Leroy C. Edozien

Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study.

Objective To determine whether the variation in unadjusted rates of caesarean section derived from routine data in NHS trusts in England can be explained by maternal characteristics and clinical risk factors. Design A cross sectional analysis using routinely collected hospital episode statistics was performed. A multiple logistic regression model was used to estimate the likelihood of women having a caesarean section given their maternal characteristics (age, ethnicity, parity, and socioeconomic deprivation) and clinical risk factors (previous caesarean section, breech presentation, and fetal distress). Adjusted rates of caesarean section for each NHS trust were produced from this model. Setting 146 English NHS trusts. Population Women aged between 15 and 44 years with a singleton birth between 1 January and 31 December 2008. Main outcome measure Rate of caesarean sections per 100 births (live or stillborn). Results Among 620u2009604 singleton births, 147u2009726 (23.8%) were delivered by caesarean section. Women were more likely to have a caesarean section if they had had one previously (70.8%) or had a baby with breech presentation (89.8%). Unadjusted rates of caesarean section among the NHS trusts ranged from 13.6% to 31.9%. Trusts differed in their patient populations, but adjusted rates still ranged from 14.9% to 32.1%. Rates of emergency caesarean section varied between trusts more than rates of elective caesarean section. Conclusion Characteristics of women delivering at NHS trusts differ, and comparing unadjusted rates of caesarean section should be avoided. Adjusted rates of caesarean section still vary considerably and attempts to reduce this variation should examine issues linked to emergency caesarean section.

Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors.

To describe the trends of severe perineal tears in England and to investigate to what extent the changes in related risk factors could explain the observed trends.

Not-patient and not-visitor: A metasynthesis fathers’ encounters with pregnancy, birth and maternity care

INTRODUCTIONnthe active engagement of fathers in maternity care is associated with long-term health and social benefits for the mother, baby and family. The maternity care expectations and experiences of expectant and new fathers have received little attention to date.nnnAIMnto identify and synthesise good quality qualitative research that explores the views and experiences of fathers who have encountered maternity care in high resource settings.nnnMETHODSnbased on a pre-determined search strategy, relevant databases were searched for papers published between January 1999 and January 2010. Backchaining of the reference lists in included papers was undertaken.nnnINCLUSION CRITERIAngood quality qualitative research studies exploring fathers involvement in maternity care through pregnancy, birth, and up to 6 months postnatally, that were undertaken in high resource countries. No language restrictions were imposed. ANALYTIC STRATEGY: the analysis was based on the metaethnographic techniques of Noblit and Hare (1988) as amended by Downe et al. (2007).nnnFINDINGSnfrom 856 hits 23 papers were included. The emerging themes were as follows: risk and uncertainty, exclusion, fear and frustration, the ideal and the reality, issues of support and experiencing transition.nnnSYNTHESISnfathers feel themselves to be partner and parent but their experience of maternity care services is as not-patient and not-visitor. This situates them in an interstitial and undefined space (both emotionally and physically) with the consequence that many feel excluded and fearful.nnnCONCLUSIONSnfathers cannot support their partner effectively in achieving the ideal of transition to a successful pregnancy, joyful birth and positive parenthood experience unless they are themselves supported, included, and prepared for the reality of risk and uncertainty in pregnancy, labour and parenthood and for their role in this context.

Risk of placenta previa in second birth after first birth cesarean section: a population-based study and meta-analysis

BackgroundObjective: To compare the risk of placenta previa at second birth among women who had a cesarean section (CS) at first birth with women who delivered vaginally.MethodsRetrospective cohort study of 399,674 women who gave birth to a singleton first and second baby between April 2000 and February 2009 in England. Multiple logistic regression was used to adjust the estimates for maternal age, ethnicity, deprivation, placenta previa at first birth, inter-birth interval and pregnancy complications. In addition, we conducted a meta-analysis of the reported results in peer-reviewed articles since 1980.ResultsThe rate of placenta previa at second birth for women with vaginal first births was 4.4 per 1000 births, compared to 8.7 per 1000 births for women with CS at first birth. After adjustment, CS at first birth remained associated with an increased risk of placenta previa (odds ratio = 1.60; 95% CI 1.44 to 1.76). In the meta-analysis of 37 previously published studies from 21 countries, the overall pooled random effects odds ratio was 2.20 (95% CI 1.96-2.46). Our results from the current study is consistent with those of the meta-analysis as the pooled odds ratio for the six population-based cohort studies that analyzed second births only was 1.51 (95% CI 1.39-1.65).ConclusionsThere is an increased risk of placenta previa in the subsequent pregnancy after CS delivery at first birth, but the risk is lower than previously estimated. Given the placenta previa rate in England and the adjusted effect of previous CS, 359 deliveries by CS at first birth would result in one additional case of placenta previa in the next pregnancy.

Multiple complications following the use of prophylactic internal iliac artery balloon catheterisation in a patient with placenta percreta

The incidence of placenta praevia/accreta is increasing, placing women at significant risk of postpartum haemorrhage with associated morbidity and mortality. National guidelines recommend prophylactic placement of internal iliac artery balloon occlusion catheters for women with abnormal placentation. We describe an elective caesarean delivery in a patient with placenta percreta who underwent this technique. She developed bilateral pseudoaneurysms, unilateral arterial rupture and compromised vascular supply to her right leg secondary to thrombus formation, and suffered massive haemorrhage, both despite and as a result of intervention. This is the first case report of multiple complications in an obstetric patient after temporary internal iliac balloon occlusion in an elective setting.

