bluuebunny/crossref_metadata_2025 huggingface dataset:
Adjuvant drugs in neuraxial anaesthesia
Authors: Cromey Catherine , Catling Susan
Published: January 2017

The addition of adjuvants to local anaesthetics for use in labour epidurals or for intrathecal administration is common practice in obstetric anaesthesia. This chapter provides an overview of the pharmacology of receptors within the epidural and intrathecal spaces and discusses the options available. Adjuncts are classified as opioid and non-opioid and each agent is explored in detail. The mechanism of action, clinical uses, effective dose ranges, speeds of onset and duration, side effects, disadvantages, and special circumstances associated with each agent are explored. Where formal guidelines exist, these are discussed in detail. Although large randomized controlled trial data is lacking, information regarding current knowledge of the behaviour of these agents in obstetric and non-obstetric practice is presented to assist clinicians when deciding about the appropriateness of each agent for their individual practice.
Alternative neural blocks for labour analgesia
Authors: Palomäki Outi , Volmanen Petri
Published: January 2017

Although neuraxial analgesia is available to the majority of parturients in developed countries, alternative neural blocks for labour analgesia are needed for medical, individual, and institutional reasons. Paracervical and pudendal blocks are usually administered transvaginally by an obstetrician. An injection of 0.25% bupivacaine using a superficial technique into the lateral fornixes gives rapid pain relief and has been found to have no negative effect on either fetal oxygenation, or maternal and neonatal outcomes. Low rates of post-analgesic bradycardia and high rates of spontaneous vaginal delivery have been described in low-risk populations. The analgesic effect of a paracervical block is moderate and is limited to the first stage of labour. A pudendal block, administered transvaginally, can be used for pain relief in the late first stage, the second stage, in cases of vacuum extraction, or for episiotomy repair. In clinical use, 1% lidocaine gives rapid pain relief but the success rate is variable. The complications of pudendal block are rare and localized. The sympathetic and paravertebral blocks are currently mainly of historic interest. However, they may benefit parturients in exceptional conditions if the anaesthesiologist is experienced in the techniques. Lumbar sympathetic block provides fast pain relief during the first stage of labour when a combination of 0.5% bupivacaine with fentanyl and epinephrine is employed. With the currently available data, no conclusion on the analgesic effects of thoracic paravertebral block can be drawn when it is used for labour pain relief. Potential maternal risks limit the use of these methods in modern obstetrics.
Prevention and management of breakthrough pain during neuraxial labour analgesia
Authors: Bauerle Jessica , Soens Mieke A.
Published: January 2017

While neuraxial analgesia is considered the gold standard for labour analgesia, breakthrough pain can occur and can significantly impair maternal satisfaction. The early identification of breakthrough pain, for example, during epidural delivery suite rounds, is not only important for adequate maternal analgesia, but also in anticipation of using the epidural catheter for other potential obstetric interventions. Identifying patients at high risk for experiencing breakthrough pain enables the anaesthesia provider to adjust their anaesthetic plan. In case breakthrough pain does occur, it should be managed promptly and aggressively, with the goal to restore adequate analgesia within a maximum of 60 minutes. This chapter reviews potential causes of breakthrough pain and strategies that can be used to prevent problems and rescue poorly functioning catheters. Results of rescue interventions should be assessed in a timely fashion and the epidural catheter should be replaced if satisfactory analgesia is not obtained.
Intraoperative management of inadequate neuraxial anaesthesia
Authors: Husain Tauqeer , Fernando Roshan
Published: January 2017

Neuraxial anaesthesia (NA) is the primary form of anaesthesia used for caesarean delivery. The popularity of NA has increased in no small part due to improvements in mortality and morbidity associated with the techniques. However, intraoperative inadequacy of NA might expose patients to the risks of repeated NA techniques, general anaesthesia, and the long-term psychological effects of pain during caesarean delivery. Additionally, clinicians may also become exposed to the medicolegal consequences of failed NA. Prevention of failed NA requires a sound knowledge of the causes and risk factors associated with inadequate NA. Furthermore, an understanding of the effects of different local anaesthetic mixtures, and methods of testing anaesthetic adequacy are also needed. Decisions in the management of inadequate NA must be taken in the context of the urgency of delivery, the maternal risk, and at what point during the operative episode the inadequacy becomes evident.
General anaesthesia for caesarean delivery
Authors: Levy David M. , Saule Ieva
Published: January 2017

