Influence of organizational factors on the offer and success rate of a trial of labor after cesarean section in Belgium: an ecological study.

BACKGROUND: Trial of Labor After Cesarean is an important strategy for reducing the overall rate of cesarean delivery. Offering the option of vaginal delivery to a woman with a history of cesarean section requires the ability to manage a potential uterine rupture quickly and effectively. This requires infrastructure and organization of the maternity unit so that the decision-to-delivery interval is as short as possible when uterine rupture is suspected. We hypothesize that the organizational characteristics of maternity units in Belgium have an impact on their proposal and success rates of trial of labour after cesarean section. METHODS: We collected data on the organizational characteristics of Belgian maternity units using an online questionnaire. Data on the frequency of cesarean section, trial of labor and vaginal birth after cesarean section were obtained from regional perinatal registries. We analyzed the determinants of the proposal and success of trial of labor after cesarean section and report the associations as mean proportions. RESULTS: Of the 101 maternity units contacted, 97 responded to the questionnaire and data from 95 was included in the analysis. Continuous on-site presence of a gynecologist and an anesthetist was associated with a higher proportion of trial of labor after cesarean section, compared to units where staff was on-call from home (51% versus 46%, p = 0.04). There is a non-significant trend towards more trial of labor after cesarean section in units with an operating room in or near the delivery unit and a shorter transfer time, in larger units (> 1500 deliveries/year) and in units with a neonatal intensive care unit. The proposal of trial of labor after cesarean section and its success was negatively correlated to the number of cesarean section in the maternity unit (Spearman' rho = 0.50 and 0.42, p value < 0.001). CONCLUSIONS: Organizational differences in maternity units appear to affect the proposal of trial of labor after cesarean section. Addressing these organizational factors may not be sufficient to change practice, given that general tendency to perform a cesarean section in the maternity unit is the main contributor to the percentage of trial of labor after cesarean.

Implications of a Reduced Length of Postpartum Hospital Stay on Maternal and Neonatal Readmissions, an Observational Study.

INTRODUCTION: Reducing the Length Of postpartum Stay (LOS) is associated with lower hospital costs, a major reason for initiating federal projects in Belgium. Disadvantages following the reduction of LOS are the risks of maternal and neonatal readmissions. This study compares readmissions with or without reduced LOS, by introducing the KOZI&Home program in the university hospital Brussels. METHODS: This is an observational study comparing the readmission rates of the length of postpartum hospital stay between two groups: the non-KOZI&Home group (> 2 days for vaginal birth and > 4 days for caesarean section) and KOZI&Home group (≤ 2 days for vaginal birth and ≤ 4 days for caesarean section). A follow-up period of 16 weeks was set up. RESULTS: The maternal readmission rate was 4,8% for the non-KOZI&Home group (n = 332) and 3.3% for the KOZI&Home group (n = 253). Neonatal readmission rates were 7.2% and 15.9% respectively. After controlling influencing factors in a multivariate model for maternal and neonatal readmissions, there were no statistical significant differences. Factors negatively affecting neonatal readmissions are (1) dismissal period October-January (OR:3.22;95% CI 1.10-9.42) and (2) low education level (OR:3.44;95% CI 1.54-7.67), for maternal readmissions it concerns whether or not LOS is known (OR:3.26;95% CI 1.21-8.81). DISCUSSION: There is no effect of the KOZI&Home program on maternal nor neonatal readmission rates. Systematically informing about postpartum LOS antenatally will enforce preparation and is important to reduce maternal readmissions. Personalized information should be given to women discharged in the period October-January and to those with a lower education level, in order to reduce neonatal readmissions.

What is already known on this subject? Reducing the 'length of stay' after giving birth is known, for example, to reduce costs and for having a more family-centered approach. Above the known advantages, there is also some conflicting literature about the disadvantages. Some of the articles shown a higer readmission rate, and others no difference in readmission rates.What this study adds? The influencing factors of maternal and neonatal readmissions are checked, in order to reduce the number of readmissions in the future. Systematically informing about postpartum LOS antenatally will enforce preparation and is important to reduce maternal readmissions. Personalized information should be given to women discharged in the period October-January and to those with a lower education level, in order to reduce neonatal readmissions.

Maternal satisfaction with reduced postnatal length of stay in Brussels: evidence from the KOZI&Home program.

