EVENT

Rural Medicine Australia- Gold Coast Events, 24-26 October, 2019.

Rural Medicine Australia (RMA) is the peak national event for rural and remote doctors of Australia. Hosted by the Australian College of Rural and Remote Medicine (ACRRM) and the Rural Doctors Association of Australia (RDAA), RMA attracts a diverse and collaborative community of junior doctors, students, educators, academics, and medical practitioners who are passionate about generalist medicine in rural and remote communities. The event includes guest speakers presenting talks about Rural Maternity and a Rural Emergency Obstetrics Training (REOT) Workshop. 
The event includes innovative and informative presentations, interactive workshops and social events, along with a heap of exhibitors... this is the biggest rural networking event of the year!

For more about the Event: rma.acrrm.org.au/about-rma
​
NEWS
 
Rural Health policy Institute- Maintaining Maternity Care is vital to Rural Hospital Stability
 
Since 2011, 134 rural hospitals have dropped obstetric services and 18 rural hospitals offering obstetrics have closed. That means that in the past eight years, 152 rural communities across USA have lost access to maternity care.
"There are a variety of financial pressures from Medicare and Medicaid exerting downward pressure on rural hospital markets," said Howard. And unfortunately, policies associated with both of those public systems "disproportionally affect rural hospitals," she added.
 
Read on to learn how the institute are finding solutions to assist Rural Maternity units and creating financial stability: https://www.aafp.org/news/practice-professional-issues/20190213nrhamaternity.html

NEWS
Australian Women fights to deliver her own daughter by Caesarean section

Australian woman Bec Secomb lay back on the operating table holding her arms aloft as her husband Josh stroked her forehead. She was about to help deliver her own baby via caesarean section."Okay, you can reach down now," she heard her obstetrician say.

It's not an option that can be routinely offered to all would-be mothers, and never for an emergency caesarean. But for a minority of Australian women who desperately want to give birth "naturally", the opportunity to be directly involved - literally hands-on - in the birth could be a game-changer when a vaginal birth is too risky for mother and baby.

Read full story here: https://www.stuff.co.nz/life-style/parenting/baby/116181009/australian-woman-fights-to-deliver-her-own-daughter-by-caesarean-section
​
 
 STUDIES
Supporting rural midwifery practice using a mobile health (mHealth) intervention: a qualitative descriptive study.
 
Geographic and digital isolation pose significant challenges to rural midwifery practice in a high income country such as Scotland. Midwives need to be involved in the development of m-health interventions for them to be acceptable and tailored to their needs in a rural and remote context.
​The study highlights how m-health interventions can support continuous professional development whilst on the move with no internet connectivity. However, pride in current practice and unease with advances in mobile technology are barriers to the adoption of an m-health intervention. M-health interventions could be of value to other specialised healthcare practitioners in these regions, including general practitioners, to manage women with complications in their pregnancies.

https://europepmc.org/abstract/med/31446762

RESOURCE

Managing Medical and Obstetric Emergencies and Trauma Course (mMOET)

​The mMOET course provides knowledge, skills and procedures to save mum and baby in life-threatening circumstances.
The aims of the course include:

• To provide the knowledge, practical skills and procedures necessary to save the mother and fetus in life-threatening circumstances.
• To present a senior systematic approach of Primary Survey, Resuscitation, Secondary Survey and Definitive Care, enabling the clinician to give the best patient care in complex situation.
• To review trauma and medical emergencies in the pregnant patient, including triage and transfer.

The Course is available in the UK, Australia and New Zealand. 
www.alsg.org/en/files/KFactsheet.pdf

NEWS

Saving a Mother and her baby, Delivering a Miracle at Oak Hill Hospital
 
This Video offers a fascinating account of how  healthcare professionals worked together save a mother and her baby after an amniotic fluid embolism was diagnosed...

Amniotic Fluid embolism is very rare and is when the amniotic fluid gets in to the blood stream causing life-threatening complications... Code Blue was called and it is amazing how the team at Oak Hill Hospital worked together to save mother and baby. 

