Research-Based Articles

Summary: Study comparing VTE prophylaxis guidelines.

Abstract: Background: Venous thromboembolism is a leading cause of maternal death worldwide. The postpartum period is a time of particularly increased risk. International guidelines provide recommendations for when a woman should be offered thromboembolism prophylaxis, however they differ greatly in their criteria as to which women qualify for low molecular weight heparin (LMWH). The aim of this study was to determine the most common risk factors for women being recommended LMWH and compare the proportion of women who would qualify for postpartum LMWH according to four international guidelines.

Materials and methods: This cross-sectional study evaluated rates of postpartum LMWH prophylaxis by applying guideline recommendations from the American College of Chest Physicians (ACCP), the Royal College of Obstetricians and Gynaecologists (RCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ). Demographic, medical and obstetric risk factors for venous thromboembolism were identified for individual women from one regional and two tertiary maternity hospitals in New South Wales, Australia between February and October 2022.

Results: A total of 338 women were included in the analyses. By applying RCOG guidelines, 53.6% of women would have qualified for postpartum LMWH compared with 40.2% of women using SOMANZ guidelines, 37.3% using SOGC guidelines, and 8.3% using ACCP guidelines. The most common risk factors were caesarean birth, maternal age greater than 35 years, body mass index above 30 kg/m2 and instrumental birth.

Conclusions: There are considerable differences in the rates of women receiving postpartum pharmacological venous thromboembolism prophylaxis when recommendations from different international guidelines are applied. These differences reflect the wide variation in guideline recommendations for the use of LMWH following birth.

Keywords: Venous thromboembolism; postpartum; guidelines; prophylaxis

Topic(s):

• Clinical consensus, guidelines, protocols
• Quality, performance, and outcome indicators

Intervention Type: Policy Development and Enforcement

Summary: Methodology study developing key performance indicators (KPI) for massive transfusion.

Abstract: Background and objectives: To develop key performance indicators (KPI) for use in quality assessment of our institutional goal-directed massive transfusion (GDMT).

Materials and methods: A team comprising our transfusion and emergency medicine departments carried out a cross-sectional data analysis of GDMT in adult patients from January 2021 to December 2022. The study was rooted in the Define, Measure, Analyse, Improve, Control (DMAIC) approach. Features of KPIs were (a) importance, (b) scientific soundness and (c) feasibility. Study parameters were defined and analysed using measures of central tendencies and benchmark comparison.

Results: Ninety-two massive transfusion events occurred and 1405 blood components were used. Trauma was the leading cause, followed by postpartum haemorrhage and upper gastrointestinal bleeding. Appropriate GDMT activation was observed only in 43.47% of events. The turnaround time (TAT) was within the benchmark in 85.8% of events with an average of 16 ± 10 min. The average utilization of blood components was 20.5 (interquartile range [IQR] = 11.3) in the appropriate group and 5.5 (IQR = 4.25) in the inappropriate group with a wastage rate of 3.5%. Duration of activation was 6.19 ± 4.59 h, and the adherence to thromboelastography was 66.3%. Overall mortality was 45.65%, and the average duration of hospital stay was 6.1 ± 5.9 days.

Conclusion: The KPIs developed were easy to capture, and the analysis provided a comprehensive approach to the quality improvement of the GDMT protocol.

Keywords: Massive transfusion, quality improvement, key performance indicators

Topic(s):

• Quality, performance, and outcome indicators
• Clinical consensus, guidelines, protocols

Intervention Type: Policy Development and Enforcement

Summary: Narrative review of critical care management strategies.

Abstract: Maternal cardiovascular disease is a leading cause of maternal death worldwide and recently, maternal mortality has increased secondary to cardiovascular causes. Maternal admissions to critical care encompass 1%-2% of all critical care admissions, and although not common, the management of the critically ill pregnant patient is complex. Caring for the critically ill pregnant cardiac patient requires integration of pregnancy-associated physiologic changes, understanding pathophysiologic disease states unique to pregnancy, and a multidisciplinary approach to timing around delivery as well as antenatal and postpartum care. Herein we describe cardiorespiratory changes that occur during pregnancy and the differential diagnosis for cardiorespiratory failure in pregnancy. Cardiorespiratory diseases that are either associated or exacerbated by pregnancy are highlighted with emphasis on perturbations secondary to pregnancy and appropriate management strategies. Finally, we describe general management of the pregnant cardiac patient admitted to critical care.

Keywords: Critical care; pregnancy; cardiac patient; review

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Consultation Direct Care

Summary: Educational module development and assessment based on student/facilitator perceptions.

Abstract: Introduction: The Association of Professors of Gynecology and Obstetrics core learning objectives for medical students include postpartum care, peripartum mood disorders, family planning, and intimate partner violence.

Methods: This module uses student prework, session slides, and a facilitator guide for a 2-hour flipped classroom case that addresses these core learning areas for medical students on their obstetrics and gynecology clerkship. We assessed the module in a range of domains with five rotations of students who participated during their clerkship and facilitators who led the session. Data were collected from students and facilitators via voluntary participation in a survey made available after the session. Data are reported as proportion of respondents who agreed or strongly agreed.

Results: Of 97 student participants, 57 completed the survey (59%). More than 85% agreed or strongly agreed that the session improved understanding or comfort in each of the learning objectives, and the majority agreed that the prework offered useful knowledge for the session (89%), that the session was interactive (91%), and that the session format was helpful in applying new knowledge (95%). Fifty-seven percent of facilitators responded; all agreed that the facilitator guide increased their confidence while teaching and that they spent less time preparing for the session than traditional didactics. Most (89%) agreed that the facilitator guide helped them promote active learning.

Discussion: With favorable student and facilitator perceptions, this module provides a tool to address several core learning objectives for medical students in the context of an interactive flipped classroom module.

Keywords: Flipped classroom; OB/GYN; contraception; postpartum care; IPV screening

Topic(s):

• Workforce training and development
• Clinical consensus, guidelines, protocols

Intervention Type: Education and Promotion Screening

Summary: Observational audit quantifying existing compliance rates of protocols with national guidelines.

Abstract: Objectives: The principal objective of this work was to assess how well the written protocols of maternity units used for the prevention and management of postpartum hemorrhage (PPH) corresponded to the 2004 French guidelines on this topic. The second objective was to assess whether or not this correspondence with the national guidelines varied according to hospital level (basic, specialized, and subspecialized) and status (teaching, public, and private).

Methods: This observational multicenter cross-sectional study took place in September 2010 and included French perinatal networks that volunteered to participate. We asked 300 French maternity units belonging to these networks to participate by emailing a copy of their department's protocol for PPH to the study team. This team designed and performed a clinical audit of these protocols, defining 16 criteria that incorporated the 2004 French guidelines for prevention and management of PPH. The main outcome measure was the percentage of units reporting protocols meeting these criteria.

Results: Of the 244 maternity units responding, 97.1 % had a written protocol but only 67.0 % had a local protocol. Protocol correspondence with the 2004 French guidelines was good for the criteria involving quantitative assessment of the quantity of blood loss (83.5 %) and secondary management of PPH (>80 %). Correspondence with the guidelines was poor in terms of defining PPH in the protocol (25.3 %) and of requiring the recording of the time of PPH diagnosis (53.2 %) and of the volume of blood loss (55.7 %). These results differed only slightly according to maternity unit status or level.

Conclusion: In all, 67.0 % (159/237) of maternity units had a local protocol for PPH. The contents of these protocols should be improved to be closer to the national guidelines.

Keywords: Postpartum hemorrhage, protocols, maternity units, audit, France

Topic(s):

• Clinical consensus, guidelines, protocols
• Quality, performance, and outcome indicators

Intervention Type: Policy Development and Enforcement

Summary: Review summarizing the clinical management approaches.

Abstract: Type 2 diabetes mellitus (DM) is a growing problem among reproductive-aged women. Contemporary trends in obesity and delayed child-bearing are expected to result in an increasing number of pregnancies affected by type 2 DM. Women with known type 2 DM can greatly benefit from preconception care as improved periconception glycemic control and weight loss can decrease the neonatal and maternal risks associated with type 2 DM and pregnancy. Antenatal mainstays of management include frequent blood glucose monitoring, insulin therapy, optimization of coexisting medical conditions, and fetal surveillance. Careful attention to postpartum glucose control, infant feeding choices, and contraceptive counseling are important aspects of immediate postpartum care.

Keywords: Type 2 diabetes, pregnancy, management, glycemic control, prenatal care

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Consultation Direct Care

Summary: Systematic review summarizing clinical practice guidelines for eating disorders.

Abstract: Background: Eating disorders during the perinatal period can pose significant risks to both the mother and the baby. Clinical practice guidelines include statements of expected practice intending to improve effectiveness and quality of care within health care services. This systematic review aimed to identify and synthesise current clinical practice guideline recommendations on the assessment, management and treatment of eating disorders during the perinatal period.

Methods: Three bibliographic databases and five guideline repository databases were searched alongside the grey literature. Guidelines were screened against eligibility criteria and recommendations for the assessment, management or treatment of eating disorders during the perinatal period were extracted. All included guidelines were assessed for quality using the AGREE-II tool. Recommendations were analysed and summarised using narrative synthesis.

Results: From the 242 records screened, 17 met inclusion criteria. Guideline quality ranged from three out of seven to seven out of seven. Six overall recommendations were formed from the narrative synthesis of data: 1) Early detection: recognising the signs and symptoms, 2) Assessment and screening: a three-pronged approach, 3) Educating and supporting the mother: the importance of knowledge, 4) Cross-system collaboration, 5) Psychological, pharmacological and medical treatment, and 6) Continued monitoring.

Conclusion: Perinatal eating disorder guideline recommendations were fairly consistent but showed considerable variability in quality and depth of recommendations. Recommendations require further contextualisation, to allow them to be operationalised and implemented within services. The review findings provide an initial framework for health care professionals responsible for supporting women with eating disorders during the perinatal period, and have several implications for policy, service delivery and health outcomes for women and their families.

Keywords: Eating disorders, perinatal, guidelines, systematic review

Topic(s):

• Clinical consensus, guidelines, protocols
• Behavioral/mental health services and substance use

Intervention Type: Policy Development and Enforcement

Summary: Descriptive article advocating for continuing education and timely multidisciplinary postpartum care.

Abstract: Obstetric anal sphincter injuries represent the minority of obstetric lacerations, but can have a significant long-term impact on urinary and fecal continence, as well as pelvic organ support. Accurate diagnosis of lacerations, appropriate repair, and close follow-up are essential to healthy healing and to improve outcomes for women. The infrequency of these injuries has resulted in a lack of familiarity with laceration repair and postpartum care of this population at all levels of practice. As such, continuing education strategies aimed at simulation, increased clinical exposure to anal sphincter injuries, and evidence-based repair techniques are important for mitigating the deficits in the current obstetric environment. Ensuring that patients have access to timely multidisciplinary postpartum care and education on the laceration incurred is essential to promote healthy healing and to optimize pelvic floor outcomes.

Keywords: Obstetric anal sphincter injury; diagnosis; repair; review

Topic(s):

• Clinical consensus, guidelines, protocols
• Workforce training and development

Intervention Type: Direct Care

Summary: Commentary suggesting priorities for achieving equity in postpartum contraceptive access.

Abstract: Equitable access to contraception and contraceptive education has the potential to mitigate health disparities related to unintended pregnancy. Pregnancy and the postpartum window frequently offer reduced insurance barriers to healthcare, increased interaction with healthcare systems and family planning providers, and an opportune time for many individuals to receive contraception; however, there are additional considerations in method type for postpartum individuals, and contraceptive counseling must be thoughtfully conducted to avoid coercion and promote shared decision-making. This commentary reviews method-specific considerations and suggests priorities for achieving equity in postpartum contraceptive access.

Keywords: Postpartum contraception; equity; access; health policy

Topic(s):

• Health equity and access to care
• Clinical consensus, guidelines, protocols

Intervention Type: Counseling Education and Promotion

Summary: Observational audit quantifying guideline adherence rates (6.0% discrepancy observed).

Abstract: Introduction: Transfusion of blood products occurs frequently as part of the treatment of post-partum haemorrhage, but since it is both expensive and has potentially severe complications, prescription of blood products should be restricted. The aim of this study was to examine if restrictive red blood cell transfusion (RBC-T) practice for obstetric patients was in line with national Danish guidelines.

Methods: A retrospective quality assurance study was conducted at Rigshospitalet, Denmark. The study counted the participation of the Department of Anaesthesiology and Surgery, the Juliane Marie Centre, the Danish Blood Bank and the Department of Obstetrics. Patients were identified via the patient database of the Danish Blood Bank in 2015-2017, and patient files were read.

Results: Out of 16,698 delivering women, 196 (1.2%) received one or more RBC-T from 2015 to 2017. A total of 133 women (67.9%) received more than one RBC-T and the median was two. The most common reason for RBC-T was a "low haemoglobin level (Hb) + anaemic symptoms" (37.0%). A total of 20.3% of all RBC-Ts were prescribed based simply on a low Hb. The most common symptom of anaemia was dizziness.

Conclusions: The majority of RBC-Ts for obstetric patients were conducted in line with the guidelines. However, 6.0% of RBC-Ts were registered to be in discrepancy with the guidelines and 20.3% of RBC-Ts were prescribed on the "low Hb" criterium solely. It is possible, though, that the 20.3% is overestimated due to insufficient descriptions of indications for RBC-T in patient files.

Keywords: Red blood cell transfusion; postpartum hemorrhage; guidelines; adherence

Topic(s):

• Quality, performance, and outcome indicators
• Clinical consensus, guidelines, protocols

Intervention Type: Policy Development and Enforcement Direct Care

Summary: Expert review providing Best Practice Advice statements (guidelines/recommendations).

Abstract: Description: The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available published evidence and expert advice regarding the clinical management of patients with pregnancy-related gastrointestinal and liver disease.

Methods: This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through the standard procedures of Gastroenterology. This article provides practical advice for the management of pregnant patients with gastrointestinal and liver disease based on the best available published evidence. The Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because formal systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: To optimize gastrointestinal and liver disease before pregnancy, preconception and contraceptive care counseling by a multidisciplinary team should be encouraged for reproductive-aged persons who desire to become pregnant. BEST PRACTICE ADVICE 2: Procedures, medications, and other interventions to optimize maternal health should not be withheld solely because a patient is pregnant and should be individualized after an assessment of the risks and benefits. BEST PRACTICE ADVICE 3: Coordination of birth for a pregnant patient with complex inflammatory bowel disease, advanced cirrhosis, or a liver transplant should be managed by a multidisciplinary team, preferably in a tertiary care center. BEST PRACTICE ADVICE 4: Early treatment of nausea and vomiting of pregnancy may reduce progression to hyperemesis gravidarum. In addition to standard diet and lifestyle measures, stepwise treatment consists of symptom control with vitamin B6 and doxylamine, hydration, and adequate nutrition; ondansetron, metoclopramide, promethazine, and intravenous glucocorticoids may be required in moderate to severe cases. BEST PRACTICE ADVICE 5: Constipation in pregnant persons may result from hormonal, medication-related, and physiological changes. Treatment options include dietary fiber, lactulose, and polyethylene glycol-based laxatives. BEST PRACTICE ADVICE 6: Elective endoscopic procedures should be deferred until the postpartum period, whereas nonemergent but necessary procedures should ideally be performed in the second trimester. Pregnant patients with cirrhosis should undergo evaluation for, and treatment of, esophageal varices; upper endoscopy is suggested in the second trimester (if not performed within 1 year before conception) to guide consideration of nonselective β-blocker therapy or endoscopic variceal ligation. BEST PRACTICE ADVICE 7: In patients with inflammatory bowel disease, clinical remission before conception, during pregnancy, and in the postpartum period is essential for improving outcomes of pregnancy. Biologic agents should be continued throughout pregnancy and the postpartum period; use of methotrexate, thalidomide, and ozanimod must be stopped at least 6 months before conception. BEST PRACTICE ADVICE 8: Endoscopic retrograde cholangiopancreatography during pregnancy may be performed for urgent indications, such as choledocholithiasis, cholangitis, and some cases of gallstone pancreatitis. Ideally, endoscopic retrograde cholangiopancreatography should be performed during the second trimester, but if deferring the procedure may be detrimental to the health of the patient and fetus, a multidisciplinary team should be convened to decide on the advisability of endoscopic retrograde cholangiopancreatography. BEST PRACTICE ADVICE 9: Cholecystectomy is safe during pregnancy; a laparoscopic approach is the standard of care regardless of trimester, but ideally in the second trimester. BEST PRACTICE ADVICE 10: The diagnosis of intrahepatic cholestasis of pregnancy is based on a serum bile acid level >10 μmol/L in the setting of pruritus, typically during the second or third trimester. Treatment should be offered with oral ursodeoxycholic acid in a total daily dose of 10-15 mg/kg. BEST PRACTICE ADVICE 11: Management of liver diseases unique to pregnancy, such as pre-eclampsia; hemolysis, elevated liver enzymes, and low platelets syndrome; and acute fatty liver of pregnancy requires planning for delivery and timely evaluation for possible liver transplantation. Daily aspirin prophylaxis for patients at risk for pre-eclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome is advised beginning at week 12 of gestation. BEST PRACTICE ADVICE 12: In patients with chronic hepatitis B virus infection, serum hepatitis B virus DNA and liver biochemical test levels should be ordered. Patients not on treatment but with a serum hepatitis B virus DNA level >200,000 IU/mL during the third trimester of pregnancy should be considered for treatment with tenofovir disoproxil fumarate. BEST PRACTICE ADVICE 13: In patients on immunosuppressive therapy for chronic liver diseases or after liver transplantation, therapy should be continued at the lowest effective dose during pregnancy. Mycophenolate mofetil should not be administered during pregnancy.

Keywords: Gastrointestinal disease, liver disease, pregnancy, clinical practice, expert review

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Consultation Policy Development and Enforcement

Summary: Development and dissemination of a patient safety bundle providing guidance.

Abstract: Cardiac conditions are the leading cause of pregnancy-related deaths and disproportionately affect non-Hispanic Black people. Multidisciplinary maternal mortality review committees have found that most people who died from cardiac conditions during pregnancy or postpartum were not diagnosed with a cardiovascular disease before death and that more than 80% of all pregnancy-related deaths, regardless of cause, were preventable. In addition, other obstetric complications, such as preeclampsia and gestational diabetes, are associated with future cardiovascular disease risk. Those with cardiac risk factors and those with congenital and acquired heart disease require specialized care during pregnancy and postpartum to minimize risk of preventable morbidity and mortality. This bundle provides guidance for health care teams to develop coordinated, multidisciplinary care for pregnant and postpartum people with cardiac conditions and to respond to cardio-obstetric emergencies. This bundle is one of several core patient safety bundles developed by the Alliance for Innovation on Maternal Health that provide condition- or event-specific clinical practices for implementation in appropriate care settings. The Cardiac Conditions in Obstetric Care bundle is organized into five domains: 1) Readiness , 2) Recognition and Prevention , 3) Response , 4) Reporting and Systems Learning , and 5) Respectful Care . This bundle is the first by the Alliance to be developed with the fifth domain of Respectful Care . The Respectful Care domain provides essential best practices to support respectful, equitable, and supportive care to all patients. Further health equity considerations are integrated into elements in each domain.

Keywords: Cardiac conditions; obstetric care; consensus bundle; maternal health; AIM

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Policy Development and Enforcement Collaboration

Summary: Development and dissemination of a patient safety bundle providing guidance.

Abstract: Sepsis in obstetric care is one of the leading causes of maternal death in the United States, with Black, Asian/Pacific Islander, and American Indian/Alaska Native obstetric patients experiencing sepsis at disproportionately higher rates. State maternal mortality review committees have determined that deaths are preventable much of the time and are caused by delays in recognition, treatment, and escalation of care. The "Sepsis in Obstetric Care" patient safety bundle provides guidance for health care teams to develop coordinated, multidisciplinary care for pregnant and postpartum people by preventing infection and recognizing and treating infection early to prevent progression to sepsis. This is one of several core patient safety bundles developed by AIM (the Alliance for Innovation on Maternal Health) to provide condition- or event-specific clinical practices that should be implemented in all appropriate care settings. As with other bundles developed by AIM, the "Sepsis in Obstetric Care" patient safety bundle is organized into five domains: Readiness, Recognition and Prevention, Response, Reporting and Systems Learning, and Respectful, Equitable, and Supportive Care. The Respectful, Equitable, and Supportive Care domain provides essential best practices to support respectful, equitable, and supportive care to all patients. Further health equity considerations are integrated into the elements of each domain.

Keywords: sepsis, obstetric care, consensus, bundle, maternal health

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Policy Development and Enforcement Direct Care

Summary: Cochrane review concluding no compelling evidence that one regimen is superior.

Abstract: Background: Magnesium sulphate is the drug of choice for the prevention and treatment of women with eclampsia. Regimens for administration of this drug have evolved over the years, but there is no clarity on the comparative benefits or harm of alternative regimens. This is an update of a review first published in 2010.

Objectives: To assess if one magnesium sulphate regimen is better than another when used for the care of women with pre-eclampsia or eclampsia, or both, to reduce the risk of severe morbidity and mortality for the woman and her baby.

Search methods: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (29 April 2022), and reference lists of retrieved studies.

Selection criteria: We included randomised trials and cluster-randomised trials comparing different regimens for administration of magnesium sulphate used in women with pre-eclampsia or eclampsia, or both. Comparisons included different dose regimens, intramuscular versus intravenous route for maintenance therapy, and different durations of therapy. We excluded studies with quasi-random or cross-over designs. We included abstracts of conference proceedings if compliant with the trustworthiness assessment.

Data collection and analysis: For this update, two review authors assessed trials for inclusion, performed risk of bias assessment, and extracted data. We checked data for accuracy. We assessed the certainty of the evidence using the GRADE approach.

