Unique and proforma birth plans: A qualitative exploration of midwives׳ experiences

Background

birth plans detailing a woman?s preferences for intrapartum care are a common feature in British maternity units, and are a means of encouraging the implementation of choice. Proforma versions may be incorporated routinely in antenatal case notes, or the woman may devise her own unique birth plan. Although women?s views of birth plans have been explored, the views of midwives have not to date been evaluated. The growth of midwife-led units in the UK has highlighted different philosophies of care, some of which can be reflected in the different types of birth plan. Given the increasingly diverse nature of UK midwifery workplaces we set out to explore and compare the experience of midwives working in midwife-led and obstetric-led settings in relation to unique and proforma birth plans.

Method

qualitative study using focus groups of midwives in a midwife-led unit (MLU; n=5) and obstetric-led unit (OLU; n=4) in the East of England. We used an interpretative phenomenological analytical approach.

Findings

three main themes arose from the data. Firstly, the term ‘birth plan’ can be misleading, and was criticised for encouraging the belief that birth can be ‘planned’. In addition, midwives claimed that ‘unique’ birth plans, especially those influenced by some consumer advocacy groups, are becoming standardised in their rejection of policies and procedures and requests for intervention-free birth. Secondly, birth plans were a source of irritation for midwives in both groups, although the cause of the irritation differed between groups. Finally, it was found that midwives in both groups felt that birth plans put pressure on them, although again, the source of the pressure, and therefore the way in which midwives reacted to this pressure, differed between groups.

Conclusions

the term ‘birth plan’ can be misleading and create false expectations. If ‘unique’ birth plans are becoming ‘standardised’ in the sense that they routinely request the same things, they are little different to proforma birth plans. Some midwives perceive pressure both from women and the wider multidisciplinary team as a result of birth plans, a perception that causes some irritation.     

A framework for reporting secondary and incidental findings in prenatal sequencing: When and for whom?

As the use of genomic sequencing (GS) in the prenatal setting becomes more widespread, laboratories and clinicians will be tasked with making decisions about whether to offer incidental and secondary findings to expectant parents and, if so, which ones. Unfortunately, few guidelines or position statements issued by professional bodies address the return of secondary findings specifically in the context of prenatal GS, nor do they offer clear guidance on whether, and which types of incidental findings should be reported. Laboratories and clinicians will also need to navigate other challenges, such as how to obtain sufficiently informed consent, workload burdens for both laboratories and clinicians, and funding. Here we discuss these, and other challenges associated with offering incidental and secondary findings in the context of prenatal GS. We outline existing guidelines for return of these findings, prenatally and in children. We review the existing literature on stakeholder perspectives on return of incidental and secondary findings and discuss the main practical and ethical challenges that require consideration. We then propose a framework to help guide decision-making, suggesting a baseline routine analysis, with additional layers of analysis that could be offered, according to local laboratory policy, with additional opt-in consent from the parents.     

Survival by self-destruction: A role for autophagy in the placenta?

Autophagy is a burgeoning area of research from yeast to humans. Although previously described as a death pathway, autophagy is now considered an important survival phenomenon in response to environmental stressors to which most organs are exposed. Despite an ever expanding literature in non-placental cells, studies of autophagy in the placenta are lagging. We review the regulation of autophagy, summarize available placental studies of autophagy, and highlight potential areas for future research. We believe that such studies will yield novel insights into how placentas protect the survival of the species by "self-eating".     

A challenge for the 21st century: whither physician-scientists in obstetrics, gynecology, and the reproductive sciences?

As we begin a new century, research in obstetrics and gynecology and its subspecialties face a crisis. Federal support to academic departments of obstetrics and gynecology through the National Institutes of Health is distressingly low in relation to that for other major specialties. In addition, academic departments face a shortage of clinically trained investigators and physician-scientists who will respond to the challenge of contributing to a greater understanding of the reproductive sciences and to the amelioration of diseases of women.     

