Reducing preventable adverse events in obstetrics by improving interprofessional communication skills - Results of an intervention study.

BACKGROUND: Progress in medicine involves the structured analysis and communication of errors. Comparability between the individual disciplines is only possible to a limited extent and obstetrics plays a special role: the expectation of a self-determined and joyful event meets with possibly serious complications in highly complex care situations. This must be managed by an interdisciplinary team with an increasingly condensed workload. Adverse events cannot be completely controlled. However, taking controllable risk factors into account and with a focused communication a reduction of preventable adverse events is possible. In the present study, the effect of interprofessional team training on preventable adverse events in an obstetric department was investigated. METHODS: The training consisted of a 4-h interdisciplinary training session based on psychological theories. Preventable adverse events were defined in six categories according to potential patterns of causation. 2,865 case records of a refence year (2018) and 2,846 case records of the year after the intervention (2020) were retrospectively evaluated. To determine the communication training effect, the identified preventable adverse events of 2018 and 2020 were compared according to categories and analyzed for obstetrically relevant controllable and uncontrollable risk factors. Questionnaires were used to identify improvements in self-reported perceptions and behaviors. RESULTS: The results show that preventable adverse events in obstetrics were significantly reduced after the intervention compared to the reference year before the intervention (13.35% in the year 2018 vs. 8.83% in 2020, p < 0.005). Moreover, obstetrically controllable risk factors show a significant reduction in the year after the communication training. The questionnaires revealed an increase in perceived patient safety (t(28) = 4.09, p < .001), perceived communication behavior (t(30) = -2.95, p = .006), and self-efficacy to cope with difficult situations (t(28) = -2.64, p = .013). CONCLUSIONS: This study shows that the communication training was able to reduce preventable adverse events and thus increase patient safety. In the future, regular trainings should be implemented alongside medical emergency trainings in obstetrics to improve patient safety. Additionally, this leads to the strengthening of human factors and ultimately also to the prevention of second victims. Further research should follow up implementing active control groups and a randomized-controlled trail study design. TRIAL REGISTRATION: The study was approved by the Ethics Committee of University Hospital (protocol code 114/19-FSt/Sta, date of approval 29 May 2019), study registration: NCT03855735 .

Post-traumatic stress syndromes following childbirth influenced by birth mode-is an emergency cesarean section worst?

PURPOSE: The experience of birth is an emotional challenge for women. Traumatic birth experiences can cause psychological stress symptoms up to post-traumatic stress disorders (PTSD), with impact on women's wellbeing. Primarily unplanned interventions can trigger birth-mode-related traumatization. The aim of the study was to evaluate whether an emergency cesarean section (ECS) is the most traumatizing. METHODS: A retrospective case-control study was undertaken. Therefore, data were collected by standardized questionnaires (Impact of Event Scale-Revised and City Birth Trauma Scale) that were sent to women with singleton pregnancies > 34 weeks of gestation who either give birth by ECS (case group, n = 139), unplanned cesarean section (UCS), operative vaginal birth (OVB), or natural birth (NB) (three control groups, n = 139 each). The investigation period was 5 years. RESULTS: Overall, 126 of 556 (22%) sent questionnaires were returned and could be analyzed (32 ECS, 38 UCS, 36 OVB, and 20 NB). In comparison to other birth modes, women with ECS were associated with a higher degree of traumatization as revealed by statistically significant differences regarding the DSM-5 criteria intrusion and stressor. In addition, women who underwent ECS declared more frequently a demand for professional debriefing compared to other birth modes. DISCUSSION: ECS is associated with more post-traumatic stress symptoms compared to other birth modes. Therefore, early interventions are recommended to reduce long-term psychological stress reactions. In addition, outpatient follow-ups by midwives or emotional support programs should be implemented as an integral component of postpartum debriefings.

[Hyperreactio Luteinalis and an Incidentally Detected FIGO IIIB Borderline Tumor of the Ovary in Pregnancy - Diagnostic, Therapy and Review of Literature]. / Hyperreactio luteinalis mit Zufallsbefund eines serösen Borderline-Tumor des Ovars FIGO IIIB im 3. Trimenon ­ Diagnostik, Therapie, Literaturrecherche.

