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A case-control study of the interaction of fetal heart rate abnormalities, fetal growth restriction, meconium in the amniotic fluid and tachysystole, in relation to the outcome of labour. BJOG 2023; 130:286-291. [PMID: 36164836 DOI: 10.1111/1471-0528.17302] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/05/2022] [Accepted: 08/29/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To quantify the incidence of intrapartum risk factors in labours with an adverse outcome, and compare them with the incidence of the same indicators in a series of consecutive labours without adverse outcome. DESIGN Case-control study. SETTING Twenty-six maternity units in the UK. POPULATION OR SAMPLE Sixty-nine labours with an adverse outcome and 198 labours without adverse outcome. METHODS Observational study. MAIN OUTCOME MEASURES Incidence of risk factors in hourly assessments for 7 hours before birth in the two groups. RESULTS A risk score combining suspected fetal growth restriction, tachysystole, meconium in the amniotic fluid and fetal heart rate abnormalities (baseline rate and variability, presence of decelerations) gave the best indication of likely outcome group. CONCLUSIONS Accurate risk assessment in labour requires fetal heart rate abnormalities to be considered in context with additional intrapartum risk factors.
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Monkeypox and pregnancy: what do obstetricians need to know? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:22-27. [PMID: 35652380 DOI: 10.1002/uog.24968] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 05/31/2022] [Accepted: 05/31/2022] [Indexed: 06/15/2023]
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A study of the healthcare resource use for the management of postpartum haemorrhage in France, Italy, the Netherlands, and the UK. Eur J Obstet Gynecol Reprod Biol 2021; 268:92-99. [PMID: 34894537 DOI: 10.1016/j.ejogrb.2021.11.432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Postpartum haemorrhage (PPH) complicates approximately 5% of births worldwide and is a leading direct cause of maternal death. Rates of PPH are increasing in many developed countries, particularly PPH related to uterine atony. There is a lack of published up-to-date information about healthcare resource use associated with management of PPH following vaginal birth. The objective of this study was to describe healthcare resource use for the management of minor PPH (blood loss 500-1,000 ml) and major PPH (blood loss > 1,000 ml) compared to uncomplicated birth (no PPH) following hospital vaginal birth in France, Italy, the Netherlands, and the UK. STUDY DESIGN In-depth interviews with two midwives from each participating country were conducted to establish differences in resource use for the management of minor PPH, major PPH, and uncomplicated birth. A web-survey was then developed and one obstetrician per participating country reviewed the survey. In total, 100 midwives (25 per country) completed the survey. Results were discussed at a multi-professional consensus meeting of midwives and obstetricians/gynaecologists (n = 6). RESULTS AND CONCLUSIONS Midwives participating in the survey estimated that 80% of women receive Active Management of the Third Stage of Labour (AMTSL) and 93% of participants specified that uterotonics would routinely be used during AMTSL. Most participants (84%) reported that blood loss is routinely measured in their hospital, using a combination of methods. PPH is associated with increased healthcare resource use, including administration of additional uterotonics and use of additional medical interventions, such as urinary catheter, intravenous fluids, and possible requirement for surgery. The number of nurses, obstetricians/gynaecologists, and anaesthetists involved in the management of PPH increases with the occurrence and severity of PPH, as well as the proportion of healthcare personnel providing continuous care. Women may spend an additional 24 h in hospital following major PPH compared to uncomplicated birth. The results of this study highlight the burden of PPH management on healthcare resources. To reduce costs associated with PPH, prevention is the most effective strategy and can be enhanced with the use of an effective uterotonic as part of the active management of the third stage of labour.
