Optimising recovery after perineal trauma: Implementation of an evidence-based patient-centred care and clinical practice guideline.

BACKGROUND: Perineal trauma and pain can affect the quality of life of women who experience vaginal birth. AIM: To investigate the effect of perineal care and pain management on women's postpartum recovery. METHODS: This was a Quasi-experimental study. In Phase 1 women were treated using our old postnatal perineal care management guideline. In Phase 2 an updated guideline was introduced (regular administration of icepacks and analgesia during the first 24-48 h postpartum). During Phase 1, pregnant women planning a vaginal birth completed a baseline questionnaire. Those who sustained perineal trauma completed a survey at 24-48 h, seven days and 12 weeks after birth. In Phase 2 we continued recruiting participants, using the same procedure, and investigated the efficacy of pain relief approaches using the new guideline. RESULTS: In Phase 1, 111 women (Group 1), and Phase 2, 146 women (Group 2) were recruited. No statistically significant differences were found between the two groups in terms of the women's pain catastrophising, their partner's responses to pain behaviours, or birth outcomes. At 24-48 h and seven days postpartum, women in Group 2 were less likely than women in Group 1 to be bothered by back or perineal pain, headache, sleeping difficulties and dizziness (p < 0.05). More women in Group 2 received regular paracetamol and perineal icepacks during their hospital stay, with less use of oxycodone in Group 2 than Group 1. CONCLUSION: The implementation of the guideline's recommendations was associated with decrease back and perineal pain, headache, sleeping difficulties and dizziness during the first seven days postpartum.

Women's experience of perinatal support in a high migrant Australian population during the COVID-19 pandemic: a mixed methods study.

BACKGROUND: As a COVID-19 risk mitigation measure, Australia closed its international borders for two years with significant socioeconomic disruption including impacting approximately 30% of the Australian population who are migrants. Migrant populations during the peripartum often rely on overseas relatives visiting for social support. High quality social support is known to lead to improved health outcomes with disruption to support a recognised health risk. AIM: To explore women's experience of peripartum social support during the COVID-19 pandemic in a high migrant population. To quantify type and frequency of support to identify characteristics of vulnerable perinatal populations for future pandemic preparedness. METHODS: A mixed methods study with semi-structured interviews and a quantitative survey was conducted from October 2020 to April 2021. A thematic approach was used for analysis. RESULTS: There were 24 participants interviewed both antenatally and postnatally (22 antenatal; 18 postnatal). Fourteen women were migrants and 10 Australian born. Main themes included; 'Significant disruption and loss of peripartum support during the COVID-19 pandemic and ongoing impact for migrant women'; 'Husbands/partners filling the support gap' and 'Holding on by a virtual thread'. Half of the participants felt unsupported antenatally. For Australian born women, this dissipated postnatally, but migrants continued to feel unsupported. Migrant women discussed partners stepped into traditional roles and duties of absent mothers and mothers-in-law who were only available virtually. CONCLUSION: This study identified disrupted social support for migrant women during the pandemic, providing further evidence that the pandemic has disproportionately impacted migrant populations. However, the benefits identified in this study included high use of virtual support, which could be leveraged for improving clinical care in the present and in future pandemics. The COVID-19 pandemic impacted most women's peripartum social support with migrant families having ongoing disruption. Gains in the pandemic included greater gender equity for domestic work as husbands/partners increased their contribution to domestic work and childcare.

Investigating service delivery and perinatal outcomes during the low prevalence first year of COVID-19 in a multiethnic Australian population: a cohort study.

