Admission cardiotocography versus intermittent auscultation of the fetal heart in low-risk pregnancy during evaluation for possible labour admission - a multicentre randomised trial: the ADCAR trial.

OBJECTIVE: To assess the effect of admission cardiotocography (ACTG) versus intermittent auscultation (IA) of the fetal heart (FH) in low-risk pregnancy during assessment for possible labour on caesarean section rates. DESIGN: A parallel multicentre randomised trial. SETTING: Three maternity units in the Republic of Ireland. POPULATION: Healthy, low-risk pregnant women, at term and ≥ 18 years old, who provided written informed consent. METHODS: Women were randomised to receive IA of the FH or 20 minutes ACTG on admission for possible labour onset, using remote telephone randomisation. Both groups received IA during labour, with conversion to continuous CTG as clinically indicated. MAIN OUTCOME MEASURES: Caesarean section (primary outcome), obstetric interventions (e.g. continuous CTG during labour, fetal blood sampling, augmentation of labour) and neonatal morbidity (e.g. metabolic acidosis, admission to the neonatal intensive care unit, neonatal death). RESULTS: Based on 3034 women (1513 and 1521 randomised to IA and ACTG, respectively), there was no statistical difference between the groups in caesarean section [130 (8.6%) and 105 (6.9%) for IA and ACTG groups, respectively; relative risk (RR) 1.24; 95% CI 0.97-1.58], or in any other outcome except for use of continuous CTG during labour, which was lower in the IA group (RR 0.90, 95% CI 0.86-0.93). CONCLUSION: Our study demonstrates no differences in obstetric or neonatal outcomes between IA and ACTG for women with possible labour onset, other than an increased risk for continuous CTG in women receiving ACTG. TWEETABLE ABSTRACT: No differences in outcomes between intermittent auscultation and admission cardiotocography for women with possible labour onset.

Interarterial Left Circumflex: The Forgotten Coronary Artery Anomaly.

Anomalous coronary artery origin is a rare, but important cause of cardiac ischemia, particularly in younger patients. These anomalies of origin can be divided into two groups, benign or malignant, based on their propensity to cause ischemia or sudden death. Symptomatic, or malignant coronary artery anomalies are usually described with respect to anomalous origins of the right coronary artery or left main coronary artery. We present a unique case of a previously unreported entity, an anomalous left circumflex coronary artery causing ischemia.

Water Use and Management in the Bakken Shale Oil Play in North Dakota.

Oil and natural gas development in the Bakken shale play of North Dakota has grown substantially since 2008. This study provides a comprehensive overview and analysis of water quantity and management impacts from this development by (1) estimating water demand for hydraulic fracturing in the Bakken from 2008 to 2012; (2) compiling volume estimates for maintenance water, or brine dilution water; (3) calculating water intensities normalized by the amount of oil produced, or estimated ultimate recovery (EUR); (4) estimating domestic water demand associated with the large oil services population; (5) analyzing the change in wastewater volumes from 2005 to 2012; and (6) examining existing water sources used to meet demand. Water use for hydraulic fracturing in the North Dakota Bakken grew 5-fold from 770 million gallons in 2008 to 4.3 billion gallons in 2012. First-year wastewater volumes grew in parallel, from an annual average of 1,135,000 gallons per well in 2008 to 2,905,000 gallons in 2012, exceeding the mean volume of water used in hydraulic fracturing and surpassing typical 4-year wastewater totals for the Barnett, Denver, and Marcellus basins. Surprisingly, domestic water demand from the temporary oilfield services population in the region may be comparable to the regional water demand from hydraulic fracturing activities. Existing groundwater resources are inadequate to meet the demand for hydraulic fracturing, but there appear to be adequate surface water resources, provided that access is available.

Perinatal outcomes in a subsequent pregnancy among women who have experienced recurrent miscarriage: a retrospective cohort study.