Below link to watch the full story:
www.youtube.com/watch?v=-WpxZRxJH08

Question: Sarah, Consultant O&G, Australia
I have used the pillow once and it was great. The case was an emergency Caesarean at full dilatation after failed instrumental. The Caesar was actually very straight forward and blood loss only 300ml. I was very impressed.  My only question is...
"Can we perform a caesar with the woman in lithotomy if we are also using a Fetal Pillow?"

Reply: Peter Dawes, Director of Sales AUS/NZ
Our guideline / information for use (IFU) directs users of Fetal Pillow to place patients legs flat on operating table. This is once you have positioned the Fetal Pillow in the posterior position toward coccyx / posterior Fornix (Balloon under engaged part of fetal head… past any caput & moulding / any position of fetal head – station zero and below).
 
Still, there are some O&G MOs that perform E-CS in stirrups and/or position the legs in mid- lithotomy position… however we feel that this reduces the ability for the balloon to elevate the Fetal Head to its capacity and if over lubricate it could move due to addition space available.
 
Laying patients legs flat on operating table prior to inflation will assist to entrap the device between Fetal head and pelvic floor and gain best uplift, lesson the ability for the device to move during inflation process.

For further information on the 'Steps and Instructions for Use' of the Fetal Pillow please visit: https://www.safeob.com/fetalpillow.html#use

NEWS
How to Reduce Maternal Mortality Rates in the United States
​
This interview provides useful information of addressing maternal mortality rates with improved management of obstetric emergencies. 
In the podcast Professor Elizabeth Howell is interviewed and explains the relatively simple ways to address this problem.Dr Howell states that, “Maternal Mortality is a real issue in the United States compared to other high-income countries. Their major causes are cardiovascular disease, haemorrhage, high blood pressure, blood clots and infection. Sadly, statistics do show that 60-63% of these deaths are shown to be preventable.”
The podcast also discusses the ‘The safety bundles’ by the ‘Alliance for Innovation and Maternal Health’ which looks at the most preventable causes of maternal deaths. The safety bundles are a format that is published and then help hospitals in implementing the bundles and resources they need when faced with this maternal mortality causes.

Listen to the full Podcast here: https://edhub.ama-assn.org/jn-learning/audio-player/17455228?resultClick=1&bypassSolrId=M_17455228
 
 RESEARCH
Obstetric Multi-Professional Training and its impact on patient outcomes in Australia
 
The aim of this study is to evaluate the implementation of the Practical Obstetric Multi-Professional Training (PROMPT) simulation using the Kirkpatrick’s framework. It explores participants’ acquisition of knowledge and skills, its impact on clinical outcomes and organisational change to integrate the PROMPT programme as a credentialing tool.
 
Participants reported an improvement of both clinical and non-technical skills highlighting principles of teamwork, communication, leadership and prioritisation in an emergency situation.
 
https://bmjopen.bmj.com/content/8/2/e017451

Do cesarean sections cause autism?

There have been a number of articles published about some new research that looks at the link between cesarean sections and autism. An article by ‘The Conversation’ highlights that whilst the study shows an association between cesarean section and autism and ADHD the study does not indicate there is a causal relationship.

Cesarean sections are more common in women who are obese, older or have history of immune conditions all of which have been linked with a child having increased risk of autism. These factors may therefore be also contributing to the study findings.
​
https://theconversation.com/theres-no-evidence-caesarean-sections-cause-autism-or-adhd-122473
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National Centre for Maternity Improvement

In the UK charity Tommys, The Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists have joined together to launch ‘The Tommys National Centre for Maternity improvement’.

