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Damage to the pelvic floor during pregnancy and vaginal delivery is an inevitable consequence of the natural birthing process. As this damage is associated with functional and anatomical problems in later life, minimizing pelvic floor damage during pregnancy and vaginal delivery may serve as an important factor in the prevention of these unwanted sequelae. Operative vaginal delivery using forceps or vacuum extractor is common practice to achieve or expedite vaginal birth for maternal or fetal indications such as maternal exhaustion or fetal distress. However, operative vaginal delivery is associated with more extensive damage to the pelvic floor and perineal structures with forceps carrying a stronger risk compared to vacuum. The evidence on this subject is discussed with possible suggestions to minimize pelvic floor damage as much as possible.

This case presents the work-up and management of a patient experiencing acute kidney injury, urinary retention, and neuropathy following surgery for pelvic organ prolapse and stress urinary incontinence. Four international experts provide their evaluation of and approach to this complex case.

Introduction and hypothesis The IUGA special interest group (SIG) identified a need for a minimum data set (MDS) to inform outcome measurements to be included and simplify data capture and standardise reporting for data collection systems. To define a minimum data set for urogynaecological surgical registries. Methods Existing registries provide an inventory of items. A modified Delphi approach was used to identify a MDS. At each stage reviewers ranked data points and used free text to comment. The rating used a scale of 0–10 at each review and a traffic light system rated the scores as desirable, highly desirable and mandatory. The scores were collated and reported back to clinicians prior to the further rounds. Outliers were highlighted and reviewers re-assessed prior to repeating the process. A comparison of the MDS was made with published outcomes. Results Reviewers were from the outcome SIG with emphasis on widespread representation. Fifteen clinicians from eight countries were involved. Four reviewers dissected the existing databases. Eighty data points were considered in four categories, background, preoperative, intraoperative and postoperative. Consensus was reached by the third round. Two points were added on review (date of surgery and urodynamics). Three background points, five preoperative points, seven intraoperative points and nine postoperative points were identified giving 24 minimum data points in the final recommendation. Conclusions An MDS has been developed for urogynaecological surgical registries. These should be mandatory points which then allow larger varying points to be assessed. These points correspond well to data points used in published papers from established databases.

BACKGROUND: Postpartum hemorrhage (PPH) can be associated with coagulopathy, which may be difficult to rapidly assess and may exacerbate blood loss. Rotational thromboelastometry (ROTEM) at the point of care can guide clinician choice of blood products and has been shown in some settings to reduce transfusions and improve outcomes. This hospital-based observational study aims to measure effects of a ROTEM-guided transfusion protocol on transfusion practice and clinical outcomes in patients with PPH managed in the operating theater. STUDY DESIGN AND METHODS: We compared a retrospective cohort of 450 consecutive patients with PPH treated in the operating theater before the introduction of a ROTEM-guided transfusion algorithm in June 2016, with 450 patients treated after its introduction. Multivariate regression was used to evaluate the effect of ROTEM introduction on the primary outcome, patients requiring a packed red blood cell (PRBC) transfusion and adjusting for demographic and obstetric confounders. Secondary outcomes included other blood product transfusions, hysterectomy, and intensive care unit admission. RESULTS: A total of 90 (20%) of patients treated prior to ROTEM introduction received a PRBC transfusion, compared with 102 (22.7%) of those treated after ROTEM introduction (95% confidence interval [CI] 1.0-2.0, p = .04). There was no difference in PRBC transfusion in patients undergoing caesarean section (95% CI 0.5-1.8, p = .99). There was a trend toward increased use of cryoprecipitate and reduced use of platelets and fresh frozen plasma after ROTEM introduction. CONCLUSION: In our institution, the introduction of ROTEM-guided transfusion did not reduce PRBC transfusion in patients with PPH treated in the operating theater.

