Impact of third- and fourth-degree perineal tears at first birth on subsequent pregnancy outcomes: a cohort study.

OBJECTIVE: To investigate, among women who have had a third- or fourth-degree perineal tear, the mode of delivery in subsequent pregnancies as well as the recurrence rate of third- or fourth-degree tears. DESIGN: A retrospective cohort study of deliveries using a national administrative database. SETTING: The English National Health Service between 1 April 2004 and 31 March 2012. POPULATION: A total of 639,402 primiparous women who had a singleton, term, vaginal live birth between April 2004 and March 2011, and a second birth before April 2012. METHODS: Multivariable logistic regression models were used to estimate odds ratios, adjusted for other risk factors. MAIN OUTCOME MEASURES: Mode of delivery and recurrence of tears at second birth. RESULTS: The rate of elective caesarean at second birth was 24.2% for women with a third- or fourth-degree tear at first birth, and 1.5% for women without (adjusted odds ratio, aOR 18.3, 95% confidence interval, 95% CI 16.4-20.4). Among women who had a vaginal delivery at second birth, the rate of third- or fourth-degree tears was 7.2% for women with a third- or fourth-degree tear at first birth, compared with 1.3% for women without (aOR 5.5, 95% CI 5.2-5.9). CONCLUSIONS: The risk of a severe perineal tear is increased five-fold in women who had a third- or fourth-degree tear in their first delivery. This increased risk should be taken into account when decisions about mode of delivery are made.

Delivering quality care: what can emergency gynaecology learn from acute obstetrics?

Emergency obstetric care in the UK has been systematically developed over the years to high quality standards. More recently, advances have been made in the organisation and delivery of care for women presenting with acute gynaecological problems, but a lot remains to be done, and emergency gynaecology has a lot to learn from the evolution of its sister special interest area: acute obstetric care. This paper highlights areas such as consultant presence, risk management, patient flow pathways, out-of-hours care, clinical guidelines and protocols, education and training and facilities, where lessons from obstetrics are transferrable to emergency gynaecology.

Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors.

OBJECTIVE: To describe the trends of severe perineal tears in England and to investigate to what extent the changes in related risk factors could explain the observed trends. DESIGN: A retrospective cohort study of singleton deliveries from a national administrative database. SETTING: The English National Health Service between 1 April 2000 and 31 March 2012. POPULATION: A cohort of 1 035 253 primiparous women who had a singleton, term, cephalic, vaginal birth. METHODS: Multivariable logistic regression was used to estimate the impact of financial year of birth (labelled by starting year), adjusting for major risk factors. MAIN OUTCOME MEASURE: The rate of third-degree (anal sphincter is torn) or fourth-degree (anal sphincter as well as rectal mucosa are torn) perineal tears. RESULTS: The rate of reported third- or fourth-degree perineal tears tripled from 1.8 to 5.9% during the study period. The rate of episiotomy varied between 30 and 36%. An increasing proportion of ventouse deliveries (from 67.8 to 78.6%) and non-instrumental deliveries (from 15.1 to 19.1%) were assisted by an episiotomy. A higher risk of third- or fourth-degree perineal tears was associated with a maternal age above 25 years, instrumental delivery (forceps and ventouse), especially without episiotomy, Asian ethnicity, a more affluent socio-economic status, higher birthweight, and shoulder dystocia. CONCLUSIONS: Changes in major risk factors are unlikely explanations for the observed increase in the rate of third- or fourth-degree tears. The improved recognition of tears following the implementation of a standardised classification of perineal tears is the most likely explanation.

Structured multidisciplinary intershift handover (SMITH): a tool for promoting safer intrapartum care.

On the labour ward, the key to achieving patient safety is the intershift handover, which affords an opportunity for the team to undertake a baseline assessment of the current situation, anticipate problems, plan contingencies and subsequently maintain situational awareness. If optimised, the handover has immense potential not only for enhancing patient safety but also for reducing stress to staff. The handover should be regarded not as an end but as the beginning of the process of maintaining individual and team situational awareness throughout the shift. Each maternity unit should have a Structured Multidisciplinary Intershift Handover (SMITH) protocol, which encompasses pre-handover, handover and post-handover guidance. This paper describes the underlying principles, benefits and content of a SMITH protocol.

What do maternity statistics tell us about induction of labour?

The National Maternity Statistics (Department of Health, 1997) show that labour is induced in one out of every five pregnancies carried to viability in England. Induced labours are associated with higher rates of further intervention such as instrumental delivery and caesarean section, and with economic costs resulting from longer stay in hospital. Women who are offered induction of labour, whether for medical or social reasons, should be advised of the risks of further intervention. Information about induction of labour should be given routinely during antenatal care since one in five women will have this experience. Care providers need to be more aware of the economics of induced labour, a factor which has not been taken into account in the longstanding debate on the merits of induction of labour for post-term pregnancy.