General anaesthesia (GA) is most often indicated for category 1 (immediate threat to life of mother or baby) caesarean delivery (CD) or when neuraxial anaesthesia has failed or is contraindicated. Secure intravenous access is essential. Jugular venous cannulation (with ultrasound guidance) is required if peripheral access is inadequate. A World Health Organization surgical safety checklist must be used. The shoulders and upper back should be ramped. Left lateral table tilt or other means of uterine displacement are essential to minimize aortocaval compression, and a head-up position is recommended to improve the efficiency of preoxygenation and reduce the likelihood of gastric contents reaching the oropharynx. Cricoid pressure is controversial. In the United Kingdom, thiopental remains the induction agent of choice, although there is scant evidence upon which to avoid propofol. In pre-eclampsia, it is essential to obtund the pressor response to laryngoscopy with remifentanil or alfentanil. Rocuronium is an acceptable alternative to succinylcholine for neuromuscular blockade. Sugammadex offers the possibility of swifter reversal of rocuronium than spontaneous recovery from succinylcholine. Management of difficult tracheal intubation is focused on ‘oxygenation without aspiration’ and prevention of airway trauma. The Classic™ laryngeal mask airway is the most commonly used rescue airway in the United Kingdom. There is a large set of data from fasted women of low body mass index who have undergone elective CD safely with a Proseal™ or Supreme™ laryngeal mask airway. Sevoflurane is the most popular volatile agent for maintenance of GA. The role of electroencephalography-based depth of anaesthesia monitors at CD remains to be established. Intraoperative end-tidal carbon dioxide tension should be maintained below 4.0 kPa.
The aetiology and management of hypotension during spinal anaesthesia for caesarean delivery
Authors: Dyer Robert A. , Arcache Michelle J. , Langesaeter Eldrid
Published: January 2017

The management of hypotension during spinal anaesthesia for caesarean delivery remains a challenge for anaesthesiologists. Close control of maternal haemodynamics is of great importance for maternal and fetal safety, as well as maternal comfort. Haemodynamic responses to spinal anaesthesia are influenced by aortocaval compression, the baricity and dose of local anaesthetic and opioid employed, the rational use of fluids, and the goal-directed use of vasopressors. The most common response to spinal anaesthesia is hypotension and an increased heart rate, which reflects a decreased systemic vascular resistance and a partial compensatory increase in cardiac output. Phenylephrine is therefore the vasopressor of choice in this scenario. Less commonly, hypotension and bradycardia may occur, possibly due to the activation of cardiac reflexes. This requires anticholinergics and/or ephedrine. The rarest occurrences are persistent refractory hypotension, or high spinal block with respiratory failure. Special considerations include patients with severe pre-eclampsia, in whom spinal anaesthesia is associated with haemodynamic stability, and less hypotension than in the healthy patient. Careful use of neuraxial anaesthesia in specialized centres has an important role to play in the management of patients with cardiac disease, in conjunction with careful monitoring. Prevention is better than cure, but should hypotension occur, rapid intervention is essential, based upon the exact clinical scenario and individual haemodynamic response.
Persistent pain after caesarean delivery and vaginal birth
Authors: Lavand’homme Patricia , Roelants Fabienne
Published: January 2017

Persistent pain after childbirth has recently received a lot of attention as potentially many women could be affected. Several pain syndromes including pelvic girdle pain, low back pain, and headaches occur during the pregnancy and can persist after delivery. The prevalence of chronic pain directly related to the delivery, at 6 months and later after childbirth, is however very low (< 2%) compared to chronic pain which occurs after other types of tissue trauma as in common surgical procedures. Acute pain is a major risk factor in the development of persistent pain after surgery and trauma. After childbirth, the severity of acute pain, independent of the mode of delivery (i.e. the degree of tissue damage) only predicts an increased risk of persistent pain (a 2.5-fold increase) at 2 months but not later. An individual’s pain response seems to be the most relevant factor in the development of persistent pain. In retrospective studies, patient-specific risk factors, such as a pre-existing chronic pain condition or pain elsewhere, were predictive factors. In prospective studies, the low incidence of persistent pain at 6 and 12 months make the analysis of risk factors unreliable.
Management of the difficult airway
Authors: Mushambi Mary C. , Pandey Rajesh
Published: January 2017

Failed or difficult intubation is still a major cause of maternal morbidity and mortality. The management of the airway in the pregnant patient requires careful consideration of anatomical and physiological changes, training issues, and situational factors. Despite significant improvements in monitoring and airway equipment, and a reduction in anaesthetic-related maternal mortality, the incidence of failed intubation in the pregnant woman in many units has remained between 1/250 and 1/300. This may result from many factors such as the reduction of the number of caesarean deliveries performed under general anaesthesia which has resulted in limited opportunities to teach airway skills in obstetrics, the increased incidence of obesity, and the rise in maternal age and associated co-morbidities. Improved training and careful planning and performance of a general anaesthetic (i.e. reducing the risk of aspiration; optimum pre-oxygenation, patient positioning, and application of cricoid pressure; and availability of appropriate airway equipment) have the potential to reduce airway-related morbidity and mortality in the pregnant woman. Simple bedside tests such as Mallampati scoring, thyromental distance, neck movement, and ability to protrude the mandible may help to predict a potential difficult airway, particularly when used in combination. Management of a predicted difficult airway requires early referral to the anaesthetists, formulation of an airway management strategy, and involvement of the multidisciplinary team in decision-making. Fibreoptic equipment and skills should be readily available when required. Management of the unpredicted difficult airway should make maintenance of maternal and fetal oxygenation the primary goal. Decision-making during a failed intubation on whether to proceed or wake the patient should involve the obstetrician and ideally be planned in advance. The periods during extubation and recovery are high risk and require preparation and planning in advance.
Neurological complications of neuraxial blockade
Authors: Moen Vibeke
Published: January 2017

