Objective To assess the nature and outcome of intrapartum referrals from primary to secondary care within the Dutch obstetric system.Design Descriptive study.Setting Dutch midwifery database (LVR1), covering 95% of all midwifery care and 80% of all Dutch pregnancies (2001-03).Population Low-risk women (280 097) under exclusive care of a primary level midwife at the start of labour either with intention to deliver at home or with a personal preference to deliver in hospital under care of a primary level midwife.Methods Women were classified into three categories (no referral, urgent referral and referral without urgency) and were related to maternal characteristics and to neonatal outcomes.Main outcome measures Distribution of referral categories, main reasons for urgent referral, Apgar score at 5 minutes, perinatal death within 24 hours and referral to a paediatrician within 24 hours.Results In our study, 68.1% of the women completed childbirth under exclusive care of a midwife, 3.6% were referred on an urgency basis and 28.3% were referred without urgency. Of all referrals, 11.2% were on an urgency basis. The main reasons for urgent referrals were fetal distress and postpartum haemorrhage. The nonurgent referrals predominantly took place during the first stage of labour (73.6% of all referrals). Women who had planned a home delivery were referred less frequently than women who had planned a hospital delivery: 29.3 and 37.2%, respectively (P < 0.001).On average, the mean Apgar score at 5 minutes was high (9.72%) and the peripartum neonatal mortality was low (0.05%) in the total study group. No maternal deaths occurred. Adverse neonatal outcomes occurred most frequently in the urgent referral group, followed by the group of referrals without urgency and the nonreferred group.Conclusions Risk selection is a crucial element of the Dutch obstetric system and continues into the postpartum period. The system results in a relatively small percentage of intrapartum urgent referrals and in overall satisfactory neonatal outcomes in deliveries led by primary level midwives.
Reported rates of postpartum urinary retention (PUR) following vaginal delivery range as high as 18%, but the risk of PUR associated with cesarean delivery is difficult to determine because of the effects of surgery and anesthesia on postpartum bladder function and also because there is no consensus on what constitutes PUR. In this study, PUR was diagnosed when ultrasonography demonstrated a postvoid residual bladder volume (PVRBV) of 150 mL or greater. Participating in this prospective study were 605 pregnant women having cesarean section. The PVRBV was estimated ultrasonically after first micturition.The overall incidence of PUR following cesarean delivery was 24.1%. The incidence of overt PUR, when no spontaneous micturition took place 6 hours after removal of the catheter and patients developed symptoms of obstructed voiding such as incomplete emptying, straining, and difficulty voiding, was 7.4%. Covert PR, with no associated urinary symptoms despite an elevated PVRBV, was more than twice as frequent (16.7%). Factors significantly associated with PUR included postoperative epidural morphine administration, multiple pregnancy, and a low body mass index at the time of delivery. After 3 months of follow-up, 5% of patients had obstructive voiding symptoms and 9.1% had irritative voiding symptoms. Differences in the frequency of voiding problems between the PUR and normal groups were not statistically significant.Nearly one-fourth of these patients developed PUR following cesarean delivery. The chief contributing factor was the use of morphine for postoperative analgesia. When transient and diagnosed at an early stage, PUR did not compromise urinary function and was not associated with subsequent voiding problems. ABSTRACTPerinatal complications are more frequent in cases of maternal diabetes, but little is known about the long-term intellectual outcome of offspring born to diabetic mothers. This study followed a cohort of Danish males born in the years 1976-1984 whose mothers were diabetic. These 282 subjects were followed up to the time of military conscription along with 870 population-based control subjects. The instrument used to gauge intelligence was the Boerge-Prien test, a 45-minute validated measure whose results correlate closely with those obtained using the Wechsler Adult Intelligence Scale.The rejection rate was 52.5% for diabetes-exposed subjects and 45.4% for control subjects. The risk difference was 7.3%, with a 95% confidence interval (CI) of 0.6 to 14.01. Analysis of the medical reasons for rejection failed to disclose diagnoses that could be related to cognitive performance. Among those who were not rejected, mean cognitive scores were 41.4 units (95% CI, 40.2-42.6) in diabetes-exposed individuals and 42.7 units (95% CI, 42.0-43.4) in control subjects. The findings were not altered when stratifying subjects by gestational age at birth or Apgar score. In a subgroup of 39 pregnancies with available data, a 1% point increase in maternal AIC (glycosylated hemoglobin) was associated with a 2.6% poi...
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