Littérature scientifique sur le sujet « MED/47 - SCIENZE INFERMIERISTICHE OSTETRICO-GINECOLOGICHE »

Background: no standard treatment are avaliable for patients with locally advanced or recurrent vulvar cancer Patients and Methods:35 patients with recurrent and 26 patients with locally advanced vulvar cancer received paclitaxel/cisplatin and or without ifosfamide every 3 weeks for up to 6 cycles. Primary objective was response rate and operability rate. Secondary objective were response duration and toxicity. Response evaluation was assessed by WHO criteria; tossicity according to common toxicity criteria. Results: Sixty-one women were included with a median age of 75 (range 43-85). On study patients receveid a median of 6 cycles. Safety: grade 3 and 4 neutropenia was seen in eleven patients (11/61=18%). Efficay: overall response was 65,3%(17/26; n 17= 2 complete responses+15 partial responses)in patients with locally advanced vulvar cancer.Overall response was 40% (14/35; n 14= 2 complete responses+12 partial responses) in patients with recurrent vulvar cancer. With amedian follow-up of 24 months, median PFS was 13 months in patients with locally advanced vulvar cancer and 9 months in patients with recurrent vulvar cancer. Operability rate was 73% in patients with locally advanced vulvar cancer and 49% in patients with recurrent vulvar cancer Conclusion: this treatment allows moderate control of locally advanced and recurrent vulvar cancer with acceptable side effects

Introduction Many professional organizations recommend breastfeeding for the first 6 months due to the numerous benefits it has for mother and child. The mother’s breastfeeding experiences in the early postpartum period, are crucial in deciding to continue it. It is important to identify, in the first days after childbirth, women who send messages that are likely to early stop breastfeeding. Many women have said to have breastfeeding difficulties in the first days after birth. Several studies (Mozingo et al,2000; Hauck et al, 2002; Kong e Lee, 2004; Nelson, 2006) have explored the motivation of early breastfeeding cessation but little is known on what "breastfeeding difficulty" really means for women. Aim of the study The aim of this qualitative study was to understand what does "latching difficulty" mean for the Italian mothers. Exploring this meaning could consent to correctly utilize Breastfeeding Assessment Score, in which the investigation of “latching difficulty” is comprised. In addition, further investigation of this topic is aimed to understand how healthcare professional could help women with latching difficulties. Methods The women who received a Breastfeeding Assessment Score (BAS) (Hall et al, 2002) less than 8, and reported “latching difficulties”, were invited to participate in the study. With purposive sampling we recruited 15 women, 48-72 hours after childbirth. We conducted semi-structured interviews which were tape-recorded and verbatim transcribed. The transcripts were read and analyzed using the fenomenologic - ermeneutic approach. Results "Latching difficulty" is related to issues including both mother’s and infant’s difficulties. Nipple-pain and infant’s sleepiness were the most reported difficulties. In spite of these difficulties, the sensation related to breastfeeding was “happiness” when the baby sucked the breast, but concern and anxiety were common too. The women reported more impediment in overcoming the breastfeeding difficulty when there was an idealization of breastfeeding, during pregnancy. The analysis resulted in the emergence of six themes, sixteen category and fifty-nine labels. The six themes was the “breastfeeding can be difficult due to the mother or the newborn”, “breastfeeding can generate positive and negative experiences”, “breastfeeding change/not change the relationship between infant and mother, who is still favoured by rooming-in”, “the mothers have developed theories about colostrum, breast milk, breastfeeding and infant formula”, “the women have developed different strategies to overcome difficulties and continue during breastfeeding”, “support during breastfeeding is very important to continue breastfeeding”. Conclusion This study enriches the theoretical framework in understanding the dynamics that can contribute to early failure of breastfeeding in Italy. Practical relevance Understanding the meaning of the item “latching difficulty” consents to a more correct interpretation of the BAS (Hall et al, 2002) by the Italian midwives and allows a more accurate identification of the mothers who need support and education during breastfeeding Research implications Since this is a qualitative study, more research is needed to understand the “latching difficulty” in the Italian environment and in other cultures.

