Balloon catheters versus vaginal prostaglandins for labour induction (CPI Collaborative): an individual participant data meta-analysis of randomised controlled trials.

BACKGROUND: Induction of labour is one of the most common obstetric interventions globally. Balloon catheters and vaginal prostaglandins are widely used to ripen the cervix in labour induction. We aimed to compare the effectiveness and safety profiles of these two induction methods. METHODS: We did an individual participant data meta-analysis comparing balloon catheters and vaginal prostaglandins for cervical ripening before labour induction. We systematically identified published and unpublished randomised controlled trials that completed data collection between March 19, 2019, and May 1, 2021, by searching the Cochrane Library, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and PubMed. Further trials done before March 19, 2019, were identified through a recent Cochrane review. Data relating to the combined use of the two methods were not included, only data from women with a viable, singleton pregnancy were analysed, and no exclusion was made based on parity or membrane status. We contacted authors of individuals trials and participant-level data were harmonised and recoded according to predefined definitions of variables. Risk of bias was assessed with the ROB2 tool. The primary outcomes were caesarean delivery, indication for caesarean delivery, a composite adverse perinatal outcome, and a composite adverse maternal outcome. We followed the intention-to-treat principle for the main analysis. The primary meta-analysis used two-stage random-effects models and the sensitivity analysis used one-stage mixed models. All models were adjusted for maternal age and parity. This meta-analysis is registered with PROSPERO (CRD42020179924). FINDINGS: Individual participant data were available from 12 studies with a total of 5460 participants. Balloon catheters, compared with vaginal prostaglandins, did not lead to a significantly different rate of caesarean delivery (12 trials, 5414 women; crude incidence 27·0%; adjusted OR [aOR] 1·09, 95% CI 0·95-1·24; I2=0%), caesarean delivery for failure to progress (11 trials, 4601 women; aOR 1·20, 95% CI 0·91-1·58; I2=39%), or caesarean delivery for fetal distress (10 trials, 4441 women; aOR 0·86, 95% CI 0·71-1·04; I2=0%). The composite adverse perinatal outcome was lower in women who were allocated to balloon catheters than in those allocated to vaginal prostaglandins (ten trials, 4452 neonates, crude incidence 13·6%; aOR 0·80, 95% CI 0·70-0·92; I2=0%). There was no significant difference in the composite adverse maternal outcome (ten trials, 4326 women, crude incidence 22·7%; aOR 1·02, 95% CI 0·89-1·18; I2=0%). INTERPRETATION: In induction of labour, balloon catheters and vaginal prostaglandins have comparable caesarean delivery rates and maternal safety profiles, but balloon catheters lead to fewer adverse perinatal events. FUNDING: Australian National Health and Medical Research Council and Monash Health Emerging Researcher Fellowship.

Progesterone for women with threatened miscarriage (STOP trial): a placebo-controlled randomized clinical trial.