Main results: For this update, a total of 16 trials (3020 women) met our inclusion criteria: four trials (409 women) compared regimens for women with eclampsia, and 12 trials (2611 women) compared regimens for women with pre-eclampsia. Most of the included trials had small sample sizes and were conducted in low- and middle-income countries. Eleven trials reported adequate randomisation and allocation concealment. Blinding of participants and clinicians was not possible in most trials. The included studies were for the most part at low risk of attrition and reporting bias. Treatment of women with eclampsia (four comparisons) One trial compared a loading dose-alone regimen with a loading dose plus maintenance dose regimen (80 women). It is uncertain whether either regimen has an effect on the risk of recurrence of convulsions or maternal death (very low-certainty evidence). One trial compared a lower-dose regimen with standard-dose regimen over 24 hours (72 women). It is uncertain whether either regimen has an effect on the risk of recurrence of convulsion, severe morbidity, perinatal death, or maternal death (very low-certainty evidence). One trial (137 women) compared intravenous (IV) versus standard intramuscular (IM) maintenance regimen. It is uncertain whether either route has an effect on recurrence of convulsions, death of the baby before discharge (stillbirth and neonatal death), or maternal death (very low-certainty evidence). One trial (120 women) compared a short maintenance regimen with a standard (24 hours after birth) maintenance regimen. It is uncertain whether the duration of the maintenance regimen has an effect on recurrence of convulsions, severe morbidity, or side effects such as nausea and respiratory failure. A short maintenance regimen may reduce the risk of flushing when compared to a standard 24 hours maintenance regimen (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.08 to 0.93; 1 trial, 120 women; low-certainty evidence). Many of our prespecified critical outcomes were not reported in the included trials. Prevention of eclampsia for women with pre-eclampsia (five comparisons) Two trials (462 women) compared loading dose alone with loading dose plus maintenance therapy. Low-certainty evidence suggests an uncertain effect with either regimen on the risk of eclampsia (RR 2.00, 95% CI 0.61 to 6.54; 2 trials, 462 women) or perinatal death (RR 0.50, 95% CI 0.19 to 1.36; 2 trials, 462 women). One small trial (17 women) compared an IV versus IM maintenance regimen for 24 hours. It is uncertain whether IV or IM maintenance regimen has an effect on eclampsia or stillbirth (very low-certainty evidence). Four trials (1713 women) compared short postpartum maintenance regimens with continuing for 24 hours after birth. Low-certainty evidence suggests there may be a wide range of benefit or harm between groups regarding eclampsia (RR 1.99, 95% CI 0.18 to 21.87; 4 trials, 1713 women). Low-certainty evidence suggests there may be little or no effect on severe morbidity (RR 0.96, 95% CI 0.71 to 1.29; 2 trials, 1233 women) or side effects such as respiratory depression (RR 0.80, 95% CI 0.25 to 2.61; 2 trials, 1424 women). Three trials (185 women) compared a higher-dose maintenance regimen versus a lower-dose maintenance regimen. It is uncertain whether either regimen has an effect on eclampsia (very low-certainty evidence). Low-certainty evidence suggests that a higher-dose maintenance regimen has little or no effect on side effects when compared to a lower-dose regimen (RR 0.79, 95% CI 0.61 to 1.01; 1 trial 62 women). One trial (200 women) compared a maintenance regimen by continuous infusion versus a serial IV bolus regimen. It is uncertain whether the duration of the maintenance regimen has an effect on eclampsia, side effects, perinatal death, maternal death, or other neonatal morbidity (very low-certainty evidence). Many of our prespecified critical outcomes were not reported in the included trials.

Authors' conclusions: Despite the number of trials evaluating various magnesium sulphate regimens for eclampsia prophylaxis and treatment, there is still no compelling evidence that one particular regimen is more effective than another. Well-designed randomised controlled trials are needed to answer this question.

Keywords: Magnesium sulphate, pre-eclampsia, eclampsia, alternative regimen, Cochrane review

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Consultation Direct Care

Summary: Review emphasizing knowledge of best practices during emergencies.

Abstract: Over the past 30 years, maternal mortality has increased in the United States to 18 deaths per 100,000 live births. Obstetric emergencies, including hemorrhage, hypertensive disorders in pregnancy, HELLP syndrome, and amniotic fluid embolism, and anesthesia complications, including high neuraxial blockade, local anesthetic systemic toxicity, and the difficult obstetric airway, contribute to maternal cardiac arrest and maternal and fetal morbidity and mortality. Expeditious intervention by the obstetric anesthesiologist is critical in these emergent scenarios, and knowledge of best practices is essential to improve maternal and fetal outcomes.

Keywords: anesthesia, obstetric disasters, emergencies, management

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care Consultation

Summary: Review providing an overview of components needed for culturally sensitive care.

Abstract: Optimal care during the antenatal and postnatal phases of the life cycle is a potentially positive determinant of health elsewhere in the continuum. A successful transition from the antenatal to the postnatal period requires early detection, optimal management, and prevention of disease; health promotion; birth preparedness; and complication readiness. Women, their babies, and families need appropriate evidence-based care based on their dignity and human rights before, during, and after birth. In this review, we present an overview of the components of antenatal and postnatal care needed to provide women a culturally sensitive and positive pregnancy and postnatal experience. The challenge of antenatal and postnatal care is determining their core components and underpinning them with evidence without overmedicalizing their practice.

Keywords: Antenatal care; Evidence-based care; Maternal health; Newborn health; Obstetric care; Postnatal care.

Topic(s):

• Promising models of care and best practices
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care Consultation

Summary: Systematic review quantifying that RhIg at delivery resulted in 70 fewer sensitized women per 1,000 compared to no RhIg, but noted the certainty of evidence was very low.

Abstract: Background: Existing systematic reviews of Rh immunoprophylaxis include only data from randomized controlled trials, have dated searches, and some do not report on all domains of risk of bias or evaluate the certainty of the evidence. Our objective was to perform an updated review, by including new trials, any comparative observational studies, and assessing the certainty of the evidence using the GRADE framework.

Methods: We searched MEDLINE, Embase and the Cochrane Library from 2000 to November 26, 2019. Relevant websites and bibliographies of systematic reviews and guidelines were searched for studies published before 2000. Outcomes of interest were sensitization and adverse events. Risk of bias was evaluated with the Cochrane tool and ROBINS-I. The certainty of the evidence was performed using the GRADE framework.

Results: Thirteen randomized trials and eight comparative cohort studies were identified, evaluating 12 comparisons. Although there is some evidence of beneficial treatment effects (e.g., at 6-months postpartum, fewer women who received RhIg at delivery compared to no RhIg became sensitized [70 fewer sensitized women per 1,000 (95%CI: 67 to 71 fewer); I2 = 73%]), due to very low certainty of the evidence, the magnitude of the treatment effect may be overestimated. The certainty of the evidence was very low for most outcomes often due to high risk of bias (e.g., randomization method, allocation concealment, selective reporting) and imprecision (i.e., few events and small sample sizes). There is limited evidence on prophylaxis for invasive fetal procedures (e.g. amniocentesis) in the comparative literature, and few studies reported adverse events.

Conclusion: Serious risk of bias and low to very low certainty of the evidence is found in existing RCTs and comparative observational studies addressing optimal effectiveness of Rh immunoprophylaxis. Guideline development committees should exercise caution when assessing the strength of the recommendations that inform and influence clinical practice in this area.

Keywords: Rh alloimmunization; prevention; systematic review; GRADE

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Direct Care Policy Development and Enforcement

Summary: Recommended antibiotic use increased from 0.3% (pre) to 75.7% (post) (P < 0.001), and wound infection/breakdown decreased by 55% (3.2% vs 1.4%).

Abstract: Objective: To evaluate the effects of a quality improvement initiative regarding the administration of antibiotics at the time of obstetric anal sphincter injury (OASIS) repair.

Methods: At University of Michigan-a tertiary care center in Ann Arbor, MI, USA, we implemented a quality improvement intervention aimed at administering a single dose of broad-spectrum antibiotics at the time of OASIS repair. Best practice recommendations and reminders were presented to the department. Cefazolin plus metronidazole or clindamycin plus gentamycin were the recommended antibiotics. The effects of this intervention were assessed based on a chart review of deliveries between January 4, 2014 and February 13, 2019, which included patient data both pre-initiative and post-initiative to compare the prevalence of antibiotic use at the time of OASIS repair.

Results: Recommended antibiotic use increased from 0.3% (1/372) pre-initiative to 75.7% (106/140) post-initiative (P < 0.001), and any antibiotic use increased from 6.5% (24/372) to 82.9% (116/140, P < 0.001). The proportion of cases complicated by wound infection/breakdown decreased by 55% after the quality improvement intervention (3.2% pre-intervention vs 1.4% post-intervention, P = 0.22).

Conclusion: Following a departmental quality improvement intervention aimed at increasing antibiotic administration at the time of OASIS repair, antibiotic use increased 13-fold. Although underpowered to detect a significant difference in wound complications, our study showed a clinically meaningful decrease in wound infection/breakdown with antibiotic administration.

Keywords: Antibiotics, obstetrical anal sphincter injury, quality improvement, postpartum, repair

Topic(s):

• Quality, performance, and outcome indicators
• Clinical consensus, guidelines, protocols

Intervention Type: Policy Development and Enforcement Education and Promotion

Summary: Recommendation for implementation citing external trial data, without presenting the AOFOG's own pre/post quantification.

Abstract: Global maternal mortality estimates 287 000 deaths in 2020. Obstetric hemorrhage is a leading cause contributing to 27% of all maternal deaths. The Asia Oceania Federation of Obstetrics and Gynaecology (AOFOG) recommendation aims to reduce the postpartum hemorrhagic deaths with the use of a care bundle approach published by the World Health Organization in the Asia Oceania region. The care bundle approach has been shown to reduce the risk of the primary outcome, a composite of severe postpartum hemorrhage, laparotomy for bleeding, or death from bleeding, compared to usual care among patients having vaginal delivery. In a large, international, parallel cluster-randomized trial, the E-MOTIVE trial. The AOFOG recommends the care bundle approach on postpartum hemorrhage to improve adherence to the World Health Organization guidelines in achieving reduction of morbidity and mortality in maternal death with postpartum hemorrhage.

Keywords: Postpartum hemorrhage; care bundle; AOFOG; WHO guidelines

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Policy Development and Enforcement Education and Promotion

Summary: Prospective cohort study suggesting prenatal planning is an important strategy based on correlational outcomes.

Abstract: Objectives: To determine whether disease remission or low disease activity state at the beginning of pregnancy in SLE patients is associated with better pregnancy outcome.

Methods: Pregnancies in SLE patients prospectively monitored by pregnancy clinics at four rheumatology centres were enrolled. Patient demographics and clinical information were collected at baseline (pregnancy visit before 8 weeks of gestation) including whether patients were in remission according to the Definition of Remission in SLE (DORIS) criteria and and/or Lupus Low Disease Activity State (LLDAS). Univariate and multivariate analysis were performed to determine predictors of disease flare and adverse pregnancy outcomes (APOs) including preeclampsia, preterm delivery, small for gestational age infant, intrauterine growth restriction and intrauterine fetal death.

Results: A total of 347 pregnancies were observed in 281 SLE patients. Excluding early pregnancy losses, 212 pregnancies (69.7%) occurred in patients who were in remission at baseline, 33 (10.9%) in patients in LLDAS, and the remainder in active patients. Seventy-three flares (24%) were observed during pregnancy or puerperium, and 105 (34.5%) APOs occurred. Multivariate analysis revealed that patients in disease remission or taking HCQ were less likely to have disease flare, while a history of LN increased the risk. The risk of APOs was increased in patients with shorter disease duration, while being on HCQ resulted a protective variable. An almost significant association between complete remission and a decreased risk of APOs was observed.

Conclusions: Prenatal planning with a firm treat-to-target goal of disease remission is an important strategy to reduce the risk of disease flares and severe obstetric complications in SLE pregnancies.

Keywords: Systemic lupus erythematosus, remission, pregnancy planning, disease activity

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care

Summary: Review assessing current practices and providing recommendations based on WHO guidelines.

Abstract: Vitamin A is an essential nutrient necessary for human growth and development, with critical roles in vision, immune function reproduction and maintenance of epithelial cellular integrity. Inadequate intake of vitamin A places populations at risk of developing diseases associated with vitamin A deficiency (VAD). VAD is highly prevalent across the Eastern Mediterranean Region (EMR) in children under 5 y and women of childbearing age. Therefore, infants and young children, pregnant women and postpartum women are commonly targeted by supplementation programs. Although, vitamin A supplementation has been shown to decrease preventable childhood diseases and deaths related to VAD, supplementation of vitamin A has been greatly misused in several countries within the EMR raising concern around the process of supplementing the target population. Countries across the EMR have reported different supplementation practices depending on the income level of the country, the availability of vitamin A and the prevalence rates of VAD. Although some countries had higher supplementation rates than others, the concern lies in the middle-income countries and their supplementation practices. Some of the countries across the region do not follow the World Health Organization's (WHO) guidelines for vitamin A supplementation for the recommended age groups. The objective of this study is to assess the vitamin A supplementation practices across the countries in the EMR, determine the gaps in the supplementation practices and the issue with supplementing to healthy populations where VAD is not a public health concern, and provide recommendations for proper vitamin A supplementation within the region.

Keywords: Vitamin A, supplementation, Eastern Mediterranean, practices

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Policy Development and Enforcement Direct Care

Summary: Summary of a Community of Practice meeting providing a series of best practices (e.g., colocation of services) to improve linkage to care.

Abstract: There is an increasing burden of hepatitis C virus among persons of reproductive age, including pregnant and breastfeeding women, in many regions worldwide. Routine health services during pregnancy present a critical window of opportunity to diagnose and link women with hepatitis C virus infection for care and treatment to decrease hepatitis C virus-related morbidity and early mortality. Effective treatment of hepatitis C virus infection in women diagnosed during pregnancy also prevents hepatitis C virus-related adverse events in pregnancy and hepatitis C virus vertical transmission in future pregnancies. However, linkage to care and treatment for women diagnosed in pregnancy remains insufficient. Currently, there are no best practice recommendations from professional societies to ensure appropriate peripartum linkage to hepatitis C virus care and treatment. We convened a virtual Community of Practice to understand key challenges to the hepatitis C virus care cascade for women diagnosed with hepatitis C virus in pregnancy, highlight published models of integrated hepatitis C virus services for pregnant and postpartum women, and preview upcoming research and programmatic initiatives to improve linkage to hepatitis C virus care for this population. Four-hundred seventy-three participants from 43 countries participated in the Community of Practice, including a diverse range of practitioners from public health, primary care, and clinical specialties. The Community of Practice included panel sessions with representatives from major professional societies in obstetrics/gynecology, maternal fetal medicine, addiction medicine, hepatology, and infectious diseases. From this Community of Practice, we provide a series of best practices to improve linkage to hepatitis C virus treatment for pregnant and postpartum women, including specific interventions to enhance colocation of services, treatment by nonspecialist providers, active engagement and patient navigation, and decreasing time to hepatitis C virus treatment initiation. The Community of Practice aims to further support antenatal providers in improving linkage to care by producing and disseminating detailed operational guidance and recommendations and supporting operational research on models for linkage and treatment. Additionally, the Community of Practice may be leveraged to build training materials and toolkits for antenatal providers, convene experts to formalize operational recommendations, and conduct surveys to understand needs of antenatal providers. Such actions are required to ensure equitable access to hepatitis C virus treatment for women diagnosed with hepatitis C virus in pregnancy and urgently needed to achieve the ambitious targets for hepatitis C virus elimination by 2030.

Keywords: Hepatitis C; linkage to care; pregnancy; postpartum; best practices; maternal health

Topic(s):

• Clinical consensus, guidelines, protocols
• Promising models of care and best practices

Intervention Type: Collaboration Case Management

Summary: Brexanolone treatment resulted in rapid and sustained improvements in PPD symptoms relative to placebo, with Number Needed to Treat (NNT) ranging from 4 to 8 and Number Needed to Harm (NNH) of 97.

Abstract: Background: Brexanolone (BRX) injection was approved by the United States Food and Drug Administration in 2019 for the treatment of adults with postpartum depression (PPD) based on two Phase 3 clinical trials. Materials and Methods: Data from the three trials were combined. PPD-specific 17-item Hamilton Rating Scale for Depression (HAMD-17) group-level minimal important difference (MID) and patient-level meaningful change (meaningful change threshold [MCT]) were estimated and applied to differences in BRX versus placebo (PBO) at hour 60 (primary endpoint) and day 30 (end of trial follow-up). Likelihood of HAMD-17 response and remission and Clinical Global Impression of Improvement (CGI-I) response for BRX versus PBO were assessed at hour 60 and as sustained through day 30 using relative risk. Associated number needed to treat (NNT) and number needed to harm (NNH) values were also estimated. Results: Two-hundred nine patients were included. The average HAMD-17 MID estimate was -2.1; the least-squared mean difference between BRX and PBO exceeded this at hour 60 and day 30. Minimal, moderate, and large MCTs were estimated to be -9, -15, and -20 points, respectively. Significantly more BRX-treated than PBO-treated patients achieved minimal, moderate, and large change (all ps < 0.05) at hour 60 and large meaningful response at day 30 (p < 0.05). BRX-treated patients were more likely to sustain HAMD-17 remission and CGI-I response through day 30 versus PBO. NNTs ranged from 4 to 8, with NNH of 97. Conclusions: BRX provided meaningful changes relative to PBO, rapid (hour 60), and sustained improvements (day 30) in PPD symptoms, low NNT, and large NNH. These results may help inform treatment decision-making. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Topic(s):

• Behavioral/mental health services and substance use
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care

Summary: Meta-analysis quantified that azithromycin use reduced the risk of maternal sepsis (OR 0.65), endometritis (OR 0.62), and maternal wound infection (OR 0.43).

Abstract: Objective: This systematic review and meta-analysis investigated whether the use of azithromycin during labour or caesarean section reduces the incidence of sepsis and infection among mothers and newborns.

Data sources: We independently searched the PubMed, Web of Science, Cochrane Library and EMBASE databases for relevant studies published before February, 2024.

Methods: We included RCTs that evaluated the effect of prenatal oral or intravenous azithromycin or placebo on intrapartum or postpartum infection incidence. We included studies evaluating women who had vaginal births as well as caesarean sections. Studies reporting maternal and neonatal infections were included in the current analysis. Review Manager 5.4 was used to analyse 6 randomized clinical trials involving 44,448 mothers and 44,820 newborns. The risk of bias of each included study was assessed using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions.Primary outcomes included the incidence of maternal sepsis and all-cause mortality and neonatal sepsis and all-cause mortality; secondary outcomes included maternal (endometritis, wound and surgical site infections, chorioamnionitis, and urinary tract infections) and neonatal outcomes (infections of the eyes, ears and skin). A random-effects model was used to test for overall effects and heterogeneity.

Results: The pooled odds ratios (ORs) were as follows: 0.65 for maternal sepsis (95% CI, 0.55-0.77; I2, 0%; P < .00001); 0.62 for endometritis (95% CI, 0.52-0.74; I2, 2%; P < .00001); and 0.43 for maternal wound or surgical site infection (95% CI, 0.24-0.78; P < .005); however, there was great heterogeneity among the studies (I2, 75%). The pooled OR for pyelonephritis and urinary tract infections was 0.3 (95% CI, 0.17-0.52; I2, 0%; P < .0001), and that for neonatal skin infections was 0.48 (95% CI, 0.35-0.65; I2, 0%, P < .00001). There was no significant difference in maternal all-cause mortality or incidence of chorioamnionitis between the two groups. No significant differences were observed in the incidence of neonatal sepsis or suspected sepsis, all-cause mortality, or infections of the eyes or ears.

Conclusion: In this meta-analysis, azithromycin use during labour reduced the incidence of maternal sepsis, endometritis, incisional infections and urinary tract infections but did not reduce the incidence of neonatal-associated infections, except for neonatal skin infections. These findings indicate that azithromycin may be potentially beneficial for maternal postpartum infections, but its effect on neonatal prognosis remains unclear. Azithromycin should be used antenatally only if the clinical indication is clear and the potential benefits outweigh the harms.

Keywords: Azithromycin, labor, infection, puerperae, newborns, meta-analysis

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care

Summary: Review summarizing risk factors and recommendations for management by a multidisciplinary team.

Abstract: Women with dilated cardiomyopathy or left ventricular (LV) dysfunction (LV ejection fraction [LVEF] < 40%) from other etiology are at increased risk of maternal and fetal mortality and morbidity. They should undergo preconception evaluation, risk assessment, and treatment modification including discontinuation and replacement of contraindicated medications. A close follow-up and treatment by a multidisciplinary team is recommended at all stages: preconception, gestation, delivery, and postpartum. An early gestational and delivery plan has to be prepared to face complications and to achieve a successful delivery and outcome. Long-term postpartum cardiac follow-up is recommended anticipating potential adverse effects of pregnancy. The recommended mode of delivery for most patients is vaginal. The indications for cesarian section are mainly obstetric, unless the patient is in severely decompensated heart failure or urgent delivery if the patient is receiving warfarin therapy. Cardiac events during pregnancy or in the first months postpartum occur in 32%-60% of patients. Prepregnancy signs of heart failure, atrial fibrillation, and New York Heart Association functional classification (NYHA FC) > II were associated with a poor cardiac outcome. Predictors of deterioration during pregnancy that are considered very high risk and should be advised to avoid pregnancy are: patients with NYHA FC III/IV unless improved under treatment and LVEF < 20%. Predictors for high risk of adverse outcome include: LVEF < 30%, NYHA FC II, ventricular tachyarrhythmias (including patients with implantable cardioverter defibrillator or cardiac resynchronization therapy defibrillator),atrial fibrillation with rapid ventricular rate, severe mitral regurgitation, significant right ventricular failure, and hypotension. Overall, despite a high rate of complications, most women with LV dysfunction can undergo a successful pregnancy.

