The effect of gestational weight gain on likelihood of referral to obstetric care for women eligible for primary, midwife-led care after antenatal booking.

OBJECTIVE: to examine the effect of gestational weight gain (GWG) on likelihood of referral from midwife-led to obstetrician-led care during pregnancy and childbirth for women in primary care at the outset of their pregnancy. DESIGN: secondary analysis of data from a prospective cohort study. SETTING: Dutch midwife-led practices. PARTICIPANTS: a cohort of 1288 women of Northern European descent, with uncomplicated, singleton pregnancy at antenatal booking who consequently were eligible for primary, midwife-led care. MEASUREMENTS: because of the absence of an established GWG guideline in the Netherlands, we compared the effect of inadequate and excessive GWG according to two GWG guidelines: the criterion traditionally used, which is based on knowledge of the physiological components of GWG, advising 10-15kg as a normal GWG irrespective of a woman׳s BMI category, and the 2009 Institute of Medicine recommendations (IOMr) on GWG, which provide BMI related advice. Outcome measures were: number of women referred from midwife-led to obstetrician-led care during pregnancy and during childbirth; indications of referral and birth outcomes. FINDINGS: GWG above traditional criteria (Tc; >15kg between 12 and 36 weeks) was associated with increased odds for referral during childbirth (adjusted odds ratio (aOR) 1.88; 95% confidence interval (CI) 1.22-2.90), but had no effect on referral during pregnancy (aOR .86; 95% CI .57-1.30). No associations were established between GWG below Tc (<10kg) and referral during pregnancy (aOR 1.08; 95% CI .78-1.50) or childbirth (aOR 1.08; 95% CI .74-1.56). No associations were found between GWG below and above the IOMr and referral during pregnancy (below IOMr: aOR 1.01; 95% CI .71-1.45; above IOMr: aOR .89; 95% CI .61-1.28) or childbirth (below IOMr: aOR .85; 95% CI .57-1.25; above IOMr: aOR 1.09; 95% CI .73-1.63). With regard to the effect of GWG according to both recommendations on indications for referral and birth outcomes, GWG above Tc was associated with higher rates of referral for hypertensive disorders (aOR 1.91; 95% CI 1.04-3.50) and for meconium stained liquor (aOR 2.22; CI 1.33-3.71) after adjusting for BMI and parity. CONCLUSIONS: GWG above Tc - irrespective of BMI category - was associated with doubled odds of referral to specialist care during childbirth. GWG below or above IOMR and GWG below TC were not associated with adverse obstetric outcomes in women who were eligible for primary care at the outset of their pregnancy. IMPLICATIONS FOR PRACTICE: weight gain <15kg between 12 and 36 weeks is advised for women in all BMI categories in this population. It is important to validate GWG guidelines in a target population before implementing them.

The impact of obesity on outcomes of midwife-led pregnancy and childbirth in a primary care population: a prospective cohort study.

OBJECTIVE: To assess the impact of obesity on the likelihood of remaining in midwife-led care throughout pregnancy and childbirth. DESIGN: Secondary analysis of data from a prospective cohort study. SETTING: Dutch midwife-led practices. POPULATION: A cohort of 1369 women eligible for midwife-led care after their first antenatal visit. METHODS: First-trimester body mass index (BMI) was calculated as weight measured at booking divided by height squared. Obstetric data were retrieved from medical records. Multiple logistic regressions were performed to examine the effects of BMI classification on midwife-led pregnancies and childbirths. MAIN OUTCOME MEASURES: Percentages of women remaining in midwife-led care throughout pregnancy and throughout childbirth. RESULTS: Of women in obesity classes II and III, 55% remained in midwife-led care throughout pregnancy and 30% remained in midwife-led care throughout birth. Compared with women of normal weight, women in obesity classes II and III had fewer midwife-led pregnancies (OR 0.38, 95% CI 0.21-0.69), and women who were overweight or in obesity class I had fewer midwife-led childbirths (OR 0.63, 95% CI 0.44-0.90; OR 0.49, 95% CI 0.29-0.84, respectively). Compared with women of normal weight, women who were obese had higher referral rates for hypertensive disorders (4 versus 14%), prolonged labour (4.6 versus 10.4%), and intrapartum pain relief (4 versus 10.4%). The women who were eligible for midwife-led birth and who were overweight or obese, had no more urgent referrals than women of normal weight. Women who were obese and who completed a midwife-led birth had no more adverse outcomes than women of normal weight, with the exception of higher rates of large for gestational age (LGA) babies (>97.7 centile; 12.1%, versus 1.9% in normal weight and versus 3.3% in overweight women). CONCLUSIONS: Although fewer women who were obese remain in midwife-led care during pregnancy and childbirth, there was no increased risk of unfavourable birth outcomes for women who were obese and eligible for a midwife-led birth when compared with women of normal weight. This indicates that when primary care midwives use a risk assessment tool throughout pregnancy and childbirth they are able to safely assign women who are obese to either midwife-led or obstetrician-led care.