STUDY QUESTION: Is a history of three or more miscarriages associated with adverse perinatal outcomes in a subsequent pregnancy? SUMMARY ANSWER: Recurrent miscarriage is associated with an increased risk of adverse perinatal outcomes, including preterm birth, very preterm birth and perinatal death, in a subsequent pregnancy. WHAT IS KNOWN ALREADY: Published data are conflicting with some studies reporting an increase in adverse perinatal outcomes in association with prior recurrent miscarriage while others report little or no increase. Large-scale population-based studies have been lacking. STUDY DESIGN, SIZE, DURATION: We performed a retrospective cohort study of 30 053 women with a singleton pregnancy who booked for antenatal care and delivery between January 2008 and July 2011. PARTICIPANTS/MATERIALS, SETTING, METHODS: All women who attended a university affiliated hospital in Ireland had a detailed obstetric history taken, recording the outcome of all previous pregnancies. We compared the obstetric and perinatal outcomes of 2030 women (6.8%) who had a history of three or more miscarriages (recurrent miscarriage) with the outcomes of 28 023 women (93.2%) who did not. Logistic regression analyses were performed, adjusting for potential confounding factors. MAIN RESULTS AND THE ROLE OF CHANCE: Women with a history of recurrent miscarriage were more likely to be obese, to have undergone assisted conception, to have had a previous perinatal death, and to be delivered by scheduled Caesarean section. Recurrent miscarriage was associated with an increased incidence of preterm birth (<37 weeks gestation, 8.1 versus 5.5%, adjOR 1.54; 95% CI 1.29-1.84), very preterm birth (<32 weeks gestation, 2.2 versus 1.2%, adjOR 1.80; 95% CI 1.28-2.53), and perinatal death (1.2 versus 0.5%, adjOR 2.66; 95% CI 1.70-4.14). The results were similar for both primary and secondary recurrent miscarriage. LIMITATIONS, REASONS FOR CAUTION: This is a retrospective cohort study and while regression analyses adjusted for potential confounding factors, residual confounding may persist. The strict definition of recurrent miscarriage is three consecutive miscarriages and while each woman in the study group had three or more miscarriages, they were only confirmed to be consecutive in the primary RM group. The affected women have not been categorized according to aetiology of recurrent miscarriage and it may be that adverse outcomes differ according to aetiological subgroup. WIDER IMPLICATIONS OF THE FINDINGS: This study highlights the need for specialist obstetric care for women who have had three or more previous miscarriages, particularly in relation to the risk of preterm delivery. STUDY FUNDING/COMPETING INTERESTS: There was no specific funding obtained for this study and there are no conflict of interests.

Risk factors and morbidity associated with suboptimal instrument placement at instrumental delivery: observational study nested within the Instrumental Delivery & Ultrasound randomised controlled trial ISRCTN 72230496.

OBJECTIVES: To identify risk factors and morbidity associated with suboptimal instrument placement at instrumental delivery. DESIGN: Observational study, nested within a randomised controlled trial. SETTING: Two university-affiliated maternity hospitals. SAMPLE: A cohort of 478 nulliparous women at term (≥37 weeks of gestation) undergoing instrumental delivery. METHODS: Univariable and multivariable logistic regression analyses were performed. MAIN OUTCOME MEASURES: Risk factors for suboptimal application of vacuum or forceps, maternal and neonatal morbidity, and the sequential use of instruments, second operator, and caesarean section following failed instrumental delivery. RESULTS: Instrument placement was suboptimal in 138 of 478 (28.8%) deliveries. Factors associated with suboptimal instrument placement included fetal malposition (OR 2.44, 95% CI 1.62-3.66), mid-cavity station (OR 1.68, 95% CI 1.02-2.78), and forceps as the primary instrument (OR 2.01, 95% CI 1.33-3.04). Compared with optimal instrument placement, suboptimal placement was associated with prolonged hospital stay (adjusted OR 2.28, 95% CI 1.30-4.02) and neonatal trauma (adjusted OR 4.25, 95% CI 1.85-9.72). Suboptimal placement was associated with a greater use of sequential instruments (adjusted OR 3.99, 95% CI 1.94-8.23) and caesarean section for failed instrumental delivery (adjusted OR 3.81, 95% CI 1.10-13.16). The mean decision to delivery interval (DDI) was 4 minutes longer in the suboptimal group (95% CI 2.1-5.9 minutes). CONCLUSIONS: Suboptimal instrument placement is associated with increased maternal and neonatal morbidity and procedural complications. Greater attention should be focused on instrument placement when training obstetricians for instrumental delivery.

