Demographic, institutional and obstetrical risk factors for postpartum haemorrhage mortality.

This study, initially presented at the SMFM Annual Conference in San Diego on 29 January 2009, sought to explore the risk factors for mortality from postpartum haemorrhage (PPH). A total of 138,316 cases of PPH from 1991 to 2000 were identified using the California Health Discharge Database. Data analysed included demographic information and clinical risk factors. PPH increased from 1.9% to 2.8%, while mortality rate decreased during the study period (1991-2000). Logistic regression showed that hysterectomy, hypertensive disorders, abruption, transverse caesarean delivery, and classical caesarean delivery, increased risk for PPH mortality, while manual placental extraction, episiotomy, and laceration repairs decreased risk. Two geographical regions, Inland Empire and Orange County, were associated with increased PPH mortality, despite having lower incidence of PPH. Teaching status and investor ownership of hospitals increased the risk of PPH mortality. There was no associated change in mortality based on hospital quality rating.

Episiotomia: revendo conceitos / Episiotomy: concepts review

A episiotomia ainda é o procedimento cirúrgico mais utilizado em obstetrícia. Seu uso rotineiro pode levar a uma série de complicações, dentre as quais se destacam: infecção, hematoma, rotura de períneo de terceiro e quarto graus, dispareunia e lesão do nervo pudendo. Este artigo é uma revisão de literatura que aborda o histórico, as indicações, as complicações, os motivos que ainda incentivam sua prática rotineira e os custos envolvidos na episiotomia. Foram utilizadas as bases de dados da Medline, Lilacs, Pubmed e Biblioteca Cochrane. Embora as evidências científicas indiquem que o uso restrito da episiotomia deva ser incorporado em todos os serviços, na América Latina verificamos que sua utilização é muito elevada, podendo atingir taxas de até 90 porcento. Sugerimos que as instituições hospitalares realizam treinamentos e atualizações acerca das diretrizes baseadas em evidências na obstetrícia.

Episiotomy is still the most widely used surgical procedure in obstetrician. Its frequent use may cause complications such as infection, 3rd and 4th grades of perineal lacerations, dyspaurenia and pudendal nerve injury. This paper is a literature review that comprises history, indications, complications, reasons that encourage the routine practice and costs implicated in episiotomy. Medline, Lilacs, Pubmed and Cochrane Library were used as databases. Although evidences suggest that restrictive use of episiotomy may be part of obstetrical care, in the Latin America its use is very common and may reach rates of up to 90 percent. It is suggested that hospital institutions should provide updating about obstetrics evidence based guidelines.

Revisión sistemática de la episiotomía / Systematic review of episiotomy

Situación: La episiotomía es la cirugía más frecuente en todo el mundo. Tradicionalmente se le han atribuido numerosas ventajas que han sido ampliamente discutidas desde los años setenta. Aun así, los profesionales de la obstetricia siguen aplicándola de manera sistemática.En un esfuerzo más por reducir el daño perineal durante el nacimiento, que puede ser causa de morbilidad del suelo pélvico a corto y largo plazo, se analizan punto por punto las consecuencias de la realización de dicha técnica.Metodología: Se realizó una búsqueda sistemática de la bibliografía en lengua inglesa. Los estudios aleatorizados se identificaron de las distintas bases de datos y fuentes primarias.Se consultaron las siguientes bases de datos: Medline, CINHAL y Cochrane.Objetivos: Analizar las ventajas, desventajas y consecuencias de la episiotomía; aumentar el conocimiento actual con relación a una técnica tan extendida en obstetricia, y disminuir el daño perineal durante el nacimiento, así como sus consecuencias a largo y corto plazo.Conclusión: La conclusión fue determinante. Toda la bibliografía recomienda un uso restrictivo de la episiotomía. Hay situaciones muy concretas, como el sufrimiento fetal agudo o la sospecha de distocia de hombros, en las que su uso es recomendado.Deberíamos abogar por un uso más moderado de una técnica, que no parece presentar ninguna de las ventajas por las que se extendió su uso (AU)

Costing the cascade: estimating the cost of increased obstetric intervention in childbirth using population data.

OBJECTIVE: To estimate the cost of "the cascade" of obstetric interventions introduced during labour for low risk women. DESIGN: A cost formula derived from population data. SETTING: New South Wales, Australia. POPULATION: All 171,157 women having a live baby during 1996 and 1997. METHODS: Four groups of interventions that occur during labour were identified. A cost model was constructed using the known age-adjusted rates for low risk women having one of three birth outcomes following these pre-specified interventions. Costs were based on statewide averages for the cost of labour and birth in hospital. MAIN OUTCOME MEASURES: The outcome measure is an "average cost unit per woman" for low risk women, predicted by the level of intervention during labour. Obstetric care is classified as either private obstetric care in a private or public hospital, or routine public hospital care. RESULTS: The relative cost of birth increased by up to 50% for low risk primiparous women and up to 36% for low risk multiparous women as labour interventions accumulated. An epidural was associated with a sharp increase in cost of up to 32% for some primiparous low risk women, and up to 36% for some multiparous low risk women. Private obstetric care increased the overall relative cost by 9% for primiparous low risk women and 4% for multiparous low risk women. CONCLUSIONS: The initiation of a cascade of obstetric interventions during labour for low risk women is costly to the health system. Private obstetric care adds further to the cost of care for low risk women.

