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PubMed2002

Child health and obstetrics-gynaecology in a problem-based learning curriculum: accepting the limits of integration and the need for differentiation.

BACKGROUND AND OBJECTIVES: The University of Manchester's undergraduate curriculum was reorganised in 1994. Problem-based learning (PBL) was chosen as the central educational method throughout the 5 years. A thematic interdisciplinary style provided a framework around which to select and integrate content. The theme for family, reproductive and child health for the 14-week Families and Children Module (FCM) in year 4 integrated content from obstetrics-gynaecology, paediatrics (including child psychiatry), genetics and public health. This paper focuses on the FCM which has put to test some of the principles of integration. METHODS: The educational process and outcome of the FCM was evaluated with information from (1) Open Forum feedback sessions (2) student questionnaires and (3) students' performance in an objective structured clinical examination (OSCE). RESULTS: Significant problems were encountered during the first year of the FCM (1997--98). An Open Forum for all students and staff was convened after each module in order to address the level of concern. Students' responses to questionnaires reflected the overall impression obtained from the Open Forum. Difficulties appeared to be more than the anxieties and challenges inherent in organisational change and were not simple practical timetabling problems. Tutors perceived a loss of coherence and student contact; students reported difficulties maintaining sufficient continuity of focus in clinical and academic learning experiences. The intended level of integration of paediatrics and obstetrics-gynaecology was unmanageable. Consequently, the FCM (1998-99) was divided into separate attachments for clinical learning and experience in paediatrics and obstetrics-gynaecology, each of 7 weeks' duration. Further open feedback sessions revealed that the modifications implemented in 1998-99 were associated with positive experiences for students and tutors. Comparison of responses to the evaluation questionnaires showed that students' overall rating of the module was higher (P=0.002) for 1998-99 (mean 3.4, SD 0.9) than for 1997-98 (mean 3.0, SD 1.1). CONCLUSIONS: We emphasise that horizontal integration can result in an experience of disintegration for students and tutors. Certain disciplines, such as paediatrics and obstetrics-gynaecology, may not have enough in common for full curriculum integration.

Curriculum↗
PubMed2000

Team midwifery care in a tertiary level obstetric service: a randomized controlled trial.

BACKGROUND: In 1996 a new model of maternity care characterized by continuity of midwifery care from early pregnancy through to the postpartum period was implemented for women attending Monash Medical Centre, a tertiary level obstetric service, in Melbourne, Australia. The objective of this study was to compare the new model of care with standard maternity care. METHODS: In a randomized controlled trial, 1000 women who booked at the antenatal clinic and met the eligibility criteria were randomly allocated to receive continuity of midwifery care (team care) from a group of seven midwives in collaboration with obstetric staff, or care from a variety of midwives and obstetric staff (standard care). The primary outcome measures were procedures in labor, maternal outcomes, neonatal outcomes, and length of hospital stay. RESULTS: Women assigned to the team care group experienced less augmentation of labor, less electronic fetal monitoring, less use of narcotic and epidural analgesia, and fewer episiotomies but more unsutured tears. Team care women stayed in hospital 7 hours less than women in standard care. More babies of standard care mothers were admitted to the special care nurseries for more than 5 days because of preterm birth, and more babies of team care mothers were admitted to the nurseries for more than 5 days with intrauterine growth retardation. No differences occurred in perinatal mortality between the two groups. CONCLUSIONS: Continuity of midwifery care was associated with a reduction in medical procedures in labor and a shorter length of stay without compromising maternal and perinatal safety. Continuity of midwifery care is realistically achievable in a tertiary obstetric referral service.

Continuity of Patient Care↗
PubMed2002

Complications associated with regional anesthesia in the obstetric patient.

The majority of obstetric patients are concerned about labor pains but also have fears regarding regional anesthesia and its potential effects on themselves and their babies. Anesthesiologists and obstetricians alike must be familiar with potential complications of obstetric regional anesthesia and analgesia, and also be able to provide the information and reassurance each patient needs. If a problem occurs during labor and delivery, it must be dealt with expertly and immediately. This article discusses the diagnostic clues, laboratory tests, and management of neurologic complications related to obstetric delivery and regional anesthesia, as well as the topics of infections, obstetric- and anesthetic-related neurologic deficits, and special tips on neurologic examination. The most common neurologic complication of spinal and epidural anesthesia, postdural puncture headache, will not be discussed in detail here.