The alliance will work on 5 work streams:

1. Identification and implementation of interventions to mitigate and manage preterm birth
2. Identification and implementation of interventions to mitigate and manage stillbirth
3. Implementation and improvement science to inform development, implementation and evaluation of interventions to support practice change
4. Practical implementation of interventions identified
5. Data analysis for improvement

There will be involvement from parents, midwives, doctors, the NHS and academic experts with the aim of preventing 600 stillbirths and 12,000 preterm births nationally.

https://www.tommys.org/our-organisation/about-us/charity-news/tommys-opens-national-centre-maternity-improvement

NICE guidance – Preterm Labour and Birth updated

NICE have updated their Preterm labor and birth guidance which covers the care of women at increased risk of or with symptoms and signs of preterm labor. The guideline includes new and updated recommendations on:

• Prophylactic vaginal progesterone and prophylactic cervical cerclage
  • When to offer prophylactic vaginal progesterone and prophylactic cervical cerclage
  • Who to consider offering prophylactic vaginal progesterone to
• Magnesium sulfate for neuroprotection
  • For women between 23+0 and 23+6 weeks of pregnancy who are in established preterm labor or having a planned preterm birth within 24 hours, discuss with the woman (and her family members or carers as appropriate) the use of intravenous magnesium sulfate for neuroprotection of the baby, in the context of her individual circumstances
• Intrapartum antibiotics
  • For guidance on the use of intrapartum antibiotics in established preterm labor, see the NICE guideline on neonatal infection (early onset).

​The guidance in full is available here - https://www.nice.org.uk/guidance/ng25

Effectiveness of financial intervention strategies for reducing cesarean section rates

A systematic review has been conducted evaluating the effectiveness of financial interventions on reducing cesarean section rates. There were 9 studies included in the review with some focusing on provider interventions and some with provider and patient interventions.

Provider interventions

• Fee equalizing for facilities – no effect
• Risk adjusted payment – could be effective

Combined provider and patent intervention

• Co-payment for elective cesarean section – no significant effect

The study concludes that risk adjusted payments may be an effective method to reduce cesarean section rates and considering stakeholder characteristics may also be important.

https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-7265-4

Association between rates of second-stage Caesarean section and instrumental delivery

A study from Hong Kong has looked at the trends in cesarean section and instrumental delivery rates. Records for cesarean sections and instrumental deliveries between 1997 and 2016 were examined. Over the period there were 87413 deliveries, 17600 (20.1%) of which were CS and 6502 (7.4%) instrumental deliveries.

Over the study period the cesarean section rate increased whilst the instrumental delivery rate decreased. The decline in instrumental delivery was replaced by second stage cesarean section.

Lack of confidence with instrumental delivery, medicolegal concerns and failed instrumental delivery may trigger a reluctance to attempt.

Training programs that include teaching on instrumental delivery skills as an alternative to cesarean section and having experience obstetricians involved are described as important for optimizing outcomes.

Read the full study here - https://www.hkjgom.org/sites/default/files/pdf/v19n2-89-association.pdf

Tips to provide best practice care to help prevent stillbirth

Safe Care Victoria is aiming to reduce the rate of stillbirths across Victoria, Australia. They have shared 6 tips to aid in providing best practice care for pregnant women:

1. Talk to your patients about the risk factors for stillbirth
2. Offer a carbon monoxide breath test at booking and 28-week appointments
3. 'Ask, Advise, Help’ to support women to cease smoking while pregnant
4. Make sure you’re across current best practice approaches to measure fetal growth and detect any abnormalities
5. Share up-to-date information on decreased fetal movements and maternal sleep position
6. Discuss timing of birth and support shared decision-making when planning for birth.

They are also encouraging women to:

• get familiar with baby’s movements and contact the midwife or obstetrician if they notice a change
• sleep on side: from 28 weeks (3rd trimester), going to sleep on your side is safer for your baby.
• seek support to quit smoking during pregnancy.

They share other support resources on their website - https://www.bettersafercare.vic.gov.au/news-and-media/six-tips-to-provide-best-practice-care-for-pregnant-women

Women with increased BMI could be having unnecessary cesarean sections

A study of 526 patients in Canada has found that patients with a higher BMI took up to 2.67 hours longer to reach a dilation of 10cm compared to women with a normal weight. A high BMI was also associated with increased oxytocin use.