Neuraxial techniques for obstetric analgesia and anaesthesia are widespread, and serious complications are extremely rare. The most common of all complications following neuraxial blockade is postdural puncture headache, but headache may also be present in pathological conditions such as pre-eclampsia and sinus vein thrombosis. Headache may also be a symptom of cranial subdural haematoma, meningitis, and epidural abscess, all rare complications of central blockade, thus introducing a potential confounder in the newly delivered woman complaining of headache. Vertebral spinal haematomas are extremely rare in the healthy obstetric patient, but haemostatic disorders might develop following placement of an epidural catheter, thus increasing the possibility of spinal haematomas. Anaesthetists must be familiar with these rare complications, and perform neuraxial blockade avoiding traumatic damage, and using aseptic techniques. The anaesthetist will be involved in diagnosing a woman with neurological symptoms after labour and delivery, and must be familiar with common intrinsic obstetric neuropathies and clinical diagnostic procedures. This chapter describes complications following neuraxial blockade, as well as preventive and diagnostic procedures.
Obstetric haemorrhage
Authors: Norman Jane E. , Clark Vicki
Published: January 2017

Major obstetric haemorrhage affects around 0.4% of pregnant women, accounts for around 50% of intensive care unit admissions amongst pregnant women, and is a significant cause of maternal death. Optimal obstetric and anaesthetic management plays an important role in reducing mortality. Such management includes antenatal optimization (ensuring that pre-delivery haemoglobin is normal, and identifying risk factors such as placenta praevia), prompt recognition of bleeding and senior involvement, and debriefing for staff and patients after the event. This chapter focuses on the causes of, and treatments for, antenatal, intrapartum, and postpartum haemorrhage. Resuscitation and therapeutic (pharmacological and surgical) strategies are described and the use of blood products and cell salvage discussed from the point of view of both the anaesthetist and the obstetrician. Lastly, current controversies, including the use of recombinant factor VII and tranexamic acid are mentioned.
Hypertension in pregnancy
Authors: Anderson John A. , Laloë Pierre-Antoine , Tuffnell Derek J.
Published: January 2017

The hypertensive disorders of pregnancy encompass a spectrum of disease, including gestational hypertension, haemolysis, elevated liver enzymes, and low platelets (HELLP syndrome), and acute fatty liver of pregnancy through to pre-eclampsia and eclampsia. These conditions can pose significant problems for clinicians and are associated with significant morbidity and mortality for both mother and baby. Pre-eclampsia and eclampsia remain one of the leading causes of maternal death worldwide. The majority of fatalities occur in settings with low healthcare resources. In the developed world, improvements over the last 60 years in antenatal and intrapartum care, along with national surveillance and audit, have led to tenfold and fivefold reductions in absolute mortality and severe morbidity from eclampsia and pre-eclampsia respectively. Conversely, the incidence of pre-eclampsia has been rising in the developed world as the average age of first maternity increases and rates of obesity and other medical conditions rise. It is therefore increasingly likely that hypertension may complicate the obstetric and anaesthetic management of pregnant women.
Liver disorders
Authors: Verslype Chris , Cassiman David , Verhaeghe Johan
Published: January 2017

Liver disease can complicate 5% of pregnancies, putting mother and child at risk for increased morbidity and mortality. Cholestasis, portal hypertension, and liver failure represent three major clinical entities that should be recognized early because of the prognostic implications. Liver disease in pregnancy is generally separated into disorders that are unique to pregnancy and those that coincide with pregnancy. This chapter recommends a systematic approach that focuses on the major differential diagnostic characteristics of pregnancy-related liver diseases and a limited set of tests for pregnancy-unrelated liver diseases. Management of these conditions should be performed by a multidisciplinary team and ranges from simple medical therapies to immediate termination of the pregnancy.
Obstetric haematology
Authors: Ladani Sapna , Hunt Beverley J. , Pavord Sue
Published: January 2017

This chapter aims to cover aspects of haematology of pregnancy, delivery, and postpartum that are not addressed in other chapters. Obstetric haematology is a vast and complex area, the importance of which has promoted the development of this as a unique subspecialty. Thrombosis and bleeding, anaemia, haemoglobinopathies, and microangiopathies still account for significant morbidity and mortality in pregnancy, despite improvements in recognition, prevention, and management. Anaemia, due to iron deficiency, is highly prevalent in the pregnant population, but with early recognition and treatment, morbidity and need for unnecessary blood transfusion can be avoided. The management of women with thrombocytopenias and inherited bleeding disorders can be complex because of the haemostatic challenges of pregnancy. Pregnancies in women with haematological disorders need to be carefully managed to reduce mortality and morbidity in the mother and fetus. This chapter addresses the management of anaemia, haemoglobinopathies (mainly sickle cell disease), thrombocytopenia, microangiopathies, and the inherited bleeding disorders.
Peripartum psychiatric disorders
Authors: Cantwell Roch
Published: January 2017

