A study recently published has looked at the impact that screening for breech presentation at 36 weeks has on the birth. The study ‘Screening for breech presentation using universal late-pregnancy ultrasonography: A prospective cohort study and cost effectiveness analysis’ found that screening could lower the risk of breech delivery.

Researchers from Cambridge recruited 4000 women to the study. The women all received a scan at 36 weeks to help determine the position of the baby with 4.6% with a breech presentation. Those with a breech presentation were either given an ECV or counselled on their options – Cesarean section or vaginal birth.

Of the 179 women with a breech presentation more than half were previously undiagnosed. ECV was tried for 84 women but was only successful in 12. The types of delivery for the 179 women were:

• 110 planned cesarean section
• 50 with emergency cesarean section
• 19 with a vaginal birth

Overall there were fewer vaginal breech deliveries and fewer late stage cesarean sections.

The study also looked at the financial/economic implications of introducing the 36 week scan. The cost for adding the additional ultrasound would be £4.27 million annually however some of this would be offset by savings made from avoiding the complications associated with a breech delivery.

The study concludes:
‘This study shows that implementation of universal late-pregnancy ultrasound to assess foetal presentation would virtually eliminate undiagnosed intrapartum breech presentation in nulliparous women. If this procedure could be implemented into routine care, for example, by midwives conducting a routine 36-wkGA appointment and using a portable ultrasound system, it is likely to be cost effective. Such a programme would be expected to reduce the consequences to the child of undiagnosed breech presentation, including morbidity and mortality.’

The full study is available here. 

Figures published on infant mortality rates due to sleep related disorders show that the rates in South Dakota are much higher than the national average.

The rate of 157.3 deaths per 100,000 births is 43% higher than the national average. Although the rate has been decreasing over the past 25 years the decrease has tapered off in the last few year. Sleep related cause include sudden infant death syndrome, accidental suffocation and strangulation. Between 2013 and 2017 95 babies in South Dakota died of sleep related causes following discharge from hospital.

Some of the possible risk factors contributing to sleep related deaths include:

• Tobacco use – infant mortality rate is more than double that of nonusers
• Income level
• Non-Hispanic blacks, American Indians and Hawaiian/pacific islanders were found to have higher infant mortality rates
• Unsafe sleep practices

To try and address the higher rate in South Dakota there are initiatives being implemented.

• South Dakota cribs for kids program providing safe sleep equipment and education for low income families
• Health recommendations have been updated
• Grants have been provided to support education initiatives

The America Academy of Paediatrics recommends a number of steps to support safe sleeping that includes placing the child on their back to sleep, keeping soft objects and bedding away from the sleeping area, avoiding smoking during pregnancy and after birth and avoid overheating.

This article details further information about the statistics and recommendations. 

​The NHS Long term plan sets out how the NHS plans to provide care over the next 10 years addressing the changing nature of healthcare and the challenges being faced. Within the plan are provisions for maternity care. The plan outlines a number of goals including:

• By 2024, 75% of women from BAME communities and a similar percentage of women from the most deprived groups will receive continuity of care from their midwife throughout pregnancy, labour and the postnatal period
• We will offer all women who smoke during their pregnancy, specialist smoking cessation support to help them quit
• The NHS will accelerate action to achieve 50% reductions in stillbirth, maternal mortality, neonatal mortality and serious brain injury by 2025
• By 2023/24, all women will be able to access their maternity notes and information through their smart phones or other devices
• All maternity services that do not deliver an accredited, evidence-based infant feeding programme, such as the UNICEF Baby Friendly Initiative, will begin the accreditation process in 2019/20
• By spring 2019, every trust in England with a maternity and neonatal service will be part of the National Maternal and Neonatal Health Safety Collaborative

To help with achieving these goals the plan outlines how the NHS plans to help achieve them.

Saving babies live care bundle
The saving babies lives care bundle will be rolled out across all maternity units in England in 2019. The bundle has shown a 20% reduction in stillbirths across those units where it is already in place. There are also plans to expand the bundle to focus on prevention of pre-term birth.

Local maternity systems
All units will be part of local maternity systems which include a named maternity safety champion bringing together all aspects of maternity care.

Clinical negligence scheme
The clinical negligence scheme will continue to financially reward those units that deliver on 10 key safety actions.

Continuity of care
Work will continue on providing continuity of care with teams being set up across the country with a particular focus on care for BAME communities. Evidence suggests that for these community’s midwifery led continuity of care leads to improved clinical outcomes.

Learning from mistakes
The healthcare safety investigation branch will review all term stillbirths, early neonatal deaths and cases of severe brain injury in babies, as well as all maternal deaths reporting on lessons learned and how to avoid similar incidents.

