Associations between birth at, or after, 41 weeks gestation and perinatal encephalopathy: a cohort study

Background Preterm birth causes long-term problems, even for infants born 1 or 2 weeks early. However, less is known about infants born after their due date and over a quarter of infants are born over 1 week late, and many still remain undelivered after 2 weeks. The aim of this work is to quantify the risks of infants developing encephalopathy when birth occurs after the due date, and if other proposed risk factors modify this relationship. Methods The dataset contain information on 4 036 346 infants born in Sweden between 1973 and 2012. Exposure was defined as birth 7, or more, days after the infants’ due date. The primary outcome was the development of neonatal encephalopathy (defined as seizures, encephalopathy or brain injury caused by asphyxia or with unspecified cause). Covariates were selected as presumed confounders a priori. Results 28.4% infants were born 1 or more weeks after their due date. An infant’s risk of being born with encephalopathy was higher in the post 41 weeks group in the unadjusted (OR 1.40 (95% CI 1.32 to 1.49)) and final model (OR 1.38 (95% CI 1.29 to 1.47)), with the relative odds of encephalopathy increasing by an estimated 20% per week after the due date, and modified by maternal age (P=0.022). Conclusions Singleton infants born at, or after, 41 weeks gestation have lower Apgar scores and higher risk of developing encephalopathy in the newborn period, and the association appeared more marked in older mothers. These data could be useful if provided to women as part of their decision-making

A model-based cost-utility analysis of multi-professional simulation training in obstetric emergencies

ObjectiveTo determine the cost-utility of a multi-professional simulation training programme for obstetric emergencies-Practical Obstetric Multi-Professional Training (PROMPT)-with a particular focus on its impact on permanent obstetric brachial plexus injuries (OBPIs).DesignA model-based cost-utility analysis.SettingMaternity units in England.PopulationSimulated cohorts of individuals affected by permanent OBPIs.MethodsA decision tree model was developed to estimate the cost-utility of adopting annual, PROMPT training (scenario 1a) or standalone shoulder dystocia training (scenario 1b) in all maternity units in England compared to current practice, where only a proportion of English units use the training programme (scenario 2). The time horizon was 30 years and the analysis was conducted from an English National Health Service (NHS) and Personal Social Services perspective. A probabilistic sensitivity analysis was performed to account for uncertainties in the model parameters.Main outcome measuresOutcomes for the entire simulated period included the following: total costs for PROMPT or shoulder dystocia training (including costs of OBPIs), number of OBPIs averted, number of affected adult/parental/dyadic quality adjusted life years (QALYs) gained and the incremental cost per QALY gained.ResultsNationwide PROMPT or shoulder dystocia training conferred significant savings (in excess of £1 billion ($1.5 billion)) compared to current practice, resulting in cost-savings of at least £1 million ($1.5 million) per any type of QALY gained. The probabilistic sensitivity analysis demonstrated similar findings.ConclusionIn this model, national implementation of multi-professional simulation training for obstetric emergencies (or standalone shoulder dystocia training) in England appeared to both be cost-saving when evaluating their impact on permanent OBPIs

Laparoscopic simulation training in gynaecology:Current provision and staff attitudes - a cross-sectional survey

<p>The objectives of this study were to explore current provision of laparoscopic simulation training, and to determine attitudes of trainers and trainees to the role of simulators in surgical training across the UK. An anonymous cross-sectional survey with cluster sampling was developed and circulated. All Royal College of Obstetricians and Gynaecologists (RCOG) Training Programme Directors (TPD), College Tutors (RCT) and Trainee representatives (TR) across the UK were invited to participate. One hundred and ninety-six obstetricians and gynaecologists participated. Sixty-three percent of hospitals had at least one box trainer, and 14.6% had least one virtual-reality simulator. Only 9.3% and 3.6% stated that trainees used a structured curriculum on box and virtual-reality simulators, respectively. Respondents working in a Large/Teaching hospital (<i>p</i> = 0.008) were more likely to agree that simulators enhance surgical training. Eighty-nine percent agreed that simulators improve the quality of training, and should be mandatory or desirable for junior trainees. Consultants (<i>p</i> = 0.003) and respondents over 40 years (<i>p</i> = 0.011) were more likely to hold that a simulation test should be undertaken before live operation. Our data demonstrated, therefore, that availability of laparoscopic simulators is inconsistent, with limited use of mandatory structured curricula. In contrast, both trainers and trainees recognise a need for greater use of laparoscopic simulation for surgical training.</p

