Fundal pressure during the second stage of labour

Background Fundal pressure during the second stage of labour involves application of manual pressure to the uppermost part of the uterus directed towards the birth canal in an attempt to assist spontaneous vaginal delivery and avoid prolonged second stage or the need for operative delivery. Fundal pressure has also been applied using an inflatable girdle. A survey in the United States found that 84% of the respondents used fundal pressure in their obstetric centres.There is little evidence to demonstrate that the use of fundal pressure is effective to improve maternal and/or neonatal outcomes. Several anecdotal reports suggest that fundal pressure is associated with maternal and neonatal complications: for example, uterine rupture, neonatal fractures and brain damage. There is a need for objective evaluation of the effectiveness and safety of fundal pressure in the second stage of labour. Objectives To determine the benefits and adverse effects of fundal pressure in the second stage of labour. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2008). Selection criteria Randomised and quasi-randomised controlled trials of fundal pressure versus no fundal pressure in women in the second stage of labour with singleton cephalic presentation. Data collection and analysis Three review authors independently assessed for inclusion all the potential studies. We extracted the data using a pre-designed form. We entered data into Review Manager software and checked for accuracy. Main results We excluded two of three identified trials from the analyses for methodological reasons. This left no studies on manual fundal pressure. We included one study (500 women) of fundal pressure by means of an inflatable belt versus no fundal pressure to reduce operative delivery rates. The methodological quality of the included study was good. Use of the inflatable belt did not change the rate of operative deliveries (RR 0.94, 95% CI 0.80 to 1.11). Fetal outcomes in terms of five-minute Apgar scores below seven (RR 4.62, 95% CI 0.22 to 95.68), low arterial cord pH (RR 0.47, 95% CI 0.09 to 2.55) and admission to the neonatal unit (RR 1.48, 95% CI 0.49 to 4.45) were also not different between the groups. There was no severe neonatal or maternal mortality or morbidity. There was an increase in intact perineum (RR 1.73, 95% CI 1.07 to 2.77), as well as anal sphincter tears (RR 15.69, 95% CI 2.10 to 117.02) in the belt group. There were no data on long-term outcomes

Improving obstetric care in low-resource settings: implementation of facility-based maternal death reviews in five pilot hospitals in Senegal

<p>Abstract</p> <p>Background</p> <p>In sub-Saharan Africa, maternal and perinatal mortality and morbidity are major problems. Service availability and quality of care in health facilities are heterogeneous and most often inadequate. In resource-poor settings, the facility-based maternal death review or audit is one of the most promising strategies to improve health service performance. We aim to explore and describe health workers' perceptions of facility-based maternal death reviews and to identify barriers to and facilitators of the implementation of this approach in pilot health facilities of Senegal.</p> <p>Methods</p> <p>This study was conducted in five reference hospitals in Senegal with different characteristics. Data were collected from focus group discussions, participant observations of audit meetings, audit documents and interviews with the staff of the maternity unit. Data were analysed by means of both quantitative and qualitative approaches.</p> <p>Results</p> <p>Health professionals and service administrators were receptive and adhered relatively well to the process and the results of the audits, although some considered the situation destabilizing or even threatening. The main barriers to the implementation of maternal deaths reviews were: (1) bad quality of information in medical files; (2) non-participation of the head of department in the audit meetings; (3) lack of feedback to the staff who did not attend the audit meetings. The main facilitators were: (1) high level of professional qualifications or experience of the data collector; (2) involvement of the head of the maternity unit, acting as a moderator during the audit meetings; (3) participation of managers in the audit session to plan appropriate and realistic actions to prevent other maternal deaths.</p> <p>Conclusion</p> <p>The identification of the barriers to and the facilitators of the implementation of maternal death reviews is an essential step for the future adaptation of this method in countries with few resources. We recommend for future implementation of this method a prior enhancement of the perinatal information system and initial training of the members of the audit committee – particularly the data collector and the head of the maternity unit. Local leadership is essential to promote, initiate and monitor the audit process in the health facilities.</p

