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PubMed2006

Professional liability payments in obstetrics and gynecology.

OBJECTIVE: The purpose of this study was to test the hypothesis that the percentage of subspecialists in obstetrics and gynecology who made payments on professional liability claims was less than the percentage of general obstetrician-gynecologists who made payments. METHODS: Professional liability payment data from the Massachusetts Board of Registration in Medicine was used. RESULTS: During the 10 years preceding August 2005, 38.6% of obstetrician-gynecologists and 32.2% of gynecologists made at least 1 professional liability payment. During the same time period, the percentage of subspecialists who made a payment was significantly less than obstetrician-gynecologists: gynecologic oncologists 10.0% (P = .012), maternal-fetal medicine 3.7% (P = .002), and reproductive endocrinologists 11.9% (P = .016). Using aggregate payment data for the period 1994-2003, the average payment per claim for specialists in maternal-fetal medicine ($1,950,000) and gynecologic oncology ($1,014,006) were above the average payment per claim for obstetrician-gynecologists ($447,983) or gynecologists ($400,338). Reproductive endocrinologists had an average payment per claim of $454,047. CONCLUSION: All specialists in the field of obstetrics and gynecology have major professional liability risks. Among subspecialists in obstetrics and gynecology, the favorable trend toward fewer physicians making payments is counterbalanced by greater payments per lost claim. LEVEL OF EVIDENCE: II-2.

Gynecology↗
PubMed2006

Patient safety in obstetrics and gynecology: an agenda for the future.

The effect of medical errors and unsafe systems of care has had a profound effect on the practice of obstetrics and gynecology. From 1975 to 2000, medical malpractice costs for obstetrician-gynecologists have risen nearly four-fold higher than that of other medical costs. In addition, it has been estimated that defensive medicine may cost society $80 billion per year. Most importantly, many obstetrician-gynecologists are frustrated and seem to be abandoning the parts of their practice they perceive to put them at higher liability risk. This article discusses other medical specialty society efforts that have been successful in addressing the area of patient safety. Efforts to better track quality outcomes has been initiated by the American College of Surgeons through the National Surgical Quality Improvement Project, and the American Society of Anesthesiologists has demonstrated both dramatically improved outcomes and reduced liability costs through a concerted patient safety effort. The author proposes changes in four areas to specifically address patient safety in obstetrics and gynecology, including: the development of reliable and reproducible quality control measures (and a system to track them); national closed claim reviews to better understand and address the most important safety and liability areas for obstetrician-gynecologists; work prospectively with pharmaceutical and surgical device manufacturers to develop innovative new products that would increase the likelihood of safe outcomes; and create a culture of safety in obstetrics and gynecology by incorporating safety education into all levels of training.

Anesthesiology↗
PubMed2006

Vesicovaginal fistula: obstetric causes.

PURPOSE OF REVIEW: Obstetric fistula has a devastating impact on the lives of women in poor countries. Currently, there is an international campaign by the World Health Organisation, United Nations Population Fund and other bodies to address this problem. This article reviews recent literature and highlights the paucity of evidence-based data. RECENT FINDINGS: Articles on the pathophysiology, co-morbidities and sequelae including physical injury to 'multiorgan systems' and social consequences associated with obstetric fistula, are discussed. In particular, the devastating social, economic and psychological effects on the health and well-being, reintegration and rehabilitation are addressed. There is a need for prevalence and incidence studies to measure the extent of this problem. The creation of well-equipped fistula centres with multidisciplinary teams to evaluate patients should be the aim. Expert surgeons and optimal databases with personnel to do research will benefit patients. SUMMARY: Prevention should involve alleviation of poverty and improvement in education, maternity services and health. Research on issues such as persistent stress incontinence following fistula closure, management of reduced bladder capacity, best technique for fistula repair, role of vaginoplasty, role of early repair in selective obstetric fistula, future reproductive function, dermatological management, and social and cultural issues must be done to improve women's health.

Cesarean Section↗
PubMed2005

Massive blood loss and transfusion in obstetrics and gynecology.

