Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk : the COSMOS randomised controlled trial

Objective  To determine whether primary midwife care (caseload midwifery) decreases the caesarean section rate compared with standard maternity care.

Design  Randomised controlled trial.

Setting  Tertiary-care women’s hospital in Melbourne, Australia.

Population  A total of 2314 low-risk pregnant women.

Methods  Women randomised to caseload received antenatal, intrapartum and postpartum care from a primary midwife with some care by ‘back-up’ midwives. Women randomised to standard care received either midwifery or obstetric-trainee care with varying levels of continuity, or community-based general practitioner care.

Main outcome measures  Primary outcome: caesarean birth. Secondary outcomes included instrumental vaginal births, analgesia, perineal trauma, induction of labour, infant admission to special/neonatal intensive care, gestational age, Apgar scores and birthweight.

Results  In total 2314 women were randomised–1156 to caseload and 1158 to standard care. Women allocated to caseload were less likely to have a caesarean section (19.4% versus 24.9%; risk ratio [RR] 0.78; 95% CI 0.67–0.91; P = 0.001); more likely to have a spontaneous vaginal birth (63.0% versus 55.7%; RR 1.13; 95% CI 1.06–1.21; P < 0.001); less likely to have epidural analgesia (30.5% versus 34.6%; RR 0.88; 95% CI 0.79–0.996; P = 0.04) and less likely to have an episiotomy (23.1% versus 29.4%; RR 0.79; 95% CI 0.67–0.92; P = 0.003). Infants of women allocated to caseload were less likely to be admitted to special or neonatal intensive care (4.0% versus 6.4%; RR 0.63; 95% CI 0.44–0.90; P = 0.01). No infant outcomes favoured standard care.

Conclusion  In settings with a relatively high baseline caesarean section rate, caseload midwifery for women at low obstetric risk in early pregnancy shows promise for reducing caesarean births.

Surgical accountability in the 1880s: the death of Susan Nixon

Susan Nixon died in 1881 following a surgical error. Her surgeon, Dr W. E. Warren, excised a normal 7-month gravid uterus under the misapprehension that he was removing a tubular pregnancy. It is believed that Mrs Nixon was the first woman in Australia to have an abdominal hysterectomy and the second to have a live Caesarean section. The surgical misadventure that resulted in Mrs Nixon's death became a public scandal, which gained currency through both parliamentary debate and the popular press.

The purpose of referring to this case is to explore the mechanisms of accountability that surgeons faced in the 1880s − a decade of rapid change in the practice of surgery. The response of late nineteenth century society to surgical error and the resultant reaction of the medical profession have resonances that are relevant to surgeons practising today.

COSMOS: COmparing standard maternity care with one-to-one midwifery support: a randomised controlled trial

Background: In Australia and internationally, there is concern about the growing proportion of women giving birth by caesarean section. There is evidence of increased risk of placenta accreta and percreta in subsequent pregnancies as well as decreased fertility; and significant resource implications. Randomised controlled trials (RCTs) of continuity of midwifery care have reported reduced caesareans and other interventions in labour, as well as increased maternal satisfaction, with no statistically significant differences in perinatal morbidity or mortality. RCTs conducted in the UK and in Australia have largely measured the effect of teams of care providers (commonly 6–12 midwives) with very few testing caseload (one-to-one) midwifery care. This study aims to determine whether caseload (one-to-one) midwifery care for women at low risk of medical complications decreases the proportion of women delivering by caesarean section compared with women receiving 'standard' care. This paper presents the trial protocol in detail.

Methods/design: A two-arm RCT design will be used. Women who are identified at low medical risk will be recruited from the antenatal booking clinics of a tertiary women's hospital in Melbourne, Australia. Baseline data will be collected, then women randomised to caseload midwifery or standard low risk care. Women allocated to the caseload intervention will receive antenatal, intrapartum and postpartum care from a designated primary midwife with one or two antenatal visits conducted by a 'back-up' midwife. The midwives will collaborate with obstetricians and other health professionals as necessary. If the woman has an extended labour, or if the primary midwife is unavailable, care will be provided by the back-up midwife. For women allocated to standard care, options include midwifery-led care with varying levels of continuity, junior obstetric care and community based general medical practitioner care. Data will be collected at recruitment (self administered survey) and at 2 and 6 months postpartum by postal survey. Medical/obstetric outcomes will be abstracted from the medical record. The sample size of 2008 was calculated to identify a decrease in caesarean birth from 19 to 14% and detect a range of other significant clinical differences. Comprehensive process and economic evaluations will be conducted.

Trial registration: Australian New Zealand Clinical Trials Registry ACTRN012607000073404.

