Publications by authors named "Melanie Basso"

17 Publications

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Guideline No. 416: Labour, Delivery, and Postpartum Care for People with Physical Disabilities.

J Obstet Gynaecol Can 2021 Feb 22. Epub 2021 Feb 22.

Calgary, AB.

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.

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

Intended Audience: Maternal-fetal medicine specialists, obstetricians, family physicians, nurses, midwives, neurologists, physiatrists, and those who care for people with physical disabilities.

Recommendations:
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http://dx.doi.org/10.1016/j.jogc.2021.02.111DOI Listing
February 2021

Directive clinique n 416 : Soins pendant l'accouchement et la période post-partum chez les personnes ayant un handicap physique.

J Obstet Gynaecol Can 2021 Feb 20. Epub 2021 Feb 20.

Calgary, Alb.

Objectif: Décrire les pratiques fondées sur des données probantes en matière de prise en charge des soins pendant l'accouchement et la période post-partum chez les personnes ayant un handicap physique au Canada.

Population Cible: La présente directive clinique aborde les besoins des personnes ayant un handicap physique en mettant l'accent sur les problèmes de santé qui affectent la force et la mobilité, ainsi que sur ceux qui touchent les fonctions ou structures neurologiques ou musculosquelettiques. Bien que certains aspects de cette directive puissent s'appliquer aux personnes ayant une déficience intellectuelle, un trouble neurodéveloppemental ou un handicap sensoriel (p. ex., perte auditive ou visuelle) seulement, les besoins de cette population sortent du cadre de la présente directive. RéSULTATS: Prestation de soins sûrs et empathiques aux personnes parturientes ayant un handicap physique. BéNéFICES, RISQUES ET COûTS: La mise en œuvre de la présente directive permettra aux fournisseurs de soins de santé de mieux connaître les complications particulières que peuvent présenter les personnes ayant un handicap physique pendant l'accouchement et la période post-partum, ce qui augmentera la probabilité d'un accouchement sécuritaire. DONNéES PROBANTES: Une revue de la littérature a été effectuée à l'aide des bases de données MEDLINE (474), Embase(36) et le Cochrane Central Register of Controlled Trials (CENTRAL; 28). Les résultats ont été filtrés pour obtenir des études observationnelles, des revues systématiques, des méta-analyses et des directives publiées en anglais depuis 2013. Les références de ces articles ont également été passées en revue. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la solidité des recommandations en utilisant la méthodologie GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PUBLIC VISé: Spécialistes en médecine fœto-maternelle, obstétriciens, médecins de famille, infirmières, sages-femmes, neurologues, physiatres et autres professionnels qui donnent des soins aux personnes ayant un handicap physique.
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http://dx.doi.org/10.1016/j.jogc.2021.02.112DOI Listing
February 2021

Perinatal Care for Women with Spinal Cord Injuries: A Collaborative Workshop for Consensus on Care in Canada.

Top Spinal Cord Inj Rehabil 2017 ;23(4):386-396

BC Women's Hospital and Health Centre, Vancouver.

In North America, there are currently no clearly defined standards of care for women with spinal cord injury (SCI) during the perinatal periods of preconception, pregnancy, labour/delivery, and postpartum. Women with SCI and their partners say resources specific to their needs are hard to find. Little evidence-informed research exists to guide clinicians in the care of women with SCI during pregnancy. To further explore these gaps in knowledge and practices for perinatal care for women with SCI, a 1-day workshop was held in Vancouver, British Columbia (BC), Canada in November 2013. Twenty-nine attendees included women with SCI, SCI-community service providers, researchers, and health care providers from maternal/fetal medicine, rehabilitation, anesthesiology, and psychiatry. A pre-meeting online survey of stakeholders elucidated 3 themes: lack of knowledge for both consumers and care providers, gaps in access to services and information, and a need for collaboration throughout the perinatal journey. The workshop addressed issues of care providers' lack of knowledge of nonmedical issues during the perinatal period, physical and attitudinal barriers to access to care for women with SCI, and the need for better collaboration and communication between care providers, the latter potentially initiated by providing information to care providers through the women with SCI themselves. Content experts attending the workshop collectively made recommendations for knowledge generation and research priorities, clinical application priorities, and the need for policy and guideline development in this field. Two information sources for women have since been developed and are available online.
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http://dx.doi.org/10.1310/sci16-00036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5667435PMC
August 2018

Limitations and opportunities of whole blood bilirubin measurements by GEM premier 4000®.