OBJECTIVE: Investigate the impact of the COVID-19 pandemic on perinatal outcomes in an Australian high migrant and low COVID-19 prevalent population to identify if COVID-19 driven health service changes and societal influences impact obstetric and perinatal outcomes. DESIGN: Retrospective cohort study with pre COVID-19 period 1 January 2018-31 January 2020, and first year of global COVID-19 period 1 February 2020-31 January 2021. Multivariate logistic regression analysis was conducted adjusting for confounders including age, area-level socioeconomic status, gestation, parity, ethnicity and body mass index. SETTING: Obstetric population attending three public hospitals including a major tertiary referral centre in Western Sydney, Australia. PARTICIPANTS: Women who delivered with singleton pregnancies over 20 weeks gestation. Ethnically diverse women, 66% overseas born. There were 34 103 births in the district that met inclusion criteria: before COVID-19 n=23 722, during COVID-19 n=10 381. MAIN OUTCOME MEASURES: Induction of labour, caesarean section delivery, iatrogenic and spontaneous preterm birth, small for gestational age (SGA), composite neonatal adverse outcome and full breastfeeding at hospital discharge. RESULTS: During the first year of COVID-19, there was no change for induction of labour (adjusted OR, aOR 0.97; 95% CI 0.92 to 1.02, p=0.26) and a 25% increase in caesarean section births (aOR 1.25; 95% CI 1.19 to 1.32, p<0.001). During the COVID-19 period, we found no change in iatrogenic preterm births (aOR 0.94; 95% CI 0.80 to 1.09) but a 15% reduction in spontaneous preterm birth (aOR 0.85; 95% CI 0.75 to 0.97, p=0.02) and a 10% reduction in SGA infants at birth (aOR 0.90; 95% CI 0.82 to 0.99, p=0.02). Composite adverse neonatal outcomes were marginally higher (aOR 1.08; 95% CI 1.00 to 1.15, p=0.04) and full breastfeeding rates at hospital discharge reduced by 15% (aOR 0.85; 95% CI 0.80 to 0.90, p<0.001). CONCLUSION: Despite a low prevalence of COVID-19, both positive and adverse obstetric outcomes were observed that may be related to changes in service delivery and interaction with healthcare providers. Further research is suggested to understand the drivers for these changes.

Clinical outcomes and cost-effectiveness of large-scale midwifery-led, paediatrician-overseen home phototherapy and neonatal jaundice surveillance: A retrospective cohort study.

AIM: To evaluate a large midwifery-led, paediatrician-overseen home jaundice surveillance and home phototherapy (HPT) programme. METHODS: We conducted a retrospective cohort study over 2019. Included were all infants with birth gestation ≥35 weeks, discharged at 4-96 h and receiving care from midwifery-at-home (a 12-h daily, 365-days hospital-based outreach service, supported by hospital paediatricians). Phototherapy was delivered via BiliSoft blanket with treatment thresholds determined by standard nomograms. The main outcomes of interest were unplanned readmissions, and cost-effectiveness based on hospital finance department actual costs. Also examined were parental compliance, device issues and safety. RESULTS: During 2019, 4308 infants received home jaundice surveillance with 86% hospital-discharged before 72 h, 82% exclusively breastfed and 69% having overseas-born mothers. Four hundred infants received HPT, comprising 101 continuing from inpatient phototherapy (IPT), 56 rebounding after IPT, and 243 home-diagnosed as needing phototherapy and triaged to HPT. Only 1 of 400 (0.25%) HPT infants required readmission. Additionally, there were 80 home-diagnosed jaundiced infants triaged to immediate readmission for IPT. Maximal serum bilirubin was 454 µmol/L. No exchange transfusion, encephalopathy or HPT-device problems occurred. An early 2019 bilirubin analyser upgrade resulted in higher bilirubin readings and some unintended subthreshold phototherapy. Supported by midwives, most parents managed HPT with ease. HPT cost $640/day compared to $2100/day for infant IPT readmission and $1000/day for a longer birth-admission stay. Up to 2 weeks' midwifery-at-home care for the whole cohort cost $2 m less than a 2-day longer birth-admission stay. CONCLUSION: Large-scale, midwifery-led, paediatrician-overseen jaundice surveillance and HPT can achieve very low unplanned readmission rates and be cost-effective.

Reporting of gestational diabetes and other maternal medical conditions: validation of routinely collected hospital data from New South Wales, Australia.