UNLABELLED: Massive perioperative or periparturitional bleeding occasionally occurs in obstetric and gynecologic patients. Placenta previa, uterine atony, and ectopic pregnancy are just a few examples of many conditions that could predispose patients to significant blood loss. Therefore, it is important for physicians specializing in obstetrics and gynecology to be proficient in managing episodes of massive hemorrhage and the practice of the most commonly used blood components. We review and update the management of massive hemorrhage for obstetrics and gynecologic patients. In addition, we explore blood component therapy, its risks and benefits. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians Learning. OBJECTIVES: After completion of this article, the reader should be able to explain the necessity of being proficient in managing episodes of massive hemorrhage, list the indications for use of various blood components, and summarize the risks and benefits of blood component therapy.

Algorithms↗
PubMed2004

Long-distance fixed-wing transport of obstetrical patients.

OBJECTIVES: Aeromedical obstetrical transports are mostly performed utilizing helicopters. The program here reviewed performs mostly fixed-wing transports. The purpose of the current study is to review our fixed-wing transfers and identify the complications encountered. METHODS: A retrospective review was conducted of the fixed-wing obstetrical air transports performed by the StatCare aeromedical transport service from July 1, 2000 through June 30, 2002. Information on each patient (age, gestational age, gravida status, diagnosis, preflight physical examination) was collected using a data sheet. Also noted were any described complications. RESULTS: During the 24-month study period, 80 fixed-wing transports were performed. In-flight complications included nausea and vomiting (80%), increased contractions (8.8%), hypertension (1.3%), hypotension (1.3%), decreased maternal respiratory drive (1.3%), and infiltrated intravenous line (1.3%). CONCLUSIONS: The complications encountered during long-distance fixed-wing aeromedical transport of obstetrical patients include nausea and vomiting, increased contractions, hypertension, hypotension, decreased maternal respiratory drive, and an infiltrated intravenous line.

Adolescent↗
PubMed2006

Complementary therapy and obstetrics and gynaecology: a time to integrate.

PURPOSE OF REVIEW: The purpose of this review is to assess the evidence and role of complementary and alternative medicine in obstetrics and gynaecology. There is increasing patient interest and use of complementary and alternative medicine therapies and there is thus a need for health practitioners to be appropriately informed of different complementary therapies. RECENT FINDINGS: This article reviews the background to complementary and alternative medicine and the evidence although limited for its introduction into mainstream obstetrics and gynaecology; the difficulty in obtaining good evidence is also discussed. SUMMARY: The conclusions drawn are that we need to develop an integrated approach to healthcare and this is particularly relevant and important in obstetrics and gynaecology. With this integration, clinical research is essential and needs encouragement from all levels.

Complementary Therapies↗
PubMedDate not supplied

Obstetrical complications and violent delinquency: testing two developmental pathways.

This study focused on the interaction between specific obstetrical complications and early family adversity in predicting violent behavior during childhood and adolescence, in a sample of 849 boys from low socioeconomic areas of Montreal, Canada. Obstetrical complication data from medical records were used to create three scales using a nonlinear principal component analysis followed by rotation. Family adversity and teacher-rated physical aggression were assessed when the boys were in kindergarten and self-reports of delinquency were collected when they were 17. Elevated scores on the Deadly Risk Situation scale of obstetrical complications (preeclampsia, umbilical cord prolapse, and induced labor) increased the risk of being violent at both 6 and 17 years of age, only among boys who grew up in high adverse familial environments. Moreover, this interaction partly accounted for the continuity between violence in childhood and adolescence. Interventions for young pregnant women from deprived environments and their babies are discussed in light of these results.

Adolescent↗
PubMed1987

Protocols in obstetric units: their use in Wales in 1983.

The Welsh Perinatal Mortality Initiative carried out an extensive enquiry into perinatal deaths in Wales between 1984 and 1986 and their report was published by the Secretary of State for Wales in December 1986. One aspect examined was the obstetric anaesthetic service and a comprehensive questionnaire was sent to all obstetric units where Caesarean sections are carried out. One of the questions was on the use of protocols in obstetrics and the results presented are disappointing.

Anesthesia, Obstetrical↗
PubMed1990

A population-based study of mild mental handicap in children: preliminary analysis of obstetric associations.

