Centile charts for birthweight for gestational age for Scottish singleton births

Background

Evidence-based practice (EBP) can provide appropriate care for women and their babies; however implementation of EBP requires health professionals to have access to knowledge, the ability to interpret health care information and then strategies to apply care. The aim of this survey was to assess current knowledge of evidence-based practice, information seeking practices, perceptions and potential enablers and barriers to clinical practice change among maternal and infant health practitioners in South East Asia.

Methods

Questionnaires about IT access for health information and evidence-based practice were administered during August to December 2005 to health care professionals working at the nine hospitals participating in the South East Asia Optimising Reproductive and Child Health in Developing countries (SEA-ORCHID) project in Indonesia, Malaysia, Thailand and The Philippines.

Results

The survey was completed by 660 staff from six health professional groups. Overall, easy IT access for health care information was available to 46% of participants. However, over a fifth reported no IT access was available and over half of nurses and midwives never used IT health information. Evidence-based practice had been heard of by 58% but the majority did not understand the concept. The most frequent sites accessed were Google and PubMed. The Cochrane Library had been heard of by 47% of whom 51% had access although the majority did not use it or used it less than monthly. Only 27% had heard of the WHO Reproductive Health Library and 35% had been involved in a clinical practice change and were able to identify enablers and barriers to change. Only a third of participants had been actively involved in practice change with wide variation between the countries. Willingness to participate in professional development workshops on evidence-based practice was high.

Conclusion

This survey has identified the need to improve IT access to health care information and health professionals' knowledge of evidence-based health care to assist in employing evidence base practice effectively.     

Preparation for Childbirth—Evidence for Efficacy

Recent research on pain and psychoprophylaxis in relation to preparation for childbirth are examined. The various findings seem to lead to the value of childbirth preparation classes in lowering anxiety levels and altering patients' assessments of their impending labors. These changes in patients' appraisals are refitted in the experience of childbirth: in lowered perceptions of pain and more positive feelings about the birth.     

Indications for HMG

The use of HMG is only justified to obtain a pregnancy, and cannot be used until after an investigation which excludes other causes of sterility, and necessitates careful surveillance. The contraindications should be respected. The author discusses the present indications for the administrations of HMG.     

4Children for parents and for midwives

This article outlines the launch of a new website which will bring together the rich, but sometimes difficult to access, body of best practice, research and evidence, that parents and professionals need when dealing with children aged from birth-five. The article sets out the scale, type and quality of information that is available, highlights what midwives could helpfully share with parents to help them deal with their children's developments, and what they could access themselves to develop their practice and ensure they remain as up to date as possible with early years developments.     

The SUCCESS program for smoking cessation for pregnant women

The Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) developed an evidence-based practice program, Setting Universal Cessation Counseling Education and Screening Standards (SUCCESS), to educate nurses and other health care practitioners about smoking cessation interventions, increase the number of practitioners providing smoking cessation interventions, and deliver a smoking cessation intervention program to childbearing women who smoke. The development, implementation, and outcomes of the SUCCESS program are described.     

Cervical or thoracic anastomosis for esophagectomy for carcinoma

A prospective trial was conducted to compare intrathoracic and cervical anastomoses after esophagectomy for squamous cell carcinoma of the middle or lower one-third of the esophagus. One hundred and twenty-three patients were randomized to have either a cervical or thoracic anastomosis. Thirty-one patients were subsequently excluded either because esophagectomy was performed without thoracotomy or the tumor was unresectable or because the randomization protocol was not complied with. Transfusion requirements and operating time were similar for the 49 patients having esophagectomy by way of the laparotomy and right thoracotomy (TA) and the 43 patients who underwent laparotomy, right thoracotomy and cervicotomy (CA). Forty-three per cent of the CA and 49 per cent of the TA patients had involved lymph nodes. An esophagectomy incorporating a cervical anastomosis resulted in a significantly greater margin of macroscopically normal esophagus above the tumor (median of 4.0 versus 1.5 centimeters for TA). A leak was significantly more frequent after cervical anastomosis (26 per cent) than thoracic (4 per cent) (p less than 0.002). Respiratory complications were more frequent with a thoracic anastomosis, but this was not statistically significant. Thirty day mortality rates were similar for the two groups: 14.3 per cent, TA, and 9.3 per cent, CA (p = N.S.). Postoperative strictures occurred in 14 per cent of TA and 23 per cent of CA patients and were most common after an anastomotic leak. The survival patterns of the two groups were similar. The median survival time for CA patients was 23 months and for TA, 20 months. Excluding hospital mortality, 47 per cent of patients were alive at two years and 30 per cent at 40 months. Survival was related to extent of disease. The greater length of tumor-free esophagus removed with a cervical anastomosis did not result in an improved long term survival period, but was associated with a significantly higher incidence of anastomotic fistula.     