Women's perceptions and experiences of fetal macrosomia.

OBJECTIVE: to explore women's perceptions and experiences of pregnancy and childbirth following birth of a macrosomic infant (birth weight ≥4000g). METHODS: a qualitative design utilising interviews conducted 13-19 weeks post partum in women's homes. The study was conducted in one Health and Social Care Trust in Northern Ireland between January and September 2010. Participants were identified from a larger cohort of women recruited to a prospective study exploring the impact of physical activity and nutrition on macrosomia. Eleven women who delivered macrosomic infants participated in this phase of the study. FINDINGS: four overarching themes emerged: preparation for delivery; physical and emotional impact of macrosomia; professional relations and perceptions of macrosomia. Findings highlighted the importance of communication with health professionals in relation to both prediction of macrosomia and decision making about childbirth, and offers further understanding into the physical and emotional impact of having a macrosomic infant on women. Furthermore, there was evidence that beliefs and perceptions relating to macrosomia may influence birth experiences and uptake of health promotion messages. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: this study provides important insight into women's experiences of macrosomia throughout the perinatal period and how they were influenced by previous birth experiences, professional relations and personal perceptions and beliefs about macrosomia. Pregnant women at risk of having a macrosomic infant may require extra support throughout the antenatal period continuing into the postnatal period. Support needs to be tailored to the woman's information needs, with time allocated to explore previous birth experiences, beliefs about macrosomia and options for childbirth.

Control prenatal vs resultado obstétrico perinatal / Prenatal care vs obstetric outcome perinatal

La cobertura del control prenatal, calidad, y atención del parto se refleja en la resolución obstétrica como en la morbi-mortalidad del binomio madre-hijo. Esta investigación aborda el problema del impacto de los controles prenatales sobre el resultado obstétrico y perinatal. Objetivo: conocer el impacto del control prenatal sobre los resultados obstétricos obtenidos. Material y método: mediante un estudio de cohortes reconstruidas en una población obtenida azarosamente por conglomerados diarios en el transcurso del mes de junio (2010), se obtuvieron 419 puérperas. El material de investigación fue el binomio madre - hijo. Algunas variables estudiadas fueron: edad, control prenatal, número de consultas, peso, talla, tensión arterial, medición fondo uterino, forma de término del embarazo, peso del producto, sexo, apgar, destino del producto, complicaciones maternas, etc. Se utilizo en el programa estadístico Riesgo® y Primer® obteniéndose el RR, RR con intervalo de confianza al 95%. Resultados. Se analizaron 395 productos mayores de 20 semanas y 35 menores, de los productos mayores de 20 semanas (f=355) tuvieron sus madres control prenatal (89.87%) y 40 no lo tuvieron (10.13%), las distocias fueron más frecuentes en las madres con control prenatal, X2=7.73 RR=1.45 IC95% 1.11-1.90, las complicaciones maternas tuvieron proporciones similares en madres con y sin control prenatal X2 = 0.0091 RR=0.96, diferencia de proporciones p=0.899, la enfermedad hipertensiva del embarazo fue la complicación mas frecuente (74.6% de ellas) sin haber diferencia entre las madres que tuvieron o no control prenatal X2 = 0.0010. Conclusión: Los resultados obtenidos señalan que en este grupo estudiado, en particular, la presencia del control prenatal no representó un factor que ayude a una resolución obstétrica y perinatal favorable, excepto en la prevención de la macrosomía (AU)

The coverage of prenatal care, quality and delivery care is reflected in the resolution as obstetric morbidity and mortality of mother and child. This research addresses the issue of the impact of prenatal care on the obstetric and perinatal outcome. Objective: To determine the impact of prenatal care on obstetric outcomes achieved. Material and method: using a reconstructed cohort study in a population cluster randomly obtained daily during the month of June (2010), 419 were women in labour. The research material was the mother - child. Some of the studied variables were age, prenatal care, number of visits, weight, height, blood pressure, fundal measurement, method of pregnancy termination, product weight, sex, apgar, destination of the product, maternal complications, etc. It was used in the statistical program Primer ® Risk ® obtaining the RR, RR with a confidence interval of 95%. Results: 395 products were analysed over 20 weeks and 35 children, of the goods over 20 weeks (f = 355) mothers had prenatal care (89.87%) and 40 did not have it (10.13%), dystocia were more common in mothers with prenatal care, X2 = 7.73 RR = 1.45 95% CI 1.11-1.90, maternal complications were similar proportions in mothers with and without prenatal X2 = 0.0091 RR = 0.96, difference in proportions p = 0.899, hypertensive disease of pregnancy was the most frequent complication (74.6% of them) without difference between the mothers had no prenatal care or X2 = 0.0010. Conclusion: Our results indicate that in this particular group studied, the presence of prenatal care is not a factor that helps an obstetric resolution and favourable perinatal, except for the macrosomia prevention (AU)

Recognition and management of the infant with Beckwith-Wiedemann Syndrome.

