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Roopnarinesingh R, Fay L, McKenna P. A 27-year review of obstetric hysterectomy. J Obstet Gynaecol May 2003; 23: 252-4.

A retrospective case-review of 52 mothers who had a peripartum hysterectomy over the past 27 years was conducted at the Rotunda hospital, Dublin, Ireland. The chief indications were uncontrollable haemorrhage due to rupture of the uterus, placenta praevia and uterine atony. Obstetric hysterectomy is a formidable operation, usually performed as a life-saving measure and requires expert surgical dexterity in order to minimise the significant morbidity. The benefits of the subtotal operation appear to be superior to those of total hysterectomy. Counselling patients having a caesarean section regarding the possibility of hysterectomy is advisable in those who have had previous uterine surgery, multiple caesarean sections or placenta praevia.

 
Sachs BP. A 38-year-old woman with fetal loss and hysterectomy. JAMA Aug 2005; 294: 833-40.
Althabe F, Buekens P, Bergel E, Belizán JM, Campbell MK, Moss N, Hartwell T, Wright LL. A Behavioral Intervention to Improve Obstetrical Care. N Engl J Med May 2008; 358: 1929 -1940.

BACKGROUND: Implementation of evidence-based obstetrical practices remains a significant challenge. Effective strategies to disseminate and implement such practices are needed. METHODS: We randomly assigned 19 hospitals in Argentina and Uruguay to receive a multifaceted behavioral intervention (including selection of opinion leaders, interactive workshops, training of manual skills, one-on-one academic detailing visits with hospital birth attendants, reminders, and feedback) to develop and implement guidelines for the use of episiotomy and management of the third stage of labor or to receive no intervention. The primary outcomes were the rates of prophylactic use of oxytocin during the third stage of labor and of episiotomy. The main secondary outcomes were postpartum hemorrhage and birth attendants' readiness to change their behavior with regard to episiotomies and management of the third stage of labor. The outcomes were measured at baseline, at the end of the 18-month intervention, and 12 months after the end of the intervention. RESULTS: The rate of use of prophylactic oxytocin increased from 2.1% at baseline to 83.6% after the end of the intervention at hospitals that received the intervention and from 2.6% to 12.3% at control hospitals (P=0.01 for the difference in changes). The rate of use of episiotomy decreased from 41.1% to 29.9% at hospitals receiving the intervention but remained stable at control hospitals, with preintervention and postintervention values of 43.5% and 44.5%, respectively (P CONCLUSIONS: A multifaceted behavioral intervention increased the prophylactic use of oxytocin during the third stage of labor and reduced the use of episiotomy.

 
Miller S, Ojengbede O, Turan J, Morhason-Bello I, Martin H, Nsima D.. A comparative study of the non-pneumatic anti-shock garment for the obstetric hemorrhage in Nigeria. International Journal of Gynecology and Obstetrics 107: 121-125.

Objective: To determine whether the non-pneumatic anti-shock garment (NASG) can improve maternal outcome. Methods: Women were enrolled in a pre-intervention phase (n=83) and an intervention phase (n=86) at a referral facility in Katsina, Nigeria, from November 2006 to November 2007. Entry criteria were obstetric hemorrhage (≥750 mL) and a clinical sign of shock (systolic blood pressure b100 mm Hg or pulse N100 beats per minute). To determine differences in demographics, condition on study entry, treatment, and outcome, t tests and χ2 tests were used. Relative risk (RR) and 95% confidence interval (CI) were estimated for the primary outcome, mortality. Results: Mean measured blood loss in the intervention phase was 73.5± 93.9 mL, compared with 340.4±248.2 mL pre-intervention (Pb0.001). Maternal mortality was lower in the intervention phase than in the pre-intervention phase (7 [8.1%]) vs 21 [25.3%]) (RR 0.32; 95% CI, 0.14–0.72). Conclusion: The NASG showed potential for reducing blood loss and maternal mortality caused by obstetric hemorrhage-related shock.

 
Miller S, Fathalla MMF, Youssif MM, Turan J, Camlin C, Al-Hussaini TK, Butrick E, Meyer C.. A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Egypt. International Journal of Gynecology and Obstetrics, Article in Press
 
Miller S, Fathalla M, Youssif MM, Turan J, Camlin C, Al-Hussaini TK, Butrick E, Meyer C.. A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Egypt. International Journal of Gynecology and Obstetrics 109: 20-25.

Objective: To assess the impact of the non-pneumatic anti-shock garment (NASG) on maternal outcome
following severe obstetric hemorrhage. Methods: A non-randomized pre-intervention/intervention study was conducted in 2 tertiary hospitals in Egypt from June 2006 to May 2008. Women with obstetric hemorrhage (estimated blood loss ≥1000 mL and/or ≥1 sign of shock [systolic blood pressure b100 mm Hg
or pulse N100 beats per minute]) were treated with either a standardized protocol (pre-intervention) or a standardized protocol plus the NASG (intervention). The primary outcome was extreme adverse outcome (EAO), combining maternal mortality and severe morbidity (cardiac, respiratory, renal, or cerebral dysfunction). Secondary outcomes were measured blood loss, urine output, emergency hysterectomy, and (individually) mortality or morbidity. Analyses were performed to examine independent association of the
NASG with EAO. Results: Mean measured blood loss decreased from 379 mL pre-intervention to 253 mL in the intervention group (Pb0.01). In a multiple logistic regression model, the NASG was associated with reduced odds of EAO (odds ratio 0.38; 95% confidence interval, 0.17–0.85). Conclusion: The NASG, in addition to standardized protocols at tertiary facilities for obstetric hemorrhage and shock, resulted in lower measured blood loss and reduced EAO.