One hundred and twenty-nine children in the 8- to 12-year-old age group in Cardiff were ascertained to have mild mental deficiency. Detailed obstetric data were obtained which indicated that nearly 69% of the children were associated with adverse obstetric factors. Fifty-five per cent had the combined pathogenetic risk factors of pre-, peri- and neonatal adversities. Forty-two per cent of the cases had non-optimal perinatal factors and 45% were considered to have prenatal causation. There were four children with chromosomal anomalies. The various adverse obstetric influences are discussed separately.

Brain Damage, Chronic↗
PubMed1977

A comparison of the performance of three multiple choice question papers in obstetrics and gynaecology over a period of three years administered at five London medical schools.

Four, and later five, of the medical schools in the one multiple choice question (MCQ) paper in Obstertrics and Gynaecology to their students at the end of the Obstetrics and Gynaecology courses. The paper was amended twice after intervals of approximately 12 months. The results showed differences in performance between the five schools on questions and alternatives within questions, which were common to all editions of the paper (the "short" paper). These differences were also shown in the first two editions of the full paper (the "long" paper), but were not apparent in the third. There was a significant improvement in performance from the first to the second paper edition of the long by approximately 11%, but this was reversed from the second to the third edition, where there was a significant decrease in performance by approximately 4%. We cannot here exclude the possibility that this decrease in the third edition has resulted from sample bias. The rank order of the schools may result from differences in methods of teaching. It seems that such relative performance between London medical schools in contributed to by the differences in course legnth and by the occurence of mid-course test. It appears also that student performance in any of the schools has not been uniform over the period of the study, there being a peak during the period when the second edition of the paper was used. Variations in student selection occuring between schools may effect some of these differences. There was also a marked difference in students' performance between Obstetrics and Gynaecology. The short papers appeared easier than the full papers. Whilst this may due to the greater clarity of phrasing for the questions of the short paper, we also believe the subject matter of the short paper may be more relevant. A distinct effect could also be shown, over the period, due to improvements in the wording of the questions. It is possible that students perform better at Obstetrics than at Gynaecology.

Curriculum↗
PubMed1993

Patterns of use of obstetrical interventions in 12 countries.

Recent obstetrical practice trends in 12 countries were surveyed. There was a 3-fold difference in caesarean section rates and a 10-fold difference in instrumental vaginal delivery rates among countries. There was a net increase in the caesarean section rate of all countries over the study period and a net decrease in the instrumental vaginal delivery rate of some countries. There was a decrease in the caesarean section rate during the last year of observation in Australia, Denmark and Finland. In general, countries with high caesarean rates also had high instrumental vaginal delivery rates. There was no consistent relationship between use of caesarean section and use of instrumental vaginal delivery, although in several countries increasing use of caesarean section was accompanied by decreasing use of instrumental vaginal delivery. Oxytocin use rates were associated positively with instrumental delivery but not with caesarean section rates. While it was not possible to determine the proportions of women who received appropriate obstetrical care, we can infer that a significant proportion of interventions were unnecessary or only marginally beneficial. Continued increases in rates of obstetrical intervention are unlikely to result in improvements in birth outcome overall and may pose a risk to mothers and their newborns.

Australia↗
PubMed1980

Laryngeal oedema as an obstetric anaesthesia complication: case reports.

Three cases of laryngeal oedema leading to endotracheal intubation difficulties in obstetric anaesthesia are described. The first case occurred immediately postpartum in a patient who developed a swollen face from strenuous bearing down efforts in the second stage of labour. The other two cases were patients with severe preeclampsia including marked generalized oedema. The possibility of the occurrence of laryngeal oedema with resultant endotracheal intubation difficulties in obstetrics should be remembered when endotracheal intubation is considered to avoid the hazard of acid aspiration. The authors prefer the use of regional anaesthetic techniques (if not contraindicated) in obstetrics, and emphasize the use of prophylactic methods to minimize the risk of acid aspiration in connection with general anaesthesia, particularly where endotracheal intubation may be difficult.

Adult↗
PubMed2007

The effect of surgery on quality of life in patients with faecal incontinence of obstetric origin.