BACKGROUND: L’apprendimento clinico ricopre in ore più del 50% dell’esperienza educativa degli studenti dei Corsi di Laurea in Ostetricia in Italia. È risaputo come l’insegnamento pratico sia vitale per lo sviluppo del “saper fare” delle future/i professioniste/i ostetriche/i. La responsabilità di integrare e facilitare l’apprendimento degli studenti nello sfaccettato mondo della pratica clinica, spetta agli assistenti di tirocinio. Tuttavia poco si sa circa l’impatto che gli assistenti di tirocinio hanno sulle esperienze di apprendimento degli studenti di Ostetricia e criteri di comportamento sono stati definiti solo in piccola parte e teoricamente, pertanto restano spesso acritici. OBIETTIVI: Costruire e validare una scheda di valutazione del professionista, in qualità di assistente di tirocinio, ad uso degli studenti del Corso di Laurea in Ostetricia. METODI: Ricerca multicentrica, svolta presso i Corsi di Laurea in Ostetricia lombardi. Sono stati effettuati focus group coinvolgendo un totale di 88 studenti di secondo e terzo anno di corso. Viene costruita la scheda di valutazione dell’assistente di tirocinio sulla base di quanto emerso dai focus group ed è stata testata l’affidabilità attraverso l’alfa di Cronbach valutato sui valori di risposta ai diversi item della scheda, compilati da studenti e valutatori esperti (gold standard). RISULTATI: I focus group esplicitano il ruolo centrale dell’assistente di tirocinio nell'apprendimento degli studenti e le attitudini che dovrebbe avere. In particolare viene sottolineata la necessità di integrare l’insegnamento clinico a quello teorico svolto in aula, implementare un apprendimento basato sulle evidenze scientifiche, fornire feedback e correggere gli errori senza umiliare lo studente. A partire dagli item suggeriti dai focus group è stata costruita una scheda composta da 33 item. La scheda risulta avere coerenza interna. Questa è stata testata grazie a 3 item valutati come “variabili spia” in quanto il contenuto semantico è stato ritenuto affine e il punteggio atteso di Scala Likert è stato rilevato privo di contraddizioni. I punteggi per i tre item sono sovrapponibili nel gruppo dei gold standard e in quello degli studenti. Per l’affidabilità della scheda, è stato calcolato l’Alpha di Cronbach: questo è risultato 0,97 per i valutatori gold standard; 0,94 per gli studenti; 0,97 per le tre variabili spia nei valutatori gold standard e 0,85 per le tre variabili spia per gli studenti. CONCLUSIONI E IMPLICAZIONI PER LA PRATICA: Sono state identificate alcune caratteristiche fondamentali di un assistente di tirocinio efficace e, in base a queste, si è costruita e validata una scheda di valutazione dell’assistente di tirocinio in Ostetricia, di cui è possibile la compilazione da parte dello studente. L’utilizzo dello strumento consente di avere un metro di valutazione dell’operato degli assistenti di tirocinio utilizzabile nei singoli Corsi di Laurea in Ostetricia e uniformemente sul territorio nazionale. Ciò rende oggettivabile da parte delle direzioni didattiche la competenza richiesta agli assistenti di tirocinio e indirizza la formazione specifica.
BACKGROUND: In Italy, practice experience provides up to 50% of the educational Midwifery student’s curricula. It is recognised as an important part of clinical practice for preregistration students and is accepted as the preceptor’s responsibility, once in practice, to provide opportunities for effective learning. However, little is known about the impact that preceptors have on Midwifery students and their effectiveness on students’ perceptions of learning. OBJECTIVES: This study is aimed at creating and validating a tool to explore the perceptions of Midwifery students on their clinical preceptors and to gather opinions on how to improve the effectiveness of clinical preceptors. METHODS: A multicentric research has been conducted at Northern Italy Bachelors in Midwifery. Focus groups consisted of 88 second and third year students. A survey tool has been created, validity and reliability have been tested through gold standards and students assessors. RESULTS: From the focus groups, it emerged that midwifery clinical preceptors should bridge the gap between theory and practice, improve evidence based learning, give useful feedback and correct students mistakes without belittling them. A 33 items survey tool has been created. It has internal consistency. Reliability has been tested through Cronbach’s Alpha: 0,97 for gold standards assessors and 0,94 for students assessors. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These results imply that, from a student perspective, the ideal clinical teaching experience is heavily influenced by the preceptors’ behaviours. A survey tool specific for Midwifery students has been created and validated. The use of this tool allows for a uniform and country wide method of assessment of preceptors’ behaviours. Therefore, this gives headmasters the required tool to objectively measure a preceptor’s level of competence.