Women are at greatest risk of suffering from mental illness during their reproductive years, and at very particular risk in relation to childbirth. Psychological adjustment, social challenges, and neurohormonal changes in pregnancy and parturition may all contribute to this risk. The consequences of maternal mental illness may be severe. Suicide is among the leading causes of maternal death in the United Kingdom and psychiatric factors are implicated in a further significant number of deaths in pregnancy and the first postnatal year. Increasing evidence points to the detrimental effect of untreated maternal anxiety and depression on infant development. Women may be taking psychotropic medication at conception, with antidepressants being one of the most frequently prescribed. Certain psychotropics have important adverse effects on the fetus and developing child, and may require careful management if prescribed in pregnancy. All professionals involved in the care of women at this time have an important role in identifying those at risk, reducing progression to future morbidity and mortality, and minimizing the adverse effects of prescribed medication.
Chronic maternal infections
Authors: Van Calsteren Kristel
Published: January 2017

Pregnant women diagnosed with chronic infections are a worldwide problem. In developed countries, the most frequently encountered are hepatitis B and C, toxoplasmosis, syphilis, herpes simplex, and Cytomegalovirus infections. In developing countries, human immunodeficiency virus and malaria are also seen commonly in pregnant women. Maternal infections are associated with various complications in pregnant women, but also with congenital infections with or without structural anomalies and long-term sequelae, fetal growth restriction, preterm delivery, and perinatal mortality. Moreover, increasing evidence suggests that maternal infection during pregnancy affects the developing immune system of the fetus independently of the vertical transmission of pathogens. This chapter discusses the pathogen characteristics, ways of transmission, clinical presentation, diagnostic options, treatment, and, if relevant, prophylaxis for the most common infections in pregnant women (excluding hepatitis which is discussed elsewhere).
Ultrasound
Authors: Immani Sudhir , Loughrey John
Published: January 2017

The use of ultrasound in obstetric anaesthesia practice has accelerated in the past decade, following a typical pattern of a small number of enthusiastic early adopters, to a current phase of more widespread use. The use of ultrasound in everyday practice has yet to include the majority of practitioners. However, more widespread availability of equipment and also training opportunities will ensure that it may be a future standard in obstetric units. The most obvious and current application for ultrasound for obstetric anaesthetists is in the improvement of the safety, quality, and success of neuraxial anaesthesia. This chapter sets out a description of current technique and knowledge of this application of ultrasound by obstetric anaesthetists and will give the reader a good overview of this topic. There are other applications of ultrasound in obstetric anaesthesia practice including vascular access, cardiac assessment in patients with cardiovascular collapse, and possibly even gastric volume assessment. Future equipment modifications may enhance the technique with smaller ultrasound probes for more accurate skin marking and also with enhanced image quality.
Social marketing planning
Authors: French Jeff
Published: January 2017

There is a lack of systematic planning in many public programmes, despite the existence of a number of well-designed and tested systematic planning models. One of the defining features of social marketing is the application of systematic and transparent planning to achieve defined and measurable social objectives. When planning social marketing interventions aimed at influencing behaviour, behavioural theories and models should have a central role in informing the intervention’s design and evaluation. However, an equally important factor in the delivery of an intervention is the application of a logical and documented planning approach in order to produce learning about what worked well and what did not. Systematic planning processes are key to understanding not only which elements of a social marketing programme are most successful but also which are most efficient. A focus on systematic planning is a valuable way to ensure that programme implementation weaknesses are addressed and mitigated.
Evaluation of social marketing programmes
Authors: Crosier Adam , McVey Dominic
Published: January 2017

This chapter considers why we evaluate, and the nature of evaluation. It also explores criticisms and limitations of evaluation and looks at the role of evaluation research as part of social marketing and behaviour change programmes. The chapter sets out how to construct an evaluation using a six-step approach, ensuring that it is an integral part of the programme from the outset. It also investigates the nature and contribution of formative, process, and summative evaluation in social marketing, which ensure that both the quantitative outcomes of an intervention and emerging insights into the process can be used to inform future projects and programmes.
Social marketing and public health strategy
Authors: French Jeff
Published: January 2017

This chapter explores how social marketing can be used to add value when developing a public health intervention that is designed to influence attitudes and behaviour. It examines the difference between how social marketing can add value to policy selection, strategy development, and operational social marketing programme delivery. The chapter explores the challenges of influencing public health policy and approaches to using social marketing principles to inform public health policy and strategy development. The advantages of developing a strategic approach to the application of social marketing are also covered, including a description of what constitutes the application of a strategic social marketing approach and how it can be analysed and evaluated. The implications for project and programme delivery, including the need for vertical and horizontal integration, are also examined.
Social franchising: strengthening health systems through private sector approaches
Authors: McBride Julie , Longfield Kim , Sievers Dana , Montagu Dominic
Published: January 2017

