The Tommy's Clinical Decision Tool, a device for reducing the clinical impact of placental dysfunction and preterm birth: protocol for a mixed-methods early implementation evaluation study.

BACKGROUND: Disparities in stillbirth and preterm birth persist even after correction for ethnicity and social deprivation, demonstrating that there is wide geographical variation in the quality of care. To address this inequity, Tommy's National Centre for Maternity Improvement developed the Tommy's Clinical Decision Tool, which aims to support the provision of "the right care at the right time", personalising risk assessment and care according to best evidence. This web-based clinical decision tool assesses the risk of preterm birth and placental dysfunction more accurately than current methods, and recommends best evidenced-based care pathways in a format accessible to both women and healthcare professionals. It also provides links to reliable sources of pregnancy information for women. The aim of this study is to evaluate implementation of Tommy's Clinical Decision Tool in four early-adopter UK maternity services, to inform wider scale-up. METHODS: The Tommy's Clinical Decision Tool has been developed involving maternity service users and healthcare professionals in partnership. This mixed-methods study will evaluate: maternity service user and provider acceptability and experience; barriers and facilitators to implementation; reach (whether particular groups are excluded and why), fidelity (degree to which the intervention is delivered as intended), and unintended consequences. Data will be gathered over 25 months through interviews, focus groups, questionnaires and through the Tommy's Clinical Decision Tool itself. The NASSS framework (Non-adoption or Abandonment of technology by individuals and difficulties achieving Scale-up, Spread and Sustainability) will inform data analysis. DISCUSSION: This paper describes the intervention, Tommy's Clinical Decision Tool, according to TiDIER guidelines, and the protocol for the early adopter implementation evaluation study. Findings will inform future scale up. TRIAL REGISTRATION: This study was prospectively registered on the ISRCTN registry no. 13498237 , on 31st January 2022.

Postnatal pelvic floor muscle stiffness measured by vaginal elastometry in women with obstetric anal sphincter injury: a pilot study.

INTRODUCTION AND HYPOTHESIS: Vaginal childbirth is associated with pelvic floor muscle (PFM) damage in a third of women. The biomechanics prediction, detection and management of PFM damage remain poorly understood. We sought in this pilot study to determine whether quantifying PFM stiffness postnatally by vaginal elastometry, in women attending a perineal trauma clinic (PTC) within 6 months of obstetric anal sphincter injury, correlates with their antecedent labour characteristics, pelvic floor muscle damage, or urinary/bowel/sexual symptoms, to inform future definitive prospective studies. METHODS: In this pilot study, we measured postnatal PFM stiffness by vaginal elastometry in 54 women. A subset of participants (n = 14) underwent magnetic resonance imaging (MRI) to define any levator ani (LA) muscle defects from vaginal childbirth. We investigated the association of PFM stiffness with demographics, labour and delivery characteristics, clinical features and MRI evidence of LA damage. RESULTS: Raised maternal BMI was associated with reduced pelvic floor stiffness (r = -0.4; p < 0.01). Higher stiffness values were associated with forceps delivery for delayed second stage of labour (n = 14) vs non-forceps vaginal delivery (n = 40; 630 ± 40 N/m vs 500 ± 30 N/m; p < 0.05), and a non-significant trend towards longer duration of the second stage of labour. Women with urinary, bowel or sexual symptoms (n = 37) demonstrated higher pelvic floor stiffness values than those without (570 ± 30 N/m vs 450 ± 40 N/m; p < 0.05). CONCLUSIONS: A history of delayed second stage of labour and forceps delivery was associated with higher PFM stiffness values in the postnatal period. Whether high pelvic muscle stiffness antenatally is a risk factor for instrumental vaginal delivery and LA avulsion is unknown.

Developing family-centred care in a neonatal intensive care unit: An action research study.

AIM: To develop, implement and evaluate family-centred interventions to promote parental involvement in caregiving in a Neonatal Intensive Care Unit. METHODOLOGY: A participatory action research approach was used to implement two changes in practice a) improved skin-to-skin contact b) unlimited parental presence at the cot-side. The changes were underpinned by a family-centred philosophy of care and education. Data were collected from staff using a questionnaire, focus groups and interviews, and from parents using focus groups and interviews. Qualitative data were analysed using Framework and quantitative data analysed using descriptive and t-test statistics. SETTING: A Neonatal Intensive Care Unit in England. FINDINGS: Changes in practice were successfully implemented. Nurses reported positively on improvements in Family Centred Care; most notably information-sharing with parents, providing family support, enabling parental participation in care and improved competence supporting parents in care-giving. These changes were reflected in parental feedback. CONCLUSION: Understanding the context of the neonatal unit can support cultural change when change is actively facilitated and owned by the staff concerned. Acknowledging parents as the main caregiver can be challenging for nurses and they require support and education to enable them to manage the changes necessary to provide Family-Centred Care.

'Two week wait' standards for suspected gynaecological malignancy. On target, but missing the point?

OBJECTIVE: To assess the two-week rapid access referral system for UK general practitioners introduced in April 2000 for women suspected of having a gynaecological cancer. STUDY DESIGN: An audit of details of women referred between 1st April 2000 and 31st March 2003 via the two-week rapid access system to one gynaecological consultant who performs gynaecological oncology surgery at the John Radcliffe Hospital, Oxford. MAIN OUTCOME MEASURES: Information on waiting times, clinical indication (postmenopausal bleeding, suspicious pelvic mass, vulval lesions, or "other" symptoms including postcoital vaginal bleeding, suspicious lesions of the cervix or vagina), and subsequent diagnosis were recorded. Data on all other women in whom a diagnosis of a gynaecological malignancy was made during the same period following referral to the same consultant's routine gynaecological outpatient clinic were also collected. RESULTS: The target time of two weeks to see a consultant was met for 94% of women referred via the rapid access system. The response time declined slightly with increasing numbers of referrals. However, the majority of women with a gynaecological malignancy were not referred via the rapid access system. CONCLUSIONS: To accommodate the two-week rapid access referrals and achieve UK government targets, there was a reduction in appointments for routine outpatient referrals. However, as the majority of women with gynaecological malignancy presented via traditional referral routes, there is a danger that their diagnoses are being delayed.