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This paper reviews evidence of how drug control has been used to uphold colonial power structures in select countries. It demonstrates the racist and xenophobic impact of drug control policy and proposes a path to move beyond oppressive systems and structures. The ‘colonization of drug control’ refers to the use of drug control by states in Europe and America to advance and sustain the systematic exploitation of people, land and resources and the racialized hierarchies, which were established under colonial control and continue to dominate today. Globally, Black, Brown and Indigenous peoples are disproportionately targeted for drug law enforcement and face discrimination across the criminal system. These communities face higher arrest, prosecution and incarceration rates for drug offenses than other communities, such as majority populations, despite similar rates of drug use and selling among (and between) different races. Current drug policies have contributed to an increase in drug-related deaths, overdoses and sustained transnational criminal enterprises at the expense of the lives of people who use drugs, their families and greater society. This review provides further evidence of the need to reform the current system. It outlines a three-pillared approach to rebuilding drug policy in a way that supports health, dignity and human rights, consisting of: (1) the decriminalization of drugs and their use; (2) an end to the mass incarceration of people who use drugs; (3) the redirection of funding away from ineffective and punitive drug control and toward health and social programs.

In the prospective multicenter Genesis study, we developed a prediction model for Cesarean delivery (CD) in term nulliparous women. The objective of this secondary analysis was to determine whether the Genesis model has the potential to predict maternal and neonatal morbidity associated with vaginal delivery.The national prospective Genesis trial recruited 2,336 nulliparous women with a vertex presentation between 39 + 0- and 40 + 6-weeks' gestation from seven tertiary centers. The prediction model used five parameters to assess the risk of CD: maternal age, maternal height, body mass index, fetal head circumference and fetal abdominal circumference. Simple and multiple logistic regression analyses were used to develop the Genesis model. The risk score calculated using this model were correlated with maternal and neonatal morbidity in women who delivered vaginally: postpartum hemorrhage (PPH), obstetric anal sphincter injury (OASI), shoulder dystocia, one- and five-minute Apgar score ≤ 7, neonatal intensive care (NICU) admission, cephalohematoma, fetal laceration, nerve palsy and fractures. The morbidities associated with spontaneous vaginal delivery were compared with those associated with operative vaginal delivery (OVD). The likelihood ratios for composite morbidity and the morbidity associated with OVD based on the Genesis risk scores were also calculated.A total of 1,845 (79%) nulliparous women had a vaginal delivery. A trend of increasing intervention and morbidity was observed with increasing Genesis risk score, including OVD (p 0.001), PPH (p 0.008), NICU admission (p 0.001), low Apgar score at one-minute (p 0.001) and OASI (p = 0.009). The morbidity associated with OVD was significantly higher compared to spontaneous vaginal delivery, including NICU admission (p 0.001), PPH (p = 0.022), birth injury (p 0.001), shoulder dystocia (p = 0.002) and Apgar score of7 at one-minute (p 0.001). The positive likelihood ratios for composite outcomes (where the OVD was excluded) increases with increasing risk score from 1.005 at risk score of 5% to 2.507 for risk score of50%.In women who ultimately achieved a vaginal birth, we have shown more maternal and neonatal morbidity in the setting of a Genesis nomogram-determined high-risk score for intrapartum CD. Therefore, the Genesis prediction tool also has the potential to predict a more morbid vaginal delivery.