BACKGROUND: Reducing the length of stay (LOS) after childbirth is a trend, including cost savings, a more family-centered approach and lower risk for nosocomial infection. Evaluating the impact of reduced LOS is important to improve the outcomes of care, which include maternal satisfaction. The aim of this study was to compare the maternal satisfaction, before and after the reduced LOS. METHODS: This study was conducted in the University Hospital Brussels, before and after implementing the KOZI&Home program (intervention). This KOZI&Home program consisted of a reduced length of stay of at least one day for both vaginal delivery and caesarean section. It also included three extra antenatal visits with the midwife, preparing for discharge and postnatal home care by an independent midwife. Women completed a questionnaire, including the Maternity Satisfaction Questionnaire (MSQ) and Home Satisfaction Questionnaire (HSQ), respectively at discharge and two weeks postpartum. Satisfaction was split into five dimensions: 'Midwives time investment', 'Provision of information', 'Physical environment', 'Privacy' and 'Readiness for discharge'. A combination of forward and backward model selection (both directions) was used for statistical analysis. RESULTS: In total, 585 women were included in this study. 332 women in the non-intervention group and 253 women in the intervention group. Satisfaction with 'provision of information' at home had a higher mean score of 4.47/5 in the intervention group versus 4.08/5 in the non-intervention group (p < 0.001). Women in the KOZI&Home group were more satisfied regarding 'privacy at home' (mean 4.74/5 versus 4.48/5) (p < 0.001) and 'readiness for discharge' (p = 0.02). CONCLUSION: The intervention was associated with a higher score in some of dimensions of satisfaction. Our study concludes that this integrated care program is acceptable for postpartum women and associated with some favourable outcomes.

Learning experiences of final-year student midwives in labor wards: A qualitative exploratory study.

INTRODUCTION: Clinical placements are an integral part of midwifery education and are crucial for achieving professional competencies. Although students' experiences on placements have been shown to play a meaningful role in their learning, they have received scant attention in the literature. The aim of this paper is to describe the learning experiences of final-year student midwives in labor wards within the Brussels metropolitan region, Belgium. METHODS: A qualitative exploratory study was conducted using two focus groups (N=20). Data analysis included: transcription of audio recordings, thematic content analysis with coding into recurrent and common themes, and broader categories. Discussions among researchers were incorporated in all phases of the analysis for integrity and data fit. RESULTS: Data analysis identified the following categories as determining student learning experiences in labor wards: 1) managing opportunities, 2) being supported, and 3) dealing with the environment. Overall, respondents were positive and enthusiastic about their learning experiences, although some felt tense and unprepared. Students expressed concerns about differences in learning opportunities between placements and found it challenging to achieve all competencies. Student learning experiences were enhanced when they had placements for longer periods with the same supportive mentors. CONCLUSIONS: Factors related to students' functioning, the healthcare professional, midwifery education and hospital environment affected their learning in labor wards. The combination of a more persevered preparation of students and mentors, together with a student-centered organization of placements, is crucial to create a positive learning experience for midwifery students in labor wards.

The experiences of last-year student midwives with High-Fidelity Perinatal Simulation training: A qualitative descriptive study.

BACKGROUND: Simulation training is a powerful and evidence-based teaching method in healthcare. It allows students to develop essential competences that are often difficult to achieve during internships. High-Fidelity Perinatal Simulation exposes them to real-life scenarios in a safe environment. Although student midwives' experiences need to be considered to make the simulation training work, these have been overlooked so far. AIM: To explore the experiences of last-year student midwives with High-Fidelity Perinatal Simulation training. METHODS: A qualitative descriptive study, using three focus group conversations with last-year student midwives (n=24). Audio tapes were transcribed and a thematic content analysis was performed. The entire data set was coded according to recurrent or common themes. To achieve investigator triangulation and confirm themes, discussions among the researchers was incorporated in the analysis. FINDINGS: Students found High-Fidelity Perinatal Simulation training to be a positive learning method that increased both their competence and confidence. Their experiences varied over the different phases of the High-Fidelity Perinatal Simulation training. Although uncertainty, tension, confusion and disappointment were experienced throughout the simulation trajectory, they reported that this did not affect their learning and confidence-building. CONCLUSION: As High-Fidelity Perinatal Simulation training constitutes a helpful learning experience in midwifery education, it could have a positive influence on maternal and neonatal outcomes. In the long term, it could therefore enhance the midwifery profession in several ways. The present study is an important first step in opening up the debate about the pedagogical use of High-Fidelity Perinatal Simulation training within midwifery education.

Inter-professional Perinatal Simulation training: A valuable educational model to improve competencies amongst student midwives in Brussels, Belgium.

