Breastfeeding Following Spinal Cord Injury: Consumer Guide for Mothers.

The World Health Organization (WHO) recommends that infants be breastfed exclusively for the first 6 months of age. However, there are few resources available on the effects a spinal cord injury (SCI) can have for breastfeeding mothers. It is difficult to find information to address the unique challenges women with SCI experience when planning or trying to breastfeed. Our international team, including women with SCI, health care providers, and SCI researchers, aims to address the information gap through the creation of this consumer guide. The purpose of this consumer guide is to share the most common issues women with SCI experience during breastfeeding and provide information, practical suggestions, recommendations, and key resources in lay language. General information about breastfeeding is available on the internet, in books, or from friends and health care providers. We do not intend to repeat nor replace general breastfeeding information or medical advice. Breastfeeding for mothers with SCI is complex and requires a team of health care providers with complementary expertise. Such a team may include family physician, obstetrician, physiatrist, neurologist, occupational and physical therapist, lactation consultant, midwife, and psychologist. We hope this consumer guide can serve as a quick reference guide for mothers with SCI planning of trying to breastfeed. This guide will also be helpful to health care providers as an educational tool.

Motherhood after Spinal Cord Injury: Breastfeeding, Autonomic Dysreflexia, and Psychosocial Health: Clinical Practice Guidelines.

The World Health Organization (WHO) recommends that children be breastfed exclusively for the first 6 months of age. This recommendation may prove challenging for women with spinal cord injury (SCI) who face unique challenges and barriers to breastfeeding due to the impact of SCI on mobility and physiology. Tailored provision of care from health care professionals (HCPs) is important in helping women navigate these potential barriers. Yet, HCPs often lack the confidence and SCI-specific knowledge to meet the needs of mothers with SCI. An international panel of clinicians, researchers, consultants, and women with lived experience was formed to create an accessible resource that can address this gap. A comprehensive survey on breastfeeding complications, challenges, resources, and quality of life of mothers with SCI was conducted, along with an environmental scan to evaluate existing postpartum guidelines and assess their relevance and usability as recommendations for breastfeeding after SCI. Building on this work, this article provides evidence-based recommendations for HCPs, including but not limited to general practitioners, obstetricians, pediatricians, physiatrists, lactation consultants, nurses, midwives, occupational therapists, and physiotherapists who work with prospective and current mothers with SCI.

Guideline No. 431: Postpartum Hemorrhage and Hemorrhagic Shock.

OBJECTIVE: This guideline aims to provide evidence for prevention, recognition, and treatment of postpartum hemorrhage including severe hemorrhage leading to hemorrhagic shock. TARGET POPULATION: All pregnant patients. BENEFITS, HARMS, AND COSTS: Appropriate recognition and treatment of postpartum hemorrhage can prevent serious morbidity while reducing costs to the health care system by minimizing more costly interventions and length of hospital stays. EVIDENCE: Medical literature, PubMed, ClinicalTrials.gov, the Cochrane Database, and grey literature were searched for articles, published between 2012 and 2021, on postpartum hemorrhage, uterotonics, obstetrical hemorrhage, and massive hemorrhage protocols. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: All members of the health care team who care for labouring or postpartum women, including, but not restricted to, nurses, midwives, family physicians, obstetricians, and anesthesiologists.

Guideline nº 431: postpartum hemorrhage and hemorrhagic shock

This guideline aims to provide evidence for prevention, recognition, and treatment of postpartum hemorrhage including severe hemorrhage leading to hemorrhagic shock. Benefits, harms, and costs Appropriate recognition and treatment of postpartum hemorrhage can prevent serious morbidity while reducing costs to the health care system by minimizing more costly interventions and length of hospital stays. Medical literature, PubMed, ClinicalTrials.gov, the Cochrane Database, and grey literature were searched for articles, published between 2012 and 2021, on postpartum hemorrhage, uterotonics, obstetrical hemorrhage, and massive hemorrhage protocols. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). All members of the health care team who care for labouring or postpartum women, including, but not restricted to, nurses, midwives, family physicians, obstetricians, and anesthesiologists.