Mental health services
There will be increased provision of mental health services both for mothers and fathers with care provided by specialist perinatal mental health services from preconception to 24 months after birth. Additionally, the types of therapies available will be expanded.

Neonatal care
The plan also includes provision for neonatal care including better design of service to improve safety and effectiveness, development of the neonatal workforce and increased support for families.

​The full plan and addition information can be found here. There is also a proposal for changes to legislation to help support the implementation of the long term plan that you can provide feedback on.

A study published in BMC Pregnancy and childbirth ‘Maternal and neonatal outcome of reverse breech extraction of an impacted fetal head during caesarean section in advanced stage of labor: a retrospective cohort study’ has found some significant differences in outcomes when comparing ‘pushing from below’ and reverse breech delivery of a baby with an impacted fetal head.

The retrospective study conducted in Switzerland analyzed the outcomes of 629 women whose baby was delivered via cesarean section in the later stages of labor.  If difficulty was faced in disimpacting the fetal head either the reverse breech technique or head pushing was used. 82 women were in the head pushing group and 55 in the reverse breech.

The study found that outcomes were improved for women in the reverse breech group. They had lower uterine extension rates, a shorter operating time and less blood loss. There was no significant difference in the fetal outcomes however 2 babies in the head pushing group suffered skull fractures, one of which resulted in death.

The paper highlighted:
‘The deeply impacted fetal head is an obstetrical emergency situation, which requires a secure delivery technique to prevent undesirable maternal and neonatal consequences’

The full paper is available here. 

The Lancet has published a study titled ‘Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis’.

The systematic review including 196 studies from 67 different countries looked at the risk of mortality in women who have had a cesarean section in low and middle income countries; estimating the cesarean deaths as a proportion of all deaths, the number of stillbirths and perinatal deaths along with risk of morbidity.

The review found that the cesarean section rate in most of the countries in the review was less than 10% with almost one quarter of cesareans being done for non-progress of labor. Findings for the rate of deaths per 1000 for those undergoing cesarean section were:

• mortality rate of 7.8 per 1000 women
• stillbirth rate of 56.8 per 1000
• perinatal death rate of 84.7 per 1000

The review also found that women undergoing an emergency cesarean section were twice as likely to die than those undergoing an elective cesarean. A third of all the maternal deaths were attributed to post-partum haemorrhage and those cesareans performed in the second stage of labor were at higher risk of complications.

The study concludes:
‘The risk of maternal death following caesarean section is disproportionately high in LMICs, and women in sub-Saharan countries have the worst outcomes. The risks do not appear to have reduced over the past nearly 30 years, and are high in countries with a low rate of caesarean sections. Offspring outcomes are poor after a caesarean section, with high stillbirth and perinatal mortality. Emergency caesarean sections, particularly when undertaken in the second stage of labor, is a major risk factor for maternal and perinatal deaths, maternal near miss, and other major complications.’

The full study is available here.

In a study titled ‘Risk of severe maternal morbidity associated with cesarean delivery and the role of maternal age: a population-based propensity score analysis’ researchers looked at 6 regions across France covering 119 maternity units. A total of 4908 women were part of the study.

In those women with maternal morbidity over 85% of women had a post-partum haemorrhage with an increased risk of severe maternal morbidity for women with cesarean deliveries during labor. The risk of maternal morbidity for women with cesarean section before labor was significantly higher only for women over 35.

The study highlights that cesarean section was associated with a significantly higher risk of severe morbidity when compared to vaginal delivery. The risk for women over 35 was particularly significant for those undergoing cesarean both before and during labor.

It is important to recognize and evaluate both the risks and benefits when performing a cesarean section.
​
The full study is available here. 

The UK government has launched a consultation on proposals to give coroners power to investigate all full term still births.

Currently coroners are only able to investigate deaths of babies who have shown signs of life after they were born. The proposal would enable coroners to provide parents with information on the cause of death as well as providing recommendations to avoid further deaths. It is stated that under the proposed system:

• Coroners will have powers to investigate all full-term stillbirths occurring from 37 weeks pregnancy
• The coroner will consider whether any lessons can be learned which could prevent future stillbirths
• Coroners will not have to gain consent or permission from any third party in exercising this power
• Coronial investigations will not replace current investigations undertaken by the hospital or NHS agencies

You can provide your views on the proposal by completing an online survey available here. 

The Patient Safety Movement foundation has developed patient safety curriculum and education resources for healthcare professionals. It is aimed at developing knowledge, skills and behaviors to support improvement of patient safety and reduction of errors.

The resources can be used by those providing education on patient safety to help facilitate teaching. It provides information on how to get started with using the resource along with educational materials.

The curriculum covers 8 topics; error science, system science, human factors, technology, teamwork and communication, leadership and leading change, culture of safety and patient oriented safe care.