Maternal creatine supplementation during pregnancy prevents long-term changes in diaphragm muscle structure and function after birth asphyxia

Using a model of birth asphyxia, we previously reported significant structural and functional deficits in the diaphragm muscle in spiny mice, deficits that are prevented by supplementing the maternal diet with 5% creatine from mid-pregnancy. The long-term effects of this exposure are unknown. Pregnant spiny mice were fed control or 5% creatine-supplemented diet for the second half of pregnancy, and fetuses were delivered by caesarean section with or without 7.5 min of in-utero asphyxia. Surviving pups were raised by a cross-foster dam until 33±2 days of age when they were euthanized to obtain the diaphragm muscle for ex-vivo study of twitch tension and muscle fatigue, and for structural and enzymatic analyses. Functional analysis of the diaphragm revealed no differences in single twitch contractile parameters between any groups. However, muscle fatigue, induced by stimulation of diaphragm strips with a train of pulses (330 ms train/sec, 40 Hz) for 300 sec, was significantly greater for asphyxia pups compared with controls (p<0.05), and this did not occur in diaphragms of creatine + asphyxia pups. Birth asphyxia resulted in a significant increase in the proportion of glycolytic, fast-twitch fibres and a reduction in oxidative capacity of Type I and IIb fibres in male offspring, as well as reduced cross-sectional area of all muscle fibre types (Type I, IIa, IIb/d) in both males and females at 33 days of age. None of these changes were observed in creatine + asphyxia animals. Thus, the changes in diaphragm fatigue and structure induced by birth asphyxia persist long-term but are prevented by maternal creatine supplementation.

Permian brachiopods from the Selong Xishan section, Xizang (Tibet), China. Part 2: palaeobiogeographical and palaeoecological implications, spiriferida, athyridida and terebratulida

Brachiopods from the Selong Group at the Selong Xishan section indicate a typical Peri-Gondwanan affinity, but possibly a rapid invasion of tropical/subtropical Tethyan elements into the Himalayan region at the very end of Permian. A brief analysis of taphonomy and composition of the Selong fauna indicate that Selong Xishan lay on the shallow continental shelf near shore and brachiopods suffered substantial abrasion from contemporaneous wave action. Species of Spiriferida, Athyridida and Terebratulida are herein described and revised. New taxa are Nakmusiella selongensis nov. gen. et sp. and ? Bullarina striata nov. sp.

Section 46:where we have been and where we are going: a review of the recent debate

Two recent reviews of Part IV of the Trade Practices Act (Commonwealth) (1974) have looked specifically at the operation of Section 46 of this Act and have come to very different conclusions concerning its efficacy. The Dawson review (2003) argued that no change to S 46 was required as the courts were providing sufficient guidance in the application of the legislation in this respect. The Senate Committee review (2004) came to different conclusions arguing that the Act needed clarification in regard to certain sections. These reports highlight the controversy that has surrounded this section of the Trade Practices Act for the past thirty years. The aim of this paper is to consider these reviews and evaluate the extent to which the High Court has been able to provide guidance in the application of legislation that prohibits the misuse of market power.

Directors' personal liability-is the proposed amendment to Section 197 acceptable when compared with Hanel v O'Neill?

On 2 June 2005, the Australian Government announced a proposal to amend s. 197 of the Corporations Act. This is to overturn the decision in Hanel v. O'Neill ("Hanel") where the South Australian Supreme Court has expanded the circumstances in which directors of trustee companies can be held personally liable for the debts under the current section 197(1) of the Corporations Act 2001 (Cth). The multiple interpretations presented in Hanel highlighted the uncertainty of s. 197 and this uncertainty is heightened in at least two subsequent cases. The article provides a detailed analysis of how the decision in Hanel is affecting the directors' freedom of management and suggests some precautionary measures that the directors could take as protection against creditor's actions under s. 197. The author welcomes the proposed amendment because the new section will create certainty for directors as to. the scope of their potential personal liability, but contends that the substance of the proposed s. 197 is not acceptable as there is potential for abuse by directors of certain trustee companies.

Section 46 of the Trade Practices Act-has the High Court made a "u-turn" on "taking advantage"?

Examination of High Court decisions on misuse of market power in regard to the element of "taking advantage" reveals inconsistency of application. Whilst being consistent regarding the need for a connection between the market power and the impugned conduct, the High Court has not been consistent regarding the degree of connection required. Two streams have developed, one supporting a high degree of connection, the other a lower degree before a firm is found to have "taken advantage" of its market power. Added to this has been the development of the "rational business explanation" which, it is argued, is either used as a defence to a s 46 action or is premised on the higher threshold of connection. Initially the high Court supported the lower threshold. In later decisions, whilst expressing support for the earlier decisions, in application the High Court favoured the higher threshold and at one point the rational business explanation. This trend appears to have been reversed with the most recent High Court decision which indicates substantive support for the earlier s 46 decisions.

Recent amendment to section 197- is it acceptable?

The majority decided in Hanel v O’Neill that directors of trustee companies
could be held personally liable to discharge the debts incurred by a
company pursuant to s 197(1) of the Corporations Act 2001 (Cth). On
18 November 2005, legislation was passed to amend s 197(1); this was to
overturn the decision. This article evaluates other relevant cases and
argues that the recent amendment to s 197 is unsatisfactory as it leaves
potential for abuse by directors of certain trustee companies. The article
suggests further reform to the section and to this end, suggests ways for
s 197 to reconcile with other parts of corporate law, such as insolvent
trading and directors’ duties.

