Maternal Asian ethnicity and obstetric intrapartum intervention: a retrospective cohort study.

BACKGROUND: Maternal ethnicity is a recognized risk factor for stillbirth, such that South Asian women have higher rates than their Caucasian counterparts. However, whether maternal ethnicity is a risk factor for intrapartum outcomes is less clear. The aim of this study is to explore associations between maternal country of birth, operative vaginal delivery and emergency cesarean section, and to identify possible mechanisms underlying any such associations. METHODS: We performed a retrospective cohort study of singleton term births among South Asian, South East/East Asian and Australian/New Zealand born women at an Australian tertiary hospital in 2009-2013. The association between maternal country of birth, operative vaginal birth and emergency cesarean was assessed using multivariate logistic regression. RESULTS: Of the 31,932 births, 54% (17,149) were to Australian/New Zealand-born women, 25% (7874) to South Asian, and 22% (6879) to South East/East Asian born women. Compared to Australian/New Zealand women, South Asian and South East/East Asian women had an increased rate of both operative vaginal birth (OR 1.43 [1.30-1.57] and 1.22 [1.11-1.35] respectively, p < 0.001 for both) and emergency cesarean section (OR 1.67 [1.53-1.82] and 1.16 [1.04-1.26] respectively, p < 0.001 and p = 0.007 respectively). While prolonged labor was the predominant reason for cesarean section among Australian/New Zealand and South East/East Asian women, fetal compromise accounted for the majority of operative births in South Asian women. CONCLUSION: South Asian and South East/East Asian women experience higher rates of both operative vaginal birth and cesarean section in comparison to Australian/New Zealand women, independent of other risk factors for intrapartum interventions.

Customised management of the third stage of labour.

BACKGROUND: Postpartum haemorrhage (PPH) rates are increasing worldwide. The rate is particularly high in women undergoing an induced or augmented labour. In response to this, we altered our hospital's protocol for the management of the third stage of labour to recommend Syntometrine, in preference to oxytocin alone, for women being induced or augmented. We set out to assess the impact of the protocol change on the PPH rate. MATERIALS AND METHODS: A random sample of 1200 women who had a singleton, term vaginal birth before and after the protocol change was taken. Exclusion criteria were then applied to match PPH risk status. Using a quasi-experimental study design, PPH rates were compared between women who had received oxytocin or Syntometrine for third stage management. RESULTS: Five hundred and forty-nine women received oxytocin prior to the protocol change and were compared with 333 women who received Syntometrine after protocol change. There was no difference in the PPH rate with respect to uterotonic used (P = 0.9). There was no evidence of an interaction between labour type, third stage uterotonic and PPH (P = 0.4). PPH rates were lowest for women who laboured spontaneously and received Syntometrine (19% oxytocin, 14% Syntometrine). The PPH rate was unchanged by uterotonic in women whose labour was augmented (34% for both). PPH was more common in women being induced who received Syntometrine (22% oxytocin, 27% Syntometrine). None of these differences were statistically significant. CONCLUSION: Compared to oxytocin, Syntometrine did not reduce the rate of PPH in women with augmented or induced labour. Other approaches to reducing PPH rates are required.

Obesity and pregnancy outcomes: Do the relationships differ by maternal region of birth? A retrospective cohort study.

BACKGROUND: We aimed to determine whether the association between obesity and a range of adverse maternal and perinatal outcomes differed in South Asian and Australian and New Zealand born women. METHODS: A retrospective cohort study of singleton births in South Asian (SA) and Australian/New Zealand (AUS/NZ) born women at an Australian hospital between 2009 and 2013. The interaction between maternal region of birth and obesity on a range of maternal and perinatal outcomes was assessed using multivariate logistic regression. RESULTS: Obesity was more strongly associated with gestational hypertension/Preeclampsia/HELLP and Gestational Diabetes Mellitus in AUS/NZ born women (p = 0.001 and p < 0.001, respectively for interaction) and was only associated with shoulder dystocia in SA born women (p = 0.006 for interaction). There was some evidence that obesity was more strongly related with admission to NICU/Special care nursery (SCN) (p = 0.06 for interaction) and any perinatal morbidity (p = 0.05 for interaction) in SA born women. CONCLUSIONS: Interventions targeted at reducing maternal obesity will have different impacts in SA compared to AUS/NZ born women.

