D P Southall’s research while affiliated with University of Staffordshire and other places

Background Russian’s invasion of Ukraine has seriously disrupted perinatal care. In a humanitarian initiative, emergency obstetric and neonatal equipment and drugs were provided by Maternal and Childhealth Advocacy International and distributed by Ukrainian partners to a selected 61 maternity hospitals throughout Ukraine. The programme included engaging mothers in labour to undertake fetal heart rate monitoring using a battery operated, portable, doppler ultrasound probe. This paper describes some characteristics of participants and analyses differences in fetal distress management and maternal / neonatal outcomes following different approaches to fetal health surveillance. Methods Data from 28,808 births were collected in specially developed database which contained information on maternal characteristics, course of pregnancy and childbirth, maternal and neonatal outcomes and donated drugs and equipment used. After informed consent, mothers (n = 13735) who agreed to use in labour fetal self-monitoring in addition to standard intrapartum fetal health surveillance, monitored and recorded fetal heart rate changes on a “contraction-by-contraction” basis into a special form. Data on maternal experience with self-monitoring were collected. Cases where fetal heart rate changes were identified (n = 1434) were extracted and analysed for differences in case management and maternal and neonatal outcomes in different approaches: joint monitoring (mother plus staff, n = 901) vs. staff only monitoring (n = 533) and different actors in case of joint monitoring (mothers, n = 512, vs. staff, n = 389). Results Vacuum assisted delivery was utilised in only < 2% cases. Caesarean section rate was 27%. Mothers reported their experience with self-monitoring as great or good in 79%. Preterm deliveries were less frequent where fetal monitoring was provided by both staff and mothers jointly. In the staff plus mother group, more often lateral tilt, intravenous fluid, spontaneous vaginal and vacuum assisted delivery and less often caesarean sections were undertaken even when fetal distress alone was an indication for operative delivery at term pregnancy. Conclusion Involvement of women may help to make delivery safer for mothers as complications may be recognized earlier and appropriately treated. Overall, the data shows that despite the full-scale war in Ukraine, it remained possible for high quality perinatal health care to continue.

Emergency medicine health workers have major roles in managing the clinical effects of armed conflict and domestic abuse on women and children. To safeguard vulnerable people from such criminal abuse, there is an urgent need for international and domestic action. International and national legal systems need to work more rapidly and efficiently with immediate power to protect against, and prevent, such abuse. Internationally, the current weakness of the United Nations Security Council to provide civilian protection, such as through UN troops on the ground and no-fly zones over conflict areas, and thereby minimise the effects of armed conflict on civilians, can, and has, largely resulted from self-serving, dangerous vetoes of the 5 permanent members with major conflicts of interest, in part related to their role in the manufacturing and global distribution of weapons. The International Court of Justice and the International Criminal Court have little immediate power to protect civilians affected by war crimes, including abuse, which breach the Geneva and other International Conventions. To date, the number of war criminals convicted by the International Criminal Court is incredibly small, and the long delay in the Courts’ decisions mean that the consequences of the war crimes sometimes continue for years. We describe new systems to better protect women and children from abuse in the home. We propose a new definition that separates ill treatment from criminal abuse that is undertaken for gain by perpetrators (who are often carers or intimate partners with antisocial personality disorders). Ill treatment undertaken within families experiencing adversity such as homelessness, poverty, displacement, and addiction requires compassion and socio-economic support. In contrast the crimes of abuse committed for gain require stronger forensic approaches investigated and addressed by special, inter-agency, forensic taskforce units led by senior experienced detectives in partnership with social, healthcare, and legal professionals. We also discuss additional issues linked to abuse, such as the links between animal/pet abuse and human abuse, the need for better systems to prevent and protect children living in institutions, better regulation of social media to protect children from scenes of violence and sexual abuse, and gun control needed to protect children, especially in the USA.