Subclassification of small bowel Crohn's disease using magnetic resonance enterography: a review using evidence-based medicine methodology.

Magnetic resonance enterography (MRE) has a growing role in imaging small bowel Crohn's disease (SBCD), both in diagnosis and assessment of treatment response. Certain SBCD phenotypes respond well to biologic therapy and others require surgery; MRE has an expanding role in triaging these patients. In this review, we evaluate the MRE signs that subclassify SBCD using evidence-based medicine (EBM) methodology and provide a structured approach to MRE interpretation.

Delivery outcomes for nulliparous women at the extremes of maternal age - a cohort study.

OBJECTIVE: To examine the associations between extremes of maternal age (≤17 years or ≥40 years) and delivery outcomes. DESIGN: Retrospective cohort study. SETTING: Urban maternity hospital in Ireland. POPULATION: A total of 36 916 nulliparous women with singleton pregnancies who delivered between 2000 and 2011. METHODS: The study population was subdivided into five maternal age groups based on age at first booking visit: ≤17 years, 18-19 years, 20-34 years, 35-39 years and women aged ≥40 years. Logistic regression analyses were performed to examine the associations between extremes of maternal age and delivery outcomes, adjusting for potential confounding factors. MAIN OUTCOME MEASURES: Preterm birth, admission to the neonatal unit, congenital anomaly, caesarean section. RESULTS: Compared with maternal age 20-34 years, age ≤17 years was a risk factor for preterm birth (adjusted odds ratio [adjOR] 1.83, 95% confidence interval [95% CI] 1.33-2.52). Babies born to mothers ≥40 years were more likely to require admission to the neonatal unit (adjOR 1.35, 95% CI 1.06-1.72) and to have a congenital anomaly (adjOR 1.71, 95% CI 1.07-2.76). The overall caesarean section rate in nulliparous women was 23.9% with marked differences at the extremes of maternal age; 10.7% at age ≤17 years (adjOR 0.46, 95% CI 0.34-0.62) and 54.4% at age ≥40 years (adjOR 3.24, 95% CI 2.67-3.94). CONCLUSIONS: Extremes of maternal age need to be recognised as risk factors for adverse delivery outcomes. Low caesarean section rates in younger women suggest that a reduction in overall caesarean section rates may be possible.

Beyond HIV microbicides: multipurpose prevention technology products.

Multipurpose prevention technologies (MPTs) that aim to simultaneously prevent unintended pregnancy, HIV-1 infection and other sexually transmitted infections are among the most innovative and complex products currently in development within women's sexual and reproductive health care. In this review article, MPTs are placed within the wider context of combination products, combination drug products and multi-indication products. The current MPT product landscape is mapped and assessed with reference to existing products for the corresponding single indications, before identifying the gaps in the current MPT product pipeline and highlighting priority products and challenges moving forward.

Instrumental delivery and ultrasound : a multicentre randomised controlled trial of ultrasound assessment of the fetal head position versus standard care as an approach to prevent morbidity at instrumental delivery.

OBJECTIVE: To determine whether the use of ultrasound can reduce the incidence of incorrect diagnosis of the fetal head position at instrumental delivery and subsequent morbidity. DESIGN: Two-arm, parallel, randomised trial, conducted from June 2011 to December 2012. SETTING: Two maternity hospitals in the Republic of Ireland. SAMPLE: A cohort of 514 nulliparous women at term (≥37 weeks of gestation) with singleton cephalic pregnancies, aiming to deliver vaginally, were recruited prior to an induction of labour or in early labour. METHODS: If instrumental delivery was required, women who had provided written consent were randomised to receive clinical assessment (standard care) or ultrasound scan and clinical assessment (ultrasound). [Correction added on 17 April 2014, after first online publication: Sentence was amended.] MAIN OUTCOME MEASURE: Incorrect diagnosis of the fetal head position. RESULTS: The incidence of incorrect diagnosis was significantly lower in the ultrasound group than the standard care group (4/257, 1.6%, versus 52/257, 20.2%; odds ratio 0.06; 95% confidence interval 0.02-0.19; P < 0.001). The decision to delivery interval was similar in both groups (ultrasound mean 13.8 minutes, SD 8.7 minutes, versus standard care mean 14.6 minutes, SD 10.1 minutes, P = 0.35). The incidence of maternal and neonatal complications, failed instrumental delivery, and caesarean section was not significantly different between the two groups. CONCLUSIONS: An ultrasound assessment prior to instrumental delivery reduced the incidence of incorrect diagnosis of the fetal head position without delaying delivery, but did not prevent morbidity. A more integrated clinical skills-based approach is likely to be required to prevent adverse outcomes at instrumental delivery.