The rate of caesarean section (CS) is increasing globally. The nulliparous, term, singleton, vertex presentation, spontaneously labouring woman (Robson Group 1/RG1) is considered low risk for CS. It has been hypothesized that more CS occur at nighttime or at weekends due to doctor fatigue. The European Working Time Directive (EWTD) was implemented in our institution in 2013 to limit doctor working hours, which aimed at reducing fatigue but arguably fractures continuity of care. This study aimed to determine the effect of nocturnal hours and weekend on-call as well as the implementation of EWTD on our RG1 CS rates.This was a population-based study in a tertiary referral centre from 2008-2017. The inclusion criteria for our study were limited to RG1. Data were analysed from an established clinical database, including mode and time of delivery. Descriptive statistics are presented as number and percent for categorical variables. Relative frequencies were tested using chi-squared test. All statistical analyses were performed using SPSS Version 26. Statistical significance was defined as p .05.There were 86,473 deliveries over the 10-year study period. There were 18,761 women in RG1. Overall the RG1 CS rate was 12.9 % (n = 2415). Rates of CS in the RG1 were not statistically different between those delivering on weekdays (12.9 %, n = 1726/13,430) and weekends (12.9 %, n = 689/5,331, OR 0.99, 95 % CI = 0.90-1.09, p = .89). During daytime hours the CS rate was 12.1 % (n = 777/6411) and at nighttime was 13.3 % (n = 1638/12,350, OR 1.10, 95 % CI = 1.01-1.21, p = .03). Comparing the time periods pre and post EWTD implementation, there was a significant increase in CS rates (12.1 % n = 1319/10,873 V 13.9 % n = 1096/7,888, OR 1.17, 95 % CI = 1.07-1.27 p.001). With respect to other modes of delivery in RG1 pre and post EWTD, there was a statistically significant decrease in operative vaginal delivery (OVD) rates (40.1%, n=4,360 V 37.7%, n=2,973, OR 0.90, 95% CI = 0.85-0.95, p = .001) CONCLUSION: This study shows an association between obstetric trainee working practices, RG1 CS and OVD rates; this is most pronounced at night and after the introduction of the EWTD. It is unlikely that obstetric trainee working practices are the only factor related to the increasing CS rate and reduced OVD rate. Consideration should be giving to addressing the needs of obstetric trainees in relation to achieving their competencies with now reduced labour ward exposure. Further study is required to see if alternate arrangements in relation to simulation training could increase the OVD rate and reduce the CS rate.

The ability to predict the need for emergency Cesarean delivery holds the potential to facilitate birth choices. The objective of the RECIPE study (Reducing Emergency Cesarean delivery and Improving the Primiparous Experience) was to externally validate a Cesarean delivery risk prediction model. This model, developed by the Genesis study, identified five key predictive factors for emergency Cesarean delivery: maternal age, maternal height, BMI, fetal head circumference (HC) and fetal abdominal circumference (AC).This prospective, observational study was conducted in two tertiary referral perinatal centers. Inclusion criteria were as follows: primiparous women with a singleton, cephalic presentation fetus in the absence of fetal growth restriction (FGR), oligohydramnios, pre-eclampsia, pre-existing diabetes mellitus or an indication for planned Cesarean delivery. Between 38 + 0 and 40 + 6 weeks' gestational age, participants attended for prenatal assessment that enabled the determination of an individualized risk calculation for emergency Cesarean delivery during labour based on maternal height, BMI, fetal HC and AC, with crucially both participants and care providers being blinded to the resultant risk prediction score. Labor, delivery and postnatal outcomes were ascertained. Calibration and receiver operator curves were generated to determine the predictive capacity for emergency Cesarean delivery of the Genesis risk prediction model in this cohort.559 primiparous participants were enrolled from May 2017 to April 2019, of whom 142 (25 %) had an emergency Cesarean delivery during labour. Participants with a low predicted risk score (10 %) had a mean predicted rate of 8% (+/- standard deviation of 2%) and a similarly low actual observed rate of Cesarean delivery (8%). Participants with a high predicted risk (50 %) had a mean predicted Cesarean delivery rate of 64 % (+/- standard deviation of 9%) and also had a high actual observed Cesarean delivery rate (62 %). The calibration curve and receiver operating characteristic curve demonstrated that this validation study had comparable discriminatory power for emergency Cesarean delivery to that described in the original Genesis study. The Area Under the Curve (AUC) in Genesis was 0.69, whereas the AUC in RECIPE was 0.72, which reflects good predictive capacity of the risk prediction model.The accuracy of the Genesis Cesarean delivery prediction tool is supported by this validation study.

peer-reviewed Objective Increased fetal size is associated with shoulder dystocia during labor and subsequent need for assisted delivery. We sought to investigate if increased fetal adiposity diagnosed sonographically in late pregnancy is associated with increased risk of operative delivery. Methods This secondary analysis of the Genesis Study recruited 2392 nulliparous women with singleton pregnancy in cephalic presentation, in a prospective, multicenter study, to examine prenatal and intrapartum predictors of Cesarean delivery. Participants underwent ultrasound and clinical evaluation between 39 + 0 and 40 + 6 weeks' gestation. Data on fetal biometry were not revealed to patients or to their managing clinicians. A fetal adiposity composite of fetal thigh adiposity and fetal abdominal wall thickness was compiled for each infant in order to determine whether fetal adiposity > 90th centile was associated with an increased risk of Cesarean or operative vaginal delivery. Results After exclusions, data were available for 2330 patients. Patients with a fetal adiposity composite > 90th centile had a higher maternal body mass index (BMI) (25 ± 5 kg/m2 vs 24 ± 4 kg/m2; P = 0.005), birth weight (3872 ± 417 g vs 3585 ± 401 g; P 90th centile were more likely to require Cesarean delivery than were those with adiposity composite ≤ 90th centile (P 90th centile remained a risk factor for Cesarean delivery (P 90th centile was more predictive of the need for unplanned Cesarean delivery than was an estimated fetal weight > 90th centile (odds ratio, 2.20 (95% CI, 1.65–2.94; P 90th centile was not associated with an increased likelihood of operative vaginal delivery when compared with having an adiposity composite ≤ 90th centile (P = 0.37). Conclusions Fetuses with increased adipose deposition are more likely to require Cesarean delivery than are those without increased adiposity. Consideration should, therefore, be given to adding fetal thigh adiposity and abdominal wall thickness to fetal sonographic assessment in late pregnancy. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd. ACCEPTED peer-reviewed