Beckwith-Wiedemann Syndrome (BWS) is the most common overgrowth syndrome in infancy. The characteristic findings are macroglossia, abdominal wall defects, and macrosomia. Genetic studies in infants with BWS demonstrate 3 major subgroups of patients: familial, sporadic, or chromosomally abnormal. Recognition in the neonatal period is important because of the high incidence of childhood malignant tumors associated with BWS. This article provides an overview of the syndrome and discusses its etiology, physical findings, and diagnostic evaluation. Management and clinical implications including family support will also be discussed.

Shoulder dystocia. Nursing interventions and risk-management strategies.

Shoulder dystocia is unpredictable; however, once identified there are reasonable steps that perinatal providers will be expected to take to attempt to dislodge the impacted shoulder. Be aware of these interventions and have a plan for what to do should dystocia occur. Stay calm and help the woman and physician or CNM through the crisis. Call for additional help as appropriate. Provide emotional support to the woman and her family. Ensure that the medical record reflects the events as accurately as possible. If an injury results, the nurse can then be sure that the team did the best they could to intervene during the emergency.

Outcomes of macrosomic infants in a nurse-midwifery service.

The purpose of this study was to compare outcomes of term infants of average birth weight with outcomes of large infants in a nurse-midwifery service. A retrospective study design was used. Data were retrieved from a computer data base that contained information from a data form routinely completed for all births. Subjects were women cared for by the nurse-midwives including those for whom the birth was conducted by a physician. The final n study population was 2,228; 322 (14.5%) of the infants weighed 4,000 g or more. Women who delivered large infants had a significantly higher prepregnant body mass index and pregnancy weight gain. Shoulder dystocia occurred more often in large infants; however, newborn intensive care unit admission rates did not differ between the average birth weight and the large infants. Apgar scores at 1 and 5 minutes were significantly lower for infants weighing > or = 4,500 g compared to those with birth weights of 2,500-3,999 g and those 4,000-4,449 g; however, these differences were not clinically significant. A trend for fewer occurrences of shoulder dystocia in the side-lying birth position was observed. Logistic regression predicting poor Apgar scores (< 7) showed parity as a protective factor and increased gestational age and higher maternal body mass index as predictive of low Apgar scores. Large infants had birth outcomes comparable to those reported by others in the medical literature, suggesting that nurse-midwifery management, including consultation with physician colleagues, can be appropriate and safe.

Behavior of macrosomic and appropriate-for-gestational-age newborns.

OBJECTIVE: To compare the behavior of macrosomic newborns who were vaginally delivered of healthy mothers without diabetes with that of non-macrosomic, appropriate-for-gestational-age (AGA) newborns. DESIGN/SETTING: Newborns were recruited conveniently from a tertiary hospital. Newborns were examined at 12-24 and 36-48 hours of age, using the Brazelton Neonatal Behavioral Assessment Scale (NBAS). PARTICIPANTS: Thirty macrosomic newborns who were delivered vaginally were matched with AGA newborns for ethnicity, maternal education, parity, and obstetric medications. MAIN OUTCOME MEASURES: Dimensions scores derived from the individual NBAS items measured reflex functioning, response decrement, orientation, motor processes, range of state, autonomic stability, and regulation of state. RESULTS: Macrosomic newborns performed weaker than AGA newborns on the reflex and motor dimensions. Both groups displayed improved motor scores on Day 2, but regulation of state scores were weaker. For orientation, AGA newborns scored higher on Day 1, and macrosomic newborns scored higher on Day 2. CONCLUSIONS: Increased head, limb, and body mass of macrosomic newborns, compared with adjacent and overall muscle strength, might have interfered with the execution of coordinated movements. Nurses can inform mothers of changes they can expect in their newborns' behavior.

Strategies useful in caring for macrosomic newborns.

Newborn macrosomia has been shown to be significantly related to weaker reflex functioning, poorer motor behavior, and decreased state regulation during the first 2 days of life. Macrosomic newborns' behavior patterns suggest that special strategies are indicated in order to decrease the effects that limb and body mass have on the execution of coordinated movements and spontaneous motor patterns. This article highlights techniques that have been found to be effective in handling, arousing, and quieting macrosomic newborns during interactions involving the Brazelton Neonatal Assessment Scale.