Failed instrumental delivery: how safe is the use of a second instrument?

An audit of failed instrumental deliveries was undertaken to assess the incidence of complications and the adequacy of documentation. When one instrument has failed to effect delivery, the use of a second instrument could in most cases be used to complete the delivery without harm to the mother or baby. However in a small but significant number of cases there are severe maternal or perinatal complications, and these could be the subject of litigation. This could be avoided by adequate pre-application assessment, standard conduct of instrumental delivery and full documentation. Inadequate documentation could be overcome by the use of a pro forma. Selective use of plastic and metal cups could reduce the incidence of failed attempts.

The use of hormone replacement therapy in women with acute myocardial infarction: an audit of current practice.

We undertook criterion-based audit of the current practice of prescribing hormone replacement therapy for women with acute myocardial infarction; the audit included 181 consecutive women admitted to one hospital with this diagnosis in one calendar year. The set standard was that, barring any contraindication, all postmenopausal women with acute myocardial infarction should be prescribed hormone replacement therapy before discharge from hospital. The evidence base of this standard derives from more than 30 epidemiological and clinical studies and a large body of biological data. Only 4.7% of the women were current users of hormone replacement therapy and the set standard was met in only 3% of eligible nonusers. Professionals caring for women who have had a myocardial infarction need to consider hormone replacement therapy as a secondary prophylaxis of myocardial infarction. Gynaecologists should liaise with colleagues in other specialties and general practice to ensure that information on the nongynaecological benefits of hormone replacement therapy is widely disseminated.

Difficulties and dilemmas in the management of congenital anomalies in twin pregnancy.

Both the incidence of twin pregnancy and the demand for prenatal diagnosis are increasing. Unfortunately, biochemical screening and ultrasound scanning are less reliable for prenatal diagnosis in twin pregnancies than in singletons. Amniocentesis and chorionic villous biopsy are usually diagnostic in singleton pregnancies but may be marred by sampling errors in twin gestations. Where a congenital anomaly has been diagnosed in a twin pregnancy, difficult decisions may have to be made, especially if one twin is unaffected. In these cases, special skills are required to ensure that adequate information, psychological support and optimal medical care are provided.

Reversal of sterilisation by the railroad technique.

OBJECTIVE: To show that a simple, easily learned and relatively inexpensive method of reversal of sterilisation provides good results. DESIGN: Retrospective observational study. SETTING: An NHS Trust Hospital. SAMPLE: Sixty-seven women aged 19 to 39 years who underwent reversal of sterilisation between January 1984 and December 1993. MAIN OUTCOME MEASURES: Pregnancy rate following reversal; rate of ectopic pregnancy. RESULTS: Thirty-four women (51%) had intrauterine pregnancies after reversal of sterilisation; intrauterine pregnancy rate in women who had been sterilised with rings or clips was 64%. Five women (7.5%) had ectopic pregnancies. CONCLUSION: This technique provides results that compare favourably with those of microsurgery. It offers hope to couples who do not meet the restrictive criteria for microsurgery and in vitro fertilisation and should appeal to purchasing authorities.

Invasive and in situ carcinoma of the cervix in young Nigerians: a clinico-pathologic study of 27 cases.

A study of young Nigerians aged 30 years and below with invasive and in-situ cervical carcinoma confirms the notion that cervical cancer occurs in all age group. All patients except one were married while all were parous. Forty four percent of the patients presented with stages III and IV disease and hence, were unsuitable for surgery. The youngest patient was aged 17 years, indicating the need tare cancer screening among adolescents and a vigorous family planning programme that emphasizes barrier contraception.

Synchronous carcinomas of cervix and ovary: case reports.

Four cases of synchronous carcinoma of the cervix and ovary are reported. In all cases the ovarian and cervical tumours were adenocarcinoma. Surgical management was determined by the extent of the tumours and the need for intracavitary radiotherapy. The dilema in determining whether the tumours were separate primaries or one primary with metastasis is discussed.

Squamous carcinoma of the cervix metastatic to the umbilicus. Case report.

Sister Joseph's nodule is a rare feature of advanced cervical carcinoma. This case is reported from a Nigerian teaching hospital where over 100 new cases of cervical carcinoma are seen annually.

The incompetent cervix--a review.

Repeated midtrimester pregnancy loss due to incompetence of the cervical os has long been recognised as a treatable condition, but the aetiology, diagnosis and management of this condition remain controversial. Some women have clinically obvious cervical incompetence and may benefit from a cerclage operation, but criteria for early diagnosis are not universally agreed upon. Universal agreement on the aetiology and diagnostic criteria is a prerequisite for determining which women may benefit from surgical management.