BMC Pediatr 2017 03 29;17(1):92. Epub 2017 Mar 29.

Perinatal Health Program, Department of Obstetrics and Gynecology, Children's and Women's Health Centre of British Columbia, University of British Columbia, Vancouver, Canada.

Background: Neonatal hyperbilirubinemia has traditionally been screened by either total serum bilirubin or transcutaneous bilirubin. Whole blood bilirubin (TwB) by the GEM Premier 4000® blood gas analyzer (GEM) is a relatively new technology and it provides fast bilirubin results with a small sample volume and can measure co-oximetry and other analytes. Our clinical study was to evaluate the reliability of TwB measured by the GEM and identify analytical and clinical factors that may contribute to possible bias.

Methods: 440 consecutive healthy newborn samples that had plasma bilirubin ordered for neonatal hyperbilirubinemia screening were included. TwB was first measured using the GEM, after which the remainder of the blood was spun and plasma neonatal bilirubin was measured using the VITROS 5600® (VITROS).

Results: 62 samples (14%) were excluded from analysis due to failure in obtaining GEM results. Passing-Bablok regression suggested that the GEM results were negatively biased at low concentrations of bilirubin and positively biased at higher concentrations relative to the VITROS results (y = 1.43x-61.13). Bland-Altman plots showed an overall negative bias of the GEM bilirubin with a wide range of differences compared to VITROS. Both hemoglobin concentration and hemolysis affected the accuracy of the GEM results. Clinically, male infants had higher mean bilirubin levels, and infants delivered by caesarean section had lower hemoglobin levels. When comparing the number of results below the 40th percentile and above the 95th percentile cut-offs in the Bhutani nomogram which would trigger discharge or treatment, GEM bilirubin exhibited poor sensitivity and poor specificity in contrast to VITROS bilirubin.

Conclusions: An imperfect correlation was observed between whole blood bilirubin measured on the GEM4000® and plasma bilirubin on the VITROS 5600®. The contributors to the observed differences between the two instruments were specimen hemolysis and the accuracy of hemoglobin measurements, the latter of which affects the calculation of plasma-equivalent bilirubin. Additionally, the lack of standardization of total bilirubin calibration particularly in newborn specimens, may also account for some of the disagreement in results.
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http://dx.doi.org/10.1186/s12887-017-0842-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5372304PMC
March 2017

Le diabète pendant la grossesse.

J Obstet Gynaecol Can 2016 07;38(7):680-694.e2

Rothesay (N.-B.).

Objectif: La présente Directive passe en revue les données probantes liées au diagnostic et à la prise en charge obstétricale du diabète durant la grossesse.

Issues: Les issues évaluées étaient les issues maternelles à court et à long terme, dont la prééclampsie, la césarienne, le diabète éventuel et d'autres complications cardiovasculaires et les issues fœtales, dont les anomalies congénitales, la mortinaissance, la macrosomie, le traumatisme de la naissance, l'hypoglycémie et les effets à long terme. RéSULTATS: La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans PubMed et The Cochrane Library au moyen d'un vocabulaire contrôlé (termes MeSH « diabète » et « grossesse ») appropriés. Le cas échéant, les résultats ont été restreints aux analyses systématiques, aux essais comparatifs randomisés / essais cliniques comparatifs et aux études observationnelles. Aucune limite n'a été imposée en matière de date, mais les résultats ont été limités aux articles publiés en anglais ou en français.

Valeurs: La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau 1). DéCLARATIONS SOMMAIRES: RECOMMANDATIONS.
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http://dx.doi.org/10.1016/j.jogc.2016.05.001DOI Listing
July 2016

Diabetes in Pregnancy.