INTRODUCTION: Hospital datasets are a valuable resource for examining prevalence and outcomes of medical conditions during pregnancy. To enable effective research and health planning, it is important to determine whether variables are reliably captured. OBJECTIVE: To examine the reliability of reporting of gestational and pre-existing diabetes, hypertension, thyroid conditions, and morbid obesity in coded hospital records that inform the population-level New South Wales Admitted Patient Data Collection. METHODS: Coded hospital admission data from two large tertiary hospitals in New South Wales, from 2011 to 2015, were compared with obstetric data, collected by midwives at outpatient pregnancy booking and in hospital after birth, as the reference standard. Records were deterministically linked and sensitivity, specificity, positive predictive values and negative predictive values for the conditions of interest were obtained. RESULTS: There were 36,051 births included in the analysis. Sensitivity was high for gestational diabetes (83.6%, 95% CI 82.4-84.7%), pre-existing diabetes (88.2%, 95% CI 84.1-91.6%), and gestational hypertension (80.1%, 95% CI 78.2-81.9%), moderate for chronic hypertension (53.5%, 95% CI 47.8-59.1%), and low for thyroid conditions (12.9%, 95% CI 11.7-14.2%) and morbid obesity (9.8%, 95% CI 7.6-12.4%). Specificity was high for all conditions (≥97.8%, 95% CI 97.7-98.0) and positive predictive value ranged from 53.2% for chronic hypertension (95% CI 47.5-58.8%) to 92.7% for gestational diabetes (95% CI 91.8-93.5%). CONCLUSION: Our findings suggest that coded hospital data are a reliable source of information for gestational and pre-existing diabetes and gestational hypertension. Chronic hypertension is less consistently reported, which may be remedied by grouping hypertension types. Data on thyroid conditions and morbid obesity should be used with caution, and if possible, other sources of data for those conditions should be sought.

Validation of anaemia, haemorrhage and blood disorder reporting in hospital data in New South Wales, Australia.

OBJECTIVE: Hospital data are a useful resource for studying pregnancy complications, including bleeding-related conditions, however, the reliability of these data is unclear. This study aims to examine reliability of reporting of bleeding-related conditions, including anaemia, obstetric haemorrhage and blood disorders, and procedures, such as blood transfusion and hysterectomy, in coded hospital records compared with obstetric data from two large tertiary hospitals in New South Wales. RESULTS: There were 36,051 births between 2011 and 2015 included in the analysis. Anaemia and blood disorders were poorly reported in the hospital data, with sensitivity ranging from 2.5% to 24.8% (positive predictive value (PPV) 12.0-82.6%). Reporting of postpartum haemorrhage, transfusion and hysterectomy showed high sensitivity (82.8-96.0%, PPV 78.0-89.6%) while moderate consistency with the obstetric data was observed for other types of obstetric haemorrhage (sensitivity: 41.9-65.1%, PPV: 50.0-56.8%) and placental complications (sensitivity: 68.2-81.3%, PPV: 20.3-72.3%). Our findings suggest that hospital data may be a reliable source of information on postpartum haemorrhage, transfusion and hysterectomy. However, they highlight the need for caution for studies of anaemia and blood disorders, given high rates of uncoded and 'false' cases, and suggest that other sources of data should be sought where possible.

Ten years of uterine rupture in an Australian tertiary hospital.

