Inconsistent Evidence: Analysis of Six National Guidelines for Vaginal Birth After Cesarean Section

Abstract: Background: Guidelines are increasingly used to direct clinical practice, with the expectation that they improve clinical outcomes and minimize health care expenditure. Several national guidelines for vaginal birth after cesarean section (VBAC) have been released or updated recently, and their range has created dilemmas for clinicians and women. The purpose of this study was to summarize the recommendations of existing guidelines and assess their quality using a standardized and validated instrument to determine which guidelines, if any, are best able to guide clinical practice. Methods: English language guidelines on VBAC were purposively selected from national and professional organizations in the United Kingdom, United States, Canada, New Zealand, and Australia. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was applied to each guideline, and each was analyzed to determine the range and level of evidence on which it was based and the recommendations made. Results: Six guidelines published or updated between 2004 and 2007 were examined. Only two of the six guidelines scored well overall using the AGREE instrument, and the evidence used demonstrated great variety. Most guidelines cited expert opinion and consensus as evidence for some recommendations. Reported success rates for VBAC ranged from 30 to 85 percent, and reported rates of uterine rupture ranged from 0 to 2.8 percent. Conclusions: VBAC guidelines are characterized by quasi‐experimental evidence and consensus‐based recommendations, which lead to wide variability in recommendations and undermine their usefulness in clinical practice. (BIRTH 37:1 March 2010)     

Mothers’ Reports of Postpartum Pain Associated with Vaginal and Cesarean Deliveries: Results of a National Survey

ABSTRACT: Background: As cesarean rates increase worldwide, a debate has arisen over the relationship of method of delivery to maternal postpartum physical health. This study examines mothers’ reports of their postpartum experiences with pain stratified by method of delivery. Methods: Listening to Mothers II was a survey of a total of 1,573 (200 telephone and 1,373 online) mothers aged 18 to 45 years, who had a singleton, hospital birth in 2005. They were interviewed by the survey research firm, Harris Interactive, in early 2006. Online respondents were drawn from an existing Harris panel. Telephone respondents were identified through a national telephone listing of new mothers. Results were weighted to reflect a United States national birthing population. Mothers were asked if they experienced any of eight postpartum conditions and the extent and the duration of the problem. Responses were compared by method of delivery. Results: The most frequently cited postpartum difficulty was among mothers with a cesarean section, 79 percent of whom reported experiencing pain at the incision in the first 2 months after birth, with 33 percent describing it as a major problem and 18 percent reporting persistence of the pain into the sixth month postpartum. Mothers with planned cesareans without labor were as likely as those with cesareans with labor to report problems with postpartum pain. Almost half (48%) of mothers with vaginal births (68% among those with instrumental delivery, 63% with episiotomy, 43% spontaneous vaginal birth with no episiotomy) reported experiencing a painful perineum, with 2 percent reporting the pain persisting for at least 6 months. Conclusions: Substantial proportions of mothers reported problems with postpartum pain. Women experiencing a cesarean section or an assisted vaginal delivery were most likely to report that the pain persisted for an extended period. (BIRTH 35:1 March 2008)     

Nutritional status and wound severity of overweight and obese patients with venous leg ulcers: A pilot study

Obesity is a chronic disease that is linked to the presence of numerous chronic illnesses, including venous disease. Venous disease can lead to chronic wounds, which may be exacerbated by vitamin, mineral, and macro-nutritional deficiencies. A cross-sectional observational design was used to examine the nutritional status of patients with chronic venous leg ulcers (VLUs) who are overweight or obese and to explore the relationship between nutritional status and severity of venous ulceration. Nutritional status was evaluated using anthropometric measurements, nutrient analysis from a 3-day dietary intake log, serum albumin, vitamins A and C, and zinc levels. Wound severity was assessed using the Leg Ulcer Measurement Tool (LUMT). Eight patients participated; six patients were men, and all eight patients were more than 50 years of age. Patients had an average daily caloric intake below their estimated caloric need. When compared with recommended daily intake levels, dietary nutrient intake was suboptimal for protein, vitamin C, and zinc. Serum levels were below normal for at least one of these nutrients in six patients. A positive correlation was found only between serum albumin, average daily intake, and percent recommended daily intake of protein (r(s) = 0.93, P = .003). An inverse relationship was found between LUMT score and serum vitamin A levels (r(s) = -0.83, P = .01), and a positive correlation was observed between LUMT score and serum vitamin C (r(s) = 0.74, P = .04). No clear relationships were shown among serum zinc, albumin, and LUMT scores. Overweight and obese patients with VLU show nutritional deficits that are similar to those of the broader population of patients with leg ulcers. The relationships found between vitamins A and C and leg ulcer severity warrant further exploration. The nutritional differences in the study need to be examined in a larger sample of overweight and normal-weight patients to determine whether overweight patients are at greater risk for prolonged VLU because of poor nutrition than non-overweight patients.     

Postpartal Nursing Diagnosis

The responsibility of nurses for postpartal patients has changed greatly in the past few years. No longer is it adequate to assess and manage only those physical problems that occur during the hospital stay. Today, potential psychosocial problems and consequences of parental knowledge deficit are part of nursing's domain of diagnosis and management. A review of the purpose of nursing diagnosis is important. Clarifying the difference between medical diagnosis and nursing diagnosis is also essential if one is to be comfortable with the process. Careful scrutiny of the unique needs of new parents will form the basis for formulating meaningful postpartal nursing diagnosis.     

Personality hardiness, ways of coping, social support and burnout in critical care nurses

Hardiness, ways of coping, social support and burnout in 103 critical care nurses were addressed in this study. Work-related and nonwork-related social support and hardiness were negatively related to burnout. Use of emotion-focused coping was positively correlated with burnout while hardiness was negatively related to the use of emotion-focused coping and positively related to both types of social support. After controlling for working nights, social support, hardiness, emotion-focused coping and problem-focused coping accounted for 44% of the variance in burnout scores.     

Trauma-induced proliferation of astrocytes in the brains of young and aged rats

The time-course and magnitude of astrocyte proliferation following neural trauma was evaluated in young adult (3 months) and mid-aged (16-19 months) male Fischer 344 rats. One to 4 days after a needle wound was made through the cortex and the hippocampus, rats received three intraperitoneal injections of 3H-thymidine at 8 hour intervals and were sacrificed 1 hour after the last injection. For astrocyte quantification, 3H-thymidine autoradiography was combined with immunohistochemical staining for glial fibrillary acidic protein followed by semithin sectioning. In areas of the cortex and hippocampus adjacent to the wound, astrocytes were categorized as unlabeled or labeled with silver grains over the nuclei. Labeling index and numerical density of astrocytes were determined using stereological methods. The results showed that in both young and older rats, astrocyte proliferation is an early glial response to neural trauma, occurring during the first 4 postlesion days and contributing to an increase in astrocyte population. Regional differences in labeling index and numerical density suggest heterogeneity in the proliferative capacity of astrocyte subpopulations in the rat brain. Compared with young animals, older rats demonstrated greater labeling in the cortex but not in the hippocampus. Thus, aging is associated with region-specific increase in astrocyte reactivity to trauma possibly due to increased availability of mitogens or enhanced sensitivity of astrocytes to mitogenic signals.