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Authors' reply re: Maternity services in the UK during the coronavirus disease 2019 pandemic: a national survey of modifications to standard care. BJOG 2021; 128:937-938. [PMID: 33550708 PMCID: PMC8013874 DOI: 10.1111/1471-0528.16639] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 11/29/2022]
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Training in the use of intrapartum electronic fetal monitoring with cardiotocography: systematic review and meta‐analysis. BJOG 2021. [PMCID: PMC8359372 DOI: 10.1111/1471-0528.16619] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Sub‐optimal classification, interpretation and response to intrapartum electronic fetal monitoring using cardiotocography are known problems. Training is often recommended as a solution, but there is lack of clarity about the effects of training and which type of training works best. Objectives Systematic review of the effects of training healthcare professionals in intrapartum cardiotocography (PROSPERO protocol: CRD42017064525). Search strategy CENTRAL, Cochrane Library, MEDLINE, EMBASE, PsycINFO, British Nursing Database, CINAHL, ERIC, Scopus, Web of Science, ProQuest, grey literature and ongoing clinical trials were searched. Selection criteria Primary studies that reported impact of training healthcare professionals in intrapartum cardiotocography. Title/abstract, full‐text screening and quality assessment were conducted in duplicate. Data collection and analysis Data were synthesised both narratively and using meta‐analysis. Risk of bias and overall quality were assessed with the Mixed Methods Appraisal Tool and GRADE. Main results Sixty‐four studies were included. Overall, training and reporting were heterogeneous, the outcomes evaluated varied widely and study quality was low. Five randomised controlled trials reported that training improved knowledge of maternity professionals compared with no training, but evidence was of low quality. Evidence for the impact of cardiotocography training on neonatal and maternal outcomes was limited, showed inconsistent effects, and was of low overall quality. Evidence for the optimal content and method of delivery of training was very limited. Conclusions Given the scale of harm and litigation claims associated with electronic fetal monitoring, the evidence‐base for training requires improvement. It should address intervention design, evaluation of clinical outcomes and system‐wide contexts of sub‐optimal practice. Tweetable abstract Training in fetal monitoring: systematic review finds little evidence of impact on neonatal outcomes. Training in fetal monitoring: systematic review finds little evidence of impact on neonatal outcomes.
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Intramuscular oxytocin versus Syntometrine ® versus carbetocin for prevention of primary postpartum haemorrhage after vaginal birth: a randomised double-blinded clinical trial of effectiveness, side effects and quality of life. BJOG 2021; 128:1236-1246. [PMID: 33300296 DOI: 10.1111/1471-0528.16622] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare intramuscular oxytocin, Syntometrine® and carbetocin for prevention of postpartum haemorrhage after vaginal birth. DESIGN Randomised double-blinded clinical trial. SETTING Six hospitals in England. POPULATION A total of 5929 normotensive women having a singleton vaginal birth. METHODS Randomisation when birth was imminent. MAIN OUTCOME MEASURES Primary: use of additional uterotonic agents. Secondary: weighed blood loss, transfusion, manual removal of placenta, adverse effects, quality of life. RESULTS Participants receiving additional uterotonics: 368 (19.5%) oxytocin, 298 (15.6%) Syntometrine and 364 (19.1%) carbetocin. When pairwise comparisons were made: women receiving carbetocin were significantly more likely to receive additional uterotonics than those receiving Syntometrine (odds ratio [OR] 1.28, 95% CI 1.08-1.51, P = 0.004); the difference between carbetocin and oxytocin was non-significant (P = 0.78); Participants receiving Syntometrine were significantly less likely to receive additional uterotonics than those receiving oxytocin (OR 0.75, 95% CI 0.65-0.91, P = 0.002). Non-inferiority between carbetocin and Syntometrine was not shown. Use of Syntometrine reduced non-drug PPH treatments compared with oxytocin (OR 0.64, 95% CI 0.42-0.97) but not carbetocin (P = 0.64). Rates of PPH and blood transfusion were not different. Syntometrine was associated with an increase in maternal adverse effects and reduced ability of the mother to bond with her baby. CONCLUSIONS Non-inferiority of carbetocin to Syntometrine was not shown. Carbetocin is not significantly different to oxytocin for use of additional uterotonics. Use of Syntometrine reduced use of additional uterotonics and need for non-drug PPH treatments compared with oxytocin. Increased maternal adverse effects are a disadvantage of Syntometrine. TWEETABLE ABSTRACT IM carbetocin does not reduce additional uterotonic use compared with IM Syntometrine or oxytocin.
