Background The number of caesarean sections (CS) is increasing globally, and repeat CS after a previous CS is a significant contributor to the overall CS rate. Vaginal birth after caesarean (VBAC) can be seen as a real and viable option for most women with previous CS. To achieve success, however, women need the support of their clinicians (obstetricians and midwives). The aim of this study was to evaluate clinician-centred interventions designed to increase the rate of VBAC. Methods The bibliographic databases of The Cochrane Library, PubMed, PsychINFO and CINAHL were searched for randomised controlled trials, including cluster randomised trials that evaluated the effectiveness of any intervention targeted directly at clinicians aimed at increasing VBAC rates. Included studies were appraised independently by two reviewers. Data were extracted independently by three reviewers. The quality of the included studies was assessed using the quality assessment tool, ‘Effective Public Health Practice Project’. The primary outcome measure was VBAC rates. Results 238 citations were screened, 255 were excluded by title and abstract. 11 full-text papers were reviewed; eight were excluded, resulting in three included papers. One study evaluated the effectiveness of antepartum x-ray pelvimetry (XRP) in 306 women with one previous CS. One study evaluated the effects of external peer review on CS birth in 45 hospitals, and the third evaluated opinion leader education and audit and feedback in 16 hospitals. The use of external peer review, audit and feedback had no significant effect on VBAC rates. An educational strategy delivered by an opinion leader significantly increased VBAC rates. The use of XRP significantly increased CS rates. Conclusions This systematic review indicates that few studies have evaluated the effects of clinician-centred interventions on VBAC rates, and interventions are of varying types which limited the ability to meta-analyse data. A further limitation is that the included studies were performed during the late 1980s-1990s. An opinion leader educational strategy confers benefit for increasing VBAC rates. This strategy should be further studied in different maternity care settings and with professionals other than physicians only.
MULTIFILE
Abstract: The key challenge of managing Floating Production Storage and Offloading assets (FPSOs) for offshore hydrocarbon production lies in maximizing the economic value and productivity, while minimizing the Total Cost of Ownership and operational risk. This is a comprehensive task, considering the increasing demands of performance contracting, (down)time reduction, safety and sustainability while coping with high levels of phenomenological complexity and relatively low product maturity due to the limited amount of units deployed in varying operating conditions. Presently, design, construction and operational practices are largely influenced by high-cycle fatigue as a primary degradation parameter. Empirical (inspection) practices are deployed as the key instrument to identify and mitigate system anomalies and unanticipated defects, inherently a reactive measure. This paper describes a paradigm-shift from predominant singular methods into a more holistic and pro-active system approach to safeguard structural longevity. This is done through a short review of several synergetic Joint Industry Projects (JIP’s) from different angles of incidence on enhanced design and operations through coherent a-priori fatigue prediction and posteriori anomaly detection and -monitoring.