J Obstet Gynaecol Can 2016 07 12;38(7):667-679.e1. Epub 2016 May 12.

Rothesay NB.

Objective: This guideline reviews the evidence relating to the diagnosis and obstetrical management of diabetes in pregnancy.

Outcomes: The outcomes evaluated were short- and long-term maternal outcomes, including preeclampsia, Caesarean section, future diabetes, and other cardiovascular complications, and fetal outcomes, including congenital anomalies, stillbirth, macrosomia, birth trauma, hypoglycemia, and long-term effects.

Evidence: Published literature was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary (MeSH terms "diabetes" and "pregnancy"). Where appropriate, results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials.

Values: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

Summary Statements: Recommendations It is recognized that the use of different diagnostic thresholds for the "preferred" and "alternative" strategies could cause confusion in certain settings. Despite this, the committee has identified the importance of remaining aligned with the current Canadian Diabetes Association 2013 guidelines as being a priority. It is thus recommended that each care centre strategically align with 1 of the 2 strategies and implement protocols to ensure consistent and uniform reporting of test results.
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http://dx.doi.org/10.1016/j.jogc.2016.04.002DOI Listing
July 2016

Acuity Assessment in Obstetrical Triage.

J Obstet Gynaecol Can 2016 Feb 28;38(2):125-33. Epub 2016 Feb 28.

Division of Reproductive Medicine, Department of Obstetrics & Gynecology, University of Ottawa, Ottawa ON.

Objective: A five-category Obstetrical Triage Acuity Scale (OTAS) was developed with a comprehensive set of obstetrical determinants. The purposes of this study were: (1) to compare the inter-rater reliability (IRR) in tertiary and community hospital settings and measure the intra-rater reliability (ITR) of OTAS; (2) to establish the validity of OTAS; and (3) to present the first revision of OTAS from the National Obstetrical Triage Working Group.

Methods: To assess IRR, obstetrical triage nurses were randomly selected from London Health Sciences Centre (LHSC) (n = 8), Stratford General Hospital (n = 11), and Chatham General Hospital (n= 7) to assign acuity levels to clinical scenarios based on actual patient visits. At LHSC, a group of nurses were retested at nine months to measure ITR. To assess validity, OTAS acuity level was correlated with measures of resource utilization.

Results: OTAS has significant and comparable IRR in a tertiary care hospital and in two community hospitals. Repeat assessment in a cohort of nurses demonstrated significant ITR. Acuity level correlated significantly with performance of routine and second order laboratory investigations, point of care ultrasound, nursing work load, and health care provider attendance. A National Obstetrical Triage Working Group was formed and guided the first revision. Four acuity modifiers were added based on hemodynamics, respiratory distress, cervical dilatation, and fetal well-being.

Conclusion: OTAS is the first obstetrical triage scale with established reliability and validity. OTAS enables standardized assessments of acuity within and across institutions. Further, it facilitates assessment of patient care and flow based on acuity.
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http://dx.doi.org/10.1016/j.jogc.2015.12.010DOI Listing
February 2016

Magnesium sulphate for fetal neuroprotection: benefits and challenges of a systematic knowledge translation project in Canada.

BMC Pregnancy Childbirth 2015 Dec 22;15:347. Epub 2015 Dec 22.

Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, Canada.

Background: Administration of magnesium sulphate (MgSO4) to women with imminent preterm birth at <34 weeks is an evidence-based antenatal neuroprotective strategy to prevent cerebral palsy. Although a Society of Obstetricians and Gynaecologists of Canada (SOGC) national guideline with practice recommendations based on relevant clinical evidence exists, ongoing controversies about aspects of this treatment remain. Given this, we anticipated managed knowledge translation (KT) would be needed to facilitate uptake of the guidelines into practice. As part of the Canadian Institutes of Health Research (CIHR)-funded MAG-CP (MAGnesium sulphate to prevent Cerebral Palsy) project, we aimed to compare three KT methods designed to impact both individual health care providers and the organizational systems in which they work.