Bladder-opening technique for hysterectomy for placenta previa percreta

The “bladder-opening” technique can be applied to cesarean hysterectomy for placenta previa percreta with bladder invasion. Cutting the bladder lateral wall with an automatic stapling/cutting apparatus enables direct visualization of the invaded bladder area and its resection. This may reduce the amount of hemorrhage and avoid accidental bladder injury.     

Endoscopy for contraception

Over the past 2 decades, endoscopic methods of tubal sterilization-- including laparoscopic, hysteroscopic, and transcervical techniques-- have been refined so as to be less aggressive. In developing countries, laparotomic, minilaparotomic, and chemical methods of tubal sterilization prevail. Hysteroscopic methods involving the injection of silicone plugs or inert devices and transcervical injections of adhesive and sclerosing substances remain largely experimental at this time. The failure rate of tubal sterilization has remained fairly constant at 0.5%, but there has been considerable progress in terms of safety and complications. The mortality rate has dropped from 4-110/100,000 cases in the early 1970s to 4-57/100,000 procedures. In the US, the mortality rate is 4.2 for surgical sterilization and 0.4 for chemical sterilization, while, in Bangladesh, these rates are 32.6 and 30.2, respectively. The greater safety of sterilization in developing countries is due, in part, to laparoscopy and the use of Falope rings or clips. Early complications requiring surgical intervention occur in 1.1% of laparotomic sterilization cases, 1.4% of minilaparotomies, and in 0.9-3.7% of laparoscopic sterilizations. The advent of microsurgical techniques has led to a drop in the ectopic pregnancy rate from 7-21% to 4-17%. In the US, 1.1% of women request sterilization reversal and 60% of such reversals result in an intrauterine pregnancy. Most successful are isthmo-isthmic and isthmo-ampullar anastomoses performed by skilled microsurgeons. The ultimate aim is to develop a noninvasive method of tubal sterilization that is fully reversible and can be performed in an outpatient setting.     

Genetic implications for newborn screening for phenylketonuria

The genetic implications for PKU are similar to those for any inherited disorder, but require an intimate knowledge of the dietary care required by these women. Unfortunately, today most women with PKU have discontinued dietary treatment by adulthood and find the restricted phe diet onerous and difficult. Fortunately, this is changing. "Diet for life" is the usual, although not yet universally, adopted practice today, but even so, there are women who conceive "off diet." This inhibits intellectual development of the fetus. If intensive services are provided for such women, fetal outcome can be improved by good blood phe control between 120 and 360 uM/L. Although prenatal diagnosis is available by fetal mutation studies, many women today resist the benefits of genetic counseling. Unfortunately, insurance companies often are unwilling to pay for such procedures as mutation analysis or the provision of low phe diets. Overall, public policy for the care of women with genetic disorders is in a state of flux and strong leadership is required to improve services.     

Symphysis-fundus measurements for detection of small for gestational age pregnancies

BACKGROUND: In Sweden measurements of the symphysis-fundus (SF) distance are used to detect small for gestational age (SGA) pregnancies. The aim of this study was to evaluate the efficiency of Swedish ultrasound-based SF reference curves in detecting SGA pregnancies. METHODS: To assess the sensitivity for detection of SGA pregnancies we performed a case-control study. Through the Swedish Medical Birth Register we identified all singleton SGA infants born in Uppsala in 1993-1997 and randomly recruited non-SGA singleton infants as controls. We included 169 term and 73 preterm SGA cases and 296 controls, all born at term. The reference curves constructed by Steingrimsdottir (S curve) and Kieler (K curve) were evaluated. Gestational age at the first alarm in the preterm SGA group was recorded. RESULTS: In term pregnancies the S curve showed a sensitivity of 32% and specificity of 90% at a cut-off of -2 SDs. The corresponding values for the K curve were 51% and 83%, respectively. In preterm SGA pregnancies the sensitivity of the S curve was 49% and of the K curve 58%. The first alarm below 2 SDs was noted before 32 weeks in 37% with the S curve and 43% with the K curve for preterm SGA pregnancies. CONCLUSIONS: Both tested Swedish SF reference curves had low sensitivities for term SGA pregnancies. Sensitivity was higher for the preterm group and SF measurements seem to be better for detecting the most severe cases of SGA.     

