Current predictors for morbidity regarding choice of birth after a previous caesarean section, show poor predictive value in prediction modelling.

INTRODUCTION: After a previous caesarean section, morbidity in the subsequent delivery in general is considered to depend on the probability of a vaginal birth after caesarean. However counselling could be improved by adding individualized probability of serious morbidity following either trial of labour or elective repeat caesarean section. The objective of this study was to develop prediction models for morbidity for both a repeat caesarean section and a trial of labor for a Dutch population. MATERIAL AND METHODS: In this cohort study, data were joined from three previous studies (SIMPLE 1, SIMPLE 2 and SIMPLE 2-implementation study). A cohort of 2592 women with one previous caesarean section and a singleton pregnancy who delivered ≥37 weeks, without a contraindication for vaginal delivery was formed. Maternal morbidity was defined as postpartum hemorrhage, blood transfusion, uterine rupture, ICU admittance or death. Neonatal morbidity was defined as asphyxia, NICU-admittance or death. Potential predictors for morbidity were chosen based on literature and expert opinion. Logistic regression was used to develop the models. Internal validation was intended using bootstrapping techniques. Main outcome measures were predictors for morbidity and for validation of the model we used the area under the receiver operating characteristic curve for discriminative capacity and calibration for accuracy. RESULTS: In 324 out of the 2592 cases (12.7 %) maternal or fetal complications occurred. In general total morbidity was higher in women choosing TOL as compared to ERCS (p < 0.001). The performance of the several developed models was insufficient, the area under the receiver operating characteristic curve did not rise above 0.6. Due to poor model performance, before correction for overfitting, interval validation was not conducted. CONCLUSION: In this large cohort, developing a Dutch population based prediction model that aimed to improve counselling on the mode of delivery, by predicting individual chances of morbidity for different delivery modes was not possible, due to lack of performance. Further study could be directed to cut off on VBAC success rates to a more general advice regarding the safest mode of delivery.

Anatomy in the daily practice of the gynecologist, essential or just window dressing?

Traditionally, anatomy was one of the basic pillars of medical training. However, due to the expansion of medical science and medical knowledge in general, anatomy teaching has steadily declined and the way anatomy is taught has changed. These changes go hand in hand with growing literature about a perceived and proven lack of anatomical knowledge. While anatomy is important for all doctors, these developments seem to be more worrying for surgical residents. At the same time, little is known about how clinicians use anatomy in daily practice. The primary aim of this study was to increase understanding of the role of anatomy in the daily practice of gynecologists. An explorative qualitative study was performed to answer the question "What is the tangible utility of solid anatomical knowledge in the daily practice of the gynecologist"? Semi-structured interviews with gynecologists and obstetrics and gynecology (ObGyn) residents from Belgium and the Netherlands were held and the responses were analyzed using a phenomenographic inductive coding approach. Anatomical knowledge was important and used for technical skills and non-technical achievements in the daily practice of gynecologists, and three themes were distinguished. Specifically, anatomical knowledge was important and used (1) for daily activities, (2) for the feeling of self-efficacy, and (3) to gain a respected name as a doctor. These findings are discussed in light of (perceived) insufficient anatomical knowledge, and recommendations are made for the postgraduate education of ObGyn doctors.

What do we need to know about anatomy in gynaecology? An international validation study.

OBJECTIVE: International validation of the Dutch Delphi study about which anatomical structures should be taught to ensure safe and competent practice among general gynaecologists. STUDY DESIGN: Validation study with gynaecologists and trainees in gynaecology from academic, non-academic teaching and non-academic, non-teaching hospitals worldwide. The relevance of 123 items included in the Dutch Delphi study was scored on a Likert scale between 1 (not relevant) and 5 (highly relevant). Consensus was defined when ≥70 % of the panellist scored the item as relevant or very relevant and the average rating was ≥4. RESULTS: A total of 192 gynaecologists and trainees from seven countries (Belgium, Germany, Norway, Oceania, Sweden, United Kingdom and United States) completed the questionnaire. Of the 123 structures, 72 (58.5%) were internationally relevant. When the 72 relevant structures from the international Delphi study were compared with the 86 relevant structures from the Dutch Delphi study, 70 (81.4%) structures matched. CONCLUSIONS: This study identified 70 anatomical structures that should be taught for safe and competent practice of general gynaecologists based on national and international validation. The results of our study identify the learning needs (i.e., the content) for an international anatomy curriculum. The development of the curriculum (i.e., the form) can be determined by each country and used to standardize and guide postgraduate training in gynaecology. This is an important step in the era of international teaching and training.

Nationwide implementation of a decision aid on vaginal birth after cesarean: a before and after cohort study.

OBJECTIVES: Woman with a history of a previous cesarean section (CS) can choose between an elective repeat CS (ERCS) and a trial of labor (TOL), which can end in a vaginal birth after cesarean (VBAC) or an unplanned CS. Guidelines describe women's rights to make an informed decision between an ERCS or a TOL. However, the rates of TOL and vaginal birth after CS varies greatly between and within countries. The objective of this study is to asses nation-wide implementation of counselling with a decision aid (DA) including a prediction model, on intended delivery compared to care as usual. We hypothesize that this may result in a reduction in practice variation without an increase in cesarean rates or complications. METHODS: In a multicenter controlled before and after cohort study we evaluate the effect of nation-wide implementation of a DA. Practice variation was defined as the standard deviation (SD) of TOL percentages. RESULTS: A total of 27 hospitals and 1,364 women were included. A significant decrease was found in practice variation (SD TOL rates: 0.17 control group vs. 0.10 intervention group following decision aid implementation, p=0.011). There was no significant difference in the ERCS rate or overall CS rates. A 21% reduction in the combined maternal and perinatal adverse outcomes was seen. CONCLUSIONS: Nationwide implementation of the DA showed a significant reduction in practice variation without an increase in the rate of cesarean section or complications, suggesting an improvement in equality of care.

What do we need to know about anatomy in gynaecology: A Delphi consensus study.

OBJECTIVE: Determination of the anatomical structures that should be taught to ensure safe and competent practice among general gynaecologists. STUDY DESIGN: A two-round Delphi survey, face-to-face meeting in focus groups and an individual interview. Participants were medical doctors and trainees from gynaecology, surgery, urology and radiology from academic, non-academic teaching and non-academic, non-teaching hospitals in the Netherlands. Relevant structures were collected from gynaecology surgery atlas based on most common gynaecological surgeries and diseases. These structures were supplemented and critically viewed in focus groups followed by a Delphi survey. In the Delphi survey gynaecologist and trainee's gynaecology from all over the Netherlands scored the items on a Likert scale between 1 (not relevant) and 5 (highly relevant). Consensus was defined when ≥ 70 % of the panellist scored the item as relevant or very relevant and the average rating was ≥ 4. Main outcome was clinically relevant anatomical structures. RESULTS: Consensus on 86 clinically relevant anatomical structures divided by nine categories. CONCLUSIONS: This study identified a core list of anatomical structures that are relevant to the safe and competent practice of general gynaecologists and that can be used to guide gynaecology postgraduate education. This is the first step in a much wider and complex process of becoming a competent gynaecologist.