Competence of healthcare professionals in diagnosing and managing obstetric complications and conducting neonatal care: a clinical vignette-based assessment in district and subdistrict hospitals in northern Bangladesh.

BACKGROUND: This study assesses the competency of maternal and neonatal health (MNH) professionals at district-level and subdistrict-level health facilities in northern Bangladesh in managing maternal and newborn complications using clinical vignettes. The study also examines whether the professional's characteristics and provision of MNH services in health facilities influence their competencies. METHODS: 134 MNH professionals in 15 government hospitals were interviewed during August and September 2016 using structured questionnaire with clinical vignettes on obstetric complications (antepartum haemorrhage and pre-eclampsia) and neonatal care (low birthweight and immediate newborn care). Summative scores were calculated for each vignette and median scores were compared across different individual-level and health facility-level attributes to examine their association with competency score. Kruskal-Wallis test was performed to identify the significance of association considering a p value<0.05 as statistically significant. RESULTS: The competency of MNH professionals was low. About 10% and 24% of the health professionals received 'high' scores (>75% of total) in maternal and neonatal vignettes, respectively. Medical doctors had higher competency than nurses and midwives (score=11 vs 8 out of 19, respectively; p=0.0002) for maternal vignettes, but similar competency for neonatal vignettes (score=30.3 vs 30.9 out of 50, respectively). Professionals working in health facilities with higher use of normal deliveries had better competency than their counterparts. Professionals had higher competency in newborn vignettes (significant) and maternal vignettes (statistically not significant) if they worked in health facilities that provided more specialised newborn care services and emergency obstetric care, respectively, in the last 6 months. CONCLUSIONS: Despite the overall low competency of MNH professionals, exposure to a higher number of obstetric cases at the workplace was associated with their competency. Arrangement of periodic skill-based and drill-based in-service training for MNH professionals in high-use neighbouring health facilities could be a feasible intervention to improve their knowledge and skill in obstetric and neonatal care.

Endometrial Biopsy: American College of Nurse-Midwives.

Endometrial biopsy can be used to diagnose endometrial hyperplasia, endometrial cancer, and uterine infections. This cost-effective procedure has minimal side effects, and complications are rare. The purpose of this clinical bulletin is to provide clinicians with guidance about endometrial biopsy including the procedure's advantages and disadvantages, indications and contraindications, and side effects. In addition, step-by-step instructions for performing endometrial biopsy, the equipment required, selection of sampling devices, and care before and after the procedure are discussed.

Abnormal Uterine Bleeding: American College of Nurse-Midwives.

Variations in uterine bleeding, termed abnormal uterine bleeding, occur commonly among women and often are physiologic in nature with no significant consequences. However, abnormal uterine bleeding can cause significant distress to women or may signify an underlying pathologic condition. Most women experience variations in menstrual and perimenstrual bleeding in their lifetimes; therefore, the ability of the midwife to differentiate between normal and abnormal bleeding is a key diagnostic skill. A comprehensive history and use of the PALM-COEIN classification system will provide clear guidelines for clinical management, evidence-based treatment, and an individualized plan of care. The purpose of this Clinical Bulletin is to define and describe classifications of abnormal uterine bleeding, review updated terminology, and identify methods of assessment and treatment using a woman-centered approach.

Can we teach core clinical obstetrics and gynaecology skills using low fidelity simulation in an interprofessional setting?

Core clinical skills acquisition is an essential component of undergraduate medical and midwifery education. Although interprofessional education is an increasingly common format for learning efficient teamwork in clinical medicine, its value in undergraduate education is less clear. We present a collaborative effort from the medical and midwifery schools of Monash University, Melbourne, towards the development of an educational package centred around a core skills-based workshop using low fidelity simulation models in an interprofessional setting. Detailed feedback on the package was positive with respect to the relevance of the teaching content, whether the topic was well taught by task trainers and simulation models used, pitch of level of teaching and perception of confidence gained in performing the skill on a real patient after attending the workshop. Overall, interprofessional core skills training using low fidelity simulation models introduced at an undergraduate level in medicine and midwifery had a good acceptance.