The Age (Education section) 2003 -

Dr Marcia Devlin is an educational psychologist and Professor of Higher Education Research at Deakin University. Marcia has a broad and extensive publication record in the scholarship of teaching and learning that incorporates academic development, student learning support and the use of information and communication technologies in teaching and learning. She writes regularly for The Age and Campus Review newspapers.

Unique marine Permian-Triassic boundary section from Western Australia

A unique marine Permian-Triassic boundary section containing rich oil source rocks has been continuously cored in a petroleum borehole from the Perth Basin of Western Australia. Such sequences, which provide a biostratigraphic and environmental record at the time of the largest extinction event of the past 500 million years, are globally rare, and this is the first to be documented in Australia. Throughout geological history there have been periods of global marine anoxia that commonly resulted in the widespread deposition of petroleum source rocks, most notably in the mid-Cretaceous and Late Jurassic. An apparent paradox is that, previously, source rocks have not been recognised in association with the Permian-Triassic boundary, despite widespread marine anoxia at this time. The Perth Basin source rocks contain abundant and unusual biomarkers, apparently related to the highly specialised and limited biota that flourished in the aftermath of the end-Permian extinction event. Local conditions may have favoured source-rock development, either due to higher productivity resulting from coastal upwelling or through enhanced preservation under strongly anoxic conditions.

Fusulinoideans from the early Midian (late Middle Permian) Metadoliolina dutkevitchi-Monodiexodina sutchanica Zone of the Senkina Shapka section, South Primorye, Far East Russia.

Fusulinoideans from the Metadoliolina dutkevitchi-Monodiexodina sutchanica Zone of the lower part of the Chandalaz Formation in the Senkina Shapka section in South Primorye, Far East Russia, are described. The fusulinoidean zone is assigned to the early Midian (=Capitanian: late Middle Permian) based mainly on the morphologie and biostratigraphic characteristics of Metadoliolina dutkevitchi. Previously, a Midian age has been established for the Metadoliolina dutkevitchi-Monodiexodina sutchanica Zone by the coexistence of Lepidolina species. However, the occurrence of Lepidolina with the two zonal species in this area has not been verified by the illustration of Lepidolina specimens. We examined a fusulinoidean-bearing sample from the Metadoliolina dutkevitchi-Monodiexodina sutchanica Zone, and three fusulinoidean species, Monodiexodina sutchanica, Pseudofusulina sp. and Metadoliolina dutkevitchi, are de-scribed and illustrated.

Acetylcysteine for prevention of acute deterioration of renal function following elective coronary angiography and intervention

Context The antioxidant acetylcysteine prevents acute contrast nephrotoxicity in patients with impaired renal function who undergo computed tomography scanning. However, its role in coronary angiography is unclear.

Objective To determine whether oral acetylcysteine prevents acute deterioration in renal function in patients with moderate renal insufficiency who undergo elective coronary angiography.

Design and Setting Prospective, randomized, double-blind, placebo-controlled trial conducted from May 2000 to December 2001 at the Grantham Hospital at the University of Hong Kong.

Participants Two hundred Chinese patients aged mean (SD) 68 (6.5) years with stable moderate renal insufficiency (creatinine clearance <60 mL/min [1.00 mL/s]) who were undergoing elective coronary angiography with or without intervention.

Intervention Participants were randomly assigned to receive oral acetylcysteine(600 mg twice per day; n = 102) or matching placebo tablets (n = 98) on the day before and the day of angiography. All patients received low-osmolality contrast agent.

Main Outcome Measures Occurrence of more than a 25% increase in serum creatinine level within 48 hours after contrast administration; change in creatinine clearance and serum creatinine level.

Results Twelve control patients (12%) and 4 acetylcysteine patients (4%) developed a more than 25% increase in serum creatinine level within 48 hours after contrast administration (relative risk, 0.32; 95% confidence interval [CI], 0.10-0.96; P = .03). Serum creatinine was lower in the acetylcysteine group (1.22 mg/dL [107.8 µmol/L]; 95% CI, 1.11-1.33 mg/dL vs 1.38 mg/dL [122.9 µmol/L]; 95% CI, 1.27-1.49 mg/dL; P = .006) during the first 48 hours after angiography. Acetylcysteine treatment significantly increased creatinine clearance from 44.8 mL/min (0.75 mL/s) (95% CI, 42.7-47.6 mL/min) to 58.9 mL/min (0.98 mL/s) (95% CI, 55.6-62.3 mL/min) 2 days after the contrast administration (P<.001).The increase was not significant in the control group (from 42.1 to 44.1 mL/min [0.70 to 0.74 mL/s]; P = .15). The benefit of acetylcysteine was consistent among various patient subgroups and persistent for at least 7 days. There were no major treatment-related adverse events.

Conclusion Acetylcysteine protects patients with moderate chronic renal insufficiency from contrast-induced deterioration in renal function after coronary angiographic procedures, with minimal adverse effects and at a low cost.