Guideline No. 416: labour, delivery, and postpartum care for people with physical disabilities

To describe evidence-based practice for managing the labour, delivery, and postpartum care of people with physical disabilities in Canada. This guideline addresses the needs of people with physical disabilities, with a focus on conditions that affect strength and mobility, as well as those that affect neurological or musculoskeletal function or structure. Although aspects of this guideline may apply to people with solely intellectual, developmental, or sensory disabilities (e.g., hearing and vision loss), the needs of this population are beyond the scope of this guideline. Safe and compassionate care for people with physical disabilities who are giving birth. Implementation of this guideline will improve health care provider awareness of specific complications people with physical disabilities may experience during labour, delivery, and the postpartum period and therefore increase the likelihood of a safe birth. A literature review was conducted using MEDLINE (474), Embase (36), and the Cochrane Central Register of Controlled Trials (CENTRAL; 28) databases. The results have been filtered for English language, publication date of 2013 to present, observational studies, systematic reviews, meta-analyses, and guidelines and references in these publications were also reviewed. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Maternal-fetal medicine specialists, obstetricians, family physicians, nurses, midwives, neurologists, physiatrists, and those who care for people with physical disabilities.

Guideline No. 416: Labour, Delivery, and Postpartum Care for People with Physical Disabilities.

OBJECTIVE: To describe evidence-based practice for managing the labour, delivery, and postpartum care of people with physical disabilities in Canada. TARGET POPULATION: This guideline addresses the needs of people with physical disabilities, with a focus on conditions that affect strength and mobility, as well as those that affect neurological or musculoskeletal function or structure. Although aspects of this guideline may apply to people with solely intellectual, developmental, or sensory disabilities (e.g., hearing and vision loss), the needs of this population are beyond the scope of this guideline. OUTCOMES: Safe and compassionate care for people with physical disabilities who are giving birth. BENEFITS, HARMS, AND COSTS: Implementation of this guideline will improve health care provider awareness of specific complications people with physical disabilities may experience during labour, delivery, and the postpartum period and therefore increase the likelihood of a safe birth. EVIDENCE: A literature review was conducted using MEDLINE (474), Embase (36), and the Cochrane Central Register of Controlled Trials (CENTRAL; 28) databases. The results have been filtered for English language, publication date of 2013 to present, observational studies, systematic reviews, meta-analyses, and guidelines and references in these publications were also reviewed. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: Maternal-fetal medicine specialists, obstetricians, family physicians, nurses, midwives, neurologists, physiatrists, and those who care for people with physical disabilities.

Limitations and opportunities of whole blood bilirubin measurements by GEM premier 4000®.

BACKGROUND: Neonatal hyperbilirubinemia has traditionally been screened by either total serum bilirubin or transcutaneous bilirubin. Whole blood bilirubin (TwB) by the GEM Premier 4000® blood gas analyzer (GEM) is a relatively new technology and it provides fast bilirubin results with a small sample volume and can measure co-oximetry and other analytes. Our clinical study was to evaluate the reliability of TwB measured by the GEM and identify analytical and clinical factors that may contribute to possible bias. METHODS: 440 consecutive healthy newborn samples that had plasma bilirubin ordered for neonatal hyperbilirubinemia screening were included. TwB was first measured using the GEM, after which the remainder of the blood was spun and plasma neonatal bilirubin was measured using the VITROS 5600® (VITROS). RESULTS: 62 samples (14%) were excluded from analysis due to failure in obtaining GEM results. Passing-Bablok regression suggested that the GEM results were negatively biased at low concentrations of bilirubin and positively biased at higher concentrations relative to the VITROS results (y = 1.43x-61.13). Bland-Altman plots showed an overall negative bias of the GEM bilirubin with a wide range of differences compared to VITROS. Both hemoglobin concentration and hemolysis affected the accuracy of the GEM results. Clinically, male infants had higher mean bilirubin levels, and infants delivered by caesarean section had lower hemoglobin levels. When comparing the number of results below the 40th percentile and above the 95th percentile cut-offs in the Bhutani nomogram which would trigger discharge or treatment, GEM bilirubin exhibited poor sensitivity and poor specificity in contrast to VITROS bilirubin. CONCLUSIONS: An imperfect correlation was observed between whole blood bilirubin measured on the GEM4000® and plasma bilirubin on the VITROS 5600®. The contributors to the observed differences between the two instruments were specimen hemolysis and the accuracy of hemoglobin measurements, the latter of which affects the calculation of plasma-equivalent bilirubin. Additionally, the lack of standardization of total bilirubin calibration particularly in newborn specimens, may also account for some of the disagreement in results.