 
Miller S, Ojengbede O, Turan JM, Morhasen-Bello IO, Martin HB, Nsima D.. A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Nigeria. International Journal of Gynecology and Obstetrics 107: 121-125.

Objective: To determine whether the non-pneumatic anti-shock garment (NASG) can improve maternal outcome. Methods: Women were enrolled in a pre-intervention phase (n=83) and an intervention phase (n=86) at a referral facility in Katsina, Nigeria, from November 2006 to November 2007. Entry criteria were obstetric hemorrhage (≥750 mL) and a clinical sign of shock (systolic blood pressure b100 mm Hg or pulse N100 beats per minute). To determine differences in demographics, condition on study entry, treatment, and outcome, t tests and χ2 tests were used. Relative risk (RR) and 95% confidence interval (CI) were estimated
for the primary outcome, mortality. Results: Mean measured blood loss in the intervention phase was 73.5± 93.9 mL, compared with 340.4±248.2 mL pre- intervention (Pb0.001). Maternal mortality was lower in the intervention phase than in the pre-intervention phase (7 [8.1%]) vs 21 [25.3%]) (RR 0.32; 95% CI, 0.14–0.72). Conclusion: The NASG showed potential for reducing blood loss and maternal mortality caused by obstetric hemorrhage-related shock.

 
el-Solh AA, Grant BJ. A comparison of severity of illness scoring systems for critically ill obstetric patients . Chest 1996; 110: 1299-1304.

STUDY OBJECTIVE: To evaluate the predictive ability of three scoring systems, acute physiology and chronic health evaluation (APACHE II), simplified acute physiology score (SAPS II), and mortality probability models (MPM II) in critically ill obstetric patients compared to a control group of non-obstetric female patients of similar age group (range, 17 to 41 years). DESIGN: A retrospective medical chart review of obstetric and nonobstetric female patients between 17 and 41 years of age. SETTING: Two university hospitals. PATIENTS: Ninety-three obstetric patients and 96 nonobstetric female patients were identified from 12,740 consecutive ICU admissions. RESULTS: The actual mortality of the obstetric and the nonobstetric group was 10.8% (95% confidence interval [CI], 5.3 to 19.0%) and 12.5% (95% CI, 6.6 to 21.0%), respectively. The observed mortality was not statistically different from the mortality predicted by APACHE II, SAPS II, and MPM II (14.7%, 7.8%, and 9.1% for the obstetric group and 10.9%, 9.0%, and 9.9% for the nonobstetric group). Predictive accuracy was assessed by the c-index, which is equivalent to the area under the receiver operator characteristic (ROC) curve. There were no significant differences in the c-index for APACHE II, SAPS II, and MPM II within or between the obstetric group ([mean +/- SE], 0.93 +/- 0.02, 0.90 +/- 0.04, and 0.91 +/- 0.04, respectively) and the nonobstetric group (0.97 +/- 0.02, 0.95 +/- 0.03, and 0.96 +/- 0.02, respectively). CONCLUSIONS: We conclude that APACHE II, SAPS II, and MPM II assess the ICU outcome of critically ill obstetric patients as accurately as nonobstetric critically ill female patients of similar age group.

 
Petter CM, Thung SF, Raab CA, Donohu KP, Copel JA, Lockwood CJ, Funai EF. A comprehensive obstetrics patient safety program improves safety climate and culture. Am J Obstet Gynecol 204: 216.e1-6.

OBJECTIVE: The purpose of this study was to determine the effect of an
obstetrics patient safety program on staff safety culture.
STUDY DESIGN: We implemented (1) obstetrics patient safety nurse, (2) protocol-based standardization of practice, (3) crew resource management training, (4) oversight by a patient safety committee, (5) 24-hour obstetrics hospitalist, and (6) an anonymous event reporting system. We administered the Safety Attitude Questionnaire on 4 occasions over 5 years (2004-2009) to all staffmembers that assessed teamwork and safety cultures, job satisfaction, working conditions, stress recognition, and perceptions of management.
RESULTS: We observed significant improvements in the proportion of staff
members with favorable perceptions of teamwork culture (39%in 2004 to
63%in 2009), safety culture (33%to 63%), job satisfaction (39%to 53%),
andmanagement (10%to 37%). Individual roles (obstetrics providers, residents,
and nurses) also experienced improvements in safety and teamwork, with significantly better congruence between doctors and nurses.
CONCLUSION: Safety programs can improve workforce perceptions of safety and an improved safety climate.

 
Geller, S, Adams, MG, Miller, S. A Continuum of Care Model for Postpartum Hemorrhage. International Journal of Fertility & Women's Medicine 52: 97-105.

The leading cause of maternal mortality is hemorrhage, generally occurring in the postpartum period. Current levels of PPH-related morbidity and mortality in low-resource settings result from institutional, environmental, cultural and social barriers to providing skilled care and preventing, diagnosing and treating PPH. Conventional uterotonics to prevent PPH are typically not available or practical for use in low-resource settings. In such deliveries, most often taking place at home or in rural health centers, underestimation of blood loss leads to a delay in diagnosis. Deficiencies in communication and transportation infrastructure impede transfer to a higher level of care. Inability to stabilize a patient who is in hemorrhagic shock rapidly results in death. To address these individual factors, we propose a continuum of care model for PPH, including routine use of prophylactic misoprostol or other appropriate uterotonic, a standardized means of blood loss assessment, availability of a non-pneumatic anti-shock garment, and systemization of communication, transportation, and referral. Such a multifaceted, systematic, contextualized PPH continuum of care approach may have the greatest impact for saving women's lives. This model should be developed and tested to be region-specific.