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Biomedical subjects

W J Hannah

Publications and source records attributed to W J Hannah.

14 recordsLinked to original sources
PubMed2000

Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group.

BACKGROUND: For 3-4% of pregnancies, the fetus will be in the breech presentation at term. For most of these women, the approach to delivery is controversial. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech-presentation pregnancies. METHODS: At 121 centres in 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned caesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up to 6 weeks post partum. The primary outcomes were perinatal mortality, neonatal mortality, or serious neonatal morbidity; and maternal mortality or serious maternal morbidity. Analysis was by intention to treat. FINDINGS: Data were received for 2083 women. Of the 1041 women assigned planned caesarean section, 941 (90.4%) were delivered by caesarean section. Of the 1042 women assigned planned vaginal birth, 591 (56.7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned caesarean section group than for the planned vaginal birth group (17 of 1039 [1.6%] vs 52 of 1039 [5.0%]; relative risk 0.33 [95% CI 0.19-0.56]; p<0.0001). There were no differences between groups in terms of maternal mortality or serious maternal morbidity (41 of 1041 [3.9%] vs 33 of 1042 [3.2%]; 1.24 [0.79-1.95]; p=0.35). INTERPRETATION: Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups.

Adult↗
PubMed1997

How can second-stage management prevent perineal trauma? Critical review.

OBJECTIVE: To learn which factors influencing perineal integrity were modifiable by physicians and pregnant women. DATA SOURCES: Medical, nursing, and midwifery literature was searched mainly for randomized controlled trials. STUDY SELECTION: We chose articles on perineal trauma pattern, sexual dysfunction or satisfaction, urinary incontinence, and pelvic floor function. We identified 80 papers and studied 16 in detail. SYNTHESIS: Five factors affected perineal integrity: episiotomy, third-trimester perineal massage, mother's position in second-stage labour, method of pushing, and administration of epidural analgesia. Episiotomy does not improve perineal outcomes when used routinely. Third-trimester perineal massage was discussed only in inadequate studies. Studies comparing position in birth chairs and recumbent versus upright positions were inadequate for making firm recommendations. Studies of methods of pushing and use of epidural analgesia were limited and uncontrolled; no recommendations were possible. CONCLUSION: Only limiting episiotomy can be strongly recommended. In the absence of strong data to the contrary, women should be encouraged to engage in perineal massage if they wish and to adopt the birth positions of their choice. Caretakers should be aware of the possibility of interfering with placental function when women hold their breath for a long time when pushing.

Delivery, Obstetric↗
PubMed1996

Postterm pregnancy: putting the merits of a policy of induction of labor into perspective.

BACKGROUND: Several randomized, controlled trials compared the policies of induction of labor and expectant management for women who reach 41 weeks' gestation, and although they suggest a better outcome for mothers and infants with such a policy in place, controversy continues as to which is the better form of care. The Canadian Multicenter Postterm Pregnancy Trial (CMPPT) enrolled 3407 women, of whom 1701 were randomized to a policy of induction of labor (induced group) and 1706 were randomized to a policy of expectant management (expectant group). Secondary analyses of data from the CMPPT were undertaken to explore a number of controversial issues. METHODS: We used data from the CMPPT to explore further the timing of delivery for women enrolled between 41 0/7 and 41 6/7 weeks' gestation, the potential impact of more liberal use of prostaglandins on cesarean section rates, and the relative merits of induced versus spontaneous labor in the two groups. RESULTS: Most women in the CMPPT (89%) were enrolled at 41 0/7 to 41 6/7 weeks' gestation, of whom 86.2 percent in the induced group and 63.6 percent in the expectant group gave birth before 42 weeks' gestation. Assuming that administration of prostaglandins would reduce the likelihood of cesarean section by 12 to 15 percent, cesarean section rates were reduced in the induction group from 21.2 percent to 20.8 to 20.9 percent, and in the expectant group from 24.5 percent 23.3 to 24.2 percent. If labor was induced as part of a policy of expectant management, the cesarean section rate was much higher (33.5%) than if labor was either spontaneous or induced as part of a policy of induction (18.5%, 22.4%). CONCLUSIONS: Women should be informed of the benefits and risks associated with the policies of induction of labor and expectant management, and their preferences regarding these policies should be respected.

Adult↗
PubMed1992

Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. The Canadian Multicenter Post-term Pregnancy Trial Group.

BACKGROUND: The rates of perinatal mortality and neonatal morbidity are higher for post-term pregnancies than for term pregnancies. It is not known, however, whether the induction of labor results in better outcomes than does serial fetal monitoring while awaiting spontaneous labor. METHODS: We studied 3407 women with uncomplicated pregnancies of 41 or more weeks' duration. The women were randomly assigned to undergo induction of labor or to have serial antenatal monitoring and spontaneous labor unless there was evidence of fetal or maternal compromise, in which case labor was induced or cesarean section was performed. In the induction group, labor was induced by the intracervical application of prostaglandin E2. Serial antenatal monitoring consisted of counts of fetal kicks, nonstress tests, and assessments of amniotic-fluid volume. The outcomes we measured were the rates of perinatal mortality, neonatal morbidity, and delivery by cesarean section. RESULTS: Among the 1701 women in the induction group, 360 (21.2 percent) underwent cesarean section, as compared with 418 (24.5 percent) of the 1706 women in the monitoring group (P = 0.03). This difference resulted from a lower rate of cesarean section performed because of fetal distress among the women in the induction group (5.7 percent vs. 8.3 percent, P = 0.003). When two infants with lethal congenital anomalies were excluded, there were no perinatal deaths in the induction group and two stillbirths in the monitoring group (P not significant). The frequency of neonatal morbidity was similar in the two groups. CONCLUSIONS: In post-term pregnancy, the induction of labor results in a lower rate of cesarean section than serial antenatal monitoring; the rates of perinatal mortality and neonatal morbidity are similar with the two approaches to management.

