Philipp Reif

Background: The aim of this study was to investigate whether time of birth, unit volume, and staff seniority impact the incidence of maternal complications in deliveries ≥34 + 0 gestational weeks.Methods: We conducted a population‐based cross‐sectional study of 87 065 deliveries occurring between 2004 and 2015 in ten public hospitals in Styria, Austria. A composite adverse maternal outcome measure of uterine atony, postpartum hysterectomy, postpartum bleeding, impaired wound healing, postpartum infections requiring antibiotic treatment, sepsis, or maternal death was used to compare outcomes by time of birth, unit volume, and staff seniority. Based on delivery data, generalized estimating equations (GEEs) were used to calculate the risk of maternal adverse outcomes.Results: Maternal adverse events occurred in 1.33% of deliveries. Incidence of maternal adverse events was highest for units with >1000 deliveries (adjusted OR 1.40; CI 95%: 1.16–1.69) and higher for perinatal centers (adjusted OR 1.35; CI 95%: 1.15–1.57) compared with reference units (500–1000 deliveries/year). Delivery during the daytime compared with the afternoon and nighttime did not affect the incidence of maternal complications (P = 0.765 and P = 0.136, respectively). Compared with resident‐guided deliveries, the odds ratio for an adverse event was the same when a consultant attended the delivery (adjusted OR 1.13; CI 95%: 0.98–1.30) but lower in deliveries managed by midwives only (adjusted OR 0.21; CI 95%: 0.07–0.64).Conclusion: Procedures performed during the night shift were not associated with increased complication rates. Delivery volume and high‐volume centers were associated with the highest risk of maternal complications, and units with 500–1000 deliveries per year were the lowest. With increasing odds of pregnancy risks, these results change, and delivering in a high‐volume center becomes at least as safe as delivering in a smaller unit.

Objective: We investigated whether time of birth, unit volume, and staff seniority affect neonatal outcome in neonates born at ≥34⁺⁰ weeks of gestation.Design: Population‐based prospective cohort study.Setting: Ten public hospitals in the Austrian province of Styria.Sample: A total of 87 065 neonates delivered in the period 2004–2015.Methods: Based on short‐term outcome data, generalised linear mixed models were used to calculate the risk for adverse and severely adverse neonatal outcomes according to time of birth, unit volume, and staff seniority.Main outcome measures: Neonatal composite adverse and severely adverse outcome measures.Results: The odds ratio for severely adverse events during the night‐time (22:01–07:29 hours) compared with the daytime (07:30–15:00 hours) was 1.35 (95% confidence interval, 95% CI 1.13–1.61). There were no significant differences in neonatal outcome comparing weekdays and weekends, and comparing office hours and shifts. Units with 500–1000 deliveries per year had the lowest risk for adverse events. Adverse and severely adverse neonatal outcomes were least common for midwife‐guided deliveries, and became more frequent with the level of experience of the doctors attending the delivery. With increasing pregnancy risks, senior staff attending delivery and delivering in a tertiary centre reduce the odds ratio for adverse events.Conclusions: Different times of delivery were associated with increased adverse neonatal outcomes. The management of uncomplicated deliveries by less experienced staff showed no negative impact on perinatal outcome. In contrast, riskier pregnancies delivered by senior staff in a tertiary centre favour a better outcome. Achieving a better balance in the total number of labour ward staff during the day and the night appears to be a greater priority than increasing the continuous presence of senior obstetrical staff on the labour ward during the out‐of‐hours period.Tweetable Deliveries during night time lead to a greater number of neonates experiencing severely adverse events.

Objective: To investigate whether knowledge of fetal outcome influences retrospective interpretation of cardiotocographic tracings and subsequent management recommendations.Design: Prospective online study.Setting: Seven university hospitals in five European countries.Population: Forty‐two intrapartum tracings from women with singleton pregnancies and uneventful antepartum courses.Methods: Using an online questionnaire, 123 healthcare professionals interpreted 42 tracings without any knowledge of fetal outcome and provided management recommendations according to the National Institute of Clinical Excellence guidelines (intrapartum care). Two months later, 93 of the 123 participants re‐interpreted the same re‐ordered tracings, this time with information on the newborn's umbilical artery pH.Outcome measures: Comparison of the evaluation of tracing features, overall tracing classification, and management recommendations between the initial analysis and re‐interpretation.Results: In newborns with umbilical artery pH ≤ 7.05, knowledge of the pH value led to significant changes in the evaluation of all basic tracing features. In this group, classification of tracings as ‘normal’ decreased 76% (8.8–2.1%, P < 0.001), whereas classification as ‘pathologic’ increased 51% (44.7–67.5%, P < 0.001). In newborns with pH 7.06–7.19, classification of tracings as ‘normal’ decreased 36% (22.4–14.4%, P < 0.001), and in those with pH ≥ 7.20, classification of tracings as ‘pathologic’ decreased 40% (23.4–14.1%, P < 0.001). In the group of newborns with umbilical artery pH ≤ 7.05, the recommendations ‘no attention needed’ decreased 75% (10.2–2.6%, P < 0.001), and the number of recommendations ‘rapid reversal of hypoxic cause or immediate delivery’ increased 70.3% (42.1–71.7%, P < 0.001).Conclusions: When provided with information on adverse fetal outcome, healthcare professionals provide a more pessimistic evaluation of basic tracing features, overall classification, and clinical management recommendations.Tweetable Knowledge of adverse fetal outcome leads to more pessimistic CTG evaluation and management recommendations.