Maternal Asian ethnicity and the risk of anal sphincter injury.

OBJECTIVE: To examine associations between maternal Asian ethnicity (South Asian and South East/East Asian) and anal sphincter injury. DESIGN: Retrospective cross-sectional study, comparing outcomes for Asian women with those of Australian and New Zealand women. SETTING: A large metropolitan maternity service in Victoria, Australia. POPULATION: Australian/New Zealand, South Asian and South East/East Asian women who had a singleton vaginal birth from 2006 to 2012. METHODS: The relation between maternal ethnicity and anal sphincter injury was assessed by logistic regression, adjusting for potential confounders. MAIN OUTCOME MEASURES: Anal sphincter injury was defined as a third or fourth degree tear (with or without episiotomy). RESULTS: Among 32,653 vaginal births there was a significant difference in the rate of anal sphincter injury by maternal region of birth (p < 0.001). After adjustment for confounders, nulliparous women born in South Asian and South East/East Asia were 2.6 (95% confidence interval 2.2-3.3; p < 0.001) and 2.1 (95% confidence interval 1.7-2.5; p < 0.001) times more likely to sustain an anal sphincter injury than Australian/New Zealand women, respectively. Parous women born in South Asian and South East/East Asia were 2.4 (95% confidence interval 1.8-3.2; p < 0.001) and 2.0 (95% confidence interval 1.5-2.7; p < 0.001) times more likely to sustain an anal sphincter injury than Australian/New Zealand women, respectively. CONCLUSION: There are ethnic differences in the rates of anal sphincter injury not fully explained by known risk factors for such trauma. This may have implications for care provision.

Comparison of Web-based and face-to-face training concerning patient education within a hospital system.

The authors examined education records of 1,661 registered nurses from four affiliated hospitals who attended either a 1-hr face-to-face instructor-led training program, an instructor-facilitated Web-based training program, or an independent Web-based training program to fulfill a training requirement concerning patient education. The authors compared post-test results, course evaluation results, and costs and also developed a demographic profile of nurses' preferences for Web-based and face-to-face learning options. There was no significant difference in course effectiveness or satisfaction between the training methods studied; however, because of the large number of nurses who selected Web-based training, it was the most cost-effective alternative.

Identifying missed opportunities to curtail antimicrobial therapy for presumed ventilator-associated pneumonia using the clinical pulmonary infection score.

BACKGROUND: Early discontinuation of antimicrobial therapy for ventilator-associated pneumonia can reduce the emergence of antimicrobial resistance, the occurrence of adverse drug events, and the cost of therapy. Evidence suggests that discontinuation of therapy by day 3 may be appropriate for patients with a clinical pulmonary infection score of 6 or less at baseline and on day 3. OBJECTIVES: To determine the proportion of patients eligible for antimicrobial discontinuation on day 3 and day 7 of therapy and to determine the proportion of eligible patients for whom antimicrobials were discontinued within these timeframes. METHODS: A 6-month observational study was conducted from October 3, 2005, to March 31, 2006, in a 27-bed medical-surgical tertiary care intensive care unit. Clinical pharmacists attended daily rounds and prospectively identified patients for inclusion in the study. A study pharmacist retrospectively calculated clinical pulmonary infection scores. Other data were obtained from the quality-improvement database and patient health records for the intensive care unit. RESULTS: Ninety-two patients were treated for ventilator-associated pneumonia during the study period, of whom 49 were included in the analysis. At day 3, 17 (35%) of the 49 patients were eligible for early discontinuation of antimicrobial therapy, but therapy was discontinued for only 2 (12%) of these 17 patients. At day 7, 10 (32%) of 31 patients were eligible for antimicrobial discontinuation, but therapy was discontinued for only 1 (10%) of these 10 patients. CONCLUSIONS: A significant opportunity exists at the authors' institution to develop and implement an antimicrobial discontinuation policy that uses the clinical pulmonary infection score to guide antimicrobial use for patients with ventilator-associated pneumonia.