Anesthesia, Conduction↗
PubMed1990

[Relations between psycho-physical acceleration and modern obstetrics].

In the highly developed countries, an acceleration of human growth and an increase in body length can be observed. The weight and length at birth are also increasing, which can be proved by our own investigation. Up to now, the theories explaining this phenomena are insufficient, because they assume the transmission of genetically acquired qualities. The reason for the acceleration is to be considered in the advancement of obstetrics as follows: Obstetrical handling, forceps and caesarean section permit the delivery of large babies, which were often lethal for mother and child. This led to an increase in the frequency of genetic developments for greater body length and weight at birth, which had formerly been limited by the high mortality rate. The trend towards larger babies is caused by an evolutionary selection of an enlargement of the brain, which must reach a certain minimum size by the time of birth. The relative enlargement of the newborn skull, made possible by advanced obstetrics, permits such increased birth weight and length. It also leads to an acceleration of growth and taller adults. The consequence of larger babies is an increasing frequency of obstetrical operations.

Birth Weight↗
PubMed1987

Court-ordered obstetrical interventions.

In a national survey, we investigated the scope and circumstances of court-ordered obstetrical procedures in cases in which the women had refused therapy deemed necessary for the fetus. We also solicited the opinions of leading obstetricians regarding such cases. Court orders have been obtained for cesarean sections in 11 states, for hospital detentions in 2 states, and for intrauterine transfusions in 1 state. Among 21 cases in which court orders were sought, the orders were obtained in 86 percent; in 88 percent of those cases, the orders were received within six hours. Eighty-one percent of the women involved were black, Asian, or Hispanic, 44 percent were unmarried, and 24 percent did not speak English as their primary language. All the women were treated in a teaching-hospital clinic or were receiving public assistance. No important maternal morbidity or mortality was reported. Forty-six percent of the heads of fellowship programs in maternal-fetal medicine thought that women who refused medical advice and thereby endangered the life of the fetus should be detained. Forty-seven percent supported court orders for procedures such as intrauterine transfusions. We conclude from these data that court-ordered obstetrical procedures represent an important and growing problem that evokes sharply divided responses from faculty members in obstetrics. Such procedures are based on dubious legal grounds, and they may have far-reaching implications for obstetrical practice and maternal and infant health.

Attitude of Health Personnel↗
PubMed2000

Factors influencing obstetric and gynecologic patients' decisions toward medical student involvement in the outpatient setting.

OBJECTIVE: We sought to determine the reasons for obstetric and gynecologic patients' acceptance or refusal of medical student participation in their outpatient care. STUDY DESIGN: A descriptive and analytic cross-sectional study of 180 patients at the University of California, San Francisco, was done to identify factors involved in patient acceptance or refusal of medical student participation in their outpatient obstetric-gynecologic visit. Responses were analyzed by Cochran-Mantel-Haenszel tests for rank order tests of factors involved in the decision to accept or decline medical student participation and chi(2) or Fisher exact tests for comparison of data among different groups. RESULTS: Reasons for accepting medical student involvement included the desire to contribute to the training of future physicians and the desire for the highest standard of care. Reasons for refusing medical student involvement included the protection of patient privacy and the low comfort level with the examination. The acceptance rate for medical students during the obstetric visits was 89.1%, and that during the gynecologic visits was 81.4%. CONCLUSION: Private faculty patients, as well as Medicaid patients, have a high acceptance of both male and female medical students in the obstetric-gynecologic outpatient setting.

Ambulatory Care↗
PubMed2002

Statistics usage in the American Journal of Obstetrics and Gynecology: has anything changed?

