Risk factors and adverse pregnancy outcomes among births affected by velamentous umbilical cord insertion: a retrospective population-based register study

Objective

To identify risk factors associated with velamentous cord insertion (VCI) and to evaluate the association between adverse pregnancy outcomes and VCI in singleton pregnancies.

Study design

The total population of women (n = 26,849) with singleton pregnancies delivered in Kuopio University Hospital during the study period between 2000 and 2011 was reviewed. Risk factors and the risk of adverse pregnancy outcomes (admission to a neonatal unit, fetal death, preterm delivery, low birth weight (LBW < 2500 g), the infant being small for its gestation age (SGA), low Apgar scores (<7) at 1 and 5 min and fetal venous pH < 7.15) were evaluated separately among women with and without VCI by means of logistic regression analyses.

Results

The incidence of VCI among women with singleton pregnancies was 2.4% (n = 633 of 26,849). Independent risk factors for VCI were nulliparity, obesity, fertility problems, placenta previa and maternal smoking. VCI was associated with a 1.38-, 2.01-, 3.93- and 1.39-fold increased risk of admission to a neonatal unit, preterm delivery (<37 gestation weeks), LBW and SGA, respectively compared to pregnancies involving normal cord insertion. Of the women with VCI, 15.3% underwent non-elective cesarean section compared to 8.3% (p ≤ 0.001) of women without VCI.

Conclusions

The results suggest that the incidence of VCI increases along with an increase in fertility problems and maternal obesity. VCI is a moderate risk condition increasing the risks of prematurity and impaired fetal growth.     

Patient safety in obstetrics

Obstetrical care providers are highly trained, highly skilled professionals working with complex systems in an unpredictable environment. Perinatal units have many built-in mechanisms that work to prevent errors from occurring. Unintentional failures usually are the result of a chain of events, almost never from a single cause or a single provider. Within most unintentional failures, there is usually no single explanatory cause for the event. Rather, there is a complex interaction between a varied set of systems, including human behavior, performance and interdependency, technological aspects, socio-cultural factors, and a range of organizational and procedural weaknesses. To enable meaningful analysis of the underlying causes of an adverse event, errors and near-misses must be made visible. The challenge lies in the integration of labor and delivery clinical core business with high-reliability organization principles. The human factors knowledge should be considered a required part of the undergraduate and postgraduate medical education. Safety science and human factors engineering need to be applied to perinatal care, and each health care professional should be able to recognize the basic theories, rules, and principles. Business and industry provide many lessons for perinatal care when focusing on error prevention through standardization, information technology, and, last but not least, acknowledging the relationship between team-building and improved performance. This will allow all obstetrical caregivers to build and maintain confidence and competency in their daily clinical activities, which ultimately is believed to result in reduction of clinical error. This review on current patient safety issues as they are applicable to the field of perinatal care attempts to create a sense of urgency towards the creation of a safety-conscious culture in obstetrics. Such a culture fosters a collective approach of responsibility to learn and improve constantly. This process takes time to develop and requires dedicated and highly visible leadership support at every level.     

Influence of Resident Involvement in Obstetrics and Gynaecology Surgery on Surgical Outcomes: Systematic Review and Meta-Analysis

Objective

The effect of resident involvement during obstetrics and gynaecology (OB/GYN) surgery on surgical outcomes is unclear. This study sought to review the evidence systematically for the influence of resident participation in OB/GYN surgery on (1) operative time, (2) estimated blood loss, and (3) perioperative complications.