Simulation training is a powerful and evidence-based teaching method for students and healthcare professionals. The described educational model of Inter-professional Perinatal Simulation training is the result of a collaborative project with the Erasmus University College Brussels, the Medical School of the Vrije Universiteit Brussel (VUB) and the University Hospital Brussels. This model enhances student midwives to acquire competencies in all fields of midwifery according to national and European legislation and to the International Confederation of Midwives Global Standards for Midwifery Education. In our educational program, simulation training enhanced the achievement of decision-making and inter-professional communication competences.

Determinants of folic acid use in a multi-ethnic population of pregnant women: a cross-sectional study.

AIMS: To investigate the possible differences in folic acid use and to identify the determinants of antenatal folic acid use among multi-ethnic pregnant women. METHODS: Three hundred and fifty pregnant women participated in this cross-sectional study in a university hospital in Brussels, Belgium. A questionnaire was used to obtain data on socio-demographic characteristics and folic acid use. χ(2)-tests and binary logistic regression analyses were performed using SPSS 17. RESULTS: In the overall cohort, 59.2% used folic acid supplements during pregnancy. This supplement use was associated with an age of 26-35 years, being of Western origin, with high education and employment status, understanding physician's instructions, and early booking for antenatal care. Education (odds ratio, OR: 2.24; 95% confidence interval, CI: 1.08-4.63) and early booking for antenatal care OR: 2.45; 95% CI: 1.11-5.40) were the most important determinants. In particular for Arab/Turkish women, a lower employment status OR: 0.42; 95% CI: 0.24-0.73) was associated with a higher risk of not using folic acid supplements. CONCLUSIONS: The lower use of folic acid supplements in Arab/Turkish ethnicities, which may be associated with an increased risk of neural tube defects, is related to socio-economic factors rather than to lower educational attainment. As recommended by other studies, fortification of ethnic minority food may be warranted to reduce the risk of neural tube defects.

Nonsurgical treatment of pyomyoma in the postpartum period.

BACKGROUND: Only 13 cases of pyomyoma related to pregnancy have been described since 1945. Treatment consists of hysterectomy, which exposes critically ill patients to operative risks and induces infertility. CASES: Three cases of pyomyoma in the postpartum period are described. Treatment using computed tomography-guided drainage was realized successfully in two cases. CONCLUSION: Therapy via drainage and lavage of pyomyoma is a viable option to preserve patient fertility. In the absence of a proper response to this treatment, total abdominal hysterectomy is the treatment of choice.

Specific congenital malformations after exposure to cyclophosphamide, epirubicin and 5-fluorouracil during the first trimester of pregnancy.

The treatment of pregnant women with chemotherapeutic drugs leads to congenital malformations in 10-20% of newborn children. We present a case of an ongoing 19-week-long pregnancy which was diagnosed in a 39-year-old woman who was being treated with CEF (cyclophosphamide, epirubicin, 5-fluorouracil) chemotherapy for an infiltrating ductal carcinoma of the breast. After termination of the pregnancy, subsequent examination of the fetus revealed micrognathia and bilateral malformations of the hands and feet. The peak exposure of the fetus to the chemotherapeutic agents was in the 5th to 6th week of the pregnancy. Both the nature of the malformations and the timing of the administration of chemotherapy are similar to another case reported previously. We conclude that chemotherapy treatments with CEF in the 5th to 6th week of pregnancy specifically generate hand and foot abnormalities and micrognathia, which is consistent with an inhibition of proliferation, leading to cell death at this embryonic stage.

Enterobius vermicularis infection with tuboovarian abscess and peritonitis occurring during pregnancy.

BACKGROUND: Extraintestinal Enterobius vermicularis infections are rare but may occasionally affect the female genital tract. Although mostly asymptomatic or causing minor clinical problems, they may lead to severe infectious complications. METHODS: Case report and review of the pertinent English language literature. RESULTS: A 31-year-old, 30-week-pregnant female was admitted with a clinical suspicion of appendicitis. At surgery, the appendix appeared normal, but generalized peritonitis of unclear origin was present. Eggs of Enterobius vermicularis were found upon microbiological and pathological examination. Because of persisting infectious disease, the patient underwent an elective caesarean section, and at that time the diagnosis of a right tuboovarian abscess was made, and salpingo-oophorectomy was performed. The pathology report confirmed the diagnosis of an E. vermicularis salpingo-oophoritis. CONCLUSION: This case was extraordinary because of a combination of tuboovarian abscess and generalized peritonitis with E. vermicularis infection occurring during late pregnancy. Ectopic enterobiasis should be considered in the differential diagnosis of pelvic infections of gynecological origin.