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Maternity services in the UK during the coronavirus disease 2019 pandemic: a national survey of modifications to standard care. BJOG 2020; 128:880-889. [PMID: 32992408 DOI: 10.1111/1471-0528.16547] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To explore the modifications to maternity services across the UK, in response to the coronavirus disease 2019 (COVID-19) pandemic, in the context of the pandemic guidance issued by the Royal College of Obstetricians and Gynaecologists (RCOG), Royal College of Midwives (RCM) and NHS England. DESIGN National survey. SETTING UK maternity services during the COVID-19 pandemic. POPULATION OR SAMPLE Healthcare professionals working within maternity services. METHODS A national electronic survey was developed to investigate local modifications to general and specialist maternity care during the COVID-19 pandemic, in the context of the contemporaneous national pandemic guidance. After a pilot phase, the survey was distributed through professional networks by the RCOG and co-authors. The survey results were presented descriptively in tabular and graphic formats, with proportions compared using chi-square tests. MAIN OUTCOME MEASURES Service modifications made during the pandemic. RESULTS A total of 81 respondent sites, 42% of the 194 obstetric units in the UK, were included. They reported substantial and heterogeneous maternity service modifications. Seventy percent of units reported a reduction in antenatal appointments and 56% reported a reduction in postnatal appointments; 89% reported using remote consultation methods. A change to screening pathways for gestational diabetes mellitus was reported by 70%, and 59% had temporarily removed the offer of births at home or in a midwife-led unit. A reduction in emergency antenatal presentations was experienced by 86% of units. CONCLUSIONS This national survey documents the extensive impact of the COVID-19 pandemic on maternity services in the UK. More research is needed to understand the impact on maternity outcomes and experience. TWEETABLE ABSTRACT A national survey showed that UK maternity services were modified extensively and heterogeneously in response to COVID-19.
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Understanding real-world maternity care using video techniques. BJOG 2019; 126:1024. [PMID: 30933400 DOI: 10.1111/1471-0528.15745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Associations between early term and late/post term infants and development of epilepsy: A cohort study. PLoS One 2018; 13:e0210181. [PMID: 30596766 PMCID: PMC6312375 DOI: 10.1371/journal.pone.0210181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 12/18/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND While life-long impacts exist for infants born one or two weeks early little evidence exists for those infants born after their due date. However interventions could be used to expedite birth if the risks of continuing the pregnancy are higher than intervening. It is known that the risk of epilepsy in childhood is higher in infants exposed to perinatal compromise and therefore may be useful as a proxy for intrapartum compromise. The aim of this work is to quantify the likelihood of children developing epilepsy based on their gestational age at birth (37-39 weeks or ≥41 weeks). METHODS The work is based on term infants born in Sweden between 1983 and 1993 (n = 1,030,168), linked to data on disability pension, child mortality and in-patient epilepsy care. The reference group was defined as infants born at 39 or 40 completed weeks of gestation; compared with infants born at early term (37/38 weeks) or late/post term (41 weeks or more). Primary outcome was defined a-priori as a diagnosis of epilepsy before 20 years of age. Secondary outcomes were childhood mortality (before five years of age), and registered for disability pension before 20 years of age. Logistic regression models were used to assess any association of the outcomes with gestational age at birth. FINDINGS In the unadjusted results, infants born 7 or more days after their due date had higher risks of epilepsy and disability pension than the reference group, but similar risks of child death. Early term infants showed higher risks of epilepsy, disability pension and child death. After adjustment for confounders, there remained a higher risk of epilepsy for both early term (OR 1·19 (1·11-1·29)) and late/post term infants (OR 1·13 (1·06-1·22)). INTERPRETATION Infants born at 37/38 week or 41 weeks and above, when compared to those born at 39 or 40 weeks gestation, have an increased risk of developing epilepsy. This data could be useful in helping women and care givers make decisions with regard to the timing of induction of labour.
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Clinical–insurer engagement to improve maternity safety in the UK, Ireland, Sweden and Australia. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2018. [DOI: 10.1177/2516043518762646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective To explore different models of clinical–insurer engagement around maternity safety and to understand how state insurers could and should engage with clinical staff to improve outcomes and reduce harm. Design Semi-structured interviews and focus groups were conducted with senior representatives from state insurers. Transcripts were analysed to identify different models of engagement. Themes were also elicited from the transcripts. A further one-day focus group allowed for clarification and elaboration of these themes. Participants Senior representatives from state insurers in England, Scotland, Wales, Republic of Ireland, Sweden and Victoria, Australia. Results A variety of clinical engagement activities were undertaken by the insurers. These included training on claims and risk management, hospital site visits, facilitating multi-professional network meetings and working with clinical experts to develop best practice recommendations. Some insurers engaged with frontline clinical staff through collaborative patient safety programmes. The themes (identity and size, data and research, incentivising improvement and system integration) were important for considering the role of state insurers within health systems and how insurers could engage with clinical teams. Conclusions This study identified different examples of clinical–insurer engagement. Whilst this was encouraging, the relationships between insurers and clinical teams could be developed further. Insurers and clinical staff could still collaborate more closely and work together in improving patient outcomes. Whilst not specifically their domain, insurers do have a role in patient safety. Closer clinical collaboration may strengthen this contribution.
