Rethinking our approach to postpartum haemorrhage and uterotonics

Analysis Rethinking our approach to postpartum haemorrhage and uterotonics BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h3251 (Published 08 July 2015) Cite this as: BMJ 2015;351:h3251 Article Related content Metrics Responses Peer review Andrew D Weeks, professor of international maternal health1, James P Neilson, professor of obstetrics and gynaecology1 Author affiliations Correspondence to: AD Weeks [email protected] Accepted 30 March 2015 Andrew Weeks and James Neilson suggest that we have inappropriately generalised evidence on the use of uterotonics from uncomplicated births to all births. They call for stronger focus on women with complex births to reduce deaths from postpartum haemorrhage Postpartum haemorrhage (defined as a bleed >500 mL) is estimated to affect 1-15% of vaginal births, depending on the definition used, the method of assessing blood loss, the setting, and the population studied. Risk factors include Asian ethnicity, obesity, previous postpartum haemorrhage, multiple pregnancy, anaemia, large baby, age over 40, induction of labour, prolonged labour, placental abruption, and caesarean delivery.1 Although global mortality from postpartum haemorrhage is falling, its incidence is increasing in high resource settings, the reasons for which are unclear.2 3 4 Many of those who survive have severe anaemia, renal failure, or psychological trauma, and the offspring may have difficulties in breast feeding and bonding. Current best practice globally is for all pregnant women to receive a uterotonic drug at the time of childbirth to prevent postpartum haemorrhage. This recommendation has been in place since the 1980s when randomised trials showed that routine prophylaxis with oxytocin based uterotonic drugs reduced the rate of postpartum haemorrhage.5 The assumption that this would translate into fewer maternal deaths—based on the understanding that atony was the most common cause of haemorrhage related deaths—led to the promotion of active management of the third stage of labour, which comprises a prophylactic uterotonic drug, early cord clamping, and controlled cord traction. Here we discuss the problems with generalising data from spontaneous vaginal (“normal”) births to complex births, and call for a change in global strategy on postpartum haemorrhage

Evaluation of acute coronary syndrome risk by hospitalists to expedite discharge of low risk patients

Chest pain is a leading cause of Emergency Department (ED) visits. Risk stratification of risk for Acute Coronary Syndrome (ACS) is applied with variability. Revaluation of ACS risk by hospitalists may provide the opportunity to identify patients eligible for expedited discharge

Self-Hypnosis for Intrapartum Pain management (SHIP) in pregnant nulliparous women: a randomised controlled trial of clinical effectiveness

Abstract Objective: (Primary): to establish the effect of antenatal group self-hypnosis for nulliparous women on intra-partum epidural use Design: Multi-method RCT Setting: Three NHS Trusts Population: Nulliparous women not planning elective caesarean, without medication for hypertension and without psychological illness. Methods: Randomisation at 28-32 weeks gestation to usual care, or to usual care plus brief self-hypnosis training (two x 90 minute groups at around 32 and 35 weeks gestation; daily audio self-hypnosis CD). Follow up at two and six weeks postnatal. Main outcome measures:- Primary: epidural analgesia Secondary: associated clinical and psychological outcomes; economic analysis. Results: 680 women were randomised. There was no statistically significant difference in epidural use: 27.9% (intervention), 30.3% (control), odds ratio (OR) 0.89 (95% confidence interval (CI): 0.64 to 1.24), or in 27 of 29 pre-specified secondary clinical and psychological outcomes. Women in the intervention group had lower actual than anticipated levels of fear and anxiety between baseline and two weeks post natal (anxiety: OR -0.72, 95% CI -1.16 to -0.28, P= 0.001); fear (OR -0.62, 95% CI -1.08 to -0.16, p = 0.009) Postnatal response rates were 67% overall at two weeks. The additional cost of the intervention per woman was £4.83 (CI -£257.93 to £267.59). Conclusions: Allocation to two third-trimester group self-hypnosis training sessions did not significantly reduce intra-partum epidural analgesia use or a range of other clinical and psychological variables. The impact of women’s anxiety and fear about childbirth needs further investigation. Trial registration: ISRCTN27575146 http://www.controlled-trials.com/ISRCTN2757514

Decades of Delay: EPA Leadership Still Lacking in Protecting America's Great River

This report demonstrates the continuing failure of EPA's voluntary approach and the continuing and growing threats of unregulated nitrogen and phosphorus pollution. EPA has the power and the duty to act to require reasonable, common-sense regulations to address the growing scourge of nutrient pollution, and it should do so. Once again, MRC calls upon EPA to remedy this state of affairs, specifically recommending that EPA:Develop numeric phosphorus criteria for each of the eight states that have yet to adopt them, and numeric nitrogen criteria for all 10 states.Require states to assess their waters for nitrogen and phosphorus pollution and to prioritize TMDL development and implementation planning accordingly.Increase oversight of the state NPDES programs to ensure that both narrative and numeric nutrient criteria are implemented through limits in permits, including the use of Water Quality Based Effluent Limits (WQBELs) where appropriate.Disapprove TMDLs that lacking reasonable assurance that nonpoint source reductions are likely to occur and lack monitoring and timelines to ensure that planned reductions actually take place. Further, EPA needs to provide oversight to ensure consistency among EPA Regions in TMDL review and approval (especially in Regions 4 and 6.)Ensure that states' Nutrient Reduction Strategies contain implementation plans detailing point and nonpoint source reductions needed, responsible parties, funding mechanisms, milestones, measurement metrics, and reasonable timelines.Require states under Section 319 of the Clean Water Act to identify programs and practices for controlling nonpoint sources of pollution to the maximum extent possible