This chapter explores the nature of franchising and how it can be applied in the health sector. The concept of social franchising is introduced and explained, together with an account of how it has developed and expanded over recent years. The chapter also explores how social franchising can contribute to the rapid spread of high-quality prevention, care, and treatment programmes. The issues of review and evaluation of social franchise performance are also explored. The chapter examines how social marketing can be used to enhance the impact of social franchising and multiply its impact in countries with less well developed health systems and facilities.
Pathophysiological changes of ageing and their relevance to anaesthesia
Authors: Dodds Chris , Kumar Chandra M. , Servin Frédérique
Published: January 2017

The molecular basis of ageing is reviewed. This includes the concept of a summation of DNA damage over a lifetime causing genome instability. Epigenetic alterations, telomeric shortening, and the possibility of their modification are discussed. Oxidative and mitochondrial DNA damage and the resulting dysfunction leading to senescence are briefly described. Systemic problems and resultant behavioural adaptation may mask the decline in functional reserve and cause some of the difficulties in identifying its presence in ill elderly patients. Specific organ system changes are then described in some detail. These include the major concerns with the cardiovascular, respiratory, renal, hepatic, neurologic, endocrine, and musculoskeletal systems. The effect of ageing on the special senses of vision and hearing are covered, with emphasis on issues of informed consent.
Anaesthetic pharmacology in the elderly
Authors: Dodds Chris , Kumar Chandra M. , Servin Frédérique
Published: January 2017

The importance of the changes and variability in pharmacology with ageing and the risks these pose in the elderly are emphasized. Detailed descriptions are given of the pharmacokinetic aspects of distribution, initial volume of distribution, and plasma binding; elimination affected by hepatic and renal clearance changes; and effect site variability. The pharmacodynamics changes are then reviewed. Specific anaesthetic agents are then described, covering the induction agents thiopentone, propofol, etomidate, ketamine, and midazolam. The volatile anaesthetics sevoflurane and desflurane, and nitrous oxide are discussed. The opioid analgesics fentanyl, alfentanil, sufentanil, and remifentanil are described followed by the opiate morphine. The much slower onset and offset of muscle relaxants in the elderly is explained, and the differences between steroid and benzylisoquinolinium compounds are described. Finally, the reversal agents, including sugammadex, are reviewed.
Anaesthesia for major abdominal surgery in the elderly
Authors: Dodds Chris , Kumar Chandra M. , Servin Frédérique
Published: January 2017

Major abdominal surgery and laparotomy are common procedures that are associated with a high risk of mortality and morbidity, especially in the elderly. Outcomes can be improved by formal risk stratification, appropriate perioperative resuscitation and optimization, early surgery, senior anaesthetist involvement, and careful postoperative critical. Assessment of dehydration is imperative because fluid losses are very common and may be difficult to measure. Hypothermia is common, and measures should be instituted to conserve heat loss. Use of nitrous oxide can cause bowel distension and should be avoided. Elderly patients should receive postoperative care in an environment that is appropriate to the degree of comorbidity and the type of surgery. Effective analgesia is known to improve outcome. Only experienced anaesthetists should manage major and emergency abdominal surgery.
Neurosurgery in the elderly
Authors: Dodds Chris , Kumar Chandra M. , Servin Frédérique
Published: January 2017

The increasing provision of neurosurgery to the elderly is reviewed in this chapter. The two major areas of practice and the forms of presentation are briefly discussed. Specific issues with the elderly neurosurgical patient are then considered, including the urgency of the surgery, surgery duration, extent of the planned procedure, and management of concurrent drug therapy. Details on the common risks with hyperventilation and hypothermia are noted, and the use of more recent anaesthetic agents, remifentanil and desflurane, is covered. Spinal surgery for decompression and stabilization for cervical, odontoid, and lumbar regions, as well as the common risks and complications are discussed. Both vertebrectomy and vertebroplasty are reviewed. Intracranial surgery, usually for decompression because of tumour or haematoma, is discussed, including the recent aggressive treatment of haemorrhagic stroke. An overview of the developing field of stem cell implantation and stereotactic ablative surgery completes the chapter.
Anaesthesia for non-theatre environments
Authors: Dodds Chris , Kumar Chandra M. , Servin Frédérique
Published: January 2017

This chapter reviews the challenges in providing safe anaesthesia outside of the operating theatre complex and the particular risks this may pose to the elderly. Generic issues with remote sites are discussed, and key points are identified: these include patient assessment, appropriate staffing and support, safety drills, environmental safety, and anaesthetic equipment and drug provision. Sedation in the elderly is identified as an area of risk, and the chapter details the problems of providing safe sedation. The areas where sedation is administered vary from endoscopy and imaging including CT and MRI, to interventional suites such those used for cardiothoracic catheterization and GI stenting. Major advances in technology have allowed the development of endovascular aortic aneurysm repair (EVAR) and transthoracic aortic valve implantation (TAVI). Psychiatric units still prescribe electroconvulsive therapy (ECT) for severe suicidal depression, especially in the elderly because of the fast response, and the related challenges for anaesthetists are reviewed.
Vascular anatomy and stroke syndromes
Authors: Markus Hugh , Pereira Anthony , Cloud Geoffrey
Published: January 2017