AIMS: Complete uterine rupture is a rare and serious complication of pregnancy. Although most commonly associated with attempted vaginal birth after caesarean (VBAC), rupture also occurs in atypical/non-VBAC cases. This retrospective, single-tertiary-institution observational study aimed to assess the prevalence and morbidity of complete uterine rupture during 2010-2020. METHODS: Hospital discharge codes and local maternity databases identified uterine rupture cases, with medical record reviews confirming the diagnosis, distinguishing complete rupture from dehiscence, and extracting additional data. VBAC attempt was defined as planned labour trial after one prior caesarean. RESULTS: Over the decade, 27 complete ruptures occurred among 58 614 women, a rate of 4.6 per 10 000 births. One woman with three successive fundal ruptures had only the first included in further analysis, leaving 25 discrete women; 19 ruptures occurred in term planned VBAC attempts and six in preterm atypical/non-VBAC cases (two nulliparas and four women with multiple prior caesareans). The VBAC-attempt rupture rate was 0.74%, similar to published reports. All five perinatal deaths occurred in preterm atypical/non-VBAC cases. In the term VBAC-attempt group, rupture-related perinatal morbidity included four cases (21%) of hypoxic-ischaemic encephalopathy, with two cases (11%) of cerebral palsy at follow-up. Overall, perinatal morbidity was highest with total fetal extrusion. Maternal blood loss ≥1500 mL or transfusion was almost threefold higher, and postnatal length-of-stay was three days longer, after vaginal than caesarean birth, with delay in rupture recognition being a factor. CONCLUSION: A high suspicion index for uterine rupture is imperative during any labour, particularly in the scarred uterus, with vigilance continuing after successful vaginal birth.

Preventing Early-Onset Group B Streptococcus neonatal infection and reducing antibiotic exposure using a rapid PCR test in term prelabour rupture of membranes.

BACKGROUND: How best to target intrapartum antibiotic prophylaxis (IAP) to minimise both Early-Onset Group B Streptococcus (EOGBS) neonatal infection and maternal/fetal antibiotic exposure is uncertain, with both routine-screening and risk-factor approaches available. AIMS: This retrospective cohort study was undertaken to examine the outcomes of a hybrid risk-and-screen approach to EOGBS prevention using GBS polymerase chain reaction (PCR). The target population was women with term prelabour rupture of membranes (TermPROM) having the risk factor of prolonged rupture of membranes (ROM) ≥18 h. MATERIALS AND METHODS: Non-labouring TermPROM women had rapid GBS PCR testing at presentation. GBS screen-positive women proceeded to induction of labour and received IAP. GBS screen-negative women were allowed home to await spontaneous labour and not given IAP regardless of duration of ROM, unless other risk factors developed. For all other women, the risk-factor approach was followed. RESULTS: From 2009 to 2018, there were 20 cases of culture-positive EOGBS, a rate of 0.36/1000 live births (95% CI 0.22-0.56/1000), comparable to other recent reports. Over 2010-2018 when laboratory data were available, 1120 TermPROM women with ROM ≥18 h avoided antibiotics because they were GBS PCR-negative (2.3% of all births, 3.6% of vaginal births) while 338 TermPROM women with ROM <18 h received targeted antibiotics for being GBS-positive. No cases of EOGBS occurred in TermPROM women, those with ROM ≥18 h, or due to protocol-compliance failure. CONCLUSIONS: A hybrid approach involving risk-factor-based IAP and intrapartum GBS PCR screening of non-labouring TermPROM women delivers acceptably low rates of EOGBS while minimising and better targeting antibiotic exposure.

A low intensity dietary intervention for reducing excessive gestational weight gain in an overweight and obese pregnant cohort.

PURPOSE: Excessive gestational weight gain is associated with detrimental outcomes to both the mother and baby. Currently, the best approach to prevent excessive gestational weight gain in overweight and obese women is undetermined. The present study aimed to evaluate the effectiveness of a group-based outpatient dietary intervention in pregnancy to reduce excessive gestational weight gain. METHODS: In this retrospective study, overweight and obese pregnant women who attended a single 90-min group education session were compared to women who received standard care alone. Total gestational weight gain, maternal and neonatal outcomes were compared between the intervention and control groups. Data were analysed using Student t, Mann-Whitney and Chi-squared tests as appropriate. A 24-h dietary recall was analysed and compared to the Australian National Nutrition Survey. RESULTS: A significant reduction in gestational weight gain was observed with this intervention (P = 0.010), as well as in the rate of small for gestational age births (P = 0.043). Those who attended the intervention had saturated fat and sodium intake levels that exceeded recommendations. Intake of pregnancy-specific micronutrients including folate, calcium and iron were poor from diet alone. CONCLUSIONS: A low-intensity antenatal dietary intervention may be effective in reducing excessive gestational weight gain, although multi-disciplinary interventions yield the best success. Further research is required to identify the optimal modality and frequency to limit excessive gestational weight gain. Dietary interventions tailored to ethnicity should also be explored. LEVEL OF EVIDENCE: Level II, controlled trial without randomization.