Keywords: Cardiomyopathy, pregnancy, left ventricular dysfunction, management

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care Consultation

Summary: Summary of evidence and presentation of a multidisciplinary plan of care.

Abstract: In recent years, the incidence of bariatric surgery has increased among women of reproductive age. Health care providers should be knowledgeable about the impact bariatric surgery has on women and developing fetuses to effectively provide care from preconception through postpartum. Although pregnancy in women with normal weight or with excess weight after bariatric surgery has better outcomes when compared to pregnancy complicated by obesity, it is associated with complications such as nutritional deficiencies, low birth weight, and fetal growth restriction. Consequently, a multidisciplinary approach is recommended to ensure adequate nutrition, counseling, and screening before and during pregnancy. This article summarizes evidence regarding pregnancy complications that may occur in women with a history of bariatric surgery and presents a nursing, advanced practice nursing, and midwifery plan of care for these women before, during, and after pregnancy.

Keywords: bariatric surgery, pregnancy, care, nutrition

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Collaboration Counseling

Summary: Review providing clinical practice recommendations, noting evidence for strong recommendations is limited.

Abstract: Introduction: The focus on perinatal mental health has expanded recently, though there is less research on post-traumatic stress disorder (PTSD). Therefore, a review of the literature was undertaken and coupled with expert clinical insights to discuss current clinical practice recommendations for PTSD in the perinatal period. Areas covered: This review covers considerations for the assessment, prevention, and treatment of PTSD during the perinatal period. Within these sections, evidence-based and promising practices are outlined. Extra attention is afforded to treatment, which includes considerations from both psychotherapeutic and psychopharmacological perspectives. This review closes with coverage of three important and related areas of consideration, including bereavement, intimate partner violence, and childhood sexual abuse. Expert opinion: Psychotherapeutic interventions for PTSD during pregnancy are limited, and no strong recommendations can be supported at this time while evidence points toward the effectiveness of cognitive behavioral therapies and eye movement desensitization therapy as first-line treatments postpartum though research evidence is also limited. Research on psychopharmacological interventions is similarly scarce, though selective serotonin reuptake inhibitors may be beneficial. Clinicians should also be mindful of additional considerations that may be needed for the treatment of PTSD in the context of bereavement, intimate partner violence, and history of sexual violence. (PsycInfo Database Record (c) 2024 APA, all rights reserved)

Topic(s):

• Behavioral/mental health services and substance use
• Clinical consensus, guidelines, protocols

Intervention Type: Counseling Screening

Summary: Retrospective study comparing diagnostic criteria for sepsis.

Abstract: Objective: Pregnancy-related mortality in the United States is the highest of all developed nations with a reported rate of 17 deaths per 100,000 live births in 2014 to 2017. Sepsis-related mortality is a major component of pregnancy-related mortality. Similar to nonpregnancy-related sepsis, the criteria for pregnancy-related sepsis are evolving. The purposes of this study were to compare three criteria for sepsis (Sepsis-2, Sepsis-3, California Maternal Quality Care Collaborative [CMQCC]) with one another and to determine patient outcomes using those three sets of criteria.

Study design: Using the electronic medical record, we obtained granular data on all patients at University of Michigan Medical Center from July 10, 2009 to September 4, 2019 with suspected sepsis (blood cultures and administration of antibiotics) during pregnancy until the 42nd postpartum day. Agreement between the three criteria were assessed with kappa and shown by a Venn diagram. Groups were compared using standardized differences and chi square, rank sum, or independent t-tests.

Results: Of the 228 patients having sepsis by any criteria, 191 (83%) patients met the criteria for Sepsis-2, 131 (57%) for Sepsis-3, and 62 (27%) met criteria according to CMQCC. Agreement between the three criteria ranged from kappa = 0.13 (95% confidence interval [CI]: 0.09, 0.18) to kappa = 0.31 (95% CI: 0.23, 0.39). Patients who met CMQCC criteria tended to have more comorbidities and higher APACHE II (Acute Physiology And Chronic Health Evaluation) scores. Mortality (by 90 days) among the groups was low with 10 (4%) patients dying. Patients meeting criteria for CMQCC sepsis had higher mortality than the non-CMQCC patients with sepsis (10 vs. 2%, standardized difference = 0.31, p = 0.027).

Conclusion: The agreement among Sepsis-2, Sepsis-3, and CMQCC diagnostic criteria is weak. CMQCC criteria identifies patients with sepsis at higher risk of death.

Keywords: Obstetric sepsis, diagnostic criteria, outcomes, retrospective study

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Disease and Health Event Investigation Epidemiology and Surveillance

Summary: Secondary analysis comparing postpartum endometritis rates (12% vs 18%) between two diagnostic criteria groups.

Abstract: Background: Chorioamnionitis can have a highly variable definition with substantial maternal and fetal morbidity, with higher frequencies in preterm births. With the recently updated intraamniotic infection diagnostic criteria by the American College of Obstetricians and Gynecologists, fewer women experiencing preterm delivery may qualify for intrapartum antibiotic treatment, potentially resulting in higher postpartum infectious morbidity.

Objective: This study aimed to estimate whether the proportion of women delivering preterm who develop postpartum endometritis differs between subjects diagnosed as having clinical chorioamnionitis and those meeting the American College of Obstetricians and Gynecologists' criteria for intraamniotic infection.

Study design: Secondary analysis was conducted using a randomized controlled trial of antenatal magnesium sulfate for the prevention of cerebral palsy. Subjects were included if they had a clinical diagnosis of chorioamnionitis and maternal temperature of ≥37.8°C and excluded if maternal temperature data were missing. The exposure group included women who met the criteria for intraamniotic infection, defined as a single maternal temperature of ≥39.0°C or maternal temperature of 38.0°C to 38.9°C plus 1 additional clinical risk factor (leukocytosis, purulent cervical drainage, or fetal tachycardia). The primary outcome was postpartum endometritis. The odds of postpartum endometritis were compared between women with intraamniotic infection and women with clinical chorioamnionitis, after adjusting for potential confounders using multivariate logistic regression.

Results: Of the original study population, 258 of 2241 (11.8%) subjects met the criteria for chorioamnionitis. Nearly all subjects (98.5%) received antibiotic treatment between randomization and delivery. A total of 144 subjects (55.8%) met the criteria for intraamniotic infection, whereas 114 (44%) only met the criteria for clinical chorioamnionitis. A total of 40 women (15.5%) experienced postpartum endometritis. Women with intraamniotic infection had higher parity (P=.02) and higher maximum maternal temperature (P<.001) and were more likely to have received antibiotic treatment (P=.04). Postpartum endometritis rates were similar between subjects with chorioamnionitis and intraamniotic infection (12% vs 18%; P=.50). After adjustment for potential confounders, the odds of developing postpartum endometritis did not differ between subjects who met the criteria for intraamniotic infection and those who did not (adjusted odds ratio, 1.28; 95% confidence interval, 0.62-2.62).

Conclusion: Patients delivering preterm who receive a diagnosis of clinical chorioamnionitis in the intrapartum period seem to have similar odds of developing postpartum endometritis as those meeting the American College of Obstetricians and Gynecologists' criteria for intraamniotic infection, suggesting that this group remains at a high risk for postpartum infectious complications.

Keywords: chorioamnionitis, intraamniotic infection, preterm delivery, postpartum, morbidity

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Epidemiology and Surveillance Disease and Health Event Investigation

Summary: Review comparing international guidelines.

Abstract: Purpose of review: Hypertensive disorders of pregnancy (HDP)-gestational hypertension, preeclampsia, and eclampsia-are a leading cause of adverse maternal and perinatal outcomes internationally. Prevention, timely diagnosis, and prompt management can reduce associated morbidity. The purpose of this review is to compare international guidelines pertaining to HDP.

Recent findings: Fourteen HDP guidelines were compared relative to guidelines for the United States (US) where the authors practice. Aspirin is universally recommended for high-risk women to reduce preeclampsia risk. Recommended dose and gestational age at initiation vary. Diagnoses of chronic hypertension, gestational hypertension, and preeclampsia in pregnant women are similar, although blood pressure (BP) thresholds for antihypertensive medication initiation and treatment targets vary due to the limitations in high-quality evidence. There are differences among international HDP guidelines related to dose and timing of aspirin initiation, thresholds for antihypertensive medication initiation, and BP targets. However, all guidelines acknowledge the significant morbidity associated with HDP and advocate for timely diagnosis and management to reduce associated morbidity and mortality. More research is needed to understand optimal BP thresholds at which to initiate antihypertensive medication regimens and BP targets in pregnancy.

Keywords: Chronic hypertension; pregnancy; antihypertensive agents; maternal outcomes; perinatal outcomes

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Direct Care Consultation

Summary: Descriptive review comparing recommendations of influential guidelines.

Abstract: Chronic hypertension in pregnancy accounts for a substantial proportion of maternal morbidity and mortality and is associated with adverse perinatal outcomes, most of which can be mitigated by appropriate surveillance and management protocols. The aim of this study was to review and compare recommendations of published guidelines on this condition. Thus, a descriptive review of influential guidelines from the National Institute for Health and Care Excellence, the Society of Obstetric Medicine of Australia and New Zealand, the International Society of Hypertension, the International Society for the Study of Hypertension in Pregnancy, the European Society of Cardiology, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynaecologists of Canada and the American College of Obstetricians and Gynecologists on chronic hypertension in pregnancy was conducted. All guidelines agree on the definition and medical management, the need for more frequent antenatal care and fetal surveillance and the re-evaluation at 6-8 weeks postpartum. There is also a consensus that the administration of low-dose aspirin is required to prevent preeclampsia, although the optimal dosage remains controversial. No universal agreement has been spotted regarding optimal treatment blood pressure (BP) targets, need for treating mild-to-moderate hypertension and postnatal BP measurements. Additionally, while the necessity of antenatal corticosteroids and magnesium sulfate for preterm delivery is universally recommended, the appropriate timing of delivery is not clearly outlined. Hence, there is a need to adopt consistent practice protocols to optimally manage these pregnancies; i.e. timely detect and treat any potential complications and subsequently reduce the associated morbidity and mortality.

Keywords: chronic hypertension; pregnancy; guidelines; management; postpartum care

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Policy Development and Enforcement Consultation

Summary: Issuance and continuous updating of living clinical recommendations/guidelines.

Abstract: To date, 18 living recommendations for the clinical care of pregnant and postpartum women with COVID-19 have been issued by the National COVID-19 Clinical Evidence Taskforce. This includes recommendations on mode of birth, delayed umbilical cord clamping, skin-to-skin contact, breastfeeding, rooming-in, antenatal corticosteroids, angiotensin-converting enzyme inhibitors, disease-modifying treatments (including dexamethasone, remdesivir and hydroxychloroquine), venous thromboembolism prophylaxis and advanced respiratory support interventions (prone positioning and extracorporeal membrane oxygenation). Through continuous evidence surveillance, these living recommendations are updated in near real-time to ensure clinicians in Australia have reliable, evidence-based guidelines for clinical decision-making

Keywords: COVID-19; pregnancy; postpartum; clinical guideline

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Policy Development and Enforcement Direct Care

Summary: Survey examining clinical management practices and identifying knowledge gaps.

Abstract: Introduction: The impact of bleeding for women with bleeding disorders (WBD) is of increasing focus and importance. Despite this, optimal management strategies are unclear and knowledge gaps persist.

Aim: To examine practices and define research priorities on diagnosis and management of WBD in Europe.

Methods: An electronic survey on clinical management of WBD was sent to 136 European haemophilia treatment centres (HTCs), including open questions on knowledge gaps and research priorities.

Results: Fifty-nine HTCs from 12 Western (WE) and 13 Central/Eastern European (CEE) countries completed the survey. Less than half runs a joint clinic (24 HTCs, 42%). Most centres without a joint clinic have a named obstetrician (81%) and/or gynaecologist (75%) available for collaboration. Overall 18/54 (33%) European HTCs do not offer preimplantation genetic diagnosis. Third trimester amniocentesis to guide obstetric management is available 28/54 HTCs (52%), less frequent in CEE compared to WE countries (5/17 vs 23/37, P = .03). 53% of HTCs (28/53) reported that only 0%-25% of WBD seek medical advice for heavy menstrual bleeding (HMB). An algorithm managing acute HMB in WBD is lacking in 22/53 (42%) HTCs. The main reported knowledge and research gaps are lack of awareness & education on WBD among patients and caregivers, optimal diagnostic strategies and effective multidisciplinary management of pregnancy & HMB.

Conclusion: Joint clinics, prenatal diagnostics and algorithms for managing acute HMB are lacking in many European HTCs. HMB may be an underestimated issue. This survey highlights the need to prioritize improvement of knowledge and patient care for WBD across Europe.

Keywords: bleeding disorder; haemophilia; heavy menstrual bleeding; postpartum haemorrhage and reproduction; survey; von Willebrand disease.

Keywords: Bleeding disorders, women, haemophilia, clinical management, Europe, survey

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Consultation Direct Care

Summary: Descriptive clinical information and current recommendations for screening and management.

Abstract: Two screening approaches are used to detect gestational diabetes, the 1-step and 2-step methods. The 1-step method is diagnostic and consists of a 75-g, 2-hour oral glucose tolerance test (OGTT). The 2-step method consists of a 50-g, 1-hour glucose challenge test, followed by a 100-g, 3-hr OGTT if initial test results are positive. All pregnant patients should be screened for gestational diabetes between 24 and 28 weeks' gestation unless pregestational diabetes is present. Lifestyle modifications are fundamental to management, and most patients are able to control blood glucose levels with these alone. Persistent hyperglycemia should be managed with drugs. Currently, insulin is the only drug approved by the Food and Drug Administration (FDA) for gestational diabetes management. Metformin or glyburide can be reasonable alternatives. For patients who require drugs, antepartum fetal surveillance is recommended starting at 32 weeks' gestation. The American College of Obstetricians and Gynecologists (ACOG) recommends delivery at 39 0/7 to 40 6/7 weeks' gestation for patients with gestational diabetes controlled with diet alone. Earlier delivery is recommended for patients with gestational diabetes controlled with drugs, at 39 0/7 to 39 6/7 weeks' gestation. Patients with gestational diabetes are at increased risk of type 2 diabetes later in life. These patients should be screened for prediabetes and diabetes between 4 and 12 weeks postpartum with a 75-g, 2-hour OGTT. Postpartum patients with a normal OGTT result should be screened every 1 to 3 years thereafter.

Keywords: Gestational diabetes, prenatal care, screening, management

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Direct Care Screening

Summary: Development of a Consensus Bundle providing guidance to address rising maternal mortality.

Abstract: In the weeks after childbirth, a woman navigates multiple challenges. She must recover from birth, learn to care for herself and her newborn, and cope with fatigue and postpartum mood changes as well as chronic health conditions. Alongside these common morbidities, the number of maternal deaths in the United States continues to increase, and unacceptable racial inequities persist. One third of pregnancy-related deaths occur between 1 week and 1 year after delivery, with a growing proportion of these deaths due to cardiovascular disease; one fifth occur between 7 and 42 days postpartum. In addition, pregnancy-associated deaths due to self-harm or substance misuse are increasing at an alarming rate. Rising maternal mortality and morbidity rates, coupled with significant disparities in outcomes, highlight the need for tailored interventions to improve safety and well-being of families during the fourth trimester of pregnancy, which includes the period from birth to the comprehensive postpartum visit. Targeted support for growing families during this transition can improve health and well-being across generations.

Keywords: postpartum care; consensus bundle; best practices; maternal health; care coordination

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Policy Development and Enforcement

Summary: Narrative review summarizing consequences of undertreatment.

Abstract: Purpose: To provide an overview of consequences of undertreatment with levothyroxine (LT4) in the common non-communicable disease, hypothyroidism.

Methods: Narrative review of the literature.

Results: Hypothyroidism is globally very prevalent at all age groups and represents a non-communicable disease in which the risks and consequences are preventable. In children and adolescents, the most devastating consequences of undertreatment are poor growth and development. Lack of early treatment in congenital hypothyroidism can lead to permanent damage of brain function. In young to middle-aged adults, consequences are often overlooked, and treatment delayed by many years. The resulting consequences are also at this age group compromised brain and physical functioning but less severe and partly reversible with treatment. The undertreated condition often results in a higher risk of several secondary devastating diseases such as increased cardiovascular disease burden, obesity, hypertension, poor physical capacity, poor quality of life. In young women of fertile age the consequences of undertreatment with LT4 are subnormal fertility, recurrent pregnancy loss, preeclampsia, compromised fetal growth and neurocognitive development. There is a further risk of 30-50% of developing postpartum thyroiditis. In the elderly population care must be given to avoid confusing a slightly high serum TSH as result of physiological age adaptation with a requirement for LT4 treatment in a truly hypothyroid patient.

Conclusion: Undertreatment of the preventable non-communicable disease hypothyroidism requires more focus both from caretakers in the healthcare system, but also from the global political systems in order to prevent the personally devastating and socioeconomically challenging consequences.

Keywords: Hypothyroidism, undertreatment, consequences, reproductive health

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care Consultation

Summary: Review summarizing conservative management approaches.

Abstract: Postpartum haemorrhage (PPH) and PPH-related deaths are disproportionately higher in low-income countries, with sub-Saharan Africa and Southern Asia accounting for approximately 85% of the global burden of PPH-related maternal deaths. Although PPH-related mortality is directly related to the amount and duration of bleeding, the high maternal death burden in resource-limited countries suggests that a great majority of these deaths would be avoidable with the appropriate resources and effective use of evidence-based interventions. Non-surgical management is often the first-line approach for PPH, but conservative surgical interventions may be required if bleeding persists or if the underlying cause is not responsive to the initial conservative measures. The appropriate interventions should be selected based on the individual's specific circumstances and clinical condition.

Keywords: postpartum hemorrhage, conservative management, uterotonics, review

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care

Summary: Randomized trial found that low-flow and short-term oxygen inhalation for parturients with epidural-related maternal fever reduces the incidence of Category II fetal heart rate tracings.

Abstract: Objectives: Epidural-related maternal fever increases the incidence of Category II fetal tracings. To compare the effectiveness of low-flow oxygen inhalation and cooling treatment for parturients with Category II fetal tracings caused by epidural-related maternal fever.

Methods: We investigated 200 pregnant women who accepted epidural analgesia during labor and had body temperature exceeding 38 °C during labor. Among the patients, 99 and 101 were randomly allocated to receive cooling treatment group (control group) and oxygen inhalation (oxygen group), respectively. The primary outcome was the incidence of Category II fetal heart rate tracings.

Results: The incidence of Category II fetal heart rate tracings in the control group was significantly higher than that in the oxygen group. However, no significant differences were noted between the two groups in terms of the Apgar scores; amniotic fluid turbidity; or maternal outcomes, including cesarean section rate, forceps delivery rate, lateral resection rate, manual removal of placenta rate, the amount of intrapartum hemorrhage, and hemorrhage at postpartum 2 h. Oxygen inhalation therapy was more effective than cooling treatment in reducing the incidence of Category II tracings.

Conclusion: Low-flow and short-term oxygen inhalation for parturients with epidural-related maternal fever reduces the incidence of Category II fetal heart rate tracings, but had no significant influence on the mode of delivery or neonatal outcomes.

Keywords: Cooling treatment, fetal tracing, labor, neonatal outcomes

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care

Summary: Discussion concluding that pregnant and lactating women should be counseled to receive COVID-19 vaccines after risk/benefit evaluation.

Abstract: Aim: To discuss available information on the opportunity for pregnant women affected by diabetes/obesity to receive COVID-19 vaccine.

Data synthesis: Pregnant women with SARS-CoV-2 (COVID-19) infection are at high risk for severe acute respiratory syndrome and adverse outcomes. Pregnant women with severe COVID-19 present increased rates of preterm delivery (<37 gestational weeks), cesarean delivery and neonatal admissions to the intensive care unit. Comorbidity such as diabetes (pregestational or gestational) or obesity further increased maternal and fetal complications. It is known that diabetic or obese patients with COVID-19 present an unfavorable course and a worse prognosis, with a direct association between worse outcome and suboptimal glycol-metabolic control or body mass index (BMI) levels. Critical COVID-19 infection prevention is important for both mother and fetus. Vaccination during pregnancy is a common practice. Vaccines against COVID-19 are distributed across the world with some population considered to have a priority. Since pregnant women are excluded from clinical trials very little information are available on safety and efficacy of COVD-19 vaccines during pregnancy. However, it is well known the concept of passive immunization of the newborn obtained with transplacental passage of protective antibodies into the fetal/neonatal circulation after maternal infection or vaccination. Moreover, it has been reported that COVID-19 vaccine-induced IgG pass to the neonates through breastmilk. Therefore, maternal vaccination can protect mother, fetus and baby.

Conclusions: After an individual risk/benefit evaluation pregnant and lactating women should be counselled to receive COVID-19 vaccines.

Keywords: COVID-19 vaccination, pregnancy, lactation, diabetes

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Consultation Direct Care

Summary: Methodology study to develop and achieve consensus on signs/symptoms for self-monitoring.

Abstract: Background: Every two minutes a woman dies from complications of pregnancy and childbirth. Most maternal deaths occur within the first 24 hours following birth, highlighting the importance of immediate postnatal care (iPNC). Self-care strategies are increasingly being employed to promote women-centred, continuous care provision. Despite international calls for development of strategies promoting self-care, none have been developed for self-monitoring in the immediate postnatal period. Fundamental to the development of a self-monitoring strategy, is an understanding of which signs and symptoms are predictive of maternal morbidity and mortality and can be easily assessed by mothers and birth companions, in health facilities, without the need for equipment. The objective of this study was to develop and achieve international consensus on the key signs and symptoms.

