Marrit Smit

Pulse oximetry in newborns with delayed cord clamping and immediate skin-to-skin contact

Objective To assess whether defined reference ranges of oxygen saturation (SpO2) and heart rate (HR) of term infants after birth also apply for infants born after midwifery supervised uncomplicated vaginal birth, where delayed cord clamping (DCC) and immediate skin to skin contact (ISSC) is routine management. Design Prospective observational study. Setting and patients Infants born vaginally after uncomplicated birth, that is, no augmentation, maternal pain relief or instrumental delivery. Interventions Midwives supervising uncomplicated birth at home or in hospital in the Leiden region (The Netherlands) used an oximeter and recorded SpO2 and HR in the first 10 min after birth. Main outcome measures SpO2 and HR values were compared to the international defined reference ranges. Results In Leiden, values of 109 infants were obtained and are comparable with previously defined reference ranges, except for a higher SpO2 (p<0.05) combined with a slower increase in the first 3 min. The Leiden cohort also had a lower HR (p<0.05) during the first 10 min with a slower increase in the first 3 min. In the first minutes after birth, tachycardia (HR>180 bpm) occurred less often, and a bradycardia (<80 bpm) more often (p<0.05). Conclusions Defined reference ranges can be used in infants born after uncomplicated vaginal birth with DCC and ISSC, but higher SpO2 and lower HR were observed in the first minutes.

Adapted protocol for pulse oximetry screening for congenital heart defects in a country with homebirths.

Pulse oximetry has been recommended for neonatal screening for critical congenital heart defects (CCHD) and is now performed in several countries where most births take place in hospital. However, there is a wide variation in perinatal care in European countries, and studies are now recommended to determine the accuracy and cost-effectiveness of CCHD screening in individual countries. In the Netherlands, a large part of births are supervised by a community-based midwife, at home or at policlinics. A screening protocol has been developed to fit into the Dutch perinatal setting, and also has the potential to increase safety in homebirths. Conclusion: the provided protocol might be useful for other countries that are planning to implement CCHD screening after homebirths or early discharge from hospital.

Postpartum haemorrhage in midwifery care in the Netherlands: validation of quality indicators for midwifery guidelines

BackgroundPostpartum haemorrhage (PPH) is still one of the major causes of severe maternal morbidity and mortality worldwide. Currently, no guideline for PPH occurring in primary midwifery care in the Netherlands is available. A set of 25 quality indicators for prevention and management of PPH in primary care has been developed by an expert panel consisting of midwives, obstetricians, ambulance personal and representatives of the Royal Dutch College of Midwives (KNOV) and the Dutch Society of Obstetrics and Gynecology (NVOG). This study aims to assess the performance of these quality indicators as an assessment tool for midwifery care and suitability for incorporation in a professional midwifery guideline.MethodsFrom April 2008 to April 2010, midwives reported cases of PPH. Cases were assessed using the 25 earlier developed quality indicators. Quality criteria on applicability, feasibility, adherence to the indicator, and the indicator’s potential to monitor improvement were assessed.Results98 cases of PPH were reported during the study period, of which 94 were analysed. Eleven indicators were found to be applicable and feasible. Five of these indicators showed improvement potential: routine administration of uterotonics, quantifying blood loss by weighing, timely referral to secondary care in homebirth and treatment of PPH using catherisation, uterine massage and oxytocin and the use of oxygen.ConclusionsEleven out of 25 indicators were found to be suitable as an assessment tool for midwifery care of PPH and are therefore suitable for incorporation in a professional midwifery guideline. Larger studies are necessary to confirm these results.

Current Practice of Cord Clamping in The Netherlands: A Questionnaire Study

Background: Recent meta-analyses recommend delayed cord clamping (DCC) after uncomplicated births as well as preterm births, but there is no clear definition of timing and uniform national guidelines are lacking. Objective: We aimed to investigate if guidelines for the timing of cord clamping (CC) are followed and what the national practice entails. Methods: A postal questionnaire concerning CC after uncomplicated vaginal, Caesarean term and preterm deliveries was sent to all midwifery practices (n = 526) and obstetrical departments (n = 94) in the Netherlands. Results: The response rate was 81% (500/620). CC protocols were present in 16 and 38% of midwifery and obstetric practices, respectively. Early cord clamping (ECC) was recommended in 54%, DCC in 33%, 6% indicated a specific time point and 7% did not specify. In current practice, DCC was applied after uncomplicated vaginal term deliveries in 90% and ECC in 6%, and no timing was specified in 4%. Midwives used DCC more often than obstetricians (97 vs. 75%). Cessation of cord pulsations was often (54%) used as a time point, 40% used a fixed time point, 2% waited for placental expulsion and 4% did not specify. ECC was preferred in obstetric practices after Caesarean deliveries (in 81%). In preterm births, ECC was practised by 36%, DCC by 54 and 10% did not specify. Conclusion: In the Netherlands, although often not protocolized, DCC is widely used after uncomplicated vaginal term and preterm deliveries, but not after Caesareans. Cessation of cord pulsation is often used as the time point for CC.

Low signal quality pulse oximetry measurements in newborn infants are reliable for oxygen saturation but underestimate heart rate

We assessed the influence of system messages (SyMs) on oxygen saturation (SpO2) and heart rate measurements after birth to see whether clinical decision‐making changed if clinicians included SyM data.