OBJECTIVE: To evaluate the results of surgery in the treatment of faecal incontinence of obstetric origin and assess the effect of treatment on the quality of life of these patients. PATIENTS AND METHODS: A consecutive series of 43 patients, who had undergone surgery for severe faecal incontinence of obstetric aetiology between March 1990 and March 2004, was studied. The following studies were carried out: clinical evaluation, anorectal manometry, anal endosonography (from 1996 on) and measurement of the pudendal nerve terminal motor latency. The degree of incontinence, both preoperative and at the end of follow-up was evaluated using the Cleveland Clinic Score (CCS). Quality of life assessment was made using the Fecal Incontinence Quality of Life Scale (FIQL). RESULTS: The study was completed on 35 (87%) of the 43 patients. The mean age in the series was 53 years, (range 28-73). After an average follow-up of 50.4 months (range 4-132) the mean CCS had reduced significantly, passing from 16 (range 8-20) to 6 (range 0-18; P < 0.001). Pudendal neuropathy was found to be a factor of poor prognosis. The results of the quality of life questionnaire at the end of follow-up were: lifestyle 3.5 (SD 0.65), coping/behaviour 3.1 (SD 0.81), depression/self perception 3.7 (SD 0.75) and embarrassment 3.3 (SD 0.91). There is a statistically significant linear relationship between incontinence measured on the CCS and quality of life. For the 14 patients undergoing surgery since the publication of the FIQL questionnaire, it was possible to complete the questionnaire preoperatively, with significant improvement found on each of the four scales (lifestyle 1.7 vs 3.5; coping/behaviour 1.4 vs 3.2; depression 2.2 vs 3.8; embarrassment 1.8 vs 3.2; P < 0.001). CONCLUSION: Surgical treatment of faecal incontinence of obstetric origin achieves good results in a high percentage of patients and has a positive effect on their quality of life. The existence of prolonged preoperative pudendal nerve motor latency indicates a poor prognosis.

Adaptation, Psychological↗
PubMed1990

The obstetric forceps--are we using the appropriate tools?

A total of 166 pairs of obstetric forceps of three different types in regular use in two major obstetric units was measured and compared with manufacturers' master instruments and drawings. As well as linear measurements of blade, shank and handle the distances between the tips and maximum distance between the blades, and the mean radius of the cephalic curve were determined. The purpose of the study was to assess the suitability of instruments in common use for present day practice. It was found that the measurements differed significantly from the original descriptions and there were wide variations between instruments of the same type, even when supplied by the same manufacturer. In some cases the blades had not been packed in matching pairs in the Central Sterile Supplies Department. It is suggested that critical reappraisal of the forceps in current use in many obstetric units is overdue. As well as a need for reconsidering the type of forceps used the dimensions of individual pairs should be checked.

Equipment Design↗
PubMed1992

Risks of anal incontinence from subsequent vaginal delivery after a complete obstetric anal sphincter tear.

OBJECTIVE: To assess the influence of various risk factors on long term anal incontinence in women with a complete obstetric tear of the anal sphincter. DESIGN: Postal questionnaire. SETTING: Department of Gynecology and Obstetrics, Aarhus University Hospital, Denmark. SUBJECTS: 152 women with complete obstetric tear of the anal sphincter. MAIN OUTCOME MEASURES: Occurrence and duration of anal incontinence in relation to any delivery. RESULTS: 56 of 121 respondents had experienced a subsequent vaginal delivery; 23 (41%) of these had had transient anorectal incontinence directly after the complete tear and four (7%) had permanent anorectal incontinence. In the 23 women with transient anorectal incontinence directly after the complete tear, 9 (39%; 95% CI 19%-59%) developed anorectal incontinence after the next delivery, and this was permanent in four (17.4%; 95% CI 2%-33%). In the 29 women without anorectal incontinence after complete tear, two had transient incontinence of flatus but for less than 14 days after the next delivery. CONCLUSIONS: Transient anal incontinence after a complete tear is a predictor of anal incontinence after subsequent vaginal delivery. The major long term problem in our study of premenopausal women was incontinence of flatus. This possibility should be discussed with the women when a further pregnancy is planned.