We report a study to design and evaluate an app to support pregnancy information provided to women through an Australian health service. As part of a larger project to provide prenatal resources for culturally and linguistically diverse groups, this study focused on the design and reception of an app with the local Vietnamese community and health professionals of a particular hospital. Our study had three stages: an initial design workshop with the hospital; prototype design and development; prototype-based interviews with health professionals and focus groups with Vietnamese women. We explore how an app of this sort must be designed for a range of different use scenarios, considering its use by consumers with a multiplicity of differing viewpoints about its nature and purpose in relation to pregnancy care.

BackgroundPregnancy apps are a booming global industry, with most pregnant women in high-income countries now using them. From the perspective of health care and health information provision, this is both encouraging and unsettling; the demand indicates a clear direction for the development of future resources, but it also underscores the importance of processes ensuring access, reliability, and quality control. ObjectiveThis review provides an overview of current literature on pregnancy apps and aims at describing (1) the ways in which apps are used by women, in general, and by those of a culturally and linguistically diverse (CALD) background; (2) the utility and quality of information provided; and (3) areas where more research, development, and oversight are needed. MethodsWe chose a narrative review methodology for the study and performed a structured literature search including studies published between 2012 and 2017. Searches were performed using MEDLINE, EMBASE, and CINAHL databases. Studies were identified for inclusion using two separate search criteria and strategies: (1) studies on pregnancy apps and pregnant women’s use of these apps and (2) studies on CALD pregnant women and their use of technology for accessing information on and services for pregnancy. Overall, we selected 38 studies. ResultsWe found that pregnancy apps were principally used to access pregnancy health and fetal development information. Data storage capability, Web-based features or personalized tools, and social media features were also popular app features sought by women. Lower rates of the pregnancy app uptake were indicated among lower-income and non-English-speaking women. Preliminary evidence indicates that a combination of technological, health literacy, and language issues may result in lower uptake of pregnancy apps by these groups; however, further investigation is required. A marked limitation of the health app industry is lack of regulation in a commercially dominated field, making it difficult for users to assess the reliability of the information being presented. Health professionals and users alike indicate that given the choice, they would prefer using pregnancy apps that are relevant to their local health care context and come from a trusted source. Evidence indicates a need for greater health professional and institutional engagement in the app development, as well as awareness of and guidance for women’s use of these resources. ConclusionsThis is the first review of pregnancy app use, types of information provided, and features preferred by pregnant women in general and by those of a CALD background in particular. It indicates the demand for access to accurate information that is relevant to users, their community, and their associated health services. Given the popularity of pregnancy apps, such apps have enormous potential to be used for the provision of accurate, evidence-based health information.

Urinary incontinence symptoms are highly prevalent among women, have a substantial effect on health-related quality of life and are associated with considerable personal and societal expenditure. Two main types are described: stress urinary incontinence, in which urine leaks in association with physical exertion, and urgency urinary incontinence, in which urine leaks in association with a sudden compelling desire to void. Women who experience both symptoms are considered as having mixed urinary incontinence. Research has revealed overlapping potential causes of incontinence, including dysfunction of the detrusor muscle or muscles of the pelvic floor, dysfunction of the neural controls of storage and voiding, and perturbation of the local environment within the bladder. A full diagnostic evaluation of urinary incontinence requires a medical history, physical examination, urinalysis, assessment of quality of life and, when initial treatments fail, invasive urodynamics. Interventions can include non-surgical options (such as lifestyle modifications, pelvic floor muscle training and drugs) and surgical options to support the urethra or increase bladder capacity. Future directions in research may increasingly target primary prevention through understanding of environmental and genetic risks for incontinence.