TITLE. Breastfeeding: validation of a reduced Breastfeeding Assessment Score (BAS) in a group of Italian women. AIM AND OBJECTIVE. To assess the accuracy of a reduced Breastfeeding Assessment Score (BAS) in a group of Italian women; the reduced BAS considers only 5 of the 8 original BAS items studied, those not indicating a pathology. BACKGROUND. The WHO and many Professional Organizations recommend exclusive breastfeeding for the first 6 months of life because of its many benefits for mother and child. A prognostic approach that identifies mothers at increased risk of early breastfeeding cessation is needed in order to provide preventive support. The BAS, elaborated in Kansas, is useful to this approach. DESIGN. This is a descriptive, prospective study. This study involves two Italian hospitals. METHOD. We included healthy Italian mothers who gave birth from July 7, 2008 to January 15, 2009. The exclusion criteria on the convenience sample were: non-Italian nationality, birth under 36 wks and twin birth. The authors calculated a reduced BAS (“reduced” because the original 8 items studied by Hall, were reduced to 5) 48 hours after birth. After 4 weeks a structured follow-up telephone interview was carried out: the primary outcome was breastfeeding cessation (including mixed feeding). RESULTS. We recruited 386 women, with 6 lost during follow-up. Out of 380 women, 127 (33.4%) stopped breastfeeding. With a cut off point of 8, the reduced BAS sensitivity was 52.0%, which increased to 77.9% by using a cut-off point of 9. We also calculated a modified BAS with different age categories, which is adequate based on the Italian situation: in this case sensitivity was 70.1%. This study suggests that a reduced BAS with a different cut-off point or modified with a different age classification is useful in identifying Italian mothers who will discontinue breastfeeding, as in both cases sensitivity does increase. RELEVANCE TO CLINICAL PRACTICE. Italian midwives could use this modified BAS to identify mothers at increased risk of early breastfeeding cessation needing special support.

Multicenter observational study using the procedures for risk assessment and / or prenatal diagnosis BACKGROUND The increased use of the screening test and prenatal diagnosis is closely correlated with the perception of risk. Often the perception of risk is adjusted according to the choice, some already made, even according to their family history and socio-cultural context. The causal relationship between real and perceived risk is very difficult to determine and many factors of different nature interfere. Often the lack of knowledge and understanding prevail in generating those feelings that lead women to make unconscious choices. OBJECTIVE The aim of the study was to evaluate the factors influencing choice of invasive techniques (CVS, amniocentesis) for prenatal diagnosis (PD) in a population of women, after childbirth, that delivery in S.Gerardo Hospital (Monza) and V.Buzzi Hospital (Milano). METHOD Structured interview in an unselected population of consecutive women (after childbirth) administered by 2 trained interviewers. The interview included social variables and clinical history, type of care during pregnancy, use of screening tests, and VAS (visual analogue scale, range from 1 to 10) of perceived risk of miscarriage due to amniocentesis (using risk of 1/200), and of a child with Down Syndrome (DS) (using a risk of 1/350). Both VAS investigated the perceived risk in term of intensity and acceptability (0 least risk and least acceptable to 10 most risk and more acceptable). Statistical analysis included logistic regression, in which all variables significant at univariate were entered, with p<0.01 or 95% CI not inclusive of unit considered significant. RESULTS 60% of women underwent screening test and 22% underwent invasive procedures. At logistic regression factors affecting the choice of screening test were: to have already had at least one miscarriage (OR=2,72 p=0,0016), to have received a consulance (OR=3,13 p=0,0017), number of visits during pregnance (OR=1,29 p=0,0003), wrong knowledge about test(OR=1,83 p=0,039). At logistic regression factors affecting the choice of invasive PD were: maternal age (OR 11,58 p<.0001),to be married (OR=0,23 p=0,005) to have received a consulance (OR=3,53 p=0,001) ,to be assisted in a public service (p=0,06), considering low the risk of miscarriage after amniocentesis (p=0,08). CONCLUSIONS: The choices regarding screening test and invasive PD are influenced by type of assistance, while social variables are less involved. The counselling should consider factors involved in perceiving risks.