Methods: The KT methods undertaken were an interactive online e-learning module available to all SOGC members, and at MAG-CP participating sites, on-site educational rounds and focus group discussions, and circulation of an anonymous 'Barriers and Facilitators' survey for the systematic identification of facilitators and barriers for uptake of practice change. We compared these strategies according to: (i) breadth of respondents reached; (ii) rates and richness of identified barriers, facilitators, and knowledge needed; and (iii) cost.

Results: No individual KT method was superior to the others by all criteria, and in combination, they provided richer information than any individual method. The e-learning module reached the most diverse audience of health care providers, the site visits provided opportunity for iterative dialogue, and the survey was the least expensive. Although the site visits provided the most detailed information around individual and organizational barriers, the 'Barriers and Facilitators' survey provided more detail regarding social-level barriers. The facilitators identified varied by KT method. The type of knowledge needed was further defined by the e-learning module and surveys.

Conclusions: Our findings suggest that a multifaceted approach to KT is optimal for translating national obstetric guidelines into clinical practice. As audit and feedback are essential parts of the process by which evidence to practice gaps are closed, MAG-CP is continuing the iterative KT process described in this paper concurrent with tracking of MgSO4 use for fetal neuroprotection and maternal and child outcomes until September 2015; results are anticipated in 2016.
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http://dx.doi.org/10.1186/s12884-015-0785-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4688933PMC
December 2015

Magnesium Sulphate for Eclampsia and Fetal Neuroprotection: A Comparative Analysis of Protocols Across Canadian Tertiary Perinatal Centres.

J Obstet Gynaecol Can 2015 Nov;37(11):975-87

Child and Family Research Institute, University of British Columbia, Vancouver BC; Department of Medicine, University of British Columbia, Vancouver BC; Department of Medicine, British Columbia Women's Hospital and Health Centre, Vancouver BC.

Background: Magnesium sulphate (MgSO4) has been recommended for fetal neuroprotection to prevent cerebral palsy, with national societies adopting new guidelines for its use. A knowledge translation project to implement Canadian guidelines is ongoing. Discussion about MgSO4 for fetal neuroprotection could not occur distinct from MgSO4 for eclampsia prophylaxis and treatment. Thus, in order to explore standardization of MgSO4 use in Canada, we sought to compare local protocols for eclampsia and fetal neuroprotection across tertiary perinatal centres.

Methods: Twenty-five Canadian tertiary perinatal centres were asked to submit their protocols for use of MgSO4 for eclampsia prophylaxis/treatment and fetal neuroprotection. Information abstracted included date of protocol, definitions of indications for treatment, details of MgSO4 administration, maternal and fetal monitoring, antidote for toxicity, and abnormal signs requiring physician attention. Descriptive analyses were used to compare site protocols with known definitions of preeclampsia. Data from the Canadian Perinatal Network (CPN) were used to verify what was done in clinical practice.

Results: Twenty-two of the 25 centres submitted protocols for eclampsia prevention/treatment. Eleven of these provided a definition of preeclampsia that warranted treatment; five of the 22 advised treatment of severe preeclampsia only. Criteria for treatment and monitoring procedures varied across centres. Sixteen of the 22 sites with protocols had data from the CPN. Of 635 women with pre-eclampsia, 422 (66.5%) received MgSO4. Twenty of 25 centres provided protocols for fetal neuroprotection. Definitions of indications were consistent across sites, except for gestational age cut-off.

Conclusion: This study suggests that local protocols are often inconsistent with published evidence. While this may be related to local institutional practices, relevant processes must be put in place to maximize uniformity of practice and improve patient care.
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http://dx.doi.org/10.1016/s1701-2163(16)30047-0DOI Listing
November 2015

Guidelines for the Management of a Pregnant Trauma Patient.

J Obstet Gynaecol Can 2015 Jun;37(6):553-74

Saint John, NB.

Objective: Physical trauma affects 1 in 12 pregnant women and has a major impact on maternal mortality and morbidity and on pregnancy outcome. A multidisciplinary approach is warranted to optimize outcome for both the mother and her fetus. The aim of this document is to provide the obstetric care provider with an evidence-based systematic approach to the pregnant trauma patient.