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Patients and hospital managers want laparoscopic simulation training to become mandatory before live operating: a multicentre qualitative study of stakeholder perceptions. BMJ SIMULATION & TECHNOLOGY ENHANCED LEARNING 2018; 5:39-45. [DOI: 10.1136/bmjstel-2017-000270] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/24/2018] [Indexed: 11/04/2022]
Abstract
BackgroundSurgical procedures are complex and susceptible to human error. Individual surgical skill correlates with improved patient outcomes demonstrating that surgical proficiency is vitally important for patient safety. Evidence demonstrates that simulation training improves laparoscopic surgical skills; however, projects to implement and integrate laparoscopic simulation into core surgical curricula have had varied success. One barrier to successful implementation has been the lack of awareness and prioritisation of simulation initiatives by key stakeholders.ObjectiveTo determine the knowledge and perceptions of patients and hospital managers on laparoscopic surgery and simulation training in patient safety and healthcare.MethodA qualitative study was conducted in the Southwest of England. 40 semistructured interviews were undertaken with patients attending general gynaecology clinics and general surgical and gynaecology hospital managers.ResultsSix key themes identified included: positive expectations of laparoscopic surgery; perceptions of problems and financial implications of laparoscopic surgery; lack of awareness of difficulties with surgical training; desire for laparoscopic simulation training and competency testing for patient benefit; conflicting priorities of laparoscopic simulation in healthcare; and drawbacks of surgical simulation training. Patients and managers were largely unaware of the risks of laparoscopic surgery and challenges for training. Managers highlighted conflicting financial priorities when purchasing educational equipment. Patients stated that they would have greater confidence in a surgeon who had undertaken mandatory surgical simulation training and perceived purchasing simulation equipment to be a high priority in the National Health Services. Most patients and hospital managers believed trainees should pass an examination on a simulator prior to live operating.ConclusionsCompetency-based mandatory laparoscopic simulation was strongly supported by the majority of stakeholders to augment the initial learning curve of surgeons.
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Associations between birth at, or after, 41 weeks gestation and perinatal encephalopathy: a cohort study. BMJ Paediatr Open 2018; 2:e000010. [PMID: 29637179 PMCID: PMC5842989 DOI: 10.1136/bmjpo-2017-000010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 11/16/2017] [Accepted: 12/12/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Preterm birth causes long-term problems, even for infants born 1 or 2 weeks early. However, less is known about infants born after their due date and over a quarter of infants are born over 1 week late, and many still remain undelivered after 2 weeks. The aim of this work is to quantify the risks of infants developing encephalopathy when birth occurs after the due date, and if other proposed risk factors modify this relationship. METHODS The dataset contain information on 4 036 346 infants born in Sweden between 1973 and 2012. Exposure was defined as birth 7, or more, days after the infants' due date. The primary outcome was the development of neonatal encephalopathy (defined as seizures, encephalopathy or brain injury caused by asphyxia or with unspecified cause). Covariates were selected as presumed confounders a priori. RESULTS 28.4% infants were born 1 or more weeks after their due date. An infant's risk of being born with encephalopathy was higher in the post 41 weeks group in the unadjusted (OR 1.40 (95% CI 1.32 to 1.49)) and final model (OR 1.38 (95% CI 1.29 to 1.47)), with the relative odds of encephalopathy increasing by an estimated 20% per week after the due date, and modified by maternal age (P=0.022). CONCLUSIONS Singleton infants born at, or after, 41 weeks gestation have lower Apgar scores and higher risk of developing encephalopathy in the newborn period, and the association appeared more marked in older mothers. These data could be useful if provided to women as part of their decision-making.
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Resident consultant cover may become part of 21st century maternity care, but it is not a panacea. BJOG 2017; 124:1332. [PMID: 28397976 DOI: 10.1111/1471-0528.14686] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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A pilot study to assess the role of the Internet to provide structured training in obstetrics and gynaecology. Health Informatics J 2016. [DOI: 10.1177/146045829700300204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Recent recommendations in the Calman Report on medical training address perceived deficiencies in the current system in the UK. These recommendations include shorter and more structured training for junior doctors. Structured training will require the provision of specific educational and assessment materials. The current expansion of the Internet may provide a timely opportunity to help with these educational challenges. Our pilot study will investigate the potential role of the Internet in the delivery of structured training materials. We will also be evaluating a number of educational strategies supported by the Internet, particularly computer based simulation, for teaching the management of two sample obstetric emergencies: post partum haemorrhage and pre-eclampsia.