Methods: A multi-step approach involving a systematic scoping review, two- round Delphi Survey, and expert consensus was employed to identify key signs and symptoms that can be self- assessed and predict morbidity and mortality in the immediate postnatal period.

Results: A comprehensive list of 351 key signs and symptoms was identified from 44 clinical practice guidelines. Subsequently, 134 signs and symptoms were reviewed by Delphi respondents and international expert consensus was achieved for 19 key signs and symptoms across seven condition categories. The signs that were considered both important and able to be self-assessed by mothers and birth companions in the first 24 hours following birth included change in consciousness, seizure, severe headache, persistent visual impairment, urinary incontinence, chest pain, shortness of breath, severe pallor, fast heartbeat, rejection of baby, suicidal/infanticidal, fever, heavy blood loss, soft flabby uterus, unable to urinate easily, foul smelling discharge, rigors, syncope/dizziness, abnormal coloured urine.

Conclusion: This study identified key signs and symptoms which can be easily assessed by mothers and birth companions in the immediate postnatal period to identify those most at risk of morbidity and mortality. Further work is needed to validate this screening tool, and adapt it regionally and nationally.

Keywords: Postnatal period; self-assessment; critical signs; Delphi study; postpartum care

Topic(s):

• Clinical consensus, guidelines, protocols
• Resources for consumers/new mothers

Intervention Type: Collaboration Education and Promotion

Summary: Methodology study using a Delphi survey to delineate the scope of teleconsultation services.

Abstract: Objective: Delineate the scope of teleconsultation services that can be effectively performed to provide women with comprehensive gynaecological and obstetrical care.

Design: Based on the literature and experts' insights, we identified a list of gynaecological and obstetrical care practices suitable for teleconsultation. A three-round Delphi consensus survey was then conducted online among a panel of French experts. Experts using a 9-point Likert scale assessed the relevance of each teleconsultation practice in four key domains: prevention, gynaecology and antenatal and postnatal care. Consensus was determined by applying a dual-criteria approach: the median score on a 9-point Likert scale and the percentage of votes either below 5 or 5 and higher.

Setting: The study was conducted at a national level in France and involved multiple healthcare centres and professionals from various geographical locations.

Participants: The panel comprised 22 French experts with 19 healthcare professionals, including 12 midwives, 3 obstetricians-gynaecologists, 4 general practitioners and 3 healthcare system users. Participants were selected to include diverse practice settings encompassing hospital and private practices in both rural and urban areas.

Primary and secondary outcome measures: The study's primary outcome was the identification of gynaecological and obstetrical care practices suitable for teleconsultation. Secondary outcomes included the level of professional consensus on these practices.

Results: In total, 71 practices were included in the Delphi survey. The practices approved for teleconsultation were distributed as follows: 92% in prevention (n=12/13), 55% in gynaecology (n=18/33), 31% in prenatal care (n=5/16) and 12% in postnatal care (n=1/9). Lastly, 10 practices remained under discussion: 7 in gynaecology, 2 in prenatal care and 1 in postnatal care.

Conclusions: Our consensus survey highlights both the advantages and limitations of teleconsultations for women's gynaecological and obstetrical care, emphasising the need for careful consideration and tailored implementation.

Keywords: Teleconsultation; gynecology; obstetrics; Delphi survey; France; remote care

Topic(s):

• Clinical consensus, guidelines, protocols
• Infrastructure development, financing, and expansion of services

Intervention Type: Consultation

Summary: Observational study identifying risk factors (age, GDM, GHTN) for Delayed Lactogenesis II (DOL II incidence 41.26%).

Abstract: Background: The timely initiation of lactogenesis II is crucial for postpartum women, with delays having significant clinical implications. This study aimed to evaluate the determinants of delayed lactogenesis II (DOL II) in high-risk pregnant women to guide clinical interventions and postnatal care protocols. Methods: We conducted a study involving high-risk pregnant women who gave birth and were admitted to our hospital''s obstetric intensive care unit for postpartum surveillance and treatment from February 1, 2023, to April 30, 2024. We utilized Pearson correlation analysis and logistic regression to determine factors linked to DOL II. Results: Our study included 206 high-risk pregnant women, with 85 (41.26%) experiencing DOL II. Pearson correlation analysis indicated strong associations between DOL II and maternal age (r = 0.452), gestational hypertension (r = 0.514), gestational diabetes (r = 0.487), and delayed colostrum secretion (r = 0.506), all statistically significant (p < 0.05). Logistic regression analysis identified age 35 years or older (OR = 2.115, 95%CI: 1.785–2.466), gestational hypertension (OR = 2.404, 95%CI: 2.125–3.107), gestational diabetes (OR = 2.556, 95%CI: 2.008–2.879), and colostrum secretion later than one hour postpartum (OR = 3.126, 95%CI: 2.682–3.605) as independent risk factors for DOL II, all with p < 0.05. Conclusions: The incidence of DOL II is significantly elevated in high-risk pregnant women, especially those aged 35 or older, those with gestational diabetes and hypertension, and those who delay the initiation of breastfeeding. It is imperative that clinical practices prioritize enhanced prenatal care and health education, robust lactation support, and improved lactation awareness among postpartum women to reduce the prevalence of DOL II.

Keywords: Delayed Onset ; Lactation Disorders Therapy ; Lactation Disorders Risk Factors ; Pregnancy, High Risk ; Postnatal Care ; Protocols ; Risk Assessment ; Human ; Female ; Adult ; Pregnancy ; Cross Sectional Studies ; Expectant Mothers Psychosocial Factors ; Intensive Care Units ; Pearson's Correlation Coefficient ; Logistic Regression ; Maternal Age ; Pre-Eclampsia ; Diabetes Mellitus, Gestational ; Odds Ratio ; Confidence Intervals ; Breast Feeding ; Lactation ; T-Tests ; Analysis of Variance ; Statistical Significance ; Data Analysis Software ; Descriptive Statistics ; Edinburgh Postnatal Depression Scale ; Scales ; Adult: 19-44 years ; Female

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Epidemiology and Surveillance

Summary: Methodological study (Delphi process) developing a consensus-based model for integrated care (reached $\ge 75%$ agreement on nine domains).

Abstract: Perinatal mental illness is an important public health issue, with one in five birthing persons experiencing clinically significant symptoms of anxiety and/or depression during pregnancy or the postpartum period. The purpose of this study was to develop a consensus-based model of integrated perinatal mental health care to enhance service delivery and improve parent and family outcomes. We conducted a three-round Delphi study using online surveys to reach consensus (≥75% agreement) on key domains and indicators of integrated perinatal mental health care. We invited modifications to indicators and domains during each round and shared a summary of results with participants following rounds one and two. Descriptive statistics were generated for quantitative data and a thematic analysis of qualitative data was undertaken. Study participants included professional experts in perinatal mental health (e.g., clinicians, researchers) (n = 36) and people with lived experience of perinatal mental illness within the past 5 years from across Canada (e.g., patients, family members) (n = 11). Consensus was reached and all nine domains of the proposed model for integrated perinatal mental health care were retained. Qualitative results informed the modification of indicators and development of an additional domain and indicators capturing the need for antiracist, culturally safe care. The development of an integrated model of perinatal mental health benefitted from diverse expertise to guide the focus of included domains and indicators. Engaging in a consensus-building process helps to create the conditions for change within health services.

Keywords: perinatal mental health, integrated care, consensus, Delphi

Topic(s):

• Clinical consensus, guidelines, protocols
• Behavioral/mental health services and substance use

Intervention Type: Collaboration

Summary: Descriptive study of the development process and resulting clinical protocol.

Abstract: Objective: To design a care protocol in Chronic Inflammatory Arthritis during the pre-conceptional period, pregnancy, postpartum and lactation. This protocol aims to be practical and applicable in consultations where patients with chronic inflammatory rheumatological diseases are treated, thus helping to better control these patients. Likewise, recommendations are offered on when patients could be consulted/referred to a specialized center by the physician.

Methods: A multidisciplinary panel of expert physicians from different specialties identified the key points, analyzed the scientific evidence, and met to develop the care protocol.

Results: The recommendations prepared have been divided into three blocks: rheumatology, gynecology and pediatrics. The first block has been divided into pre-pregnancy, pregnancy and postpartum visits.

Conclusions: This protocol tries to homogenize the follow-up of the patients from the moment of the gestational desire until the year of life of the infants. It is important to perform tests in patients of childbearing age and use drugs compatible with pregnancy. If appropriate, the patient should be referred to specialized units. Multidisciplinarity (rheumatology, gynecology and pediatrics) is essential to improve the control and monitoring of these patients and their offspring.

Keywords: chronic inflammatory arthritis; pregnancy; care protocol; multidisciplinary care; postpartum

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Consultation

Summary: Scoping review identifying gaps in current discharge policies and assessment criteria.

Abstract: Background: Despite the existence of global recommendations, postnatal care provided following childbirth is variable and often fails to address a woman's concerns about herself and the parents' concerns about their baby. Discharge from a facility after birth is a key moment to ensure the woman, parents and newborn receive support for the transition to care in the home. We mapped the current policies, guidance and literature on discharge preparation and readiness to identify key concepts and evidence and inform recommendations to be considered in a World Health Organization (WHO) guidance on postnatal care.

Methods: We were guided by the Johanna Briggs Institute approach, and developed inclusion criteria based on existing defintions of discharge preparation and readiness, and criteria for discharge readiness compiled by international professional organisaitons. To identify guidelines and policies we searched websites and archives of guideline organisations, and contacted individuals and professional societies working on postnatal care. We searched 14 electronic databases to locate published research and other literature on discharge preparation and readiness. For documents that met the inclusion criteria we extracted key characteristics, summarised discharge readiness criteria and components and discharge preparation steps, and characterised interventions to improve discharge preparation.

Results: The review provides a systematic map of criteria for discharge that are in use and the common steps healthcare providers take in preparing women and newborns for the transition home. The mapping also identified interventions used to strengthen discharge preparation, theories and models that conceptualise discharge preparation, scales for measuring discharge readiness and qualitative studies on the perspectives of women, men and healthcare providers on postnatal discharge.

Conclusions: The findings highlight contrasts between the research literature and policy documents. They indicate potential gaps in current discharge policies, and point to the need for more comprehensive discharge assessment and education to better identify and meet the needs of women, parents/caregivers and families prior to discharge and identify those who may require additional support.

Keywords: Discharge preparation; postpartum; policy; scoping review

Topic(s):

• Clinical consensus, guidelines, protocols
• Nonclinical postpartum care

Intervention Type: Consultation Policy Development and Enforcement

Summary: The percentage of deliveries with active management of the third stage of labor rose notably (P<0.0001) following guideline publication.

Abstract: Background: The publication of several sets of French guidelines was unfortunately not accompanied by planned assessment of their impact on practices. The goal of this study was to assess the impact of eight French perinatal guidelines on actual obstetric practices.

Methods: Historical cohort setting in France: the Audipog database of 299,412 pregnancies from 1994 to 2006, from which we extracted a sub-sample by randomLy selecting from each participating maternity ward all births occurring during a single month of each year (n=107,450 pregnancies). The main outcome measure was the incidence of pertinent perinatal indicators related to these guidelines. These included site of delivery for low-birth-weight infants (1998), caesarean delivery (2000), preterm delivery (2002), breastfeeding (2002), smoking and pregnancy (2004), immediate postpartum hemorrhages (2004), early discharge after delivery (2004) and episiotomies (2005). Standardised rates, before and after the year of each guideline, were compared using a Chi(2) test.

Results: The percentage of children weighing less than 1500 g at birth born in Level III hospitals increased through 1999 but dropped subsequently, without ever returning to the 1994 level (P<0.0001). The overall caesarean rate climbed slowly but regularly from 1994 through 2006 (P<0.0001). Use of antenatal corticosteroids for women hospitalised for threatened preterm labour and in children born before 33 weeks has fluctuated since the release of the guideline (P>0.05). Exclusive breastfeeding at discharge from the maternity ward has increased slowly (P<0.0001). The percentage of deliveries with active management of the third stage of labour rose notably from 1999 to 2006 (P<0.0001), and smoking cessation during pregnancy rose slightly in 2006 (P<0.0001). Since 1994, early discharges have become slowly, slightly, but regularly more frequent for all women (P<0.0001). The guideline on episiotomies has had a slight positive effect in the short term (P<0.0001).

Conclusions: Globally, the impact on actual practices of clinical practice guidelines, except the guideline concerning the active management of the third stage of labour, was low. Most of the changes observed in practices began before the pertinent guideline was published.

Keywords: Perinatal guidelines, Obstetric practices, Impact

Topic(s):

• Clinical consensus, guidelines, protocols
• Quality, performance, and outcome indicators

Intervention Type: Policy Development and Enforcement

Summary: Systematic review and meta-analysis found that early discharge (24-28 hours) after C-section was not associated with an increase in the rate of maternal readmission, but the rate of neonatal readmission and neonatal jaundice were significantly higher.

Abstract: Objective: The aim of this systematic review and meta-analysis was to assess whether early discharge from hospital after cesarean delivery (CD) affects the rate of maternal readmission.

Data source: The research was conducted using PubMed, Embase, Web of Sciences, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials as electronic databases, from the inception of each database to August 2023 with RCT as publication type. No restrictions for language or geographic location were applied.

Study eligibility criteria: Selection criteria included only RCTs comparing the effect of earlier versus later hospital discharge after CD.

Study appraisal and synthesis methods: The primary outcome was the rate of maternal readmission. The summary measures were reported as relative risk (RR) or as mean difference (MD) with 95% confidence intervals (CI) using the random effects model of Mentel-Haenszel. I-squared (Higgins I2) greater than 0% was used to identify heterogeneity. "Early" and "late" hospital discharge was first considered according to each study's definition and then a subgroup analysis was performed including only studies defining as "early" a discharge within 24-28 hours and "late" a discharge at ≥48 hours after CD. The study was registered on PROSPERO (CRD 42024529885).

Results: Seven RCTs including 4,267 individuals, of which 2,125 (49.8%) randomized in the early discharge and 2,142 (50.2%) in the late discharge group were included. There was no difference between the two groups in the rate of maternal readmission (3.6% vs. 3.4%, RR 1.10; 95% CI 0.80-1.52). There was no significant difference in both maternal complications diagnosed within 6 weeks after CD and neonatal complications. Early discharge after CD was associated with improved psychological wellbeing and was cost-effective. The subgroup analysis of the primary outcomes only in high-quality studies showed similar results: no difference in the rate of maternal readmission was observed (3.8% vs. 3.2%, RR 1.20; 95% CI 0.63-2.30) between the two groups. When focusing only on studies comparing 24-28-hour versus ≥ 48-hour hospital discharge, the rate of maternal readmission did not differ between the two groups, while the rates of neonatal readmission and neonatal jaundice were significantly higher in the early discharge group.

Conclusions: There is no increase in the rate of maternal readmission following early hospital discharge at 24-28 hours as opposed to later hospital discharge after a CD. The rates of neonatal readmission and neonatal jaundice were significantly higher in the early discharge group. Patients undergoing uncomplicated CDs might be discharged from the hospital at 24-28 hours postpartum, as long as close neonatal outpatient follow-up is done in 1-2 days; if this is unfeasible, discharge at 48 hours seems to be safe and effective for both mother and baby. Early discharge after CD was associated with improved psychological wellbeing and was cost-effective. El resumen está disponible en Español al final del artículo.

Keywords: Cesarean section, early discharge, meta-analysis, maternal outcomes, neonatal outcomes

Topic(s):

• Quality, performance, and outcome indicators
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care

Summary: Cochrane Review comparing effects of early discharge vs. standard care.

Abstract: Background: Length of postnatal hospital stay has declined dramatically in the past 50 years. There is ongoing controversy about whether staying less time in hospital is harmful or beneficial. This is an update of a Cochrane Review first published in 2002, and previously updated in 2009.

Objectives: To assess the effects of a policy of early postnatal discharge from hospital for healthy mothers and term infants in terms of important maternal, infant and paternal health and related outcomes.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (21 May 2021) and the reference lists of retrieved articles.

Selection criteria: Randomised controlled trials comparing early discharge from hospital of healthy mothers and term infants (at least 37 weeks' gestation and greater than or equal to 2500 g), with the standard care in the respective settings in which trials were conducted. Trials using allocation methods that were not truly random (e.g. based on patient number or day of the week), trials with a cluster-randomisation design and trials published only in abstract form were also eligible for inclusion.

Data collection and analysis: Two review authors independently assessed trials for inclusion and risk of bias, extracted and checked data for accuracy, and assessed the certainty of evidence using the GRADE approach. We contacted authors of ongoing trials for additional information.

Main results: We identified 17 trials (involving 9409 women) that met our inclusion criteria. We did not identify any trials from low-income countries. There was substantial variation in the definition of 'early discharge', ranging from six hours to four to five days. The extent of antenatal preparation and midwifery home care offered to women following discharge in intervention and control groups also varied considerably among trials. Nine trials recruited and randomised women in pregnancy, seven trials randomised women following childbirth and one did not report whether randomisation took place before or after childbirth. Risk of bias was generally unclear in most domains due to insufficient reporting of trial methods. The certainty of evidence is moderate to low and the reasons for downgrading were high or unclear risk of bias, imprecision (low numbers of events or wide 95% confidence intervals (CI)), and inconsistency (heterogeneity in direction and size of effect). Infant outcomes Early discharge probably slightly increases the number of infants readmitted within 28 days for neonatal morbidity (including jaundice, dehydration, infections) (risk ratio (RR) 1.59, 95% CI 1.27 to 1.98; 6918 infants; 10 studies; moderate-certainty evidence). In the early discharge group, the risk of infant readmission was 69 per 1000 infants compared to 43 per 1000 infants in the standard care group. It is uncertain whether early discharge has any effect on the risk of infant mortality within 28 days (RR 0.39, 95% CI 0.04 to 3.74; 4882 infants; two studies; low-certainty evidence). Early postnatal discharge probably makes little to no difference in the number of infants having at least one unscheduled medical consultation or contact with health professionals within the first four weeks after birth (RR 0.88, 95% CI 0.67 to 1.16; 639 infants; four studies; moderate-certainty evidence). Maternal outcomes Early discharge probably results in little to no difference in women readmitted within six weeks postpartum for complications related to childbirth (RR 1.12, 95% CI 0.82 to 1.54; 6992 women; 11 studies; moderate-certainty evidence) but the wide 95% CI indicates the possibility that the true effect is either an increase or a reduction in risk. Similarly, early discharge may result in little to no difference in the risk of depression within six months postpartum (RR 0.80, 95% CI 0.46 to 1.42; 4333 women; five studies; low-certainty evidence) but the wide 95% CI suggests the possibility that the true effect is either an increase or a reduction in risk. Early discharge probably results in little to no difference in women breastfeeding at six weeks postpartum (RR 1.04, 95% CI 0.96 to 1.13; 7156 women; 10 studies; moderate-certainty evidence) or in the number of women having at least one unscheduled medical consultation or contact with health professionals (RR 0.72, 95% CI 0.43 to 1.20; 464 women; two studies; moderate-certainty evidence). Maternal mortality within six weeks postpartum was not reported in any of the studies. Costs Early discharge may slightly reduce the costs of hospital care in the period immediately following the birth up to the time of discharge (low-certainty evidence; data not pooled) but it may result in little to no difference in costs of postnatal care following discharge from hospital, in the period up to six weeks after the birth (low-certainty evidence; data not pooled).

Authors' conclusions: The definition of 'early discharge' varied considerably among trials, which made interpretation of results challenging. Early discharge probably leads to a higher risk of infant readmission within 28 days of birth, but probably makes little to no difference to the risk of maternal readmission within six weeks postpartum. We are uncertain if early discharge has any effect on the risk of infant or maternal mortality. With regard to maternal depression, breastfeeding, the number of contacts with health professionals, and costs of care, there may be little to no difference between early discharge and standard discharge but further trials measuring these outcomes are needed in order to enhance the level of certainty of the evidence. Large well-designed trials of early discharge policies, incorporating process evaluation and using standardized approaches to outcome assessment, are needed to assess the uptake of co-interventions. Since none of the evidence presented here comes from low-income countries, where infant and maternal mortality may be higher, it is important to conduct future trials in low-income settings.

Keywords: Early postnatal discharge; hospital; mothers; infants; review

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Policy Development and Enforcement Referral and Follow-Up

Summary: Review describing management and investigating outcomes of early discharge.

Abstract: Purpose: To describe the management of early discharge (less than 48 h after birth) attempts and investigate maternal and neonatal outcomes throw an exhaustive review.

Methods: This review was conducted according to PRISMA statement. The search was applied to PubMed and Google Scholar databases. Articles published before 2000 were not included to limit conclusions related to outdated medical practices. Eligibility assessment and analysis were performed independently by two reviewers.

Results: Of approximately 600 articles, 21 articles met the inclusion criteria, including 9 randomized trials. Fourteen studies were conducted in developed countries. Median primiparous rate was 40%. Home-visit, consultation and exclusive telephone follow-up were planned in 12, 4 and 3 studies respectively. Among the 100,311 patients of this review, mean rates of rehospitalization for maternal and neonatal causes were 1.9% [0.3-4.8] and 3.2% [0-10.1] respectively. Median breastfeeding rates at 2 weeks, 1 month and 3-6 months were 85% [73.2-100], 82% [62-91] and 63% [10-95] respectively.

Conclusion: Length of stay after childbirth is not discriminating mother and newborn safety. The optimal length of stay would rather depend on the health of the mother and infant, the maternity discharge organization, the medical follow-up, and the subsequent support.