Determining the arterial territory in which a stroke occurs is important in diagnosis. It also has major implications for management; for example, treatment of a symptomatic carotid stenosis differs greatly to that of an incidental stenosis in a patient with posterior circulation stroke. This chapter describes the arterial supply of the brain and links it to stroke syndromes that present acutely to the stroke clinician. It also covers the venous supply which is important in understanding cerebral venous thrombosis.
Secondary prevention of stroke
Authors: Markus Hugh , Pereira Anthony , Cloud Geoffrey
Published: January 2017

In the secondary prevention of stroke chapter the case is made for preventing recurrent stroke by targeted evidence-based intervention based on the aetiological cause of stroke. Lifestyle measures such as smoking cessation as well as pharmacological prevention strategies are discussed. Blood pressure treatment, lipid lowering, and antiplatelet therapy are all examined. Since the last edition there has been a major advance in the stroke prevention treatment of atrial fibrillation with the licensing of new anticoagulant agents and the evidence for their use is reviewed. Surgical and endovascular interventions for extracranial and intracranial stenosis are also outlined, including carotid endarterectomy, carotid stenting, extracranial-intracranial bypass, and intervention for vertebral artery disease.
Cerebral venous thrombosis
Authors: Markus Hugh , Pereira Anthony , Cloud Geoffrey
Published: January 2017

Most stroke results from arterial disease but venous occlusion can also cause stroke, and other neurological complications. This condition is uncommon and needs a high index of suspicion if it is not to be missed. The clinical presentations are varied and can mimic other neurological conditions. The diagnosis is important because with appropriate treatment the prognosis can be much better than for arterial infarction.
Recovery and rehabilitation
Authors: Markus Hugh , Pereira Anthony , Cloud Geoffrey
Published: January 2017

Life is never the same after stroke and the processes that can help go into picking up the pieces and returning to a pre-stroke life and lifestyle are outlined in this recovery and rehabilitation chapter. The principles of neuronal plasticity and stroke recovery are discussed as well as the rehabilitation process. Multidisciplinary team care is the cornerstone of treatment and the individual roles of team members are outlined. The common complications that can follow stroke are individually reviewed including immobility, spasticity, communication (aphasia and dysarthria) and swallowing difficulties (dysphagia), low mood (depression) and psychological sequelae, incontinence, pain syndromes, neglect, inattention, and visual loss (hemianopia). Post-stroke epilepsy is also reviewed in this chapter. The transitioning into life in a community setting including discharge planning and vocational rehabilitation is also included.
Vascular dementia
Authors: Markus Hugh , Pereira Anthony , Cloud Geoffrey
Published: January 2017

Patients with cerebrovascular disease can develop dementia in the absence of stroke symptoms or as a consequence to stroke. In this chapter, concepts, classification, and definitions of vascular dementia are outlined with a discussion of the overlap between vascular dementia and Alzheimer's disease. Investigation of the vascular dementia patient for treatable causes and to inform management is discussed as there are sections on therapy, promoting independence, and assessments of mental capacity. Depression is common in vascular dementia and a section is dedicated to the assessment and management of this. The concept of mild vascular cognitive impairment is also discussed.
Organization of stroke services
Authors: Markus Hugh , Pereira Anthony , Cloud Geoffrey
Published: January 2017

The chapter on organization of stroke services discusses the evidence for stroke unit care and defines what this means within hospitals. The chapter sets out the patient pathway starting with pre-hospital care the assessment using the Face Arm Speech Test (FAST). It then moves to the acute hospital care emergency department (Recognition of Stroke in the Emergency Room, ROSIER) and consideration of thrombolysis and admission to an acute stroke unit. Rehabilitation and transition of care into the community including early support discharge bookends the chapter. Staffing levels are discussed as is the relationship between stroke unit nursing levels and mortality.
Introduction
Authors: Medforth Janet , Ball Linda , Walker Angela , Battersby Sue , Stables Sarah
Published: January 2017

This chapter comprises a midwifery definition and explains the midwife’s role, focusing on the challenges of a changing population demographic with increasing levels of complexity, ill health, and maternal morbidity. Highlights from the latest MBRRACE (2014) report are reflected as is new evidence of the value of midwifery-led care in all settings. Statutory supervision of midwifery in its current model is unique to UK midwifery and there are proposed changes to the regulatory framework pending in 2017. Meanwhile, current supervision arrangements remain in place until regulations are redrafted. Drug administration information is updated and the latest Human Medicines Regulations (2012) are cited along with the list of midwives exemptions. Independent prescribing is included here to indicate how by undertaking further approved training a midwife could be permitted to prescribe medicines promptly and without delay whilst giving care, e.g. prescription of antibiotics for mastitis, infected perineum, or urinary tract infection.
Antenatal care
Authors: Medforth Janet , Ball Linda , Walker Angela , Battersby Sue , Stables Sarah
Published: January 2017