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Reduction in resource use with the misoprostol vaginal insert vs the dinoprostone vaginal insert for labour induction: a model-based analysis from a United Kingdom healthcare perspective. BMC Health Serv Res 2016; 16:49. [PMID: 26864022 PMCID: PMC4750172 DOI: 10.1186/s12913-016-1278-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 01/22/2016] [Indexed: 11/16/2022] Open
Abstract
Background In view of the increasing pressure on the UK’s maternity units, new methods of labour induction are required to alleviate the burden on the National Health Service, while maintaining the quality of care for women during delivery. A model was developed to evaluate the resource use associated with misoprostol vaginal inserts (MVIs) and dinoprostone vaginal inserts (DVIs) for the induction of labour at term. Methods The one-year Markov model estimated clinical outcomes in a hypothetical cohort of 1397 pregnant women (parous and nulliparous) induced with either MVI or DVI at Southmead Hospital, Bristol, UK. Efficacy and safety data were based on published and unpublished results from a phase III, double-blind, multicentre, randomised controlled trial. Resource use was modelled using data from labour induction during antenatal admission to patient discharge from Southmead Hospital. The model’s sensitivity to key parameters was explored in deterministic multi-way and scenario-based analyses. Results Over one year, the model results indicated MVI use could lead to a reduction of 10,201 h (28.9 %) in the time to vaginal delivery, and an increase of 121 % and 52 % in the proportion of women achieving vaginal delivery at 12 and 24 h, respectively, compared with DVI use. Inducing women with the MVI could lead to a 25.2 % reduction in the number of midwife shifts spent managing labour induction and 451 fewer hospital bed days. These resource utilisation reductions may equate to a potential 27.4 % increase in birthing capacity at Southmead Hospital, when using the MVI instead of the DVI. Conclusions Resource use, in addition to clinical considerations, should be considered when making decisions about labour induction methods. Our model analysis suggests the MVI is an effective method for labour induction, and could lead to a considerable reduction in resource use compared with the DVI, thereby alleviating the increasing burden of labour induction in UK hospitals.
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Effective interprofessional simulation training for medical and midwifery students. BMJ SIMULATION & TECHNOLOGY ENHANCED LEARNING 2015; 1:87-93. [PMID: 35515198 DOI: 10.1136/bmjstel-2015-000022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/14/2015] [Indexed: 11/04/2022]
Abstract
Introduction Good interprofessional teamworking is essential for high quality, efficient and safe clinical care. Undergraduate interprofessional training has been advocated for many years to improve interprofessional working. However, few successful initiatives have been reported and even fewer have formally assessed their educational impact. Methods This was a prospective observational study of medical and midwifery students at a tertiary-level maternity unit. An interprofessional training module was developed and delivered by a multiprofessional faculty to medical and midwifery students, including short lectures, team-building exercises and practical simulation-based training for one obstetric (shoulder dystocia) and three generic emergencies (sepsis, haemorrhage, collapse). Outcome measures were interprofessional attitudes, assessed with a validated questionnaire (UWE Interprofessional Questionnaire) and clinical knowledge, measured with validated multiple-choice questions. Results Seventy-two students participated (34 medical, 38 midwifery). Following training median interprofessional attitude scores improved in all domains (p<0.0001), and more students responded in positive categories for communication and teamwork (69-89%, p=0.004), interprofessional interaction (3-16%, p=0.012) and interprofessional relationships (74-89%, p=0.006). Scores for knowledge improved following training for medical students (65.5% (61.8-70%) to 82.3% (79.1-84.5%) (median (IQR)) p<0.0001) and student midwives (70% (64.1-76.4%) to 81.8% (79.1-86.4%) p<0.0001), and in all subject areas (p<0.0001). Conclusions This training was associated with meaningful improvements in students' attitudes to teamwork, and knowledge acquisition. Integrating practical tasks and teamwork training, in authentic clinical settings, with matched numbers of medical and non-medical students can facilitate learning of both why and how to work together. This type of training could be adopted widely in undergraduate healthcare education.
