What does basic science tell us about the use of uterotonics?

Pharmacotherapy with uterotonics remains the mainstay of the management for post-partum haemorrhage. Clinical studies evaluating the efficacy of these drugs are fraught with confounders, which may influence uterine contractility and blood loss. For this reason, a range of techniques have been developed to study myometrial function in vitro, allowing for the comparison of various drugs in a controlled-simulated physiological environment.In this review, we focus on the main classes of uterotonic drugs and outline their molecular and physiological basis of action. We explore the evidence related to appropriate drug dosing and relative efficacy, and compare the evidence gleaned from clinical and in vitro studies. We discuss the mechanism of oxytocin desensitisation and how basic science has helped us understand this phenomenon. We also discuss the in vitro research findings for each of the main classes of uterotonic drugs that have contributed to an improved understanding of the management of post-partum haemorrhage and, ultimately, better care for mothers.     

What are pregnant women eating? Nutrient and food group differences by race

OBJECTIVE: The purpose of this study was to identify foods that contributed most to nutrient and fiber intake in a sample of pregnant women in North Carolina. STUDY DESIGN: This was a prospective study of women in the Pregnancy, Infection, and Nutrition Study (n = 2247 women). Dietary information during the second trimester was collected with the use of a food frequency questionnaire. The contribution of each food item to the population's intake was calculated. RESULTS: Overall, low nutrient-dense foods were major contributors to energy, fat, and carbohydrates, whereas fortified foods were important sources of iron, folate, and vitamin C. The median energy intake for this population was 2478 kcal. The median dietary intakes of iron were below the recommended levels. Although black women consumed more calories on average, white women, after energy adjustment, consumed greater amounts of protein, iron, folate, and fiber. CONCLUSION: These data emphasize the importance of evaluating both the nutrient density in the diet and the frequency of consumption in the assessment of the diets of pregnant women.     

What do maternity statistics tell us about induction of labour?

The National Maternity Statistics (Department of Health, 1997) show that labour is induced in one out of every five pregnancies carried to viability in England. Induced labours are associated with higher rates of further intervention such as instrumental delivery and caesarean section, and with economic costs resulting from longer stay in hospital. Women who are offered induction of labour, whether for medical or social reasons, should be advised of the risks of further intervention. Information about induction of labour should be given routinely during antenatal care since one in five women will have this experience. Care providers need to be more aware of the economics of induced labour, a factor which has not been taken into account in the longstanding debate on the merits of induction of labour for post-term pregnancy.     

What can a meta-analysis tell us about traditional birth attendant training and pregnancy outcomes?

OBJECTIVE: to summarise the available published and unpublished studies on traditional birth attendant (TBA) training effectiveness. DESIGN: a meta-analysis. STUDY SAMPLE: sixty studies (n=60) spanning 1971-1999 from 24 countries and three regions. MEASUREMENTS: the effect size index, Cohen's h for each outcome; the variance-weighted mean effect size and 95% confidence interval for sub-group of outcomes; homogeneity tests on the distribution of the weighted mean effect sizes; and sensitivity analysis to detect the presence of publication bias. FINDINGS: TBA training was associated with significant increases in attributes such as TBA 'knowledge' (90%), 'attitude' (74%), 'behaviour' (63%) and 'advice' (90%) over the untrained TBA baseline. Results for 'behaviour' and 'advice' in specific content areas related to peri-neonatal health outcome, however, reveal sources of variability and underscore the conflicting evidence on TBA training. TBA training was also associated with small but significant decreases in peri-neonatal mortality (8%) and birth asphyxia mortality (11%). Incomplete reporting limited the assessment of neonatal mortality due to tetanus and acute respiratory infection, maternal mortality, as well as assessment of the relationship between intervention characteristics and outcomes. The quality of studies included in the meta-analysis lack sufficient rigour to address the question of causality. Thus, while the data suggest that TBA training is effective in terms of the outcomes measured, we are unable to demonstrate that it is a cost-effective intervention. IMPLICATIONS: skilled attendance at birth is a distant reality in many developing countries and effective community-based strategies are needed to help reduce high levels of mortality. Given the magnitude of peri-neonatal mortality, the associations observed between TBA training peri-neonatal and birth asphyxia mortality, and TBA attributes in content relevant to peri-neonatal survival, we suggest that these strategies may usefully include TBA training in appropriate settings. If TBAs are to be trained, however, it is imperative that their training be adequately evaluated in order to develop the strong evidence base that is lacking to-date and that is necessary for sound policy and programming.     