This chapter comprises confirming the pregnancy, the signs and symptoms of pregnancy, pregnancy testing and how to go about it, pregnancy adaptation, how the body changes in response to the pregnancy, the booking interview, and where, when, how, and why it takes place. Pregnancy screening and risk assessment, based on the medical, social, and obstetric history, is outlined. Blood group and the rhesus factor, their importance in terms of preventing haemolytic disease in the newborn, and anti-D prophylaxis are explained. Down’s syndrome risk screening protocols, gaining consent, and the testing options are presented, as well as antenatal examination and how and when this is carried out, the abdominal examination procedure, and the significance of findings and how this relates to fetal well-being. Monitoring fetal growth and well-being by a variety of clinical and technical measures is also included, explaining the procedure for measuring growth and plotting the results on a customized chart.
Health advice in pregnancy
Authors: Medforth Janet , Ball Linda , Walker Angela , Battersby Sue , Stables Sarah
Published: January 2017

This chapter begins with a discussion of the concepts of fetal programming and epigenetics and the relevance of both to health advice in pregnancy. The topics of smoking (including e-cigarettes), alcohol intake, diet and nutrition, weight gain, body mass index, food safety, folic acid, iron and vitamin D supplementation, nut allergies, exercise, and employment during pregnancy are each covered in depth. The current advice and guidance which should be given to women and their families during pregnancy relative to each topic are also discussed.
Minor disorders of pregnancy
Authors: Medforth Janet , Ball Linda , Walker Angela , Battersby Sue , Stables Sarah
Published: January 2017

A general discussion of the concept of key minor disorders of pregnancy is followed by an explanation of the incidence, causes, side effects, and recommended management of a range of minor disorders, including nausea, constipation, indigestion and heartburn, varicose veins, haemorrhoids, backache, and frequency of micturition.
Infections and sepsis
Authors: Medforth Janet , Ball Linda , Walker Angela , Battersby Sue , Stables Sarah
Published: January 2017

This chapter includes the latest guidance on antenatal screening for infections, viral infections, bacterial infections, rubella antibodies (latest guidance), syphilis, HIV screening, and group B haemolytic Streptococcus. Other infections, such as coughs and colds, influenza, urinary tract infections, chickenpox, toxoplasmosis, and postnatal infections, and recognition and management of sepsis are included. Discussions includes diagnosis, the latest recommendations for treatment options, potential outcomes, and fetal effects.
Medical conditions during pregnancy
Authors: Medforth Janet , Ball Linda , Walker Angela , Battersby Sue , Stables Sarah
Published: January 2017

This chapter comprises a review of common medical conditions, including asthma, thyroid conditions, cardiac conditions, and renal diseases. There is a small section on renal transplant and care of the woman during pregnancy. Insulin-dependent diabetes, non-insulin-dependent diabetes, gestational diabetes, and their impact on pregnancy are discussed. The effect of pregnancy on the conditions themselves is reviewed, along with recognition and management of pregnancy changes due to the condition. Pregnancy management options, including altered physiology and pharmacological treatment, are discussed. Clinical and laboratory investigations are also listed. The section on cardiac conditions refers to circulatory changes during pregnancy and how these may be affected by a range of different cardiac conditions, both those that are congenital and those acquired. Pregnancy management, investigations, and clinical observations used to detect deterioration are included.
Pain relief in labour: pharmacological
Authors: Medforth Janet , Ball Linda , Walker Angela , Battersby Sue , Stables Sarah
Published: January 2017

This chapter considers the pharmacological options which a woman may choose to utilize during her labour and birth to help her cope with the pain. Options are described in conjunction with the current evidence base for their effectiveness and recommendations for safe use. They include nitrous oxide and oxygen (Entonox®), pethidine, diamorphine, and lumbar epidural anaesthesia.
Management of malpositions and malpresentations
Authors: Medforth Janet , Ball Linda , Walker Angela , Battersby Sue , Stables Sarah
Published: January 2017

This chapter considers the causes, diagnosis, and consequences of malpositions and malpresentations in pregnancy and birth. Malpositions included are the occipito-posterior positions and the malpresentations discussed include the face, brow, and shoulder presentations. The midwife’s management of these problems is covered, along with the possible outcomes for the mother and baby.
Maternal emergencies during pregnancy, labour, and postnatally
Authors: Medforth Janet , Ball Linda , Walker Angela , Battersby Sue , Stables Sarah
Published: January 2017

Maternal emergencies during pregnancy, labour, birth, and the postnatal period are covered. Blood tests during pregnancy and detecting deviations from the norm are included. Maternal emergencies and their management considered include: major obstetric haemorrhage, uterine rupture, eclampsia, emboli (pulmonary embolus and amniotic fluid embolus), HELLP syndrome, disseminated intravascular coagulation, uterine inversion, shock, and maternal resuscitation. Guidelines for admission to a high-dependency unit and current maternal morbidity and mortality data are included.
Postnatal care
Authors: Medforth Janet , Ball Linda , Walker Angela , Battersby Sue , Stables Sarah
Published: January 2017