Adnexal masses affect 2-10% of all pregnancies. The highest incidence of 1-6% can be seen in the first trimester, with a high rate of spontaneous remission. Two percent of these masses are malignant neoplasms or borderline tumors. A rare benign mass of the adnexa in pregnancy is hyperreactio luteinalis characterised by bilateral, multicystic ovaries with a frequent occurrence in the 3rd trimester. Clinical signs include maternal hyperandrogenaemia with virilisation, hyperemesis, nonspecific abdominal pain or laboratory findings of hyperthyroidism and elevated ß-HCG. Hyperreactio luteinalis does not require therapy due to complete spontaneous remission postpartum, but is often treated surgically in graviditate. In our case we report a first-time gravida in the 31st week of pregnancy with a symptomatic 25-cm multicystic, partly solid mass. After antenatal corticosteroid therapy, an exploratory laparotomy with right adnexectomy was performed on suspicion of malignancy. Histology revealed a hyperreactio luteinalis with an incidental finding of a serous borderline tumor of the ovary (FIGO IIIB). At 33 weeks of gestation, a pathological CTG was observed, and an urgent secondary caesarean section by re-longitudinal laparotomy was performed. Postpartum completion surgery revealed no further neoplastic cells.

["Helplessness, Giving up of Any Self-Responsibility and Self-Determination" - a Qualitative Evaluation of Traumatizing Birth Experiences in Relation to Birth Mode]. / "Hilflosigkeit, das Abgeben jeglicher Selbstverantwortung und Selbstbestimmtheit" ­ eine qualitative Auswertung von traumatisierenden Geburtserlebnissen in Relation zum Geburtsmodus.

Background Childbirth is combined with emotional challenges and individual anxiety. Unexpected birth experiences can trigger stress reactions and even post-traumatic stress disorders. Aim of the study The aim of the study was the qualitative evaluation of stressful perceived birth experiences and desired interventions.Methods A content-analytic evaluation of 117 free-text answers was conducted regarding stressful birth experiences and desired interventions using categories and frequencies in relation to birth mode.Findings Five themes emerged from the structured free text analysis: 1) Stressful experiences describing fear concerning the child and separation from the child after an emergency caesarean section; 2) Inadequate communication after an operative vaginal birth and unplanned caesarean section; 3) Feelings of failure and guilt after unplanned birth modes; 4) Helplessness with loss of personal control and the feeling of being at the mercy after an emergency caesarean section; 5) Inadequate support due to the absence of empathy or insufficient care. Expected interventions include immediate debriefing and professional psychological support.Conclusion Women-centered communication during childbirth and debriefing of stressful birth experiences are significant interventions for strengthening maternal well-being and mental health. They can have a positive impact on the development of a healthy mother-child relationship.

The effect of pelvic floor muscle training on pelvic floor function and sexuality postpartum. A randomized study including 300 primiparous.

PURPOSE: Although pregnancy and childbirth are physiological processes they may be associated with pelvic floor disorders. The aim of this study was to evaluate the influence of pelvic floor muscle training on postpartum pelvic floor and sexual function of primiparous. METHODS: This is a randomized prospective study including 300 primiparous women. Due to the dropout 200 women were analyzed. Inclusion criteria were the delivery of the first, mature baby, the ability to speak and understand German. The participants were evaluated by clinical examinations and questionnaires after 6 and 12 months postpartum. After 6 months, the women were randomized in two groups. Compared to the control group the intervention groups participated in 45-min pelvic floor muscle training and pelvic floor perception once a week over 6 weeks. RESULTS: The results of the questionnaires showed no significant differences between the groups after 12 months. A significant stronger pelvic floor muscle strength was found for the intervention group after 12 months. The improvement of the pelvic floor and sexual function over the time showed a significant improvement in both groups. CONCLUSION: Supervised pelvic floor muscle training did not improve both the pelvic floor and the female sexual function in comparison to the control group. After 12 months, the pelvic floor and sexual function improved significant in all women. TRIAL REGISTRATION: German Clinical Trials Register (DRKS00024725), retrospectively registrated.

