Helen Simpson

The impact of maternal BMI status on pregnancy outcomes with immediate short-term obstetric resource implications: a meta-analysis.

Obesity is rising in the obstetric population, yet there is an absence of services and guidance for the management of maternal obesity. This systematic review aimed to investigate relationships between obesity and impact on obstetric care. Literature was systematically searched for cohort studies of pregnant women with anthropometric measurements recorded within 16‐weeks gestation, followed up for the term of the pregnancy, with at least one obese and one comparison group. Two researchers independently data‐extracted and quality‐assessed each included study. Outcome measures were those that directly or indirectly impacted on maternity resources. Primary outcomes included instrumental delivery, caesarean delivery, duration of hospital stay, neonatal intensive care, neonatal trauma, haemorrhage, infection and 3rd/4th degree tears. Meta‐analysis shows a significant relationship between obesity and increased odds of caesarean and instrumental deliveries, haemorrhage, infection, longer duration of hospital stay and increased neonatal intensive care requirement. Maternal obesity significantly contributes to a poorer prognosis for mother and baby during delivery and in the immediate post‐partum period. National clinical guidelines for management of obese pregnant women, and public health interventions to help safeguard the health of mothers and their babies are urgently required.

Trends in maternal obesity incidence rates, demographic predictors, and health inequalities in 36 821 women over a 15‐year period

Objective  The aim of this study was to identify trends in maternal obesity incidence over time and to identify those women most at risk and potential‐associated health inequalities.

An Evaluation of the Implementation of Maternal Obesity Pathways of Care: A Mixed Methods Study with Data Integration

Objectives Maternal obesity has multiple associated risks and requires substantial intervention. This research evaluated the implementation of maternal obesity care pathways from multiple stakeholder perspectives. Study Design A simultaneous mixed methods model with data integration was used. Three component studies were given equal priority. 1: Semi-structured qualitative interviews explored obese pregnant women’s experiences of being on the pathways. 2: A quantitative and qualitative postal survey explored healthcare professionals’ experiences of delivering the pathways. 3: A case note audit quantitatively assessed pathway compliance. Data were integrated using following a thread and convergence coding matrix methods to search for agreement and disagreement between studies. Results Study 1: Four themes were identified: women’s overall (positive and negative) views of the pathways; knowledge and understanding of the pathways; views on clinical and weight management advice and support; and views on the information leaflet. Key results included positive views of receiving additional clinical care, negative experiences of risk communication, and weight management support was considered a priority. Study 2: Healthcare professionals felt the pathways were worthwhile, facilitated good practice, and increased confidence. Training was consistently identified as being required. Healthcare professionals predominantly focussed on women’s response to sensitive obesity communication. Study 3: There was good compliance with antenatal clinical interventions. However, there was poor compliance with public health and postnatal interventions. There were some strong areas of agreement between component studies which can inform future development of the pathways. However, disagreement between studies included a lack of shared priorities between healthcare professionals and women, different perspectives on communication issues, and different perspectives on women’s prioritisation of weight management. Conclusion The differences between healthcare professionals’ and women’s priorities and perspectives are important factors to consider when developing care pathways. Shared perspectives could help facilitate more effective implementation of the pathway interventions that have poor compliance.

Role of the midwife and the obstetrician in obstetric critical care - a case study from the James Cook University Hospital.

The role of the obstetrician and the midwife are fundamental to the successful antenatal management, delivery and postpartum management of the critically ill obstetric patient. However, there is a dearth of published literature on the integrated management of these roles. This chapter addresses these issues by reporting on experiences at James Cook University Hospital in developing a more holistic approach to patient management and critical care through appraisal of these roles, and resulting extension of the role of the midwife to encompass physiological assessment, understanding the effects of pregnancy on disease, interpretation of, and acting on, blood results including arterial gases, and development of the service through the development of guidelines and undertaking audits. The role of the midwife has been extended taking an overview of critical care of the mother, baby and family. The resulting development of the role of the obstetrician encompasses leadership, clinical knowledge, documentation, guideline development, risk management and the communication functions of debrief, audit and education. Development of the roles has reduced admissions to intensive care and increased patient satisfaction and adherence to policies at James Cook University Hospital. This paper provides a critical appraisal of this role development and discusses some of the lessons learned.