Perinatal Care for Women with Spinal Cord Injuries: A Collaborative Workshop for Consensus on Care in Canada.

Background: In North America, there are currently no clearly defined standards of care for women with spinal cord injury (SCI) during the perinatal periods of preconception, pregnancy, labour/delivery, and postpartum. Women with SCI and their partners say resources specific to their needs are hard to find. Little evidence-informed research exists to guide clinicians in the care of women with SCI during pregnancy. Objectives: To further explore these gaps in knowledge and practices for perinatal care for women with SCI, a 1-day workshop was held in Vancouver, British Columbia (BC), Canada in November 2013. Methods: Twenty-nine attendees included women with SCI, SCI-community service providers, researchers, and health care providers from maternal/fetal medicine, rehabilitation, anesthesiology, and psychiatry. A pre-meeting online survey of stakeholders elucidated 3 themes: lack of knowledge for both consumers and care providers, gaps in access to services and information, and a need for collaboration throughout the perinatal journey. The workshop addressed issues of care providers' lack of knowledge of nonmedical issues during the perinatal period, physical and attitudinal barriers to access to care for women with SCI, and the need for better collaboration and communication between care providers, the latter potentially initiated by providing information to care providers through the women with SCI themselves. Results: Content experts attending the workshop collectively made recommendations for knowledge generation and research priorities, clinical application priorities, and the need for policy and guideline development in this field. Conclusion: Two information sources for women have since been developed and are available online.

Diabetes in Pregnancy.

OBJECTIVE: This guideline reviews the evidence relating to the diagnosis and obstetrical management of diabetes in pregnancy. OUTCOMES: The outcomes evaluated were short- and long-term maternal outcomes, including preeclampsia, Caesarean section, future diabetes, and other cardiovascular complications, and fetal outcomes, including congenital anomalies, stillbirth, macrosomia, birth trauma, hypoglycemia, and long-term effects. EVIDENCE: Published literature was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary (MeSH terms "diabetes" and "pregnancy"). Where appropriate, results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. VALUES: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). SUMMARY STATEMENTS: Recommendations It is recognized that the use of different diagnostic thresholds for the "preferred" and "alternative" strategies could cause confusion in certain settings. Despite this, the committee has identified the importance of remaining aligned with the current Canadian Diabetes Association 2013 guidelines as being a priority. It is thus recommended that each care centre strategically align with 1 of the 2 strategies and implement protocols to ensure consistent and uniform reporting of test results.

Le diabète pendant la grossesse.

OBJECTIF: La présente Directive passe en revue les données probantes liées au diagnostic et à la prise en charge obstétricale du diabète durant la grossesse. ISSUES: Les issues évaluées étaient les issues maternelles à court et à long terme, dont la prééclampsie, la césarienne, le diabète éventuel et d'autres complications cardiovasculaires et les issues fœtales, dont les anomalies congénitales, la mortinaissance, la macrosomie, le traumatisme de la naissance, l'hypoglycémie et les effets à long terme. RéSULTATS: La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans PubMed et The Cochrane Library au moyen d'un vocabulaire contrôlé (termes MeSH « diabète ¼ et « grossesse ¼) appropriés. Le cas échéant, les résultats ont été restreints aux analyses systématiques, aux essais comparatifs randomisés / essais cliniques comparatifs et aux études observationnelles. Aucune limite n'a été imposée en matière de date, mais les résultats ont été limités aux articles publiés en anglais ou en français. VALEURS: La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau 1). DéCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Acuity Assessment in Obstetrical Triage.