Novel and flexible ultrasound simulation with smartphones and tablets in fetal echocardiography.

PURPOSE: Evaluation of a novel ultrasound-simulation-app for training fetal echocardiography as a possible useful addition for students, residents and specialist doctors. Furthermore, comparison to a conventional learning-method with special attention on orientation and recognition of physiological structures. METHODS: Prospective two-arm study with the participation of 226 clinical students. 108 students were given an extract from a textbook on fetal echocardiography (PDF-group, n = 108) for 30 min to study. 118 students were able to use the new ultrasound-simulator-app (Simulator-group, n = 118) to learn for 30 min. The knowledge of the students was examined both before and after the learning-period by having them identify sonographic structures in videos using single-choice selection. RESULTS: There were no significant differences between the two groups regarding age (p = 0.87), gender (p = 0.28), and the number of previously performed ultrasound-examinations (p = 0.45). In the Simulator-group, there was a significantly higher learning effect regarding the proportion of students with an increase of correct answers in the video test examination (p = 0.005). At the end of learning, the students in the Simulator-group needed significantly less time to display the structures in the app's simulation (median initially 10.9 s vs. 6.8 s at the end; p < 0.001). CONCLUSIONS: The novel ultrasound-simulation-app seems to be a useful addition and improvement to ultrasound training. Previous difficulties such as simultaneously having patients, ultrasound-machines, and professors at disposal can thus be avoided. This means that another important step towards remote learning can be taken, which has been proven increasingly essential lately, due to the COVID-19 pandemic.

Fishing for (in)continence: long-term follow-up of women with OASIS-still a taboo.

PURPOSE: Obstetric anal sphincter injuries (OASIS) increase the risk for pelvic floor dysfunctions. The goal of this study was to examine the long-term outcomes after OASIS on pelvic floor functions and quality of life. MATERIAL AND METHODS: Between 2005 and 2013, 424 women had an OASIS at the Women University Hospital Ulm. Out of these 71 women completed the German pelvic floor questionnaire, which includes questions regarding prolapse symptoms as well as bladder, bowel and sexual function. In addition, 64 women were physically examined, including a speculum examination to evaluate the degree of prolapse, a cough test to evaluate urinary stress incontinence (SI) and an evaluation of both pelvic floor sphincter (modified Oxford score) and anal sphincter contraction. RESULTS: A high rate of pelvic floor disorders after OASIS was found, as 74.6% of women reported SI, 64.8% flatus incontinence and 18.3% stool incontinence, respectively. However, only few women stated a substantial negative impact on quality of life. The clinical examination showed that a positive cough test, a weak anal sphincter tone and a diagnosed prolapse correlated with the results of the self-reported questionnaire. CONCLUSION: On one hand, OASIS has an influence on pelvic floor function going along with lots of complaints, while on the other hand, it still seems to be a taboo topic, as none of the participants spoke about the complaints after OASIS with a doctor. Therefore, the gynecologist should actively address these issues and offer therapy options for the women with persisting problems.

[Incarceration of the Gravid Uterus in the Second Trimester - Diagnostics, Successful Therapy and Review of Literature]. / Posteriore Sakkulation des Uterus im zweiten Trimenon ­ Diagnostik, erfolgreiche Therapie und Literatur.

A rare complication in obstetrics is the incarceration of the gravid uterus. If the uterus remains retroverted, the fundus persists in the pelvic cavity. Due to growth, the familiar anatomy of the uterus changes and undetected incarceration can lead to a serious maternal morbidity. Early treatment can enable a normal prolongation of pregnancy. In our case, we report a first gravida with initial diagnosis of a posterior sacculation of the uterus in the 21st week of pregnancy. After confirmed diagnosis by MRI, the reduction of the uterus by vaginal digital lifting of the uterus and simultaneous rectoscopic CO2 filling was successful. A spontaneous delivery without complications after rupture of membranes followed in the 35th week of pregnancy.

Preventable Adverse Events in Obstetrics-Systemic Assessment of Their Incidence and Linked Risk Factors.