Adult↗
PubMed1991

Opinion leaders vs audit and feedback to implement practice guidelines. Delivery after previous cesarean section.

A randomized controlled trial with 76 physicians in 16 community hospitals evaluated audit and feedback and local opinion leader education as methods of encouraging compliance with a guideline for the management of women with a previous cesarean section. The guideline recommended clinical actions to increase trial of labor and vaginal birth rates. Charts for all 3552 cases in the study groups were audited. After 24 months the trial of labor and vaginal birth rates in the audit and feedback group were no different from those in the control group, but rates were 46% and 85% higher, respectively, among physicians educated by an opinion leader. Duration of hospital stay was lower in the opinion leader education group than in the other two groups. The overall cesarean section rate was reduced only in the opinion leader education group. There were no adverse clinical outcomes attributable to the interventions. The use of opinion leaders improved the quality of care.

Cesarean Section↗
PubMed1991

Obstetrical attitudes and practices before and after the Canadian Consensus Conference Statement on Cesarean Birth.

This paper describes one aspect of a research program aimed at reducing the incidence of cesarean section in Ontario for women with a previous cesarean section or a breech presentation. Using data from multiple sources--surveys of obstetricians, and hospital administrators, and hospital record statistics, the authors attempt to assess the response of obstetricians to pressure to change their practice. This pressure comes principally from the Canadian Consensus Conference Statement on Cesarean Birth, released in June 1986 and subsequently endorsed by a number of professional organizations. The Statement provides clear guidelines for the management of labour in women with previous cesarean section or a breech presentation. The findings present a number of interpretive challenges. Based on their response to hypothetical cases obstetricians are favourably disposed to considering a trial of labour for women with previous cesarean section and breech presentation. However, both their reported practices, as well as hospital statistics indicate the continued high prevalence of cesarean section, though there is a small decline in cesareans for previous cesarean section. There was no evidence that hospitals lacked appropriate facilities for a trial of labour or had unduly restricted formal policies. Furthermore, although awareness of and agreement with the Consensus Statement recommendations was high, when questioned on the actual details of the recommendations, obstetrician's recall was surprisingly low. Respondents tended to err in the direction of choosing more conservative measures than those recommended by the Statement.(ABSTRACT TRUNCATED AT 250 WORDS)

Attitude of Health Personnel↗
PubMed1989

Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians.

Guidelines for medical practice can contribute to improved care only if they succeed in moving actual practice closer to the behaviors the guidelines recommend. To assess the effect of such guidelines, we surveyed hospitals and obstetricians in Ontario before and after the release of a widely distributed and nationally endorsed consensus statement recommending decreases in the use of cesarean sections. These surveys, along with discharge data from hospitals reflecting actual practice, revealed that most obstetricians (87 to 94 percent) were aware of the guidelines and that most (82.5 to 85 percent) agreed with them. Attitudes toward the use of cesarean section were congruent with the recommendations even before their release. One third of the hospitals and obstetricians reported changing their practice as a consequence of the guidelines, and obstetricians reported rates of cesarean section in women with a previous cesarean section that were significantly reduced, in keeping with the recommendations (from 72.2 percent to 61.1 percent; P less than 0.01). The surveys also showed, however, that knowledge of the content of the recommendations was poor (67 percent correct responses). Furthermore, data on actual practice after the publication of the guidelines showed that the rates of cesarean section were 15 to 49 percent higher than the rates reported by obstetricians, and they showed only a slight change from the previous upward trend. We conclude that guidelines for practice may predispose physicians to consider changing their behavior, but that unless there are other incentives or the removal of disincentives, guidelines may be unlikely to effect rapid change in actual practice. We believe that incentives should operate at the local level, although they may include system-wide economic changes.

Cesarean Section↗
PubMed1988

Classical versus low-segment transverse incision for preterm caesarean section: maternal complications and outcome of subsequent pregnancies.

In a retrospective, controlled, follow-up study of 326 women who had a primary preterm caesarean section, the risks of postoperative maternal morbidity and uterine rupture or dehiscence in subsequent pregnancies were investigated in relation to the mode of incision (classical compared with low-segment transverse incision). The classical incision was associated with a higher frequency of postpartum fever in the immediate postoperative period (16% compared with 6%, P less than 0.01). Of the 326 patients reviewed 286 (88%) were contacted for information about subsequent pregnancies. Information was obtained for 70 pregnancies subsequent to a classical caesarean section, and 71 pregnancies subsequent to a low-segment transverse caesarean section, which had continued for more than 20 weeks gestation. Of the pregnancies after the classical operation 13% had abnormal scars compared with none of those after the low-segment transverse operation (P = 0.0014). The frequency of scar dehiscence was 6% after a classical scar compared with none after a low-segment transverse scar (P = 0.0581).

Adult↗