Contemporary approaches to monitoring quality of care in obstetrics often focus on comparing Cesarean Delivery rates. Varied rates can complicate interpretation of quality of care. We previously developed a risk prediction tool for nulliparous women who may require intrapartum Cesarean delivery which identified five key predictors. Our objective with this study was to ascertain if patient heterogeneity can account for much of the observed variation in Cesarean delivery rates, thereby enabling Cesarean delivery rates to be a better marker of quality of care.This is a secondary analysis of the Genesis study. This was a large prospective study of 2336 nulliparous singleton pregnancies recruited at seven hospitals. A heterogeneity score was calculated for each hospital. An adjusted Cesarean delivery rate was also calculated incorporating the heterogeneous risk score.A cut-off at the 90th percentile was determined for each predictive factor. Above the 90th percentile was considered to represent 'high risk' (with the exception of maternal height which identified those below the 10th percentile). The patient heterogeneous risk score was defined as the number of risk factors90th percentile (10th percentile for height). An unequal distribution of high-risk patients between centers was observed (p 0.001). The correlation between the Cesarean delivery rate and the patient heterogeneous risk score was high (0.76, p 0.05). When adjusted for patient heterogeneity, Cesarean delivery rates became closer aligned.Inter-institutional diversity is common. We suggest that crude comparison of Cesarean delivery rates between different hospitals as a marker of care quality is inappropriate. Allowing for marked differences in patient characteristics is essential for correct interpretation of such comparisons.

Spontaneous platelet aggregation has not been adequately assessed as a potential risk factor for adverse outcomes in pregnancy. Therefore the objective of this study was to assess spontaneous platelet aggregation (SPA), measured via a novel functional assay, as a risk factor for hypertensive disease and intra-uterine growth restriction (IUGR).This was a prospective longitudinal study. Spontaneous platelet aggregation was assessed as a marker of platelet reactivity using a modification of light transmission aggregometry. Platelet reactivity was assessed in four groups: non-pregnant healthy female volunteers (n=30), longitudinally in normal uncomplicated pregnancy (n=50), hypertensive disorder (n=40) and IUGR (n=30). The mean percentage SPA was plotted and compared across all groups.Spontaneous platelet aggregation was significantly reduced in the first trimester compared to the non-pregnant group (p-value=0.003). The mean aggregation for the hypertensive group was 1.9%, (95% CI -0.08 to 4.02) and for the IUGR group was 1.6%, (95% CI -0.6 to 3.72). Platelet aggregation in the hypertensive group was significantly reduced compared to the normal pregnant group (p0.05). Spontaneous platelet aggregation was also reduced in the IUGR group compared to normal pregnancy (p0.05).This study demonstrates that a reduction of spontaneous platelet aggregation may be a novel risk factor for adverse pregnancy outcomes such as pre-eclampsia and IUGR. The most clinically significant finding is that SPA is significantly lower in pregnancies complicated by hypertension and IUGR compared to those who had a normal pregnancy outcome. Further studies should be carried out to asses if spontaneous platelet aggregation may be a clinically useful tool for the prediction of pre-eclampsia and IUGR.

Generalized pustular psoriasis of pregnancy is a rare dermatosis with potential serious consequences for both the mother and fetus. Treatment is difficult and historically steroids were the mainstay of treatment. Cyclosporin has been used for a few cases resistant to steroids. We report our own experience of two cases of generalized pustular psoriasis of pregnancy. Cases of generalized pustular psoriasis of pregnancy need review by a dermatologist with experience of skin disorders in pregnancy. Both the fetus and mother need to be monitored closely when systemic illness occurs, as there is a risk of stillbirth. Maternal sepsis is a known complication of generalized pustular psoriasis of pregnancy. Cyclosporin, when used appropriately is effective and relatively safe.