Keywords: early postpartum discharge; safety; maternal outcomes; newborn outcomes; review

Topic(s):

• Quality, performance, and outcome indicators
• Clinical consensus, guidelines, protocols

Intervention Type: Referral and Follow-Up

Summary: RCT comparing immediate vs. delayed pushing found that immediate pushing did not increase perineal lacerations, POP-Q measures, or patient-reported pelvic floor symptoms at 6 weeks and 6 months postpartum.

Abstract: Objective: To assess whether immediate or delayed pushing in the second-stage results in higher risk of pelvic floor morbidity.

Methods: This study was a planned secondary aim of a multicenter randomized clinical trial that included nulliparous patients at 37 weeks of gestation or greater in labor with neuraxial analgesia. Participants were randomized in the second stage to initiate pushing immediately or wait 60 minutes before pushing. Participants had pelvic floor assessments at 1-5 days postpartum, 6 weeks postpartum, and 6 months postpartum. Rates of perineal lacerations, pelvic organ prolapse quantification (POP-Q) measures, and scores on validated symptom-specific distress and quality-of-life questionnaires (PFDI-20 [Pelvic Floor Distress Inventory], PFIQ [Pelvic Floor Impact Questionnaire], FISI [Fecal Incontinence Severity Index], and MMHQ [Modified Manchester Health Questionnaire]) were compared. It was estimated that 630 participants would provide more than 80% power to detect a 40% difference in second-degree or greater perineal lacerations and approximately 80% power to detect a 40% difference in stage 2 or greater pelvic organ prolapse (POP).

Results: Among 2,414 participants in the primary trial conducted between May 19, 2014, and December 16, 2017, 941 (39%) had pelvic floor assessments: 452 immediate pushing and 489 delayed pushing. The mean age was 24.8 years, and 93.4% had vaginal delivery. There were no significant differences in perineal lacerations at delivery and POP at 6 weeks and 6 months postpartum. Changes from baseline in total and subscale scores for the PFDI-20, the PFIQ, and the MMHQ were not significantly different at 6 weeks postpartum and 6 months postpartum. The change in FISI score was higher in the immediate pushing group at 6 months (2.9±5.7 vs 2.0±4.5, difference 0.9, P =.01), but less than the minimum important difference of 4.

Conclusion: Among nulliparous patients in the second stage with neuraxial analgesia, immediate pushing, compared with delayed pushing, did not increase perineal lacerations, POP-Q measures, or patient-reported pelvic floor symptoms at 6 weeks and 6 months postpartum.

Keywords: second-stage pushing, pelvic floor, postpartum, randomized trial

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care

Summary: Review summarizing a trial's findings, without presenting original quantified data.

Abstract: The author describes a recent trial on the effect of the timing of pushing during the second stage of labor on postpartum pelvic floor morbidity.

Keywords: second-stage labor, pushing, pelvic floor, morbidity

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care

Summary: Earlier device placement reduced device failure and the need for transfusion, and transfusion/blood loss were similar between the two devices compared.

Abstract: Objective: To compare intrauterine balloon tamponade and vacuum-induced hemorrhage-control devices in a multicenter hospital system using a standardized three-stage postpartum hemorrhage response algorithm.

Methods: As part of a quality improvement project, data were prospectively collected through ongoing detailed hemorrhage case audits from 65 facilities from August 2022 to February 2024. Postpartum hemorrhage-control devices are recommended for stage 2 or 3 of the postpartum hemorrhage algorithm. The primary outcomes were 1) quantitative blood loss after device placement, 2) rate of packed red blood cell (RBC) transfusion, 3) use of 3 units of packed RBCs or more, and 4) device failure.

Results: During the 17-month observation period, there were 123,292 deliveries, and postpartum hemorrhage occurred in 5,931 (4.8%). Postpartum hemorrhage-control devices were used in 11.2% of cases (666 total, intrauterine balloon tamponade n=300, and vacuum-induced hemorrhage control n=366). For intrauterine balloon tamponade and vacuum-induced hemorrhage-control devices, quantitative blood loss (median and interquartile range) after device placement was similar at 194 (67-440) mL and 240 (113-528) mL ( P =.40), respectively, as was the rate of any packed RBC transfusion (59.7% vs 50.0%, P =.08), transfusion of 3 packed RBC units or more (27.0% vs 24.9%, P =.53), and device failure (7.7% vs 8.5%, P =.70). Placement of either device at a quantitative blood loss between 1,000 and 1,499 mL compared with 1,500 mL or more resulted in significantly lower rates of packed RBC transfusion (39.1% vs 70.3%, P <.001), transfusion of 3 or more packed RBC units (13.7 vs 38.1%, P <.001), and device failure (3.4% vs 12.9%, P <.001).

Conclusion: Transfusion and blood loss after device placement were similar with both hemorrhage-control devices. Earlier hemorrhage-control device placement reduced device failure and the need for transfusion.

Keywords: Postpartum hemorrhage, intrauterine balloon tamponade, vacuum device, effectiveness

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care Consultation

Summary: Review measured effect of devices/protocols, reporting mixed/unclear results for the composite outcome and hysterectomy.

Abstract: Objectives: To evaluate uterine tamponade devices' effectiveness for atonic refractory postpartum haemorrhage (PPH) after vaginal birth and the effect of including them in institutional protocols.

Search strategy: PubMed, EMBASE, CINAHL, LILACS, POPLINE, from inception to January 2021.

Study selection: Randomised and non-randomised comparative studies.

Outcomes: Composite outcome including surgical interventions (artery ligations, compressive sutures or hysterectomy) or maternal death, and hysterectomy.

Results: All included studies were at high risk of bias. The certainty of the evidence was rated as very low to low. One randomised study measured the effect of the condom-catheter balloon compared with standard care and found unclear results for the composite outcome (relative risk [RR] 2.33, 95% CI 0.76-7.14) and hysterectomy (RR 4.14, 95% CI 0.48-35.93). Three comparative studies assessed the effect of including uterine balloon tamponade in institutional protocols. A stepped wedge cluster randomised controlled trial suggested an increase in the composite outcome (RR 4.08, 95% CI 1.07-15.58) and unclear results for hysterectomy (RR 4.38, 95% CI 0.47-41.09) with the use of the condom-catheter or surgical glove balloon. One non-randomised study showed unclear effects on the composite outcome (RR 0.33, 95% CI 0.11-1.03) and hysterectomy (RR 0.49, 95% CI 0.04-5.38) after the inclusion of the Bakri balloon. The second non-randomised study found unclear effects on the composite outcome (RR 0.95, 95% CI 0.32-2.81) and hysterectomy (RR 1.84, 95% CI 0.44-7.69) after the inclusion of Ebb or Bakri balloon.

Conclusions: The effect of uterine tamponade devices for the management of atonic refractory PPH after vaginal delivery is unclear, as is the role of the type of device and the setting.

Keywords: Uterine tamponade, postpartum haemorrhage, vaginal birth, systematic review

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care

Summary: Meta-analysis quantified that SCC utilization improved quality of preeclampsia management (OR = 7.05).

Abstract: Introduction: The World Health Organization (WHO) Safe Childbirth Checklist (SCC) is a 29-item checklist based on essential childbirth practices to help health-care workers to deliver consistently high quality maternal and perinatal care. The Checklist was intended to reduce maternal and perinatal mortality and address the primary cause of maternal death, intrapartum stillbirth, and early neonatal death. The objective of this review was to locate international literature reporting on the effectiveness of utilizing the WHO safe childbirth checklist on improving essential childbirth practices, early neonatal death, stillbirth, maternal mortality, and morbidity.

Methods: We searched MEDLINE, google scholar, Cochrane Central Register of Controlled Trials (CENTRAL), met-Register of Controlled Trials (m-RCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/stop/search/en) to retrieve all available comparative studieshttp://www.opengrey.eu/ published in English after 2008. Two reviewers did study selection, critical appraisal, and data extraction independently. We did a random or fixed-effect meta-analysis to pool studies together and effect estimates were expressed as an odds ratio. Quality of evidence for major outcomes was assessed using the Grading of Recommendations, Assessment, development, and evaluation(GRADE).

Results: We retained three cluster randomized trials and six pre-and-post intervention studies reporting on WHO SCC's. The WHO SCC utilization improved quality of preeclampsia management(moderate quality of evidence) (OR = 7.05 [95% CI 2.34-21.29]), maternal infection management(moderate quality of evidence) (OR = 7.29[95%CI 2.29-23.27]), Partograph utilization(moderate quality of evidence) (OR = 3.81 [95% 1.72-8.43]), postpartum counselling(low quality of evidence) (RR = 132.51[95% 49.27-356.36]) and still birth(moderate quality of evidence) (OR = 0.92[95% CI 0.87-0.96]). However, the utilization of the checklist had no impact on early neonatal death (very low quality of evidence) (OR = 1.07[95%CI [1.01-1.13]) and maternal death (low quality of evidence) (OR = 1.06[95% CI 0.77-1.45]).

Conclusions: Moderate quality of evidence indicates that WHO SCC utilization is effective in reducing stillbirth and Improving preeclampsia management, maternal infection management and partograph utilization Low quality of evidence indicates that WHO SCC is effective in enhancing postpartum danger sign counseling. Low and very low quality of evidence suggests that WHO SCC has no impact on maternal and early neonatal death, respectively.

Keywords: Safe childbirth checklist; WHO; maternal outcome; perinatal outcome

Topic(s):

• Clinical consensus, guidelines, protocols
• Quality, performance, and outcome indicators

Intervention Type: Policy Development and Enforcement

Summary: RCT objective; missing quantified outcome change in the abstract.

Abstract: Objective: To compare differences in postpartum blood pressure (BP) control (BP below 140/90 mm Hg) for participants with hypertension randomized to receive antihypertensive treatment compared with no treatment during pregnancy.

Methods: This study was a planned secondary analysis of a multicenter, open-label, randomized controlled trial (The CHAP [Chronic Hypertension and Pregnancy] trial). Pregnant participants with mild chronic hypertension (BP below 160/105 mm Hg) were randomized into two groups: active (antihypertensive treatment) or control (no treatment unless severe hypertension, BP 160/105 mm Hg or higher). Study outcomes were BP control below 140/90 mm Hg (primary) and medication nonadherence based on a composite score threshold (secondary) at the 6-week postpartum follow-up visit. Participants without follow-up BP measurements were excluded from analysis of the BP control outcome. Participants without health care professional-prescribed antihypertensives at delivery were excluded from the analysis of the adherence outcome. Multivariable logistic regression was used to adjust for potential confounders.

Results: Of 2,408 participants, 1,684 (864 active, 820 control) were included in the analysis. A greater percentage of participants in the active group achieved BP control (56.7% vs 51.5%; adjusted odds ratio [aOR] 1.22, 95% CI, 1.00-1.48) than in the control group. Postpartum antihypertensive prescription was higher in the active group (81.7% vs 58.4%, P <.001), and nonadherence did not differ significantly between groups (aOR 0.81, 95% CI, 0.64-1.03).

Conclusion: Antihypertensive treatment of mild chronic hypertension during pregnancy was associated with better BP control below 140/90 mm Hg in the immediate postpartum period.

Keywords: Hypertension; Pregnancy; Postpartum; Blood pressure control; Antihypertensive therapy

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care

Summary: Study description/implied protocol; no specific results or quantifiable outcomes provided.

Abstract: Objective: To determine whether a single low dose of esketamine administered after childbirth reduces postpartum depression in mothers with prenatal depression. Design: Randomised, double blind, placebo controlled trial with two parallel arms. Setting: Five tertiary care hospitals in China, 19 June 2020 to 3 August 2022. Participants: 364 mothers aged >=18 years who had at least mild prenatal depression as indicated by Edinburgh postnatal depression scale scores of >=10 (range 0-30, with higher scores indicating worse depression) and who were admitted to hospital for delivery. Interventions: Participants were randomly assigned 1:1 to receive either 0.2 mg/kg esketamine or placebo infused intravenously over 40 minutes after childbirth once the umbilical cord had been clamped. Main Outcome Measures: The primary outcome was prevalence of a major depressive episode at 42 days post partum, diagnosed using the mini-international neuropsychiatric interview. Secondary outcomes included the Edinburgh postnatal depression scale score at seven and 42 days post partum and the 17 item Hamilton depression rating scale score at 42 days post partum (range 0-52, with higher scores indicating worse depression). Adverse events were monitored until 24 hours after childbirth. Results: A total of 364 mothers (mean age 31.8 (standard deviation 4.1) years) were enrolled and randomised. At 42 days post partum, a major depressive episode was observed in 6.7% (12/180) of participants in the esketamine group compared with 25.4% (46/181) in the placebo group (relative risk 0.26, 95% confidence interval (CI) 0.14 to 0.48; P < 0.001). Edinburgh postnatal depression scale scores were lower in the esketamine group at seven days (median difference -3, 95% CI -4 to -2; P < 0.001) and 42 days (-3, -4 to -2; P < 0.001). Hamilton depression rating scale scores at 42 days post partum were also lower in the esketamine group (-4, -6 to -3; P < 0.001). The overall incidence of neuropsychiatric adverse events was higher in the esketamine group (45.1% (82/182) v 22.0% (40/182); P < 0.001); however, symptoms lasted less than a day and none required drug treatment. Conclusions: For mothers with prenatal depression, a single low dose of esketamine after childbirth decreases major depressive episodes at 42 days post partum by about three quarters. Neuropsychiatric symptoms were more frequent but transient and did not require drug intervention. (PsycInfo Database Record (c) 2024 APA, all rights reserved)

Topic(s):

• Behavioral/mental health services and substance use
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care Education and Promotion Screening

Summary: Review summarizing available evidence and protocols for emergency department management.

Abstract: Maternal stroke contributes to a significant burden of disease in the pregnant and postpartum patient populations, with an incidence nearly 3-fold that of comparable nonpregnant cohorts. Emergency clinicians must maintain a high index of suspicion for cerebrovascular injury in these patients, as rapid diagnosis and emergent management can prevent devastating neurological outcomes. Data on management of cerebrovascular injury in pregnant and postpartum patients are limited, but management of maternal stroke in the emergency department aligns closely with protocols established for nonpregnant patients. This issue discusses the risk factors associated with maternal stroke, and reviews the available evidence for emergency department management of maternal stroke, including thrombolytic and interventional therapies.

Keywords: stroke, pregnancy, postpartum, emergency management

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Consultation

Summary: Hospital length of stay decreased by an average of 7.9 hours (p < 0.001), and opioid consumption decreased by an average of 36.5 mg of oxycodone per patient after ERAS protocol implementation.

Abstract: Objective: The aim of this study is to assess the effect of a resident-led enhanced recovery after surgery (ERAS) protocol for scheduled prelabor cesarean deliveries on hospital length of stay and postpartum opioid consumption.

Study design: This retrospective cohort study included patients who underwent scheduled prelabor cesarean deliveries before and after implementation of an ERAS protocol at a single academic tertiary care institution. The primary outcome was length of stay following cesarean delivery. Secondary outcomes included protocol adherence, inpatient opioid consumption, and patient-centered outcomes. The protocol included multimodal analgesia and antiemetic medications, expedited urinary catheter removal, early discontinuation of maintenance intravenous fluids, and early ambulation.

Results: A total of 250 patients were included in the study: 122 in the pre-ERAS cohort and 128 in the post-ERAS cohort. There were no differences in baseline demographics, medical comorbidities, or cesarean delivery characteristics between the two groups. Following protocol implementation, hospital length of stay decreased by an average of 7.9 hours (pre-ERAS 82.1 vs. post-ERAS 74.2, p < 0.001). There was 89.8% adherence to the entire protocol as written. Opioid consumption decreased by an average of 36.5 mg of oxycodone per patient, with no significant differences in pain scores from postoperative day 1 to postoperative day 4 (all p > 0.05).

Conclusion: A resident-driven quality improvement project was associated with decreased length of hospital stay, decreased opioid consumption, and unchanged visual analog pain scores at the time of hospital discharge. Implementation of this ERAS protocol is feasible and effective.

Key points: · Enhanced recovery after surgery (ERAS) principles can be effectively applied to cesarean delivery with excellent protocol adherence.. · Patients who participated in the ERAS pathway had significant decreases in hospital length of stay and opioid pain medication consumption with unchanged visual analog pain scores postoperative days 1 through 4.. · Resident-driven quality improvement projects can make a substantial impact in patient care for both process measures (e.g., protocol adherence) and outcome measures (e.g., opioid use)..

Keywords: Enhanced recovery, cesarean, opioid use, hospital stay, quality improvement

Topic(s):

• Quality, performance, and outcome indicators
• Clinical consensus, guidelines, protocols

Intervention Type: Policy Development and Enforcement Policy Development and Enforcement

Summary: Review discussing rising incidence and incomplete implementation of guidelines.

Abstract: Postpartum/peripartum hemorrhage (PPH) is an obstetric emergency complicating 1-10% of all deliveries and is a leading cause of maternal mortality and morbidity worldwide. However, the incidence of PPH differs widely according to the definition and criteria used, the way of measuring postpartum blood loss, and the population being studied with the highest numbers in developing countries. Despite all the significant progress in healthcare, the incidence of PPH is rising due to an incomplete implementation of guidelines, resulting in treatment delays and suboptimal care. A consensus clinical definition of PPH is needed to enable awareness, early recognition, and initiation of appropriate intensive treatment. Unfortunately, the most used definition of PPH based on blood loss ≥500 ml after delivery suffers from inaccuracies in blood loss quantification and is not clinically relevant in most cases, as the amount of blood loss does not fully reflect the severity of bleeding.

Keywords: definition of PPH; epidemiology of PPH; postpartum/peripartum hemorrhage; risk and causes of PPH

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Epidemiology and Surveillance Education and Promotion

Summary: Retrospective analysis describing the administration patterns of oxytocin in out-of-hospital births.

Abstract: Primary postpartum hemorrhage (PPH) is a life-threatening obstetric emergency that can be mitigated through the administration of a uterotonic to actively manage the third stage of labor. This study describes the prehospital administration of oxytocin by paramedics following attendance of out-of-hospital (OOH) births. A retrospective analysis was undertaken of all OOH births between the 1^st January 2018 and 31^st December 2018 attended by the Queensland Ambulance Service. The demographic and epidemiological characteristics of patients that were administered oxytocin and the occurrence of adverse side effects were described. In total, 350 OOH births were included in this study with the majority involving multigravidas women (94.3%) and all but two involving singleton pregnancies. Oxytocin was administered following 222 births (63.4%), while 67 patients (19.1%) declined administration preferring a physiological third stage of labor, and in 61 cases (17.4%) oxytocin was withheld by the attending paramedic. There were no documented adverse events or side effects following administration. Oxytocin administration occurred on average 14 minutes (interquartile range 9-25) following the time of birth. The median time from oxytocin administration to placenta delivery was 10 minutes (interquartile range 5-22). Oxytocin is well accepted and safe treatment adjunct for the management of the third stage of labor in OOH births and should be considered for routine practice by other emergency medical services.

Keywords: Oxytocin Administration and Dosage ; Emergency Medical Technicians ; Home Childbirth ; Prehospital Care In Pregnancy ; Human ; Female ; Adult ; Pregnancy ; Retrospective Design ; Descriptive Statistics ; Patient Safety ; Mann-Whitney U Test ; Data Analysis Software ; Adult: 19-44 years ; Female

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Epidemiology and Surveillance

Summary: Systematic review focused on defining essential PNC components and developing signal functions for monitoring and evaluation (Guideline/Methodology).

Abstract: Background: Postnatal Care (PNC) is one of the healthcare-packages in the continuum of care for mothers and children that needs to be in place to reduce global maternal and perinatal mortality and morbidity. We sought to identify the essential components of PNC and develop signal functions to reflect these which can be used for the monitoring and evaluation of availability and quality of PNC.

Methods: Systematic review of the literature using MESH headings for databases (Cinahl, Cochrane, Global Health, Medline, PubMed, and Web of Science). Papers and reports on content of PNC published from 2000-2020 were included. Narrative synthesis of data and development of signal function through 7 consensus-building workshops with 184 stakeholders.

Results: Forty-Eight papers and reports are included in the systematic review from which 22 essential components of PNC were extracted and used to develop 14 signal functions. Signal functions are used in obstetrics to denote a list of interventions that address major causes of maternal and perinatal morbidity or mortality. For each signal function we identified the equipment, medication and consumables required for implementation. The prevention and management of infectious diseases (malaria, HIV, tuberculosis) are considered essential components of routine PNC depending on population disease burden or whether the population is considered at risk. Screening and management of pre-eclampsia, maternal anaemia and mental health are recommended universally. Promotion of and support of exclusive breastfeeding and uptake of a modern contraceptive method are also considered essential components of PNC. For the new-born baby, cord care, monitoring of growth and development, screening for congenital disease and commencing vaccinations are considered essential signal functions. Screening for gender-based violence (GBV) including intimate partner- violence (IPV) is recommended when counselling can be provided and/or a referral pathway is in place. Debriefing following birth (complicated or un-complicated) was agreed through consensus-building as an important component of PNC.

Conclusions: Signal functions were developed which can be used for monitoring and evaluation of content and quality of PNC. Country adaptation and validation is recommended and further work is needed to examine if the proposed signal functions can serve as a useful monitoring and evaluation tool.

Keywords: postnatal care; essential components; monitoring; evaluation; systematic review

Topic(s):

• Clinical consensus, guidelines, protocols
• Quality, performance, and outcome indicators

Intervention Type: Policy Development and Enforcement

Summary: Development and dissemination of ten Principles of Care (PoC) to standardize management.

Abstract: Introduction: Despite increasing awareness of issues faced by women and girls with inherited BDs (WGBD), standards of care are lacking, with disparities in diagnosis and treatment for WGBD across Europe. We aimed to develop practical principles of care (PoC) to promote standardization of care for WGBD within European Haemophilia Treatment and Comprehensive Care Centres (HTC/CCCs).