Confounding effect of ethnic diversity on booking-in body mass index and prevalence of gestational diabetes and hypertensive disorders in pregnant women in western Sydney 1997-2016.

BACKGROUND: Maternal obesity is a key risk factor for morbidity in pregnancy. Accurate data on trends in obesity are required in high-risk populations such as in western Sydney to implement effective policy. AIMS: This study examines multi-site public hospital data on maternal ethnicity, body mass index (BMI), gestational diabetes mellitus (GDM) and hypertension across 20 years in Western Sydney Local Health District (WSLHD). MATERIALS AND METHODS: This is a retrospective cohort study of all women who delivered a live birth beyond 20 weeks at Westmead, Blacktown and Auburn Hospitals (WSLHD) between 1 January 1997 and 31 December 2016. RESULTS: There were 112 308 pregnant women included. Between 1997 and 2006, mean booking-in BMI climbed from 24.9 (median 23.9) to peak at 26.2 (24.9). It then fell to 25.3 (24.1) in 2012 before rising to 25.6 (24.4) in 2016. Rates of hypertensive disorders changed little over the period, with a small fall in pre-eclampsia. In contrast, there was a progressive upward trend in the prevalence of GDM, accelerating considerably after 2010. These trends were associated with a shifting ethnic profile with proportions of Australia/New Zealand-born women falling from 56.9% to 36.8%, while those from South Asia increased from 4.5% to 26.3%. CONCLUSIONS: Western Sydney booking-in BMI fluctuated between 1997 and 2016, reaching its peak in 2006. Despite this, rates of GDM progressively rose, with one in six mothers in western Sydney now diagnosed with some form of the condition. Both patterns are associated with a notable shift in the ethnic profile of patients booking-in to antenatal care in the region.

The association between haemoglobin levels in the first 20 weeks of pregnancy and pregnancy outcomes.

BACKGROUND: Low haemoglobin has been linked to adverse pregnancy outcomes. Our study aimed to assess the association of haemoglobin (Hb) in the first 20 weeks of pregnancy, and restoration of low Hb levels, with pregnancy outcomes in Australia. METHODS: Clinical data for singleton pregnancies from two tertiary public hospitals in New South Wales were extracted for 2011-2015. The relationship between the lowest Hb result in the first 20 weeks of pregnancy and adverse outcomes was determined using adjusted Poisson regression. Those with Hb <110 g/L were classified into 'restored' and 'not restored' based on Hb results from 21 weeks onwards, and risk of adverse outcomes explored with adjusted Poisson regression. RESULTS: Of 31,906 singleton pregnancies, 4.0% had Hb <110 and 10.2% had ≥140 g/L at ≤20 weeks. Women with low Hb had significantly higher risks of postpartum haemorrhage, transfusion, preterm birth, very low birthweight, and having a baby transferred to higher care or stillbirth. High Hb was also associated with higher risks of preterm, very low birthweight, and transfer to higher care/stillbirth. Transfusion was the only outcome where risk decreased with increasing Hb. Risk of transfusion was significantly lower in the 'restored' group compared with the 'not restored' group (OR 0.39, 95% CI 0.22-0.70), but restoration of Hb did not significantly affect the other outcomes measured. CONCLUSIONS: Women with both low and high Hb in the first 20 weeks of pregnancy had higher risks of adverse outcomes than those with normal Hb. Restoring Hb after 20 weeks did not improve most adverse outcome rates but did reduce risk of transfusion.

Haemoglobin trajectories during pregnancy and associated outcomes using pooled maternity and hospitalization data from two tertiary hospitals.