STUDY QUESTION: In women with threatened miscarriage, does progesterone supplementation until the completion of the first trimester of pregnancy increase the probability of live birth? SUMMARY ANSWER: In women with threatened miscarriage, 400 mg vaginal progesterone nightly, from onset of bleeding until 12 weeks, did not increase live birth rates. WHAT IS KNOWN ALREADY: Limited evidence has indicated that vaginal micronized progesterone may make little or no difference to the live birth rate when compared with placebo in women with threatened miscarriage. Subgroup analysis of one recent randomized trial reported that in women with bleeding and at least one previous miscarriage, progesterone might be of benefit. STUDY DESIGN, SIZE, DURATION: We performed a randomized, double-blinded, placebo-controlled trial between February 2012 and April 2019. Eligible pregnant women under 10 weeks gestation, experiencing a threatened miscarriage as apparent from vaginal bleeding were randomized into two groups in a 1:1 ratio: the intervention group received 400 mg progesterone as vaginal pessaries, the control group received placebo vaginal pessaries, both until 12 weeks gestation. The primary endpoint was live birth. We planned to randomize 386 women (193 per group). The study was stopped at a planned interim analysis for futility after randomization of 278 women. PARTICIPANTS/MATERIALS, SETTING, METHODS: This trial was conducted at the Mater Mothers' Hospital, a tertiary centre for maternity care in South Brisbane, Queensland, Australia. We randomized 139 women to the intervention group and 139 women to the placebo group. Primary outcome data were available for 136 women in the intervention group and 133 women in the placebo group. MAIN RESULTS AND THE ROLE OF CHANCE: The live birth rates were 82.4% (112/136) and 84.2% (112/133) in the intervention group and placebo group, respectively (risk ratio (RR) 0.98, 95% CI 0.88 to 1.09; risk difference -0.02, 95% CI -0.11 to 0.07; P = 0.683). Among women with at least one previous miscarriage, live birth rates were 80.6% (54/67) and 84.4% (65/77) (RR 0.95, 95% CI 0.82-1.11; P = 0.550). No significant effect was seen from progesterone in women with two (RR 1.28, 95% CI 0.96-1.72; P = 0.096) or more (RR 0.79, 95% CI 0.53-1.19; P = 0.267) previous miscarriages. Preterm birth rates were 12.9% and 9.3%, respectively (RR 1.38; 95% CI 0.69 to 2.78; P = 0.361). Median birth weight was 3310 vs 3300 g (P = 0.992). There were also no other significant differences in obstetric and perinatal outcomes. LIMITATIONS, REASONS FOR CAUTION: Our study was single centre and did not reach the planned sample size because it was stopped prematurely at an interim analysis. WIDER IMPLICATIONS OF THE FINDINGS: We did not find evidence supporting the treatment effect of vaginal progesterone in women with threatened miscarriage. Progesterone in this setting should not be routinely used for threatened miscarriage. The treatment effect in women with threatened miscarriage after previous miscarriages warrants further research. STUDY FUNDING/COMPETING INTEREST(S): Mothers' and babies Golden Casket Clinical Fellowship (L.A.M.). Progesterone and placebo pessaries were provided by Perrigo Australia.B.W.J.M. reports grants from NHMRC, personal fees from ObsEva, personal fees from Merck KGaA, personal fees from Guerbet, personal fees from iGenomix, outside the submitted work. TRIAL REGISTRATION NUMBER: ACTRN12611000405910. TRIAL REGISTRATION DATE: 19 April 2011. DATE OF FIRST PATIENT'S ENROLMENT: 06 February 2012.

Is a randomized controlled trial of waterbirth possible? An Australian feasibility study.

BACKGROUND: The safety of waterbirth is contested because of the lack of evidence from randomized trials and conflicting results. This research assessed the feasibility of a prospective study of waterbirth (trial or cohort). METHODS: We conducted a prospective cohort study at an Australian maternity hospital. Eligible women with uncomplicated pregnancies at 36 weeks of gestation were recruited and surveyed about their willingness for randomization. The primary midwife assessed waterbirth eligibility and intention on admission in labor, and onset of second stage. Primary outcomes measured feasibility. Intention-to-treat analysis, and per-protocol analysis, compared clinical outcomes of women and their babies who intended waterbirth and nonwaterbirth at onset of second stage. RESULTS: 1260 participants were recruited; 15% (n = 188) agreed to randomization in a future trial. 550 women were analyzed by intention-to-treat analysis: 351 (waterbirth) and 199 (nonwaterbirth). In per-protocol analysis, 14% (n = 48) were excluded. Women in the waterbirth group were less likely to have amniotomy and more likely to have water immersion and physiological third stage. There were no differences in other measures of maternal morbidity. There were no significant differences between groups for serious neonatal morbidity; four cord avulsions occurred in the waterbirth group with none in the landbirth group. An RCT would need approximately 6000 women to be approached at onset of second stage. CONCLUSIONS: A randomized trial of waterbirth compared with nonwaterbirth, powered to detect a difference in serious neonatal morbidity, is unlikely to be feasible. A powered prospective study with intention-to-treat analysis at onset of second stage is feasible.

