The effect of exercise and nutrition interventions on physical functioning in patients undergoing haematopoietic stem cell transplantation: a systematic review and meta-analysis.

PURPOSE: Haematopoietic stem cell transplantation (HSCT) is potentially lifesaving. However, it comes with negative consequences such as impaired physical functioning, fatigue and poor quality of life. The aim of this systematic review and meta-analysis is to determine the effect of exercise and nutrition interventions to counteract negative consequences of treatment and improve physical functioning in patients receiving HSCT. METHODS: This systematic review and meta-analysis included randomised controlled trials from three electronic databases between 2009 and 2020. The trials included adult patients receiving HSCT and an exercise or nutrition intervention. Study selection, bias assessment and data extraction were independently performed by two reviewers. Physical functioning outcomes were meta-analysed with a random-effects model. RESULTS: Thirteen studies were included using exercise interventions (n = 11) and nutrition interventions (n = 2); no study used a combined intervention. Meta-analysis of the trials using exercise intervention showed statistically significant effects on 6-min walking distance (standardised mean difference (SMD) 0.41, 95% CI: 0.14-0.68), lower extremity strength (SMD 0.37, 95% CI 0.12-0.62) and global quality of life (SMD 0.27, 95% CI: 0.08-0.46). CONCLUSION: Our physical functioning outcomes indicate positive effects of exercise interventions for patients receiving HSCT. Heterogeneity of the exercise interventions and absence of high-quality nutrition studies call for new studies comparing different types of exercise studies and high quality studies on nutrition in patients with HSCT.

Understanding the perspectives and values of midwives, obstetricians and obstetric registrars regarding episiotomy: qualitative interview study.

OBJECTIVES: Insight into perspectives and values of care providers on episiotomy can be a first step towards reducing variation in its use. We aimed to gain insight into these perspectives and values. SETTING: Maternity care in the Netherlands. PARTICIPANTS: Midwives, obstetricians and obstetric registrars working in primary, secondary or tertiary care, purposively sampled, based on their perceived episiotomy rate and/or region of work. PRIMARY AND SECONDARY OUTCOME MEASURES: Perspectives and values of care providers which were explored using semistructured in-depth interviews. RESULTS: The following four themes were identified, using the evidence-based practice-model of Satterfield et al as a framework: 'Care providers' vision on childbirth', 'Discrepancy between restrictive perspective and daily practice', 'Clinical expertise versus literature-based practice' and 'Involvement of women in the decision'. Perspectives, values and practices regarding episiotomy were strongly influenced by care providers' underlying visions on childbirth. Although care providers often emphasised the importance of restrictive episiotomy policy, a discrepancy was found between this vision and the large number of varying indications for episiotomy. Although on one hand care providers cited evidence to support their practice, on the other hand, many based their decision-making to a larger extent on clinical experience. Although most care providers considered women's autonomy to be important, at the moment of deciding on episiotomy, the involvement of women in the decision was perceived as minimal, and real informed consent generally did not take place, neither during labour, nor prenatally. Many care providers belittled episiotomy in their language. CONCLUSIONS: Care providers' underlying vision on episiotomy and childbirth was an important contributor to the large variations in episiotomy usage. Their clinical expertise was a more important component in decision-making on episiotomy than the literature. Women were minimally involved in the decision for performing episiotomy. More research is required to achieve consensus on indications for episiotomy.

Which level of risk justifies routine induction of labor for healthy women?

Although induction of labor can be crucial for preventing morbidity and mortality, more and more women (and their offspring) are being exposed to the disadvantages of this intervention while the benefit is at best small or even uncertain. Characteristics such as an advanced maternal age, a non-native ethnicity, a high Body Mass Index, an artificially assisted conception, and even nulliparity are increasingly considered an indication for induction of labor. Because induction of labor has many disadvantages, a debate is urgently needed on which level of risk justifies routine induction of labor for healthy women, only based on characteristics that are associated with statistically significant small absolute risk differences, compared to others without these characteristics. This commentary contributes to this debate by arguing why induction of labour should not routinely be offered to all women where there is a small increase in absolute risk, and no any other medical risks or complications during pregnancy. To underpin our statement, national data from the Netherlands were used reporting stillbirth rates in groups of women based on their characteristics, for each gestational week from 37 weeks of gestation onwards.

[Advantages of midwife-led continuity model of care]. / Voordelen van continue zorg door verloskundigen.

