SummaryIron deficiency is the most common deficiency state in the world, affecting more than 2 billion people globally. Although it is particularly prevalent in less-developed countries, it remains a significant problem in the developed world, even where other forms of malnutrition have already been almost eliminated. Effective management is needed to prevent adverse maternal and pregnancy outcomes, including the need for red cell transfusion. The objective of this guideline is to provide healthcare professionals with clear and simple recommendations for the diagnosis, treatment and prevention of iron deficiency in pregnancy and the postpartum period. This is the first such guideline in the UK and may be applicable to other developed countries. Public health measures, such as helminth control and iron fortification of foods, which can be important to developing countries, are not considered here. The guidance may not be appropriate to all patients and individual patient circumstances may dictate an alternative approach. Keywords: iron, iron depletion, iron deficiency, anaemia, pregnancy.The guideline group was selected by the British Society for Haematology, Obstetric Haematology Group (BSH OHG) and British Committee for Standards in Haematology (BCSH), to be representative of UK-based medical experts. MEDLINE and EMBASE were searched systematically for publications from 1966 until 2010 using the terms iron, anaemia, transfusion and pregnancy. Opinions were also sought from experienced obstetricians and practice development midwives. The writing group produced the draft guideline, which was subsequently considered by the members of the BSH Obstetric Haematology Group and revised by consensus by members of the General Haematology Task Force of the BCSH. The guideline was then reviewed by a sounding board of approximately 50 UK haematologists, the BCSH and the BSH Committee and comments incorporated where appropriate. Criteria used to quote levels of recommendation and grades of evidence are as outlined in the Procedure for Guidelines Commissioned by the BCSH. Summary of key recommendations• Anaemia is defined by Hb <110 g/l in the first trimester, <105 g/l in the second and third trimesters and <100 g/l in the postpartum period.• Full blood count (FBC) should be assessed at booking and at 28 weeks.• All women should be given dietary information to maximize iron intake and absorption.• Routine iron supplementation for all women in pregnancy is not recommended in the UK.• Unselected screening with routine use of serum ferritin is generally not recommended although individual centres with a particularly high prevalence of 'at risk' women may find this useful.• For anaemic women, a trial of oral iron should be considered as the first line diagnostic test, whereby an increment demonstrated at 2 weeks is a positive result.• Women with known haemoglobinopathy should have serum ferritin checked and offered oral supplements if their ferritin level is <30 lg/l. • Women with unknown haemoglobinopathy status with a normocyti...

Objective  To explore the views of health professionals on the factors influencing repeat caesarean section. Design  Qualitative study involving semi‐structured interviews with professionals who care for women in pregnancy and labour. Setting  Acute hospital trust with two maternity units and community midwifery service, Leicestershire, UK. Sample  Twenty‐five midwives and doctors. Methods  Interviews with professionals were undertaken using a prompt guide. All interviews were audiotaped and transcribed verbatim. Analysis was based on the constant comparative method, assisted by QSR N5 software. Main outcome measures  Identification of factors influencing professional decision making about repeat caesarean section. Results  Decision making in relation to repeat caesarean is a complex process involving several parties. Professionals identify the relevance of evidence for decision making for repeat caesarean. However, professionals feel that following strict protocols is of limited value because of the perceived substandard quality of evidence in this area, other external pressures and the contingent, unique and often unanticipated features of each case. Professionals also perceive that the organisation of care plays an important role in rates of repeat caesarean. Conclusions  Decision making for repeat caesarean is a social practice where standardised protocols may have limited value. Attention needs to be given to the multiple parties involved in the decision‐making process. Reflective practice, opinion leadership and role modelling may offer ways forward but will require evaluation.

Objective  To assess and explain deviations from recommended practice in National Institute for Clinical Excellence (NICE) guidelines in relation to fetal heart monitoring. Design  Qualitative study. Setting  Large teaching hospital in the UK. Sample  Sixty‐six hours of observation of 25 labours and interviews with 20 midwives of varying grades. Methods  Structured observations of labour and semistructured interviews with midwives. Interviews were undertaken using a prompt guide, audiotaped, and transcribed verbatim. Analysis was based on the constant comparative method, assisted by QSR N5 software. Main outcome measures  Deviations from recommended practice in relation to fetal monitoring and insights into why these occur. Results  All babies involved in the study were safely delivered, but 243 deviations from recommended practice in relation to NICE guidelines on fetal monitoring were identified, with the majority (80%) of these occurring in relation to documentation. Other deviations from recommended practice included indications for use of electronic fetal heart monitoring and conduct of fetal heart monitoring. There is evidence of difficulties with availability and maintenance of equipment, and some deficits in staff knowledge and skill. Differing orientations towards fetal monitoring were reported by midwives, which were likely to have impacts on practice. The initiation, management, and interpretation of fetal heart monitoring is complex and distributed across time, space, and professional boundaries, and practices in relation to fetal heart monitoring need to be understood within an organisational and social context. Conclusion  Some deviations from best practice guidelines may be rectified through straightforward interventions including improved systems for managing equipment and training. Other deviations from recommended practice need to be understood as the outcomes of complex processes that are likely to defy easy resolution.

Background: Employee engagement is the emotional commitment of the employee towards the organisation. We aimed to analyse baseline work engagement using Utrecht Work Engagement Scale (UWES) at a teaching hospital. Methods: We have conducted a cross-sectional study within the National Health Service (NHS) Teaching Hospital in the UK. All participants were working age population from both genders directly employed by the hospital. UWES has three constituting dimensions of work engagement as vigor, dedication, and absorption. We conducted the study using UWES-9 tool. Outcome measures were mean score for each dimension of work engagement (vigor, dedication, absorption) and total score compared with control score from test manual. Results: We found that the score for vigor and dedication is significantly lower than comparison group (P< 0.0001 for both). The score for absorption was significantly higher than comparison group (P< 0.0001). However, total score is not significantly different. Conclusion:The study shows that work engagement level is below average within the NHS employees. Vigor and dedication are significantly lower, these are characterised by energy, mental resilience, the willingness to invest one's effort, and persistence as well as a sense of significance, enthusiasm, inspiration, pride, and challenge. The NHS employees are immersed in work. Urgent need to explore strategies to improve work engagement as it is vital for improving productivity, safety and patient experience.