Actualización del tratamiento médico de la hemorragiauterina disfuncional / An update of the medical management of dysfunctional uterine bleeding

La hemorragia uterina disfuncional es un transtorno frecuente ginecológico. Es un diagnóstico de exclusión, y el clínico debe proceder a una evaluación lógica y escalonada de todas las causas de sangrado anormal. La menorragia en la mayoría de los casos se asocia con anovulación. El tratamiento médico debería ser la primera opción terapéutica y puede ser dividido en terapia no hormonal y hormonal. Los dos principales tratamientos para la menorragia asociada a ciclos ovulatorios son no hormonales, mediante un antifibrinolítico como el ácido tranexámico y antiinflamatorios. Tradicionalmente la terapia hormonal para la menorragia ha estado constituida por los progestágenos y los anticonceptivos orales. El sistema intrauterino de liberación de levonorgestrel ofrece un nuevo concepto terapéutico que combina una eficaz contracepción con una reducción del sangrado menstrual. Es una buena alternativa conservadora a la resección endometrial y parece ser una importante alternativa a la medicación oral. En el manejo de la pérdida menstrual excesiva hay una evidencia demostrada de que muchos médicos no prescriben los tratamientos más adecuados. El incremento en la utilización de tratamientos efectivos mejoraría las expectativas de las pacientes y supondría una alternativa a la cirugía (AU)

[Diagnostic hysteroscopy in abnormal uterine bleeding. Five-years' experience]. / L'isteroscopia diagnostica nel sanguinamento uterino anomalo. Cinque anni di esperienza.

BACKGROUND: Hysteroscopy has acquired a central role in the clinical diagnosis of intrauterine pathologies. This study evaluated the feasibility, procedure modality, tolerability, complications and diagnostic accuracy of hysteroscopy in the management of patients with abnormal uterine bleeding (AUB). METHODS: This retrospective study was carried out on 512 women (age range: 38-80 years, mean age: 63) with AUB who attended our hysteroscopy outpatient service from January 1996 to December 2001. After undergoing transvaginal sonography, the patients were referred for further diagnostic studies. Ambulatory hysteroscopy without premedication was performed using a Hamou hysteroscope and physiological solution or CO(2) as distension medium. Guided biopsy with a Novak cannula completed the examination. When focal lesions were found, the patients were referred for surgical treatment (hysteroscopic resection, hysterectomy, etc.). Hysteroscopic and histologic findings were then compared. RESULTS: Locoregional or general anaesthesia was required in only 9.3% of cases to complete the examination. Overall, the examination was well tolerated; one case of serious complications (vagal syndrome which resolved rapidly) and 18 cases of shoulder blade pain were recorded. The hysteroscopic picture was normal in 25% of cases, benign pathology was diagnosed in 58.6% and suspected malignant neoplasia in 16.4%. Correlation rates between hysteroscopic and histologic diagnoses are reported for the various hysteroscopic pictures. CONCLUSIONS: Ambulatory hysteroscopy was shown to be a simple, safe, well tolerated and reliable procedure in the diagnosis of AUB across all age groups. Its widespread use can drastically reduce the need for conventional curettage, thereby increasing patient satisfaction and lowering costs.

Six thousand office diagnostic-operative hysteroscopies.

OBJECTIVE: To compare CO(2) and normal saline as distention media in office diagnostic hysteroscopy. METHODS: The outcome of more than 6000 office hysteroscopies was analyzed. We used carbon dioxide or saline as distension medium. Minor hysteroscopic techniques were performed when indicated. RESULTS: The major indication was abnormal uterine bleeding (45%). Satisfactory hysteroscopy was achieved in 92. 4% with CO(2) and in 98.3% with saline (P<0.05). Local anesthesia was used in 54 patients (1.5%) with CO(2) and in three patients (0. 1%) with saline (P<0.001). Four hundred and two women (16.3%) underwent hysteroscopic procedures under saline hysteroscopy. Endometrial polyps were removed in 281 patients, 75 IUDs were removed, 14 fibroids were extracted, uterine septa were excised in 11 cases and mild and moderate adhesions were transected in 21 patients. CONCLUSION: Saline office diagnostic hysteroscopy offers at least all the advantages of the CO(2) hysteroscopy, and gives the possibility to easily 'find and treat in situ' many of the lesions observed.

Paracervical anaesthesia in outpatient hysteroscopy: a randomised double-blind placebo-controlled trial.

OBJECTIVE: To evaluate the efficacy and safety of paracervical anaesthesia in reducing pain during outpatient hysteroscopy and endometrial biopsy. DESIGN: Prospective, randomised, placebo-controlled, double-blind study. POPULATION: One hundred women undergoing outpatient hysteroscopy and endometrial biopsy for abnormal uterine bleeding. INTERVENTIONS: Paracervical block using 10 mL of either 2% lignocaine or normal saline before the procedure. MAIN OUTCOME MEASURES: Evaluation of pain at different stages of hysteroscopy using a visual analogue scale together with blood pressure and heart rate monitoring. RESULTS: Compared with placebo, paracervical anaesthesia significantly reduced the pain only at the time of insertion of the hysteroscope, but not at the subsequent stages of the procedure. However, paracervical injection of lignocaine resulted in a higher incidence of bradycardia and hypotension. CONCLUSIONS: Paracervical anaesthesia not only fails to reduce pain during outpatient hysteroscopy and endometrial biopsy, but also carries a risk of inducing bradycardia and hypotension, which is probably a result of inadvertent intravascular injection.