Objective A limited number of platelet function studies in intrauterine growth restriction (IUGR) have yielded conflicting results. We sought to evaluate platelet reactivity in IUGR using a novel platelet aggregation assay. Study Design Pregnancies with IUGR were recruited from 24 weeks' gestation (estimated fetal weight

Splenic rupture in pregnancy is a rare event. It is generally due to trauma or an underlying splenic pathology. Timely diagnosis and intervention of splenic rupture is essential given the high rates of associated maternal and fetal morbidity and mortality. This case illustrates a 38 year old lady in the third trimester of pregnancy who presented with maternal collapse and a non-reassuring foetal heart rate tracing following a fall at home one week previously. A massive hemoperitoneum was identified at caesarean section and a splenectomy was performed. Histological examination revealed a littoral cell angioma of the spleen. This vascular tumour arising in the splenic red pulp sinuses is a rare entity and specific immunophenotypic features help distinguish it from other vascular tumours of the spleen. Both trauma and an underlying splenic pathology led to splenic rupture in this unique case.

This chapter considers the impact of new technology on compliance with obligations under the VCDR. It focuses on the provisions of the VCDR that establish the inviolability of diplomatic archives and correspondence and considers the challenges posed by technology that was not available at the time of the drafting of that treaty but which is now commonplace. It evaluates the ever-present risk of unauthorized digital access to diplomatic correspondence and archives, including by non-State actors (eg WikiLeaks), and examines whether the framework of the VCDR is still adequate to deal with those challenges. The chapter also addresses the submission of protected information obtained in violation of the VCDR as evidence in proceedings before international tribunals, including the International Court of Justice (ICJ). The chapter analyses the admissibility of that evidence and offers answers on how international courts should deal with that information.

This paper examines palliative care within the human rights in patient care framework, which clarifies state obligations and addresses the rights of both patients and providers. In the context of palliative care, these rights extend beyond the right to health and include patient rights to freedom from torture, cruel and inhuman treatment, non-discrimination and equality, bodily integrity, privacy and confidentiality, information, and right to a remedy. They also encompass provider rights to decent working conditions, freedom of association, and due process. The paper then looks at a case study of Armenia, acknowledging how the government’s commitment to palliative care, combined with awareness raising and advocacy by human rights organizations, created an enabling environment for the realization of human rights in patient care in the context of palliative care.

Context Palliative care patients face legal issues that impact their quality of life. Legal support, embedded in holistic palliative care services, has developed globally over the last decade to address this. Objectives This article aims to trace the origins of legal support for palliative care patients, detail models of legal support, and describe achievements and challenges. Methods The article draws on years of work in this area and the available literature. Results Common legal issues include disposing of property and drafting wills, planning for children, dealing with debt and securing social benefits, and addressing discrimination. Diverse approaches to integrating legal support include developing paralegal skills, accessing skilled legal advice, empowering patients and families, and building awareness of rights among health care workers. Conclusion There is robust and growing acceptance of legal support as a key component of holistic palliative care, and many palliative care professionals are identifying and addressing the legal needs they encounter through mediation, guidance on basic rights, or referrals to a lawyer. Addressing legal problems can contribute to peace of mind, well-being, and the health of patients.

Increased duration of the second stage of labor provides clinical challenges in decision-making regarding the optimal mode of delivery that minimizes maternal and neonatal morbidity.In a large cohort of uncomplicated nulliparous singleton cephalic labors, we sought to examine the effect of increasing duration of second stage on delivery and perinatal outcome.The GENESIS Study recruited 2336 nulliparous patients with vertex presentation in a prospective double-blinded study to examine prenatal and intrapartum predictors of delivery. Metrics included maternal demographics, duration of second stage, mode of delivery, and associated maternal and neonatal outcomes. Indicators of morbidity included third- or fourth-degree tear, postpartum hemorrhage, neonatal intensive care unit admission, low Apgar scores, cord pH7.20 and a composite of birth injury that included cephalohematoma, fetal laceration, brachial plexus palsy, facial nerve palsy, and fetal fracture.Of 2336 recruited nulliparous participants, 1872 reached the second stage of labor and had complete data for analysis. Increased maternal age (P=.02) and birthweight (P.001) were found to be associated with a longer second stage. Increasing second stage duration was found to impact on mode of delivery, such that at1 hour duration the spontaneous vaginal delivery rate was 63% vs 24% at3 hours (P.001). Operative vaginal delivery increased from 35% at1 hour to 65% at3 hours (P.001). The rate of cesarean delivery increased with duration of the second stage from 1.2% at1 hour to 11% at3 hours (P.001). The rates of third- or fourth-degree tear increased with second stage duration (P=.003), as did postpartum hemorrhage (P.001). The composite neonatal birth injury rate increased from 1.8% at1 hour to 3.4% at3 hours. The maximum rate of birth injury was 6.5% at 2-3 hours (P.001). Multiple logistic regression analysis that controlled for maternal age and birthweight confirmed that operative vaginal delivery, perineal trauma, postpartum hemorrhage, and neonatal birth injury remained significantly more likely with increasing second stage duration.In a prospective cohort of nulliparous pregnancies, increasing duration of second stage of labor was associated with increased rates of operative vaginal and cesarean delivery. Although almost 90% of term nulliparous women with a second stage of labor3 hours will succeed in achieving a vaginal birth, this success comes at a maternal morbidity cost, with a 10% risk of severe perineal injury and an increasing rate of significant neonatal injury.