Methods: The co-creation process, supported by the European Association for Haemophilia and Allied Disorders, consisted of four multidisciplinary meetings with health care providers (HCPs) experienced in WGBD care, and European Haemophilia Consortium representatives, combined with broad patient and HCP consultations in the European haemophilia community. Relevant medical societies outside Europe were contacted for confirmation.

Results: We developed ten PoC for WGBD, stressing the importance and benefits of a centralized, multidisciplinary, comprehensive, family-centred approach to support and manage WGBD during all life stages. These PoC emphasise the right to equitable access and quality of care for all people with BDs, irrespective of gender. Multiple medical societies outside Europe also confirmed their support for endorsement.

Conclusions: Ten PoC for WGBD evolved from an iterative process among stakeholders, supported by relevant medical societies worldwide. These PoC can serve as a benchmark for diagnosis and comprehensive multidisciplinary management of WGBD, and improve awareness of their unique challenges. They offer a framework to guide HTC/CCCs in providing equitable care for all WGBD, both in their own services and in other healthcare settings. Implementation of these principles aims to positively impact the health, wellbeing and quality of life for WGBD.

Keywords: Inherited bleeding disorders, women, girls, principles of care, multidisciplinary care

Topic(s):

• Clinical consensus, guidelines, protocols
• Dyadic, culturally congruent, family-centered care

Intervention Type: Policy Development and Enforcement

Summary: Advocacy for and description of a standardized evaluation strategy/protocol.

Abstract: Postpartum hemorrhage is an obstetric emergency that is the leading and the most preventable cause of maternal death that occurs on the day of birth. The treatment of postpartum hemorrhage in a timely fashion is crucial to prevent morbidity and mortality. The accurate assessment of blood loss during delivery and the postpartum period remains a major challenge. Hence, it is imperative to have a standardized evaluation strategy for accurate assessment of blood loss, adequate classification of hemorrhage, and timely initiated interventions. The multidisciplinary evaluation strategy should be in place regardless of the delivery route.

Keywords: Female Humans Maternal Death* Maternal Mortality Postpartum Hemorrhage* / diagnosis Postpartum Hemorrhage* / prevention & control Postpartum Period Pregnancy

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care Disease and Health Event Investigation

Summary: Quality improvement study objective; missing quantified outcome change in the abstract.

Abstract: Background: In line with a nationwide commitment to decrease opioid prescribing, in October 2017, our department implemented a new departmental policy to cease routine provision of opioid prescriptions at the time of discharge following vaginal delivery.

Objective: This study aimed to evaluate the effect of this policy on the number of discharge opioid prescriptions provided and outpatient encounters observed postpartum.

Study design: This was a retrospective cohort study of patients who underwent vaginal delivery at our institution from November 2016 to January 2018. We reviewed delivery and postpartum records for patients 18 years or older, without chronic opioid use or contraindication to nonsteroidal antiinflammatory medication use. The primary outcome was the proportion of patients provided with an opioid prescription at the time of discharge following vaginal delivery. The secondary outcome was the number of unscheduled patient encounters related to pain in the 6-week postpartum period. Fisher's exact test was used to compare these outcomes before and after implementation of the new departmental opioid-prescribing policy.

Results: A total of 1188 charts were reviewed; among those charts, 810 met the inclusion criteria. Notably, 405 patients delivered before the guideline, and 405 patients delivered after its implementation. After the implementation of the new departmental policy, there was a 10-fold decrease in opioid prescriptions provided from 323 (79.8%) to 29 (7.2%) (P<.01). Although the number of unscheduled outpatient encounters postpartum increased slightly from 22 to 37 encounters after the implementation of the new departmental policy, this difference was not statistically significant (P=.08).

Conclusion: Limiting opioid prescribing after vaginal delivery is associated with a considerable decrease in the number of discharge opioid prescriptions provided and does not significantly increase the number of outpatient encounters related to pain postpartum.

Keywords: Opioid prescribing, vaginal delivery, policy, pain management

Topic(s):

• Quality, performance, and outcome indicators
• Clinical consensus, guidelines, protocols

Intervention Type: Policy Development and Enforcement Epidemiology and Surveillance

Summary: Review summarizing evidence and recommending specific techniques and procedures.

Abstract: The goal of standardizing the technique of the routine, uncomplicated cesarean delivery (CD) is to decrease maternal morbidity while optimizing neonatal outcomes. During the procedure, a family-oriented CD is recommended. The low transverse cesarean skin incision (created with either scalpel or diathermy) is preferred with either the Joel-Cohen or Pfannenstiel methods being acceptable. For patients with obesity (BMI > 35kg/m2), surgeons may also elect either the Cohen (including supraumbilical) or Pfannenstiel (infraumbilical or infrapannus) technique as there are similar outcomes, however the Cohen approach has been associated with lower Apgar scores and decreased surgeon satisfaction related to the feasibility of the incision. Diathermy may be preferred for subcutaneous tissue opening as compared to sharp dissection. Though postoperative recovery outcomes may be improved with an extraperitoneal approach to CD, a transperitoneal technique is the current standard of care. The initial fascial incision is made sharply, further extension can be carried out either sharply or bluntly. Inferior dissection of the rectus muscle can be omitted and routine cutting of the muscles is not needed. If necessary, a Maylard modification is acceptable. Though based on limited data, blunt peritoneal entry and extension should be considered. With regards to uterine entry and delivery: bladder flap creation should be omitted, a low transverse hysterotomy is recommended with blunt cephalo-caudad expansion, and manual delivery of the fetal head should be performed. If the fetal head is impacted, then reverse breech extraction may be preferred for maternal benefit. Delayed cord clamping is recommended for at least 30 seconds and up to 120 seconds (recommended for preterm deliveries) with either routine or selected umbilical cord gas collection being considered. In areas where available, carbetocin is more effective in prevention of postpartum hemorrhage (PPH). Otherwise, the combination of oxytocin plus either misoprostol or methergine should be utilized. There is insufficient evidence regarding the effectiveness of uterine massage for PPH prevention. Spontaneous removal of the placenta with gentle cord traction is recommended.

Keywords: Cesarean delivery, intraoperative management, evidence-based, review

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Consultation Direct Care

Summary: Review summarizing evidence and making specific recommendations for standardizing routine postoperative care.

Abstract: The following review focuses on routine postoperative care after cesarean delivery (CD), including specific Enhanced Recovery After Cesarean recommendations as well as important postpartum counseling points. Following CD, there is insufficient evidence to support administration of prophylactic multi-dose antibiotics to all patients. Additional antibiotic doses are indicated for the following scenarios: patients with obesity who did not receive preoperative azithromycin, CD lasting ≥4 hours since prophylactic dose, blood loss >1500 mL, or those with an intra-amniotic infection. An oxytocin infusion for prevention of postpartum hemorrhage should be continued post-CD. While initial measures to prevent postoperative pain occur in the intraoperative period, with the consideration of 1 g intravenous (IV) acetaminophen and IV or intramuscular nonsteroidal anti-inflammatory medications (eg, 30 mg IV ketorolac), the focus postoperatively continues with this multimodal approach with scheduled acetaminophen per os (PO, 650 mg every 6 hours) and nonsteroidal agents (ketorolac 30 mg IV every 6 hours for 4 doses followed by ibuprofen 600 mg PO every 6 hours) being recommended. Short-acting opioids should be reserved for breakthrough pain. Low-risk patients should receive mechanical thromboprophylaxis until ambulation with chemoprophylaxis being reserved for patients with additional risk factors. When an indwelling bladder catheter was placed intraoperatively for scheduled CD, it should be removed immediately postoperatively. Chewing gum to aid in return of bowel function and early oral intake of solid food can occur immediately after CD and within 2 hours, respectively. For prevention of postoperative nausea and vomiting, administration of 5HT3 antagonists with the addition of either a dopamine antagonist or a corticosteroid is recommended based on noncesarean data. Early ambulation after CD starting 4 hours postoperatively is encouraged and should be incentivized by pedometer. For patients that receive a dressing over the CD skin incision, limited evidence supports leaving it in place for 48 hours. Adjunct nonpharmacologic interventions for postoperative recovery discussed in this review are acupressure, acupuncture, aromatherapy, coffee, ginger, massage, reiki, and transcutaneous electrical nerve stimulation. In the low-risk patient, hospital discharge may occur as early as 24 to 28 hours if close (ie, 1-2 days) outpatient neonatal follow-up is available due to the potential for neonatal jaundice; otherwise, patients should be discharged at 48 to 72 hours postoperatively. Upon discharge, the multimodal pain control recommendations of acetaminophen and ibuprofen should be continued. If short-acting opioids are necessary, the prescribing practices should be individualized based upon the inpatient opioid requirements. Other portions of postoperative/postpartum counseling during the inpatient stay include the optimal interpregnancy interval of 18 to 23 months, encouraging exclusive breastfeeding for at least 6 months, quick resumption of physical activity, and vaginal intercourse guidance as tolerated. Patients should also be counseled pre-CD on the option of immediate postpartum intrauterine devices insertion, intraoperative salpingectomy, or placement of long-acting reversible contraception in the postpartum period. Implementation of such evidence-based postoperative care protocols decrease length of stay, surgical site infection rates, and improve patient satisfaction and breastfeeding rates. El resumen está disponible en Español al final del artículo.

Keywords: Cesarean delivery, postoperative care, evidence-based, review

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Consultation Direct Care

Summary: Review summarizing evidence and recommending specific protocols and interventions.

Abstract: Preoperative preparation for cesarean delivery is a multistep approach for which protocols should exist at each hospital system. These protocols should be guided by the findings of this review. The interventions reviewed and recommendations made for this review have a common goal of decreasing maternal and neonatal morbidity and mortality related to cesarean delivery. The preoperative period starts before the patient's arrival to the hospital and ends immediately before skin incision. The Centers for Disease Control and Prevention recommends showering with either soap or an antiseptic solution at least the night before a procedure. Skin cleansing in addition to this has not been shown to further decrease rates of infection. Hair removal at the cesarean skin incision site is not necessary, but if preferred by the surgical team then clipping or depilatory creams should be used rather than shaving. Preoperative enema is not recommended. A clear liquid diet may be ingested up to 2 hours before and a light meal up to 6 hours before cesarean delivery. Consider giving a preoperative carbohydrate drink to nondiabetic patients up to 2 hours before planned cesarean delivery. Weight-based intravenous cefazolin is recommended 60 minutes before skin incision: 1-2 g intravenous for patients without obesity and 2 g for patients with obesity or weight ≥80 kg. Adjunctive azithromycin 500 mg intravenous is recommended for patients with labor or rupture of membranes. Preoperative gabapentin can be considered as a way to decrease pain scores with movement in the postoperative period. Tranexamic acid (1 g in 10-20 mL of saline or 10 mg/kg intravenous) is recommended prophylactically for patients at high risk of postpartum hemorrhage and can be considered in all patients. Routine use of mechanical venous thromboembolism prophylaxis is recommended preoperatively and is to be continued until the patient is ambulatory. Music and active warming of the patient, and adequate operating room temperature improves outcomes for the patient and neonate, respectively. Noise levels should allow clear communication between teams; however, a specific decibel level has not been defined in the data. Patient positioning with left lateral tilt decreases hypotensive episodes compared with right lateral tilt, which is not recommended. Manual displacers result in fewer hypotensive episodes than left lateral tilt. Both vaginal and skin preparation should be performed with either chlorhexidine (preferred) or povidone iodine. Placement of an indwelling urinary catheter is not necessary. Nonadhesive drapes are recommended. Cell salvage, although effective for high-risk patients, is not recommended for routine use. Maternal supplemental oxygen does not improve outcomes. A surgical safety checklist (including a timeout) is recommended for all cesarean deliveries.

Keywords: Cesarean delivery, preoperative management, evidence-based, review

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Consultation Education and Promotion

Summary: Review synthesizing evidence and recommendations for various interventions in postpartum care.

Abstract: In the setting of postpartum care after vaginal delivery, rooming-in is associated with a higher rate of exclusive breastfeeding rate at hospital discharge, but there is insufficient evidence to support or refute rooming-in to increase breastfeeding at 6 months. Education and support for breastfeeding are valuable interventions to promote initiation of breastfeeding whether it is offered by a healthcare professional, nonhealthcare professional, or peer. A combined intervention, a professional provider-led intervention, having a protocol available for the provider training program, and implementation during both the prenatal and postnatal periods increased the rate of exclusive breastfeeding for 6 months. There is no single effective treatment for breast engorgement. Breast massage, continuing breastfeeding, and pain relief are recommended by national guidelines. Nonsteroidal anti-inflammatory drugs and acetaminophen are better than placebo for relief of pain caused by uterine cramping and perineal trauma; acetaminophen is effective in breastfeeding individuals who underwent episiotomy; and local cooling pain relievers have been shown to reduce perineal pain for 24 to 72 hours, compared with no treatment. There is insufficient evidence to assess the safety and efficacy of postpartum routine universal thromboprophylaxis after vaginal delivery. Anti-D immune globulin administration is recommended in Rhesus-negative individuals who have given birth to a Rhesus-positive infant. There is very low-quality evidence that a universal complete blood count is useful in reducing the risk of receiving blood products. In the absence of any postpartum complication, there is insufficient evidence to recommend a routine postpartum ultrasound. Measles, mumps, and rubella combination; varicella; human papillomavirus; and tetanus, diphtheria, and pertussis vaccines should be administered in nonimmune individuals in the postpartum period. Smallpox and yellow fever vaccines should be avoided. Individuals undergoing postplacental placement are more likely to use an intrauterine device at 6 months than those advised to follow-up for placement during outpatient postpartum care. An implant is safe and effective for immediate postpartum contraception. There is insufficient evidence to support or refute the routine administration of micronutrient supplements in breastfeeding women. Placentophagia does not provide any benefits and exposes mothers and offspring to infectious risks. Therefore, it should be discouraged. Because of the low level of evidence, there is insufficient data to assess the efficacy of home visits in the postpartum period. There is insufficient evidence to recommend when to resume daily activities, and individuals should be counseled to return to prepregnancy level of activity or exercise when comfortable. Sexual activity, housework exercise, driving, climbing stairs, and lifting weights should be resumed as soon as postpartum individuals want. A behavioral educational intervention reduces depression symptoms and increases breastfeeding duration. Physical activity after delivery is protective against postpartum mood disorders. There is no strong evidence that supports early discharge after vaginal delivery compared with standard discharge (ie, ≥48 hours).

Keywords: breastfeeding; contraception; delivery; labor; postpartum; rooming in; vaginal delivery

Topic(s):

• Clinical consensus, guidelines, protocols
• Nonclinical postpartum care

Intervention Type: Consultation

Summary: Providing evidence-based recommendations aimed at reducing unindicated intravenous fluid administration.

Abstract: Intravenous fluid (IVF) administration is a ubiquitous medical intervention. Although there are clear benefits to IVF in certain obstetric scenarios, IVF is often given in unindicated circumstances; the ongoing IVF shortage highlights an opportunity to reduce unindicated IVF in obstetrics. This document provides evidence-based recommendations to reduce IVF use within general obstetric practice. The three sections address IVF use within (1) antepartum care, (2) intrapartum care, and (3) postpartum care, including postpartum hemorrhage (PPH) risk reduction. Using the GRADE framework, we provide a summary of the available evidence surrounding use of IVF in obstetrics and recommend strategies to reduce IVF. We recommend transitioning intravenous (IV) antibiotics to IV push or oral when possible, discontinuing IVF bolus prior to neuraxial anesthesia or for the treatment of preterm labor, and avoiding unnecessary continuous IVF infusions. There may be further opportunities for fluid conservation with IV medications that could be given intramuscularly. These suggestions for IVF use reduction should be evaluated based on local need and capabilities as well as the characteristics and risk factors of the population. Patients with sepsis, PPH, burns, diabetic ketoacidosis, and hemodynamic instability should not have a reduction in IVF administration as these diagnoses have evidence-based resuscitation guidelines that include IVF. The recommendations presented may be applicable beyond the immediate IVF shortage and should be considered as an area for future research.

Keywords: Obstetric guidance, intravenous fluids, shortage, evidence-based, review

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Consultation Direct Care

Summary: Cross-sectional survey characterizing variability in existing practice patterns.

Abstract: Background: The risk of venous thromboembolism (VTE) is 15 to 35-fold higher in the postpartum period compared to non-pregnant individuals. Clinical practice guidelines recommend the use of postpartum thromboprophylaxis with low molecular weight heparin (LMWH) for 6 weeks in individuals at high risk of developing VTE. However, a marked reduction in the risk of VTE risk occurs beyond the third week of the postpartum period.

Objective: We sought to characterize practice patterns of clinicians who manage postpartum individuals at high risk of VTE.

Methods: We conducted a cross-sectional study using a self-administered electronic questionnaire. The survey explored the use of postpartum thromboprophylaxis in high-risk individuals. Descriptive statistics were used to summarize survey responses.

Results: Of the 113 participants that responded to the initial invitation, 78 completed the survey (Europe (53.9 %); North America (23.2 %); Australia and New Zealand (19.0 %)). For individuals with a prior unprovoked or provoked deep venous thrombosis or pulmonary embolism, cerebral vein thrombosis and splanchnic vein thrombosis, 97.4 %, 93.5 %, 91.0 % and 88.5 % of the respondents recommended six weeks of postpartum thromboprophylaxis using LMWH, respectively. The recommendation for 6 weeks of thromboprophylaxis in patients with sickle cell disease and obstetric APS was comparatively lower (70.5 and 78.2 % respectively). Respondents with higher practice volumes and more years of experience in clinical practice were more likely to recommend a shorter duration of thromboprophylaxis.

Conclusion: Our study highlights the variability in clinician recommendations and the acceptability of treatment durations for postpartum thromboprophylaxis in high-risk conditions. Prospective studies are needed to determine optimal duration and establish evidence-based management.

Keywords: postpartum, anticoagulation, survey, healthcare providers, practice variation

Topic(s):

• Clinical consensus, guidelines, protocols
• Workforce training and development

Intervention Type: Epidemiology and Surveillance Direct Care

Summary: Commentary reviewing current data and advocating for vaccination.

Abstract: For over a year, the world has been gripped by the coronavirus disease 2019 (COVID-19) pandemic, which has had far-reaching effects on society. The integrity of national health care systems has also been challenged, owing to shifts in guidance and misinformation. Although initial reports suggested that pregnant people were not at increased risk of severe COVID-19, current data arising from the "third wave" paint a much more concerning picture. In addition, pregnant and lactating people were excluded from vaccine trials, which has hindered the ability of health care professionals to provide evidence-based counselling regarding the safety and efficacy of the available vaccines in these populations. This commentary reviews the current data on the safety of COVID-19 vaccines in pregnancy. The evidence is clear that the risks of hospitalization and severe maternal and potentially fetal morbidity from COVID-19 in pregnancy far outweigh the very minimal risks of COVID-19 vaccination in pregnancy.

Keywords: COVID-19 vaccine; pregnancy; lactation; commentary

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Advocacy Education and Promotion

Summary: Methodology study using a Delphi process to develop a consensus taxonomy.

Abstract: Background: States, territories, non-profits, and tribes are eligible to obtain federal funding to implement federally endorsed evidence-based home visiting programs. This represents a massive success in translational science, with $400 million a year allocated to these implementation efforts. This legislation also requires that 3% of this annual funding be allocated to tribal entities implementing home visiting in their communities. However, implementing stakeholders face challenges with selecting which program is best for their desired outcomes and context. Moreover, recent reviews have indicated that when implemented in practice and delivered at scale, many evidence-based home visiting programs fail to replicate the retention rates and effects achieved during clinical trials. To inform program implementers and better identify the active ingredients in home visiting programs that drive significant impacts, we aimed to develop an expert derived consensus taxonomy on the elements used in home visiting practice that are essential to priority outcome domains.

Methods: We convened a panel of 16 experts representing researchers, model representatives, and program implementers using a Delphi approach. We first elicited standard practice elements (SPEs) using open-ended inquiry, then compared these elements to behavior change techniques (BCTs) given their general importance in the field of home visiting; and finally rated their importance to 10 outcome domains.

Results: Our process identified 48 SPEs derived from the panel, with 83 additional BCTs added based on the literature. Six SPEs, mostly related to home visitor characteristics and skills, were rated essential across all outcome domains. Fifty-three of the 83 BCTs were rated unnecessary across all outcome domains.

Conclusions: This work represents the first step in a consensus-grounded taxonomy of techniques and strategies necessary for home visiting programs and provides a framework for future hypothesis testing and replication studies.

Keywords: home visiting; standard practice; Delphi process; evidence-based programs; implementation

Topic(s):

• Promising models of care and best practices
• Clinical consensus, guidelines, protocols
• Nonclinical postpartum care

Intervention Type: Consultation Counseling

Summary: Scoping review detailing the interventions and outcomes studied by primary research articles, not presenting a direct intervention measure.

Abstract: Problem: Despite the significance of the perinatal period, postnatal care remains insufficient for optimising long-term health.

Background: The perinatal period is a vulnerable time in a woman's life-course health trajectory. Supporting transitions from hospital to primary care is essential to promote health and guide evidence-based follow-up care.

Aim: The aims are to (i) explore existing knowledge and practice in Australia regarding maternal postnatal transitions of care between hospital and primary care and (ii) understand the enablers and barriers to implementing optimal postnatal discharge and handover of care from the maternity to primary health setting.

Methods: A scoping review was conducted according to PRISMA-ScR guidelines. Medline, Embase, CINAHL, Scopus and The Cochrane Library were searched using MeSH terms, subject headings and keywords. Full-text articles in English were included from 1st January 2010-8 th June 2024.