Transvaginal Sonography Post–Office Hysteroscopy as a Screening Tool for Tubal Patency: A Reliable and Feasible Technique in an Outpatient Setting

ObjectiveTo determine feasibility and accuracy of post-hysteroscopic transvaginal ultrasonography (TVUS) measurement of pelvic fluid accumulation as a screening method for tubal patency (TP).MethodsWe conducted a retrospective cohort study of 85 patients who underwent uterine cavity assessment by office hysteroscopy at our university-affiliated fertility centre from November 2019 to October 2020. During the study period, two-dimensional (2D) TVUS was performed pre- and post-hysteroscopy to evaluate TP. Patient records were reviewed for demographics, diagnosis, and prior/subsequent TP testing. Predictive values for TP were calculated.ResultsPelvic fluid accumulation post-hysteroscopy was found in 65.9% of patients (56). Accumulation of fluid was seen with the use of as little as 10–50 mL of saline. Using more fluid did not increase the likelihood of demonstrating TP (P = 0.17). A trend towards more false-negative results for TP was observed when less fluid was used (7.7% with 10–50 mL vs. 3.8% with 60–190 mL and 1.3% with 200–760 mL; P = 0.10). The positive predictive value (PPV) of TVUS post-hysteroscopy in comparison to known patency/occlusion was 100%; negative predictive value (NPV) was 33%; sensitivity was 82.8%; and specificity was 100%. Similar values were seen in a second analysis that included patients with highly suspected patent or occluded tubes (n = 60); presumed predictive values were: PPV 100%, NPV 42%, sensitivity 78.8%, and specificity 100%. The use of more fluid did not increase pain (P = 0.75). This finding remains after accounting for confounders (e.g., pre-medication, endometrial biopsy).ConclusionTVUS pre- and post-hysteroscopy is feasible in an outpatient setting, and can serve as a reliable screening tool for TP. When hysteroscopy is performed and TP is not known, TVUS can be added for screening, potentially omitting the need for more invasive examinations. With limited non-urgent ambulatory services, it is of upmost importance to maximize information from a single procedure.     

A “Boots on the Ground” Perspective of Caring for the Women and Children in Afghanistan

In 1972 Margarete V. Silberberg wrote about her nursing experience when caring for women at a Kabul, Afghanistan, hospital. Based on my experience during a recent deployment to Afghanistan, I describe providing health care to Afghan women and children as a military Women's Health Nurse Practitioner. Delivering health care presented the threat of physical harm for the health care team and those who received the care. Afghan women and children continue to experience significant cultural, religious, and social circumstances that limit their education, personal development, protection from abuse, and access to health care.     

A time for change and a time for equality — Infertility services and the NHS

The provision of infertility services has always provoked controversy. On the one hand, patients' groups and clinicians involved with infertile couples have long campaigned against the ‘postcode lottery’. On the other hand, commissioners have been reluctant to commit resources to what they see as a low priority in health care. The issue has been brought back into the news with the government's decision to ask the National Institute of Clinical Excellence to review the inequalities in provision of fertility services. This article sets out the evidence for viewing infertility as an illness that deserves public funding, and argues that assisted conception should be viewed in the same light as other chronic non-life-threatening conditions that are currently funded by the NHS.     

Evaluating the Impact of Overactive Bladder on Sexual Health in Women: What Is Relevant?

IntroductionTo assess sexual health, relevant, valid, and reliable questionnaires need to be used.AimTo assess the relevance and content validity of three sexual health questionnaires in women with overactive bladder (OAB) and urinary incontinence.Main Outcome MeasuresSexual Quality of Life Questionnaire––Female (SQoL‐F), Sexual Function Questionnaire (SFQ), and Pelvic Organ Prolapse–Incontinence Sexual Function Questionnaire (PISQ).MethodsWomen with OAB and urinary incontinence were recruited from five urology clinics in the United States; those who were interested in participating were mailed questionnaire packets with instructions. Each questionnaire item was followed by three questions regarding the understandability, relevance, and impact of bladder condition when responding to the question. Patients returned the completed questionnaires by mail; clinical information was obtained from chart review.ResultsA total of 129 patients (74% response) returned the questionnaires. The mean age was 56 years; 78% were white; 64% were married. In this sample, 64% had urge incontinence; 32% had mixed incontinence; and 4% had stress incontinence. Participants experienced bladder symptoms for a mean of 12.2 years with the following treatments: surgery (43%), bladder training (26%), exercise/biofeedback (42%), and medications (67%). SQoL‐F items were understood by more than 97% of the respondents, more than 89% for SFQ, and more than 82% for PISQ. There were two SQoL‐F items, one SFQ item, and 11 PISQ items that less than 60% of the respondents deemed relevant to their bladder condition. Correlations among questionnaire items and relevance to bladder condition ranged from 0.04 to 0.64 for the SQoL‐F, 0.04 to 0.47 for the SFQ, and 0.01 to 0.58 for the PISQ.ConclusionWomen with OAB found the majority of items on all three questionnaires to be relevant to their bladder condition. Of these questionnaires, the SQoL‐F had the highest understandability, fewest questions considered irrelevant, and correlated well with OAB symptoms. Coyne KS, Margolis MK, Brewster‐Jordan J, Sutherland SE, Bavendam T, and Rogers RG. Evaluating the impact of overactive bladder on sexual health in women: What is relevant? J Sex Med 2007;4:124–136.     

