Intermittent auscultation in obstetric practice in tertiary health facilities in Nigeria. Are we doing it correctly?

Background: Intermittent auscultation (IA) was the main method of foetal monitoring in Nigeria, with the pinard stethoscope more in use than the hand-held Doppler. Aim of the study to produce a guideline on IA, conduct an audit on its use and to give a recommendation for future practice. Methods: A mixed-method design-observational-descriptive, review and an audit carried out in tertiary centres in Rivers State, Nigeria. The WHO 2018, FIGO 2015 and other guidelines on IA were reviewed. Good practice points were extracted from the literatures and used to produce a guideline. 17 review criteria for the audit were chosen from the guideline and used to test 150 doctors, midwives and nurses. Data were analysed with Epi. info 2020. Results: A guideline on IA was created. Out of the 150 participants, correct answers to the questions were given as follows: foetal movements over the preceding 24 hours before IA, determination of foetal lie, assessment of presentation and position before IA and identification of point of application of foetal stethoscope on maternal abdomen by 121 (80.67%), 17 (11.33%) and 34 (22.67%) respectively; frequency of IA in the antenatal period, duration of IA and maternal pulse palpation during IA for 13-98 (8.67-65.33%), 121 (80%) and 0 (0%) respectively; in labour, questions on timing of IA, ruling out hypoxia in early labour, determination of the baseline FHR and recording of the findings on IA for 61-130 (40.67-86.67%); interval and duration of IA and management of abnormal findings in the antenatal period and in labour, interval and duration of IA at 2-18 (1.33-12%).Conclusions: The performance of IA by obstetric practitioners was poor; that may account for some of the wrong management plan in the antenatal and intra-partum periods. A quarterly or yearly drills on IA were therefore recommended.

Intra-Hepatic Cholestasis of Pregnancy and Its Consequences: A Review

Background: The most common cause of liver illness in pregnancy is intrahepatic cholestasis (IHCP). It has a varying incidence due to geographic variance; factors such as advanced age, multiple pregnancy, family history, and previous pregnancy cholestasis have demonstrated a higher prevalence in these patients. Cholestasis in pregnancy has an aetiology that is currently unknown. It usually occurs after ovarian hyperstimulation syndrome in early pregnancy and coincides with growing oestrogen levels in the second half of pregnancy [1]. The ABCB4 gene mutation is largely associated in a subtype of progressive familial intrahepatic cholestasis, where disease clustering in first-degree relatives increases hereditary predisposition. Itchy palms and soles with elevated liver enzymes and bile acids are the most common symptoms. Some of the reported maternal problems in these patients include preterm labour, HELLP syndrome, acute fatty liver of pregnancy, and postpartum haemorrhage [2]. There are no precise antenatal foetal monitoring tests that can predict foetal fatalities in the womb. To reduce perinatal death with expectant treatment beyond this gestation, it is recommended that a pregnancy be terminated near 36–37 weeks of pregnancy.

Role of Ultrasonography in Screening High Risk Mothers for Detection of IUGR

Introduction: The 10th percentile of expected foetal weight for gestational age is classified as intrauterine growth restriction (IUGR) or foetal growth restriction. IUGR occurs for a variety of reasons. Any issue with the placenta is a major contributor. Aims and objectives: 1) To determine the role of ultrasonography in screening high risk mothers for detection of IUGR. 2) To find out the impact of fetal parameters on the extent of IUGR.3) For correlation between sonographic pattern of IUGR and the birth weight. 4) For correlation between doppler parameters and perinatal outcome. Materials and methods: This is a prospective study done over a period of 2 years in Mamata General Hospital (MGH) from Oct 2017 to Oct 2019. Study included 50 pregnant women with high risk factors and clinically suspected IUGR attending for ultrasound examination were subjected to Uterine, Umbilical and Middle cerebral artery Doppler along with morphology and biometry scan after fulfilling the inclusion and exclusion criteria. Results: Reverse, absence or slow end diastolic flow was considered abnormal which was seen in 33 patients. Nine patients had Absent /Reversed end diastolic flow of which, 3 patients had IUD, 4 had Still births, 2 were admitted in NICU with apgar at 1min <7. Middle cerebral artery was abnormal in 10 patients, of which 8 patients had IUGR babies with adverse perinatal outcome. MCA/UA S.D ratio, which was abnormal in 19 patients of which 16 patients had adverse perinatal outcome. Conclusion: Doppler has proven to be more sensitive than other methods of foetal monitoring in recognising fetal compromises early and assisting in the proper time of delivery. Keywords: Ultrasonography, doppler, IUGR.