Morbidity experienced by women before and after operative vaginal delivery: prospective cohort study nested within a two-centre randomised controlled trial of restrictive versus routine use of episiotomy.

OBJECTIVE: To explore: (1) the antenatal and postnatal morbidity experienced by women in relation to operative vaginal delivery (OVD); and (2) the impact of restrictive versus routine use of episiotomy. DESIGN: Longitudinal prospective cohort study embedded within a two-centre randomised controlled trial (RCT). SETTING: Two UK tertiary-level maternity units. POPULATION: Antenatally recruited participants of an RCT of restrictive versus routine use of episiotomy at OVD. METHODS: A self-completing questionnaire was administered antenatally, before hospital discharge, at 6 weeks and at 1 year postpartum. MAIN OUTCOME MEASURES: Urinary and anal incontinence, dyspareunia, perineal pain and psychological morbidity. RESULTS: Longitudinal data have revealed that morbidities historically associated with OVD were often as prevalent, if not more prevalent, in the third trimester of pregnancy than postpartum. Restrictive episiotomy use was associated with: a higher incidence of perineal pain in the immediate postpartum period (98.9% restrictive versus 87.8% routine, RR 1.10, 95% CI 1.01-1.21); greater psychological morbidity in the immediate postpartum period (mean scores on the Edinburgh Postnatal Depression Scale, Edinburgh Postnatal Depression Score (EPDS) 6.7 restrictive versus 5.1 routine; P = 0.01 ); and more stress urinary incontinence at 6 weeks postpartum (42.2% restrictive versus 27.2% routine, RR 1.55, 95% CI 1.00-2.40); however, this had resolved by 1 year. No other differences were found between the groups at 6 weeks and 1 year postpartum. CONCLUSIONS: Morbidities previously attributed to OVD may in fact be present antenatally, to a greater or similar degree. A restrictive approach to the use of episiotomy at OVD may increase rates of urinary morbidity, in particular stress incontinence and perineal pain, in the immediate postpartum period.

Maternal and neonatal morbidity in relation to the instrument used for mid-cavity rotational operative vaginal delivery: a prospective cohort study.

OBJECTIVE: To compare the maternal and neonatal morbidity associated with alternative instruments used to perform a mid-cavity rotational delivery. DESIGN: A prospective cohort study. SETTING: Two university teaching hospitals in Scotland and England. POPULATION: Three hundred and eighty-one nulliparous women who had a mid-cavity rotational operative vaginal delivery. METHODS: A data collection sheet was completed by the research team following delivery. MAIN OUTCOME MEASURES: Postpartum haemorrhage, third- and fourth-degree perineal tears, low cord pH, neonatal trauma, and failed or sequential operative vaginal delivery. RESULTS: One hundred and sixty-three women (42.8%) underwent manual rotation followed by non-rotational forceps delivery, 73 (19.1%) had a rotational vacuum delivery, and 145 (38.1%) delivered with the assistance of rotational (Kielland) forceps. The rates of postpartum haemorrhage were similar when comparing manual rotation with rotational vacuum (adjusted OR 1.42, 95% CI 0.66-3.98), and when comparing manual rotation with Kielland forceps (adjusted OR 1.22, 95% CI 0.71-2.88). The results were comparable for third- and fourth-degree perineal tears (adjusted OR 0.85, 95% CI 0.13-1.89; adjusted OR 0.94, 95% CI 0.39-1.82), low cord pH (adjusted OR 1.76, 95% CI 0.44-6.91; adjusted OR 1.12, 95% CI 0.44-2.83), neonatal trauma (adjusted OR 0.50, 95% CI 0.16-1.55; adjusted OR 3.25, 95% CI 0.65-16.17), and admission to the neonatal intensive care unit (adjusted OR 1.47, 95% CI 0.45-4.81; adjusted OR 1.04, 95% CI 0.49-2.19). The sequential use of instruments was less likely with manual rotation and forceps than with rotational vacuum delivery (0.6 versus 36.9%, OR 0.01, 95% CI 0.002-0.090). CONCLUSIONS: Maternal and perinatal outcomes are comparable with Kielland forceps, vacuum extraction, and manual rotation, with few serious adverse outcomes. With appropriate training mid-cavity rotational delivery can be practiced safely, including the use of Kielland forceps.