The utility of routine screening for anaemia at 36 weeks gestation.

Anaemia is a global disease, affecting over 1 billion people worldwide; 12% of Australian women experience anaemia in pregnancy. Professional bodies/institutions recommend screening for and treating anaemia in pregnancy but there is inconsistency in recommendations for when to screen. A ten-year retrospective analysis was undertaken of 10 518 pregnancies where there was not a specific indication for repeat blood tests. Using a 28-week haemoglobin (Hb) threshold of ≥110 g/L, seven out of ten could safely forego a routine 36-week full blood count. Less than 2.5% would then be anaemic at 36 weeks, none of whom would have had a Hb < 90 g/L.

Induction of labour involving an amniotomy: Waiting compared to immediate oxytocin.

During induction of labour (IOL), the optimal timing of oxytocin following amniotomy is unknown, with limited data to guide decision-making. This study aimed to see whether a 2-h delay after amniotomy before starting oxytocin during IOL reduced the use of oxytocin as well as other positive or negative impact. A propensity-score-matched cohort study assessed the maternal, neonatal and process outcomes of 1168 women (584 per group) comparing immediate oxytocin to a 2-h delay ('wait') after amniotomy. Women who waited were significantly less likely to receive oxytocin (61.2 vs 100%, P < 0.001) but more likely to receive antibiotics (14.7 vs 10.3%, P = 0.021), to be delivered by caesarean section (20.0 vs 14.6%, P = 0.013) and to be exclusively breastfeeding during discharge (77.2 vs 71.2%, P = 0.019). These findings provide further information for women and caregivers regarding the risks and benefits of a short delay before starting oxytocin.

Five-year trends in induction of labour in a large Australian metropolitan maternity service.

BACKGROUND: The World Health Organisation recommends that induction of labour (IOL) be performed only with a clear medical indication. Australian rates of IOL appear to be rising, with more than one-third of women having labour induced. This may reflect changing clinician and consumer perceptions of the benefits and potential harms of term IOL. AIMS: To understand recent trends in the rates and indications for IOL. MATERIALS AND METHODS: A retrospective cohort study was undertaken in a Level 6 maternity facility, in metropolitan South-East Queensland, Australia. Routinely collected data were gathered between 2015 and 2020. Exclusion criteria were multiple pregnancies, stillbirth and pre-labour rupture of membranes. Pre-labour rupture of membranes was excluded due to inability to assess if IOL for this indication was a true induction or augmentation of labour. Indications for induction were grouped into maternal, fetal, elective indications, 'post-dates' and decreased fetal movements (DFM). Rates of IOL and frequency of the various indications were compared over time. RESULTS: About 46 530 livebirths occurred during the study period, with labour induced in 31.7%. The proportion of women undergoing IOL increased from 29.8% in 2015 to 33.4% in 2019 (P < 0.001). The proportion of inductions for DFM and elective indications increased over time, with a substantial decrease in 'post-dates' IOL. CONCLUSIONS: This large contemporary analysis of IOL trends in Australia has demonstrated rising rates and changing indications for IOL. There remain large knowledge gaps in areas such as care of women with DFM, definitions and management of 'post-term pregnancy', and the economic and service impacts of rising trends in the rate of IOL.

Clinicians' attitudes towards a co-leadership structure for maternity emergency teams: An interview study.

Shared leadership improves team performance in many domains and is present in some interprofessional healthcare teams. Despite the dominant paradigm of a singular obstetrician leader in maternity emergencies, co-leadership, a specific form of shared leadership, has been identified as a potentially beneficial to clinical care. This qualitative interview study addresses the gaps in knowledge regarding clinician attitudes toward co-leadership and how a co-leadership structure might be implemented within a maternity care setting. Twenty-five clinicians (midwives, obstetricians and anaesthetists) working in the birthing units of two tertiary maternity units were interviewed and a conventional content analysis conducted. Clinicians viewed co-leadership as potentially beneficial to patient care through improved leadership performance and co-leader back up behavior. Implementation of co-leadership was thought to require a supportive organizational culture, agreed patient management protocols and the participation in simulation training. Enacting co-leadership required adaptable leadership sharing practices, effective communication, and high levels of trust between the co-leaders. These findings inform the future implementation strategies for co-leadership in interprofessional healthcare teams.