Objective Platelets play an important role in the pathophysiology of uteroplacental disease and platelet reactivity may be an important marker of uteroplacental disease activity. However, platelet reactivity has not been evaluated comprehensively in normal pregnancy. We sought to evaluate platelet reactivity using a number of agonists at defined time points in pregnancy using a novel platelet assay and compare these with a nonpregnant cohort. Design Prospective longitudinal study. Setting Outpatient department of a large tertiary referral centre. Sample Eighty participants with 30 nonpregnant women and 50 pregnant women assessed longitudinally. Methods This was a prospective cohort study performed longitudinally throughout uncomplicated singleton pregnancies with participants recruited before 15 weeks of gestation. They were controlled for a number of factors known to affect platelet reactivity. Blood samples were obtained in each trimester. Thirty nonpregnant healthy female volunteers also had a platelet assay performed. A modification of standard light transmission aggregometry was used to assess platelet function, with light absorbance measured following the addition of five different agonists at submaximal concentrations. Dose–response curves were plotted for each agonist for the nonpregnant cohort and in each trimester for the pregnant cohort. Main outcome measures Dose–response curves and median effective concentration. Results When compared with the nonpregnant controls a significant reduction was demonstrated in platelet reactivity to collagen during the first trimester of pregnancy (P

Background In contemporary practice many nulliparous women require intervention during childbirth such as operative vaginal delivery or cesarean delivery (CD). Despite the knowledge that the increasing rate of CD is associated with increasing maternal age, obesity and larger infant birthweight, we lack a reliable method to predict the requirement for such potentially hazardous obstetric procedures during labor and delivery. This issue is important, as there are greater rates of morbidity and mortality associated with unplanned CD performed in labor compared with scheduled CDs. A prediction algorithm to identify women at risk of an unplanned CD could help reduced labor associated morbidity. Objective In this primary analysis of the Genesis study, our objective was to prospectively assess the use of prenatally determined, maternal and fetal, anthropomorphic, clinical, and ultrasound features to develop a predictive tool for unplanned CD in the term nulliparous woman, before the onset of labor. Materials and Methods The Genesis study recruited 2336 nulliparous women with a vertex presentation between 39+0 and 40+6 weeks' gestation in a prospective multicenter national study to examine predictors of CD. At recruitment, a detailed clinical evaluation and ultrasound assessment were performed. To reduce bias from knowledge of these data potentially influencing mode of delivery, women, midwives, and obstetricians were blinded to the ultrasound data. All hypothetical prenatal risk factors for unplanned CD were assessed as a composite. Multiple logistic regression analysis and mathematical modeling was used to develop a risk evaluation tool for CD in nulliparous women. Continuous predictors were standardized using z scores. Results From a total enrolled cohort of 2336 nulliparous participants, 491 (21%) had an unplanned CD. Five parameters were determined to be the best combined predictors of CD. These were advancing maternal age (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.09 to 1.34), shorter maternal height (OR, 1.72; 95% CI, 1.52 to 1.93), increasing body mass index (OR, 1.29; 95% CI, 1.17 to 1.43), larger fetal abdominal circumference (OR, 1.23; 95% CI, 1.1 to 1.38), and larger fetal head circumference (OR, 1.27; 95% CI, 1.14 to 1.42). A nomogram was developed to provide an individualized risk assessment to predict CD in clinical practice, with excellent calibration and discriminative ability (Kolmogorov–Smirnov, D statistic, 0.29; 95% CI, 0.28 to 0.30) with a misclassification rate of 0.21 (95% CI, 0.19 to 0.25). Conclusion Five parameters (maternal age, body mass index, height, fetal abdominal circumference, and fetal head circumference) can, in combination, be used to better determine the overall risk of CD in nulliparous women at term. A risk score can be used to inform women of their individualized probability of CD. This risk tool may be useful for reassuring most women regarding their likely success at achieving an uncomplicated vaginal delivery as well as selecting those patients with such a high risk for CD that they should avoid a trial of labor. Such a risk tool has the potential to greatly improve planning hospital service needs and minimizing patient risk.