OBJECTIVE: Our purpose was to compare statistical listing and usage between articles published in the American Journal of Obstetrics and Gynecology in 1994 with those published in 1999. STUDY DESIGN: All papers included in the obstetrics, fetus-placenta-newborn, and gynecology sections and the transactions of societies sections of the January through June 1999 issues of the American Journal of Obstetrics and Gynecology (volume 180, numbers 1 to 6) were reviewed for statistical usage. Each paper was given a rating for the cataloging of applied statistics and a rating for the appropriateness of statistical usage, when possible. These results were compared with the data collected on a similar review of articles published in 1994. RESULTS: Of the 238 available articles, 195 contained statistics and were reviewed. In comparison to the articles published in 1994, there were significantly more articles that completely cataloged applied statistics (74.3% vs 47.4%) (P <.0001), and there was a significant improvement in appropriateness of statistical usage (56.4% vs 30.3%) (P <.0001). CONCLUSION: Changes in the Instructions to Authors regarding the description of applied statistics and probable changes in the behavior of researchers and Editors have led to an improvement in the quality of statistics in papers published in the American Journal of Obstetrics and Gynecology.

Gynecology↗
PubMed2002

How virtual reality may enhance training in obstetrics and gynecology.

OBJECTIVE: Contemporary training in obstetrics and gynecology is aimed at the acquisition of a complex set of skills oriented to both the technical and personal aspects of patient care. The ability to create clinical simulations through virtual reality (VR) may facilitate the accomplishment of these goals. The purpose of this paper is 2-fold: (1) to review the circumstances and equipment in industry, science, and education in which VR has been successfully applied, and (2) to explore the possible role of VR for training in obstetrics and gynecology and to suggest innovative and unique approaches to enhancing this training. MATERIAL AND METHODS: Qualitative assessment of the literature describing successful applications of VR in industry, law enforcement, military, and medicine from 1995 to 2000. Articles were identified through a computer-based search using Medline, Current Contents, and cross referencing bibliographies of articles identified through the search. RESULTS: One hundred and fifty-four articles were reviewed. This review of contemporary literature suggests that VR has been successfully used to simulate person-to-person interactions for training in psychiatry and the social sciences in a variety of circumstances by using real-time simulations of personal interactions, and to launch 3-dimensional trainers for surgical simulation. These successful applications and simulations suggest that this technology may be helpful and should be evaluated as an educational modality in obstetrics and gynecology in two areas: (1) counseling in circumstances ranging from routine preoperative informed consent to intervention in more acute circumstances such as domestic violence or rape, and (2) training in basic and advanced surgical skills for both medical students and residents. CONCLUSION: Virtual reality is an untested, but potentially useful, modality for training in obstetrics and gynecology. On the basis of successful applications in other nonmedical and medical areas, VR may have a role in teaching essential elements of counseling and surgical skill acquisition.

Clinical Competence↗
PubMed2003

Evaluation of pelvic and breast examination skills of interns in obstetrics and gynecology and internal medicine.

OBJECTIVE: The purpose of this study was to evaluate the pelvic and breast examination skills of a group of interns who were entering obstetrics and gynecology and internal medicine and to determine whether previous experience predicts performance. STUDY DESIGN: This was a prospective study that, with the use of an examination with a standardized format of 26 skills, assessed the performance of 10 interns who were entering internal medicine and 9 interns who were entering obstetrics and gynecology. chi(2) analysis and Fisher exact tests were used. RESULTS: There was no significant difference in overall performance on the pelvic and breast examinations between the two groups. The obstetrics and gynecology interns performed significantly better (P<.05) on the three skills that assessed professional conduct. There was considerable variability within each group. There was no correlation between previous clinical experience and performance on the skills assessment, nor was there a correlation between perceived competence and actual performance. CONCLUSIONS: Previous clinical experience does not predict performance in a standardized assessment of pelvic and breast examination skills nor does it account for the great variability in competence levels in interns who are entering obstetrics and gynecology and internal medicine.

Breast↗
PubMed1999

Incidence and obstetric risk factors of postpartum anal incontinence.