Thermal treatment of carbon-fibre-reinforced polymers (Part 2: Energy recovery and feedstock recycling).

The use of carbon fibre (CF)-reinforced plastics has grown significantly in recent years, and new areas of application have been and are being developed. As a result, the amount of non-recyclable waste containing CF is also rising. There are currently no treatment methods for this type of waste. Within this project different approaches for the treatment of waste containing CF were investigated. Main subject of the research project were large-scale investigations on treatment possibilities and limits of waste containing CF in high temperature processes, with focus on the investigation of process-specific residues and possible fibre emission. The results showed that the two conventional thermal waste treatment concepts with grate and rotary kiln firing systems are not suitable for a complete oxidation of CFs due to the insufficient process conditions (temperature and dwell time). The CFs were mainly discharged via the bottom ash/slag. Due to the partial decomposition during thermal treatment, World Health Organization (WHO) fibres occurred in low concentrations. The tests run in the cement kiln plant have shown the necessity of comminution for waste containing CF. With respect to the short testing times and moderate quantities of inserted CF, a final evaluation of the suitability of this disposal path was not possible. The use of specially processed waste containing CF (carbon-fibre-reinforced plastic (CFRP) pellets) as a carbon substitute in calcium carbide production led to high carbon conversion rates. In the unburned furnace dust, which is marketed as a by-product of the process, CFs in relevant quantities could be detected.

Implications of scale dependence for cross-study syntheses of biodiversity differences.

Biodiversity studies are sensitive to well-recognised temporal and spatial scale dependencies. Cross-study syntheses may inflate these influences by collating studies that vary widely in the numbers and sizes of sampling plots. Here we evaluate sources of inaccuracy and imprecision in study-level and cross-study estimates of biodiversity differences, caused by within-study grain and sample sizes, biodiversity measure, and choice of effect-size metric. Samples from simulated communities of old-growth and secondary forests demonstrated influences of all these parameters on the accuracy and precision of cross-study effect sizes. In cross-study synthesis by formal meta-analysis, the metric of log response ratio applied to measures of species richness yielded better accuracy than the commonly used Hedges' g metric on species density, which dangerously combined higher precision with persistent bias. Full-data analyses of the raw plot-scale data using multilevel models were also susceptible to scale-dependent bias. We demonstrate the challenge of detecting scale dependence in cross-study synthesis, due to ubiquitous covariation between replication, variance and plot size. We propose solutions for diagnosing and minimising bias. We urge that empirical studies publish raw data to allow evaluation of covariation in cross-study syntheses, and we recommend against using Hedges' g in biodiversity meta-analyses.

Using the Consolidated Framework for Implementation Research to design and implement a perinatal education program in a large maternity hospital.

BACKGROUND: Implementation science aims to embed evidence-based practice as 'usual care' using theoretical underpinnings to guide these processes. Conceptualising the complementary purpose and application of theoretical approaches through all stages of an implementation project is not well understood and is not routinely reported in implementation research, despite call for this. This paper presents the synthesis and a collective approach to application of a co-design model, a model for understanding need, theories of behaviour change with frameworks and tools to guide implementation and evaluation brought together with the Consolidated Framework for Implementation Research (CFIR). METHOD: Using a determinant framework such as the CFIR provides a lens for understanding, influencing, and explaining the complex and multidimensional variables at play within a health service that contribute to planning for and delivering effective patient care. Complementary theories, models, frameworks, and tools support the research process by providing a theoretical and practical structure to understanding the local context and guiding successful local implementation. RESULTS: This paper provides a rationale for conceptualising the multidimensional approach for implementation using the worked example of a pregnancy, birth, postnatal and early parenting education intervention for expectant and new parents at a large maternity hospital. CONCLUSION: This multidimensional theoretical approach provides useful, practical guidance to health service researchers and clinicians to develop project specific rationale for their theoretical approach to implementation projects.