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Abstract
Multidisciplinary training has improved maternity outcomes when the training has been well attended, regular, in house, used high-fidelity simulators, and integrated teamwork training. If these principles were used in other settings, better clinical care may result. This before-after study sought to establish whether a short multidisciplinary training intervention can improve recognition of the deteriorating patient using an aggregated physiological parameter scoring system (Early Warning Score [EWS]). Nursing, medical, and allied nursing staff participated in an hour-long training session, using real-life scenarios with simple tools and structured debriefing. After training, staff were more likely to calculate EWS scores correctly (68.02% vs 55.12%; risk ratio [RR] = 1.24, 95% confidence interval [CI] = 1.07-1.44), and observations were more likely to be performed at the correct frequency (78.57% vs 68.09%; RR = 1.20, 95% CI = 1.09-1.32). Multidisciplinary training, according to core principles, can lead to more accurate identification of deteriorating patients, with implications for subsequent care and outcome.
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Modified obstetric early warning scoring systems (MOEWS): validating the diagnostic performance for severe sepsis in women with chorioamnionitis. Am J Obstet Gynecol 2015; 212:536.e1-8. [PMID: 25446705 DOI: 10.1016/j.ajog.2014.11.007] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 10/08/2014] [Accepted: 11/03/2014] [Indexed: 01/10/2023]
Abstract
OBJECTIVE We sought to compare the predictive power of published modified obstetric early warning scoring systems (MOEWS) for the development of severe sepsis in women with chorioamnionitis. STUDY DESIGN This was a retrospective cohort study using prospectively collected clinical observations at a single tertiary unit (Chicago, IL). Hospital databases and patient records were searched to identify and verify cases with clinically diagnosed chorioamnionitis during the study period (June 2006 through November 2007). Vital sign data (heart rate, respiratory rate, blood pressure, temperature, mental state) for these cases were extracted from an electronic database and the single worst composite recording was identified for analysis. Global literature databases were searched (2014) to identify examples of MOEWS. Scores for each identified MOEWS were derived from each set of vital sign recordings during the presentation with chorioamnionitis. The performance of these MOEWS (the primary outcome) was then analyzed and compared using their sensitivity, specificity, positive and negative predictive values, and receiver-operating characteristic curve for severe sepsis. RESULTS Six MOEWS were identified. There was wide variation in design and pathophysiological thresholds used for clinical alerts. In all, 913 women with chorioamnionitis were identified from the clinical database. In all, 364 cases with complete data for all physiological indicators were included in analysis. Five women developed severe sepsis, including 1 woman who died. The sensitivities of the MOEWS in predicting the severe deterioration ranged from 40-100% and the specificities varied even more ranging from 4-97%. The positive predictive values were low for all MOEWS ranging from <2-15%. The MOEWS with simpler designs tended to be more sensitive, whereas the more complex MOEWS were more specific, but failed to identify some of the women who developed severe sepsis. CONCLUSION Currently used MOEWS vary widely in terms of alert thresholds, format, and accuracy. Most MOEWS have not been validated. The MOEWS generally performed poorly in predicting severe sepsis in obstetric patients; in general severe sepsis was overdetected. Simple MOEWS with high sensitivity followed with more specific secondary testing is likely to be the best way forward. Further research is required to develop early warning systems for use in this setting.
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Measuring quality of maternity care. Best Pract Res Clin Obstet Gynaecol 2015; 29:1132-8. [PMID: 25913563 DOI: 10.1016/j.bpobgyn.2015.03.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 03/20/2015] [Accepted: 03/23/2015] [Indexed: 10/23/2022]
Abstract
Health-care organisations are required to monitor and measure the quality of their maternity services, but measuring quality is complex, and no universal consensus exists on how best to measure it. Clinical outcomes and process measures that are important to stakeholders should be measured, ideally in standardised sets for benchmarking. Furthermore, a holistic interpretation of quality should also reflect patient experience, ideally integrated with outcome and process measures, into a balanced suite of quality indicators. Dashboards enable reporting of trends in adverse outcomes to stakeholders, staff and patients, and they facilitate targeted quality improvement initiatives. The value of such dashboards is dependent upon high-quality, routinely collected data, subject to robust statistical analysis. Moving forward, we could and should collect a standard, relevant set of quality indicators, from routinely collected data, and present these in a manner that facilitates ongoing quality improvement, both locally and at regional/national levels.
