The Management of Nausea and Vomiting of Pregnancy.

OBJECTIVES: To review the evidence-based management of nausea and vomiting of pregnancy and hyperemesis gravidarum. EVIDENCE: MEDLINE and Cochrane database searches were performed using the medical subject headings of treatment, nausea, vomiting, pregnancy, and hyperemesis gravidarum. The quality of evidence reported in these guidelines has been described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on Preventative Health Care. BENEFITS: Nausea and vomiting of pregnancy has a profound effect on women's health and quality of life during pregnancy as well as a financial impact on the health care system, and its early recognition and management is recommended. COST: Costs, including hospitalizations, additional office visits, and time lost from work, may be reduced if nausea and vomiting in pregnancy is treated early.

Relative urgency for referral from primary care to rheumatologists: the Priority Referral Score.

OBJECTIVE: Timely access to rheumatology consultation is fundamental to appropriate and effective management of patients with musculoskeletal and autoimmune diseases. Yet, for a variety of reasons, limited and delayed access is commonplace. Moreover, information exchange for referral is often inadequate or poorly communicated. The objective of this work was to improve referral from primary care to rheumatology by formulating and testing a clinically coherent, reliable, and non-diagnosis-dependent Priority Referral Score (PRS). METHODS: Using a deliberative process, a clinical panel of 10 primary care providers (PCPs) and rheumatology specialists reviewed clinical case scenarios and engaged in a highly iterative process to develop criteria, definitions, and weights for the PRS, a linear 100-point scale to rate the relative urgency of referral. Following tool formulation, clinicians uninvolved with the process tested the PRS against their clinical judgment. RESULTS: The PRS comprises 8 criteria, with 2-4 levels for each criterion, and each having a weight generated through conjoint analysis, which forced choices around the comparative urgency of all of the criteria and levels. The PRS showed a strong correlation between clinical rankings of rheumatologists and PCPs in both the deliberative panel, and the physicians subsequently involved in the testing of the PRS. CONCLUSION: No standardized priority-setting criteria are available for the full range of primary care referrals to rheumatologists. The PRS had face value with panelists and provided acceptable interrater and intrarater reliability when tested with other rheumatologists and PCPs. Pilot testing with other clinicians and in other settings is justified and prerequisite to use in clinical practice.

Guidelines for investigating stillbirths: an update of a systematic review.

OBJECTIVE: To identify formal, publicly available guidelines for stillbirth investigation and to identify the most appropriate clinical practice guideline (or component of a guideline) for use in Alberta. METHODS: A systematic literature search was conducted to identify primary and secondary research studies published between January 1985 and August 2006 and formal, publicly available guidelines on the subject of stillbirth investigation. The Cochrane Library, PubMed, EMBASE, CINAHL, HealthSTAR, Science Citation Index, BIOSIS, and the NHS and CRD databases were searched. The methodological quality of the selected primary research studies was assessed according to specific criteria. RESULTS: All six of the publicly available clinical practice guidelines selected for this review outlined similar steps in the stillbirth investigation but differed about which tests to include and which components should be core or additional investigations. They agreed on including several elements for routine investigation, such as complete autopsy and detailed examination of the cord and placenta. Of 61 retrieved primary research studies, only seven met the inclusion criteria. No studies compared the value of specific guidelines. Although reviewed evidence highlights the value of fetal autopsy and placental examinations as integral components of stillbirth investigation, the value of other components is still not clear. CONCLUSIONS: No firm scientific judgement could be made about which clinical practice guideline for stillbirth investigation is the most appropriate or which components are essential. Currently here is no generally accepted reference guideline for stillbirth investigation. Fetal autopsy and placental examination remain important components, assuming the postmortem examination is of high quality. These data may be helpful in counselling parents who are considering whether or not to consent to a postmortem examination.

Nausea and vomiting of pregnancy: a tailored approach to treatment.

Nausea and vomiting of pregnancy is a multifactorial condition with significant adverse effects on quality of life and health of mother and fetus that warrants recognition, investigation, and treatment. Safe therapies are available and should be offered readily to all women suffering from this condition.

Does supplementary prenatal nursing and home visitation support improve resource use in a universal health care system? A randomized controlled trial in Canada.

BACKGROUND: The addition of supplementary prenatal support may improve the health and well-being of high-risk women and families. The objective of this randomized controlled trial was to examine the impact of supplementary prenatal care on resource use among a community-based population of pregnant women. METHODS: Pregnant women from three urban maternity clinics were randomized (a) to current standard of physician care, (b) to current standard of care plus consultation with a nurse, or (c) to (b) plus consultation with a home visitor. Participants were 1,352 women who received 3 telephone interviews. The primary outcome was resource use (e.g., attended prenatal classes, used nutritional counseling). RESULTS: Overall, those in the nurse intervention group were more likely to attend an "Early Bird" prenatal class and parenting classes, and to use nutrition counseling and agencies that assist with child care. Women provided with extra nursing and home visitation supports were more likely to use a written resource guide, nutrition counseling, and agencies that assist with child care. Among women at higher risk (e.g., language barriers, young maternal age, low income), the nurse intervention significantly increased use of early prenatal classes, whereas the nurse and home visitor intervention significantly increased use of the written resource guide and nutrition counseling. The intervention substantially increased the amount of information received on numerous pregnancy-related topics but had little impact on resource use for mental health and poverty-related needs. Among those with added support, resource use among low-risk women was generally greater than among high-risk women. CONCLUSIONS: Additional support provided by nurses, or nurses and home visitors, can successfully address informational needs and increase the likelihood that women will use existing community-based resources. This finding was true even for high-risk women, although this intervention did not reduce the difference in resource use between high- and low-risk women.