BACKGROUND AND OBJECTIVES: This study aimed to describe how haemoglobin trajectories in pregnant Australian women were associated with subsequent postpartum haemorrhage, blood transfusion and other outcomes. MATERIALS AND METHODS: The study was conducted in two tertiary public hospitals in Australia, using routinely collected maternity and hospital data on singleton pregnancies (2011-2015). Latent class growth modelling defined trajectories among those with at least one haemoglobin in each of three antenatal time periods (0-15, 16-30 and 31+ weeks; n = 7104). Observed over expected ratios were calculated after predicting expected outcomes with adjusted logistic regression. RESULTS: The mean minimum haemoglobin levels across the three periods were 127·9, 116·5 and 119·3 g/l. We identified seven groups of women with similar haemoglobin trajectories: five with parallel U-shaped trajectories, one with increasing and one with decreasing trajectory. Thirty-eight women (0.5%) had very low haemoglobin across the pregnancy and the highest adverse outcomes, including higher than expected blood transfusion risk. One hundred thirteen women (1.6%) with a progressively decreasing trajectory also had higher risk of transfusion. Women with high haemoglobin across the antenatal period had higher than expected risk of preterm birth, small for gestational age and infants transferred to higher care. CONCLUSIONS: Haemoglobin trajectories across pregnancy can predict women at higher risk of requiring transfusion around birth. Women who maintain high haemoglobins across the pregnancy are worthy of increased surveillance as they carry increased risks of newborn morbidity.

Foley catheter silicone versus latex for term outpatient induction of labour: A randomised trial.

BACKGROUND: Both silicone and latex single-balloon Foley catheters are available for cervical ripening but no literature exists to compare them. Local experience suggested more frequent insertion-related accidental rupture of the membranes (acROM) with silicone. AIMS: To compare the performance of silicone versus latex catheters with respect to acROM and other outcomes. MATERIALS AND METHODS: Women undergoing outpatient Foley catheter cervical ripening were randomised to a silicone or latex catheter. Data were collected on the primary outcome, acROM, and secondary outcomes including catheter insertion failure, unplanned hospital admission and patient-reported discomfort, together with intrapartum fever and antibiotics for suspected chorioamnionitis along with general obstetric and neonatal outcomes. RESULTS: Among 534 recruited women, acROM was significantly more common with a silicone compared to a latex catheter at 7.2% (19/265) versus 1.5% (4/269) (relative risk (RR) 4.8; 95% CI 1.7-14.0). Insertion failure was significantly less common with silicone than latex at 2.6% (7/265) versus 9.3% (25/269) (RR 0.3; 95% CI 0.1-0.6). However, when the alternative catheter was subsequently tried, the final failure rates were 1.9% silicone (5/265) versus 2.6% latex (7/269). Insertion-related hospital admission was higher with silicone at 9.4% (25/265) than latex at 4.8% (13/269) (RR 2.1; 95% CI 1.1-4.1). All other obstetric outcomes were similar between the groups. CONCLUSION: When used for cervical ripening, a silicone Foley catheter is associated with a higher rate of acROM than a latex catheter but a lower rate of insertion failure. It may, therefore, be reasonable to attempt insertion with a latex catheter initially and manage insertion failures with a silicone catheter.

Outpatient cervical ripening: discomfort/pain during speculum and Foley catheter insertion.