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Maternal sepsis incidence, aetiology and outcome for mother and fetus: a prospective study. BJOG 2014; 121:1754-5. [DOI: 10.1111/1471-0528.13123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2014] [Indexed: 11/26/2022]
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Analysis of legal claims-informing litigation systems and quality improvement. BJOG 2013; 121:6-10. [DOI: 10.1111/1471-0528.12491] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2013] [Indexed: 11/29/2022]
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The thistle study: a stepped-wedge clustered trial of an intrapartum emergencies training package in Scottish maternity units. Trials 2013. [PMCID: PMC3980426 DOI: 10.1186/1745-6215-14-s1-p142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Adaptation and implementation of local maternity dashboards in a Zimbabwean hospital to drive clinical improvement. Bull World Health Organ 2013; 92:146-52. [PMID: 24623908 DOI: 10.2471/blt.13.124347] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 10/17/2013] [Accepted: 10/20/2013] [Indexed: 11/27/2022] Open
Abstract
PROBLEM The Commission on Information and Accountability for Women's and Children's Health of the World Health Organization (WHO) reported that national health outcome data were often of questionable quality and "not timely enough for practical use by health planners and administrators". Delayed reporting of poor-quality data limits the ability of front-line staff to identify problems rapidly and make improvements. APPROACH Clinical "dashboards" based on locally available data offer a way of providing accurate and timely information. A dashboard is a simple computerized tool that presents a health facility's clinical data graphically using a traffic-light coding system to alert front-line staff about changes in the frequency of clinical outcomes. It provides rapid feedback on local outcomes in an accessible form and enables problems to be detected early. Until now, dashboards have been used only in high-resource settings. LOCAL SETTING An overview maternity dashboard and a maternal mortality dashboard were designed for, and introduced at, a public hospital in Zimbabwe. A midwife at the hospital was trained to collect and input data monthly. RELEVANT CHANGES Implementation of the maternity dashboards was feasible and 28 months of clinical outcome data were summarized using common computer software. Presentation of these data to staff led to the rapid identification of adverse trends in outcomes and to suggestions for actions to improve health-care quality. LESSONS LEARNT Implementation of maternity dashboards was feasible in a low-resource setting and resulted in actions that improved health-care quality locally. Active participation of hospital management and midwifery staff was crucial to their success.
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W389 DEVELOPMENT OF SIMULATION TEACHING FOR THE MANAGEMENT OF MATERNAL SEPSIS. Int J Gynaecol Obstet 2012. [DOI: 10.1016/s0020-7292(12)62111-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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O208 DO MEDICAL STUDENTS ACQUIRE ADEQUATE BASIC GYNAECOLOGY EXAMINATION SKILLS DURING AN 8-WEEK CLINICAL ATTACHMENT? Int J Gynaecol Obstet 2012. [DOI: 10.1016/s0020-7292(12)60638-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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O640 MATERNITY DASHBOARDS: A TOOL TO MEASURE AND IMPLEMENT TIMELY IMPROVEMENT IN MATERNITY CARE - THEIR CURRENT USE ACROSS THE SOUTHWEST STRATEGIC HEALTH AUTHORITY. Int J Gynaecol Obstet 2012. [DOI: 10.1016/s0020-7292(12)61070-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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O635 SENIOR CLINICIAN PRESENCE ON LABOUR WARD AND PATIENT OUTCOME: A MULTICENTER MIXED-METHODS STUDY. Int J Gynaecol Obstet 2012. [DOI: 10.1016/s0020-7292(12)61065-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Training to reduce adverse obstetric events with risk of cerebral palsy. Am J Obstet Gynecol 2011; 204:e15-6. [PMID: 21272847 DOI: 10.1016/j.ajog.2010.11.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Accepted: 11/17/2010] [Indexed: 10/18/2022]
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Monitoring healthcare quality in an obstetrics and gynaecology department using a CUSUM chart. BJOG 2011; 118:379-80; author reply 380-1. [DOI: 10.1111/j.1471-0528.2010.02812.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double-blind randomised trial. BJOG 2010. [DOI: 10.1111/j.1471-0528.2010.02740.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
The objective of this study was to identify any residual challenges in a unit with a track record of good clinical performance. A cross-sectional survey of frontline caregiver attitudes was conducted using a validated psychometric instrument. A total of 69% (91 of 132) of eligible participants completed questionnaires. The results indicated positive safety culture, teamwork climate, and job satisfaction. Perceptions of high workload and insufficient staffing levels were the most prominent negative observations but not to the detriment of job satisfaction or perception of work conditions. Male staff had consistently better safety attitudes in multivariate analyses. The authors identified 24-hour consultant (attending) presence and better support by management as prerequisites for further improvement. Teamwork and safety attitudes are positive in a unit with established interprofessional team training. Establishing better support by senior clinical and management leaders was identified as a necessary intervention to improve attitudes and safety.