OBJECTIVE: A five-category Obstetrical Triage Acuity Scale (OTAS) was developed with a comprehensive set of obstetrical determinants. The purposes of this study were: (1) to compare the inter-rater reliability (IRR) in tertiary and community hospital settings and measure the intra-rater reliability (ITR) of OTAS; (2) to establish the validity of OTAS; and (3) to present the first revision of OTAS from the National Obstetrical Triage Working Group. METHODS: To assess IRR, obstetrical triage nurses were randomly selected from London Health Sciences Centre (LHSC) (n = 8), Stratford General Hospital (n = 11), and Chatham General Hospital (n= 7) to assign acuity levels to clinical scenarios based on actual patient visits. At LHSC, a group of nurses were retested at nine months to measure ITR. To assess validity, OTAS acuity level was correlated with measures of resource utilization. RESULTS: OTAS has significant and comparable IRR in a tertiary care hospital and in two community hospitals. Repeat assessment in a cohort of nurses demonstrated significant ITR. Acuity level correlated significantly with performance of routine and second order laboratory investigations, point of care ultrasound, nursing work load, and health care provider attendance. A National Obstetrical Triage Working Group was formed and guided the first revision. Four acuity modifiers were added based on hemodynamics, respiratory distress, cervical dilatation, and fetal well-being. CONCLUSION: OTAS is the first obstetrical triage scale with established reliability and validity. OTAS enables standardized assessments of acuity within and across institutions. Further, it facilitates assessment of patient care and flow based on acuity.

Magnesium sulphate for fetal neuroprotection: benefits and challenges of a systematic knowledge translation project in Canada.

BACKGROUND: Administration of magnesium sulphate (MgSO4) to women with imminent preterm birth at <34 weeks is an evidence-based antenatal neuroprotective strategy to prevent cerebral palsy. Although a Society of Obstetricians and Gynaecologists of Canada (SOGC) national guideline with practice recommendations based on relevant clinical evidence exists, ongoing controversies about aspects of this treatment remain. Given this, we anticipated managed knowledge translation (KT) would be needed to facilitate uptake of the guidelines into practice. As part of the Canadian Institutes of Health Research (CIHR)-funded MAG-CP (MAGnesium sulphate to prevent Cerebral Palsy) project, we aimed to compare three KT methods designed to impact both individual health care providers and the organizational systems in which they work. METHODS: The KT methods undertaken were an interactive online e-learning module available to all SOGC members, and at MAG-CP participating sites, on-site educational rounds and focus group discussions, and circulation of an anonymous 'Barriers and Facilitators' survey for the systematic identification of facilitators and barriers for uptake of practice change. We compared these strategies according to: (i) breadth of respondents reached; (ii) rates and richness of identified barriers, facilitators, and knowledge needed; and (iii) cost. RESULTS: No individual KT method was superior to the others by all criteria, and in combination, they provided richer information than any individual method. The e-learning module reached the most diverse audience of health care providers, the site visits provided opportunity for iterative dialogue, and the survey was the least expensive. Although the site visits provided the most detailed information around individual and organizational barriers, the 'Barriers and Facilitators' survey provided more detail regarding social-level barriers. The facilitators identified varied by KT method. The type of knowledge needed was further defined by the e-learning module and surveys. CONCLUSIONS: Our findings suggest that a multifaceted approach to KT is optimal for translating national obstetric guidelines into clinical practice. As audit and feedback are essential parts of the process by which evidence to practice gaps are closed, MAG-CP is continuing the iterative KT process described in this paper concurrent with tracking of MgSO4 use for fetal neuroprotection and maternal and child outcomes until September 2015; results are anticipated in 2016.