Parto prematuro e canto materno: effetti sull’attaccamento post-natale, sul benessere neonatale e sull’allattamento. Studio randomizzato controllato. TIN-Lullabies 2013 Abstract Background: Mother- infant bonding has a well-established importance for the development, cognitive and behavioral well-being of the baby. Consider a premature birth: mother and infant are in a situation of greater vulnerability. That's why it is even more necessary that midwives must provide for the protection of their health. In this context, the use of maternal singing to the baby could be a tool to suggest mothers to be able to get into the complexity of the situation through a simple but significant and direct channel. Therefore, singing could be a connection that helps the mother and the baby to keep together in a situation in which contact is limited. Mother’s singing could increase the development of the attachment bond, that is crucial for the future health of the child. Objectives: To assess the effect of lullaby maternal singing on postnatal attachment after a premature birth; to evaluate the effect of lullaby maternal singing on wellbeing and behavior of the newborn and on type of feeding up to 3.5 months after randomization. Methods:: It is a single-center randomized controlled trial. Mother and infant whose birth took place between 32 and 34 gestational weeks will be enrolled at Maternal and Neonatal Department at San Gerardo Hospital in Monza. A total of at least 128 new mothers must be included in the study. The recruitment will be done within 48 hours of birth. The data collection will begin after the recruitment and it will end at 3.5 months from randomization. The demographic, social, obstetric data of mother and newborn will be detected and recorded in an appropriate form. The Postnatal Attachment (mother-infant) will be evaluated through Mother-to-Infant Bonding Scale. Data about infant’s vital signs will be taken from the computerized clinical documentation. The data about breastfeeding will be taken during the intermediate evaluations during the hospitalization of babies in NICU and will continue after returning home. Results: The research aims to analyze the effect of maternal singing of lullaby on post-natal attachment, well-being and behavior of the newborn, as well as the type of breastfeeding from birth to 3.5 months after enrollment in a sample of mothers and premature infants whose birth took place between 32 and 34 gestational weeks. Conclusions: Maternal singing of lullaby could be another instrument that midwives can use during the assistance with mothers who live the experience of a premature birth. It could be a stimulus to increase mother-infant attachment and improve neonatal growth.

Abstract. Title: Breastfeeding: validation of a reduced Breastfeeding Assessment Score (BAS) in a group of Italian women Aim and objective. To assess the accuracy of a reduced Breastfeeding Assessment Score (BAS) in a group of Italian women; the reduced BAS considers only 5 of the 8 original BAS items studied, those not indicating a pathology. Background. The WHO and many Professional Organizations recommend exclusive breastfeeding for the first 6 months of life because of its many benefits for mother and child. A prognostic approach that identifies mothers at increased risk of early breastfeeding cessation is needed in order to provide preventive support. The BAS, elaborated in Kansas, is useful to this approach. Design. This is a descriptive, prospective study. This study involves two Italian hospitals. Method. We included healthy Italian mothers who gave birth from July 7, 2008 to January 15, 2009. The exclusion criteria on the convenience sample were: non-Italian nationality, birth under 36 wks and twin birth. The authors calculated a reduced BAS (“reduced” because the original 8 items studied by Hall, were reduced to 5) 48 hours after birth. After 4 weeks a structured follow-up telephone interview was carried out: the primary outcome was breastfeeding cessation (including mixed feeding). Results. We recruited 386 women, with 6 lost during follow-up. Out of 380 women, 127 (33.4%) stopped breastfeeding. With a cut off point of 8, the reduced BAS sensitivity was 52.0%, which increased to 77.9% by using a cut-off point of 9. We also calculated a modified BAS with different age categories, which is adequate based on the Italian situation: in this case sensitivity was 70.1%. This study suggests that a reduced BAS with a different cut-off point or modified with a different age classification is useful in identifying Italian mothers who will discontinue breastfeeding, as in both cases sensitivity does increase. Relevance to clinical practice. Italian midwives could use this modified BAS to identify mothers at increased risk of early breastfeeding cessation needing special support.

