Showing papers by "Peter Brocklehurst published in 2017"
TL;DR: Use of computerised interpretation of cardiotocographs in women who have continuous electronic fetal monitoring in labour does not improve clinical outcomes for mothers or babies.
128 citations
16 Jan 2017
TL;DR: In this paper, the authors discuss the effects of gender stereotypes on women's sexual behavior and propose a method to reduce gender stereotypes in the context of women's body image and sexual health.
Abstract: 1. 妊産褥婦のメンタルヘルス不調が考えられたときは、まず、緊 急の対応を要するか否かを見極める。 (I) 2. 緊急性がある場合は、自治体・圏域の精神科救急情報センター に連絡する。あるいは、圏域保健所の精神保健福祉担当部署・ 者や市町村自治体の精神保健福祉、母子保健担当部署・者に連 絡する。 (I) 3. 緊急性はないが、精神科専門治療の必要がある場合、精神科受 診を勧奨する。その際、圏域保健所の精神保健福祉担当部署・ 者と連携をはかる。 (I) 4. 育児・家庭環境の問題があり、母子保健関係者が介入した方が 良い場合、まず医療機関スタッフが相談にのった上で居住地自 治体の母子保健担当部署の保健師等に連絡し、DV があればそ れらに加え女性相談センターへの相談を勧める。 (I) 5. 出生した乳児の安全性確保の必要性がある場合、児童相談所・ 子ども家庭支援センター、または保健師に連絡する。 (I) 日本周産期メンタルヘルス学会 周産期メンタルヘルス コンセンサスガイド 2017 初版 2017.03.31
105 citations
TL;DR: Overall iodide supplementation provided no benefit to neurodevelopment measured at 2 years of age, and there was evidence of weak interaction between iodide supplements and hypothyroxinemic status in the language composite score and 1 subtest score.
Abstract: BACKGROUND: The recommendation for enteral iodide intake for preterm infants is 30 to 40 μg/kg per day and 1 μg/kg per day for parenteral intake. Preterm infants are vulnerable to iodide insufficiency and thyroid dysfunction. The hypothesis tested whether, compared with placebo, iodide supplementation of preterm infants improves neurodevelopment. METHODS: A randomized controlled trial of iodide supplementation versus placebo in infants RESULTS: One thousand two hundred seventy-three infants (637 intervention, 636 placebo) were recruited from 21 UK neonatal units. One hundred thirty-one infants died, and neurodevelopmental assessments were undertaken in 498 iodide and 499 placebo-supplemented infants. There were no significant differences between the intervention and placebo groups in the primary outcome: mean difference cognitive score, −0.34, 95% confidence interval (CI) −2.57 to 1.89; motor composite score, 0.21, 95% CI −2.23 to 2.65; and language composite score, −0.05, 95% CI −2.48 to 2.39. There was evidence of weak interaction between iodide supplementation and hypothyroxinemic status in the language composite score and 1 subtest score. CONCLUSIONS: Overall iodide supplementation provided no benefit to neurodevelopment measured at 2 years of age.
52 citations
TL;DR: Comparisons confirm advantages of giving birth in midwife-led settings for low risk women and strategies to decrease rates of medical intervention in obstetric units in England and to reduce rates of avoidable transfer, episiotomy and augmentation of labour in the Netherlands.
Abstract: Objectives: To compare mode of birth and medical interventions between broadly equivalent birth settings in England and the Netherlands. Methods: Data were combined from the Birthplace study in England (from April 2008 to April 2010) and the National Perinatal Register in the Netherlands (2009). Low risk women in England planning birth at home (16,470) or in freestanding midwifery units (11,133) were compared with Dutch women with planned home births (40,468). Low risk English women with births planned in alongside midwifery units (16,418) or obstetric units (19,096) were compared with Dutch women with planned midwife-led hospital births (37,887). Results: CS rates varied across planned births settings from 6.5% to 15.5% among nulliparous and 0.6% to 5.1% among multiparous women. CS rates were higher among low risk nulliparous and multiparous English women planning obstetric unit births compared to Dutch women planning midwife-led hospital births (adjusted (adj) OR 1.89 (95% CI 1.64 to 2.18) and 3.66 (2.90 to 4.63) respectively). Instrumental vaginal birth rates varied from 10.7% to 22.5% for nulliparous and from 0.9% to 5.7% for multiparous women. Rates were lower in the English comparison groups apart from planned births in obstetric units. Transfer, augmentation and episiotomy rates were much lower in England compared to the Netherlands for all midwife-led groups. In most comparisons, epidural rates were higher among English groups. Conclusions: When considering maternal outcomes, findings confirm advantages of giving birth in midwife-led settings for low risk women. Further research is needed into strategies to decrease rates of medical intervention in obstetric units in England and to reduce rates of avoidable transfer, episiotomy and augmentation of labour in the Netherlands.