For each topic learning objectives are provided along with examples of demonstrating how they are met. There are videos, clinical cases and local experience examples provided along with further clinical resources and suggested reading.

The curriculum is available here.

A randomized trial has been published looking into the impact proactive telephone-based peer support has on breastfeeding.

The randomized trial conducted across 3 Australian hospitals involved more than 1000 women. The women were randomized to 2 groups – 1 with normal care and the other with normal care plus proactive phone-based support from a trained peer volunteer for up to 6 months post-partum. Only first-time mothers were included in the study.

The study measured the number of babies receiving any breast milk at six months finding that 75% of infants in the peer support group were receiving breast milk compared to 69% with only the usual support. Women in the peer support group had a 23% lower risk of stopping breastmilk feeding.

The study concludes:
‘Providing first time mothers with telephone-based support from a peer with at least six months personal breastfeeding experience is an effective intervention for increasing breastfeeding maintenance in settings with high breastfeeding initiation.’

The study is available here. 

Dr Lesley Roberts, Consultant Obstetrician & Gynecologist shares her thoughts on cesarean section and maternal requests.

'Since the change in the NICE guideline we have seen increasing numbers of ladies requesting and even demanding elective LSCS. 

Some trusts have decided to deny such requests.

We are in Surrey and recently I have been approached from ladies in other counties many miles from us whose requests have been denied.

We need to have a much better debate around the whole issue of choice in childbirth. We have something like a postcode lottery in relation to what is and is not available to mothers and their partners.

The litigation costs are very high when things do not go well, and many women (and men) suffer the psychological consequences of a birth that did end up being as they had hoped.

 I suspect if all ladies were given the option many more would request a caesaerean section.

I am not in the caesarean for all camp as I personally chose to aim for a vaginal birth and was lucky enough to be able to experience the joy of homebirth as well as the unexpected need for an emergency LSCS on another occasion.

What I advocate is that there should be a choice and that choice is a fully informed one.
​
​Lets get the debate going.'

The institute for perinatal quality improvement has a free webinar series to provide education and support on important perinatal quality improvement topics.

The latest webinar will be on ‘Implementing best practice PPH bundle’ covering policies, practices and procedures, reviewing key parts of the PPH bundle and discussing how it can be implemented.

The webinar series library also contains webinars on other important topics including baby friendly guidelines, care of African American and black mothers and utilizing telehealth.

To sign up to the webinar and access previous recordings click here. 

800 women in the US die each year during pregnancy or within 42 days after delivery highlights a report from JAMA network. The report outlines the lack of standardization in reporting across states and the incomplete data on causes of death.

Review committees across states are analyzing patient records to identify what went wrong however some committees and unfunded and under resourced. Suitable analysis of the data and relevant action can lead to significant reduction in maternal deaths as demonstrated by Hospital Corporation of America.

It is estimated that more than 60% of pregnancy related deaths can be prevented with major causes including:

• Medical errors
• ineffective treatments
• lack of care coordination by clinicians and hospitals

Other causes relate to a mother mental health with a large proportion of deaths from suicide or drug overdoses.

Work is being done to try and tackle some of these causes through action including:

• Combining newborn and the mother’s post-partum wellbeing check
• Integrating workers supporting women including doulas and community health workers
• Addressing the racial disparities

The full articles available here provides more details on the current situation. 

USA Today has conducted an in-depth investigation into US hospitals provision of maternity care; collecting data from hospital quality records, examining details of 150 cases where something went wrong and contacting 75 birthing hospitals.

​The investigation highlights where failings in the standard of care have occurred but also recognizes the impact that focusing on improving safety can have as seen in California. A number of reports are covered in the investigation including stories from women, data on specific hospitals and where hospitals are failing.

You can search for information on specific hospitals here. The site provides information on 951 hospitals across 13 states. Information is provided on the number of births in each hospitals and rates of maternal morbidity with a breakdown of the rates for black mothers and low income mothers.

The investigation includes a series of videos ‘I am one of the 50,000’. It includes videos of women telling their stories of some of the injuries and complications that they have suffered. The videos can be seen here.

The investigation reports encourage women to ask their healthcare providers questions and understand better the hospitals policies and practice around childbirth safety. Also provided is a ‘life-saving tips’ resource document.  

The full investigation reports can be read here. 

The Agency for Healthcare Research and Quality have released an app to help support patients and caregivers prepare for medical appointments. The app is available to be downloaded onto mobiles and is designed to help individuals prepare question they may wish to ask their healthcare provider. It also has the ability to capture images of relevant information such as medical prescription bottles. The app provides access to further education resources.

​This video provides more details on the app and where to access. 

NICE have published a new guideline ‘Intrapartum care for women with existing medical conditions or obstetric complications and their babies’.