In recent years, criminologists have devoted growing attention to the extent to which ‘punitiveness’ is emerging as a central feature of many criminal justice systems. In gauging punitiveness, these studies typically rely either on attitudinal data derived from surveys that measure individual support for punitive sentences or on the size of the prison population. We take a different approach, exploring the aims, content and outcomes of various Acts of Parliament passed between 1982 and 1998 in England and Wales. Our argument is that while a trend towards punitiveness is detectable, this was, in the case of England and Wales, attributable to wider discourses stemming from the New Right of the 1980s. This in turn promoted a new conception of how best to tackle rising crime. We show that while the year 1993 stands out as a key point in the growing trajectory of punitiveness in England and Wales, the ideas and rhetoric around ‘toughness’ in the criminal justice system can be traced back much further than this. Our article brings these matters to the attention of political scientists and demonstrates how historical institutionalist thinking can guide and inform interdisciplinary work at the interface between political science and criminology.

OBJECTIVE: We sought to evaluate the use and safety of Kielland's rotational forceps for delivery in current obstetric practice at a tertiary care obstetric unit. METHODS: Data were obtained pertaining to all such attempted deliveries from 1997 through 2011. The outcomes analyzed included maternal obstetric features, induction and duration of labor, use of analgesia, fetal position and station, birth weight, seniority of the obstetrician, success and failure rates, and associated maternal and neonatal morbidity. RESULTS: There were 144 cases, of which 129 resulted in successful vaginal delivery (89.6%) and 15 were unsuccessful (10.4%). A senior obstetrician was present at all deliveries. The maternal morbidity was relatively low: third-degree or fourth-degree tear less than 1%, postpartum hemorrhage 12.4%, and urinary incontinence 7.8%. There were no cases of forceps-related neonatal trauma or hypoxic-ischemic encephalopathy. CONCLUSION: Contrary to earlier reports, in these circumstances, use of Kielland's forceps is associated with a high successful delivery rate and apparently low maternal and neonatal morbidity. (Obstet Gynecol 2012; 120: 766-70) DOI:http://10.1097/AOG.0b013e3182695581

Perineal injury sustained during childbirth, and more particularly third and fourth degree tears, can have substantial effects on future continence, sexual function and the choice of method of childbirth in the future. The aim of our audit was to see if the use of clinical risk management methods could help improve documentation and clincial outcomes for women who sustained an obstetric anal sphincter injury. A proforma for the management of obstetric anal sphincter injury was introduced to the labour ward. We found that after the introduction of the proforma documentation improved significantly for classification of the type of injury ( P < .01), counts of swabs, instuments and sharps ( P < .01) and future pregnancy information ( P < .05). This audit demonstrates how simple clinical risk managment strategies can help ensure the best standards of care are implemented.

Objective The aim of this study was to characterize platelet function in pregnant patients with a history of unexplained recurrent miscarriage (RM) in the third trimester of a subsequent viable pregnancy, a time at which platelet dysfunction may be associated with an increased obstetric risk. Study design A prospective study was performed comparing 30 viable pregnancies that had reached at least 28 weeks’ gestation amongst patients who had a background history of unexplained RM, with 30 healthy pregnant controls at a similar gestational age. Platelet function was determined by means of platelet aggregation in response to 5 different agonists at multiple concentrations. Results Amongst the 30 RM patients with ongoing viable pregnancies, we demonstrated significantly reduced platelet aggregation compared to the pregnant controls in the third trimester. For three out of five agonists, we demonstrated statistically significantly decreased platelet aggregation and for all five agonists we demonstrated significantly decreased platelet aggregation in the postnatal period. There were no obvious differences in obstetric outcomes. Conclusion This study shows that women with a history of unexplained RM have reduced platelet function after 28 weeks’ gestation in their subsequent pregnancies compared to healthy pregnant controls, but without this difference leading to any obvious increase in adverse obstetric risk.