Innovation in immediate neonatal care: development of the Bedside Assessment, Stabilisation and Initial Cardiorespiratory Support (BASICS) trolley

OBJECTIVE: Babies receive oxygen through their umbilical cord while in the uterus and for a few minutes after birth. Currently, if the baby is not breathing well at birth, the cord is cut so as to transfer the newborn to a resuscitation unit. We sought to develop a mobile resuscitation trolley on which newly born babies can be resuscitated while still receiving oxygenated blood and the 'placental transfusion' through the umbilical cord. This would also prevent separation of the mother and baby in the first minutes after birth. DESIGN: Multidisciplinary iterative product development. SETTING: Clinical Engineering Department of a University Teaching Hospital. METHODS: Following an initial design meeting, a series of prototypes were developed. At each stage, the prototype was reviewed by a team of experts in the laboratory and in the hospital delivery suite to determine ease of use and fitness for purpose. A commercial company was identified to collaborate on the trolley's development and secure marking with the Conformite Europeenne mark, allowing the trolley to be introduced into clinical practice. RESULTS: The trolley is a small mobile resuscitation unit based on the concept of an overbed hospital table. It can be manoeuvred to within 50 cm of the mother's pelvis so that the umbilical cord can remain intact during resuscitation, irrespective of whether the baby is born naturally, by instrumental delivery or by caesarean section. Warmth for the newborn comes from a heated mattress and the trolley has the facility to provide suction, oxygen and air. CONCLUSIONS: This is the first mobile resuscitation device designed specifically to facilitate newborn resuscitation at the bedside and with an intact cord. The next step is to assess its safety, its acceptability to clinicians and parents, and to determine whether it allows resuscitation with an intact cord

Achieving community-based postpartum follow up in eastern Uganda: the field experience from the MamaMiso Study on antenatal distribution of misoprostol.

BackgroundAdvance provision of misoprostol to women during antenatal care aims to achieve broader access to uterotonics for the prevention of postpartum hemorrhage. Studies of this community-based approach usually involve antenatal education as well as timely postpartum follow-up visits to confirm maternal and neonatal outcomes. The MamaMiso study in Mbale, Uganda sought to assess the feasibility of conducting follow-up visits in the postpartum period following advance provision of misoprostol for postpartum hemorrhage prevention. MamaMiso recruited women during antenatal care visits. Participants were asked to contact the research team within 48 h of giving birth so that postpartum follow-up visits could be carried out at their homes. Women's baseline and delivery characteristics were collected and analyzed with respect to follow-up time ('on time' ≤ 7 days, 'late' > 7 days, and 'lost to follow up'). Every woman who was followed up late due to a failure to report the delivery was asked for the underlying reasons for the delay. When attempts at following up participants were unsuccessful, a file note was generated explaining the details of the failure. We abstracted data and identified themes from these notes.ResultsOf 748 recruited women, 700 (94%) were successfully followed up during the study period, 465 (62%) within the first week postpartum. The median time to follow up was 4 days and was similar for women who delivered at home or in facilities and for women who had attended or unattended births. Women recruited at the urban hospital site (as opposed to rural health clinics) were more likely to be lost to follow up or followed up late. Of the women followed up late, 202 provided a reason. File notes explaining failed attempts at follow up were generated for 164 participants. Several themes emerged from qualitative analysis of these notes including phone difficulties, inaccurate baseline information, misperceptions, postpartum travel, and the condition of the mother and neonate.ConclusionsKeeping women connected to the health system in the postpartum period is feasible, though reaching them within the first week of their delivery is challenging. Understanding characteristics of women who are harder to reach can help tailor follow-up efforts and elucidate possible biases in postpartum study data. Trial Registration Number ISRCTN70408620 December 28, 2011

Foehn jets over the Larsen C Ice Shelf, Antarctica

Previously unknown foehn jets have been identified to the east of the Antarctic Peninsula (AP) above the Larsen C Ice Shelf. These jets have major implications for the east coast of the AP, a region of rapid climatic warming and where two large sections of ice shelf have collapsed in recent years. During three foehn events across the AP, leeside warming and drying is seen in new aircraft observations and simulated well by the Met Office Unified Model (MetUM) at ∼1.5 km grid spacing. In case A, weak southwesterly flow and an elevated upwind inversion characterise a highly nonlinear flow regime with upwind flow blocking. In case C strong northwesterly winds characterise a relatively linear case with little upwind flow blocking. Case B resides somewhere between the two in flow regime linearity. The foehn jets – apparent in aircraft observations where available and MetUM simulations of all three cases – are mesoscale features (up to 60 km in width) originating from the mouths of leeside inlets. Through back trajectory analysis they are identified as a type of gap flow. In cases A and B the jets are distinct, being strongly accelerated relative to the background flow, and confined to low levels above the Larsen C Ice Shelf. They resemble the ‘shallow foehn’ of the Alps. Case C resembles a case of ‘deep foehn’, with the jets less distinct. The foehn jets are considerably cooler and moister relative to adjacent regions of calmer foehn air. This is due to a dampened foehn effect in the jet regions: in case A the jets have lower upwind source regions, and in the more linear case C there is less diabatic warming and precipitation along jet trajectories due to the reduced orographic uplift across the mountain passes