Introduction Midwifery models of care help to enhance perinatal health outcomes, women's satisfaction, and continuity of care. Despite the ubiquitous presence of certified midwives at births in Germany, no research has investigated the diversity of midwives' practice patterns. Describing the variety of working patterns through which midwives provide intrapartum care may contribute to improving the organisation of midwifery services. Methods This cross-sectional survey took place in the region of Hannover and Hildesheim, Germany. Midwives attending births and practicing in hospitals and/ or out-of-hospital were able to participate. Midwives who did not attend births were excluded. We assessed midwives' scope of services, practice locations, employment patterns, continuity of care, mid-wife-led births, and midwives' level of agreement with core values of midwifery care. The response rate of the survey was 32.7 % (69/211). Results We found that midwifery care services can be described according to midwives' employment patterns. The majority of midwives were employed in a hospital to provide intrapartum care (74.2 %, n = 49), and most also independently offered one or more antenatal and/ or postpartum service/s. Only 25.8 % (n = 17) of midwives offered their services independently (laborist model of care). Independent midwives attended births in all three possible settings: hospital, free-standing birth centres and home. Significantly more independent midwives than employed midwives offered antenatal care and lactation consulting. Compared to employed midwives, significantly more independent midwives provided antenatal, intrapartum, and postpartum care to the same women, were more likely to know women before labour, and to offer one-to-one care during labour. Discussion The most common practice pattern among surveyed midwives was 'employment in a hospital' for provision of intrapartum care with additional postpartum and few antenatal services provided on an independent basis. Midwives who worked solely independently reported more continuity and one-to-one intrapartum care with women. Most midwives did not work in patterns that offered continuity of care or consistently provide one-to-one care. Future research should assess whether women in Germany desire more services similar to caseload midwifery.

Zusammenfassung Einleitung Die Sicherheit der außerklinischen Geburt wird international unterschiedlich bewertet. In Deutschland können Frauen mit niedrigem Risiko ihren Geburtsort frei wählen. Landesspezifische Untersuchungen sind bisher selten, jedoch nötig, da die Gesundheitssysteme sehr variieren und eine Vergleichbarkeit der Studien erschweren. Methoden Klinische und geplante außerklinische Geburten wurden 2005 in Niedersachsen prospektiv mit dem gleichen Dokumentationsinstrument erhoben. Frauen mit Einlingsschwangerschaft in Schädellage mit avisierter vaginaler Geburt ab 34+0 Schwangerschaftswochen post menstruationem wurden eingeschlossen. Von 4 424 Geburtsverläufen wurden anhand von Risikofaktoren 1 273 Geburtsverläufe ausgewählt. Außerklinische und klinische Geburten wurden mittels Odds Ratio, Chi-Quadrat-Test nach Pearson sowie dem Mann-Whitney-Test verglichen. Ergebnisse Außerklinisch gebaren 152 (36,6%) Erst- und 263 (63,4%) Mehrgebärende, in der Klinik 439 (51,2%) Erst- und 419 (48,8%) Mehrgebärende. Die intrapartale Verlegungsrate vom außerklinischen Setting in die Klinik lag bei 10,1%. Außerklinisch Gebärende waren älter und hatten einen höheren Bildungsstand. Bei den Klinikgeburten hatten Frauen häufiger einen Migrationshintergrund. Außerklinisch Gebärende nahmen häufiger eine Hebammenbetreuung vor und während des Gebärens in Anspruch. Außerklinisch wurde seltener eingeleitet und interveniert. In der Klinik wurden häufiger die Herztöne des Kindes mittels CTG, außerklinisch vor allem intermittierend überwacht. Die Geburtsdauer war bei außerklinisch gebärenden Frauen signifikant länger im Vergleich zu Frauen, die in der Klinik geboren haben (Median: EG: 9,01 h vs. 7,38 h; MG: 4,53 h vs. 4,25 h). Außerklinisch erlebten Erstgebärende (94,7%) häufiger eine Spontangeburt als in der Klinik (73,6%). Bei allen erfassten kindlichen Outcomes, mütterlichem Blutverlust und schweren Dammverletzungen zeigte sich kein Unterschied. Ein intakter Damm und Plazentalösungsstörungen waren in der Klinik seltener. Diskussion Bei guter Risikobewertung und Verlegungsorganisation bietet eine außerklinische Geburt ein angemessenes Sicherheitsniveau. Die Vorteile der außerklinischen Geburt wie persönliche Betreuung und weniger Interventionen sollten in Klinikkreißsälen integriert werden und können zu einer Verbesserung der Versorgung und Steigerung der Spontangeburtenrate beitragen.