BACKGROUND: Anal incontinence in young women may be the result of injury to the pelvic floor during vaginal delivery. This study was conducted to evaluate the relationship between obstetric risk factors and the prevalence of anal incontinence 3 months and 1 year after delivery. METHODS: Three hundred consecutive women who delivered in the obstetric ward of the Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, were prospectively interviewed 3 months postpartum with regard to the symptom of anal incontinence. Patients with anal incontinence that started after delivery were questioned about the type, frequency, and severity of the problem, concomitant stress urinary incontinence (SUI), previous colorectal assessment, and wish for further evaluation and treatment. Obstetric data were collected from the women's medical charts. Symptomatic patients were followed-up 1 year postpartum. RESULTS: Anal incontinence was reported by 21 patients: 19 were incontinent to gas, whereas only 2 patients were incontinent to solid feces (6.3% and 0.7% of the study population, respectively). Five patients (24% of the anal-incontinent patients) also had concomitant SUI. The length of the first and second stages of labor, operative vaginal delivery, and episiotomy were found to be associated (P < 0.05) with the development of anal incontinence at 3 months postpartum. At I year postpartum all patients with combined anal incontinence and SUI had persistent symptoms. CONCLUSION: The major obstetric risk factors for postpartum anal incontinence are prolonged first and second stages of labor, operative vaginal delivery, and the use of episiotomy.

Adult↗
PubMed2003

Obstetric hysterectomy: fifteen years' experience in a Nigerian tertiary centre.

The aim of this study was to determine the incidence, indications, associations and complications of obstetric hysterectomy in our centre with a view to suggesting ways of improving outcome. This is a descriptive study of patients who had obstetric hysterectomy in the University of Benin Teaching Hospital from January 1986 to December 2000. Data obtained from hospital records were analysed using appropriate computer statistical software for graphs and chi(2) test. In the period under study there were 20 344 deliveries. There were 46 obstetric hysterectomies, resulting in an incidence of 0.226%. Incidence increased with increasing maternal age from 0.10% at 20 years to 0.706% at 40 years and above. Incidence also increased with parity from 0.028% at para 0 to 1.298% for grandmultiparous women. The indications for the procedure were ruptured uterus 14/40 (35.0%), atonic postpartum haemorrhage 13/40 (32.5%) and placenta praevia 9/40 (22.5%); 12/40 (30.0%) of patients had previous caesarean sections. Subtotal hysterectomy had been undertaken in 43.5% of cases. There was a maternal mortality rate of 12.5%. Mortality was associated with torrential continuing haemorrhage and septicaemia. Urinary tract injury occurred in 7.50% of patients. Injury to the urinary tract was associated with previous caesarean section and total hysterectomy. Obstetric hysterectomy can have grave consequences. Availability of blood products, intensive monitors and limitation of family size is advised.

Adult↗
PubMed2004

Are obstetric risk factors and bowel symptoms associated with defaecographic and manometric abnormalities in women awaiting hysterectomy?

Abdominal hysterectomy has been shown to affect anorectal function. These studies are either population-based or have been performed retrospectively. It is not clear from the literature whether those subjects awaiting hysterectomy already have an element of pelvic floor failure and which may be related to obstetric risk factors. A complete anorectal assessment was performed in a group of women awaiting hysterectomy who did not volunteer any bowel symptoms. The patients studied were part of an ongoing study of the functional effects of abdominal hysterectomy. All had their anorectal function assessed before their respective surgery by a questionnaire (functional bowel score), Cleveland continence score, endoanal ultrasound (U/S), anal manometry, defaecatory proctogram and colonic transit. A detailed obstetric history, which included risk factors such as parity, type of delivery, duration of labour and elevated birth weight, were also recorded. Patients with previous bowel disease, bowel surgery and anal sphincter repair were excluded. There were 39 subjects with a median age of 43 years (range 31-65), respectively. Thirty-three rectocoeles and 22 intussusceptions were demonstrated. Two had poor puborectalis function, while five had cough incontinence. Two women had abnormal colonic transit. Thirteen had abnormal anal manometry. Endoanal ultrasound was normal in all patients. None of the obstetric risk factors were associated with rectocoele, intussusception or abnormal anal manometry. Low squeeze pressure was associated significantly with more bowel symptoms (P=0.03). However, rectocoele, intussusception, abnormal colonic transit, abnormal resting anal pressure and maximal tolerated volume were not statistically significantly associated with bowel symptoms. The majority of female subjects who were awaiting hysterectomy had physiological and proctographic abnormalities consistent with pelvic floor failure. Obstetric risk factors were not associated with rectocoele, intussusception, abnormal colonic transit and anal manometry in this cohort of patients. Similarly, the majority of proctographic abnormalities were not associated with bowel symptoms. However, a trend was noted associating bowel symptoms with manometric abnormalities.

Adult↗
PubMed2006

Survey of surgical experience during training in obstetrics and gynaecology in the UK.