Hysterectomy for benign conditions

Patients and doctors will benefit from evidence based guidelines nnI n contemporary clinical practice, patients should be given sufficient information about the reason for any treatment offered, the risks and benefits of the treatment, and the alternative options. For women undergoing hysterectomy, this ideal has scarcely been fulfilled. One reason for this has been the paucity of evidence on which to base counselling; the other is that gynaecologists, owing to limitations in their training, have not always been in a position to offer their patients a genuine choice of treatment options.nnHysterectomy has long been regarded as an operation performed by “hyster-happy,”1 mostly male, surgeons. The medical historian Roy Porter counted the rising tide of hysterectomies among manifestations of the “abuse of gynaecological surgery to control women” in the 19th century.2 Although campaigns against unnecessary hysterectomy have been vocal,3 this operation survived the feminist whirlwind of the mid to late 20th century and remains one of the most commonly performed operations in the world. In the United States, 600 …

Impact of third‐ and fourth‐degree perineal tears at first birth on subsequent pregnancy outcomes: a cohort study

To investigate, among women who have had a third‐ or fourth‐degree perineal tear, the mode of delivery in subsequent pregnancies as well as the recurrence rate of third‐ or fourth‐degree tears.

The timing of elective caesarean delivery between 2000 and 2009 in England

BackgroundIn 2004, the National Institute for Clinical Excellence (NICE) recommended that an elective caesarean section for an uncomplicated pregnancy should not be carried out before 39 completed weeks due to increased risk of respiratory morbidity in newborns. We describe the trends and variation across 63 English NHS trusts in the timing of elective caesarean section (CS) for low-risk singleton deliveries.MethodsWe identified elective CS deliveries between 1st April 2000 and 28th February 2009 in English NHS trusts using the Hospital Episode Statistics. We selected women with uncomplicated pregnancies who had an elective CS delivery after 34 completed weeks of gestation, and analysed the trends and the trust-level variation in the timing of elective CS. The impact of the NICE guidance on the monthly rate of elective CS deliveries performed after 39 weeks was estimated using an interrupted time-series design with autoregressive integrated moving average (ARIMA).ResultsThere were 118,456 elective CS deliveries at the 63 NHS trusts. The overall proportion of elective CS deliveries done after 39 completed weeks steadily increased from 39% in 2000/01 to 63% in 2008/09. The proportions rose from 43% to 67% for women with breech presentation and from 35% to 62% for women with a previous CS. There was significant variation across NHS trusts in each year; in 2008/09, with the proportions of elective CS done after 39 weeks ranging from 28% to 89% (Inter-quartile range limits: 54% to 72%). We found a small but statistically significant increase in the proportion immediately after the publication of the NICE guidance, but its rate of growth rate declined slightly thereafter.ConclusionsNHS trusts in our study have responded to the new evidence on the benefits of delaying elective CS to after 39 weeks gestation. However, substantial differences between NHS trusts remain, which indicates there is room for further improvement. We suggest that maternity services and commissioners adopt the timing of elective caesarean as a quality indicator to support clinical practice.

UK law on consent finally embraces the prudent patient standard

But it will take much more to change clinical practice

Antenatal mental health referrals: Review of local clinical practice and pregnant women׳s experiences in England

OBJECTIVEnto investigate (i) the consistency and completeness of mental health assessment documented at hospital booking; (ii) the subsequent management of pregnant women identified as experiencing, or at risk of, mental health problems; and (iii) womens experiences of the mental health referral process.nnnDESIGNnmixed methods cohort studynnnSETTINGnlarge, inner-city hospital in the north of EnglandnnnPARTICIPANTSnwomen (n=191) booking at their first formal antenatal appointment; mean gestational age at booking 13 weeks.nnnMETHODSnwomen self-completed the routine mental health assessment in the clinical handheld maternity notes, followed by a research pack. Documentation of mental health assessment (including assessment of depression symptoms using the Whooley and Arroll questions, and mental health history), mental health referrals and their management were obtained from womens health records following birth. Longitudinal semi-structured interviews were conducted with a purposive sub-sample of 22 women during and after pregnancy.nnnFINDINGSndocumentation of responses to the Whooley and Arroll questions was limited to the handheld notes and symptoms were not routinely monitored using these questions, even for women identified as possible cases of depression. The common focus of referrals was on the womens previous mental health history rather than current depression symptoms, assessed using the Whooley questions. Women referred to a Mental Health Specialist Midwife for further support were triaged based on the written referral and few met eligibility criteria. Although some women initially viewed the referral as offering a safety net, analysis of health records and subsequent interviews with women both indicated that communication regarding the management of referrals was inadequate and women tended not to hear back about the outcome of their referral.nnnKEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICEnmental health assessment was introduced without ensuring that identified needs would be managed consistently. Care pathways and practices need to encompass identification, subsequent referral and management of mental ill-health, and ensure effective communication with patients and between health professionals.