Introduction Internationally, there is debate on the safety of different birth settings inside and outside of hospitals. Low-risk women in Germany can choose where they give birth, and out-of-hospital births are especially necessary in regions lacking infrastructure. To date, national studies are required. Materials and Methods We investigated planned out-of-hospital (OH) and hospital births in Lower Saxony, Germany, in 2005. Women with a singleton fetus in the vertex position were included once they reached 34 + 0 gestational weeks. 1 273 out of 4 424 births were included via risk assessment. Outcomes were compared using Pearson's chi-squared test, the Mann-Whitney test, and logistic regression. Results 152 (36.6 %) nulliparae (NP) and 263 (63.4 %) multiparae (MP) gave birth out of hospital, 439 (51.2 %) nulliparae and 419 (48.8 %) multi-parae in a hospital. 10.1 % of women whose care started outside of the hospital needed a transfer to the hospital. Women who planned OH were older and had a higher level of education. Women without a migration background displayed an increased rate of out-of-hospital birth. A higher proportion received their antenatal care from midwives rather than medical doctors. Induction of labor was less likely for women with planned out-of-hospital births, as were other intrapartum interventions. In hospital births, fetal monitoring was more likely performed via cardiotocograph instead of intermittent auscultation. Duration of labor was significantly longer in OH births (median: NP: 9.01 h vs. 7.38 h; MP: 4.53 h vs. 4.25 h). Nulliparae had more spontaneous births out-ofhospital (94.7 %) than in hospital (73.6 %). There was no difference in adverse fetal outcomes, blood loss, and severe perineal lacerations. The perineum was less frequently intact in hospital births. Retained placenta was more often documented in out-of-hospital births. Conclusions In an out-of-hospital setting, fewer interventions were performed, spontaneous births occurred more often, and there was no difference in neonatal outcomes. OH birth appears reasonably safe with thorough pre-labor risk assessment and good transfer management. Some beneficial aspects of OH birth care (like continuity of care and restriction of routine interventions) could be adopted by hospital labor wards, leading to a higher rate of vaginal births and improved care.

Fat cells are fragile cells with a short life span outside the body. Ways to reduce cell death in a biochemical way are almost unknown due to scarce information on the type of cellular death that is induced in fat tissue. This study was designed to investigate the apoptotic pathways of fat tissue in a permanent perfusion bioreactor system with the Hannover preservation solution and the Eurocollins solution in fat flaps of rats. In Lewis rats, the inguinal adipofascial flaps were elevated bilaterally and placed in a bioreactor at 37°C. To detect caspases 3, 8, 9 and 12, immunofluorescence stains of fat tissue specimen were analysed at several time points after preservation of flaps were placed in Hannover solution and Eurocollins solution for 10 days. An additional visual assessment of viability by a calcein based life/dead test was performed. It revealed a superior viability of the adipose tissue preserved in Hannover solution. Immunofluorescence staining demonstrated that apoptotic pathways via mitochondria, endoplasmatic reticulum and death receptors were activated, as Caspases 8, 9 and 12 were detected. Caspase 3 as an effector in the common apoptotic pathway was detected as well. Adipose tissue preserved at 37°C ex vivo in a bioreactor system undergoes apoptosis. Immunofluorescence examination of the fat tissue preserved ex vivo revealed that apoptotic pathways via mitochondria, endoplasmatic reticulum and death receptors are being activated. Significantly less activation of Caspase 3, 8, 9 and 12 in flaps preserved in Hannover solution in comparison to Eurocollins was found, supporting the anti apoptotic characteristics of Hannover solution. Based on these findings, further research to modify the apoptotic pathways to ameliorate viability of fat tissue can be performed.