Outcomes: Significant health and economic outcomes considered in comparing alternative practices.

Evidence: Published literature was retrieved through searches of Medline, CINAHL, and The Cochrane Library from October 2007 to September 2013 using appropriate controlled vocabulary (e.g., pregnancy, Cesarean section, hypotension, domestic violence, shock) and key words (e.g., trauma, perimortem Cesarean, Kleihauer-Betke, supine hypotension, electrical shock). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English between January 1968 and September 2013. Searches were updated on a regular basis and incorporated in the guideline to February 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

Values: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

Benefits, Harms, And Costs: This guideline is expected to facilitate optimal and uniform care for pregnancies complicated by trauma. Summary Statement Specific traumatic injuries At this time, there is insufficient evidence to support the practice of disabling air bags for pregnant women. (III) Recommendations Primary survey 1. Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by a definitive pregnancy test or ultrasound scan. (III-C) 2. A nasogastric tube should be inserted in a semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic gastric content. (III-C) 3. Oxygen supplementation should be given to maintain maternal oxygen saturation > 95% to ensure adequate fetal oxygenation. (II-1B) 4. If needed, a thoracostomy tube should be inserted in an injured pregnant woman 1 or 2 intercostal spaces higher than usual. (III-C) 5. Two large bore (14 to 16 gauge) intravenous lines should be placed in a seriously injured pregnant woman. (III-C) 6. Because of their adverse effect on uteroplacental perfusion, vasopressors in pregnant women should be used only for intractable hypotension that is unresponsive to fluid resuscitation. (II-3B) 7. After mid-pregnancy, the gravid uterus should be moved off the inferior vena cava to increase venous return and cardiac output in the acutely injured pregnant woman. This may be achieved by manual displacement of the uterus or left lateral tilt. Care should be taken to secure the spinal cord when using left lateral tilt. (II-1B) 8. To avoid rhesus D (Rh) alloimmunization in Rh-negative mothers, O-negative blood should be transfused when needed until cross-matched blood becomes available. (I-A) 9. The abdominal portion of military anti-shock trousers should not be inflated on a pregnant woman because this may reduce placental perfusion. (II-3B) Transfer to health care facility 10. Transfer or transport to a maternity facility (triage of a labour and delivery unit) is advocated when injuries are neither life- nor limb-threatening and the fetus is viable (≥ 23 weeks), and to the emergency room when the fetus is under 23 weeks' gestational age or considered to be non-viable. When the injury is major, the patient should be transferred or transported to the trauma unit or emergency room, regardless of gestational age. (III-B) 11. When the severity of injury is undetermined or when the gestational age is uncertain, the patient should be evaluated in the trauma unit or emergency room to rule out major injuries. (III-C) Evaluation of a pregnant trauma patient in the emergency room 12. In cases of major trauma, the assessment, stabilization, and care of the pregnant women is the first priority; then, if the fetus is viable (≥ 23 weeks), fetal heart rate auscultation and fetal monitoring can be initiated and an obstetrical consultation obtained as soon as feasible. (II-3B) 13. In pregnant women with a viable fetus (≥ 23 weeks) and suspected uterine contractions, placental abruption, or traumatic uterine rupture, urgent obstetrical consultation is recommended. (II-3B) 14. In cases of vaginal bleeding at or after 23 weeks, speculum or digital vaginal examination should be deferred until placenta previa is excluded by a prior or current ultrasound scan. (III-C) Adjunctive tests for maternal assessment 15. Radiographic studies indicated for maternal evaluation including abdominal computed tomography should not be deferred or delayed due to concerns regarding fetal exposure to radiation. (II-2B) 16. Use of gadolinium-based contrast agents can be considered when maternal benefit outweighs potential fetal risks. (III-C) 17. In addition to the routine blood tests, a pregnant trauma patient should have a coagulation panel including fibrinogen. (III-C) 18. Focused abdominal sonography for trauma should be considered for detection of intraperitoneal bleeding in pregnant trauma patients. (II-3B) 19. Abdominal computed tomography may be considered as an alternative to diagnostic peritoneal lavage or open lavage when intra-abdominal bleeding is suspected. (III-C) Fetal assessment 20. All pregnant trauma patients with a viable pregnancy (≥ 23 weeks) should undergo electronic fetal monitoring for at least 4 hours. (II-3B) 21. Pregnant trauma patients (≥ 23 weeks) with adverse factors including uterine tenderness, significant abdominal pain, vaginal bleeding, sustained contractions (> 1/10 min), rupture of the membranes, atypical or abnormal fetal heart rate pattern, high risk mechanism of injury, or serum fibrinogen < 200 mg/dL should be admitted for observation for 24 hours. (III-B) 22. Anti-D immunoglobulin should be given to all rhesus D-negative pregnant trauma patients. (III-B) 23. In Rh-negative pregnant trauma patients, quantification of maternal-fetal hemorrhage by tests such as Kleihauer-Betke should be done to determine the need for additional doses of anti-D immunoglobulin. (III-B) 24. An urgent obstetrical ultrasound scan should be undertaken when the gestational age is undetermined and need for delivery is anticipated. (III-C) 25. All pregnant trauma patients with a viable pregnancy who are admitted for fetal monitoring for greater than 4 hours should have an obstetrical ultrasound prior to discharge from hospital. (III-C) 26. Fetal well-being should be carefully documented in cases involving violence, especially for legal purposes. (III-C) Obstetrical complications of trauma 27. Management of suspected placental abruption should not be delayed pending confirmation by ultrasonography as ultrasound is not a sensitive tool for its diagnosis. (II-3D) Specific traumatic injuries 28. Tetanus vaccination is safe in pregnancy and should be given when indicated. (II-3B) 29. Every woman who sustains trauma should be questioned specifically about domestic or intimate partner violence. (II-3B) 30. During prenatal visits, the caregiver should emphasize the importance of wearing seatbelts properly at all times. (II-2B) Perimortem Caesarean section 31. A Caesarean section should be performed for viable pregnancies (≥ 23 weeks) no later than 4 minutes (when possible) following maternal cardiac arrest to aid with maternal resuscitation and fetal salvage. (III-B).
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http://dx.doi.org/10.1016/s1701-2163(15)30232-2DOI Listing
June 2015