Clinical-insurer engagement to improve maternity safety in the UK, Ireland, Sweden and Australia

Objective To explore different models of clinical–insurer engagement around maternity safety and to understand how state insurers could and should engage with clinical staff to improve outcomes and reduce harm. Design Semi-structured interviews and focus groups were conducted with senior representatives from state insurers. Transcripts were analysed to identify different models of engagement. Themes were also elicited from the transcripts. A further one-day focus group allowed for clarification and elaboration of these themes. Participants Senior representatives from state insurers in England, Scotland, Wales, Republic of Ireland, Sweden and Victoria, Australia. Results A variety of clinical engagement activities were undertaken by the insurers. These included training on claims and risk management, hospital site visits, facilitating multi-professional network meetings and working with clinical experts to develop best practice recommendations. Some insurers engaged with frontline clinical staff through collaborative patient safety programmes. The themes (identity and size, data and research, incentivising improvement and system integration) were important for considering the role of state insurers within health systems and how insurers could engage with clinical teams. Conclusions This study identified different examples of clinical–insurer engagement. Whilst this was encouraging, the relationships between insurers and clinical teams could be developed further. Insurers and clinical staff could still collaborate more closely and work together in improving patient outcomes. Whilst not specifically their domain, insurers do have a role in patient safety. Closer clinical collaboration may strengthen this contribution. </jats:sec

Associations between early term and late/post term infants and development of epilepsy:A cohort study

Background While life-long impacts exist for infants born one or two weeks early little evidence exists for those infants born after their due date. However interventions could be used to expedite birth if the risks of continuing the pregnancy are higher than intervening. It is known that the risk of epilepsy in childhood is higher in infants exposed to perinatal compromise and therefore may be useful as a proxy for intrapartum compromise. The aim of this work is to quantify the likelihood of children developing epilepsy based on their gestational age at birth (37–39 weeks or ≥41 weeks). Methods The work is based on term infants born in Sweden between 1983 and 1993 (n = 1,030,168), linked to data on disability pension, child mortality and in-patient epilepsy care. The reference group was defined as infants born at 39 or 40 completed weeks of gestation; compared with infants born at early term (37/38 weeks) or late/post term (41 weeks or more). Primary outcome was defined a-priori as a diagnosis of epilepsy before 20 years of age. Secondary outcomes were childhood mortality (before five years of age), and registered for disability pension before 20 years of age. Logistic regression models were used to assess any association of the outcomes with gestational age at birth. Findings In the unadjusted results, infants born 7 or more days after their due date had higher risks of epilepsy and disability pension than the reference group, but similar risks of child death. Early term infants showed higher risks of epilepsy, disability pension and child death. After adjustment for confounders, there remained a higher risk of epilepsy for both early term (OR 1·19 (1·11–1·29)) and late/post term infants (OR 1·13 (1·06–1·22)). Interpretation Infants born at 37/38 week or 41 weeks and above, when compared to those born at 39 or 40 weeks gestation, have an increased risk of developing epilepsy. This data could be useful in helping women and care givers make decisions with regard to the timing of induction of labour

Temporal trends in stillbirth over eight decades in England and Wales:A longitudinal analysis of over 56 million births and lives saved by improvements in maternity care