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Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double-blind randomised trial. BJOG 2010; 117:929-36. [PMID: 20482535 DOI: 10.1111/j.1471-0528.2010.02585.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the effectiveness of carbetocin and oxytocin when they are administered after caesarean section for prevention of postpartum haemorrhage (PPH). STUDY DESIGN Double-blind randomised single centre study (1:1 ratio). SETTING Teaching hospital in Bristol, UK with 6000 deliveries per annum. POPULATION Women at term undergoing elective or emergency caesarean section under regional anaesthesia, excluding women with placenta praevia, multiple gestation and placental abruption. METHODS Women were randomised to receive either carbetocin 100 microg or oxytocin 5 IU intravenously after the delivery of the baby. Perioperative care was otherwise normal and use of additional oxytocics was at the discretion of the operating obstetrician. Analysis was by intention to treat. PRIMARY OUTCOME MEASURE The proportion of women in each arm of the trial that needed additional pharmacological oxytocic interventions. RESULTS Significantly more women needed additional oxytocics in the oxytocin group (45.5% versus 33.5%, Relative risk 0.74, 95% CI 0.57-0.95). The majority of women had oxytocin infusions. There were no significant differences in the secondary outcomes, including major PPH, blood transfusions and fall in haemoglobin. CONCLUSIONS Carbetocin is associated with a reduced use of additional oxytocics. It is unclear whether this may reduce rates of PPH and blood transfusions.
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Healthcare evaluation of the use of atosiban and fibronectin for the management of pre-term labour. J OBSTET GYNAECOL 2010; 29:507-11. [DOI: 10.1080/01443610903003191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Category-1 caesarean section: a survey of anaesthetic and peri-operative management in the UK*. Anaesthesia 2010; 65:362-8. [DOI: 10.1111/j.1365-2044.2010.06265.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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P8 Improving the accuracy of blood loss estimation at antepartum haemorrhage using a semi-quantitative, pictorial, visual assessment tool. Int J Gynaecol Obstet 2009. [DOI: 10.1016/s0020-7292(09)61500-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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I90 Effective training for obstetric emergencies. Int J Gynaecol Obstet 2009. [DOI: 10.1016/s0020-7292(09)60090-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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O864 Profile of attitudes to safety, teamwork and working conditions in a maternity unit with embedded inter-professional learning. Int J Gynaecol Obstet 2009. [DOI: 10.1016/s0020-7292(09)61237-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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I91 Training for shoulder dystocia. Int J Gynaecol Obstet 2009. [DOI: 10.1016/s0020-7292(09)60091-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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P429 The use of progesterone in the management of pregnancy of unknown location. Int J Gynaecol Obstet 2009. [DOI: 10.1016/s0020-7292(09)61921-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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O865 Mat-dash: A statistically informed automated maternity dashboard tool. Int J Gynaecol Obstet 2009. [DOI: 10.1016/s0020-7292(09)61238-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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P146 Laparoscopic adjustable gastric banding (LAGB) management and pregnancy outcomes in morbidly obese women in a UK teaching hospital over a 4-year period. Int J Gynaecol Obstet 2009. [DOI: 10.1016/s0020-7292(09)61637-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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P153 Review of management of laparoscopic banding in pregnancy. Int J Gynaecol Obstet 2009. [DOI: 10.1016/s0020-7292(09)61644-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
OBJECTIVE To assess the feasibility and validity of a maternal satisfaction measurement tool, the SaFE study Patient Perception Score (PPS), after operative delivery. DESIGN Cross-sectional survey. SETTING A large maternity unit in England. SAMPLE 150 women who had had an operative birth. METHODS We recruited women within 24 hours of birth and quantified their satisfaction with two questionnaires: PPS, and the Mackey Childbirth Satisfaction Rating Scale (CSRS; modified). MAIN OUTCOME MEASURES Participation rate to determine feasibility; Cronbach's alpha as measure of internal consistency; PPS satisfaction scores for groups of accoucheurs of different seniority to assess construct validity; correlation coefficient of PPS scores with total scores from the CSRS questionnaire to establish criterion validity. RESULTS Participation rate approached 85%. We observed high scores for most births except a few outliers. Internal consistency of the PPS was high (Cronbach's alpha=0.83). Total PPS scores correlated strongly with total CSRS scores (Spearman's r=0.64, P<0.001). CONCLUSIONS The PPS is a simple and valid tool for patient-centred assessments. High scores were observed for most births but there were a small minority of accoucheurs who consistently scored poorly and these data could be used during appraisal and training.
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