Measuring the impact of cardiotocograph decision support software on neonatal outcomes: A propensity score-matched observational study.

BACKGROUND: This study follows the 2017 UK INFANT Collaborative Group RCT, which compared neonatal outcomes with and without the use of the INFANT cardiotocograph decision support system for over 46 000 patients in labour. The original trial failed to demonstrate a significant improvement to neonatal outcomes; however, the study design was subject to methodological critique. AIMS: This Australian retrospective cohort study aimed to report perinatal outcomes before and after the introduction of INFANT decision support software for cardiotocograph use in labour. MATERIALS AND METHODS: The study cohort was divided into two equivalent 18-month epochs, before and after the introduction of INFANT-Guardian® CTG decision support system. Propensity score matching analysis was undertaken to balance pre- and post-implementation groups by baseline covariates. The matched cohort included 11 154 public-funded women between November 2016 and 2019, with a singleton live fetus ≥34 + 0 weeks, being induced or in spontaneous labour. The main outcome measures were: a composite measure of serious adverse neonatal outcome comprising of one or more of: admission to intensive care nursery >48 h, Apgar <4 at 5 min, cord arterial pH <7.0, hypoxic ischaemic encephalopathy grade 2 or 3, therapeutic hypothermia, neonatal death. RESULTS: The incidence of the composite primary outcome was significantly lower following implementation of INFANT (0.57% vs. 1.00%; OR 0.57, 95%CI 0.37-0.88; P = 0.01). A significant reduction in nursery admission >48 h was also observed (0.05% vs. 0.30%; OR 0.18, 95%CI 0.05-0.60; P = 0.002). CONCLUSIONS: INFANT software is associated with a reduction in serious adverse neonatal outcomes, without increasing the rate of operative delivery.

Adherence to best practice: Preventing surgical site infection following caesarean section in Australia.

BACKGROUND: Surgical site infection (SSI) following caesarean section is a serious but underreported problem with an estimated incidence of 5-9%. It is essential to identify adherence to established prevention strategies to reduce the incidence rate. AIMS: The aims of this study were to quantify unwarranted variation from evidence-based practice on the prevention of SSI at caesarean section in Australia; and to identify predictors of not implementing an existing infection prevention bundle: pre-incision antibiotic prophylaxis, vaginal preparation and spontaneous placenta removal. MATERIALS AND METHODS: An online cross-sectional survey of obstetricians and obstetric Diplomates was conducted in 2016. The primary outcome was adherence to an existing infection prevention bundle, with demographic and clinical variables predicting adherence through multivariable binary logistic regression. RESULTS: Forty-nine percent of respondents (response rate 39.6%) reported implementing zero or only one element of the infection prevention bundle. The types of respondents most likely to have poor adherence were Diplomates (adjusted odds ratio (aOR) 2.58), obstetricians practising in private hospitals (aOR 3.34), those usually practising in public and private hospitals (aOR 2.23), and those not usually implementing a surgical safety checklist (aOR 3.77). CONCLUSIONS: Adherence to best practice at caesarean section is low among many Australian obstetricians. Infection control practitioners and obstetricians need to collaboratively implement surgical safety checklists at caesarean section, and monitor implementation using process key performance indicators, and audit and feedback. These strategies will reduce unwarranted variation from evidence-based infection control practice.

Predicting the duration of induction of labour in nulliparous women.