[english] Background: Anticoagulation is a crucial element in microsurgery. Although various clinical studies and international surveys have revealed that anticoagulation strategies can vary and result in similar outcomes, anticoagulative regimen are far away from standardization. In Germany and german speaking countries standardized anticoagulation protocols concerning free flap surgery do not exist so far. Methods: To evaluate the current practice of clinics in Germany, Austria and Switzerland with specialization in microsurgery we performed a questionnaire surveying the perioperative regimen of anticoagulant and antiplatelet therapy in free flap surgery. The microsurgeons were interrogated on several anticoagulant, rheologic and antiplatelet medications, their dosage and perioperative frequency of application pre-, intra- and postoperative.Results: The questionnaire revealed that the used antithrombotic and perioperative regimens varied from department to department presumably based on the personal experience of the surgeon. Multiple approaches are used with a wide range of anticoagulants used either alone or in combination, with different intervals of application and different dosages. Conclusion: Therefore consensus meetings should be held in future leading to conduct prospective multicenter studies with formulation of standardized anticoagulative and perioperative protocols in microsurgery reducing flap failure to other than pharmacologic reasons.[german] Hintergrund: Die Antikoagulation stellt ein zentrales Element in der Mikrochirurgie dar. Zahlreiche klinische Studien und internationale Erhebungen zu antikoagulatorischen Strategien weisen eine grosse Varianz bei vergleichbaren Resultaten nach, entbehren jedoch einer Standardisierung. Auch in Deutschland und deutschsprachigen Ländern fehlen bislang standardisierte Regime zur Antikoagulation in der Mikrochirurgie.Methodik: Zur Erhebung der antikoagulatorischen Praxis unter mikrochirurgischen Kliniken in Deustchland, Österreich und der Schweiz erstellten wir einen Fragebogen zur Erfassung des jeweiligen perioperativen Regimes im Hinblick auf die Antikoagulation bei freien Lappentransplantaten.Erfasst wurden verschiedene Antikoagulantien, Rheologika und Thrombozytenaggregationshemmer, sowie deren prä-. intra- und postoperative Dosierung und Art der Anwendung.Ergebnisse: Die perioperativen Regime und verwendeten Antikoagulantien zeigen von Klinik zu Klinik eine große Varianz. Diese Heterogenität scheint am Ehesten auf der Erfahrung des Operateurs denn auf einer evidenzbasierten Datenlage zu beruhen.Sie zeigt sich sowohl in der Vielzahl der verwendeten Antikoagulantien als auch in der Art ihrer Anwendung und Dosierung.Schlussfolgerung: Aus der erhobenen Datenlage ergibt sich die Forderung nach Initiierung einer Multi-Center-Studie mit Formulierung eines evidenzbasierten Standards zur perioperativen Antikoagulation in der Mikrochirurgie, so dass sich die Ursachen für Verluste freier Lappentransplantate auf solche nicht pharmakologischer Art reduzieren lassen.

Background: Anticoagulation is a crucial element in microsurgery. Although various clinical studies and international surveys have revealed Andreas Jokuszies Christine Radtke that anticoagulation strategies can vary and result in similar outcomes, Christian Herold anticoagulative regimen are far away from standardization. In Germany Bernhard Vaske and german speaking countries standardized anticoagulation protocols concerning free flap surgery do not exist so far. Peter M. Vogt Methods: To evaluate the current practice of clinics in Germany, Austria and Switzerland with specialization in microsurgery we performed a Microsurgery Reporting Group questionnaire surveying the perioperative regimen of anticoagulant and antiplatelet therapy in free flap surgery. Themicrosurgeonswere interrogated on several anticoagulant, rheologic and antiplatelet medications, their dosage and perioperative frequency of application pre-, intraand postoperative. 1 Department of Plastic, Hand and Reconstructive Surgery, Hanover Medical School, Hanover, Germany Results: The questionnaire revealed that the used antithrombotic and perioperative regimens varied from department to department presum2 Department of Biometry, Hanover Medical School, Hanover, Germany ably based on the personal experience of the surgeon. Multiple approaches are used with a wide range of anticoagulants used either alone or in combination, with different intervals of application and different dosages. Conclusion: Therefore consensus meetings should be held in future leading to conduct prospective multicenter studies with formulation of standardized anticoagulative and perioperative protocols inmicrosurgery reducing flap failure to other than pharmacologic reasons.

The aim of this study was to evaluate the relevant conditions for safe free flap transfers. The authors retrospectively studied the data from 150 patients who received free flaps at a single institution. Many parameters were analyzed to reveal if there was a correlation with respect to surgical or medical complications. Regarding safety of free tissue transfer, we found a worse prognosis in flaps where a revision of the microanastomosis had to be performed. Platelet count and leukocyte count had an impact on the prognosis. Patients older than 60 years did not have an increased rate of surgical complications. Apart from active osteomyelitis, the presence of comorbid conditions did not significantly impair the outcome of flap transfer, although smoking and diabetes correlated with minor surgical complications like wound breakdown or hematoma, respectively. Besides one case of lethal heart failure of an octogenarian patient, no severe medical complications occurred in this series of patients. Microvascular free tissue transfer is not significantly impaired by age and most comorbidities. Osteomyelitis as well as elevated leukocytes and lowered platelets may increase the complication rate and worsen the surgical prognosis. Smoking and diabetes might prolong the hospital course of the patients.