Rationalizing definitions and procedures for optimizing clinical care and public health in fetal death and stillbirth.

Obstet Gynecol 2015 Apr;125(4):784-788

Perinatal Services BC, Provincial Health Services Authority, the Department of Obstetrics and Gynaecology, University of British Columbia, the School of Population and Public Health, University of British Columbia, and Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada.

Despite the recent focus on stillbirth, there remains a profound need to address problems associated with the definitions and procedures related to fetal death and stillbirth. The current definition of fetal death, first proposed in 1950, needs to be updated to distinguish between the timing of fetal death (which has etiologic and prognostic significance) and the timing of stillbirth (ie, the delivery of the dead fetus). Stillbirth registration procedures, modeled after live birth registration and not death registration, also need to be modernized because they can be an unnecessary burden on some grieving families. The problems associated with fetal death definitions and stillbirth-associated procedures are highlighted by selective fetal reduction in multifetal pregnancy; in many countries, the fetus reduced at 10-13 weeks of gestation and delivered at term gestation requires stillbirth registration and a burial permit even if fetal remains cannot be identified. An international consensus is needed to standardize the definition of reportable fetal deaths; ideally this should be based on the timing of fetal death and should address the status of pregnancy terminations. In this article, we list propositions for initiating an international dialogue that will rationalize fetal death definitions, registration criteria, and associated procedures, and thereby improve clinical care and public health.
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http://dx.doi.org/10.1097/AOG.0000000000000717DOI Listing
April 2015

Magnesium sulphate for fetal neuroprotection: a cost-effectiveness analysis.

BMC Health Serv Res 2013 Dec 19;13:527. Epub 2013 Dec 19.

School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada.

Background: The aim of this study was to assess the cost-effectiveness of administering magnesium sulphate to patients in whom preterm birth at < 32+0 weeks gestation is either imminent or threatened for the purpose of fetal neuroprotection.