WHO recommendations for misoprostol use for obstetric and gynecologic indications

BackgroundMisoprostol, a prostaglandin E₁ analog, stimulates uterine contractility and cervical ripening. A number of randomized trials and systematic reviews have evaluated its use in obstetric and gynecologic conditions. Misoprostol is inexpensive, stable at room temperature, and available in more than 80 countries, making it particularly useful in resource-poor settings. WHO recognizes the crucial role of misoprostol in reproductive health and has incorporated recommendations for its use into 4 reproductive health guidelines focused on induction of labor, prevention and treatment of postpartum hemorrhage, and management of spontaneous and induced abortion.Methods and resultsAll guidelines were prepared in accordance with the WHO Handbook for Guideline Development. The process included: identification of priority questions and critical outcomes; retrieval of evidence; assessment and synthesis of evidence; formulation of recommendations; and planning for dissemination, implementation, impact evaluation, and updating. The present report summarizes recommendations for misoprostol use in line with each guideline.ConclusionThe present comprehensive reference document was designed to enable clinicians and policy makers to quickly access and compare recommendations for the use of misoprostol in various reproductive health settings.     

Proposal for changes in diagnostic criteria for sexual dysfunctions

IntroductionOfficially sanctioned diagnostic criteria have a major influence on treatment decisions and on how populations are defined for clinical research. The Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association has had a major influence on research concerning the treatment of sexual disorders and has been criticized on numerous grounds.AimThe purpose of this article is to describe the evolution of criteria sets in the DSM and to critically evaluate suggestions for modification of this system.MethodAll living members of the DSM work groups on sexual dysfunction were contacted regarding their recollections of the evolution of criteria sets. Literature concerning diagnostic criteria for the sexual dysfunctions in the DSM, as well as literature suggesting modification of this system, was reviewed.Main Outcome MeasureRecommendations for changes in the DSM-V system were based upon a review of the evidence concerning optimal criteria for each diagnostic entity.ResultsThe original diagnostic system from sexual disorders in the DSM was developed by expert opinion, literature searches, and solicitation of feedback for other experts in the field. There have been minimal changes in the DSM criteria for sexual dysfunctions because of the requirement that there be substantial empirical data before modification of the system would be considered. An international consensus group has suggested major modification in criteria concerning female sexual dysfunctions. There is a growing database that documents the need to change criteria for premature ejaculation.ConclusionsIt is recommended that some of the suggested modifications to the criteria sets for sexual dysfunctions be adopted by the DSM-V committee. It is also recommended that specific criteria related to duration and severity be adopted, in order to clearly distinguish sexual disorders from transient alterations in sexual function related to life stress and relationship discord. Segraves R, Balon R, and Clayton A. Proposal for changes in diagnostic criteria for sexual dysfunctions.     

Methotrexate treatment for tubal pregnancy. Criteria for medical approach

AIM: The purpose of this retrospective study is to underline the indications for the use of systemic methotrexate (MTX) in tubal pregnancies. METHODS: One hundred and four (n=104) consecutive women were treated in our Department for tubal pregnancy. The database analysis showed that after careful respect for inclusion criteria, the treatment chosen was the intravenous administration of MTX in 68 patients, whereas laparoscopy constituted the primary treatment in 36 patients. A single dose of MTX was intravenously administered, diluted in saline solution, with a dosage of 50 mg/m2 of body surface. Close serum beta-hCG monitoring was performed, and in the case of a short fall, a 2nd dose of methotrexate was submitted. RESULTS: The overall success rate of MTX treatment was 91%; the 2nd dose of MTX was used in 12% of patients, whereas in only 6 out of 68 patients included in the medical treatment group a surgical approach for suspected tubal rupture was necessary. CONCLUSION: Treatment with methotrexate is effective and safe in the presence of these criteria: patient hemodynamically stable, absence of tubal rupture sign and hemoperitoneum, an adnexal mass with a diameter < or = 5 cm, an amenorrhea < or = 6 weeks and HCG levels < or = 10,000 mIU/ml. Laparoscopy is indicated in diagnostic uncertainty, when MTX is not suggested, when adnexal mass is > 5 cm, or in patients in which beta-hCG levels was > 10,000 mIU/ml.     

Predictions for the decision-to-delivery interval for emergency cesarean sections in Norway

