</p

Reasons contributing towards delays in the induction process.

Reasons contributing towards delays in the induction process.</p

Frequency of delays in IOL processes.

ObjectivesTo explore local induction of labour pathways in the UK National Health Service to provide insight into current practice.DesignNational survey.SettingHospital maternity services in all four nations of the UK.SampleConvenience sample of 71 UK maternity units.MethodsAn online cross-sectional survey was disseminated and completed via a national network of obstetrics and gynaecology specialist trainees (October 2021-March 2022). Results were analysed descriptively, with associations explored using Fisher’s Exact and ANOVA.Main outcome measuresInduction rates, criteria, processes, delays, incidents, safety concerns.Results54/71 units responded (76%, 35% of UK units). Induction rate range 19.2%-53.4%, median 36.3%. 72% (39/54) had agreed induction criteria: these varied widely and were not all in national guidance. Multidisciplinary booking decision-making was not reported by 38/54 (70%). Delays reported ‘often/always’ in hospital admission for induction (19%, 10/54) and Delivery Suite transfer once induction in progress (63%, 34/54). Staffing was frequently reported cause of delay (76%, 41/54 ‘often/always’). Delays triggered incident reports in 36/54 (67%) and resulted in harm in 3/54 (6%). Induction was an area of concern (44%, 24/54); 61% (33/54) reported induction-focused quality improvement work.ConclusionsThere is substantial variation in induction rates, processes and policies across UK maternity services. Delays appear to be common and are a cause of safety concerns. With induction rates likely to increase, improved guidance and pathways are critically needed to improve safety and experience of care.</div

Comparison of location, size and neonatal care level^b'*' of participating maternity units with units across the UK.

Comparison of location, size and neonatal care levelb'*' of participating maternity units with units across the UK.</p

Maximum number of inductions able to be booked per day per size of unit.

Maximum number of inductions able to be booked per day per size of unit.</p

Criteria for outpatient IOL across responding units.

Criteria for outpatient IOL across responding units.</p

Local criteria for IOL in participating units (n = 39).

Local criteria for IOL in participating units (n = 39).</p

Pregnancy outcomes in women with primary biliary cholangitis and primary sclerosing cholangitis: a retrospective cohort study

Objective To determine maternal, obstetric and neonatal outcomes in a cohort of women with primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) Design Retrospective cohort study. Setting 10 specialist centres managing pregnant women with liver disease Population Women with a diagnosis of PBC and PSC and a pregnancy of =20 completed weeks’ gestation. Methods Retrospective case notes review Main outcome measures Adverse outcomes were defined as maternal: development of ascites, variceal bleeding, encephalopathy and jaundice; obstetric events: gestational hypertension, pre-eclampsia and postpartum haemorrhage; and neonatal: stillbirth, preterm delivery, and admission to neonatal unit. The relationship of alanine transferase (ALT) and bile acid levels with gestation at delivery was studied. Results The first recorded pregnancies of 34 women with PSC and 27 with PBC were analysed. There were 60 livebirths and one intrapartum stillbirth that did not occur in the context of maternal cholestasis. Overall median gestation of delivery was 38 weeks, but the rate of preterm birth was 28% (17/61 deliveries) of which 76% (13/17) were spontaneous. Gestation at birth negatively correlated with maternal serum ALT concentration at booking (p=0.017) and serum bile acid concentration during pregnancy (p=0.016). There were no other significant correlations and maternal and neonatal outcomes were good. Conclusion Pregnancy in PBC and PSC is well tolerated, but women should be counselled regarding the increased risk of preterm birth. Measurement of maternal ALT and bile acids may help identify women at risk of preterm delivery

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial

BackgroundTranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding.MethodsWe did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124.FindingsBetween July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98).InterpretationWe found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial.</div