Background/Definition of the Problem: In recent years, postoperative management has changed towards rapid mobilisation, early oral feeding and rapid rehabilitation (known as Fast-Track or Enhanced Recovery Concepts). This study analysed the postoperative length of stay after vaginal hysterectomy in 3 different periods of time. Material and Methods: In the period October 2011 – September 2012, 75 patients underwent vaginal hysterectomies (± adnexectomy); another 114 vaginal or laparoscopic hysterectomies with additional operations (e.g. prolapse surgery and incontinence surgery) and malignancies were not included. The time periods August 1995 – July 1996 (n = 50) and October 1996 – September 1997 (n = 96) served as a comparison. Reducing the length of stay was not an explicit goal. Results: The median postoperative stay was shortened from 7 (5–9) to 5 (3–15) or 3 (0–5) days (p < 0.001). The recovery rate remained unchanged at 2.7 % (n = 2), cf. 2 % (n = 1) and 3.1 % (n = 3). In 40/75 cases (53.3 %), the surgery took place on the day of admission. Conclusion: The length of hospital stay after vaginal hysterectomy has more than halved since 1995/1996 and continues to decline. This development occurred without a shortened stay being an explicit goal of the clinic. The shortened length of stay does not appear to have a negative impact on postoperative complications and recovery rate. Hintergrund/Fragestellung: Postoperatives Management hat sich in den letzten Jahren in Richtung rascher Mobilisierung, frühe orale Nahrungsaufnahme und rascher Rehabilitation gewandelt (sog. Fast-Track- oder Enhanced-Recovery-Konzepte). Diese Studie analysiert die postoperative Aufenthaltsdauer nach vaginaler Hysterektomie in 3 Zeiträumen. Material und Methodik: Im Zeitraum 10/2011–9/2012 wurde bei 75 Patientinnen eine vaginale Hysterektomie (± Adnexektomie) durchgeführt; weitere 114 vaginale oder laparoskopische Hysterektomien mit Zusatzoperationen (z. B. Deszensus-, Inkontinenz-OP) oder Malignomen wurden nicht eingeschlossen. Als Vergleich dienten die Zeiträume 8/1995–7/1996 (n = 50) und 10/1996–9/1997 (n = 96). Reduktion der Aufenthaltsdauer war kein explizites Ziel. Ergebnisse: Der mediane postoperative Aufenthalt verkürzte sich von 7 (5–9) auf 5 (3–15) bzw. 3 (0–5) Tage (p < 0,001). Die Wiederaufnahmerate blieb unverändert bei 2,7 % (n = 2), vgl. 2 % (n = 1) bzw. 3,1 % (n = 3). In 40/75 Fällen (53,3 %) erfolgte die OP am Aufnahmetag. Schlussfolgerung: Die Aufenthaltsdauer nach vaginaler Hysterektomie hat sich seit 1995/1996 mehr als halbiert und ist weiterhin rückläufig. Diese Entwicklung passierte, ohne dass ein verkürzter Aufenthalt ein explizites Ziel der Klinik gewesen wäre. Die verkürzte Aufenthaltsdauer zeigt keine negativen Auswirkungen auf die postoperative Komplikations- bzw. Wiederaufnahmerate.

Although fetal blood sampling for pH is well established the use of lactate has not been widely adopted. This study validated the performance and utility of a handheld point-of-care (POC) lactate device in comparison with the lactate and pH values obtained by the ABL 800 blood gas analyzer. The clinical performance and influences on accuracy and decision-making criteria were assessed with freshly taken fetal blood scalp samples (n=57) and umbilical cord samples (n=310). Bland-Altman plot was used for data plotting and analyzing the agreement between the two measurement devices and correlation coefficients (R²) were determined using Passing-Bablok regression analysis. Sample processing errors were much lower in the testing device (22.8% vs. 0.5%). Following a preclinical assessment and calibration offset alignment (0.5 mmol/L) the test POC device showed good correlation with the reference method for lactate FBS (R²=0.977, p<0.0001, 95% CI 0.9 59-0.988), arterial cord blood (R²=0.976, p<0.0001, 95% CI 0.967-0.983) and venous cord blood (R²=0.977, p<0.0001, 95% CI 0.968-0.984). A POC device which allows for a calibration adjustment to be made following preclinical testing can provide results that will correlate closely to an incumbent lactate method such as a blood gas analyzer. The use of a POC lactate device can address the impracticality and reality of pH sample collection and testing failures experienced in day to day clinical practice. For the StatStrip Lactate meter we suggest using a lactate cut-off of 5.1 mmol/L for predicting fetal acidosis (pH<7.20).

To evaluate the efficacy of misoprostol in the treatment of missed or incomplete abortion in relation to uterine position. In a retrospective cohort study, misoprostol was evaluated as first-line treatment for missed and incomplete abortion before 13 gestational weeks. Between 2009 and 2011, women received 600 μg of sublingual misoprostol for missed abortion or 400 μg for incomplete abortion. Follow-up examinations were performed 7-10 days later, with the option of a second administration of misoprostol. Success was defined by the absence of vaginal bleeding or sonographic signs of incomplete abortion, and falling levels of β-human chorionic gonadotropin. In total, 111 women were included in the study. A single-dose regimen was effective for 73 (65.8%) women. The overall success rate, including repeat doses, was 73.0% (81/111). There were no significant differences in treatment success between women with missed abortion and those with incomplete abortion (56/89 [62.9%] vs 18/22 [81.8%]; P=0.152). Anteverted uterine position was associated with significantly higher success rates compared with diverging position (62/86 [72.1%] vs 4/18 [22.2%]; P=0.001). Misoprostol is an effective treatment for early pregnancy failure. Uterine position might impact the success of medical treatment for missed abortion.