RESEARCH
Planned mode of delivery after a previous cesarean section and short-term maternal and perinatal outcomes: A Population-based record linkage cohort study in Scotland. 

• A cohort study of 74,043 term singleton births in Scotland to women with one or more previous cesarean sections.
• Found that attempting a vaginal birth compared to having an elective repeat cesarean section is associated with an increased risk of the mother having serious birth-related complications such as uterine rupture and blood transfusion, as well as an increased risk of adverse perinatal outcomes.
• Conversely, found that attempting a vaginal birth is associated with an increased likelihood of breastfeeding, whereas the association with other maternal outcomes appears to differ according to whether a woman has any prior vaginal deliveries and the number of previous cesarean sections she has had.
• However, the absolute risk of adverse maternal and perinatal outcomes was found to be small for either delivery approach: overall, just 1.8% of those attempting a vaginal birth and 0.8% of those having an elective repeat cesarean section experienced serious maternal complications, and 8.0% of those attempting a vaginal birth and 6.4% of those having an elective repeat cesarean section experienced one or more of the adverse perinatal outcomes considered.

​Full Study: journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002913#abstract0

NHS response to study: www.nhs.uk/news/pregnancy-and-child/planned-caesareans-safer-women-past-history-caesarean-sections/

RESEARCH

Maternal Mortality in the United States...

The U.S. maternal mortality rate has significantly increased from 7.2 deaths per 100,000 live births in 1987 to 16.7 deaths per 100,000 live births in 2016, and the data indicate that more than half of these deaths are preventable.

Unnecessary cesarean sections, limited receipt of proper prenatal and postnatal care, and racial or ethnic disparities are likely contributing to soaring mortality rates.

State maternal mortality review committees are increasingly considered necessary for collecting standardized data on pregnancy-related deaths and providing recommendations and strategies for effective interventions targeting quality and performance improvements.
Read more: www.americanactionforum.org/insight/maternal-mortality-in-the-united-states/#ixzz64Ml2jVrT

NEWS

Tips for getting through Emotional and Physical Pain after a C-section (A Personal Story)

1. Remind yourself that Pain is temporary
2. Take it really easy the first few days- week to prevent any damage to the incision.
3. It is OK to have HELP during your recovery
4. Pay close attention to your feelings. De-brief your birth and talk to someone (like your midwife).
5. Don't allow a C-section to prevent you from enjoying your time as a mother and with your baby.

For more details: www.yahoo.com/lifestyle/tips-getting-emotional-physical-pain-181315199.html

The Fetal Pillow has undergone many Evidence based studies to show its effectiveness when handling a deeply impacted Fetal head at second stage Caesarean section. Studies have been performed worldwide and have shown the following results when using the Fetal Pillow:
- An improvement in Apgar score
- Decrease in Uterine extensions
- Lower mean intra-operative blood loss
- A decrease need for NICU or ICU
- A shorter duration of postpartum hospital admission
- Safe, effective and easy to use.

To view all evidence and studies on Fetal Pillow visit www.safeob.com/evidence.html

Further studies from the United States will be released in 2020. Keep posted. 

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
​
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