Australian & New Zealand Journal of Obstetrics & Gynaecology最新文献

Background

There are no published Australian population-based data on serious COVID-19-associated maternal morbidity before and after widespread vaccination.

Aims

To compare COVID-19 infection rates, intensive care unit (ICU) admissions, and length of stay in hospitalised pregnant patients before and after achieving 70% state-wide maternal COVID-19 vaccination coverage.

Material and Methods

Population-based retrospective cohort study involving all hospital-admitted episodes for pregnant patients over 15-years-old with COVID-19 in Victoria from 1 March 2020 to 31 March 2022. Phase 1 was defined as March 2020—October 2021 when maternal vaccination coverage < 70%; Phase 2 was defined as November 2021–March 2022 when maternal vaccination coverage ≥ 70%. Primary outcomes include COVID-19 rates, ICU admission rates, and length of stay. A p-value of < 0.05 was considered statistically significant.

Results

We analysed 215,363 hospital admissions, among which 2,128 (0.99%) had COVID-19. The percentage of admitted pregnant patients with COVID-19 was higher in Phase 2 than Phase 1 (3.27% vs. 0.41% respectively, p < 0.001). However, Phase 2 was associated with lower maternal ICU admission rates (2.02% vs. 5.39%, p < 0.001) and lower median length of stay (2.19 vs. 3.11 days, p < 0.001) compared with Phase 1. The risk of COVID-19 was significantly lower in socioeconomically advantaged pregnant patients (aRR = 0.83 [95% CI, 0.76–0.90], p < 0.001) and pregnant patients ≥ 30-years-old (aRR = 0.81 [95% CI, 0.74–0.88], p < 0.001).

Conclusions

Maternal ICU admission risk and length of stay were significantly lower among pregnant patients with COVID-19 during Phase 2, which is likely due to the combined effects of high maternal COVID-19 vaccination coverage and changes in SARS-CoV-2 variants.

Background

Placenta praevia (PP) is a significant obstetric complication associated with antepartum haemorrhage (APH) and adverse maternal and fetal outcomes. Identifying risk factors for APH in women with PP is important for guiding management decisions.

Aims

This study aimed to identify risk factors associated with APH amongst women admitted to a single tertiary hospital with PP.

Materials and Methods

A retrospective cohort study was undertaken, utilising data from the hospital's maternity dataset (2007–2021) and included publicly funded women with PP after 24 weeks gestation. Exclusions comprised multiple pregnancies, fetal abnormalities, intra-uterine fetal death and deliveries at other hospitals. Baseline characteristics, outcomes and potential risk factors for APH were analysed through bivariate and stepwise logistic regression.

Results

Of the 430 cases with PP, 112 (26%) were admitted with APH. Of these, 45 had two or more admissions with APH, constituting 40% of the APH cohort. Those requiring admission were more likely to deliver at an early gestation, and their baby required nursery admission. Factors independently associated with APH included a higher number of previous caesarean sections, parity, Caucasian ethnicity and major PP.

Conclusions

Most women with PP will not require an admission with APH. In considering inpatient versus outpatient management, multiparous Caucasian women with a major PP appear more likely to be at risk of APH admission and premature delivery. These findings underscore the importance of tailoring clinical decision-making.

Background

Chronic pelvic pain (CPP) is a common and debilitating presentation for adolescent and young adult females. Medical management is often utilised as first line therapy with surgical management considered if medical treatment has been unsuccessful. Laparoscopy in this young population remains controversial due to the high recurrence rate of pain, requirement for repeat surgeries and surgical risks. There is a need for prospective, longitudinal studies comparing medical and surgical management to guide management of young patients with CPP.

Aims

To determine the effect of the first laparoscopy in an adolescent and young adult female population and assess its association with CPP.

Materials and Methods

Patients aged 16–25 will be recruited from the gynaecological service at the study sites. Consented participants will be randomised to the surgical or non-surgical arms. Those in the surgical arm will have a laparoscopy performed and those in the non-surgical arm will be medically managed. At recruitment and at 6 weeks, 6 months, 12 months and 24 months follow-up, patients will complete a number of validated questionnaires assessing pain and quality of life. An amendment was made to methodology to include patients who will choose their management pathway for CPP.

Results

An independent t-test or Mann–Whitney U test will be used to compare the questionnaire scores between the surgical and non-surgical groups. For questionnaire scores at baseline and follow-up within the same arm, a paired t-test or Wilcoxon signed-rank test will be used. A p-value of < 0.05 will be statistically significant.

Background

Anecdotal experience suggests that WHO Safer Surgery Checklist has become a ‘tickbox’ exercise, resulting in variable team engagement and efficacy.