In the Dutch maternity care system women at low risk of complications in pregnancy and birth are distinguished from women at an increased risk. Primary care midwives are responsible for the care in the low-risk group, whereas obstetricians are responsible for care when the risk is increased. Most professionals and stakeholders agree that more continuity of care is warranted but there is no consensus on the ideal organization of care. A midwife-led continuity model of care has been shown to offer several health benefits compared with other models, such as 'shared care'. We argue that this model would be appropriate for the Netherlands. Midwives should provide care where possible and obstetricians where necessary in order to use the expertise of both professions most effectively. This requires an extension of the scope of practice for primary care midwives. This model requires good cooperation between midwives and obstetricians.

Perinatal factors related to negative or positive recall of birth experience in women 3 years postpartum in the Netherlands.

BACKGROUND: Little research has been conducted to date on women's postnatal emotional well-being and satisfaction with the care received in the Netherlands. The aim of this study was to investigate Dutch women's views of their birth experience 3 years after the event. METHODS: A questionnaire was mailed to all women who had given birth in 2001 and who had at least one prenatal, perinatal, or postnatal visit to the participating midwifery practice. Women who had a subsequent birth after the index birth in 2001 were not excluded. We specifically asked respondents to reflect on the birth that occurred in 2001. Women were asked to say how they felt now looking back on their labor and birth, with five response options from "very happy" to "very unhappy." RESULTS: We received 1,309 postnatal questionnaires (response rate 44%). The sample was fairly representative with respect to the mode of delivery, place of birth, and obstetric interventions compared with the total Dutch population of pregnant women; however, the sample was not representative for ethnicity and initial caregiver. Three years after delivery, most women looked back positively on their birth experience, but more than 16 percent looked back negatively. More than 1 in 5 primiparas looked back negatively compared with 1 in 9 multiparas. Adjusted odds ratios (OR) for looking back negatively 3 years later included having had an assisted vaginal delivery or unplanned cesarean delivery (OR 2.6, 95% CI 1.59-4.14), no home birth (OR 1.4, 95% CI 1.04-1.93), referral during labor (OR 2.4, 95% CI 1.48-3.77), not having had a choice in pain relief (OR 2.9, 95% CI 1.91-4.45), not being satisfied in coping with pain (OR 4.9, 95% CI 2.55-9.40), a negative description of the caregivers (OR 2.9, 95% CI 1.85-4.40), or having had fear for the baby's life or her own life (OR 2.3, 95% CI 1.47-3.48). CONCLUSIONS: A substantial proportion of Dutch women looked back negatively on their birth experience 3 years postpartum. Further research needs to be undertaken to understand women's expectations and experiences of birth within the Dutch maternity system and an examination of maternity care changes designed to reduce or modify controllable factors that are associated with negative recall.

A retrospective study of the success, safety and effectiveness of external cephalic version without tocolysis in a specialised midwifery centre in the Netherlands.

BACKGROUND: to evaluate the effectiveness of external cephalic version (ECV) without tocolysis or epidural analgesia, the complications associated with the procedure and the association between the number of ECV attempts and cephalic presentation at birth and caesarean section. METHODS: retrospective cohort study of all (n=924) ECVs carried out between 1996 and 2000 in a specialised midwifery centre in the Netherlands. After bivariate analysis, those variables with a p value under 0.05 were considered statistically significant and were tested in a logistic regression model using backward stepwise selection. Analyses were carried out separately for first ECV attempts and second ECV attempts. FINDINGS: in total, 958 ECVs were analysed, 889 first attempts and 69 repeat attempts. Seventy per cent of all first ECVs were carried out before 37 weeks, but half of those were carried out between 36 and 37 weeks. The success rate for first ECV was 41% and for the second ECV 29%. Bivariate analysis showed that the success of the first ECV was positively influenced by parity, non-Dutch origin, higher birth weight, higher age and longer duration of pregnancy. After logistic regression, parity (odds ratio [OR] 2.8, 95% CI 2.1 to 3.7), non-Dutch origin (OR 1.8, 95% CI 1.2 to 2.8) and birth weight (OR 1.7, 95% CI 1.4 to 2.0) remained factors that independently influenced the success of ECV. The odds ratio for duration of pregnancy at first ECV was borderline significant: OR 1.2 (1.0 to 1.4). After an unsuccessful first ECV, only 13% of the women received a second ECV. The prevalence of cephalic presentation at birth increased with 3% after a second ECV. Three cases of complications were reported during or very shortly after the first ECV, and these did not result in serious complications. No complications were reported after a second ECV. CONCLUSION: ECV without tocolysis is a safe procedure for pregnant women and their babies. Repeat ECV increases the number of cephalic presentations at birth and should be considered after an unsuccessful ECV.