Adult↗
PubMed1993

A paramedic based emergency domiciliary obstetric service: the South Glamorgan experience.

OBJECTIVE: To assess the potential benefits of using extended trained ambulance personnel (paramedics) as primary responders for domiciliary obstetric and gynecological emergencies. DESIGN: An observational study of performance and analysis of operational data in a newly established service. SETTING: A mixed urban and rural population served by South Glamorgan Health Authority. MAIN OUTCOME MEASURES: Work load, response times, management and transfer of patients, efficiency of communications and appropriateness of training. RESULTS: There was an initial increase in requests above that when a hospital-based service operated. Targets for response times were met. The mean response time for providing appropriate skilled help was halved compared with the previous arrangements and a safe and efficient service was provided. Prompt transport and advance notice and preparation for reception in the delivery unit contributed to optimal management. Medical staff depletion in the delivery unit was minimised. CONCLUSION: An Emergency Domiciliary Obstetric Service based on primary response by specially trained ambulance service paramedics can beneficially replace traditional hospital-based Obstetric Flying Squads.

Allied Health Personnel↗
PubMed1993

The effect of introduction of umbilical Doppler recordings to obstetric practice.

OBJECTIVE: To assess the effect on obstetric practice of clinician access to umbilical artery Doppler ultrasound results. DESIGN: Randomised controlled trial. SETTING: A large teaching hospital. SUBJECTS: Two thousand two hundred and eighty-nine pregnancies defined as being at risk by referral for Doppler or fetal monitoring. INTERVENTIONS: Continuous wave Doppler studies of umbilical artery. Results immediately available to clinicians. MAIN OUTCOME MEASURES: Fetal outcome: perinatal mortality, Apgar score and admission to the neonatal unit. Obstetric intervention: admission to hospital, induction of labour and caesarean section. Use of of fetal well being: cardiotocography, biophysical profile and ultrasound biometry. RESULTS: The treatment and control groups were comparable in age, parity, gestation at point of entry and risk features. There were no overall differences in perinatal outcome, obstetric intervention or use of fetal monitoring. Examination of a subset recruited only because of hypertension or suspected intrauterine growth retardation (n = 754) similarly showed no difference attributable to group randomisation. Comparison of only those pregnancies retrospectively defined as low risk and high risk showed more use of cardiotocography in the high risk group with access to Doppler (P = 0.007) but no difference in the low risk group. CONCLUSION: Doppler umbilical artery recording has been shown to perform well in prediction power of antenatal fetal compromise. What has been examined in this study is the response of clinicians to the test. The results suggest that obstetricians do not use the test to modify their risk assessment, and, therefore, the need for fetal monitoring in particular pregnancies. There is a real need for accumulation of information from very large data sets, particularly in the prediction power of Doppler for antenatal fetal compromise from apparently chronic utero-placental cause to guide use of monitoring resources. If simply added to existing fetal monitoring techniques in a hospital where these are widely used, then umbilical artery Doppler recordings may at present simply involve extra resources of staff and expenses, without benefit.

Adult↗
PubMed1993

Experience of autologous blood transfusion in an obstetrics and gynaecology department.

OBJECTIVE: To demonstrate the potential and effectiveness of autologous blood transfusion in an obstetric and gynaecological practice. SETTING: The Department of Obstetrics and Gynaecology and the department of Haematology, University College Hospital, Galway, Ireland. SUBJECTS: One hundred and sixty-eight women undergoing abdominal hysterectomy, 42 women undergoing repair procedures, and 56 women undergoing elective caesarian sections participated in this programme. RESULTS: In the abdominal hysterectomy group 329 units of blood were collected of which 48% were transfused to the donors. In the repair group 82 units of blood were collected of which 21.9% were transfused to the donors. In the elective caesarian section group 105 units of blood were collected of which 64.7% were transfused to the donors. Overall the donation procedure was well tolerated with infrequent donor reactions. CONCLUSION: Our experience demonstrates that autologous blood transfusion is a safe and reasonable transfusion practice in the setting of obstetrics and gynaecology.

Adult↗