Aims

To observe the quality and completeness of ‘Time Out’, together with the level of team engagement during obstetrics and gynaecology procedures.

Materials and Methods

Results

Data from 70 obstetrics and gynaecology cases were collected over 8 weeks. ‘Time Out’ was clearly announced in 91.4% and was performed in all cases but not all items were communicated in the correct ‘challenge and response’ manner. Mean percentage of questions appropriately ‘challenged’ and ‘responded’ to was 92% ± 6.86%. Mean duration of ‘Time Out’ was 92.01 ± 86.9 s and observed distractions were auditory (61%), visual (26%), irrelevant chatter (22.5%) and theatre traffic (13%). In 92.8%, at least two team members were not engaged and were performing non-essential tasks. The likelihood of a team member being able to ‘speak up’ was 8.78/10 (±0.71) and this appeared independent of whether it was led by nurses, doctors, operating department practitioners or healthcare support workers.

Conclusion

Although performed in all cases, ‘Time Out’ is often not clearly announced or completed in the correct ‘challenge and response’ manner. It is plagued by avoidable distractions and suboptimal team engagement. Greater awareness is crucial to ensure more complete team involvement.

Background

Previously it was recognised onset of Lactogenesis II was delayed in women with Type I diabetes compared to women without diabetes, but the effect of gestational diabetes was unclear. Some clinicians suggest pregnant women with diabetes express breastmilk in late pregnancy to hasten onset of Lactogenesis II.

Aims

To confirm if Lactogenesis II occurs later in women with diabetes in pregnancy, and test if advice to express antenatally hastens Lactogenesis II.

Materials and Methods

Data from the DAME (Diabetes Antenatal Milk Expression) randomised controlled trial collected at recruitment and 2 weeks postpartum were compared with a concurrent purposively recruited cohort of women without diabetes in pregnancy. Timing of lactogenesis and adjusted percentage differences were calculated. Study sample was women from both studies with complete data for included measures to assess onset of Lactogenesis II (maternal perception).

Results

Conclusions

Lactogenesis II occurs later for women with diabetes in pregnancy than women without diabetes. Our findings do not provide evidence that antenatal expressing hastens onset of lactation in women with diabetes in pregnancy.

Trial Registration

ClinicalTrials.gov identifier: ACTRN12611000217909

Background

Although consent has long been accepted as necessary in maternity care, the concept of informed consent for planned vaginal birth has polarised maternity politics. The publication of the NSW Consent Manual outlines new standards of informed consent, signalling the need for examination of current maternity consent practices.

Aims

To examine informed consent and disclosure of material risks in birth in a prospective qualitative study of midwives and obstetricians.

Materials and Methods

Qualitative study using semi-structured interviews to examine practices and perspectives of obstetricians and midwives.

Results

Twenty-two telephone interviews were concluded. Five sub-themes were identified: (1) non-compliance with the NSW Consent Manual, (2) risk communication/informed consent in maternity care, (3) consent practices in instrumental birth, (4) who should deliver risk information and when (5) barriers to change in consent practice (obstetricians only).

Conclusions

One hundred per cent of participants (18 obstetricians, 4 midwives) described risk communication/informed consent practices that were non-complaint with the standards set out in the 2020 NSW Consent Manual. Eighty-three per cent (15/18) of obstetricians reported that current hospital-wide maternity care practices in risk communication/informed consent are inadequate. Sixty-one per cent (11/18) of obstetricians specifically singled out informed consent practices regarding instrumental birth to be inadequate. Ninety-four per cent (17/18) of obstetricians believe that maternity care consent practices need to be improved. The results of this study indicate that material risks of vaginal birth, caesarean section and instrumental birth, are not routinely disclosed during antenatal courses. Urgent resources and structural change are required to uphold women's legal right to bodily autonomy.

Background

Delivery of safe maternity care requires not only individual competence but collective team work, influenced by knowledge, team culture and physical working spaces. The ideal layout for a birthing unit is not known, but deliberate changes to the built environment can influence patient care.

Aims

To explore the impact of creation of an open ‘hub’ on maternity team culture in a tertiary birthing unit and how physical changes to the environment shape values and practice.

Materials and Methods

Semi-structured interviews of members of the interprofessional team in a tertiary birth suite were performed and analysed using thematic analysis.

Results

Seventeen healthcare workers participated in interviews. Themes included: (i) enhanced psychological safety; (ii) impacts on teamwork; (iii) unintended consequences; and (iv) future directions for team cohesion and collaboration.

Conclusions

Changes to the built environment can impact team work. This qualitative study identified benefits and unintended consequences to removing a wall, creating a maternity hub. Individuals, departmental leadership, and hospital executives should consider how changes to the built environment can be an effective and efficient way to shape teamwork and organisational culture.