Comparing second-line tests to assess fetal wellbeing in Labor: a feasibility study and pilot randomized controlled trial.

OBJECTIVE: To explore the feasibility of conducting a randomized controlled trial (RCT) designed to compare the performance of digital fetal scalp stimulation (dFSS) and fetal blood sampling (FBS) as second-line tests of fetal wellbeing in Labor. DESIGN: A feasibility study included 66 women who consented to both dFSS and FBS performed contemporaneously. A pilot randomized controlled trial included 50 women who were randomized to either dFSS or FBS. SETTING: University-affiliated maternity hospital. POPULATION: Women in Labor who required second-line testing of fetal well-being following abnormal fetal heart rate monitoring. OUTCOME MEASURES: The primary outcome of interest was delivery by emergency cesarean section. Secondary outcomes included maternal and perinatal morbidity outcomes and procedural factors. RESULTS: Of the 66 women recruited to the feasibility study 50 (76%) received the two interventions as per protocol. The demographic data indicated that future RCT should be limited to nulliparous women. After initial training and reminders, the dFSS procedure appeared to be acceptable to patients and clinicians and was interpreted appropriately. Recruitment of eligible women to the pilot RCT was successful (88%) with 50 of 63 eligible women randomized (79%) and no drop-outs. The cesarean section rate was high in both arms as expected with a cohort of women requiring second-line tests for abnormal fetal heart rate monitoring in Labor (5/25; 20% dFSS versus 13/25; 52% FBS, p = .018). Conservative estimates suggest that a sample size of 2500 randomized women would be required for a definitive RCT. CONCLUSIONS: This study suggests that dFSS, which has the potential to be a reliable alternative to FBS, could be evaluated in a well-designed randomized controlled trial. TRIAL REGISTRATION: The definitive trial has been registered ISRCTN 13295826.

Digital fetal scalp stimulation (dFSS) versus fetal blood sampling (FBS) to assess fetal wellbeing in labour-a multi-centre randomised controlled trial: Fetal Intrapartum Randomised Scalp Stimulation Trial (FIRSST NCT05306756).

BACKGROUND: Cardiotocography (CTG) is a screening test used to detect fetal hypoxia in labour. It has a high false positive rate resulting in many potentially unnecessary caesarean sections. Fetal blood sampling (FBS) is a second-line test of the acid-base status of the fetus. It is used to provide either reassurance that it is safe for labour to continue or objective evidence of compromise so that delivery can be expedited. Digital fetal scalp stimulation (dFSS) to elicit a fetal heart rate acceleration is an alternative less invasive second-line test of fetal wellbeing. This study aims to provide robust evidence on the role of these two second-line tests in assessing fetal wellbeing and potentially preventing operative delivery. METHODS: A multi-centre parallel group randomised controlled trial (RCT) is planned in four maternity centres in Ireland. The study aims to recruit 2500 nulliparous women with a term (≥37+0 weeks) singleton pregnancy who require a second-line test of fetal wellbeing in labour due to an abnormal CTG. Women will be allocated randomly to dFSS or FBS on a 1:1 ratio. The primary outcome is caesarean section. With 1250 women in each arm, the study will have 90% power to detect a difference of 5-6%, at a two-sided alpha significance level of 5%, assuming a caesarean section rate of at least 20% in the dFSS group. DISCUSSION: If the proposed study shows evidence that dFSS is a safe, reliable and effective alternative to FBS, this would have ground-breaking implications for labour management worldwide. It could potentially lead to a reduction in invasive procedures and emergency caesarean sections. TRIAL REGISTRATION: ClinicalTrials.gov NCT05306756. Registered on 31 March 2022. The trial commenced enrolment on 10 May 2022. Ethical committee approval has been granted by the Research Ethics Committee (REC) of each hospital: Dublin/CWIUH REC: 12.06.2019; Cork/UCC REC: 29.11.2019; Galway/NUIG REC: 06.09.2019; Limerick/UL REC: 30.09.2019.