BACKGROUND: To explain the variation in decision-to-delivery intervals in emergency cesarean sections in Norway. METHODS: A seven-month prospective registration of all emergency cesareans provided by 24 maternity units. The clinician in charge filled in a predesigned form for each delivery that obtained detailed information about obstetric history, the pregnancy, indication, the date and time of delivery, decision-to-delivery interval, seniority of the surgeon, and neonatal outcome until hospital discharge. To take account of the clustered nature of our observations, data were analyzed by multilevel regression. RESULTS: 1,511 singleton emergency cesarean sections with known decision-to-delivery interval were included. The average decision-to-delivery interval for all emergency cesarean sections was 52.4 min, for acute cesarean sections 58.7 min, and for urgent emergency operations 11.8 min. Most of the decision-to-delivery interval variation was at patient level, not between departments. Several significant decision-to-delivery interval predictors were identified: 1. abruptio placentae (-54 min), umbilical cord prolapse (-37 min), and fetal stress (-35 min); 2. general anesthesia (versus regional) (-15 min), 3. cesarean sections performed during night-time (-10 min), 4. seniority of the surgeon (-6 min), and 5. cervical opening (for each cm: -6 min). CONCLUSIONS: The variance in the decision-to-delivery interval was mainly explained by the different nature of the cesarean sections. The most important predictors, which all acted to reduce decision-to-delivery interval, were the three indications abruptio placentae, cord prolapse, and fetal stress. Sections performed during night-time had significantly reduced decision-to-delivery interval. The size of the maternal units as measured by number of deliveries per year was not a significant predictor.     

Guideline for the use of antenatal corticosteroids for fetal maturation

The aim is to present a document, which is based on current evidence and serves as a guideline for use in clinical practice. The following questions are addressed: Is the use of antenatal corticosteroids (ACS) an effective therapy? Who are the candidates for antenatal corticosteroid therapy? Is there benefit after 34 weeks' gestation? When is the optimal time to treat? Which are the optimal steroids; what is the ideal dose and route of administration? Are there any contraindications to the administration of ACS? Are antenatal corticosteroids indicated in women with premature rupture of membranes (PROM)? Is the use of ACS recommended in pregnancies complicated by maternal diabetes mellitus? Should the treatment with corticosteroids be repeated?     

Evaluating treatments for preterm labor: possible solutions for some methodological problems

The usual evaluation procedures for labor-inhibiting therapies are criticized and a new measure is proposed. This measure (rate of pregnancy prolongation) is shown to fulfil the criteria of high sensitivity to treatment effects and of unbiasedness for the gestational age of patients. The use of analysis of covariance is proposed as a solution for the problem of confounding background variables. The advantages of the new evaluation procedure are illustrated by the analysis of a clinical trial of labor inhibition by hypnotic relaxation.     

Request for operative reduction of the labia minora; a proposal for a practical guideline for gynecologists

The increase in women's request for labia reduction surgery raises medical and ethical dilemmas for the gynecological surgeon. A bio-psycho-social approach is suggested; the problem is put forward from the perspective of the medical ethical principles and a practical guideline is proposed.     

Investigations for infertility

Infertility affects approximately 10% of the population with variable incidences across the world. Although it is not an identifiable physical disease, its psychological impact on the affected couple can be severe and can lead to social disability. The clinician needs to be tactful and sensitive in his/her investigation of the infertile couple, and history taking is very important to establish the plan of investigation. A clear protocol should be designed where the role of each level of health care is well determined, and information provided to the couple on the proposed plan of action. Investigations should be carried out in a reasonably short space of time so that an appropriate modality of treatment, or at least reassurance, can be provided to the couple. The value of some investigations can be questioned and the cost, safety, convenience and evidence-base should help in deciding on the appropriate method.     

Social egg freezing: for better, not for worse

The possibility for healthy women to cryopreserve their oocytes in order to counter future infertility has gained momentum in recent years. However, women tend to cryopreserve oocytes at an age that is suboptimal from a clinical point of view--in their late thirties--when both oocyte quantity and quality have already considerably diminished and success rates for eventually establishing a pregnancy are thus limited. This also gives rise to ethical concerns, as the procedure is seen as giving false hope to (reproductively speaking) older women. This study evaluates which measures can be taken to turn social freezing into a procedure that is both clinically and ethically better than the current practice. The main objective of these measures is to convince those women who are most likely to (want to) reproduce at an above-average age to cryopreserve their oocytes at a time when this intervention is still likely to lead to a live birth and to discourage fertility clinics from specifically targeting women who have already surpassed the age at which good results can be expected. The possibility for healthy women to cryopreserve their oocytes in order to counter future infertility has gained momentum in recent years. However, women tend to cryopreserve oocytes at a time that is suboptimal from a clinical point of view - in their late thirties - when both oocyte quantity and quality have already considerably diminished and success rates for eventually establishing a pregnancy are thus limited. This also gives rise to ethical concerns, as the procedure is seen as giving false hope to (reproductively speaking) older women. We evaluate which measures can be taken to turn social freezing into a procedure that is both clinically and ethically better than the current practice and discern three different steps: creating public awareness; offering individualized, age-specific information and counselling; and offering predictive tests such as anti-Müllerian hormone measurements or antral follicle count. The main objective of these measures is to convince those women who are most likely to benefit from social freezing to present themselves before age 35 and to discourage fertility clinics from specifically targeting women who have already surpassed the age at which good results can be expected.