Obstetric fistula in low‐income countries

ObjectiveTo identify, survey, and systematically review the current knowledge regarding obstetric fistula as a public health problem in low‐income countries from the peer‐reviewed literature.MethodsThe Medline and Science Citation Index databases were searched to identify public health articles on obstetric fistula in low‐income countries. Quantitative evidence‐based papers were reviewed.ResultsThirty‐three articles met the criteria for inclusion: 18 hospital‐based reviews; 6 on risk factors/prevention; 4 on prevalence/incidence measurement; 3 on consequences of obstetric fistula; and 2 on community‐based assessments.ConclusionObstetric fistula has received increased international attention as a public health problem, but reliable research on the burden of disease and interventions is lacking.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135537/1/ijgo85.pd

Estimating the prevalence of obstetric fistula: a systematic review and meta-analysis.

BACKGROUND: Obstetric fistula is a severe condition which has devastating consequences for a woman's life. The estimation of the burden of fistula at the population level has been impaired by the rarity of diagnosis and the lack of rigorous studies. This study was conducted to determine the prevalence and incidence of fistula in low and middle income countries. METHODS: Six databases were searched, involving two separate searches: one on fistula specifically and one on broader maternal and reproductive morbidities. Studies including estimates of incidence and prevalence of fistula at the population level were included. We conducted meta-analyses of prevalence of fistula among women of reproductive age and the incidence of fistula among recently pregnant women. RESULTS: Nineteen studies were included in this review. The pooled prevalence in population-based studies was 0.29 (95% CI 0.00, 1.07) fistula per 1000 women of reproductive age in all regions. Separated by region we found 1.57 (95% CI 1.16, 2.06) in sub Saharan Africa and South Asia, 1.60 (95% CI 1.16, 2.10) per 1000 women of reproductive age in sub Saharan Africa and 1.20 (95% CI 0.10, 3.54) per 1000 in South Asia. The pooled incidence was 0.09 (95% CI 0.01, 0.25) per 1000 recently pregnant women. CONCLUSIONS: Our study is the most comprehensive study of the burden of fistula to date. Our findings suggest that the prevalence of fistula is lower than previously reported. The low burden of fistula should not detract from their public health importance, however, given the preventability of the condition, and the devastating consequences of fistula

Knowledge of obstetric fistula prevention amongst young women in urban and rural Burkina Faso: a cross-sectional study

Obstetric fistula is a sequela of complicated labour, which, if untreated, leaves women handicapped and socially excluded. In Burkina Faso, incidence of obstetric fistula is 6/10,000 cases amongst gynaecological patients, with more patients affected in rural areas. This study aims to evaluate knowledge on obstetric fistula among young women in a health district of Burkina Faso, comparing rural and urban communities. This cross-sectional study employed multi-stage sampling to include 121 women aged 18-20 years residing in urban and rural communities of Boromo health district. Descriptive statistics and multiple logistic regression analysis were used to compare differences between the groups and to identify predictors of observed knowledge levels. Rural women were more likely to be married (p<0.000) and had higher propensity to teenage pregnancy (p=0.006). The survey showed overall poor obstetric fistula awareness (36%). Rural residents were less likely to have adequate preventive knowledge than urban residents [OR=0.35 (95%-CI, 0.16–0.79)]. This effect was only slightly explained by lack of education [OR=0.41 (95%-CI, 0.18–0.93)] and only slightly underestimated due to previous pregnancy [OR=0.27 (95%-CI, 0.09–0.79)]. Media were the most popular source of awareness amongst urban young women in contrast to their rural counterparts (68% vs. 23%). Most rural young women became ‘aware’ through word-of-mouth (68% vs. 14%). All participants agreed that the hospital was safer for emergency obstetric care, but only 11.0% believed they could face pregnancy complications that would require emergency treatment. There is urgent need to increase emphasis on neglected health messages such as the risks of obstetric fistula. In this respect, obstetric fistula prevention programs need to be adapted to local contexts, whether urban or rural, and multi-sectoral efforts need to be exerted to maximise use of other sectoral resources and platforms, including existing routine health services and schools, to ensure sustainability of health literacy efforts

Rapport du Comité d'experts constitué par l'Union européenne à l'occasion de la Quatrième Conférence Africaine sur le Population