Placental growth factor in assessment of women with suspected pre-eclampsia to reduce maternal morbidity: a stepped wedge cluster randomised control trial (PARROT Ireland).

OBJECTIVE: To determine whether the addition of placental growth factor (PlGF) measurement to current clinical assessment of women with suspected pre-eclampsia before 37 weeks' gestation would reduce maternal morbidity without increasing neonatal morbidity. DESIGN: Stepped wedge cluster randomised control trial from 29 June 2017 to 26 April 2019. SETTING: National multisite trial in seven maternity hospitals throughout the island of Ireland PARTICIPANTS: Women with a singleton pregnancy between 20+0 to 36+6 weeks' gestation, with signs or symptoms suggestive of evolving pre-eclampsia. Of the 5718 women screened, 2583 were eligible and 2313 elected to participate. INTERVENTION: Participants were assigned randomly to either usual care or to usual care plus the addition of point-of-care PlGF testing based on the randomisation status of their maternity hospital at the time point of enrolment. MAIN OUTCOMES MEASURES: Co-primary outcomes of composite maternal morbidity and composite neonatal morbidity. Analysis was on an individual participant level using mixed-effects Poisson regression adjusted for time effects (with robust standard errors) by intention-to-treat. RESULTS: Of the 4000 anticipated recruitment target, 2313 eligible participants (57%) were enrolled, of whom 2219 (96%) were included in the primary analysis. Of these, 1202 (54%) participants were assigned to the usual care group, and 1017 (46%) were assigned the intervention of additional point-of-care PlGF testing. The results demonstrate that the integration of point-of-care PlGF testing resulted in no evidence of a difference in maternal morbidity-457/1202 (38%) of women in the control group versus 330/1017 (32%) of women in the intervention group (adjusted risk ratio (RR) 1.01 (95% CI 0.76 to 1.36), P=0.92)-or in neonatal morbidity-527/1202 (43%) of neonates in the control group versus 484/1017 (47%) in the intervention group (adjusted RR 1.03 (0.89 to 1.21), P=0.67). CONCLUSIONS: This was a pragmatic evaluation of an interventional diagnostic test, conducted nationally across multiple sites. These results do not support the incorporation of PlGF testing into routine clinical investigations for women presenting with suspected preterm pre-eclampsia, but nor do they exclude its potential benefit. TRIAL REGISTRATION: ClinicalTrials.gov NCT02881073.

Prevalence and predictors of periconceptional folic acid uptake--prospective cohort study in an Irish urban obstetric population.