Background: In low-resource settings with few health workers, Fetal Heart Rate (FHR) monitoring in labour can be inconsistent and unreliable. An initiative to improve fetal monitoring was implemented in two public hospitals in rural Liberia; the country with the second lowest number of midwives and nurses in the world (1.007 per 10,000 of the population). The initiative assessed the feasibility of educating women in labour to monitor their own FHR and alert a midwife of changes detected.Methods and Interventions: 474 women admitted in labour without obstetric complications were approached. 461 consented to participate (97%) and 13 declined. Those consenting were trained to monitor their FHR using a sonicaid for approximately one minute immediately following the end of every uterine contraction and to inform a midwife of changes. If changes were confirmed, standard clinical interventions for fetal distress (lateral tilt, intravenous fluids and oxygen) were undertaken and, when appropriate, accelerated delivery by vacuum or Caesarean section. Participants provided views on their experiences; subsequently categorized into themes. Neonatal outcomes regarding survival, need for resuscitation, presence of birth asphyxia, and treatment were recorded.Results: 461 out of 474 women gave consent, of whom 425 (92%) completed the monitoring themselves. 387 of 400 women who gave comments, reported positive and 13 negative experiences. 28 participants reported FHR changes, confirmed in 26 cases with meconium stained liquor in 17. Fetal death was identified on admission during training in one mother. 13 neonates required resuscitation, with 12 admitted to the neonatal unit. One developed temporary seizures suggesting birth asphyxia. All 26 neonates were discharged home apparently well. In 2 mothers, previously unrecognized obstetric complications (cord prolapse and Bandl’s ring with obstructed labour) accompanied FHR changes. Resuscitation was needed in 8 neonates without identified FHR changes including one of birth weight 1.3 Kg who could not be resuscitated. There were no intrapartum stillbirths in participants. Conclusions: Women in labour were able to monitor and detect changes in their FHR. Most found the experience beneficial. The absence of intrapartum stillbirths after admission and the low rate of poor neonatal outcomes are promising and warrant further investigation.

Background: In low-resource settings with few health workers, Fetal Heart Rate (FHR) monitoring in labour can be inconsistent and unreliable. An initiative to improve fetal monitoring was implemented in two public hospitals in rural Liberia; the country with the second lowest number of midwives and nurses in the world (1.007 per 10,000 of the population). The initiative assessed the feasibility of educating women in labour to monitor their FHR and alert a midwife of changes detected.Methods and Interventions: 474 womenadmitted in labour without obstetric complications were approached. 461 consented to participate (97%) and 13 declined. Those consenting were trained to monitor their FHR using a sonicaid for approximately one minute immediately following the end of every uterine contraction and to inform a midwife of changes. If changes were confirmed, standard clinical interventions for fetal distress (lateral tilt, intravenous fluids and oxygen) were undertaken and, when appropriate, accelerated delivery by vacuum or Caesarean section. Participants provided views on their experiences; subsequently categorized into themes. Neonatal outcomes regarding survival, need for resuscitation, presence of birth asphyxia, and treatment were recorded.Results: 461 out of 474 women gave consent, of whom 425 (92%) completed the monitoring themselves. 387 of 400 women who gave comments, reported positive and 13 negative experiences.28 participants reported FHR changes, confirmed in 26 cases with meconium stained liquor in 17. Fetal death was identified on admission during training in one mother. 13 neonates required resuscitation, with 10 admitted to the neonatal unit. One developed temporary seizures suggesting birth asphyxia. All 26 neonates were discharged home apparently well. In 2 mothers, previously unrecognized obstetric complications (cord prolapse and Bandl’s ring with obstructed labour) accompanied FHR changes. Resuscitation was needed in 8 neonates without identified FHR changes including one of birth weight 1.3 Kg who could not be resuscitated. There were no intrapartum stillbirths in participants. Conclusions: Women in labour were able to monitor and detect changes in their FHR. Most found the experience beneficial. The absence of intrapartum stillbirths after admission and the low rate of poor neonatal outcomes are promising and warrant further investigation.

