Implementation of universal umbilical cord pH analysis in Denmark. A national register-based study.

INTRODUCTION: Umbilical cord blood gas analysis provides information about intrapartum hypoxia and is considered an important measure of quality in maternity care. Universal measurement of umbilical cord pH (UC-pH), as part of umbilical cord blood gas analysis, has been recommended in Denmark since 2009. The recommendation is that UC-pH is measured from the umbilical cord artery (pHUA ) and vein (pHUV ). The aim of this study was to evaluate the national implementation of universal measurement of UC-pH. MATERIAL AND METHODS: The study consisted of two parts. First, an evaluation of the implementation, that is, the proportion of births with measured UC-pH since the recommendation was introduced. Second, an evaluation of the cases in which UC-pH was missing. This analysis only involved births with gestational age ≥35 + 0 weeks. RESULTS: In the period 2009 to 2018 there were 560 889 singleton, live births with registered gestational age in Denmark. The proportion of births with measured pHUA and pHUV increased from 12.4% in 2009 to 82.8% in 2015 and then declined to 76.9% in 2018 (p < 0.001). When comparing the group with missing pH from one or both vessels to the group with both pHUA and pHUV we found lower occurrence of pregnancy and births complications in the first group, body mass index ≥35 (unadjusted RR: 0.89, 95% CI: 0.85-0.93), pregnancy induced medical conditions (RR: 0.86, 95% CI: 0.84-0.89), fetal distress during birth (RR: 0.77, 95% CI: 0.76-0.79), emergency cesarean section (RR: 0.80, 95% CI: 0.78-0.83) and serious births events (RR: 0.80, 95% CI: 0.74-0.86). In contrast, the occurrence of placental insufficiency (RR: 1.07, 95% CI: 1.03-1.11), small for gestational age (RR: 1.36, 95% CI: 1.30-1.43, for <2.3th percentile), hypothermia treatment (RR: 1.60, 95% CI: 1.21-2.14) and neonatal death (RR: 1.96, 95% CI: 1.40-2.74) were higher in the group without measured pHUA and pHUV . CONCLUSIONS: The use of UC-pH measurement has increased markedly in Denmark since universal measurement was recommended in 2009. Missing UC-pH from one or both vessels was associated with less complicated pregnancies and with small for gestational age, hypothermia treatment and neonatal death.

How often will midwives and obstetricians experience obstetric emergencies or high-risk deliveries: a national cross-sectional study.

OBJECTIVE: To estimate how often midwives, specialty trainees and doctors specialised in obstetrics and gynaecology are attending to specific obstetric emergencies or high-risk deliveries (obstetric events). DESIGN: A national cross-sectional study. SETTING: All hospital labour wards in Denmark. PARTICIPANTS: Midwives (n=1303), specialty trainees (n=179) and doctors specialised in obstetrics and gynaecology (n=343) working in hospital labour wards (n=21) in Denmark in 2018. METHODS: Categories of obstetric events comprised of Apgar score <7/5 min, eclampsia, emergency caesarean sections, severe postpartum haemorrhage, shoulder dystocia, umbilical cord prolapse, vaginal breech deliveries, vaginal twin deliveries and vacuum extraction. Data on number of healthcare professionals were obtained through the Danish maternity wards, the Danish Health Authority and the Danish Society of Obstetricians and Gynaecologists. We calculated the time interval between attending each obstetric event by dividing the number of events occurred with the number of healthcare professionals. OUTCOME MEASURES: The time interval between attending a specific obstetric event. RESULTS: The average time between experiencing obstetric events ranged from days to years. Emergency caesarean sections, which occur relatively frequent, were attended on average every other month by midwives, every 9 days for specialty trainees and every 17 days by specialist doctors. On average, rare events like eclampsia were experienced by midwives only every 42 years, every 6 years by specialty trainees and every 11 years by specialist doctors. CONCLUSIONS: Some obstetric events occur extremely rarely, hindering the ability to obtain and maintain the clinical skills to manage them through clinical practice alone. By assessing the frequency of a healthcare professionals attending an obstetric emergency, our study contributes to assessing the need for supplementary educational initiatives and interventions to learn and maintain clinical skills.

Developing Core Competency-Based Learning Objectives for Postgraduate Curricula for Postanesthesia Nurses-A Delphi Study.