First Birth at Home or in Hospital in Aotearoa/New Zealand: Intrapartum Midwifery Care and Related Outcomes

<p>A woman's first birth experience can be a powerfully transformative event in her life, or can be so traumatic it affects her sense of 'self' for years. It can influence her maternity future, her physical and emotional health, and her ability to mother her baby. It matters greatly how her first birth unfolds. Women in Aotearoa/New Zealand enjoy a range of options for provision of maternity care, including, for most, their choice of birth setting. Midwives who practice in a range of settings perceive that birth outcomes for first-time mothers appear to be 'better' at home. An exploration of this perception seems warranted in light of the mainstream view that hospital is the optimal birth setting. The research question was: "Do midwives offer the same intrapartum care at home and in hospital, and if differences exist, how might they be made manifest in the labour and birth events of first-time mothers?" This mixed-methods study compared labour and birth events for two groups of first-time mothers who were cared for by the same midwives in a continuity of care context. One group of mothers planned to give birth at home and the other group planned to give birth in a hospital where anaesthetic and surgical services were available. Labour and birth event data were collected by a survey which was generated following a focus group discussion with a small group of midwives. This discussion centred around whether these midwives believed their practice differed in each setting, and what influenced care provision in each place. Content analysis of the focus group data saw the emergence of four themes relating to differences in practice: midwives' use of space, their use of time, the 'being' and 'doing' of midwifery and aspects relating to safety. Survey data were analysed using SPSS. Despite being cared for by the same midwives, women in the hospital-birth group were more likely to use pharmacological methods of pain management, experienced more interventions (ARM, vaginal examinations, IV hydration, active third stage management and electronic foetal monitoring) and achieved spontaneous vaginal birth less often than the women in the homebirth group. These findings strengthen the evidence that for low risk first-time mothers a choice to give birth at home can result in a greater likelihood of achieving a normal birth. The study offers some insights into how the woman's choice of birth place affects the care provided by midwives, and how differences in care provision can relate to differences in labour and birth event outcomes.</p>

First Birth at Home or in Hospital in Aotearoa/New Zealand: Intrapartum Midwifery Care and Related Outcomes

<p>A woman's first birth experience can be a powerfully transformative event in her life, or can be so traumatic it affects her sense of 'self' for years. It can influence her maternity future, her physical and emotional health, and her ability to mother her baby. It matters greatly how her first birth unfolds. Women in Aotearoa/New Zealand enjoy a range of options for provision of maternity care, including, for most, their choice of birth setting. Midwives who practice in a range of settings perceive that birth outcomes for first-time mothers appear to be 'better' at home. An exploration of this perception seems warranted in light of the mainstream view that hospital is the optimal birth setting. The research question was: "Do midwives offer the same intrapartum care at home and in hospital, and if differences exist, how might they be made manifest in the labour and birth events of first-time mothers?" This mixed-methods study compared labour and birth events for two groups of first-time mothers who were cared for by the same midwives in a continuity of care context. One group of mothers planned to give birth at home and the other group planned to give birth in a hospital where anaesthetic and surgical services were available. Labour and birth event data were collected by a survey which was generated following a focus group discussion with a small group of midwives. This discussion centred around whether these midwives believed their practice differed in each setting, and what influenced care provision in each place. Content analysis of the focus group data saw the emergence of four themes relating to differences in practice: midwives' use of space, their use of time, the 'being' and 'doing' of midwifery and aspects relating to safety. Survey data were analysed using SPSS. Despite being cared for by the same midwives, women in the hospital-birth group were more likely to use pharmacological methods of pain management, experienced more interventions (ARM, vaginal examinations, IV hydration, active third stage management and electronic foetal monitoring) and achieved spontaneous vaginal birth less often than the women in the homebirth group. These findings strengthen the evidence that for low risk first-time mothers a choice to give birth at home can result in a greater likelihood of achieving a normal birth. The study offers some insights into how the woman's choice of birth place affects the care provided by midwives, and how differences in care provision can relate to differences in labour and birth event outcomes.</p>

Unique Severe COVID-19 Placental Signature Independent of Severity of Clinical Maternal Symptoms

