The midforceps: maternal and neonatal outcomes

A retrospective review of midforceps deliveries occurring between 1976 and 1982 at a county teaching hospital is presented. Midforceps deliveries were performed in 0.8% of deliveries (176 of 21,414) during this period, a rate reflecting the general admonition against potentially traumatic injury to the infant. Under these conditions, midforceps deliveries were associated with active and second-stage labor abnormalities, abnormal fetal heart rate patterns, maternal perineal lacerations, low 1-minute Apgar scores, and neonatal cephalohematomas more frequently than were deliveries of the remainder of the patients. Epidural anesthesia was significantly associated with midforceps deliveries. Midforceps patients were matched to similar groups who were delivered by cesarean section or low forceps or who had spontaneous births. The findings do not document an increase in short-term neonatal morbidity in the midforceps group under the conditions described.     

The Shenandoah University Midwifery Initiative: a model for midwifery education

There has been a significant decline in the number of nurse-midwifery education programs in the United States in the past decade. This decline presents a challenge as the profession seeks to respond to the Pew Foundation's call to increase access to midwifery care in the United States. Collaborative arrangements between universities that house nurse-midwifery programs and other universities in the region could be an effective strategy to increase access to nurse-midwifery education, thereby increasing access to nurse-midwifery care.     

Maternal and neonatal outcomes in advanced maternal age: a retrospective cohort study

Objectives: To describe the effect of extremely advanced maternal age (EAMA) on maternal/neonatal outcomes.

Methods: This was a case-control study in which 127 women ≥40 years at the time of delivery out of 2853 singleton hospital deliveries in Ondokuz Mayis University between 1 January 2008 and 31 August 2010 constituted the study group. One hundred and twenty-seven else were chosen randomly out of 2412, 21–35 years old women, via a computer system as controls. Demographic features of 254 mothers and infants as well as maternal and neonatal complications were recorded.

Results: Mean maternal age was 41.5?±?1.9 (40–49) years in EAMA group and 28.9?±?4.2 (21–35) years in controls. Primigravidity was 19.6% in the EAMA group, whereas 37.8% in controls (p?=?0.003). No difference was found between groups according to route of delivery, stillbirth, preterm birth, congenital abnormalities, gender of babies, NICU admission and respiratory problems (for all p?>?0.05). A 5th min Apgar score <7 was more frequent in babies born to EAMA mothers compared to controls (9.8% versus 4.9%, p?=?0.004).

Conclusion: The present study shows that EAMA mothers and their offsprings have similar peri and neonatal risks compared to younger mothers, except lower 5th minute Apgar scores. We conclude that with good perinatal care, EAMA women and their babies can pass through the perinatal period with similar risks of younger women.     

Case series of multiple repeat caesarean sections: operative,maternal, and neonatal outcome

Objective: The objective of this study is to review the maternal and neonatal morbidity and mortality associated with six or more caesarean section (CS).

Methods: We conducted a retrospective chart review, at King Abdulaziz University Hospital (KAUH) in Jeddah, for all patients admitted between 2000 through 2010 and identified five patients having more than six CS deliveries.

Results: Deliveries occurred in the ranges of 31–38 weeks, from which four cases required emergency CS. There were two cases in the series with a placenta previa. There was a single case of uterine dehiscence. Only one case required a blood transfusion and was complicated with a placenta accreta, bladder injury, urinary tract infection, and prolonged maternal hospital stay with neonatal intensive care unit (NICU) admission. All cases had moderate to severe adhesion intra-operatively. Operative time was long in all cases with a range 55–106?min. One of the five cases had a postoperative wound infection. Finally, none of the current series showed fetal or maternal mortalities.

Conclusions: The long-term complications associated with CS should be discussed with patients in the first and subsequent pregnancies. This case series highlighted the outcomes in these unique cases of higher order caesareans.     