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La Grossesse Chez la Célibataire à Niamey (Niger)

L'objectif de ce travail est de décrire le profil socio-économique de la femme célibataire enceinte et de préciser l'influence de ce statut sur la grossesse et l'accouchement. Entre avril 1995 et février 1996, une enquête prospective en population à Niamey a permis de sélectionner 181 femmes célibataires enceintes, que nous avons appariées avec des femmes mariées de même âge, de parité identique et résidant dans le même quartier. Les tests de Mc Nemar et de Wilcoxon ont été utilisés. Parallèlement, des entretiens qualitatifs ouverts ont été menés avec les patientes et le personnel de santé. Les célibataires représentent 6,1% de la population des femmes enceintes. L'âge médian est de 19 ans, et 72% sont primipares. Elles sont bien intégrées dans leur quartier et sont le plus souvent scolarisées. 24% ont une activité professionnelle, mais 31% ne disposent d'aucun revenu. Les célibataires se présentent moins fréquemment et plus tardivement à la consultation prénatale que les femmes mariées. Elles prennent plus rarement un traitement martial préventif. Les modalités d'accouchement sont identiques, mais le risque d'accoucher de nouveau-nés de faible poids de naissance est multiplié par 2,4. Enfin, la connaissance des méthodes contraceptives et des lieux de prescription sont identiques, mais les pratiques sont plus fréquentes chez les célibataires. (Rev Afr Santé Reprod 2001; 5[2]: 98-104) ABSTRACT The objectives of this study are to describe the socio-economic profile of single mothers and to specify the influence of this status on pregnancy and delivery. Between April 1995 and February 1996, a cohort study in Niamey allowed the selection of 181 single mothers, matched by age and parity with married pregnant women living in the same district. We used the McNemar's and Wilcoxon's statistic tests. In parallel, qualitative open interviews were conducted with patients and health care providers. Single mothers represent 6.1% of the study population. The median age was 19 years and 72% were primiparas. They received some level of education, at least primary and were well integrated in their district. Twenty four per cent were employed and 31% had no income. Single mothers' attendance and punctuality at prenatal care centre were not as good as married women and also as their compliance with iron prophylactic treatment. The mode of delivery was identical but the risk of low birthweight infant was 2.4 more frequent in single mothers. Finally, knowledge of contraceptive methods and access to them were indentical, but single mothers used them more frequently than married women. (Afr J Reprod Health 2001; 5[2]: 98-104) KEY WORDS: Grossesse, célibataire, Niger, soins prénatal

Obstetric fistulae: incidence estimates for sub-Saharan Africa

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Obstetric fistula in Southern Sudan: situational analysis and Key Informant Method to estimate prevalence.

BACKGROUND: Obstetric fistula is a severe condition which can have devastating consequences for a woman's life. Despite a considerable literature, very little is known about its prevalence. This project was conducted to carry out a situational analysis of fistula services in South Sudan and to pilot test the Key Informant Method (KIM) to estimate the prevalence of fistula in a region of South Sudan. METHODS: Key stakeholder interviews, document reviews and fistula surgery record reviews were undertaken. A KIM survey was conducted in a district of Western Bahr-el-Ghazal in January 2012. One hundred sixty-six community-based distributors, traditional birth attendants and village midwives were trained as key informants to identify women with fistula in the community. Women identified were subsequently examined by an obstetrician and nurse to verify whether they had a fistula. RESULTS: There were limited fistula repair services in South Sudan. Approximately 50-80 women per year attend periodic campaigns, with around half having a fistula and receiving a repair. On average a further 5 women a year received fistula repair from hospital services. Ten women with potential fistula were identified via KIM; all confirmed by the obstetrician. Of these, three were from the survey area, which had 8,865 women of reproductive age (15-49 years). This gives a minimal estimated prevalence of at least 30 fistulas per 100,000 women of reproductive age (95% CI 10-100). CONCLUSIONS: Routine fistula repair services available do not meet the population's needs. The pilot study suggests that KIM can be used to identify women with fistula in the community. Data on fistula are generally poor; the KIM methodology we used in South Sudan yielded a lower fistula prevalence than estimates reported previously in the region