(1) Background: Adverse events (AEs) are an inherent part of all medical care. Obstetrics is special: it is characterized by a very high expectation regarding safety and has rare cases of harm, but extremely high individual consequences of harm. However, there is no standardized identification, documentation, or uniform terminology for the preventability of AEs in obstetrics. In this study, therefore, an obstetrics-specific matrix on the preventable factors of AEs is established based on existing literature to enable standardized reactive risk management in obstetrics. (2) Methods: AEs in obstetrics from one hospital from the year 2018 were retrospectively evaluated according to a criteria matrix regarding preventability. Risk factors for preventable AEs (pAEs) were identified. (3) Results: Out of 2865 births, adverse events were identified in 659 cases (23%). After detailed case analysis, 88 cases (13%) showed at least 1 pAE. A total of 19 risk factors could be identified in 6 categories of pAEs. (4) Conclusion: Preventable categories of error could be identified. Relevant obstetric risk factors related to the error categories were identified and categorized. If these can be modified in the future with targeted measures of proactive risk management, pAEs in obstetrics could also be reduced.

Obstetric and fetal short- and long-term outcomes of delayed-interval delivery in multiple pregnancies.

INTRODUCTION: Multiple pregnancies are at higher risk of preterm birth. However, both children do not necessarily have to be born and exposed to the morbidity of prematurity. One option is a delayed-interval delivery with reduction of morbidity and mortality for the second twin. The present case series demonstrates the feasibility and safety of this procedure including the long-term outcome of the surviving children compared to the overall outcome of premature born children at the same perinatal center. MATERIAL: Retrospective evaluation of all cases of delayed-interval deliveries in multiple pregnancies from 2003 to 2020 at the Women's and Children's Hospital of the University Hospital Ulm. RESULTS: In 17 cases, the delivery of the second twin could be delayed, on average by 36 days. Pregnancies with delivery of the first twin before 22 weeks of gestation had a longer prolongation than pregnancies with delivery of the first twin after 22 weeks (53 vs. 22 days). If a cerclage was placed after the delivery of the first twin a longer prolongation interval could be achieved (45 vs. 19 days). No severe maternal morbidity occurred, and the short- and long-term outcome of the second twin did not differ from age-matched controls. CONCLUSIONS: In multiple pregnancies with extremely preterm birth of the first twin, delivery of the second twin can in some cases be successfully postponed without serious maternal morbidity or additional fetal complications. Delivery of the first twin before 22 weeks of gestation and placement of a cerclage is associated with a longer prolongation interval.

Pre-viable preterm premature rupture of membranes under 20 weeks of pregnancy: A retrospective cohort analysis for potential outcome predictors.

OBJECTIVE: While preterm premature rupture of membranes complicates an estimated 3 % of pregnancies, rupture near the limit of fetal viability is rarer (estimated 0.04 %). This study aimed to analyze maternal and neonatal outcomes in patients with premature preterm rupture of membranes (PPROM) before 20 0/7 weeks of pregnancy with the goal of identifying potential outcome predictors. STUDY DESIGN: This retrospective cohort study examined 60 patients with preterm premature rupture of membranes before 20 0/7 weeks of pregnancy from 01/01/2008 through 12/31/2018 in a university hospital setting. Two patients were excluded from analysis due to fetal kidney dysplasia. Multiples (5 twins, 2 triplets) were excluded. The remaining 51 cases were analyzed. RESULTS: Thirty-three patients (Range 12 5/7 weeks to 19 2/7 weeks) medically terminated pregnancy (64.7 %). Ten patients spontaneously aborted (19.6 %). Fifteen patients were diagnosed with intraamniotic infection (29.4 %). Neonatal mortality was 28.6 %% (one case of pulmonary hypoplasia). The baby take home rate was 9.8 % (27.8 % after excluding medical terminations) after a mean prolongation of 92.9 days. Neonatal morbidity included respiratory distress syndrome (57.1 %), infection (100 %, including all cases (direct postpartum and during admission), one case of sepsis), pulmonary hypoplasia (42.9 %), pulmonary hypertension (28.6 %), bronchopulmonary dysplasia (14.3 %), and sepsis combined pneumonia (14.3 %). 57.1 % of the infants could be discharged without severe morbidity and 80 % of the survivors had normal development at two and four years. CONCLUSION: Anhydramnios combined with low gestational age at PPROM appear to negatively influence neonatal outcome after pre-viable preterm premature rupture of membranes. The incidence of neonatal complications decreased with increasing gestational age. Survival without long term severe morbidity is possible. Maximal therapy is an interdisciplinary decision and the patients should be counseled accordingly. Delivery in centers where potential postnatal complications including pulmonary hypoplasia, severe bronchopulmonary dysplasia and respiratory distress syndrome can be aggressively treated is recommended.