The 2002 RCOG survey of training reported that the percentage of obstetric and gynaecology trainees who class their operative training as good or very good has declined from 45% in 1995, to 39% in 2002; reduction in years of training and number of working hours may have further impact on the surgical experience. In this study, we have attempted to assess the level of surgical confidence reported by senior and recently accredited trainees in obstetrics and gynaecology in the UK via an anonymised postal questionnaire. A total of 103 replies were received from 202 questionnaires. Some 99% of the respondents said they felt competent to carry out a simple total abdominal hysterectomy; 61.2% could confidently dissect the ureter and 55.3% could repair major damage to the bladder. However, when managing major obstetric haemorrhage, only 44.6% of respondents felt confident to perform a caesarean hysterectomy; 27.1% could dissect the ureter and 41.7% could apply a B-Lynch suture to the uterus. The level of competence increased with seniority and also with additional time spent in research, subspecialty training or other specialties. There appears to be an appropriate level of confidence in carrying out gynaecological surgical procedures by senior trainees and new consultants. However, surprisingly few respondents were confident in performing any surgical procedure necessary in the management of major obstetric haemorrhage. This may have serious implications in the provision of out of hours senior cover for maternity units in the future.

Clinical Competence↗
PubMed2005

Availability, distribution and use of emergency obstetric care in northern Tanzania.

The objective of this study is to determine the availability, distribution and quality of facilities providing delivery services, as well as their use by pregnant women. The study is a survey of all facilities providing delivery services (n = 129) in six districts in northern Tanzania. The framework provided by the UNICEF/UNFPA/WHO (UN) Guidelines is applied. An attempt is made to answer the first three questions in this audit outline: are there enough emergency obstetric care (EmOC) facilities? Are they well distributed? And are enough women using them? The results show that there is a very low availability of basic emergency obstetric care (BEmOC) units (1.6/500,000), and a relatively high availability of comprehensive emergency obstetric care (CEmOC) units (4.6/500,000), both with large urban/rural variation. The percentage of expected deliveries in EmOC facilities is 36%, compared with the UN Guidelines minimum accepted threshold of 15%. Nevertheless, the distribution shows a much higher utilization in urban districts compared with rural, indicating that mothers have to travel long distances to receive adequate services when in need of them. The paper also discusses the provisional context of the services in terms of level of facilities providing them and their public/private mix. Most facility deliveries are conducted at CEmOC facilities. Pregnant women tend to utilize the services of voluntary agencies to a greater degree than government services in rural areas, while the government services have a higher burden of the workload in urban areas. A majority (86%) of the deliveries occurring in voluntary agency facilities occur in a qualified EmOC facility. Against a backdrop of a large availability of any facility regardless of their emergency obstetric care status (41.9/500,000), this paper argues that given the large number of potential BEmOC facilities, it seems more efficient to shift resources within the BEmOC level, compared with from CEmOC level down to BEmOC level, to improve access to quality services. There is a large potential for quality improvement, in particular at dispensary and health centre levels. We argue that the main barrier to access to quality care is not the mother's ignorance or their ability to get to a facility, but the actual quality of care meeting them at the facility.

Emergency Medical Services↗
PubMed2001

Review of unexplained infertility and obstetric outcome: a 10 year review.

BACKGROUND: Increased maternal and fetal risks have been reported in pregnancies following unexplained infertility. Our aims were to examine the obstetric and perinatal outcome of singleton pregnancies in couples with unexplained infertility and explore the impact of fertility treatment. METHODS: Women with unexplained infertility were identified from the Aberdeen Fertility Clinic Database. Their unit numbers were matched against the Aberdeen Maternity and Neonatal Databank (AMND) in order to extract obstetric records of those women with subsequent pregnancy outcomes. The general obstetric population served as a control group. RESULTS: Women with unexplained infertility were older [30.8 versus 27.9 years, 95% confidence interval (CI) for difference = +2.4 to +3.4] and more likely to be primiparous (59 versus 40%, 95% CI = +1.3 to +1.9). After adjusting for age and parity they had a higher incidence of pre-eclampsia, abruptio placentae, preterm labour, emergency Caesarean section and induction of labour in comparison with the general population (P < 0.05). Perinatal outcome did not differ between women with unexplained infertility and those of the general population. The multiple pregnancy rate was 5.4% higher following fertility treatment than in women who conceived spontaneously (95% CI = +2.8 to +9.7). CONCLUSIONS: Women with unexplained infertility are at higher risk of obstetric complications which persist even after adjusting for age, parity and fertility treatment. The reasons are however unclear and merit further study.