Training for prehospital obstetric emergencies

In this edition of the EMJ ( see page 457 ) Dobbie and Cooke1 review the most common causes of litigation against UK ambulance services. They conclude that the key clinical areas to be addressed are obstetric care, spinal injury assessment and decision-making regarding non-conveyance to hospital. As with hospital practice, prehospital obstetric incidents resulting in litigation made up a significant proportion of the more costly claims. In the period from December 1995 to April 2005 there were 13 obstetric cases out of the total 272 claims (4.8%). However, the average value of the obstetric cases was £815 000. For all claims, regardless of cause, there were 24 between £100 000 and £1 million and 17 valued at more than £1 million. Of the latter, four were obstetric cases, based on either an alleged failure to identify and manage a problem or lack of appropriate equipment for the treatment of a preterm baby. The largest claim from the total was for £3 375 000 and relates to an alleged lack of equipment to care for a baby born at 26 weeks. The development of paramedic practitioners, emergency care practitioners and treat and refer guidelines for paramedics may be beginning to address concerns about the accuracy of decisions related to non-conveyance of patients seen by ambulance services.2 The introduction of guidelines for ruling out cervical spine injury should, conversely, focus the attention of practitioners on …

Pre-Hospital Obstetric Emergency Training: The Practical Approach

Working Group. Contributors. Foreword. Preface. Acknowledgements. Contact details and website information. Chapter 1 Obstetric services. Chapter 2 Law, ethics and governance related to pregnancy. Chapter 3 Anatomical and physiological changes in pregnancy. Chapter 4 Normal delivery. Chapter 5 Structured approach to the obstetric patient. Chapter 6 Emergencies in early pregnancy and complications following gynaecological surgery. Chapter 7 Emergencies in late pregnancy Chapter 8 Emergencies after delivery. Chapter 9 Care of the baby at birth. Chapter 10 Management of non-obstetric emergencies. Chapter 11 Cardiac arrest and shock in pregnancy. Abbreviations. Glossary. References. Index.

Use of the cell salvage for re-infusion of autologous blood retrieved vaginally in a case of major postpartum haemorrhage

We report an index case which describes usage of vaginally retrieved autologous blood for cell salvage as a life-saving measure in the context of a major postpartum haemorrhage in a Jehovah’s Witness patient refusing donor blood transfusion. Intraoperative blood cell salvage is a well established efficacious technique for blood replacement and can be life-saving particularly in patients refusing allogeneic blood products [1–3]. Despite initial concerns of its use in obstetrics because of the theoretical risk of amniotic fluid embolism and haemolytic disease in future pregnancies, it is considered to be safe when used during caesarean sections [1–3]. Vaginal blood is traditionally perceived as possibly contaminated and hence the re-infusion of salvaged vaginal blood has not been routinely practised. A 35 year old Jehovah’s Witness presented at term with a previous history of postpartum haemorrhage. Her advance directive implied that she did not accept blood or primary blood components, but accepted minor fractions of blood and cell salvage. Her medical risk factors included a body mass index of 43, penicillin allergy and previous colitis. Antenatally she received oral iron and her haemoglobin was 13.3 g/dl. She was admitted in spontaneous labour. In view of an intrapartum pyrexia, she received intravenous cefuroxime and metronidazole. An epidural was sited during the active phase of labour and following augmentationwith syntocinon a spontaneous vaginal delivery of a healthy 3.8 kg male baby was achieved. Despite primary prevention of blood loss with oxytocin, she required a manual removal of her placenta which was complicated by major postpartum haemorrhage. At 40 min postpartum, the major haemorrhage alert call was activated due to ongoing blood loss and the low haemacue reading which was 8.3 g/dl.The bleeding was not controlled despite the use of Misoprostol, Syntocinon infusion, Ergometrine, four doses of carboprost, tranexamic acid, 4 units of fresh frozen plasma and recombinant Factor VII. In view of the life-threatening situation, the benefits of the autologous transfusionwas considered to outweigh the potential risk of infection and the small risk of amniotic fluid embolism, and a joint decision was made by 2 obstetricians to re-infuse the vaginally salvaged blood. Prior to the manual removal of the placenta, the perineum and vagina had been cleaned with aseptic precautions and covered with sterile drapes. The vaginal blood was retrieved directly via a wide bore suction cannula. Large blood clots retrieved vaginally were collected in a sterile dish under aseptic precautions, fromwhich it was re-cycled and processed by the cell salvage machine (Haemonetics). She was transfused 380 ml of re-cycled blood processed with leucocyte-depletion filter. Intraoperatively, she had received further doses of cefuroxime and metronidazole.