Methods: Multiple decision tree models and probabilistic sensitivity analyses were used to compare the administration of magnesium sulphate with the alternative of no treatment. Two separate cost perspectives were utilized in this series of analyses: a health system and a societal perspective. In addition, two separate measures of effectiveness were utilized: cases of cerebral palsy (CP) averted and quality-adjusted life years (QALYs).

Results: From a health system and a societal perspective, respectively, a savings of $2,242 and $112,602 is obtained for each QALY gained and a savings of $30,942 and $1,554,198 is obtained for each case of CP averted when magnesium sulphate is administered to patients in whom preterm birth is imminent. From a health system perspective and a societal perspective, respectively, a cost of $2,083 is incurred and a savings of $108,277 is obtained for each QALY gained and a cost of $28,755 is incurred and a savings of $1,494,500 is obtained for each case of CP averted when magnesium sulphate is administered to patients in whom preterm birth is threatened.

Conclusions: Administration of magnesium sulphate to patients in whom preterm birth is imminent is a dominant (i.e. cost-effective) strategy, no matter what cost perspective or measure of effectiveness is used. Administration of magnesium sulphate to patients in whom preterm birth is threatened is a dominant strategy from a societal perspective and is very likely to be cost-effective from a health system perspective.
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http://dx.doi.org/10.1186/1472-6963-13-527DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3878233PMC
December 2013

Determinants of increases in stillbirth rates from 2000 to 2010.

CMAJ 2013 May 8;185(8):E345-51. Epub 2013 Apr 8.

Perinatal Services BC, Vancouver, BC.

Background: After decades of decline, stillbirth rates have increased in several industrialized countries in recent years. We examined data from the province of British Columbia, Canada, in an attempt to explain this unexpected phenomenon.

Methods: We carried out a retrospective population-based cohort study of all births in British Columbia from 2000 to 2010. Outcomes of interest included overall stillbirth rates, birth weight-and gestational age-specific stillbirth rates, rates of spontaneous stillbirths (excluding pregnancy terminations that satisfied the definition of stillbirth [fetal death with a birth weight ≥ 500 g or gestational age at delivery ≥ 20 wk], hereafter referred to as "pregnancy terminations") and rates of congenital anomalies among live-born infants. We used logistic regression to adjust for changes in maternal age, parity, weight before pregnancy and multiple births.

Results: Overall, stillbirth rates increased by 31% (95% confidence interval [CI] 13% to 50%), from 8.08 per 1000 total births in 2000 to 10.55 per 1000 in 2010. The rate of stillbirths with a birth weight of less than 500 g increased significantly (p(trend) = 0.03), whereas the rate of stillbirths with a birth weight of 1000 g or more decreased significantly (p(trend) = 0.009). The rate of spontaneous stillbirths decreased nonsignificantly by 16%, from 5.7 per 1000 total births in 2000 to 4.8 per 1000 in 2010. There was a significant decline of 30% (95% CI 6% to 47%) in the rate of spontaneous stillbirth with a birth weight of 1000 g or more between 2000 and 2010; adjustment for maternal factors did not appreciably change this temporal effect. The prevalence of congenital anomalies among live-born infants decreased significantly, from 5.21 per 100 live births during the first 3 years (2000-02) to 4.77 per 100 during the final 3 years (2008-10).

Interpretation: Increases in pregnancy terminations were responsible for the increases observed in stillbirth rates and were associated with declines in the prevalence of congenital anomalies among live-born infants.
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http://dx.doi.org/10.1503/cmaj.121372DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3652963PMC
May 2013

On "Quality patient care in labor and delivery: a call to action".

J Obstet Gynecol Neonatal Nurs 2012 Jul-Aug;41(4):461. Epub 2012 Jun 12.

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http://dx.doi.org/10.1111/j.1552-6909.2012.01377.xDOI Listing
June 2013

SOGC Clinical Practice Guidelines: Obesity in pregnancy. No. 239, February 2010.