The cost-effectiveness of routine versus restrictive episiotomy in Argentina.

OBJECTIVE: This article provides the estimates of the cost implications of switching from routine to restrictive episiotomy in 2 provinces in Argentina (Santa Fe and Salta) from the viewpoint of the health provider. STUDY DESIGN: A decision-tree model was constructed that used the probabilities and patient outcomes (the results of a trial in Argentina), resource use, cost, and local epidemiologic data from interviews with obstetricians in the selected provinces and from literature reviews. Probabilistic sensitivity analysis was conducted, which provided 90% confidence ranges for the cost data. RESULTS: For each low-risk vaginal delivery, there is a potential reduction in provider cost of $20.21 (range, $19.36-$21.09) with a restrictive policy of episiotomy in Santa Fe province and a reduction of $11.63 (range, $10.89-$12.42) in Salta province. CONCLUSION: The more effective policy of restrictive episiotomy is also less costly than that of routine episiotomy. The results are robust and consistent in both provinces. Further research is required to confirm the appropriate indications for episiotomy and the impact on outcomes of variations in episiotomy cost rates.

Women's choice? The impact of private health insurance on episiotomy rates in Australian hospitals.

OBJECTIVE: To assess the extent to which variations in episiotomy rates in Australian hospitals are justified by clinical variables and to further explore the relationships between episiotomy, insurance status, perineal trauma and outcomes for babies. DESIGN: A retrospective analysis of anonymous medical record data using logistic regression models, aimed at identifying factors influencing both episiotomy rates and outcomes for babies. SETTING: A large regional public hospital, New South Wales, Australia. PARTICIPANTS: The study sample consisted of 2028 women who delivered vaginally during a 12 month period during 1996-1997. RESULTS: After controlling for clinical and other factors privately insured women were estimated to be up to twice as likely to experience episiotomy as publicly insured women. This difference most plausibly reflects differences in labour management styles between obstetricians and midwives. Other significant contributors to episiotomy were instrumental delivery, indications of possible fetal distress and lower parity. Severe perineal trauma (third degree tear) was found to be positively associated with episiotomy. Furthermore, the incidence of additional tears requiring suture was also substantially higher among privately insured women, the net effect being that these women had a substantially lower chance of achieving an intact perineum. Neither episiotomy nor insurance status had any significant effect on the well-being of babies. IMPLICATIONS FOR PRACTICE: Private health insurance appears to deny many women the opportunity of achieving normal vaginal delivery with intact perineum. Episiotomy rates amongst privately insured women in Australia may be higher than is clinically appropriate, and severe perineal trauma within this study was associated with this practice.

Episiotomy in NSW hospitals 1993-1996: towards understanding variations between public and private hospitals.

Episiotomy rates for women experiencing childbirth in New South Wales (NSW) hospitals are another indicator that private insurance may be a risk factor for obstetric intervention. A recent comparison of episiotomy rates in NSW public and private hospitals between 1993 and 1996 revealed that episiotomy rates were 12 to 15 percentage points higher in NSW private hospitals than in public hospitals studied. Rates also appear to be declining in NSW public hospitals, yet this trend is not evident in the NSW private hospitals studied. Although private hospital patients were almost twice as likely to experience forceps or vacuum delivery (often associated with episiotomy), this leaves a 6 to 8 percentage point difference unexplained. Given the potential health-related quality of life issues associated with perineal trauma during childbirth, further analysis of the clinical make-up of privately insured women may help determine the extent to which clinical explanations exist to support the differences in this childbirth intervention.

Cost analysis of a mucoadhesive foam versus conventional treatment for postepisiotomy patients.

The cost of treating postepisiotomy pain and edema with foam containing 1% hydrocortisone acetate and 1% pramoxine hydrochloride and a spray with 20% benzocaine was compared in 200 postpartum patients. Treatment with foam was demonstrated to be more effective than benzocaine spray with greater pain relief and reduction of edema as shown by lower patient need of supplemental pain-relief measures. Treatment with foam was also determined to be less expensive than benzocaine spray when the cost of the supplemental pain-relief measures for benzocaine-treated patients were assessed. Methods used to determine actual hospital costs are presented, and supplemental pain relief treatments are discussed. Use of this type of cost analysis may be useful to the P & T Committee when determining actual cost-effectiveness of different treatment modalities.