BACKGROUND: Considering the public health importance of stillbirth, this study quantified the trends in stillbirths over eight decades in England and Wales. METHODS: This longitudinal study utilized the publicly available aggregated data from the Office for National Statistics that captured maternity information for babies delivered in England and Wales from 1940 to 2019. We computed the trends in stillbirth with the associated incidence risk difference, incidence risk ratio, and extra lives saved per decade. RESULTS: From 1940-2019, 56 906 273 births were reported. The stillbirth rate declined (85%) drastically up to the early 1980s. In the initial five decades, the estimated number of deaths per decade further decreased by 67 765 (9.49/1000 births) in 1940-1949, 2569 (0.08/1000 births) in 1950-1959, 9121 (3.50/1000 births) in 1960-1969, 15 262 (2.31/1000 births) in 1970-1979, and 10 284 (1.57/1000 births) in 1980-1989. However, the stillbirth rate increased by an additional 3850 (0.58/1000 births) stillbirths in 1990-1999 and 693 (0.11/1000 births) stillbirths in 2000-2009. The stillbirth rate declined again during 2010-2019, with 3714 fewer stillbirths (0.54/1000 births). The incidence of maternal age 35 years) increased. CONCLUSIONS: The stillbirth rate declined drastically, but the rate of decline slowed in the last three decades. Though teenage pregnancy (<20 years) had reduced, the prevalence of women with a higher risk of stillbirth may have risen due to an increase in advanced maternal age. Improved, more personalised care is required to reduce the stillbirth rate further

Emergency training for in-hospital-based healthcare providers:effects on clinical practice and patient outcomes

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: 1. To assess the effects of emergency training for in‐hospital‐based healthcare providers on patient outcomes. 2. To assess the effects of emergency training for in‐hospital‐based healthcare providers on clinical care practices or organisational practice or both. 3. To identify any essential components of effective emergency training programmes for in‐hospital‐based healthcare providers

Obstetric brachial plexus injuries (OBPIs):health-related quality of life in affected adults and parents

Background Obstetric brachial plexus injuries (OBPIs) are rare but can have significant implications for those affected, their caregivers and the health system. Symptoms can range from restricted movement to complete paralysis of the arm. We investigated health-related quality of life in adults with OBPIs and parents of children with permanent OBPIs, compared these with population norms, and investigated whether certain socio-demographic or clinical factors were associated with the quality of life in these cohorts. Methods A cross-sectional study examined 50 affected adults and 78 parents. Participants completed EQ-5D-5L and characteristics questionnaires. EQ-5D-5L responses were mapped onto an EQ-5D-3L value set to generate utility scores. Mean utility scores were compared with English population norms. Univariable and multivariable linear regression models were conducted to assess for associations between participant characteristics and the utility scores. Results The overall mean utility scores for affected adults and parents were 0.56 (SD 0.28) and 0.80 (SD 0.19) respectively. Affected adults (95% CI (-0.38, -0.22), p<0.001) and parents of children with permanent OBPIs (95% CI (-0.10, -0.02), p=0.007) had lower mean utility scores, and therefore quality of life, compared to English population norms. For affected adults, previous OBPI surgery (95% CI (0.01, 0.25), p=0.040), employment in non-manual work (95% CI (0.06, 0.30), p=0.005) and having a partner (95% CI (0.04, 0.25), p=0.009) appeared to be positively associated with the utility score. Affected adults receiving disability benefits related to OBPIs appeared to have worse utility scores than those not receiving any disability benefits (95% CI (-0.31, -0.06), p=0.005). For parents, employment was associated with better utility scores (95% CI (0.02, 0.20), p=0.024) but the presence of one or more medical condition appeared to be associated with worse utility scores (95% CI (-0.16, -0.04), p=0.001). Conclusions Adults with OBPIs and parents of children with permanent OBPIs reported worse utility scores, and therefore quality of life, compared to the English general population. We also identified certain characteristics as possible factors to consider when dealing with utility scores in these cohorts. The utility scores in this study can be used in future economic evaluations related to OBPIs

Fetal head position and perineal distension associated with the use of the BD Odon Device™ in operative vaginal birth:a simulation study

To investigate (1) the placement of the BD Odon Device on the model fetal head and (2) perineal distention during simulated operative vaginal births conducted with the BD Odon Device