OBJECTIVE: To examine discomfort/pain associated with the Foley catheter insertion process and explore factors affecting discomfort/pain. DESIGN: This cohort study conducted in the context of larger randomised clinical trial comparing silicone and latex Foley catheters. SETTING: A tertiary hospital in Western Sydney. PARTICIPANTS: Outpatient pregnant women (eligible participants in the main study). INTERVENTIONS: We asked about the discomfort/pain expectations and experience during the digital vaginal examination and insertion of the speculum, insertion of the Foley catheter and while the catheter was in situ. MEASUREMENTS: We used visual analog scale and a purposefully designed questionnaire to measure outcomes. FINDINGS: We found digital vaginal examination and speculum insertion (mean pain score = 4.6-4.7/10) to be significantly more uncomfortable than Foley catheter insertion (mean pain score = 3/10), while having the catheter in situ for a median of 14 h was mid-way in discomfort (mean pain score = 3.7/10). Only 12-13% of women experienced no discomfort during digital vaginal examination and speculum insertion, while about 40% experienced no discomfort during Foley catheter insertion. We identified no factors that influenced the experience of discomfort during speculum insertion. However, being overseas-born (odds ratio = 1.91, 95% = 1.10, 3.33) and experiencing discomfort during the speculum insertion (odds ratio = 8.15, 95% = 3.19, 20.79) increased the chance of discomfort on catheter insertion. Women's discomfort was not influenced by inserter designation or experience. KEY CONCLUSIONS: Digital vaginal examination and speculum insertion were moderately uncomfortable while insertion of a Foley catheter and having the catheter in situ for several hours were less uncomfortable procedures. IMPLICATIONS FOR PRACTICE: Only 8% of insertions were rated as difficult by staff while 70% were rated easy. This, together with the fact that the inserter's level of experience had no influence on women's discomfort, are reassuring for midwives who wish to teach and learn this common procedure.

Readmissions for surgical site infections following caesarean section.

This retrospective study was conducted to identify the incidence and characteristics associated with readmissions for surgical site infections following caesarean section in a tertiary hospital from 2012 to 2015. Of 6334 patients who underwent caesarean section, 165 (2.6%) were readmitted, most commonly for surgical site infection (25.5%, n = 42). Thirty-seven of these patients (88%) had an emergency caesarean compared to five (12%) following an elective caesarean section. Of the women with surgical site infections, 69% were overweight and 14% had diabetes. Emergency caesarean sections were responsible for the majority of readmissions, particularly in women with co-morbidities that predisposed them to infection.

Point-of-care measurement of fetal blood lactate - Time to trust a new device.

BACKGROUND: Point-of-care lactate devices are used worldwide for intrapartum decision making. Current practice is often based on Lactate Pro (Arkray) but its imminent product discontinuation necessitates determination of an optimal replacement device. AIMS: To evaluate the performance of Lactate Pro and two other point-of-care devices, Lactate Pro 2 (Arkray) and StatStrip (Nova Biomedical), and to derive scalp lactate cut-offs equivalent to the current intervention trigger of >4.8 mmol/L. MATERIALS AND METHODS: Paired umbilical cord arterial and venous blood samples from 109 births were tested on the three point-of-care products (two devices each), cross-compared with the reference method blood gas analyser. RESULTS: All brands deviate from the blood gas analyser, with Lactate Pro and StatStrip results consistently lower and Lactate Pro 2 consistently higher. Standard deviation from the blood gas analyser was smallest for StatStrip (0.78 mmol/L, cord artery), and largest for Lactate Pro 2 (1.03 mmol/L, cord artery). Within-brand variation exists and is similar for all brands (mean absolute difference on cord artery 0.23-0.30 mmol/L). Equivalent values to the 4.8 mmol/L intervention threshold based on Lactate Pro are 4.9-5.0 mmol/L for StatStrip and 5.3-5.9 mmol/L for Lactate Pro 2, calculated by receiver-operating characteristic analysis. CONCLUSIONS: StatStrip appears superior to Lactate Pro 2 to replace the original Lactate Pro. Using StatStrip, the 4.8 mmol/L intervention threshold equivalent was 4.9-5.0 mmol/L. The variation in accuracy of point-of-care lactate devices may exceed the small increments (eg <4.2 mmol/L vs >4.8 mmol/L) that guide obstetric decisions.

Who is and isn't having babies with Down syndrome in western Sydney: a ten year hospital cohort study.

