Does residency training improve cognitive competence in obstetric and gynaecologic surgery?

OBJECTIVE: To develop an operative knowledge assessment tool to evaluate the cognitive competence of trainees in obstetric and gynaecologic surgery and to determine the rate of change in competence during a five-year residency program. METHODS: Twenty-eight participants in five training groups (PGY-1 to PGY-5) in McGill University's residency program in obstetrics and gynaecology underwent an evaluation based on surgical cognitive competence (SCC) assessment tools developed for three different obstetric and gynaecologic operations: open total abdominal hysterectomy (TAH), Caesarean section, and laparoscopic bilateral tubal sterilization (BTL). The tools were developed as checklists listing every step in each operation based on techniques described in current surgical texts. Using analysis of variance and linear regressions, statistical significance was established for procedure-specific scores and overall SCC scores. In addition, the rate of change of cognitive competence throughout the training years was calculated. Finally, using a t test, the overall SCC score was compared to a "critical steps score". RESULTS: Critical steps scores and overall SCC scores increased with training experience at an average yearly rate of 13.36% (P < 0.001). Procedure-specific scores increased yearly, by 15.73% for TAH (P < 0.001), 8.06% for Caesarean section (P < 0.001), and 16.31% for BTL (P < 0.001). The difference between overall scores and critical steps scores was not statistically significant for the study cohort (P = 0.94). CONCLUSION: Surgical cognitive competence among obstetrics and gynaecology residents can be reliably assessed with our evaluation tool, and it increases proportionally with residency education, reaching maximum scores during the final year of training. This type of information may be helpful in ascertaining how long a residency program should be.

Intrapartum temperature changes following the intravenous crystalloid bolus for epidural analgesia.

OBJECTIVE: To assess the effect of the intravenous crystalloid bolus given before epidural analgesia on maternal temperature during labour. Multiple studies have demonstrated a hyperthermic trend in parturient women receiving epidural analgesia. This temperature rise may be affected by the pre-epidural intravenous crystalloid bolus. METHODS: Intrapartum oral temperatures were recorded in 40 singleton parturient women immediately before and after an intravenous bolus of Ringer's lactate solution (1L at room temperature [21 degrees C]) and at one hour after standardized insertion of an epidural catheter for analgesia. Exclusion criteria included antibiotic administration, chorioamnionitis, and initial maternal temperature above 37.5 degrees C. Group means were compared using the 2-tailed paired Student t test. RESULTS: There was no significant trend towards a decrease in maternal temperature after the crystalloid bolus (mean change -0.07 degree C, P = 0.33). Similarly, there was no initial trend towards an increased maternal temperature after epidural insertion (mean change + 0.02 degrees C, P > 0.7). Separate analyses using parity, body mass index, and bolus duration as covariates showed that these variables did not affect maternal temperature changes (P > or = 0.2). CONCLUSION: Our study indicates that intravenous infusion of a crystalloid bolus at room temperature before induction of epidural analgesia does not significantly decrease parturient temperature.