Anti-D in Rh(D)-negative pregnant women: are at-risk pregnancies and deliveries receiving appropriate prophylaxis?

OBJECTIVE: Although anti-D prophylaxis has greatly reduced the rate of Rh-immunization, there remain women who sensitize during or after pregnancy because of inadequate prophylaxis. The purpose of this study was to compare adherence to prophylaxis recommendations for antenatal and postnatal anti-D immunoglobulin administration. METHODS: We conducted a retrospective cohort study of all pregnancies recorded at the Royal Victoria Hospital between 2001 and 2006 to determine the rates of antenatal and postnatal prophylaxis in Rh(D)-negative women. We compared adherence to anti-D prophylaxis recommendations between our institution's physician-dependent antenatal approach and the protocol-based postpartum approach. Logistic regression analysis was used to estimate the odds ratio and 95% confidence intervals of determinants of non-adherence to current recommendations for anti-D prophylaxis. RESULTS: Antenatal administration was analyzed in 1868 pregnancies in eligible Rh-negative women. Among these women, 85.7% received appropriate antenatal prophylaxis and 98.5% of eligible women received appropriate postnatal prophylaxis. Factors independently associated with non-adherence to antepartum prophylaxis included first visit in the third trimester (P < 0.001), transfer from an outside hospital (P = 0.03), and physician licensing before 1980 (P = 0.04). CONCLUSION: Unlike hospital-based protocol-dependent systems, physician-dependent systems for antenatal anti-D prophylaxis remain subject to errors of omission. A more standardized system is needed to ensure effective antenatal prophylaxis.

Comparison of obstetric outcomes between on-call and patients' own obstetricians.

BACKGROUND: The question "will you be delivering my baby?" is one that pregnant women frequently ask their physicians. We sought to determine whether obstetric outcomes differed between women whose babies were delivered by their own obstetrician (regular-care obstetrician) and those attended by an on-call obstetrician who did not provide antenatal care. METHODS: We performed a cohort study of all live singleton term births between 1991 and 2001 at the Royal Victoria Hospital in Montréal. We excluded breech deliveries, elective cesarean sections and deliveries with placenta previa or prolapse of the umbilical cord. Logistic regression analysis was used to compare obstetric outcomes (e.g., cesarean delivery, instrumental vaginal delivery and episiotomy) between the regular-care and on-call obstetricians after adjustment for potential confounders. RESULTS: A total of 28,332 eligible deliveries were attended by 26 obstetricians: 21,779 (76.9%) by the patient's own obstetrician and 6553 (23.1%) by the on-call obstetrician. Compared with women attended by their regular-care obstetrician, those attended by an on-call obstetrician had higher rates of cesarean delivery (11.9% v. 11.4%, adjusted odds ratio [OR] 1.13, 95% confidence interval [CI] 1.03-1.24, p < 0.01) and of third-or fourth-degree tears (7.9% v. 6.4%, adjusted OR 1.21, 95% CI 1.07-1.36, p < 0.01) but lower rates of episiotomy (38.5% v. 42.9%, OR 0.77, 95% CI 0.72-0.82, p < 0.001). No differences were observed between the groups in the rate of instrumental vaginal delivery. The increase in the overall rate of cesarean delivery among women attended by an on-call obstetrician was due mainly to an increase in cesarean deliveries during the first stage of labour because of nonreassuring fetal heart tracing (2.9% v. 1.7%, adjusted OR 1.79, 95% CI 1.49-2.15, p < 0.001). The time of day of delivery did not modify the observed effects. INTERPRETATION: The type of attending obstetrician (regular care v. on call) had a minor effect on obstetric outcomes.