The study highlights that care providers should take into consideration the time it takes for labor to progress in women with high BMI to help avoid undertaking premature cesarean sections.

https://www.sciencedirect.com/science/article/abs/pii/S1701216319304682

Second victim experience is an underestimated problem

A study in the Netherlands has looked at the experiences of healthcare providers who have been involved in a patient safety incident during their careers.

4369 doctor and nurse respondents were involved, 462 of which had been involved in an incident in the last 6 months that caused permanent harm or death. Those who had experienced an incident were more likely to report symptoms including hyper-vigilance, they felt doubts about knowledge or skill, felt unable to provide quality care and felt uncomfortable within a team. Where the outcome of the incident was more severe these symptoms lasted longer.

The study concludes ‘Attention should be given to how to cope with these symptoms as they profoundly affect personal well-being, professional performance as well as teamwork-related efforts directly influencing patient safety and the provision of quality care.’

https://bmjopen.bmj.com/content/9/7/e029923

NHS Resolution – Maternity Litigation

NHS Resolution has published its latest annual reports which details the types and value of litigation claims. Again, the highest value of claims relate to obstetrics where claims account for 10% of the volume of claims but an estimated 50% of the total value. This is a slight increase on the estimated value from 2017/18 of 48%.

The reports outlines that in 2018/19 the cost of harm was approximately £9 billion of which around 60% (£5.4 billion) related to obstetrics. For every baby born in England hospitals pay out about £1100 in indemnity costs.

NHS Resolution has attempted to address the high rates of maternity claims through research, early notification and financial incentives for best practice. With attempts at identifying maternity incidents, sharing learning and providing earlier support to families.

The report provides more details - https://resolution.nhs.uk/wp-content/uploads/2019/07/NHS-Resolution-Annual-Report-2018-19.pdf

Conjoined twins separated
​
Pakistani conjoined twins Safa and Marwa have been separated during surgery at London Great Ormond Street hospital. The twins who were joined at the head were separated in a procedure that took 50 hours and involved a team of 100 staff. The separation process for the twins took place over 4 months and they have now returned home. 

Patient Safety Network – Maternal Safety

The patient safety network has produced a guide to maternal safety. The resource summarizes the key issues facing mothers in the US, Statistics around who is at most risk, factors contributing to maternity related deaths and education and resource guides available to support pregnant women.
​
https://psnet.ahrq.gov/primers/primer/50/Maternal-Safety

Organisational interventions to reduce cesarean sections

 A systematic review has been published looking at organisation interventions and the impact on rates of cesarean birth. The study identified several interventions that impacted the cesarean section rates:

• Midwife led models of care – where the midwife is the lead professional in planning, organisation and delivery of a woman's care
  • Women were less likely to have a cesarean section overall
  • Women were less likely to have a planned cesarean section
  • There were no significant different between groups of for emergency cesarean section, instrumental delivery, labour augmentation, epidural use, special care admission and induction of labour
• Continuous midwifery care
  • No significant difference on rates of cesarean sections
• Audit and feedback to promote implementation of evidence-based practice
  • Small but significant impact on cesarean section reduction
• Hospital policy of mandatory second opinion for cesarean section
  • Small but significant impact on cesarean section reduction

The study concludes that:
‘women allocated to midwife-led models of care implemented across pregnancy, labour, birth, and the postnatal period were, on average, less likely to experience CS (overall), planned CS, and episiotomy compared with women allocated to routine care.’

https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-019-2351-2

First live birth after deceased donor uterine transplant

A baby has been born at Cleveland clinic in the US after the mother received a uterus transplant from a deceased donor. The mother is part of a trial at the clinic where they are using wombs from donors who have recently died. This reduces the risk of harm a living donor would face if donating their uterus.

​https://health.clevelandclinic.org/for-the-first-time-in-north-america-woman-gives-birth-after-uterus-transplant-from-deceased-donor/