Abruptio Placentae↗
PubMed1989

Anesthetic management for obstetric hysterectomy: a multi-institutional study.

A prospectively designed review of all obstetric hysterectomies performed in five university hospitals between November 1, 1984 and October 31, 1987 has been performed. There were 41,107 deliveries and 46 obstetric hysterectomies, an incidence of 0.11%. Twenty-five hysterectomies were elective and 21 were emergent. The indication for 11 of the 21 emergency hysterectomies was placenta previa and/or accreta. Women in the emergency group had greater intraoperative blood loss, were more likely to have intraoperative hypotension, and were more likely to receive donor blood than women in the elective group (P less than 0.05). Twelve patients (eight from the elective group and four from the emergency group) received continuous epidural anesthesia, and none required intraoperative induction of general anesthesia. There was no evidence that epidural anesthesia significantly affected blood loss, crystalloid replacement, or requirement for transfusion in the elective group. Abnormal placentation now represents a major indication for emergency obstetric hysterectomy. Furthermore, significant hemorrhage is more likely with emergency obstetric hysterectomy than with elective hysterectomy. Finally, elective cesarean hysterectomy is not a contraindication to performance of continuous epidural anesthesia.

Adult↗
PubMed2000

How much labor is in a labor epidural? Manpower cost and reimbursement for an obstetric analgesia service in a teaching institution.

BACKGROUND: Some anesthesiologists avoid provision of obstetric analgesia services (OAS) because of low reimbursement rates for the work involved. This study defines the manpower costs of operating an OAS in a tertiary referral center and examines reimbursement for this cost. METHODS: The time spent providing OAS in a total of 55 parturients was studied prospectively using a modification of classic time and motion studies. RESULTS: Mean duration of OAS in our population was 412 +/- 313 min. Mean bedside anesthesia staff time was 90 +/- 40 min, and mean number of visits to each patient's bedside was 6.3 +/- 2.0 visits. Assuming staffing on demand for service (intermittent staffing), a minimum of 2.5 full-time equivalent (FTE) attending anesthesiologists was required to meet demand. With intermittent staffing, labor cost was $325 per patient. Actual practice at Duke University Medical Center is around-the-clock (dedicated) staffing, which requires 4.4 FTEs at a cost of $728 per patient. Neither average indemnity reimbursement ($299) nor Medicaid reimbursement ($204) covered the cost per OAS patient. Breaking even is possible under indemnity reimbursement because operating room reimbursement subsidizes OAS costs. Breaking even cannot occur with Medicaid reimbursement under any circumstances. CONCLUSIONS: Obstetric analgesia services requires a minimum of 2.5 FTE attending anesthesiologists at Duke University Medical Center. With the current payer mix, positive-margin operating room activities associated with the obstetric service are not sufficient to compensate for the losses incurred by an OAS. Around-the-clock dedicated obstetric staffing (4.4 FTEs) cannot operate profitably under any reasonable circumstances at our institution.

Adult↗
PubMed1988

Student performance on the NBME Part II subtest and subject examination in obstetrics-gynecology.

Clerkship directors in obstetrics-gynecology often use the National Board of Medical Examiners (NBME) norms to evaluate third-year medical students' performance on the NBME obstetrics-gynecology subject examination. A comparison of the scores of 342 students at the Medical College of Georgia School of Medicine showed that the students performed significantly better on the NBME subject examination than on the Part II subtest in obstetrics-gynecology. These results concur with the findings of the NBME, which advises directors wishing to adjust the criterion group norms to determine the average difference observed in a school's performance on the two examinations and to use that difference or some portion of it in their interpretation of percentile scores on the subject examination. Additional analyses revealed that a single, linear weight may inappropriately adjust these scores, that student performance on the Part II subtest depends on specialty choice (obstetrics-gynecology versus all others), and that time and sequence of the clerkship were unrelated to the students' performance on the two examinations.

Achievement↗