The guideline covers recommendations for the care of women in labor and birth requiring additional support due to medical conditions or complications in pregnancy. The aim is to improve the outcome and experiences for women and babies.

The guideline includes recommendations on heart disease, bleeding disorders, sepsis, asthma, obesity, previous cesarean section and small/large for gestational age baby.

It is designed for both healthcare professionals and women and their families with the guideline highlighting that ‘Supporting women to make decisions about their care is particularly important during the intrapartum period. Healthcare professionals should ensure that women have the information they need to make decisions and to give consent’.

Along with the recommendations NICE have provided a baseline assessment tool to help care providers in reviewing current practice and assessing if it meets the guideline recommendations.
​
The guideline and supporting resources can be found here. 

A study has been published exploring the views of midwives of the skills they use to avoid perineal trauma. Previous studies were found to show that the practice of midwives has a significant influence on the rate of perineal trauma and rates in Ireland and New Zealand were particularly low. The study involved interviews with midwives from both Ireland and New Zealand.

There were four themes identified:

Calm controlled birth

• Calmly observing the birth to determine if the woman was in the second stage of labor
• Building a trusting relationship with the woman to help talk her through the birth
•  Supporting the women to be in control

Position and technique in the early second stage

• Supporting women to labor in upright positions
• Observing the perineum
• Using techniques such as a hot compress or lubricant

Hands on or off

• Hands on providing support when required
• Pressure on the baby’s head to slow things down

Slow, blow and breathe the baby out

• Focus on breathing techniques
• Wait between birth of head and shoulders

The study whilst only small provides some insight into techniques that have been successfully used by midwives. The study concludes: ‘we recommend that the advice of these midwife experts be followed, and that these techniques be taught to student midwives. Further research to test the ‘MEPPI’ method in a controlled, before-and-after study, or cluster randomised trial, is required to assess its applicability to all midwives, and for all women.’

The full study is available here. 

Test your knowledge of reduced fetal movement and stillbirth with this quiz from MDedge OBGYN. The quiz bases on a recent study test you on the findings from the study and how they relate to practice.

Give it ago here. 

An article from Ob.Gyn news on a recently published paper highlights that Insulin-treated diabetes in pregnancy significantly increases the risk of large-for-gestational-age offspring and preterm birth. The research from Finland comprised almost 650,000 live births and looked at the impact of diabetes and weight on maternal outcomes.

The article highlights that researchers found women with insulin treated diabetes had a 43 times higher risk of having a large for gestational age baby and a 11 times greater risk of preterm birth.

There was also found to be a slight increased risk for mothers with diabetes not treated with insulin. With a slight risk also for mothers with high prepregnancy BMI but no diabetes.

To read the full article and more details on the study visit click here. 

A study has been published in the Social Science & Medicine journal titled ‘How to be a very safe maternity unit: An ethnographic study’. The study looks at the performance of a UK Maternity unit and how it achieved and sustained safety outcomes.

The researchers spent time observing the day to day activities on the ward, attending training sessions and conducting interviews with staff. The study identified a number of mechanisms that contributed to safety:

• Collective competence
• Insistence on technical proficiency
• Monitoring, coordination and distributed cognition
• Clearly articulated and constantly reinforced standards of practice, behavior, and ethics
• Monitoring multiple sources of intelligence about the unit's state of safety
• Highly intentional approach to safety and improvement
• Structural influences on mechanisms for safety

Collective competence
All members of the maternity have shared goals e.g. safe birth, there was collaborative decision making across professions and open discussions between doctors and midwives.

Insistence on technical proficiency
Individuals are required to perform clinical task to high level of proficiency, PROMPT training program helped with achieving this supporting drills and simulations. There was also frequent knowledge sharing with case discussions.

Monitoring, coordination and distributed cognition
Unit structure meant staff had specific roles monitoring the internal and external situation. They also planned ahead and anticipated possible problems, were encouraged to voice and discuss concerns and effectively used and updated the unit’s whiteboard.

Clearly articulated and constantly reinforced standards of practice, behavior, and ethics
The standards and policies were followed and reinforced with staff striving to achieve them with deviations from standards actively managed.

Monitoring multiple sources of intelligence about the unit's state of safety
Data and feedback were collected and monitored, a maternity dashboard used to identify and audits possible trends and a culture open to staff raising concerns.

Highly intentional approach to safety and improvement
Safety is viewed as something requiring constant vigilance with the design of space, equipment and technology all supporting safe practice. Individually staff are encouraged and support to take responsibility for safety and improvements and there is also a role for formal risk management systems.

The study concludes ‘our analysis suggests that foregrounding a specific intervention or programme as the major explanation for safety performance may risk rendering invisible or backgrounding important features of context that are generative of safety.’

The full findings of the study can be read here.