“Anti-Mullerian Hormone: Marker for Ovarian Response in Controlled Ovarian Stimulation for IVF Patients”: A First Pilot Study in the Indian Population

Objective

To measure the levels of early follicular phase Anti-Mullerian hormone (AMH) in Indian patients of IVF and to evaluate the AMH as a predictive marker of ovarian response in assisted reproductive technology outcome.

Methods

Sixty women (age 25–40 years) selected for in vitro fertilization treatment were included in this study. Analysis of day-2 serum samples was done for the AMH, FSH, Inhibin B, and LH by ELISA kit methods. USG was done for the antral follicle count (AFC) and oocytes’ retrieval. Hormone parameters were compared and correlated with the oocytes’ retrieval count and the AFC. The discriminant analysis was done to compare relevance of different parameters for predicting ovarian response.

Result(s)

The Anti-Mullerian hormone showed a significant correlation with the oocytes’ retrieval after ovulation induction for IVF (r = 0.648, p < 0.0001) and no correlation was seen with serum FSH, LH, and Inhibin. Serum AMH levels show 80 % sensitivity and 80 % specificity in predicting poor ovarian response.

Conclusion(s)

There is a significant correlation between day-2 serum AMH levels and the oocytes’ retrieval count in women undergoing ovulation induction for IVF, and the AMH is a good marker as the negative predictive values for the success of ART. There is no correlation found between other hormonal ovarian reserve markers and the oocytes’ retrieval count.     

Laparoscopy training for obstetrics and gynaecology trainees? A pilot study in the Eastern Deanery, UK

Training in laparoscopic surgery has been difficult to implement, worldwide. This survey aims to identify the current status of laparoscopic training in the Eastern Deanery, UK. We hope to identify factors which influence training and propose solutions towards improving it. Methods: All 75 trainees within the 14 National Health Service (NHS) Hospitals of the Eastern Deanery were sent out a postal questionnaire in September 2006. The response rate was 89.3%. Seventy four to eighty three percent were performing various level 1 procedures and only a small percentage were doing level 2 and level 3 procedures. All respondents felt the necessity to be independently competent in level 1 and 2 procedures by the end of their training programme but two-thirds remained sceptical about achieving their training objectives. The main factors hindering training were: inability to be the primary surgeon (87%), lack of theatre time (60%) and availability of simulator training (55%). The results reflect the lack of provision for laparoscopic training at most hospitals in the UK Eastern Deanery. This has also been reflected in another survey amongst Welsh trainees. Individual hospitals must be encouraged to provide simulator training. The training programme should allocate more time for supervised simulator sessions and live surgical training. The provision of Consultant led emergency daytime lists could provide a unique training opportunity in the management of ectopic pregnancies and ovarian cysts. Designated teaching lists and individualised training programmes are other solutions.     

Medical genetics and genomics training in obstetrics and gynecology residencies: are we ready for the future?*

Objective: The primary objective of this study is to evaluate the availability and duration of formal medical genetics and genomics (MGG) education during obstetrics and gynecology (OB/GYN) residency training in the United States compared to other noncore OB/GYN rotations.

Methods: We performed a review of rotation schedules published in all American Council for Graduate Medical Education (ACGME)-accredited OB/GYN residency programs’ websites during the month of December 2016. Information regarding availability and duration of MGG rotation and other noncore OB/GYN rotations (ultrasound, breast health, and family planning) were collected.

Results: Among 256 ACGME-accredited OB/GYN residency programs, rotation schedule was available for 238 (93%). Only 34 programs (14.3%) had some form of MGG rotations. In the GLM, when compared to other noncore OB/GYN rotations, the mean duration of MGG rotation was significantly less than ultrasound (0.07 versus 0.57 months, p?p?Conclusions: Despite the growing importance of MGG in day-to-day OB/GYN practice, only a limited number of ACGME-accredited OB/GYN residency programs offer an MGG rotation. When compared to other noncore OB/GYN rotations, such as, ultrasound and family planning, any MGG rotation was significantly shorter. With clear evidence that MGG will continue to radically change practice of OB/GYN in the future, it is imperative that steps need to be taken to address this deficiency in training.