BACKGROUND: Screening for Down syndrome (DS) is a key component of antenatal care, recommended to be universally offered to women irrespective of age or background. Despite this, the diagnosis of DS is often not made until the neonatal period. AIMS: To retrospectively describe and compare the differences in populations with an antenatal diagnosis (AD) and neonatal diagnosis (ND) of DS and to explore why an antenatal diagnosis was not made. MATERIALS AND METHODS: The cohorts were women cared for at Westmead Hospital whose pregnancy received a diagnosis of DS between 2006 and 2015. The demographic variables of the AD and ND cohorts were examined and reasons why an antenatal diagnosis was not made in the ND cohort were analysed. RESULTS: There were 127 diagnoses of DS in the 10-year period, of which 41% were in the ND cohort (n = 52) and 59% in the AD (n = 75). Declaring a religious affiliation rather than Nil Religion was significantly more common in the ND cohort (88.5%) and especially the ND sub-cohort who declined DS screening/testing (95.8%) than the AD cohort (72%, P < 0.05). Women who were not offered screening were significantly younger (P < 0.001) than those who were, with 69% and 20% being ≤30 years, respectively. CONCLUSIONS: The proportion of DS pregnancies diagnosed in the antenatal period in western Sydney could be increased by ensuring younger women are not falsely reassured that DS screening is unnecessary for them. While religious affiliation may be a factor when women decline screening, ensuring appropriate counselling remains important.

Sublingual misoprostol for management of empty sac or missed miscarriage: The first two years' experience at a metropolitan Australian hospital.

BACKGROUND: Misoprostol management of miscarriage is only now becoming widely used in Australia. AIMS: To review the efficacy, safety and the popularity of outpatient sublingual misoprostol in empty sac/missed miscarriage management over its first two years of availability in a metropolitan Australian hospital. MATERIALS AND METHODS: A retrospective cohort review was undertaken of women choosing sublingual misoprostol 600 µg (three tablets) × three doses for miscarriage management. Principal outcomes assessed were miscarriage resolution without the need for curettage and complications. Additionally, the relative popularity of misoprostol versus surgery by place of birth and over time, and the return of pregnancy tissue for histology were analysed. RESULTS: Between 1 December 2012 and 30 November 2014, 279 women chose sublingual misoprostol for nonurgent miscarriage management, while 420 chose surgery (40 and 60%, respectively). Of the misoprostol cohort, 269 had complete data; 239 of 269 (88.8%) had resolution without curettage, nine (3.3%) had acute curettage, 21 (7.8%) had nonacute curettage, 30 (11.15%) had unplanned emergency department presentation, 11 (4.1%) had unplanned admission, three (1.1%) had blood transfusion and one (0.4%) had an infection requiring admission. Misoprostol was as popular with Australian-born as overseas-born women; 53.5% of patients returned histopathology specimens; one (0.7%) demonstrated partial hydatidiform mole. CONCLUSIONS: Outpatient management of missed/empty gestational sac miscarriage using sublingual misoprostol is associated with a high rate of avoiding curettage and the low rate of complication. It is equally popular with Australian-born and overseas-born women. Just over 50% returned pregnancy tissue for analysis.

Documentation of instrumental vaginal deliveries: The benefits of a pro forma.

BACKGROUND: Instrumental vaginal deliveries (IVDs) account for approximately 11% of births in Australia. Complications resulting from IVD can occasionally be the subject of litigation. The Royal College of Obstetricians and Gynaecologists suggests a standardised pro forma in their guidelines as an aid to accurate and complete IVD documentation. Many units, including ours, use less structured reporting, which is probably also less adequate. AIM: To assess whether the introduction of a dedicated IVD form improves the quality of IVD documentation. METHOD: Analysis of the quality of IVD documentation before and after the implementation of a new dedicated IVD form. A survey to evaluate clinicians' opinion on the new standardised form. RESULTS: Significant improvement was found in documentation of key information including the documentation of caput (p < 0.05), type of instrument, number of ventouse cup detachments, moulding of specific sutures, abdominal palpation (number of fifths of foetal head palpable), liquor colour and total time of instrument application (p < 0.001). A majority of clinicians believed the form to be beneficial in terms of completeness and that it reduced the amount of time required for documentation. CONCLUSIONS: IVD documentation is enhanced by the use of a dedicated form. Clinical judgement may also be enhanced by the discipline involved in the formal assessment required by the form.