Risk and safety in context: medical pluralism and agency in childbirth in an eastern Moroccan oasis

This article aims to improve the understandings of safety and risk in childbirth in Morocco from a critical medical anthropological perspective. It is based upon nine weeks' of fieldwork undertaken in the town of Ifli,¹ an oasis in Eastern Morocco, on the border with Algeria. Ethnographic material stemmed mainly from participant observation and semi-structured interviews conducted between April and July 2009. This research sheds light on the interplay between the socio-cultural context and the broader political economy of health in shaping the knowledge and practices of childbirth. The core issues emerging from the fieldwork are the local concepts of risk in the birthing process through mothers’ and birth attendants’ experiences within medical pluralistic frames of reference. This article shall argue that ethnographic insights can play a crucial role not only in understanding socio-cultural dimensions of childbirth, but also in implementing novel approaches to reproductive health care in this area, such as the exchange of experiences between trained and local, non-trained midwives.²     

Mother-to-Child Transmission of HIV in Canada: A Population Health Risk Management Perspective

The standard of prenatal care in Canada for preventing transmission of the human immunodeficiency virus (HIV) from mother to infant is universal counselling and voluntary testing of pregnant women for the virus. Appropriate treatmentof HIV-positive women reduces the risk of viral transmission to the infant to less than 1%. Despite this, too many children in Canada are born with HIV because their mothers were not tested. The barriers to screening include lack of appropriate resources and lack of training in this area. As a result, physicians find HIV test-counselling too time-consuming or believe that testing is not relevant to their patient population. Risk management strategies to improve screening rates and decrease transmission, including community action and technological strategies such as vaccines and rapid testing kits, are reviewed. The "advisory" option, the process of risk communication between health-care providers, the government, and the public, for the purpose of making recommendations, is a key component toward the success of universal screening. A shift to simplified screening and "opt-out" testing procedures is recommended.     

Risk factors for Toxoplasma gondii infection in mothers of infants with congenital toxoplasmosis: Implications for prenatal management and screening

OBJECTIVE: The purpose of this study was to determine whether demographic characteristics, history of exposure to recognized transmission vehicles, or illness that was compatible with acute toxoplasmosis during gestation identified most mothers of infants with congenital toxoplasmosis. STUDY DESIGN: Mothers of 131 infants and children who were referred to a national study of treatment for congenital toxoplasmosis were characterized demographically and questioned concerning exposure to recognized risk factors or illness. RESULTS: No broad demographic features identified populations that were at risk. Only 48% of mothers recognized epidemiologic risk factors (direct or indirect exposure to raw/undercooked meat or to cat excrement) or gestational illnesses that were compatible with acute acquired toxoplasmosis during pregnancy. CONCLUSION: Maternal risk factors or compatible illnesses were recognized in retrospect by fewer than one half of North American mothers of infants with toxoplasmosis. Educational programs might have prevented acquisition of Toxoplasma gondii by those mothers who had clear exposure risks. However, only systematic serologic screening of all pregnant women at prenatal visits or of all newborn infants at birth would prevent or detect a higher proportion of these congenital infections.     

Application of a Risk Management Framework to Parent Sleep During Skin-to-Skin Care in the NICU

As NICU staff work to increase the frequency, duration, and comfort of skin-to-skin care (SSC) sessions, barriers to implementation are frequently encountered. Safety concerns are often raised when parents fall asleep during SSC intentionally or unintentionally. We present a risk management framework that we use in clinical practice to address risk related to parent sleep during SSC. Our approach is based on the steps of the Risk Management Life Cycle, which include the following: establish context, identify risk, analyze risk, respond to risk, and monitor and adapt response to risk. Clinicians may use this framework in clinical practice to manage risks related to prolonged SSC, specifically when parents relax and fall asleep during SSC.     