How do women feel about being weighed during pregnancy? A qualitative exploration of the opinions and experiences of postnatal women

Objectiveto explore routine weighing in antenatal care and weight management in pregnancy with women who have been weighed during pregnancy.Designa qualitative study utilising semi-structured telephone interviews, and thematic analysis.Settingparticipants resided in Dublin, Ireland and had been weighed during pregnancy.Participantsindividual telephone interviews conducted with ten postpartum women (nine months postpartum).Findingsexperiences of routine weighing were positive, and participants believed it should be part of standard antenatal care. Several benefits to routine weighing were cited, including providing reassurance and minimising postpartum weight retention. It was felt that there was a lack of information provided on gestational weight gain and healthy lifestyle in pregnancy, and that healthcare professionals are ideally placed to provide this advice. Increased information provision was seen as a method to improve healthy lifestyle behaviours in pregnancy.Key conclusions and implications for practicethese findings contribute to the current debate about the re-introduction of routine weighing throughout pregnancy (Allen-Walker et al., 2016). Women stated that they expected to be weighed during pregnancy and, contrary to previous claims, there was no evidence that routine weighing during antenatal care caused anxiety. From discussions it was clear that women desired more information on gestational weight gain and a healthy lifestyle, and felt that health professionals should provide this.     

What are pregnant women in a rural Niger Delta community's perceptions of conventional maternity service provision? An exploratory qualitative study

At present there is under utilization of maternity service provision in Nigeria, with only a third of childbearing women electing to deliver in healthcare facilities. This is relevant since Nigeria's maternal mortality rate is second highest in the world and is estimated at 1,100 per 100,000 live births. To date, studies have sought cause and effect and have neglected the opinion of the people about what they perceive to be problematic and what they believe constitutes satisfactory maternity service provision. An exploratory qualitative study was carried out to identify pregnant women in a rural Niger Delta community's perceptions of conventional maternity service provision. Participants included 8 pregnant Niger Delta women from differing sub-groups within the homogeneous population. Semi-structured interviews were conducted to explore informants' views of what constitutes satisfactory maternity service provision, what comprises inadequate care, barriers that obstruct delivery of maternity care, and what promotes positive outcomes. Five major themes emerged from the data. These included: (1) Women's requirements for information; (1a) nutritional and dietary advice, (1b) how to recognise developing complications, (1c) appropriate fetal development, (1e) importance of attending clinics; (2) Staff services required: (2a) availability, (2b) well managed, and (2c) good quality; (3) Apparatus: (3a) equipment available, (3b) adequate infrastructure; (4) Affordability; (5) Place of traditional and spiritual methods. The interviewed childbearing Niger Delta women voiced several factors that they considered altered their satisfaction with maternity service provision. Finding out more about what causes satisfaction/dissatisfaction in childbearing women facilitates maternity care professionals to improve standards of care and allocate resources more effectively. Policy changes are driven by initiatives that reinforce strengths of current specification and recognise weaknesses. In addition, the WHO recommends that working towards improving health related culture is important.     

Child neurodevelopmental outcomes following preterm and term birth: What can the placenta tell us?