Results: Eighteen studies were included, 14 focused on care in specific states and four Australia-wide. Maternal postnatal transition of care between hospital and primary care varied. Critical components of care that were valued by women and healthcare providers and promoted effective care transitions were grouped into four concepts: "Woman-centred discharge planning and process", "Integrated care", "Follow-up care" and "Continuity of care". Discharge communication across Australian health services is diverse. Women and healthcare providers require clear discharge communication that highlights complications, guides follow-up and promotes continuity.

Conclusion: Australian postnatal transition between hospital and primary care is inconsistent and ineffective. Lack of robust handover between services hinders evidence-based follow-up care after postnatal discharge from hospital, particularly following pregnancy complications.

Keywords: Postnatal care; transition of care; hospital; primary care; Australia; scoping review

Topic(s):

• Promising models of care and best practices
• Clinical consensus, guidelines, protocols

Intervention Type: Referral and Follow-Up Counseling

Summary: Scoping review identifying facilitators and barriers to implementing guidelines (Implementation Focus).

Abstract: Background: Postnatal care (PNC) has the potential to prevent a substantial burden of maternal and newborn morbidity and mortality. This scoping review aimed to identify and synthesise themes related to facilitators and barriers of implementation of guidelines on routine PNC for women (postpartum care) in all settings.

Methods: This is a scoping review guided by the standard principles of Arksey & O'Malley's framework. We used the critical interpretive synthesis method to synthesise the whole body of evidence. We searched four databases (Medline, Embase, Global Health, CINAHL Plus) using a combination of search terms comprising four key concepts: postnatal care, routine care, guidelines and implementation. No restrictions on country or language of publication were applied. We excluded studies not presenting findings about PNC for women. We thematically charted the themes of studies included based on title and abstract screening. All studies included after full text screening were described and their results synthesised using the socio-ecological model framework. We did not conduct a risk of bias analysis or quality assessment of included studies.

Results: We identified a total of 8692 unique records and included 43 studies which identified facilitators and barriers to implementing routine guidelines in provision of PNC to women. Three quarters of studies pertained to PNC provision in high-income countries. Specific facilitators and barriers were identified and thematically presented based on whether they affect the provision of PNC or the intersection between provision of PNC and its use by women and families. We applied a critical global health lens to synthesise three constructs in the literature: finding a balance between standardisation and individualisation of PNC, the fragmented PNC provision landscape complicating the experiences of women with intersecting vulnerabilities, and the heavy reliance on the short postpartum period as an opportunity to educate and retain women and newborns in the health system.

Conclusions: This interpretive synthesis of evidence shows that the fragmented and narrow nature of PNC provision presents specific challenges to developing, adapting and implementing routine PNC guidelines. This results in a lack of linkages to social support and services, fails to address intersecting vulnerabilities and inequities among women, and negatively influences care seeking. There is a lack of evidence on how processes of individualising PNC provision can be applied in practice to support health workers in providing woman-centered PNC in various global settings.

Keywords: postnatal care; guideline implementation; facilitators; barriers; systematic review

Topic(s):

• Clinical consensus, guidelines, protocols
• Health equity and access to care

Intervention Type: Policy Development and Enforcement Counseling

Summary: Observational/case-control study quantifying current adherence rates, notes improvement over time but lacks specific pre/post metrics for the QI intervention.

Abstract: Background: The American College of Obstetricians and Gynecologists recommends that pregnant patients receive expeditious treatment with first-line antihypertensive agents within 1 hour of confirmed severe hypertension to reduce the risk for maternal stroke. However, it is unknown how often this guideline is followed and what factors influence a patient's likelihood of receiving guideline-concordant care.

Objective: We aimed to identify factors associated with receiving guideline-concordant treatment for an obstetrical hypertensive emergency.

Study design: We present a case-control study of all pregnant and postpartum patients who had persistent severe hypertension (≥2 systolic blood pressures ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg, or both within 1 hour of each other) during their delivery hospitalization at a tertiary hospital from October 1, 2013, to August 31, 2020. Data were extracted from the hospital electronic medical records using standard definitions and billing and diagnosis codes. We defined receipt of the recommended treatment as administration of a first-line antihypertensive agent (intravenous labetalol, intravenous hydralazine, or immediate-release oral nifedipine) within 60 minutes of the first or second severe-range blood pressure measurement during their delivery hospitalization. Delayed treatment was defined as the administration of a first-line agent >60 minutes after the second elevated blood pressure measurement. Patients were considered untreated if a first-line agent was never administered. Maternal sociodemographic, clinical and pregnancy factors, and time and day of the week of the hypertensive emergency were compared among patients who received the recommended treatment, those who received delayed treatment, and those who were untreated. Bivariate analyses were performed, and multinomial and multivariable logistic regression models were used to adjust for potential confounders.

Results: Of the 39,918 deliveries in the cohort, 1987 (5.0%) were complicated by severe, persistent obstetrical hypertension. Of these patients, 532 (26.8%) received the recommended treatment, 356 (17.9%) received delayed treatment, and 1099 (55.3%) did not receive any first-line antihypertensive therapy. The multinomial regression models that were used to compare these 3 groups indicated that patients who received the recommended treatment were more likely to be Black (adjusted odds ratio, 1.85; 95% confidence interval, 1.36-2.51), Hispanic (adjusted odds ratio, 1.77; 95% confidence interval, 1.28-2.52), or pregnant and at <37 weeks of gestation (adjusted odds ratio, 6.65; 95% confidence interval, 5.08-8.72). Treatment was less likely if the severe obstetrical hypertension emergency occurred overnight (7:00 PM to 6:59 AM) (adjusted odds ratio, 0.79; 95% confidence interval, 0.64-0.97) or during the postpartum period (adjusted odds ratio, 0.66; 95% confidence interval, 0.51-0.86).

Conclusion: Approximately half of obstetrical patients with at least 2 documented severely elevated blood pressure measurements did not receive the recommended antihypertensive treatment. Of those who did receive treatment, about 40% had delayed treatment. Black and Hispanic race and preterm gestation were associated with an increased likelihood of receiving the recommended treatment when compared with White race and term pregnancies. Patients whose severe obstetrical hypertension emergency occurred overnight and those who were postpartum were less likely to receive any first-line antihypertensive treatment. Overall, patients without sociodemographic and clinical risk factors for severe obstetrical hypertension or other pregnancy complications were less likely to be treated. However, treatment improved significantly over time with the implementation of targeted quality measures and specific institutional policies based on the American College of Obstetricians and Gynecologists' latest severe obstetrical hypertension management guidelines.

Keywords: obstetric hypertension, treatment, acute onset, factors

Topic(s):

• Quality, performance, and outcome indicators
• Clinical consensus, guidelines, protocols

Intervention Type: Policy Development and Enforcement

Summary: Narrative review summarizing risks and management strategies.

Abstract: People with cystic fibrosis (pwCF) have experienced increased survival and wellbeing in recent decades, such that more than half of those living with CF are adults. Consequently, sexual and reproductive health is increasingly important for pwCF, because many are considering parenthood. Most men and some women with CF (wwCF) will have reduced fertility, which in both sexes is multifactorial. However, unplanned pregnancies in women are not rare, and contraception and its interaction with CF complications need to be addressed by the CF team. Reduced fertility may be overcome in most pwCF through use of assisted reproductive technologies; however, the risk of having offspring with CF must be considered. Most wwCF will have normal pregnancies, but premature birth is common, especially in the setting of reduced lung function and CF-related diabetes (CFRD); optimization of treatment is recommended during pregnancy planning. Parenting imposes an increased burden on pwCF, with the challenges of caring for the newborn, postpartum physiologic changes, and maintaining CF treatments. Most drugs used to treat CF are considered safe in pregnancy and lactation, but exceptions need to be acknowledged, including the limited data regarding safety of CF transmembrane conductance regulator (CFTR) modulators during conception, pregnancy, and lactation. Because most pwCF are eligible for highly effective CFTR modulators, fertility, contraception, and pregnancy in people with CF is changing. Prospective studies regarding these issues in people treated with CFTR modulators are paramount to provide evidence-based guidance for management in the current era of CF care.

Keywords: Cystic fibrosis, fertility, pregnancy, maternal outcomes, review

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Consultation Counseling

Summary: Joint statement outlining priorities and collaborative strategies.

Abstract: Contraception, and the opportunity and ability to decide the timing, number, and spacing of one's pregnancies, is not just critical for maternal and infant health, but necessary for the attainment of basic reproductive rights. Short inter-pregnancy intervals have significant consequences for both maternal and newborn mortality, including preterm birth and maternal anemia, and they are a key cause of preventable deaths worldwide. Addressing the unmet need for contraception could have widespread implications for health equity and access. Integrating comprehensive contraceptive services into various health settings including antenatal care, postpartum care, and child immunization visits is vital. Contraceptive counseling should be holistic, and should involve shared decision-making and patient autonomy. Contraceptive counseling is particularly important in the post-pregnancy period, where loss to follow-up may be high, and for adolescents and other vulnerable populations who are often overlooked in these discussions. Addressing the unmet need for contraception requires collaboration and teamwork among healthcare professionals, particularly midwives and physicians, who have the opportunity to amplify one another's efforts, share best practices, advocate for broader contraceptive services, and strengthen training among midwifery and medical trainees. Members of FIGO and ICM have worked together to produce this joint statement, identifying priorities within contraceptive provision and underlining key collaborative strategies to address the unmet need for contraception.

Keywords: contraception, FIGO, ICM, recommendations, statement

Topic(s):

• Clinical consensus, guidelines, protocols
• Nonclinical postpartum care

Intervention Type: Policy Development and Enforcement Policy Development and Enforcement

Summary: Viewpoint expanding on a 3-phase recovery model and calling for research to guide safe return to sport.

Abstract: There is minimal evidence to guide return to exercise after pregnancy and childbirth, and even less information on safe return to competitive sport. The International Olympic Committee has suggested a 3-phase approach to postpartum recovery in athletes. This Viewpoint expands on that 3-phase model and incorporates a multidisciplinary approach to ensure comprehensive care of postpartum athletes to facilitate safe return to sport with optimal health and performance outcomes. Adopting a multidisciplinary approach may also open new research avenues to ameliorate the dearth of knowledge regarding musculoskeletal recovery and facilitate the development of guidelines to inform clinicians and postpartum women about safe return to exercise, particularly, high-intensity or high-impact activities. J Orthop Sports Phys Ther 2020;50(6):281-284. doi:10.2519/jospt.2020.0607.

Keywords: postpartum, athletes, care, rehabilitation, commentary

Topic(s):

• Nonclinical postpartum care
• Clinical consensus, guidelines, protocols

Intervention Type: Consultation

Summary: Summary of reviewed literature and proposed action items (e.g., target postpartum opioid prescribing, use multimodal analgesia); no quantified intervention effect.

Abstract: This article summarizes the Gerard W. Ostheimer Lecture given at the 2019 Society for Obstetric Anesthesia and Perinatology annual meeting. The article summarizes key articles published in 2018 that were presented in the 2019 Ostheimer Lecture, with a focus on maternal mortality, maternal complications, analgesic and anesthetic management of vaginal and cesarean deliveries, postpartum care, and the impact of anesthesia on maternal outcomes. The reviewed literature highlights many opportunities for anesthesiologists to impact maternal care and outcomes. The major themes presented in this manuscript are maternal mortality including amniotic fluid and cardiac arrest; postpartum hemorrhage; venous thromboembolism; management of spinal-induced hypotension; postpartum care including opioid use, postcesarean analgesia, and postpartum depression. A proposed list of action items and research topics based on the literature from 2018 is also presented. Specifically, anesthesiologists should use prophylactic vasopressor infusions during elective cesarean delivery; use a structured algorithm to diagnose pulmonary embolus, and reevaluate the use of D-dimer measurements; target postpartum opioid analgesia and prescribing; use multimodal postcesarean delivery analgesia, preferably with neuraxial hydrophilic opioids; and study any association between labor analgesia on postpartum depression.

Keywords: obstetric anesthesia, advances, safety, pain management

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Consultation

Summary: Guideline summarizing recommendations for the diagnosis, therapy, and follow-up.

Abstract: This guideline summarizes recommendations for the diagnosis, therapy, and follow-up of gestational diabetes mellitus, including screening, management during pregnancy, and postpartum care to reduce long-term risks for mother and child.

Keywords: NONE

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Screening

Summary: Insufficient information (no abstract provided).

Abstract: Background: Understanding the causes of maternal deaths is essential for policy and program development.

Methods: Systematic analysis of global and regional maternal mortality data from 2009 to 2020, using WHO and partner databases.

Findings: The leading causes of maternal death globally were obstetric hemorrhage, hypertensive disorders, and sepsis, with regional variation. Progress has been made in some regions, but preventable causes remain prevalent.

Interpretation: Continued investment in health systems and targeted interventions are needed to reduce maternal mortality worldwide.

Keywords: Maternal mortality, Causes of death, Global health, WHO, Systematic analysis

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Epidemiology and Surveillance Case Management

Summary: Guideline describing evidence-based practice for managing labor, delivery, and postpartum care.

Abstract: Objective: To describe evidence-based practice for managing the labour, delivery, and postpartum care of people with physical disabilities in Canada.

Target population: This guideline addresses the needs of people with physical disabilities, with a focus on conditions that affect strength and mobility, as well as those that affect neurological or musculoskeletal function or structure. Although aspects of this guideline may apply to people with solely intellectual, developmental, or sensory disabilities (e.g., hearing and vision loss), the needs of this population are beyond the scope of this guideline.

Outcomes: Safe and compassionate care for people with physical disabilities who are giving birth.

Benefits, harms, and costs: Implementation of this guideline will improve health care provider awareness of specific complications people with physical disabilities may experience during labour, delivery, and the postpartum period and therefore increase the likelihood of a safe birth.

Evidence: A literature review was conducted using MEDLINE (474), Embase (36), and the Cochrane Central Register of Controlled Trials (CENTRAL; 28) databases. The results have been filtered for English language, publication date of 2013 to present, observational studies, systematic reviews, meta-analyses, and guidelines and references in these publications were also reviewed.

Keywords: physical disabilities; postpartum care; labor; delivery; guidelines

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Consultation Referral and Follow-Up

Summary: Guideline providing evidence-based information and recommendations on cannabis use.

Abstract: Objective: To provide health care providers with the best evidence on cannabis use and women's health. Areas of focus include screening, dependence, and withdrawal; communication and documentation; pregnancy (including maternal and fetal outcomes); maternal pain control; postpartum care (including second-hand smoking and parenting); and breastfeeding.

Target population: The target population includes women who are planning a pregnancy, pregnant, or breastfeeding.

Benefits, harms, and costs: Discussing cannabis use with women who are planning a pregnancy, pregnant, or breastfeeding allows them to make informed choices about their cannabis use. Based on the limited evidence, cannabis use in pregnancy or while breastfeeding should be avoided, or reduced as much as possible if abstaining is not feasible, given the absence of safety and long-term follow up data on cannabis-exposed pregnancies and infants.

Evidence: PubMed and Cochrane Library databases were searched for articles relevant to cannabis use during pregnancy and breastfeeding published between January 1, 2018, and February 5, 2021. The search terms were developed using the MeSH terms and keywords and their variants, including cannabis, cannabinoids, cannabidiol, CBD, THC, marijuana, edible, pregnancy, pregnant, prenatal, perinatal, postnatal, breastfeed, breastfed, lactation, nursing, fetus, fetal, neonatal, newborn, and child. In terms of publication type, all clinical trials, observational studies, reviews (including systematic reviews and meta-analyses), guidelines, and conference consensus statements were included. The main inclusion criteria were pregnant and breastfeeding women as the target population, and exposure to cannabis as the intervention of interest.

Validation methods: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

Keywords: Cannabis use; pregnancy; postpartum; breastfeeding; guideline

Topic(s):

• Clinical consensus, guidelines, protocols
• Behavioral/mental health services and substance use

Intervention Type: Screening Epidemiology and Surveillance

Summary: Guideline reviewing diagnosis, prediction, prevention, and management of HDP.

Abstract: Objective: This guideline was developed by maternity care providers from obstetrics and internal medicine. It reviews the diagnosis, evaluation, and management of the hypertensive disorders of pregnancy (HDPs), the prediction and prevention of preeclampsia, and the postpartum care of women with a previous HDP.

Target population: Pregnant women.

Benefits, harms, and costs: Implementation of the recommendations in these guidelines may reduce the incidence of the HDPs, particularly preeclampsia, and associated adverse outcomes.

Evidence: A comprehensive literature review was updated to December 2020, following the same methods as for previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines, and references were restricted to English or French. To support recommendations for therapies, we prioritized randomized controlled trials and systematic reviews (if available), and evaluated substantive clinical outcomes for mothers and babies.

Validation methods: The authors agreed on the content and recommendations through consensus and responded to peer review by the SOGC Maternal Fetal Medicine Committee. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, along with the option of designating a recommendation as a "good practice point." See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).The Board of the SOGC approved the final draft for publication.

Intended users: All health care providers (obstetricians, family doctors, midwives, nurses, and anesthesiologists) who provide care to women before, during, or after pregnancy.

Keywords: Hypertensive disorders, pregnancy, guideline, diagnosis, management

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Screening Screening

Summary: Guideline summarizing evidence and making recommendations for the diagnosis, classification, and management.

Abstract: Objective: To summarize the current evidence and to make recommendations for diagnosis and classification of vasa previa and for management of women with this diagnosis.

Target population: Pregnant women with vasa previa or low-lying fetal vessels.

Options: To manage vasa previa in hospital or at home, and to perform a cesarean delivery preterm or at term, or to allow a trial of labour when a diagnosis of vasa previa or low-lying fetal vessels is suspected or confirmed.

Outcomes: Prolonged hospitalization, preterm birth, rate of cesarean delivery, and neonatal morbidity and mortality.

Benefits, harms, and costs: Women with vasa previa or low-lying fetal vessels are at an increased risk of maternal and fetal or postnatal adverse outcomes. These outcomes include a potentially incorrect diagnosis, need for hospitalization, unnecessary restriction of activities, an early delivery, and an unnecessary cesarean delivery. Optimization of diagnostic and management protocols can improve maternal and fetal or postnatal outcomes.

Evidence: Medline, Pubmed, Embase, and the Cochrane Library were searched from inception to March 2022, using medical subject headings (MeSH) and keywords related to pregnancy, vasa previa, low-lying fetal vessels, antepartum hemorrhage, short cervix, preterm labour, and cesarean delivery. This document presents an abstraction of the evidence rather than a methodological review.

Validation methods: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

Keywords: Vasa previa, diagnosis, management, guideline, obstetrics

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Screening Epidemiology and Surveillance

Summary: Guideline focused on identification, screening, treatment, and referral strategies.

Abstract: Objective: To help perinatal health care providers identify and assist pregnant and postpartum patients with perinatal mental illness, specifically perinatal mood and anxiety disorders. Areas of focus include risk factors and identification, screening, treatment, and referral.

Target population: All individuals who are pregnant or in the first year postpartum.

Outcomes: Open dialogue and evidence-informed care for perinatal mood and anxiety disorders, including competency for identification, screening, treatment, and referral, which will lead to improvements in patient care.

Benefits, harms, and costs: Pregnant and postpartum individuals with untreated perinatal mental illness, including mood and anxiety disorders, may suffer devastating effects and their family may experience short- and long-term adverse outcomes.

Evidence: A literature search was conducted using Medline (Ovid), PubMed, Embase and the Cochrane library from inception to June 2024. Additional articles were identified from article bibliographies and grey literature published by reputable societies and organizations (see online Appendix A).

Validation methods: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix B (Tables B1 for definitions and B2 for interpretations of strong and weak recommendations).

Keywords: Perinatal mood disorder, anxiety, guideline, screening, treatment

Topic(s):

• Clinical consensus, guidelines, protocols
• Behavioral/mental health services and substance use

Intervention Type: Screening

Summary: Data analysis and evaluation comparing existing guidelines with real-life clinical implementation practices.

Abstract: Objectives: Venous thromboembolism is one of the most serious complications of the postpartum period, and international societies have various thromboprophylaxis guidelines for its prevention. This study compares postpartum venous thromboprophylaxis recommendations from the American College of Obstetrics and Gynecology (ACOG) and the Royal College of Obstetricians and Gynecologists (RCOG) with real-life clinical practices.

Study design: Data analysis of 1000 postpartum women at a tertiary care center focused on patient demographics, venous thromboembolism risk factors, and clinical thromboprophylaxis practices. Patient-specific risk factors were compared between ACOG and RCOG guidelines, assessing Low-Molecular-Weight-Heparin dosages and durations. Guideline compliance, undertreatment/overtreatment rates, and the required number of prefilled Low-Molecular-Weight-Heparin syringes were evaluated.

Results: Significant discrepancies were observed between ACOG and RCOG guidelines, particularly in Low Molecular Weight Heparin dosages and durations. Consensus rates with clinical approaches were around 53%, with inconsistencies leaning towards undertreatment (RCOG) and overtreatment (ACOG). The number of required prefilled Low-Molecular-Weight-Heparin syringes was notably higher according to RCOG compared to ACOG guidelines.

Conclusion: Postpartum Venous thromboembolism prophylaxis guidelines from American College of Obstetrics and Gynecology and Royal College of Obstetricians and Gynecologists exhibit substantial differences, leading to variations in clinical practice. Further research on the significance of Venous thromboembolism risk factors is essential for improving risk assessment tools and refining guideline recommendations for pregnancy-related Venous thromboembolism prevention.

Keywords: venous thromboprophylaxis, postpartum, guidelines, ACOG, RCOG

Topic(s):

• Clinical consensus, guidelines, protocols
• Quality, performance, and outcome indicators

Intervention Type: Policy Development and Enforcement

Summary: Descriptive cross-sectional quantitative study examining women's guidance/experiences.