The principles of postnatal care within this chapter focus on the midwife’s role in monitoring the well-being of the mother through knowledge of the physiological processes of involution of the uterus and the return of the circulatory and excretory systems to their normal parameters. Care of the perineum management of perineal pain and monitoring for any signs of infection or sub-involution are included. The psychological and emotional aspects of postnatal recovery are incorporated, along with parent education, post-operative care, and the subsequent care of women who suffer from a pre-existing medical condition such as diabetes.
Care of the newborn
Authors: Medforth Janet , Ball Linda , Walker Angela , Battersby Sue , Stables Sarah
Published: January 2017

This is a comprehensive chapter giving details of the management of the neonate who is well and also management protocols for neonates who are suffering from a number of common difficulties and for whom the midwife is responsible for detecting and managing their care and advising parents. Routine screening and monitoring growth and well-being are accompanied by separate topics on a range of issues such as hypoglycaemia, hypothermia, and neonatal infection. Recommendations following the latest national guidance are used to support this chapter.
Institutions as Barriers and Facilitators of Health Information Systems Reform
Authors: Sahay Sundeep , Sundararaman T , Braa Jørn
Published: January 2017

An Expanded PHI perspective needs to consider institutions seriously. The institutional context helps us to understand why so often public health information systems fail to deliver, and also how could they have done better. There are four sets of institutions that shape the development and use of health information systems: those that deliver healthcare; those that manage healthcare; those that make decisions on policy; and, those who finance health information systems, including external donors. The formal rules, informal conventions, and cultures in which each of these institutions function tend to constrain the introduction and use of health information systems. The introduction of health information systems thus becomes a process of negotiation where the owners of the various institutions need to find consent over what each will gain or lose. Morever, the design of information systems needs to factor in and address the design of institutions in which such systems are embedded.
Replication Study of Meaning-Centered Group Psychotherapy in Spain
Authors: Gil Francisco , Fraguell Clara , Limonero Joaquín T.
Published: January 2017

This chapter assesses the benefits of the Spanish version of meaning-centered group psychotherapy (MCGP). A pilot study was conducted from 2013 to 2015, and a qualitative analysis of themes that emerged from the pilot groups of MCGP was performed to study the efficacy of this Spanish model of psychotherapy in patients with advanced cancer (stage IV). Each of the eight group sessions addresses a specific topic: introduction to the concept of meaning (1), cancer and meaning (2), history of the concept of meaning (3 and 4), sources of meaning (5–7), and closing (8). Utilizing outcome measures validated for this sample, primarily the changes in emotional and spiritual well-being were evaluated. A practical manual of the Spanish version of MCGP and a protocol for training of future therapists have been developed to facilitate the delivery of this type of psychotherapeutic intervention in other cancer centers in Spain.
Case 3
Authors: Scoutt Leslie M. , Hamper Ulrike M. , Angtuaco Teresita L.
Published: January 2017

This is a case from the Gynecology section of Ultrasound. The specific content of each case and its diagnosis are necessarily hidden from this abstract. Each case contains case history, followed immediately by the diagnosis, which is supported with findings, differential diagnosis, teaching points, management, and further reading suggestions.
Case 6
Authors: Scoutt Leslie M. , Hamper Ulrike M. , Angtuaco Teresita L.
Published: January 2017

This is a case from the Gynecology section of Ultrasound. The specific content of each case and its diagnosis are necessarily hidden from this abstract. Each case contains case history, followed immediately by the diagnosis, which is supported with findings, differential diagnosis, teaching points, management, and further reading suggestions.
Case 7
Authors: Scoutt Leslie M. , Hamper Ulrike M. , Angtuaco Teresita L.
Published: January 2017

This is a case from the Gynecology section of Ultrasound. The specific content of each case and its diagnosis are necessarily hidden from this abstract. Each case contains case history, followed immediately by the diagnosis, which is supported with findings, differential diagnosis, teaching points, management, and further reading suggestions.
Case 9
Authors: Scoutt Leslie M. , Hamper Ulrike M. , Angtuaco Teresita L.
Published: January 2017

This is a case from the Gynecology section of Ultrasound. The specific content of each case and its diagnosis are necessarily hidden from this abstract. Each case contains case history, followed immediately by the diagnosis, which is supported with findings, differential diagnosis, teaching points, management, and further reading suggestions.
Case 13
Authors: Scoutt Leslie M. , Hamper Ulrike M. , Angtuaco Teresita L.
Published: January 2017

This is a case from the Gynecology section of Ultrasound. The specific content of each case and its diagnosis are necessarily hidden from this abstract. Each case contains case history, followed immediately by the diagnosis, which is supported with findings, differential diagnosis, teaching points, management, and further reading suggestions.
Case 15
Authors: Scoutt Leslie M. , Hamper Ulrike M. , Angtuaco Teresita L.
Published: January 2017

This is a case from the Gynecology section of Ultrasound. The specific content of each case and its diagnosis are necessarily hidden from this abstract. Each case contains case history, followed immediately by the diagnosis, which is supported with findings, differential diagnosis, teaching points, management, and further reading suggestions.