Summertime Bacillus cereus colonization of hospital newborns traced to contaminated, laundered linen.

BACKGROUND: Routine screening of premature newborns for haemolytic streptococci, Staphylococcus aureus and enteric Gram-negative bacteria done at birth using umbilical swabs identified clustering of babies colonized with Bacillus cereus in summers of 2009 and 2010 at a 400-bedded UK general hospital. AIM: To determine the source of this organism by focusing on the clinical environment. METHODS: Umbilical swab screening was extended to all newborns and the labour ward environment, including construction-related dust, was sampled for B. cereus. FINDINGS: During the summer of 2009, 65% of newborns had umbilical swabs which were culture positive for B. cereus. Blood agar and B. cereus selective agar impression plates of unused labour ward linen, and freshly received linen from the hospital's external laundry, gave mainly confluent growth of B. cereus in >85% of items sampled. In-use and exposed healthcare products including liquid handwashing agents, paper hand-towels, vaginal lubricants, labour ward dust and air were culture negative. Linen contamination and umbilical swab culture positivity both approached zero in autumn. B. cereus colonization of newborn umbilici recurred in summer 2010 and unused laundered linen was again found to be as contaminated. Washing linen at the laundry in a washer-extractor, with higher dilution than the continuous tunnel washer normally used, coincided with lowering of detectable B. cereus numbers in unused washed linen and no clustering in newborns the following summer (2011). CONCLUSION: Freshly laundered linen can be contaminated with B. cereus with subsequent spread and colonization of newborns. This contamination appears to be associated with low-dilution washing and high ambient temperatures.

The unbooked mother: a cohort study of maternal and foetal outcomes in a North London Hospital.

OBJECTIVE: The aim of the study was to determine the pregnancy outcome of unbooked compared to booked women of similar parity and ethnic background over a period of 18 months at the North Middlesex University Hospital (NMUH), London. METHODS: A retrospective cohort study from September 2006 to March 2008 comparing the socio-demographics, foetal and maternal outcomes of pregnancies of unbooked versus booked women. Women who received no antenatal care or who delivered within 3 days of the initial booking visit were categorized as 'unbooked' while the next delivered women on the labour ward register (matched for ethnicity and parity) who booked prior to the second trimester served as comparison. Fischer's exact test (two-tailed), student's t test and Pearson's chi-square test, odds ratio and 95% confidence interval were used to compare the two groups statistically. RESULTS: There were 91 unbooked births in the 18 month study period. Unbooked mothers were younger (26.0 +/- 6.68 vs. 29.2 +/- 6.10 years, p < 0.0001), more likely to be unemployed, unmarried and non-English speaking compared to matched booked mothers (all p < 0.01). The rate of Caesarean sections ([OR] = 0.85, 95% [CI] = 0.39-1.88), p > 0.05), birth asphyxia, Apgar scores <7 at 1 min ([OR] = 1.10, 95% [CI] = 0.52-2.35, p = 0.80) and intrauterine foetal death (stillbirth) ([OR] = 2.03, 95% [CI] = 0.28-14.60, p = 0.60) were comparable between the two groups. However, unbooked mothers were five times more likely to have preterm delivery ([OR] = 6.44, 95% [CI] = 2.24-18.50, p < 0.0002); three times more likely to have low birth weight babies (<2,500 g) ([OR] = 2.87, 95% [CI] = 1.21-6.82, p < 0.02) and twice as likely to have postpartum haemorrhage ([OR] = 1.85, 95% [CI] = 0.69-4.98, p = 0.3). CONCLUSION: Unbooked women were more at risk of adverse foetal and maternal outcomes than booked women, even within a population of young, relatively healthy immigrant women.

Observer accuracy and reproducibility of visual estimation of blood loss in obstetrics: how accurate and consistent are health-care professionals?

OBJECTIVES: To evaluate the observer accuracy and intra-observer test-retest reliability of visual estimation of blood loss by midwives and obstetricians. METHODS: This was a prospective, single-blinded observational study conducted at a London teaching hospital. The accuracy of visually estimating five maternity pads that had been soaked with 25, 50, 100, 150 and 200 ml of blood was assessed. The reproducibility in estimating the same volume (two sets of pads soaked with 50, 100, 150 and 200 ml of blood randomly placed at separate stations) was evaluated by asking participants to visually estimate these volumes. RESULTS: Although there is a tendency to overestimate, the mean percentage difference (estimated-actual volumes) was not significantly different among consultants, trainees and midwives. Visual estimations were especially inaccurate with smaller volumes, which could be overestimated by up to 540%. Test-retest reliability was poor for the larger volumes but statistically acceptable for the smaller volumes, although the difference between the two estimates of the same volume could be as much as 300%. CONCLUSIONS: Visual estimations were inaccurate by health-care professionals who have a tendency to overestimate. Experience did not appear to have a confounding effect on accuracy. Further training in visual assessment skills is necessary in order to improve the clinicians' estimation.

Management of complicated second stage of labour in stillbirths: a review of the literature and lessons learnt from two cases in the UK.