Innovations in Midwifery Education: The Academic Medical Center Model

Workforce analyses project a need for women's health care providers, especially in maternity care. With a stagnant number of certified nurse‐midwife/certified midwife (CNM/CM) education programs, the present production of new CNMs/CMs is not robust enough to meet the growing demand. This article describes an existing but underutilized model for CNM/CM education programs, based in an academic medical center with an existing academic affiliation. Advantages include a federal funding source through the Centers for Medicare and Medicaid Services, lower tuition costs than most current programs, and expanded job satisfaction for CNMs/CMs in clinical practice.     

Pictorial maternal and neonatal records for illiterate traditional birth attendants

A pictorial card was devised for illiterate traditional birth attendants to record the important events during pregnancy, childbirth and the neonatal period. Between October 1979 and July 1980, traditional birth attendants from 15 villages completed 88 pictorial records. The card has served successfully as a prompting device to ensure continuing maternal and newborn care.     

Costs of maternal and neonatal medical care for triplet and quadruplet pregnancies in Japan

Aims  It is well documented that maternal morbidity and neonatal morbidity and mortality increase alike in high-order multiple (HOM) births. There have, however, been few reports concerning the costs of maternal and neonatal medical care associated with HOM births. This is the first such report on the situation in Japan. Materials and methods  All triplet and quadruplet pregnancies managed at this institution from before 16 weeks’ gestation, and delivered at no earlier than 22 weeks’ gestation, between 1997 and 2002 were included. Prophylactic cervical ligature, hospitalization to prevent premature labor from 23 weeks’ gestation until delivery, and delivery by cesarean section, were all routine for HOM pregnancies. All women with singleton and twin pregnancies, who underwent in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) and also delivered their babies at no earlier than 22 weeks’ gestation at this institution, between 1997 and 2002, were also examined as controls. Prophylactic cervical ligature, preventive hospitalization, and cesarean section were not routine in the control group. Results  The average gestational ages at delivery in singleton (n = 58), twin (n = 21), triplet (n = 14) and quadruplet (n = 1) pregnancies, were 39.4, 35.6, 31.9 and 25.1 weeks, respectively (P < 0.001 by Anova). Birthweights were 2886 ±425 g, 2117 ± 623 g, 1430 ± 373 g, and 633 ± 77 g (mean ± SD), respectively (P < 0.001). The average inpatient medical care cost for mother and child(ren), from maternal admissions after 12 weeks’ gestation to the discharge of all family members from hospital, was ￥703 279 yen (∼US$5861), ￥4 903 270 (∼US$40 861), ￥11 810 327 (∼US$98 419), and ￥44 961 000 (∼US$374 675), respectively (P< 0.001). Conclusion  The present study outlined the high costs of medical care for HOM pregnancies. Not only from a medical viewpoint, but also from the viewpoint of medical costs, it is important to avoid HOM pregnancies as a result of infertility treatment.     

Emergency Birth Hybrid Simulation with Standardized Patients in Midwifery Education: Implementation and Evaluation

Structured simulations have become a critical part of health professions education at every level, particularly for high‐risk, low‐incidence scenarios. This article describes the implementation and evaluation of a hybrid simulation of emergency birth situations in a graduate midwifery program. In the fall of 2011 and spring of 2012, nurse‐midwifery students twice participated in 2 simulated emergencies—shoulder dystocia and postpartum hemorrhage—using hybrid simulation (a standardized patient paired with a birth task trainer). Students found the simulations to be realistic. The use of best practices (ie, repetitive practice, team learning, small group debriefing, and large group debriefing) enhanced the quality of the simulation experience and the learners’ reflection about their professional skills, strengths, weaknesses, and confidence in managing these 2 obstetric emergencies. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.     

International service learning in midwifery and nursing education

The health of women and childbearing families is a global concern that must be addressed if we are to be successful in ensuring healthy families. Numerous strategies have been suggested to increase appreciation for the global factors that influence maternal and child health and the overall health status of a community. Inclusion of cultural content in courses offered in educational programs and provision of clinical learning experiences in diverse communities have commonly been used in midwifery and nursing education. This article reviews the concept of service learning and its application in a course that provides an opportunity for students to participate in an international immersion program. Evaluation of the course found that participants increased their knowledge and skills in providing reproductive health care, developed appreciation for the knowledge and skills of traditional birth attendants, and expanded their world view of women and families in communities.     

