Perinatal management: Lessons learned from the neonatal research network

Recent contributions of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) regarding obstetrical perinatal interventions and neonatal delivery room practices include the following: the impact of multiple antepartum factors including maternal diabetes, hypertension, obesity and mode of delivery on outcomes of extremely preterm newborns, effects of delayed delivery interval for extremely preterm multiples, effects of antenatal steroids on preterm newborn outcomes and the impact of antenatal magnesium sulfate therapy on neurodevelopmental outcomes for extremely preterm infants. NRN studies also contribute important evidence for neonatal delivery room resuscitation guidelines including umbilical cord management and maintenance of euthermia immediately after birth. The updated NRN outcome calculator helps better counsel families regarding possible outcomes for the most immature newborns if resuscitation is attempted at birth. Thus, the NRN provides substantial information regarding effects of perinatal management on newborn infants.     

Development and Implementation of a Perinatal Education Consortium

The North Puget Sound Perinatal Education Consortium provides a collaborative framework for planning, implementing, and evaluating a basic orientation program for newly hired and cross-trained perinatal nurses. The program currently provides 9 days of prenatal, labor and delivery, mother-infant couplet, and neonatal didactic orientation at no cost to registrants from participating hospitals. Consortium hospitals supply instruction time and additional services to support this high-quality, regional, perinatal orientation program.     

Developing a Documentation System That Works

A documentation system that facilitates accurate and complete recording is needed by every obstetric/neonatal nursing service. Developing an individualized system is a major undertaking. However, specific steps can be taken to ease the process. These steps are described, beginning with the assessment phase and concluding with evaluation.     

The Mexican Experience Adapting CenteringPregnancy: Lessons Learned in a Publicly Funded Health Care System Serving Vulnerable Women

Group antenatal care is an innovative model of health care in which all components of antenatal care—clinical, educational, and supportive—happen in a group context with health care professionals as facilitators. CenteringPregnancy is the most studied model of group antenatal care, now widely implemented in the United States. This model has been shown to be effective in improving health and behavioral outcomes in the United States, but there is less known about the experience adapting group antenatal care in settings outside the US health care system. This article describes the adaptation of the CenteringPregnancy model to a Mexican context. We describe the Mexican health care context and our adaptation process and highlight key factors to consider when adapting the content and modality of the CenteringPregnancy model for diverse populations and health systems. Our findings are relevant to others seeking to implement group antenatal care in settings outside the US health care system.     

Litigations Involving Ureteral Injury Related to Minimally Invasive Gynecologic Surgery: Lessons Learned from a Legal Literature Review

Ureteral injury is a known complication of minimally invasive gynecologic surgery. Despite being discussed preoperatively and included in consent forms, litigations that involve such injury continue to be prevalent. Our aim was to review all major litigations involving ureteral injuries related to minimally invasive gynecologic surgery to determine the most common allegations from plaintiffs and highlight factors that aided defendants. We used Lexis Nexis, a comprehensive legal database, to search all publicly available federal- and state-level cases on ureteral injury related to gynecologic surgeries. Fifty-nine cases resulted from our search. Of these cases, 19 were deemed pertinent to our question. These 19 cases occurred between 1993 and 2018. The most common allegations included medical negligence, lack of informed consent, and medical battery. Eight of 19 cases (42%) were decided in favor of the defendants, 3 of 19 cases (16%) in favor of the plaintiffs, and the remaining cases proceeded to further trial or are ongoing. The monetary compensation to a plaintiff was as high as $426,079.50. Meticulous documentation, comprehensive consent procedure, timely postoperative evaluation, and the use of immediate postoperative cystoscopy were the critical factors that aided the defendants. Meticulous documentation, a comprehensive consent procedure, timely postoperative evaluation, and the use of immediate postoperative cystoscopy can aid minimally invasive gynecologic surgeons involved in litigations involving ureteral injury.     

Implementation of the Zambia Electronic Perinatal Record System for comprehensive prenatal and delivery care

Objective

To characterize prenatal and delivery care in an urban African setting.

Methods

The Zambia Electronic Perinatal Record System (ZEPRS) was implemented to record demographic characteristics, past medical and obstetric history, prenatal care, and delivery and newborn care for pregnant women across 25 facilities in the Lusaka public health sector.