Int J Gynaecol Obstet 2010 Aug;110(2):167-73

Objective: To review the evidence and provide recommendations for the counselling and management of obese parturients.

Outcomes: OUTCOMES evaluated include the impact of maternal obesity on the provision of antenatal and intrapartum care, maternal morbidity and mortality, and perinatal morbidity and mortality.

Evidence: Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetrical anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to April 2009. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

Values: The evidence obtained was reviewed and evaluated by the Maternal Fetal Medicine and Clinical Practice Obstetric Committees of the SOGC under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care.

Benefits, Harms, And Costs: Implementation of the recommendations in this guideline should increase recognition of the issues clinicians need to be aware of when managing obese women in pregnancy, improve communication and consultation amongst the obstetrical care team, and encourage federal and provincial agencies to educate Canadians about the values of entering pregnancy with as healthy a weight as possible.
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http://dx.doi.org/10.1016/j.ijgo.2010.03.008DOI Listing
August 2010

SOGC CLINICAL PRACTICE GUIDELINE: guidelines for the management of vasa previa.

Int J Gynaecol Obstet 2010 Jan;108(1):85-9

Objectives: To describe the etiology of vasa previa and the risk factors and associated condition, to identify the various clinical presentations of vasa previa, to describe the ultrasound tools used in its diagnosis, and to describe the management of vasa previa.

Outcomes: Reduction of perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short-term and long-term maternal morbidity and mortality.

Evidence: Published literature on randomized trials prospective cohort studies, and selected retrospective cohort studies was retrieved through searches of PubMed or Medline, CINAHL, and the Cochrane Library, using appropriate controlled vocabulary (e.g., selected epidemiological studies comparing delivery by Caesarean section with vaginal delivery studies comparing outcomes when vasa previa is diagnosed antenatally vs.intrapartum) and key words (e.g. vasa previa). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated into the guideline to October 1, 2008. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies,clinical practice guideline collections, clinical trial registries, and from national and international medical specialty societies.

Values: The evidence collected was reviewed by the Diagnostic Imaging Committee and the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on Preventive Health Care.

Benefits, Harms, And Costs: The benefit expected from this guideline is facilitation of optimal and uniform care for pregnancies complicated by vasa previa.

Sponsors: The Society of Obstetricians and Gynaecologists of Canada.
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http://dx.doi.org/10.1016/j.ijgo.2009.09.011DOI Listing
January 2010

SOGC clinical practice guideline: Vaginal delivery of breech presentation: no. 226, June 2009.

Int J Gynaecol Obstet 2009 Nov;107(2):169-76

Objectives: To review the physiology of breech birth; to discern the risks and benefits of a trial of labour versus planned Caesarean section; and to recommend to obstetricians, family physicians, midwives, obstetrical nurses, anaesthesiologists, pediatricians, and other health care providers selection criteria, intrapartum management parameters, and delivery techniques for a trial of vaginal breech birth.

Options: Trial of labour in an appropriate setting or delivery by pre-emptive Caesarean section for women with a singleton breech fetus at term.

Outcomes: Reduced perinatal mortality, short-term neonatal morbidity, longterm infant morbidity, and short- and long-term maternal morbidity and mortality.

Evidence: Medline was searched for randomized trials, prospective cohort studies, and selected retrospective cohort studies comparing planned Caesarean section with a planned trial of labour; selected epidemiological studies comparing delivery by Caesarean section with vaginal breech delivery; and studies comparing long-term outcomes in breech infants born vaginally or by Caesarean section. Additional articles were identified through bibliography tracing up to June 1, 2008.

Values: The evidence collected was reviewed by the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the criteria and classifications of the Canadian Task Force on Preventive Health Care.

Validation: This guideline was compared with the 2006 American College of Obstetrician's Committee Opinion on the mode of term singleton breech delivery and with the 2006 Royal College of Obstetrician and Gynaecologists Green Top Guideline: The Management of Breech Presentation. The document was reviewed by Canadian and International clinicians with particular expertise in breech vaginal delivery.
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http://dx.doi.org/10.1016/j.ijgo.2009.07.002DOI Listing
November 2009