51 citations
TL;DR: Evidence shows that lying down in the second stage of labour results in more spontaneous vaginal births in nulliparous women with epidural analgesia, with no apparent disadvantages in relation to short or longer term outcomes for mother or baby.
Abstract: INTERVENTIONS
Women were allocated to an upright or lying down position, using a secure web based randomisation service, stratified by centre, with no masking of participants or clinicians to the trial interventions.
MAIN OUTCOME MEASURES
The primary outcome was spontaneous vaginal birth. Women were analysed in the groups into which they were randomly allocated, regardless of position recorded at any time during the second stage of labour (excluding women with no valid consent, who withdrew, or who did not reach second stage before delivery). Secondary outcomes included mode of birth, perineal trauma, infant Apgar, delivery (adjusted risk ratio 1.08, 99% confidence interval 0.99 to 1.18), obstetric anal sphincter injury (1.27, 0.88 to 1.84), infant Apgar score <4 at five minutes (0.66, 0.06 to 6.88), and maternal faecal incontinence at one year (1.18, 0.61 to 2.28).
CONCLUSIONS
Evidence shows that lying down in the second stage of labour results in more spontaneous vaginal births in nulliparous women with epidural analgesia, with no apparent disadvantages in relation to short or longer term outcomes for mother or baby.
37 citations
TL;DR: The authors conclude that the opportunities for improving neonatal outcomes likely lie in guidance of how to clinically respond to fetal heart rate tracings as opposed to the interpretation of the fetal heart rates themselves.
Abstract: Summary Background Continuous electronic fetal heart-rate monitoring is widely used during labour, and computerised interpretation could increase its usefulness. We aimed to establish whether the addition of decision-support software to assist in the interpretation of cardiotocographs affected the number of poor neonatal outcomes. Methods In this unmasked randomised controlled trial, we recruited women in labour aged 16 years or older having continuous electronic fetal monitoring, with a singleton or twin pregnancy, and at 35 weeks' gestation or more at 24 maternity units in the UK and Ireland. They were randomly assigned (1:1) to decision support with the INFANT system or no decision support via a computer-generated stratified block randomisation schedule. The primary outcomes were poor neonatal outcome (intrapartum stillbirth or early neonatal death excluding lethal congenital anomalies, or neonatal encephalopathy, admission to the neonatal unit within 24 h for ≥48 h with evidence of feeding difficulties, respiratory illness, or encephalopathy with evidence of compromise at birth), and developmental assessment at age 2 years in a subset of surviving children. Analyses were done by intention to treat. This trial is completed and is registered with the ISRCTN Registry, number 98680152. Findings Between Jan 6, 2010, and Aug 31, 2013, 47 062 women were randomly assigned (23 515 in the decision-support group and 23 547 in the no-decision-support group) and 46 042 were analysed (22 987 in the decision-support group and 23 055 in the no-decision-support group). We noted no difference in the incidence of poor neonatal outcome between the groups—172 (0·7%) babies in the decision-support group compared with 171 (0·7%) babies in the no-decision-support group (adjusted risk ratio 1·01, 95% CI 0·82–1·25). At 2 years, no significant differences were noted in terms of developmental assessment. Interpretation Use of computerised interpretation of cardiotocographs in women who have continuous electronic fetal monitoring in labour does not improve clinical outcomes for mothers or babies. Funding National Institute for Health Research.
27 citations
TL;DR: The findings support the recommendation that ‘low risk’ women can be informed that planned birth in an FMU is associated with a lower rate of instrumental delivery and a higher rate of ‘straightforward vaginal birth’ compared with plannedBirth in an AMU; and that outcomes for babies do not appear to differ between FMUs and AMUs.