Maternity care by family physicians: characteristics of successful and sustainable models.

OBJECTIVE: To provide examples of sustainable and rewarding models of maternity care that can help reduce the attrition of family practitioners from intrapartum maternity care practice. METHODS: We surveyed a cohort of family physicians providing maternity care in primary care settings, using various models, to determine how each model handled the challenges of this practice. RESULTS: Different models of care are effective; there is no single best model of family practice maternity care. Successful models provide care for a substantial volume of patients, have call schedules that are appropriate for the volume of patients and number of participating physicians, have protocols for patient management, and have flexible and compatible clinic members. CONCLUSION: Structured sign-out models of care that incorporate innovative models for funding assist many family physicians in Canada in continuing to provide maternity care. Family medicine residents must be encouraged to incorporate these models of maternity care into their future practices.

Guidelines for operative vaginal birth.

OBJECTIVE: To provide guidelines for operative vaginal birth in the management of the second stage of labour. OPTIONS: Non-operative techniques, episiotomy, and Caesarean section are compared to operative vaginal birth. outcome: Reduced fetal and maternal morbidity and mortality. EVIDENCE: MEDLINE and Cochrane databases were searched using the key words 'vacuum' and 'birth' as well as 'forceps' and 'birth' for literature published in English from January 1970 to June 2004. The level of evidence and quality of recommendations made are described using the Evaluation of Evidence from the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS: 1. Non-operative interventions such as one-to-one support, partogram use, oxytocin use, and delayed pushing in women using epidurals will decrease need for operative birth. (I-A) 2. Manual rotation may be used alone or in conjunction with instrumental birth with little or no increased risk to the pregnant woman or to the fetus. (III-B) 3. Routine episiotomy is not necessary for an assisted vaginal birth. (II-1E) 4. When operative intervention in the second stage of labour is required, the options, risks, and benefits of vacuum, forceps, and Caesarean section must be considered. The choice of intervention needs to be individualized, as one is not clearly safer or more effective than the other. (II-B) 5. Failure of the chosen method, vacuum and/or forceps, to achieve delivery of the fetus in a reasonable time should be considered an indication for abandonment of the method. (III-C) 6. Adequate clinical experience and appropriate training of the operator are essential to the safe performance of operative deliveries. Hospital credentialing boards should grant privileges for performing these techniques only to an appropriately trained individual who demonstrates adequate skills. (III-C). VALIDATION: The Clinical Practice Obstetrics Committee and Executive and Council of the Society of Obstetricians and Gynaecologists of Canada approved these guidelines.

The management of nausea and vomiting of pregnancy.

OBJECTIVES: To review the evidence-based management of nausea and vomiting of pregnancy (NVP) and hyperemesis gravidarum. EVIDENCE: MEDLINE and Cochrane database searches were performed using the medical subject headings (MeSH) of treatment, nausea, vomiting, pregnancy, and hyperemesis gravidarum. The quality of evidence reported in these guidelines has been described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam. BENEFITS: NVP has a profound effect on women's health and quality of life during pregnancy, as well as a financial impact on the health care system, and its early recognition and management are recommended. (III-B) COST: Costs, including hospitalizations, additional office visits, and time lost from work, may be reduced if NVP is treated early.

Hemorrhagic shock.

OBJECTIVE: To review the clinical aspects of hemorrhagic shock and provide recommendations for therapy. OPTIONS: Early recognition of hemorrhagic shock and prompt systematic intervention will help avoid poor outcomes. OUTCOMES: Establish guidelines to assist in early recognition of hemorrhagic shock and to conduct resuscitation in an organized and evidence-based manner. EVIDENCE: Medline references were sought using the MeSH term "hemorrhagic shock." All articles published in the disciplines of obstetrics and gynaecology, surgery, trauma, critical care, anesthesia, pharmacology, and hematology between 1 January 1990 and 31 August 2000 were reviewed, as well as core textbooks from these fields. Selected references from these articles and book chapters were also obtained and reviewed. The level of evidence has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS: 1. Clinicians should be familiar with the clinical signs of hemorrhagic shock. (III-B) 2. Clinicians should be familiar with the stages of hemorrhagic shock. (III-B) 3. Clinicians should assess each woman's risk for hemorrhagic shock and prepare for the procedure accordingly. (III-B) 4. Resuscitation from hemorrhagic shock should include adequate oxygenation. (II-3A) 5. Resuscitation from hemorrhagic shock should include restoration of circulating volume by placement of two large-bore IVs, and rapid infusion of a balanced crystalloid solution. (I-A) 6. Isotonic crystalloid or colloid solutions can be used for volume replacement in hemorrhagic shock (I-B). There is no place for hypotonic dextrose solutions in the management of hemorrhagic shock (I-E). 7. Blood component transfusion is indicated when deficiencies have been documented by clinical assessment or hematological investigations (II-2B). They should be warmed and infused through filtered lines with normal saline, free of additives and drugs (II-3B). 8. Vasoactive agents are rarely indicated in the management of hemorrhagic shock and should be considered only when volume replacement is complete, hemorrhage is arrested, and hypotension continues. They should be administered in a critical care setting with the assistance of a multidisciplinary team. (III-B) 9. Appropriate resuscitation requires ongoing evaluation of response to therapy, including clinical evaluation, and hematological, biochemical, and metabolic assessments. (III-B) 10. In hemorrhagic shock, prompt recognition and arrest of the source of hemorrhage, while implementing resuscitative measures, is recommended. (III-B)VALIDATION: These guidelines have been reviewed by the Clinical Practice Obstetrics Committee and approved by Executive and Council of the Society of Obstetricians and Gynaecologists of Canada. SPONSORS: The Society of Obstetricians and Gynaecologists of Canada.