Background: Although the risk for transplacental transmission of SARS-CoV-2 is rare, placental infections with adverse functional consequences have been reported. This study aims to analyse histological placental findings in pregnancies complicated by SARS-CoV-2 infection and investigate its correlation with clinical symptoms and perinatal outcomes. We want to determine which pregnancies are at-risk to prevent adverse pregnancy outcomes related to COVID-19 in the future. Methods: A prospective, longitudinal, multicentre, cohort study. All pregnant women presenting between April 2020 and March 2021 with a nasopharyngeal RT-PCR-confirmed SARS-CoV-2 infection were included. Around delivery, maternal, foetal and placental PCR samples were collected. Placental pathology was correlated with clinical maternal characteristics of COVID-19. Results: Thirty-six patients were included, 33 singleton pregnancies (n = 33, 92%) and three twin pregnancies (n = 3, 8%). Twenty-four (62%) placentas showed at least one abnormality. Four placentas (4/39, 10%) showed placental staining positive for the presence of SARS-CoV-2 accompanied by a unique combination of diffuse, severe inflammatory placental changes with massive perivillous fibrin depositions, necrosis of syncytiotrophoblast, diffuse chronic intervillositis, and a specific, unprecedented CD20+ B-cell infiltration. This SARS-CoV-2 placental signature seems to correlate with foetal distress (75% vs. 15.6%, p = 0.007) but not with the severity of maternal COVID-19 disease. Conclusion: We describe a unique placental signature in pregnant patients with COVID-19, which has not been reported in a historical cohort. We show that the foetal environment can be seriously compromised by disruption of placental function due to local, devastating SARS-CoV-2 infection. Maternal clinical symptoms did not predict the severity of the SARS-CoV-2-related placental signature, resulting in a lack of adequate identification of maternal criteria for pregnancies at risk. Close foetal monitoring and pregnancy termination in case of foetal distress can prevent adverse pregnancy outcomes due to COVID-19 related placental disease.

Various modalities of induction of labour and its feto-maternal outcomes: An observational study

: In order for induction to be successful, it should result in labour with adequate uterine contraction and progressive dilatation of cervix with the outcome of a vaginal delivery with minimal risk to both mother and foetus. Primary outcome of the current study was to compare various modalities of Induction of Labour, alone or in combination & to evaluate the different outcomes of mother and baby.: History, general, obstetrical, vaginal examination to record Modified Bishop score, basic investigations and recent obstetric ultrasound was noted of 200 pregnant mothers and the results were analyzed. Foetal monitoring was done in all except those with confirmed IUFD cases. Methods used were Dinoprostone, Misoprostol, Oxytocin, Amniotomy and Mechanical Dilatation with Foley’s catheter; single or in combination with each other.: Among the 200 mothers, 118(59%) delivered vaginally and 82 (41%) mothers underwent LSCS. Dinoprostone gel was the dominant method used followed by misoprostol and oxytocin respectively. NICU admissions were required in 21.7%, 25,8% & 33.3% of the mothers who were induced with Dinoprostone, Misoprostol and Oxytocin respectively. 14 babies were diagnosed with IUFD, all delivered vaginally, out of which 10 were induced with misoprostol and 4 were induced with mechanical dilatation. Majority of the patients who underwent induction with dinoprostone alone delivered by LSCS (63.4%) but Dinoprostone with ARM & oxytocin for induction had a better outcome. Induction with Dinoprostone followed by misoprostol lead to more LSCS than SVD and there were 1%(2 babies) of perinatal mortality due to Meconium Aspiration Syndrome.: Misoprostol and Mechanical induction were the most preferred method in cases of IUFD. Induction with a combination of Dinoprostone with ARM or Oxytocin lead to more vaginal delivery than Dinoprostone alone, so this should be preferred. Induction with Dinoprostone followed by misoprostol lead to more LSCS and perinatal mortality so a combination of them should be given cautiously.

Case Report on Management of Pregnancy in a Patient with Small Muscular Ventricular Septal Defect

Introduction: Maternal morbidity and mortality during pregnancy is significantly associated with hypertensive disorders. Patient history: A 33 years old female was admitted in AVBRH with chief complaint of breathing difficulty with G2P1A1L1 having 30 weeks of gestational age with previous LSCS and conception with small muscular ventricular septal defect, normal function and rhythm for the period of gestation. Obstetric history: Patient had bad obstetric history of 1 induced abortion. Clinical findings: The patient had undergone various investigations like blood tests, USG, Physical examination and antenatal per abdominal examination. Medical Management: Patient was treated with calcium supplement and iron supplement. Nursing management: Administered fluid replacement i.e. DNS and RL, Foetal monitoring, hourly vital sign monitoring. Conclusion: Timely treatment of Ventricular Small Muscular Septal Defect and Management in pregnancy improved the outcome of pregnancy.

The use of continuous foetal monitoring technologies that enable mobility in labour for women with complex pregnancies: A survey of Australian and New Zealand hospitals

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