Birthing under the Condition of the COVID-19 Pandemic in Germany: Interviews with Mothers, Partners, and Obstetric Health Care Workers.

BACKGROUND: The COVID-19 pandemic and the necessary containment measures challenge obstetric care. Support persons were excluded while protection measures burdened and disrupted the professionals' ability to care and communicate. The objective of this study was to explore the first-hand experience of the impact of the COVID-19 pandemic on mothers, their partners, and obstetric professionals regarding birth and obstetric care in a university hospital. METHODS: To answer the descriptive research questions, we conducted a qualitative content analysis using a data triangulation approach. We carried out 35 semi-structured interviews with two stratified purposive samples. Sample one consisted of 25 mothers who had given birth during the pandemic and five partners. Sample two included 10 obstetric professionals whose insights complemented the research findings and contributed to data validation. Participants were recruited from the study sample of a larger project on patient safety from two German university hospitals from February to August 2021. The study was approved by two ethics committees and informed consent was obtained. RESULTS: Mothers complied with the rules, but felt socially isolated and insecure, especially before transfer to the delivery room. The staff equally reported burdens from their professional perspective: They tried to make up for the lack of partner and social contacts but could not live up to their usual professional standards. The exclusion of partners was seen critically, but necessary to contain the pandemic. The undisturbed time for bonding in the maternity ward was considered positive by both mothers and professionals. CONCLUSION: The negative effects of risk mitigation measures on childbirth are to be considered carefully when containment measures are applied.

A Scary Complication: Single-center Study on Management and Outcome of Cesarean Scar Pregnancy.

A cesarean scar pregnancy (CSP) is a scary and life-threatening complication of cesarean section (CS). Nevertheless, the incidence of CS is constantly growing. The CSP incidence is 0,15% of pregnancies after CS which represents 6,1% of all ectopic pregnancies in women with condition after CS. Therefore, it should be more present in the clinical daily routine. From mild nonspecific symptoms to hypovolemic shock, diagnosis and therapy must be performed quickly. With the progressive growth of the scar pregnancy, a uterine rupture involves the risk of severe bleeding, and an emergency hysterectomy could be necessary. Prolongation of pregnancy has been successful only in a few cases. We report 11 cases from our hospital in the past 10 years. In the discussion, treatment options of this complication with an increasing incidence, which is associated with serious morbidity and mortality, are presented based on the current literature. Treatment options include drug therapy, but also surgical or combined procedures with radiological intervention.

A scary complication: single-center study on management and outcome of cesarean scar pregnancy

Abstract A cesarean scar pregnancy (CSP) is a scary and life-threatening complication of cesarean section (CS). Nevertheless, the incidence of CS is constantly growing. The CSP incidence is 0,15% of pregnancies after CS which represents 6,1% of all ectopic pregnancies in women with condition after CS. Therefore, it should be more present in the clinical daily routine. From mild nonspecific symptoms to hypovolemic shock, diagnosis and therapy must be performed quickly. With the progressive growth of the scar pregnancy, a uterine rupture involves the risk of severe bleeding, and an emergency hysterectomy could be necessary. Prolongation of pregnancy has been successful only in a few cases.We report 11 cases from our hospital in the past 10 years. In the discussion, treatment options of this complication with an increasing incidence, which is associated with serious morbidity and mortality, are presented based on the current literature. Treatment options include drug therapy, but also surgical or combined procedures with radiological intervention.