Abstract: For low risk women, there is good evidence that planned birth in a midwifery unit is associated with a reduced risk of maternal interventions compared with planned birth in an obstetric unit. Findings from the Birthplace cohort study have been interpreted by some as suggesting a reduced risk of interventions in planned births in freestanding midwifery units (FMUs) compared with planned births in alongside midwifery units (AMUs). However, possible differences have not been robustly investigated using individual-level Birthplace data. This was a secondary analysis of data on ‘low risk’ women with singleton, term, ‘booked’ pregnancies collected in the Birthplace national prospective cohort study. We used logistic regression to compare interventions and outcomes by parity in 11,265 planned FMU births and 16,673 planned AMU births, adjusted for potential confounders, using planned AMU birth as the reference group. Outcomes considered included adverse perinatal outcomes (Birthplace primary outcome measure), instrumental delivery, intrapartum caesarean section, ‘straightforward vaginal birth’, third or fourth degree perineal trauma, blood transfusion and maternal admission for higher-level care. We used a significance level of 1% for all secondary outcomes. There was no significant difference in adverse perinatal outcomes between planned AMU and FMU births. The odds of instrumental delivery were reduced in planned FMU births (nulliparous: aOR 0.63, 99% CI 0.46–0.86; multiparous: aOR 0.41, 99% CI 0.25–0.68) and the odds of having a ‘straightforward vaginal birth’ were increased in planned FMU births compared with planned AMU births (nulliparous: aOR 1.47, 99% CI 1.17–1.85; multiparous: 1.86, 99% CI 1.35–2.57). The odds of intrapartum caesarean section did not differ significantly between the two settings (nulliparous: p = 0.147; multiparous: p = 0.224). The overall pattern of findings suggested a trend towards lower intervention rates and fewer adverse maternal outcomes in planned FMU births compared with planned AMU births. The findings support the recommendation that ‘low risk’ women can be informed that planned birth in an FMU is associated with a lower rate of instrumental delivery and a higher rate of ‘straightforward vaginal birth’ compared with planned birth in an AMU; and that outcomes for babies do not appear to differ between FMUs and AMUs.
17 citations
TL;DR: Despite evidence that antibiotics are associated with increased functional impairment at 7 years, educational test scores and special needs at 11’years of age show no differences between trial groups.
Abstract: Background Antibiotics used for women in spontaneous preterm labour without overt infection, in contrast to those with preterm rupture of membranes, are associated with altered functional outcomes in their children. Methods From the National Pupil Database, we used Key Stage 2 scores, national test scores in school year 6 at 11 years of age, to explore the hypothesis that erythromycin and co-amoxiclav were associated with poorer educational outcomes within the ORACLE Children Study. Results Anonymised scores for 97% of surviving children born to mothers recruited to ORACLE and resident in England were analysed against treatment group adjusting for key available socio-demographic potential confounders. No association with crude or with adjusted scores for English, mathematics or science was observed by maternal antibiotic group in either women with preterm rupture of membranes or spontaneous preterm labour with intact membranes. While the proportion receiving special educational needs was similar in each group (range 31.6–34.4%), it was higher than the national rate of 19%. Conclusions Despite evidence that antibiotics are associated with increased functional impairment at 7 years, educational test scores and special needs at 11 years of age show no differences between trial groups. Trial registration number ISCRT Number 52995660 (original ORACLE trial number).
16 citations
[...]
TL;DR: This paper aims to demonstrate the efforts towards in-situ applicability of EJ/LL/MQ screening for Down's syndrome in the context of maternal and infant health care.
14 citations
TL;DR: There is clear evidence of the benefit of adopting a lying-down position in second-stage labour in nulliparous women with epidural analgesia, with no apparent disadvantages in either short- or long-term outcomes for mother or baby, and this is cost neutral for the NHS.