A significant proportion of children born preterm will experience some level of neurodevelopmental impairment. Changes in placental function have been observed with many antenatal conditions that are risk factors for preterm birth and/or poor neurodevelopment including fetal growth restriction and in-utero inflammation. This review will highlight placental factors that have been studied to understand the underlying mechanisms and identify biomarkers that lead to poor child neurodevelopmental outcomes. These include changes in gross morphological and histopathological structure and the placental inflammatory response to prenatal infection. Further, we will describe the placenta's role as both a barrier to maternally-derived bioactive substances critical for normal fetal brain development, such as cortisol, and a source of neuroactive steroids and neurotrophins known to have critical functions in neuronal proliferation, axonal growth, myelination and the regulation of apoptosis. Finally, emerging data supporting the potential utility of novel placental biomarkers in the early prediction of poor neurodevelopmental outcome in infants born both preterm and term will be discussed. These include the assessment of genetic variants (e.g. single nucleotide polymorphisms in placental tissue) and epigenetic biomarkers (e.g. placental microRNAs and placental DNA methylation). With the placenta the key tissue regulating the fetal environment, integration of observed changes in placental function with genetic and epigenetic variations may advance our ability to predict future infant health. Ultimately, this may facilitate targeted allocation of health resources with the aim of improving lifelong neurodevelopmental capability.     

Do normal-weight women pregnant with twins are at the lowest risk of developing preeclampsia?

Objective: To determine the relation between preeclampsia (PE) and pregravid body mass index (BMI) in twin pregnancy.

Methods: Retrospective cohort study of 542 women pregnant with twins.

Results: Forty-nine patients developed PE (9%). Underweight, overweight and obese women were at a higher risk of PE than normal-weight mothers. There was no linear (p?=?0.7) but significant U-shaped relation between BMI and PE (p?2.

Conclusions: Nonlinear relation between PE occurrence and BMI suggests that using homogeneous PE risks of BMI groups may be incorrect.     

What do midwives need to know about approaches of women towards labour pain management? A qualitative interview study into expectations of management of labour pain for pregnant women receiving midwife-led care in the Netherlands

Objective

to investigate factors important to women receiving midwife-led care with regard to their expectations for management of labour pain.

Design

semi-structured ante partum interviews and analyses using constant comparison method.

Participants

fifteen pregnant women between 36 and 40 weeks gestation receiving midwife-led care.

Setting

five midwifery practices across the Netherlands between June 2009 and July 2010.

Main outcome

women's expectations regarding management of labour pain.

Results

we found three major themes to be important in women's expectations for management of labour pain: preparation, support and control and decision-making. In regards to all these themes, three distinct approaches towards women's planning for pain management in labour were identified: the ‘pragmatic natural’, the ‘deliberately uninformed’ and the ‘planned pain relief’ approach.

Conclusion

midwives need to recognise that women take different approaches to pain management in labour in order to adapt care to the individual woman.     

What about the women? Ethical and policy aspects of egg supply for cloning research

As more and more countries open their doors to human cloning and embryonic stem cell research, scientists will be confronted with one fundamental problem: where will all the eggs come from? The mass harvesting of eggs raises serious issues about women's health, status and well-being. This paper critically examines proposals for ova supply such as altruistic donation, surplus IVF eggs and commercial sale. It questions the meaningfulness of informed consent and the risk–benefit ratio in a climate where powerful economic and social forces increasingly view the risks to women as the necessary trade-off for scientific advance.     

Do women with polycystic ovary syndrome have an increased risk of cardiovascular disease? Review of the evidence

Polycystic ovary syndrome (PCOS) is a reproductive endocrine disorder found in ~5% of the general population and is characterized by chronic anovulation, hyperandrogenism, and insulin resistance. Women with PCOS are at increased risk for the development of Type II diabetes and may represent a unique group of women at high risk for the development of coronary heart disease (CHD). More adverse CHD risk profiles of women with PCOS have been demonstrated in several studies, yet actual health outcome studies have been inconclusive as to whether this translates into increased rates of cardiovascular disease in PCOS cases when compared to controls. This review focuses on the controversy surrounding the potential relationship between cardiovascular disease outcomes and polycystic ovary syndrome.