This study examined if the modified Bishops score (MBS) at the start of an induction of labour (IOL) (VE-1) or if the MBS after pharmacological/mechanical ripening (VE-2) was the better predictor of the duration of induced labour and whether there was one component of the score that was most predictive of time to delivery.The measures at VE-2 were correlated more strongly with the time to birth, than VE-1 measures. At both VE-1 and VE-2, component measures (especially position of the cervix) showed weak correlation compared to composite measures. Omitting position from the composite score resulted in a simplified modified Bishops score (sMBS) that had the highest correlation coefficients. A model comprising sMBS and 5 clinical variables explained ∼73% of the variance.The vaginal examination findings prior to an IOL do not impact how long the labour may take. A more favourable cervix ∼12 h later (measured using a 4-item composite of dilatation, length, consistency and station) predicts a quicker induced labour.Impact statementWhat is already known? Induction of labour (IOL) is a common obstetric intervention in Australia. The IOL process can be a protracted and sometimes frustrating experience for women, and it may not result in a vaginal birth. A 'failed induction' or 'failure to progress' are relatively common indications for caesarean section (CS) in this setting where, despite many hours of an oxytocin infusion, the woman does not establish or progress in the active phase of labour.What does this study add? The measures at VE-2 were correlated more strongly with the time to birth, than VE-1 measures. At both VE-1 and VE-2, component measures (especially position of the cervix) showed weak correlation compared to composite measures. Omitting position from the composite score resulted in a simplified modified Bishops score (sMBS) that had the highest correlation coefficients. A model comprising sMBS and 5 clinical variables explained ∼73% of the variance.What are the implications of these findings? It is not the initial VE that is most predictive of the duration of labour but rather the VE after cervical ripening (mechanical or pharmacological). Simplified MBS (without the component of position of cervix) is most predictive of labour duration.

Conventional land-use intensification reduces species richness and increases production: A global meta-analysis.

Most current research on land-use intensification addresses its potential to either threaten biodiversity or to boost agricultural production. However, little is known about the simultaneous effects of intensification on biodiversity and yield. To determine the responses of species richness and yield to conventional intensification, we conducted a global meta-analysis synthesizing 115 studies which collected data for both variables at the same locations. We extracted 449 cases that cover a variety of areas used for agricultural (crops, fodder) and silvicultural (wood) production. We found that, across all production systems and species groups, conventional intensification is successful in increasing yield (grand mean + 20.3%), but it also results in a loss of species richness (-8.9%). However, analysis of sub-groups revealed inconsistent results. For example, small intensification steps within low intensity systems did not affect yield or species richness. Within high-intensity systems species losses were non-significant but yield gains were substantial (+15.2%). Conventional intensification within medium intensity systems revealed the highest yield increase (+84.9%) and showed the largest loss in species richness (-22.9%). Production systems differed in their magnitude of richness response, with insignificant changes in silvicultural systems and substantial losses in crop systems (-21.2%). In addition, this meta-analysis identifies a lack of studies that collect robust biodiversity (i.e. beyond species richness) and yield data at the same sites and that provide quantitative information on land-use intensity. Our findings suggest that, in many cases, conventional land-use intensification drives a trade-off between species richness and production. However, species richness losses were often not significantly different from zero, suggesting even conventional intensification can result in yield increases without coming at the expense of biodiversity loss. These results should guide future research to close existing research gaps and to understand the circumstances required to achieve such win-win or win-no-harm situations in conventional agriculture.

Implementation of gestational weight gain guidelines - what's more effective for ensuring weight recording in pregnancy?

BACKGROUND: Pregnant women who gain weight in accordance with guidelines have the lowest risk of pregnancy and birth-related complications. However, evidence-practice gaps often exist. To address pregnancy weight management barriers, a stepped implementation science approach was used, comprising targeted in-services, provision of scales for clinic rooms, and changes to routine weight recording in a hospital electronic medical record. The aim of this study was to assess the cumulative influence of evidence-based interventions on staff's compliance to recording of antenatal weights. METHODS: Retrospective data analysis of weight recording over three 15-month cohorts across April 2014-December 2017. Variables calculated from data included: proportion of women with weight recorded at booking and proportion of women who had a weight recorded at each visit. Generalised estimating equation modelling was used to examine differences in weight recording compliance rates between cohorts, pre-pregnancy body mass index categories, model of care and clinicians. RESULTS: There were approximately 13,000 pregnancies in each cohort. The proportion of women who had a weight recorded at each visit per cohort differed significantly between cohorts from 4.2% (baseline), 18.9% (scales and in-services) to 61.8% (medical record prompts), p < 0.001. CONCLUSION: Significant improvements were achieved through systematic barrier analysis and subsequent mapping and implementation of appropriate and effective interventions. Improvements were observed across the entire service, in all models of care with all professional groups demonstrating increased recording of weights.