Abstract: Background Epidural analgesia leads to increased risk of instrumental vaginal delivery (IVD). There is debate about whether or not posture in second-stage labour influences the incidence of spontaneous vaginal birth (SVB). Objectives In nulliparous women with epidural analgesia, does a policy of adopting an ‘upright position’ throughout second-stage labour increase the incidence of SVB compared with a policy of adopting a ‘lying-down’ position? Design Two-arm randomised controlled trial. Setting Maternity units in England and Wales. Participants Nulliparous women aged ≥ 16 years, at ≥ 37 weeks’ gestation with singleton cephalic presentation and intended SVB, in second-stage labour with an epidural providing effective pain relief. Interventions (1) Upright position to maintain the pelvis in as vertical a plane as possible; and (2) lying-down position to maintain the pelvis in as horizontal a plane as possible. Main outcome measures The primary outcome measure was incidence of SVB. Secondary outcomes included augmentation, interventions to maintain blood pressure, duration of labour, episiotomy, genital tract trauma, post-partum haemorrhage, maternal satisfaction, neonatal metabolic acidosis, 5-minute Apgar score of < 4, resuscitation at birth and admission to neonatal unit. At 1 year for (1) women: urinary or faecal incontinence, dyspareunia and health-related quality of life; (2) for infants: major morbidity. A cost–consequences analysis with a time horizon of 1 year after the birth from a NHS perspective. Results Between October 2010 and January 2014, 3236 women were randomised from 41 centres in England and Wales. There was a statistically significant difference in the incidence of SVB between groups, with 35.2% of women achieving a SVB in the upright group, compared with 41.1% in the lying-down group (adjusted risk ratio 0.86, 95% confidence interval 0.78 to 0.94). There was no evidence of differences in most of the secondary maternal or neonatal outcomes, or in long-term outcomes at the 12-month follow-up. No significant overall cost differences were observed between upright and lying-down positions for mothers or their babies. Limitations Measurement of adherence was challenging in this unmasked trial, and adherence could be influenced by midwives’ beliefs about the allocated positions. If adherence was poor, this would have diluted the difference between the two groups. Conclusions There is clear evidence of the benefit of adopting a lying-down position in second-stage labour in nulliparous women with epidural analgesia, with no apparent disadvantages in either short- or long-term outcomes for mother or baby, and this is cost neutral for the NHS. Future work Questions remain about whether or not other positions could increase the incidence of SVB further in this group of women. The results also raise questions about the role of maternal position in second-stage labour in women without an epidural. Trial registration Current Controlled Trials ISRCTN35706297. Funding This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in Health Technology Assessment, Vol 21, No. 65. See the NIHR Journals Library website for further project information.
14 citations
TL;DR: Routine monitoring of all women would prevent much neonatal morbidity, but Peter Brocklehurst believes that it will increase the risk of harm from unnecessary caesarean sections.
Abstract: Routine monitoring of all women would prevent much neonatal morbidity, argue Edward Mullins and Christoph Lees, but Peter Brocklehurst believes that it will increase the risk of harm from unnecessary caesarean sections
TL;DR: The aim of this project was to describe the methods used for conducting local reviews of care of women with severe maternal morbidity, and to compare lessons identified for future care through external and local reviews.
Abstract: © Published by the BMJ Publishing Group Limited. Background Detailed local case review is commonly used as a strategy to improve care. However, recent reports have highlighted concerns over quality of local reviews in maternity care. The aim of this project was to describe the methods used for conducting local reviews of care of women with severe maternal morbidity, and to compare lessons identified for future care through external and local reviews. Methods Thirty-three anonymised clinical records from women with severe maternal morbidities were obtained, together with the report of the local review of their care. The methodology used for the local reviews was described, including specific tools used, team members involved, their disciplines, report format and whether an action plan with recommendations for audit was produced. Multidisciplinary external reviewers considered the records using a standard confidential enquiry approach. A thematic analysis of lessons learned from the two approaches was undertaken. Results A formal report of the local review was produced for 11/33 cases; 4 of these used root cause analysis. A further 12 local reviews consisted of a group discussion with output noted in a spreadsheet; 5 consisted of a timeline with good practice points and 5 had no formal review. Patients were involved in five local reviews; only one was multidisciplinary. Action plans were recorded in 14 local reviews; 3 of these included a recommendation to audit the proposed changes. External reviews identified additional messages for care and highlighted aspects of good care in every case, whereas only 55% (n=18) of local reviews identified good care (p<0.0005). Conclusions The quality of local reviews can clearly be improved. Very few of the reviews involved patients. Local reviews should be multidisciplinary, generate an action plan, and the implementation of recommendations should be audited. Improvements in local reviews may be achieved by standardised training or development of national protocols.