Abstract: Objectives: to investigate puerperal women who received guidance on childbirth during prenatal care and the behaviors experienced in the labor process within the context of good obstetric practices from the perspective of puerperal women.

Methods: a descriptive cross-sectional quantitative study conducted with 203 puerperal women admitted to the shared rooms of a teaching hospital between May and July 2017 during the immediate postpartum period. For data collection, was used an instrument adapted from the hospital questionnaire for puerperal women that was developed by the Oswaldo Cruz Foundation.

Results: only 48.3% of puerperal women received the eight orientations regarding good obstetric practices during prenatal care, which were not experienced in the labor process, especially regarding referral and behaviors of the hospital team. Unfavorable socioeconomic conditions were significant in relation to guidelines provided during prenatal care.

Conclusions: prenatal care was negatively evaluated and there was lack of compliance with good obstetric practices and non-recommended behaviors in the labor process in the maternity ward.

Keywords: prenatal care, childbirth, puerperal women, qualitative research

Topic(s):

• Quality, performance, and outcome indicators
• Clinical consensus, guidelines, protocols

Intervention Type: Education and Promotion Epidemiology and Surveillance

Summary: Rapid review providing recommendations for future research.

Abstract: Background: Advances in postnatal care for hemolytic disease of the fetus and newborn (HDFN) have occurred over the past decades, but little is known regarding the frequency of postnatal treatment and the clinical outcomes of affected neonates. Most studies reporting on HDFN originate from high-income countries or relatively large centers, but important differences between centers and countries may exist due to differences in prevalence and available treatment options. We therefore aimed to evaluate the postnatal treatment landscape and clinical outcomes in neonates with Rhesus factor D (Rh(D))- and/or K-mediated HDFN and to provide recommendations for future research.

Methods: We conducted a rapid literature review of case reports and series, observational retrospective and prospective cohort studies, and trials describing pregnancies or children affected by Rh(D)- or K-mediated HDFN published between 2005 and 2021. Information relevant to the treatment of HDFN and clinical outcomes was extracted. Medline, ClinicalTrials.gov and EMBASE were searched for relevant studies by two independent reviewers through title/abstract and full-text screening. Two independent reviewers extracted data and assessed methodological quality of included studies.

Results: Forty-three studies reporting postnatal data were included. The median frequency of exchange transfusions was 6.0% [interquartile range (IQR): 0.0-20.0] in K-mediated HDFN and 26.5% [IQR: 18.0-42.9] in Rh(D)-mediated HDFN. The median use of simple red blood cell transfusions in K-mediated HDFN was 50.0% [IQR: 25.0-56.0] and 60.0% [IQR: 20.0-72.0] in Rh(D)-mediated HDFN. Large differences in transfusion rates were found between centers. Neonatal mortality amongst cases treated with intrauterine transfusion(s) was 1.2% [IQR: 0-4.4]. Guidelines and thresholds for exchange transfusions and simple RBC transfusions were reported in 50% of studies.

Conclusion: Most included studies were from middle- to high-income countries. No studies with a higher level of evidence from centers in low-income countries were available. We noted a shortage and inconsistency in the reporting of relevant data and provide recommendations for future reports. Although large variations between studies was found and information was often missing, analysis showed that the postnatal burden of HDFN, including need for neonatal interventions, remains high.

Keywords: Hemolytic disease; fetus; newborn; postnatal care; outcomes

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Consultation Referral and Follow-Up

Summary: Qualitative study identifying misconceptions and recommending targeted models of care.

Abstract: Background: Pregnant women are a priority group for hepatitis B testing. Guideline-based care during antenatal and post-partum periods aims to prevent mother-to-child transmission of hepatitis B virus and lower the risk of liver complications in mothers. This qualitative study explored knowledge of hepatitis B and experiences of hepatitis B related care among pregnant women and mothers.

Methods: Semi-structured interviews were conducted with thirteen women with hepatitis B who were attending antenatal or post-partum hepatitis B care. The interviews were thematically analysed to assess knowledge and understanding of hepatitis B. Participants were recruited from specialist clinics in metropolitan Melbourne between August 2019 and May 2020.

Results: Four major themes were identified from interviews: (1) knowledge and understanding of hepatitis B, (2) treatment pathways, (3) accessing hepatitis B related care, and (4) disclosing status to friends. Most participants displayed an understanding of hepatitis B transmission, including mother to child transmission. The main motivator of post-partum attendance was reassurance gained concerning their child's health. Sources of hepatitis B information included doctors, online information and family. Participants identified parents and siblings as sources of support and reported an unwillingness to disclose hepatitis B status to friends.

Conclusions: Women attending antenatal or post-partum care reported having overall positive experiences, particularly regarding reassurance of their child's health, but displayed misconceptions around horizontal transmission. Knowledge gained from these results can contribute to the development of targeted models of care for pregnant women and mothers with young children to ensure their successful linkage to care.

Keywords: Hepatitis B, pregnancy, maternal care, qualitative study, Australia

Topic(s):

• Dyadic, culturally congruent, family-centered care
• Clinical consensus, guidelines, protocols

Intervention Type: Education and Promotion Screening

Summary: Review highlighting presentation, evaluation, and evidence-based management strategies.

Abstract: Introduction: Eclampsia is a rare partum and puerperal condition that carries a high rate of morbidity and mortality.

Objective: This review highlights the pearls and pitfalls of the care of patients with eclampsia, including presentation, evaluation, and evidence-based management in the emergency department (ED).

Discussion: Eclampsia is a hypertensive disease of pregnancy defined by new onset tonic-clonic, focal, or multifocal seizures or unexplained altered mental status in a pregnant or postpartum patient in the absence of other causative etiologies. However, signs and symptoms of preeclampsia and prodromes of eclampsia are often subtle and non-specific, making the diagnosis difficult. Thus, it should be considered in pregnant and postpartum patients who present to the ED. Laboratory testing including complete blood cell count, renal and liver function panels, electrolytes, glucose, coagulation panel, fibrinogen, lactate dehydrogenase, uric acid, and urinalysis, as well as imaging to include head computed tomography, can assist, but these evaluations should not delay management. Components of treatment include emergent obstetric specialist consultation, magnesium administration, and blood pressure control in patients with hypertension. Definitive treatment of eclampsia requires emergent delivery in pregnant patients. If consultants are not in-house, emergent stabilization and immediate transfer are required.

Conclusions: An understanding of eclampsia can assist emergency clinicians in rapid recognition and timely management of this potentially deadly disease.

Keywords: eclampsia, high risk, emergency, management

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Direct Care

Summary: Review highlighting evaluation and management strategies for hemophilia emergencies.

Abstract: Introduction: Hemophilia is a bleeding disorder due to coagulation pathway factor deficiency that is associated with significant morbidity and mortality.

Objective: This review highlights the pearls and pitfalls of the emergency department (ED) evaluation of hemophilia, including diagnostic procedures, imaging, and management based on current evidence.

Discussion: Hemophilia is marked by deficiency in factor VIII (in hemophilia A) or IX (in hemophilia B), which may result in severe bleeding. The severity of the disease depends upon factor levels. Patients with severe deficiency most commonly present in the first two years of life. Severe bleeding may include intracranial hemorrhage, retroperitoneal bleeding, large hematomas, bleeding within the chest or abdomen/pelvis, and subacute or delayed postpartum bleeding. ED management is the immediate replacement of clotting factors based on the suspicion of bleed rather than the confirmation of one. The doses for factor concentrate replacement to achieve factor levels of 100% are 50 U/kg for FVIII and 100 U/kg for FIX. The development of inhibitors can complicate the clinical picture and treatment possibilities. Consultation with the hematology specialist is recommended to assist with evaluation and management.

Conclusion: Emergency physician knowledge of hemophilia, including the presentation, evaluation, and management, can improve the care of these patients.

Keywords: Hemophilia, emergency, rare disease, management, morbidity

Topic(s):

• Clinical consensus, guidelines, protocols
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Direct Care

Summary: Scoping review comparing Australian guidelines to NICE/WHO recommendations, noting a high level of agreement but identifying disagreements and modifications that warrant examination.

Abstract: Background: There is no single national guideline in Australia on the provision of postnatal care, which means there is potential for significant variation in the standard and quality of care. This review aimed to systematically identify, synthesise, and assess the quality of postnatal care guidelines produced for use in Australia. A second aim was to compare postnatal care recommendations in Australian guidelines to the National Institute for Health and Care Excellence's (NICE) and the World Health Organization's (WHO) postnatal care recommendations, to identify gaps and areas of disagreement. We focussed on recommendations regarding postnatal assessment of the woman or newborn, infant feeding, discharge planning, or community-based care.

Methods: A scoping review was undertaken informed by the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews. A database search and a manual search of state and national government health departments, professional associations and research institute websites was performed to identify relevant guidelines and recommendations. Guideline quality was assessed using the AGREE II tool. Guideline recommendations from Australia were mapped to 67 NICE/WHO recommendations. Recommendations that partially agreed, were modified, or in disagreement underwent further analysis.

Results: A total of 31 Australian postnatal guidelines were identified and overall, these were of moderate- to high-quality. Of the 67 NICE/WHO recommendations, most agreed with the recommendations contained in Australian guidelines. There were five NICE/WHO recommendations with which corresponding Australian recommendations disagreed. There were 12 NICE/WHO recommendations that were commonly modified within Australia's guidelines. There were three NICE/WHO recommendations that did not appear in any Australian guideline.

Conclusions: Recommendations from postnatal guidelines in Australia have a high level of agreement with corresponding NICE/WHO recommendations. The few disagreements and modifications found in guideline recommendations - both across Australia's guidelines and between Australia's and the NICE/WHO guidelines - are worrying and warrant further examination, as they may result in different standards of care across Australia. Identified gaps in guidance should be prioritised for inclusion in new or updated guidelines where appropriate.

Keywords: postnatal care; guidelines; Australia; international standards; scoping review

Topic(s):

• Clinical consensus, guidelines, protocols
• Quality, performance, and outcome indicators

Intervention Type: Policy Development and Enforcement Collaboration

Summary: Scientific statement reviewing current standards for diagnosis, management, and follow-up.

Abstract: Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal morbidity and mortality in the United States and globally. This scientific statement reviews the current standards for diagnosis, management, and follow-up of HDP, including chronic hypertension, gestational hypertension, preeclampsia, and eclampsia. It highlights the importance of timely recognition and treatment, postpartum follow-up, and transitions to primary care. The statement also identifies gaps in care and research, and provides recommendations for improving outcomes for pregnant and postpartum individuals with hypertension.

Keywords: Hypertension, Pregnancy, Postpartum, Preeclampsia, Maternal health, Clinical guidelines

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Policy Development and Enforcement Referral and Follow-Up

Summary: Survey quantifying priority rankings of counseling topics.

Abstract: Background: Inflammatory bowel disease (IBD) commonly affects women of reproductive age. Many patients lacking knowledge about IBD and reproduction make uninformed decisions, such as voluntary childlessness and medication cessation. Education should be individualized to the patient's knowledge base and include topics of most importance to the patient. Our study aimed to describe the priority rankings of topics selected by patients seeking preconception and pregnancy counseling.

Methods: As part of an ongoing prospective study, patients with IBD were asked to rank, in order of importance, nine a priori preconception, pregnancy, and postpartum topics they would like addressed by our specialized care team, which includes an IBD physician and a high-risk obstetrician. χ2 and Fisher's exact tests were used to assess associations between clinical and demographic characteristics and priority rankings, and a p value cutoff for significance was set as .05.

Results: One hundred and fifty-eight women with IBD (mean (IQR) age; 32 (28-37) years) were seen in consultation, and 116 (70 (60%) CD, 43 (37%) UC, and 3 (3%) IBD-U) completed intake forms were analyzed. There were 78 (68%) women seen in the preconception stage, median age 31 (IQR 28-34), and 38 women (32%) were pregnant, median age 32 (IQR 28-33). Safety of IBD medications during pregnancy was most commonly ranked as top priority (40%) for all patients regardless of pregnancy status, followed by control of IBD disease activity and impact on pregnancy (31%), impact of IBD and surgery on fertility (19%), pregnancy outcomes for the baby (18%), mode of delivery (6%), inheritance of IBD (4%), breastfeeding (2%), nutritional health (2%), and vaccines and newborn care (1%). The impact of IBD and surgery on fertility was ranked as the number one priority more often in the preconception group (p value < 0.01) and mode of delivery in the pregnancy group (p value 0.04).

Conclusion: Safety of IBD medications remains a priority topic for patients seeking preconception and pregnancy counseling.

Keywords: Inflammatory bowel disease, preconception counseling, pregnancy, patient priorities

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Counseling Advocacy

Summary: Discussion suggesting the implementation of a gendered approach to ensure the needs of women are considered during vaccine development.

Abstract: The COVID-19 pandemic has imposed unprecedented health and socioeconomic challenges on public health, disrupting it on a global scale. Given that women and children are widely considered the most vulnerable in the times of emergency, whether in war or during a pandemic, the current pandemic has also severely disrupted access to reproductive and child health services. Despite this, data on the effect of the pandemic on pregnant women and newborns remain scarce, and gender-disaggregated indicators of mortality and morbidity are not available. In this context, we suggest the implementation of a gendered approach to ensure the specific needs of women and their newborns are considered during the development of COVID-19 vaccines. Taking into account gender-based biological differences, the inclusion of pregnant and lactating mothers in clinical trials for the development of COVID-19 vaccines is of vital importance.

Keywords: COVID-19, vaccine development, gendered approach, women, children

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Advocacy Policy Development and Enforcement

Summary: Observational study quantified significantly lower rates of total abdominal hysterectomy (98.2% in control vs 1.8% in NASG group) and decreased hospital days in the NASG group.

Abstract: Objective: The objective of this article was to compare hemodynamic and perfusion parameters as well as the clinical outcomes in critically ill patients with postpartum hemorrhage (PPH) who received treatment with a nonpneumatic antishock garment (NASG) as part of an intervention package, with a group of patients in similar conditions who did not receive an NASG.Methods: This observational study analyzed a historic cohort of 154 patients with PPH, secondary hypovolemic shock and signs of hypoperfusion who were admitted to this institution from 2012 to 2015. Group 1 (n= 77) was managed with NASG and Group 2 (n = 77) received interventions other than NASG. Hypoperfusion markers and maternal outcomes were compared in both groups.Results: Of 154 patients included in the analysis, 36.4% required a total abdominal hysterectomy (TAH) to achieve hemorrhage control, 98.2% of whom belonged to Group 2 and 1.8% to Group 1 (p = .001). The use of blood products was more common in Group 2 (p < .001), as was the administration of vasoactive agents. The mean number of days of hospitalization at the Obstetric High Dependency Unit (OHDU) was significantly lower in Group 1 and reached a statistically significant p value. Only two cases of maternal death occurred in Group 2.Discussion: The use of NASG in the management of PPH is a cost-effective strategy for patients with severe shock and signs of hypoperfusion and is optimal in a limited-resource scenario. In this study, the use of NASG was related to better outcomes in a statistically significant manner with better results regarding maternal outcomes such as uterine preservation and decreased transfusion requirements and hospital days.Conclusions: NASG, associated with the use of uterotonic agents and other strategies for PPH control, is a safe tool that helps reduce morbimortality in critically ill patients with PPH.

Keywords: antishock garment, postpartum hemorrhage, hypoperfusion, management

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care Screening

Summary: Cohort study found that medication therapy can increase vaginal delivery rate and reduce platelet transfusion volume compared to no treatment.

Abstract: Background: Clinical research data showed a series of adverse events in the delivery period of primary immune thrombocytopenia (ITP) patients, including high cesarean section rate. Consensus report proposed that for patients with platelet count below 50 × 109/L, prednisone or intravenous immunoglobulins (IVIg) can be given to raise the platelet count in third trimester in preparation for labor.

Objectives: To evaluate the effect of low-dose prednisone or IVIg therapy on delivery outcomes in patients with ITP.

Study design: This was a cohort study that included pregnant women with ITP from January 2017 to December 2022. Patients with platelet counts of (20-50) ×109/L at the time of delivery (≥34 weeks) and who had not received any medication before were enrolled in the study. Patients were divided into the pre-delivery medication group (oral prednisone or IVIg) and untreated group according to their preferences. The differences in vaginal delivery rate, postpartum bleeding rate, and platelet transfusion volume between the two groups were compared using t-test, Wilcoxon rank-sum test, and χ2 test. Logistic regression analysis was used to identify the factors affecting vaginal delivery rate and postpartum bleeding rate, and multiple linear regression analysis was used to identify the factors affecting platelet transfusion volume.

Results: During the study period, a total of 96 patients with ITP were enrolled, including 70 in the pre-delivery medication group and 26 in the untreated group. The platelet count of pre-delivery medication group was 54.8 ± 34.5 × 109/L, which was significantly higher than that of untreated group 34.4 ± 9.0 × 109/L (p = .004). The vaginal delivery rate of the medication group was higher than the untreated group [60.0% (42/70) vs. 30.8% (8/26), χ2 = 6.49, p = .013]. After adjusting for the proportion of multiparous women and gestational weeks, the results showed that medication therapy during the peripartum period was associated with vaginal delivery (OR = 4.937, 95% CI: 1.511-16.136, p = .008). The postpartum bleeding rates were 22.9% (16/70) and 26.9% (7/26) in the medication group and untreated group, respectively, with no significant difference between the two groups (χ2 = 0.17, p = .789), while the platelet transfusion volume was lower in the medication group than untreated group [(1.1 ± 1.0) vs. (1.6 ± 0.8) U].

Conclusion: Pre-delivery medication therapy can increase vaginal delivery rate, reduce platelet transfusion volume, but does not decrease the incidence of postpartum hemorrhage.

Keywords: Immune thrombocytopenia, pregnancy, medication, delivery outcome, cohort

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Direct Care Collaboration

Summary: Documented VTE risk assessment increased from an average of 61% (pre-EHR) to 98% (post-EHR), and the proportion of high-risk patients receiving discharge prescriptions increased from 7% to 87%.

Abstract: Purpose: Venous thromboembolism (VTE) accounts for a significant proportion of pregnancy-related mortality. In response to a series of VTEs at our institution and in accordance with mounting medical evidence for increased assessment, we implemented a universal, standardized obstetric VTE risk assessment process during antepartum and postpartum admissions and corresponding pharmacological thromboprophylaxis, which extends into the postdischarge period to prevent pregnancy-associated VTE in our urban, safety-net population.

Summary: This quality improvement (QI) project used the Institute for Healthcare Improvement's Model for Improvement. We analyzed data from chart audits, patient and pharmacy outreach, and electronic reports using statistical process control charts. A review of 407 charts showed an increase in the proportion of patients undergoing documented risk assessment from 0% to 80% (average of 61%) from July 2015 to June 2016. The average risk assessment rate increased from 61% to 98% from July 2016 through March 2021 after the screening was integrated into the electronic health record (EHR). Rate of receipt of recommended thromboprophylaxis during admission increased from an average of 85% before EHR integration to 94% after integration. The proportion of high-risk patients receiving prescriptions upon discharge increased from 7% before EHR integration to 87% after integration. We interviewed 117 patients by telephone, of whom 74% continued the medications at home.

Conclusion: An interprofessional team can achieve high rates of obstetric inpatient VTE risk assessment, pharmacological thromboprophylaxis initiation, and outpatient continuation using QI methodology.

Keywords: venous thromboembolism, obstetrics, prophylaxis, implementation

Topic(s):

• Quality, performance, and outcome indicators
• Clinical consensus, guidelines, protocols

Intervention Type: Policy Development and Enforcement Direct Care

Summary: Patients receiving the oxytocin bolus protocol were approximately 75% less likely to receive a secondary uterotonic agent compared to the infusion cohort (OR 0.25, P < 0.01).

Abstract: Objective: We hypothesized that patients who underwent cesarean delivery and received oxytocin boluses followed by an infusion would have a lower incidence of secondary uterotonic administration compared to patients who had an oxytocin infusion without boluses. Methods: Patients who had cesarean deliveries at our hospital from September 1, 2021 through December 31, 2021 and from September 1, 2022 through December 31, 2022, corresponding to the oxytocin bolus and oxytocin infusion cohorts, respectively, were included. Patient demographic, physical, and clinical characteristic data were collected by a study investigator. Intramyometrial oxytocin, intramuscular methylergonovine, intramuscular carboprost tromethamine, and sublingual misoprostol were defined as secondary uterotonics. Results: There were 266 and 283 patients in the oxytocin bolus and oxytocin infusion cohorts, respectively. The odds ratio for patients in the oxytocin bolus cohort receiving a secondary uterotonic was 0.25 (95% confidence interval 0.16, 0.41; P < 0.01). Conclusion: Patients in the oxytocin bolus cohort were approximately 75% less likely to receive a secondary uterotonic agent compared to patients in the oxytocin infusion cohort. A limitation of this study was that we defined intramyometrial administration of oxytocin as a secondary uterotonic, and our results may not be generalizable to hospitals that do not use intramyometrial oxytocin.

Keywords: Cesarean Section ; Oxytocin Administration and Dosage ; Protocols ; Oxytocics Therapeutic Use ; Drug Utilization ; Texas ; Human ; Adult ; Middle Age ; Retrospective Design ; Prospective Studies ; Nonexperimental Studies ; Academic Medical Centers ; Sociodemographic Factors ; Electronic Health Records ; Labor ; Bivariate Statistics ; Unpaired T-Tests ; Wilcoxon Signed Rank Test ; Postpartum Hemorrhage ; Fisher's Exact Test ; Descriptive Statistics ; Data Analysis Software ; Female ; Odds Ratio ; Confidence Intervals ; Adult: 19-44 years ; Middle Aged: 45-64 years ; Female

Topic(s):

• Clinical consensus, guidelines, protocols
• Quality, performance, and outcome indicators

Intervention Type: Direct Care Referral and Follow-Up