Simplifying the language of fetal monitoring.

BACKGROUND: Health professionals in Australia and New Zealand have used various intrapartum fetal surveillance (IFS) guidelines, with clear differences in how these guidelines present information. Based on clinician feedback, the 2015 Queensland Clinical Guideline on IFS structured the prose-based Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) IFS Guidelines as a traffic-light matrix and represented the categorical terms of unlikely, maybe, possible and likely fetal compromise, as the colours GREEN, BLUE, AMBER, and RED, respectively. AIMS: To determine whether the interpretation of the RANZCOG IFS Guidelines in Table Format is more accurate and quicker compared to the current presentation of the RANZCOG Guideline in prose format. MATERIALS AND METHOD: Twenty-nine clinicians, naïve to the use of the RANZCOG IFS Guidelines, interpreted ten cardiotocographs (CTGs) using one format and then the alternative format (totalling 580 CTG interpretations). Accuracy and time to decision were recorded as well as a participant questionnaire. A repeated measures analysis of variance was used to compare differences. RESULTS: Compared to prose format, clinicians interpreted CTGs quicker using the table format (P < 0.01), especially CTGs representative of unlikely and maybe fetal compromise. There was a trend toward more accurate interpretation for table format for all clinicians, with significance among medical officers (P = 0.02). Participants responded more favourably to the table format regarding questions about ease of use, determining actions required, and desire to use the system in the future (P < 0.01). CONCLUSIONS: Presenting the RANZCOG IFS Guideline in table format as opposed to prose format improved the speed and accuracy of CTG interpretation and is preferred by clinicians.

Improved laparoscopic skills in gynaecology trainees following a simulation-training program using take-home box trainers.

BACKGROUND: Lack of time and access to equipment are recognised barriers to simulation training. AIM: To investigate the effect of a take-home laparoscopic simulator training program on the laparoscopic skills of gynaecology trainees. METHOD: Participants (n = 17 in 2015, n = 16 in 2016) were supplied with a box trainer, associated equipment and instructions on self-directed training. A program was designed and implemented in 2015 comprising of ten weekly laparoscopic skills tasks and modified in 2016 to eight monthly tasks. Half of the participants were randomly allocated a supervisor. Participants performed baseline and post-training assessments of laparoscopic skills in a box trainer task (thread transfer) and virtual reality simulator tasks (laparoscopic tubal ligation and bilateral oophorectomy). RESULTS: Trainees in 2015 demonstrated an improvement in the median time to complete the laparoscopic tubal ligation task (baseline 124 s vs post-training 91 s, P = 0.041). There was no difference in the number of tubal ligation bleeding incidents, or in the time taken to complete the box trainer thread transfer task. In 2016 trainees demonstrated improvement in tubal ligation time (baseline 251 vs 71 post-training, P = 0.021) and bilateral oophorectomy time (baseline 891 s vs 504 post-training, P = 0.025). There was no significant difference in other outcome measures. There was no difference found in performance when groups were compared by supervisor allocation. CONCLUSION: A take-home box trainer simulation-training program was associated with improvement in laparoscopic skills. This type of program may improve trainee access to simulation training.

Trainee Performance in Loop Electrosurgical Excision Procedure (LEEP) After Simulation Training.