Midwifery care of the woman with menorrhagia.

Menorrhagia is characterized by excessive menstrual bleeding and is defined as a menstrual blood loss of greater than 80 mL. Approximately one in ten women in the United States experiences menorrhagia. Although rarely life-threatening, menorrhagia can have a negative impact on women's lives, and its treatment can improve the quality of life for many women with this condition. This article reviews the definition, diagnosis, pathophysiology, assessment, and treatment of menorrhagia as well as the impact of menorrhagia and its treatment on the quality of life for women with this condition. The role of the midwife in the care of the woman with menorrhagia is also reviewed.

Common peripartum emergencies.

Peripartum emergencies occur in patients with no known risk factors. When the well-being of the fetus is in question, the fetal heart rate pattern may offer etiologic clues. Repetitive late decelerations may signify uteroplacental insufficiency, and a sinusoidal pattern may indicate severe fetal distress. Repetitive variable decelerations suggesting umbilical cord compression may be relieved by amnioinfusion. Regardless of the etiology of the nonreassuring fetal heart pattern, measures to improve fetal oxygenation should be attempted while options for delivery are considered. Massive obstetric hemorrhage requires prompt action. Clinical signs, such as painless bleeding, uterine tenderness and nonreassuring fetal heart patterns, may help to differentiate causes of vaginal bleeding that may or may not require emergency cesarean delivery. The causes of postpartum hemorrhage include uterine atony, vaginal or cervical laceration, and retained placenta. The challenge of managing shoulder dystocia is to effect a rapid delivery while avoiding neonatal and maternal morbidity. The McRoberts maneuver has been shown to be the safest and most successful technique for relieving shoulder dystocia. Eclampsia responds best to magnesium sulfate, supportive care and supplemental hydralazine or labetalol as needed for severe hypertension.

A vaginoscopic approach to reduce the pain of office hysteroscopy.

We developed a new approach to diagnostic hysteroscopy that reduces patient discomfort and increases the possible applications of hysteroscopy. Between February 1992 and March 1996, 1200 hysteroscopies were performed at our institution. Of these, the last 680 were done using the vaginoscopic approach without preselection. Discomfort was reduced in all patients, including those with moderate stenosis of the internal cervical os. Vaginoscopy is easy to perform and incurs no additional cost for the patient. It is ideal for office hysteroscopy and in patients who otherwise might require general anesthesia, such as virgins and older women with somewhat stenotic vaginas.

The use of topical anesthesia in diagnostic hysteroscopy and endometrial biopsy.

STUDY OBJECTIVE: To determine whether the pain and discomfort of routine hysteroscopy with endometrial biopsy to diagnose infertility and endometrial pathology can be minimized by topical application of mepivacaine. DESIGN: Prospective, randomized, double-blind study. SETTING: The Department of Obstetrics and Gynecology at a teaching hospital in Rome, Italy. PATIENTS: Eighteen women undergoing diagnostic hysteroscopy. INTERVENTIONS: Hysteroscopy and endometrial biopsy were performed after transcervical injection of 5 ml 2% mepivacaine or 5 ml saline solution into the uterine cavity. MEASUREMENTS AND MAIN RESULTS: Difficulty introducing the hysteroscope was rated by the operator on a scale of 1 to 3. An observer scored visible signs of each woman's distress using a three-point scale. The patients reported their pain 15, 30, 60, 120 minutes after the procedure on a visual analog scale. Mepivacaine was more effective than placebo according to all measurements. CONCLUSIONS: Topical mepivacaine reduced the pain experienced during and after hysteroscopy and endometrial biopsy.

Panoramic CO2 hysteroscopy.

The method of CO2 panoramic hysteroscopy was described. It can be performed as an office procedure without the need for preliminary cervical dilatation or even a paracervical nerve block. The risks are minimal, and the benefits of being able to see the uterine cavity are manifold. Hysteroscopy is a relatively simple endoscopic procedure to learn, and its use in the diagnosis and management of abnormal uterine bleeding was emphasized.

Dysfunctional uterine bleeding: diagnosis and treatment.

Dysfunctional uterine bleeding is not a specific diagnosis. It encompasses a spectrum of endocrinologic dysfunction which must be considered in reference to the presence or absence of ovulation. Specific causes must not be forgotten, particularly in those women who do not respond as expected to hormonal therapy. A variety of empiric therapies are used which have no benefit, such as thyroid hormone in the absence of proven hypothyroidism, corticosteroid in the absence of proven adrenal hypofunction, and megavitamin therapies in the absence of nutritional disorders. Curettage is valuable for diagnosis, not for therapy. Medical therapy offers a successful alternative to hysterectomy in many women, but the choice must be made on an individual basis. Medical and surgical management should not be viewed as competitive treatment regimens.