Objective To identify health literacy issues when providing maternity care to culturally and linguistically diverse (CALD) women, and the strategies needed for health professionals to collaboratively address these issues. Methods A qualitative case study design was undertaken at one large metropolitan Australian hospital serving a highly CALD population. Semistructured interviews were conducted with a range of maternity healthcare staff. The data were analysed thematically. The study is informed by a framework of cultural competence education interventions for health professionals and a health literacy framework. Results Eighteen clinicians participated in the interviews (seven midwives, five obstetricians, five physiotherapists, one social worker, and one occupational therapist). Emergent themes of health literacy-related issues were: patient-based factors (communication and cultural barriers, access issues); provider-based factors (time constraints, interpreter issues); and enablers (cultural awareness among staff, technology). Conclusions There are significant health literacy and systemic issues affecting the hospital’s provision of maternity care for CALD women. These findings, mapped onto the four domains of cultural competence education interventions will inform a technology-delivered health literacy intervention for CALD maternity patients. This approach may be applied to other culturally diverse healthcare settings to foster patient health literacy. What is known about the topic? There are health inequities for pregnant women of culturally and linguistically diverse (CALD) backgrounds. Low health literacy compounded by language and cultural factors contribute to these inequities and access to interpreters in pregnancy care remains an ongoing issue. Pregnancy smart phone applications are a popular source of health information for pregnant women yet these apps are not tailored for CALD women nor are they part of a regulated industry. What does this paper add? This paper provides clinician and language service staff perspectives on key health literacy issues that are both patient-based and provider-based. This research confirms that the complex interplay of social and practical factors contributes to and perpetuates low health literacy, creating barriers to health access; it also highlights several enablers for increasing CALD health literacy and access. These include greater health practitioner awareness and accommodation of CALD women’s needs and the provision of culturally and linguistically appropriate eHealth resources. What are the implications for practitioners? eHealth resources are emerging as valuable enabling tools to address the health literacy and information needs of pregnant women. However, these resources need to be used adjunctively with health practitioner communication. Both resource developers and health practitioners need to understand issues affecting CALD patients and their needs. Developers need to consider how the resource addresses these needs. Training of health professionals about culture-specific issues may help to enhance communication with, and therefore health literacy among, individual cultural groups. Further, formalised language and interpreting training of bi- or multilingual health professionals is advised to ensure that they are able to interpret to a professional standard when called on to do so.

The current system of prevocational training does not meet the needs of junior doctors because of a high administrative workload, insufficient funding for education, and a lack of centralised guidance for trainees, teachers and hospitals. The Australian Curriculum Framework for Junior Doctors is designed to identify the training objectives for the prevocational years. The Framework has the potential to improve the quality of training of junior doctors, but this depends on how well it is implemented and resourced. It is imperative that any group responsible for implementing or assessing the Framework have a representative junior doctor, among others, on its decision-making committee. Stringent accreditation of training institutions is vital to the effective implementation of the Framework. The Framework should be used to promote teaching and learning, not as a barrier to vocational training or as a check-list to complete.

The need for invasive urodynamic functional studies prior to the surgical treatment of uncomplicated female stress incontinence has been questioned following the findings of recent randomized controlled trials. But how generalizable are these research findings to the urogynaecological population in practice?

Avulsion of the puborectalis muscle from its bony insertion is common in women presenting with prolapse. We present a simple vaginal technique for levator reconstruction. This is a prospective surgical pilot study comprising 17 patients enrolled to undergo levator repair in the context of prolapse surgery. This was performed through a lateral colpotomy at the level of the hymen using a mesh patch for reinforcement. We performed 20 levator repairs in 17 women (three bilateral). There were no intraoperative complications. Recovery was unremarkable in all cases. Results are given for a mean follow-up of 1.3 years. Most (13/17, 76 %) women were satisfied with the outcome. Six patients complained of symptoms of recurrent prolapse, three of de novo dyspareunia, and four of pain related to the repair site on palpation. There were two mesh erosions, one of which healed with oestrogen treatment. Prolapse recurrence beyond the hymen was observed in five patients. The mean hiatal area on Valsalva was reduced from 36.84 cm2 to 30.71 cm2 (P = 0.001). Direct surgical repair of a levator avulsion is feasible at the time of prolapse surgery. However, its effect on prolapse recurrence and hiatal dimensions is relatively disappointing, suggesting that there often is microscopic trauma and functional muscle impairment in addition to the avulsion.