Title: longitudinal and multicentre study and evaluation of the pre and early postnatal factors associated with the risk of childhood overweight and obesity. Location: Italy, Lombardia, centres for the monitoring of infants' body weight in Monza e Brianza ASL. Aim: evaluation of the anthropometric variations in children up to 6-7 months of life and their association with pre and postnatal factors. Study design and duration: multicentre cohort study. Subjects enrolled between March and October 2013 had been measured until the seventh month of life in four occasions. Inclusion criteria: mothers with children within 60 days of life, who attended the centres to monitor the growth of their children; the only exclusion criterion was the ignorance of the Italian language. Data collection: weight and length assessment, self-administration of a questionnaire. Statistical methods: 171 mother-child dyads. The anthropometric prenatal and parental data had been expressed as standard deviation score with the aim of removing the effects of age, sex and number of previous deliveries. The role of a set of covariates on the evolution of parental roles, breastfeeding and weaning has been analyzed with a generalised linear mixed model, based on binomial distribution and link logit. Weight growth (expressed as SDS) has been analyzed with an analogous linear mixed model, based on Gaussian distribution and identity link. Conclusions: the analysis showed that some prenatal factors and obstetrical variables, such as BMI and weight gain, have a direct role in determining the growth trends. These factors may be modified by the preventive approach that caracterises midwifery. Birthweight affects both maternal feeding choices for their children and growth trends. The study highlighted the role of father and health professionals of family care health centers, who can affect growth trend or growth related feeding choices, such as weaning timing.

One of the most important goals of modern obstetric care is to ensure compliance with the physiology while ensuring , with excellent supervision , good maternal and neonatal outcomes . The aim of this study was to analyze maternal and neonatal outcomes of pregnant women at term low risk ( nulliparous and multiparous ) admitted in spontaneous labor and midwife assisted autonomy in a level III center . We observed a group of low-risk women with a singleton pregnancy obstetrician , the situation in the longitudinal , cephalic presentation and admitted in spontaneous labor . Our hypothesis is that , in hospitals run by the midwife labor in women at low risk on admission may be a possible way to secure the de-medicalization . Maternal and neonatal outcomes considered were : type of delivery , episiotomy, , postpartum hemorrhage ( PPH) , transfusions , pH and Apgar score of newborns, the prevalence of SGA and LGA infants , admissions TIN , perinatal mortality . Women at low obstetric risk ( 50.3 % of all parts of the center ) have been assisted by the midwife autonomy , according to the protocol in place . Women who were in the stages of labor with obstetric risk and therefore become at risk obstetrician excluded from our work. Medical supervision for emerging risk factors in the first or second stage of labor was required in 16.1 % and 8.6 % of cases, respectively . Epidural analgesia was performed in 29.8 % of cases. , Although the latter group of women was not considered by the autonomy midwife . There are only 22.9 % of low-risk women recruited and managed autonomously by the midwife . The results suggest that in a hospital environment , labor, midwife managed independently in low-risk women with a lot of benefits can be realized without additional risks for the mother and the baby and avoiding complications due to transfers from other structures chosen for the confinement to ' hospital.