Survey of prophylactic use of uterotonics in the third stage of labour in the Netherlands

OBJECTIVE aim of this study was to investigate current knowledge and practice regarding AMTSL in midwifery practices and obstetric departments in the Netherlands. DESIGN web-based and postal questionnaire. SETTING in August and September 2011 a questionnaire was sent to all midwifery practices and all obstetric departments in the Netherlands. PARTICIPANTS all midwifery practices (528) and all obstetric departments (91) in the Netherlands. MEASUREMENTS AND FINDINGS the response was 87.5%. Administering prophylactic uterotonics was seen as a component AMTSL by virtually all respondents; 96.1% of midwives and 98.8% of obstetricians. Cord clamping was found as a component of AMTSL by 87.4% of midwives and by 88.1% of obstetricians. Uterine massage was only seen as a component of AMTSL by 10% of the midwives and 20.2% of the obstetricians. Midwifery practices routinely administer oxytocin in 60.1% of births. Obstetric departments do so in 97.6% (p<0.01). Compared to 1995, the prophylactic use of oxytocin had increased in 2011 both by midwives (10-59.1%) and by obstetricians (55-96.4%) (p<0.01). KEY CONCLUSIONS prophylactic administration of uterotonics directly after childbirth is perceived as the essential part of AMTSL. The administration of uterotonics has significantly increased in the last decade, but is not standard practice in the low-risk population supervised by midwives. IMPLICATIONS FOR PRACTICE the evidence for prophylactic administration of uterotonics is convincing for women who are at high risk of PPH. Regarding the lack of evidence of AMTSL to prevent PPH in low risk (home) births, further research concerning low-risk (home) births, supervised by midwives in industrialised countries is indicated. A national guideline containing best practices concerning management of the third stage of labour supervised by midwives, should be composed and implemented.

Shoulder dystocia in primary midwifery care in the Netherlands

In the Netherlands, low‐risk pregnancies are managed by midwives in primary care. Despite strict definitions of low risk, obstetric complications can occur. Midwives seldom encounter uncommon labour complications, but are sufficiently trained to manage these. We assessed neonatal and maternal outcome after management of shoulder dystocia in primary midwifery care.

Ambulance Transfer in Case of Postpartum Hemorrhage after Birth in Primary Midwifery Care in The Netherlands: A Prospective Cohort Study.

BACKGROUND The objective of this prospective cohort study was to assess whether the 45-minute prehospital limit for ambulance transfer is met in case of postpartum hemorrhage (PPH) after midwifery-supervised home birth in The Netherlands and evaluate the process of ambulance transfer, maternal condition during transfer, and outcomes in relation to whether this limit was met. METHODS Using ambulance report forms and medical charts, ambulance intervals, urgency coding, clinical condition (using the lowest Revised Trauma Score, [RTS]), and maternal outcomes were collected. From April 2008 to April 2010, midwives reported 72 cases of PPH. Associations between duration of the ambulance transfer, maternal condition during ambulance transfer and outcomes were analyzed. The main outcome measures were duration of ambulance transfer, RTS, blood loss, surgical procedures, and blood transfusions. RESULTS Seventy-two cases were reported, 18 (25%) were excluded: 54 cases were analyzed. In 63 percent, the 45-minute prehospital limit was met, 75.9 percent received a RTS of 12, indicating optimal Glasgow Coma Scale, systolic blood pressure, and respiratory frequency. In 24.1 percent a decrease in systolic blood pressure was found (RTS 10 or 11). We found no difference in outcomes between women with different RTS or in whom the 45-minute prehospital limit was or was not met. CONCLUSIONS We found no relation between the duration of ambulance transfer and maternal condition or outcomes. All women fully recovered. The low-risk profile of women in primary care, well-organized midwifery, and ambulance care in The Netherlands are likely to contribute to these findings.

Net Environmental - Economic Benefit Analysis Model

ABSTRACT To be able to compare various response strategies for oil spill response a Net Environmental – Economic Benefit Analysis model (NEEBA) has been developed by TNO. This model consists of an oil behaviour module, a response module and an ecological effect module. In the oil behaviour module a quantitative division of the oil volume over the different compartments (air, water surface and water column) is determined on the basis of spreading, transport and weathering. This module determines also the fate of the remaining oil after one of the response options has been applied. With the ecological effect module the effects on organisms at the water surface, in the water column and on the sea floor are determined. In order to come up with one benefit score a simplified weighing method has been chosen to compare the effects on different species. The NEEBA score is therefore expressed in costs, using the costs of fish as basis. The “costs” of the other organisms in relation to fish are dependent on their p...

5ICCN_017: Feasibility study of pulse oximetry screening for critical congenital heart defects after home births in the Netherlands

Background and aims Cardiovascular compromise is associated with poor outcome in the preterm neonate, with gestational age and male sex as independent risk factors for hypotension, developmental injury and death. Recent work has highlighted the microvasculature as important in the development of cardiovascular compromise in the preterm. We aimed to further characterise microvascular changes that occur in the preterm newborn, identify potential windows for therapeutic intervention and explore the mechanisms underlying this dysfunction. Methods Preterm neonates were studied during circulatory transition. Microvascular blood flow was characterised over time by laser Doppler. We developed a guinea pig model for studying the mechanisms underlying regulation of blood flow (delivery at GA62/71) and also undertook studies in the preterm piglet. Results We observed significantly different patterns of microvascular tone regulation between male and female human (p = 0.01) and guinea pig (p = 0.01) neonates. Overproduction of vasodilators (carbon monoxide r = 0.495; p < 0.001; hydrogen sulphide r = 0.37, p = 0.0004), and decreased sympathetic nervous activity (r = 0.424, p = 0.025) was associated with increased microvascular flow. We were additionally able to characterise aspects of this physiology in the preterm piglet. Conclusions We propose a paradigm shift whereby inherent physiological differences between the preterm and term, and male and female, lead to inappropriate dilatation of the microvasculature, insufficient preload to the struggling myocardium and functional hypovolaemia, thus resulting in central hypotension and cardiovascular compromise. We now have evidence of many of the mechanisms underlying this dysregulation and propose future research be directed at interventional opportunities.