The stillbirth rate for singletons in the UK is approximately 5.3/1,000 births/year. Macrosomic babies are associated with obstructed labour and shoulder dystocia. Some 3.3% of stillborns weigh over 4 kg, when such problems are likely to be encountered. In developed countries, caesarean section is regarded as being more civilised than destructive operations for obstructed labour prior to full cervical dilatation in an interuterine death. However, when the cervix is fully dilated or severe shoulder dystocia is encountered, fetal destructive operations have half the maternal mortality rate of that associated with caesarean section, with fewer long-term sequelae. A significant obstacle in performing destructive operations in developed countries is the lack of skilled practitioners. It is difficult to acquire these skills in the UK, however simulated training can be provided with manikins. We feel mothers should be informed of the alternative of a destructive operation, potentially avoiding unnecessary caesarean section.

Transcultural considerations in obstetrics and gynaecology: what the clinician needs to know.

Healthcare professionals working in the field of obstetrics and gynaecology may encounter patients from a variety of cultural backgrounds, particularly in our inner cities. These women may have similar cultural beliefs and values about aspects of care they experience compared with native women, but they may also have differing beliefs and may present with preconceptions about the care they expect to receive. In our experience, traditional medical training has limited core teaching on the existence of such cultural variations, and professionals often only experience them through working in the clinical setting. This review was, therefore, undertaken with the aim of increasing awareness of such variations, in order to promote more holistic management, and ultimately to enhance patient care.

Demographics and outcome of elective cerclage in a multi-ethnic London district general hospital.

Elective cerclage is a rare procedure, but is reported to be relatively more common in developing countries. This variation in rate may be reflected in a multi-ethnic population as seen in London. Our study analysed the epidemiology and rate of elective cerclage performed in a London district general hospital. Factors contributing to the outcome of the procedures were also reviewed. A total of 41 elective cerclages were performed in the hospital between 2000 and 2007. Data from these were collected retrospectively, including maternal history, operative details, and gestational age at delivery. Fisher's exact test was used for statistical analysis. Of the 41 cases, 19 pregnancies were carried to term (>or=37 weeks' gestation), nine were pre-term (24-36 weeks' gestation) and seven miscarried (<24 weeks' gestation); six cases had not yet delivered. All of the patients were immigrants from developing countries but ethnicity did not affect the operative outcome (p = 0.89, Fisher's exact). The other factors studied were also noted to have no significant impact on success. These included cervical length at insertion (p = 1.00, Fisher's exact), type of suture (p = 0.90, Fisher's exact) and average gestation at insertion (p = 0.20, Fisher's exact). In conclusion, all patients requiring intervention in this study originated from developing countries. This is a disproportionately high figure relative to the demographic breakdown of the study population. Such a finding may be due to geographical variation of risk factors for cervical incompetence but may also be influenced by observer bias. Additional studies are needed to further investigate the influence of ethnicity on the rate of elective cerclage. None of the variables analysed in this study significantly affected the outcome of the procedure.

Is there still a role for emergency cerclage in the developed world? An experience from a London district hospital.

INTRODUCTION: Cervical incompetence appears to have a greater prevalence in the developing world, which possibly extends to multi-ethnic communities in the UK. Emergency cerclage has been found to have a relative degree of success in patients detected on ultrasound or presenting clinically. Our study aimed to look at the emergency cerclage outcome in the multi-ethnic population of our district hospital. METHODS: Sixty-two cases of cervical cerclage were reviewed retrospectively from 2000 to 2006 with 16 cases being emergencies. Maternal history, presentation, operation details and outcome were recorded. RESULTS: Of the 16 emergency cases, 8 were successful (delivery over 24 weeks gestation), 7 failed and 1 had not yet delivered. The failure rate was found to be significantly higher in the black African women (P = 0.04). Diagnosis by ultrasound as opposed to clinical presentation was associated with a better outcome (P = 0.03). The most significant determinant of outcome was the presence of coliforms on presentation, all of which failed (P = 0.007). CONCLUSION: In this small sample of patients requiring emergency cerclage, findings are suggestive of a poor outcome in black African women, which may be related to previous obstetric history. Similarly the presence of infection especially coliforms is also associated with poor prognosis, while ultrasound diagnosis of dilating cervix rather than clinical diagnosis had a better outcome. Early screening for infection, use of prophylactic antibiotics and sonographic monitoring are likely to improve the success rate of emergency cervical cerclage.

The effects of nomegestrol acetate subdermal implant (Uniplant) on serum cholesterol, triglycerides, and lipoproteins in Nigerian users.

The study was conducted to assess the effects of a nomegestrol acetate subdermal contraceptive implant (Uniplant(R)) on the lipid profiles of indigenous Nigerian women. Cholesterol content of the major lipoproteins, along with total cholesterol and triglycerides, were measured in fasting blood samples collected before implant insertion and then at months 1, 3, 6, and 12 of use. All volunteers were of the reproductive age, healthy, and had no contraindications to hormonal contraception. The mean levels of cholesterol and low density lipoprotein-cholesterol (LDL-C) increased gradually, albeit insignificantly, from insertion to month 12 of implant use. An initial decline in the mean levels of high density lipoprotein-cholesterol (HDL-C), reaching a minimal level (37.31 +/- 4.95 mg/dl) at month 3 of implant use, was observed. This was followed by a gradual rise that peaked (39.73 +/- 5.53 mg/dL) at month 12. These values were, however, not significantly different from the preinsertion value. The only significant difference (p <0. 005 ) was in the mean level of triglycerides at month 12 (90.90 +/- 17.75 mg/dL) when compared with the preinsertion mean level of 81.77 +/- 24.14 mg/dL. Both values were, however, within normal limits. These results indicate that Uniplant does not have a deleterious effect on the lipid profiles of Nigerian acceptors and can be safely prescribed to women seeking contraception.