Background: In low-resource settings with few health workers, the Fetal Heart Rate (FHR) in women in labour can be inadequately monitored contributing to poor outcomes. An initiative to improve fetal monitoring was implemented in two public hospitals in rural Liberia with extremely limited health workforces, to assess the feasibility of educating women in labour to monitor their FHR and alert their attending midwife of any changes which might indicate fetal distress. Methods and Interventions: Over 15 months, 474 women admitted in labour without obstetric complications were approached. After informed consent, 461 agreed (97%) and 13 refused. Those consented were trained to monitor the FHR using a sonicaid for approximately one minute immediately after the end of every uterine contraction and inform her midwife of changes. If relevant changes were confirmed, standard clinical interventions for possible fetal distress (lateral tilt and intravenous fluids and glucose) and, when appropriate, accelerated delivery by vacuum or Caesarean section were undertaken. Participants provided views on their monitoring experience; subsequently categorized into themes. Neonatal outcomes regarding survival, need for resuscitation, presence of birth asphyxia, and treatment were recorded. Results: 461 out of 474 women gave consent, of whom 426 (92%) completed the monitoring themselves. 386 (97%) of 400 who gave comments, reported positive experiences and 14 reported only negative experiences. 28 participants identified FHR changes, confirmed in 26 cases. Meconium stained liquor accompanied FHR changes in 18 of these 26 (69%). 13 of these 26 neonates required resuscitation, with 10 admitted to the neonatal unit. One developed temporary seizures suggesting birth asphyxia. All 26 neonates were discharged home apparently well. In 2 mothers, previously unrecognized obstetric complications (cord prolapse and Bandl’s ring with obstructed labour) accompanied FHR changes. Resuscitation was needed in 8 neonates without identified FHR changes. One (birth weight 1.3 Kg) could not be resuscitated. There were no intrapartum stillbirths or maternal deaths in participants. Conclusions: Women in labour were able to monitor and detect changes in their FHR. Most found the experience positive and empowering. The absence of intrapartum stillbirths and low number of poor neonatal outcomes are promising but warrant further research.

Background: In low-resource settings with few health workers, Fetal Heart Rate (FHR) monitoring in labour can be inconsistent and unreliable. An initiative to improve fetal monitoring was implemented in two public hospitals in rural Liberia; the country with the second lowest number of midwives and nurses in the world (1.007 per 10,000 of the population). The initiative assessed the feasibility of educating women in labour to monitor their own FHR and alert a midwife of changes detected. Methods: 474 women admitted in labour without obstetric complications were approached. 461 consented to participate (97%) and 13 declined. Those consenting were trained to monitor their FHR using a sonicaid for approximately one minute immediately following the end of every uterine contraction and to inform a midwife of changes. If changes were confirmed, standard clinical interventions for fetal distress (lateral tilt, intravenous fluids and oxygen) were undertaken and, when appropriate, accelerated delivery by vacuum or Caesarean section. Participants provided views on their experiences; subsequently categorized into themes. Neonatal outcomes regarding survival, need for resuscitation, presence of birth asphyxia, and treatment were recorded. Results: 461 out of 474 women gave consent, of whom 425 (92%) completed the monitoring themselves. 387 of 400 women who gave comments, reported positive and 13 negative experiences. 28 participants reported FHR changes, confirmed in 26 cases with meconium stained liquor in 17. Fetal death was identified on admission during training in one mother. 13 neonates required resuscitation, with 12 admitted to the neonatal unit. One developed temporary seizures suggesting birth asphyxia. All 26 neonates were discharged home apparently well. In 2 mothers, previously unrecognized obstetric complications (cord prolapse and Bandl’s ring with obstructed labour) accompanied FHR changes. Resuscitation was needed in 8 neonates without identified FHR changes including one of birth weight 1.3 Kg who could not be resuscitated. There were no intrapartum stillbirths in participants. Conclusions: Women in labour were able to monitor and detect changes in their FHR. Most found the experience beneficial. The absence of intrapartum stillbirths after admission and the low rate of poor neonatal outcomes are promising and warrant further investigation.

The latest predictions regarding the spread of Ebola in west Africa are alarming and leave little time for effective action.1 2 A possible solution would be to transfer Ebola positive patients to suitable “isolation hospitals” in well resourced countries. Our recent experience in Liberia suggests there is too little time to create and staff enough Ebola treatment units (ETUs) to control the epidemic.3 In west Africa, increasing numbers of …

Kiguli and colleagues (authors of the FEAST study) did not deal with one concern that was raised at a World Health Organization expert meeting on the fluid management of shock in children in March 2013.1 At this meeting, I raised the question of whether the nature of the intravenous fluids given might have influenced the results. In particular, I was worried that 0.9% saline was the main additional fluid given. Also of concern is that, according to a …