OBJECTIVE: The aim of the study was to review the performance of trainees in loop electrosurgical excision procedure (LEEP) procedures after the introduction of a simulation training program. MATERIALS AND METHOD: A simulation training program was introduced in September 2016 for gynecology trainees at the study institution. Trainees were encouraged to perform at least 3 simulated LEEP procedures before operating. For a 12-month period after the introduction of training, data on operating time and specimen quality measures of clear margin status, adequate depth, and absence of fragmentation were reviewed. This was compared with a 12-month period before simulation training (from September 2014-September 2015). Trainees were surveyed for feedback on the training. RESULTS: In total, 135 LEEP procedures were reviewed: 68 before and 67 after simulator training. Trainee specimens after training were more likely to be nonfragmented (89.2% vs 55.9%, p = .003), have clear margins (72.2% vs 41.9%, p = .015), and meet "all criteria" (46% vs 20.6%, p = .043) than trainee specimens before training. There was no change in depth adequacy (70.3% vs 67.7%, p = .99). Median trainee procedure time reduced from 18 minutes (interquartile range = 11-24) before training to 8 minutes after training (interquartile range = 6-11) (p = <0.001). There was no significant change in operating time or specimen quality from LEEP procedures performed by attendings (who did not use the simulator). Trainee and attending procedural outcomes were similar after training. Trainees had mostly positive views on the training, though reported time constraints as a barrier to simulation. CONCLUSIONS: After the introduction of an LEEP simulation training program, operative time and specimen quality from trainee procedures seemed to improve.

Midwifery leadership in maternity emergencies: a video analysis.

Maternity emergencies require effective leadership due to their time-critical high stakes nature, and like many emergency teams are recommended to have a singular leader. Midwives possess many of the skills required for leadership, but the extent to which they contribute to leadership in emergencies is unknown. In this video analysis study of 16 interprofessional teams responding to a simulated post-partum hemorrhage, a functional view of leadership was applied to determine midwifery contribution to leadership. The number and type of leadership utterances by team members during an emergency response was assessed, and midwifery and doctor leadership utterances compared. Midwives contributed just over 40% of all leadership utterances, indicating the occurrence of interprofessional shared leadership, despite the recommendation for a singular leadership. While the number of leadership utterances per scenario was similar for midwives and doctors, midwives contributed less to utterances of a clinical nature compared to doctors but a similar amount of non-clinical leadership. Further exploration of the factors which influence midwifery leadership in emergencies and the impact it may have on patient care is warranted.

Redesigning induction of labour processes.

BACKGROUND: An 'in-hours' birth represents a desired outcome following induction of labour (IOL) in terms of safety, efficiency and satisfaction. Women booked for IOL are often not commenced at their allocated times, and these sometimes complex births happen after-hours. AIMS: To measure the effect of an 11:00 hours commencement time for IOL. MATERIALS AND METHODS: A discrete-event-simulation patient-flow model was constructed. Multiple staffing and scheduling combinations were tested, before a brief pilot and subsequent introduction of a second IOL commencement time. A retrospective cohort study was performed using routinely collected data, comparing outcomes in two four-month time periods, before and after introduction of the new schedule. During Time Period A, women underwent cervical ripening at 19:00 hours and were reviewed the next morning for amniotomy and oxytocin infusion (ARM/oxytocin). During Time Period B, women were either admitted at 11:00 hours for cervical ripening followed by 23:00 hours ARM/oxytocin, or at 19:00 hours for cervical ripening followed by 06:00 hours ARM/oxytocin. The primary outcome measure was the likelihood of an in-hours birth (defined as 07:00-19:00 hours). RESULTS: In an analysis of 1689 women undergoing IOL, the new IOL booking schedule was associated with a 14.7% increase in in-hours birth (68.4% vs 53.7%; P < 0.01), and a corresponding reduction in overnight births. Although the IOL to birth time was unaltered, we observed a decrease in IOL delays and admission-to-birth time, and a greater likelihood of vaginal birth within 24 h of admission. CONCLUSIONS: Introducing a 11:00 hours start-time for IOL has been associated with a significant increase in in-hours births.