TL;DR: It is possible to collect a range of biological samples from women around the time of delivery, and this was acceptable for most women, and these data inform study design and protocol development for large-scale birth cohorts.
Abstract: Few data are available to guide biological sample collection around the time of birth for large-scale birth cohorts. We are designing a large UK birth cohort to investigate the role of infection and the developing immune system in determining future health and disease. We undertook a pilot to develop methodology for the main study, gain practical experience of collecting samples, and understand the acceptability of sample collection to women in late pregnancy. Between February–July 2014, we piloted the feasibility and acceptability of collecting maternal stool, baby stool and cord blood samples from participants recruited at prolonged pregnancy and planned pre-labour caesarean section clinics at University College London Hospital. Participating women were asked to complete acceptability questionnaires. Overall, 265 women were approached and 171 (65%) participated, with ≥1 sample collected from 113 women or their baby (66%). Women had a mean age of 34 years, were primarily of white ethnicity (130/166, 78%), and half were nulliparous (86/169, 51%). Women undergoing planned pre-labour caesarean section were more likely than those who delivered vaginally to provide ≥1 sample (98% vs 54%), but less likely to provide maternal stool (10% vs 43%). Pre-sample questionnaires were completed by 110/171 women (64%). Most women reported feeling comfortable with samples being collected from their baby (<10% uncomfortable), but were less comfortable about their own stool (19% uncomfortable) or a vaginal swab (24% uncomfortable). It is possible to collect a range of biological samples from women around the time of delivery, and this was acceptable for most women. These data inform study design and protocol development for large-scale birth cohorts.
Journal Article•
TL;DR: 1. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009, JAMA 2012;307:1934–1940
Abstract: 1. Patrick SW, Schumacher RE, Benneyworth BD, et al. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009. JAMA. 2012;307:1934–1940. 2. Almario CV, Seligman NS, Dysart KC, et al. Risk factors for preterm birth among opiate-addicted gravid women in a methadone treatment program. Am J Obstet Gynecol. 2009;201:326. e321–326.e326. 3. Cleary BJ, Donnelly JM, Strawbridge JD, et al. Methadone and perinatal outcomes: a retrospective cohort study. Am J Obstet Gynecol. 2011;204:139. e131–139.e139. 4. Hulse GK, Milne E, English DR, et al. The relationship between maternal use of heroin and methadone and infant birth weight. Addiction. 1997;92:1571–1579. 5. Keegan J, Parva M, Finnegan M, et al. Addiction in pregnancy. J Addictive Diseases. 2010;29:175–191. 6. ACOG Committee Opinion No. 524. Opioid abuse, dependence, and addiction in pregnancy. Obstet Gynecol. 2012;119:1070–1076. 7. Benningfield MM, Arria AM, Kaltenbach K, et al. Cooccurring psychiatric symptoms are associated with increased psychological, social, and medical impairment in opioid dependent pregnant women. Am J Addict. 2010;19:416–421. 8. Meyer M, Wagner K, Benvenuto A, et al. Intrapartum and postpartum analgesia for women maintained on methadone during pregnancy. Obstet Gynecol. 2007;110(pt 1):261–266. 9. Meyer M, Paranya G, Keefer Norris A, et al. Intrapartum and postpartum analgesia for women maintained on buprenorphine during pregnancy. Eur J Pain. 2010;14:939–943. 10. Finnegan LP, Connaughton JF Jr., Kron RE, et al. Neonatal abstinence syndrome: assessment and management. Addict Dis. 1975;2:141–158.
17 Aug 2017
TL;DR: This research presents a novel and scalable approach called “informed consent” that allows for rapid and efficient evaluation of the pros and cons of various treatment options for mothers-to-be and their unborn children.
Abstract: 1 Clinical and Population Perinatal Health Research, Kolling Institute, Northern Sydney Local Heath District, Sydney, New South Wales 2065, Australia 2 Sydney Medical School Northern, University of Sydney, Sydney, New South Wales, Australia 3 Institute of Applied Health Research, University of Birmingham, UK 4 Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, UK