BACKGROUND: Neural tube defects (NTDs) are severe abnormalities of the central nervous system that occur as a result of abnormal development in the third and fourth weeks of gestation. Studies have shown that periconceptional folic acid (FA) can reduce both the incidence and recurrence of NTDs. METHODS: A cohort study was carried out using the electronic hospital booking records of women delivering in a large Dublin maternity hospital between 2000 and 2007. Logistic regression analyses were performed to measure the associations between maternal factors and optimal FA use. RESULTS: Of the 61,252 women in the cohort, 85% reported taking FA at some point during the periconceptional period; however, only 28% took FA as recommended. Factors associated with taking the recommended amount of FA included nulliparity [adjusted OR: 1.35 (95% CI: 1.28-1.43)], early booking (<12 weeks) [OR: 1.24 (95% CI: 1.17-1.31)], increasing maternal age (e.g. 30-34 years) [OR: 1.39 (95% CI: 1.30-1.48)], private health care [OR: 4.32 (95% CI: 4.1-4.6)] and fertility treatment [OR: 2.88 (95% CI: 2.44-3.40)]. Factors associated with taking less than recommended or no FA included unplanned pregnancy [OR: 0.08 (0.07-0.08)], lower socio-economic status (e.g. unemployed) [OR: 0.63 (95% CI: 0.55-0.71)], non-Irish nationality [OR: 0.82 (0.74-0.90)] and smokers [OR: 0.51 (95% CI: 0.47-0.55)]. CONCLUSIONS: Social, demographic and economic factors have an important influence on the FA uptake. Vulnerable groups who report limited uptake of FA need to be specifically targeted in future Public Health campaigns and further consideration needs to be given to the debate on food fortification in countries where this is currently not available.

Signatures of vicariance, postglacial dispersal and spawning philopatry: population genetics of the walleye Sander vitreus.

Population genetic relationships reveal the signatures of current processes such as reproductive behaviour and migration, as well as historic events including vicariance and climate change. We analyse population structure of native walleye Sander vitreus across North America, encompassing 10 nuclear DNA microsatellite loci, 26 spawning sites and 921 samples from watersheds across the Great Lakes, Lake Winnipeg, upper Mississippi River, Ohio River and Mobile Bay of the Gulf Coast. Geographical patterning is assessed using phylogenetic trees, pairwise F(ST) analogues, hierarchical partitioning, Mantel regression, Bayesian assignment and Monmonier geographical networks. Results reveal congruent divergences among population groups, corresponding to historic isolation in glacial refugia, dispersal patterns and basin divisions. Broad-scale relationships show genetic isolation with geographical distance, but reproductive groups within basins do not -- with some having pronounced differences. Greatest divergence distinguishes outlying Gulf Coastal and northwest populations, the latter tracing to dispersal from the Missourian refugium to former glacial Lake Agassiz, and basin isolation approximately 7000 ya. Genetic barriers in the Great Lakes separate groups in Lakes Superior, Huron's Georgian Bay, Erie and Ontario, reflecting contributions from Mississippian and Atlantic refugia, and changes in connectivity patterns. Walleye genetic patterns thus reflect vicariance among watersheds and glacial refugia, followed by re-colonization pathways and changing drainage connections that established modern-day northern populations, whose separations are maintained through spawning site fidelity. Conservation management practices should preserve genetic identity and unique characters among these divergent walleye populations.

Qualitative analysis by interviews and video recordings to establish the components of a skilled low-cavity non-rotational vacuum delivery.

OBJECTIVES: The objectives of this study were to define the components of a skilled low-cavity non-rotational vacuum delivery (occiput anterior, vertex at station +2 or below and less than 45-degree rotation from midline) and to facilitate the transfer of skills from expert to trainee obstetricians. DESIGN: Qualitative study using interviews and video recordings. SETTING: Two university teaching hospitals (St Michael's Hospital, Bristol, and Ninewell's Hospital, Dundee). PARTICIPANTS: Ten obstetricians and eight midwives identified as experts in conducting or supporting operative vaginal deliveries. METHODS: Semi-structured interviews were carried out using routine clinical scenarios. The experts were also video recorded conducting low-cavity vacuum deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were independently coded by three researchers and compared for consistency of interpretation. The experts reviewed the coded interviews and video data for respondent validation and clarification. The themes that emerged following the final coding were used to formulate a list of skills. MAIN OUTCOME MEASURES: Key technical skills of a low-cavity non-rotational delivery. RESULTS: The final list included detailed technical skills required for conducting a low-cavity vacuum delivery. The combination of semi-structured interviews and simulation videos allowed the formulation of a comprehensive skills tool for future evaluation. CONCLUSION: This explicitly defined skills list could aid trainees understanding of the technique of low-cavity vacuum delivery. This is an important first step in evaluating clinical competence in intrapartum procedures.