Consensus Statement No. 434: Simulation in Obstetrics and Gynaecology

ObjectiveTo provide a comprehensive and current overview of the evidence for the value of simulation for education, team training, patient safety, and quality improvement in obstetrics and gynaecology, to familiarize readers with principles to consider in developing a simulation program, and to provide tools and references for simulation advocates.Target populationProviders working to improve health care for Canadian women and their families; patients and their families.OutcomesSimulation has been validated in the literature as contributing to positive outcomes in achieving learning objectives, maintaining individual and team competence, and enhancing patient safety. Simulation is a well-developed modality with established principles to maximize its utility and create a safe environment for simulation participants. Simulation is most effective when it involves interprofessional collaboration, institutional support, and regular repetition.Benefits, Harms, and CostsThis modality improves teamwork skills, patient outcomes, and health care spending. Upholding prescribed principles of psychological safety when implementing a simulation program minimizes harm to participants. However, simulation can be an expensive tool requiring human resources, equipment, and time.EvidenceArticles published between 2003 and 2022 were retrieved through searches of Medline and PubMed using the keywords “simulation” and “simulator.” The search was limited to articles published in English and French. The articles were reviewed for their quality, relevance, and value by the SOGC Simulation Working Group. Expert opinion from relevant seminal books was also considered.Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).Intended AudienceAll health care professionals working to improve Canadian women’s health, and relevant stakeholders, including granting agencies, physician/nursing/midwifery colleges, accreditation bodies, academic centres, hospitals, and training programs.Recommendations

• 1.Health care professionals in obstetrics and gynaecology should understand the value of both in situ and off-site simulation as a tool for education, patient safety, and quality improvement at both the team and individual levels (strong, moderate).
• 2.Health care professionals in obstetrics and gynaecology should be aware of the overall cost reduction associated with the use of simulation (strong, moderate).
• 3.Stakeholders at all levels must commit to an ongoing simulation program, including identifying, training, and supporting simulation advocates, as well as securing adequate funding. This approach leads not only to organizational readiness but also to quality improvement and positive culture change (strong, moderate).
• 4.Providers of obstetrical and gynaecological care should be familiar with key simulation modalities and principles of how to advance knowledge using simulation (conditional, low).
• 5.Purposeful simulation activities must be based on local needs assessments and knowledge gaps (conditional, low).
• 6.Interprofessional/interdisciplinary teams should participate in the design, implementation, and evaluation of team training and in situ simulation programs (strong, high).
• 7.Debriefing must be promoted as a fundamental component of the experiential learning process. Team debriefing/peer debriefing with a written guide can be as effective (as an alternative) as expert debriefing (strong, high).
• 8.Psychological safety must be established for all personnel within the simulation and the debriefing (strong, moderate).
• 9.Program evaluation, a system to measure the efficacy of a learning activity, must be included in the planning of simulation activities to assess whether the targeted outcomes of the program were achieved (strong, moderate).
• 10.Simulation-based activities should be designed in a culturally sensitive and socially responsible way, similar to all other aspects of health professionals’ education (strong, low).

     

A multisite audit to assess how women with complex social factors access and engage with maternity services

Objectiveto audit women with socially complex lives’ documented access to and engagement with antenatal care provided by three inner city, UK maternity services in relation to birth and neonatal outcomes, and referral processes.Backgroundwomen living socially complex lives, including young mothers, recently arrived immigrants, non-English speaking, and those experiencing domestic violence, poor mental health, drug and alcohol abuse, and poverty experience high rates of morbidity, mortality and poor birth outcomes. This is associated with late access to and poor engagement with antenatal care.Methoddata was collected from three separate NHS trusts data management systems for a total of 182 women living socially complex lives, between January and December 2015. Data was presented by individual trust and compared to standards derived from NICE guidelines, local trust policy and national statistic using Excel and SPSS Version 22. Tests of correlation were carried out to minimise risks of confounding factors in characteristic differences.Findingsnon-English speaking women were much less likely to have accessed care within the recommended timeframes, with over 70% of the sample not booked for maternity care by 12 weeks gestation. On average 89% primiparous women across all samples had less than the recommended number of antenatal appointments. No sample met the audit criteria in terms of number of antenatal appointments attended. Data held on the perinatal data management systems for a number of outcomes and processes was largely incomplete and appeared unreliable.Conclusionthis data forms a baseline against which to assess the impact of future service developments aimed at improving access and engagement with services for women living with complex social factors. The audit identified issues with the completeness and reliability of data on the perinatal data management system.