Impact of advanced maternal age on neonatal survival of twin small-for-gestational-age subtypes

AIM: We examined the impact of advanced maternal age (>40 years old) on the survival of twin small-for-gestational-age (SGA) infants, that is, infants who were smaller in size than was expected for the baby's sex, genetic heritage, and gestational age. METHODS: The present study was a retrospective cohort study on twin live births in the USA from 1995 to 1998 inclusive. Two categories of SGA babies were defined: discordant (when only one of a twin pair was SGA) and concordant (when both were SGA). Otherwise, the twin pair was appropriate-for-gestational-age (AGA) concordant. RESULTS: 192,195 twin pairs were analyzed. The incidence of SGA discordance and concordance was 11.8% and 3.9%, respectively. The occurrence of both SGA subtypes tended to decrease with increasing maternal age. The unadjusted risk for neonatal mortality increased when both twins were affected (15.8: 22.8 and 56.6 per 1000 among AGA concordant, SGA discordant and SGA concordant twins; P-value for trend < 0.0001). Using maternal-age-specific AGA babies as reference, the adjusted risk for neonatal mortality climbed progressively with advancing maternal age in a dose-dependent pattern, being lowest among teenagers and highest in mothers aged > or =40 years. CONCLUSIONS: SGA discordance and concordance declined with advancing maternal age. In contrast, neonatal mortality of both SGA subtypes worsened with the increase in maternal age compared with that of the age-specific AGA infants. These findings are potentially useful to care providers in counseling older women, a group that is progressively increasing in size and is most susceptible to twining.     

Workshop for New Leaders: Innovative Midwifery Teaching for Obstetrics and Gynecology Residents

The Workshop for New Leaders represents an innovative project undertaken by the midwifery faculty at a teaching hospital in New England. The midwifery faculty sought to expand their educational offerings to the obstetrics and gynecology residents. Utilizing creative thinking strategies, the idea for a leadership workshop was originated in an effort to augment the professionalism curriculum mandated by the Accreditation Council of Graduate Medical Education for residents. Over time, this workshop has become a highlight for each class. Not only has this workshop facilitated transition from learner to leader as the residents approach their final year of training, it has also helped to enhance interprofessional relationships. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.     

Mode of delivery in the preterm gestation and maternal and neonatal outcome

Objective.?To determine if the mode of delivery in preterm gestations is associated with changes in maternal and neonatal outcome.

Methods.?A retrospective cohort study that included all singleton deliveries occurring after spontaneous onset of labour between 25?+?0 and 32?+?6 weeks of gestation. Cases of early preterm delivery were identified from clinical records and classified according to the mode of delivery. The following outcomes were derived for each case and compared between caesarean and vaginal deliveries: perinatal death, cranial findings compatible with haemorrhage or white matter disease in the neonate, new-onset of maternal severe anaemia or pyrexia.

Results.?From 1990 to 2007, 109 cases of spontaneous preterm labour were retrospectively selected, including 50 (45.8%) caesarean sections and 59 (54.2%) vaginal deliveries. Perinatal death occurred in 10 infants (9.1%), whereas among survivors abnormal cerebral findings were detected in 20, including 6 cases with haemorrhage, 12 with white matter findings and 2 with both. At multiple logistic regression, a birthweight lower than 1100?g was the only predictor of all adverse outcomes, whereas male sex increased the risk of white matter findings. Caesarean section compared to vaginal delivery conferred a higher risk of maternal complications (23/50 or 46% vs. 6/59 or 10.2%; OR: 11.9, CI 95%: 4.2–333; p?<?0.0005).

Conclusions.?In severely premature infants born after spontaneous onset of labour, the risk of adverse perinatal outcome does not seem to depend upon the mode of delivery, whereas the risk of maternal complications is significantly increased after Caesarean section.