Results

From June 1, 2007, to January 31, 2010, 115 552 pregnant women had prenatal and delivery information recorded in ZEPRS. Median gestation age at first prenatal visit was 23 weeks (interquartile range [IQR] 19-26). Syphilis screening was documented in 95 663 (83%) pregnancies: 2449 (2.6%) women tested positive, of whom 1589 (64.9%) were treated appropriately. 111 108 (96%) women agreed to HIV testing, of whom 22% were diagnosed with HIV. Overall, 112 813 (98%) of recorded pregnancies resulted in a live birth, and 2739 (2%) in a stillbirth. The median gestational age was 38 weeks (IQR 35-40) at delivery; the median birth weight of newborns was 3000 g (IQR 2700-3300 g).

Conclusion

The results demonstrate the feasibility of using a comprehensive electronic medical record in an urban African setting, and highlight its important role in ongoing efforts to improve clinical care.     

An Education Program for Nurses from Referring Hospitals in a Perinatal Regionalization System

Administering high-quality perinatal care at a regional center involves more than providing in-center services. An outreach education program was developed for nurses in referring hospitals. The authors believe that through the carefully phased development of un outreach education program, quality perinatal care on all levels can be realized.     

Randomized Trial of Oxybutynin Extended Versus Immediate Release for Women Aged 65 and Older with Overactive Bladder: Lessons Learned from Conducting a Trial

ObjectiveThis trial was designed to investigate the effectiveness of extended release versus immediate release oxybutynin in reducing symptoms of overactive bladder in a community-dwelling female population over the age of 65.MethodsThis was a prospective randomized 12-week, open-label study. The primary outcome was number of micturitions per 24 hours, 12 weeks after treatment. The a priori sample size estimate was 60 patients per group.ResultsOf the 318 women approached, only 72 women (23%) were enrolled over 34 months (33 in the immediate release group, and 39 in the extended release group). The study was stopped prematurely because of recruitment difficulties and an interim analysis revealing the need for a much larger sample than had been estimated to show a significant difference between treatments. After 12 weeks of treatment, there was no difference between the oxybutynin extended release and immediate release groups in the number of micturitions per 24 hours or in other outcomes.ConclusionThis study did not demonstrate differences between oxybutynin extended release and immediate release and in reducing symptoms of overactive bladder or quality of life, possibly because the study did not reach the necessary sample size. The difficulty in recruiting subjects for the trial likely resulted from the onerous study requirements (4 study visits required over 12 weeks) and the downtown location of the study centres: these factors would cause particular difficulties for women overage 65 with overactive bladder, for whom travelling may be a problem. Evidence is needed to guide prescribing for older patients, but designing research to obtain adequate sample sizes is difficult. Studies in older subjects should ensure that a much larger budget is allocated for recruitment than would be allocated for studies in younger subjects, that meticulous attention is paid to issues of transport and access, and that support is provided for subjects who agree to take part in research.     

Colorectal Anastomotic Stenosis: Lessons Learned after 1643 Colorectal Resections for Deep Infiltrating Endometriosis

Study Objective

To evaluate the incidence, risk factors, and treatment of colorectal anastomotic stenosis in patients who undergo rectosigmoid resection for deep infiltrating endometriosis (DIE).

A Case Series of Uterine Rupture: Lessons to be Learned for Future Clinical Practice

Objective

In this article, we try to discuss risk factors and diagnostic difficulties for uterine rupture.

Methods

Case series of 12 cases of uterine rupture observed in the Norfolk and Norwich University Hospital in the UK, with an average yearly birth rate of 6,000 deliveries, over a 6-year period.

Results

In the present case series, there was no maternal mortality, and uterine rupture was a rare occurrence (12 in 36,000 births). Uterine rupture is associated with clinically significant uterine bleeding, fetal distress, expulsion or protrusion of the fetus, placenta or both into the abdominal cavity, and the need for prompt cesarean delivery and uterine repair or hysterectomy. The risk factors for rupture include previous cesarean sections, multiparity, malpresentation and obstructed labor, uterine anomalies, and use of prostaglandins for induction of labor. Previous cesarean section is, however, the most commonly associated risk factor. The most consistent early indicator of uterine rupture is the onset of a prolonged, persistent, and profound fetal bradycardia.

Conclusion

In this case series, we suggest that the signs and symptoms of uterine rupture are typically nonspecific, which makes diagnosis difficult. Delay in definitive therapy causes significant fetal morbidity. The inconsistent signs and the short time in prompting definitive treatment of uterine rupture make it a challenging event. For the best outcome, vaginal birth after previous cesarean section needs to be looked after in an appropriately staffed and equipped unit for an immediate cesarean delivery and advanced neonatal support.