PURPOSE: Postanesthesia care unit (PACU) nurse competencies involve the ability to care for patients receiving complex treatment. Well-educated PACU nurses are required to provide safe patient care, and accordingly, they require investment in their education. However, core competencies for PACU nurses that are based on systematic methods for curriculum development and consensus have not been established. The purpose of this study was to develop a nationwide consensus on core competency-based learning objectives for a postgraduate PACU nursing curriculum. DESIGN: Nationwide Delphi Study using Kern's six steps of curriculum development as a framework. METHODS: Forty-one anesthesiologists and 38 PACU nurses from 37 Danish departments of anesthesiology were invited to participate. In Delphi round 1, the participants listed core competencies for PACU nurses within 12 predefined categories. We analyzed the responses using an inductive and manifest approach to content analysis and developed learning objectives in accordance with the Structure of Observed Learning Outcomes and Simpson taxonomies. In Delphi round 2 and 3, the participants rated and rerated the learning objectives on a 7-point Likert scale, measuring statements of agreement. Consensus was predefined as a median score of 6 and or greater. The main outcome was a prioritized list of competency-based learning objectives for a postgraduate PACU nurse curriculum. FINDINGS: Twenty-six nurses and 14 anesthesiologists (51%) completed all Delphi rounds, representing 22 (60%) departments of anesthesiology. Consensus was reached on 180 learning objectives. The learning objectives described competencies ranging from basic to complex nursing tasks and emphasized the knowledge and skills needed to identify and initiate treatment of postoperative complications. CONCLUSIONS: Nationwide consensus on core competencies for postgraduate curricula for PACU nurses was achieved through the Delphi method. Our study exemplifies the range of complex knowledge and skills needed to work as a PACU nurse. The learning objectives are applicable in postgraduate curricula designed for PACU nurses.

Establishment of consensus on content and learning objectives for an interprofessional education in childhood cancer: a Delphi survey.

BACKGROUND: Complex treatment, care and rehabilitation require continuous healthcare professional development and maintenance of competencies in collaboration with other professionals. Interprofessional education in childhood cancer involves several groups of healthcare professionals with both general and specific knowledge and skills. OBJECTIVE: To establish consensus on content and interprofessional learning objectives for an interprofessional education in childhood cancer. DESIGN: A three-round Delphi survey in Scandinavian childhood cancer departments. PARTICIPANTS: Healthcare professionals appointed by their head of departments and head nurses based on their profession and their involvement in continuing professional development. MAIN OUTCOME MEASURES: A prioritised list of interprofessional learning objectives with a mean score of ≥3 on a five-point scale (1=not relevant, 5=extremely relevant). RESULTS: 12 childhood cancer departments participated with 30 healthcare professionals: 11 nurses, 10 medical doctors, 5 social workers, 2 physiotherapists and 2 pedagogues. In total, 28 (93%), 25 (83%) and 22 (73%) completed the first, second and third round, respectively. In the first round, we asked open-ended questions and used directed content analysis to analyse 386 statements. We formulated 170 interprofessional learning objectives in six categories: (1) acute life-threatening situations, (2) gastrointestinal toxicities and side effects, (3) pain, (4) palliation, (5) play and activity, and (6) prescription and administration of medicine. The second round resulted in 168 interprofessional learning objectives receiving a mean score of ≥3 on a five-point scale. Final agreement in the third round resulted in a prioritised list of 168 learning objectives. CONCLUSIONS: Consensus on content and interprofessional learning objectives for an interprofessional education in childhood cancer was established across five groups of healthcare professionals in three countries. Some learning objectives are generic and can be applied in settings other than childhood cancer, where healthcare professionals collaborate to provide patients and families optimal treatment and care.

Incidences of obstetric outcomes and sample size calculations: A Danish national registry study based on all deliveries from 2008 to 2015.

INTRODUCTION: In high-income countries the majority of pregnancies have a good outcome, and many adverse obstetric outcomes rarely occur. This makes demonstrating clinically relevant and statistically significant effects of new interventions a challenge. The objective of the study was to report incidences of important obstetric outcomes and to calculate sample sizes for tentative studies. MATERIAL AND METHODS: The study was a registry-based study. Data were retrieved from the Danish Medical Birth Registry and included all deliveries in Denmark from 2008 to 2015. The total population included 465 919 deliveries. The study population comprised intended vaginal deliveries with a single fetus in cephalic presentation at term (n = 381 567). Incidences were reported for 20 outcomes considering the relevance for the patients and the severity of the outcomes. We calculated the sample sizes required in tentative obstetric studies to detect risk reductions of 25 and 50%, for tests at the 5% level, using a power of 80 and 90%. For the randomized controlled trials we calculated the sample size required for comparing two proportions with equal-sized groups. For the cohort study we calculated the sample size also required for two proportions but with unequal sized groups. Outcome measures for sample size calculation were neonatal mortality, Apgar score <7 at 5 minutes and emergency cesarean section. RESULTS: The incidence of neonatal mortality, Apgar score <7 at 5 minutes and emergency cesarean section was 0.05, 0.58 and 10.5%, respectively. Using neonatal mortality as the outcome in a tentative randomized controlled trial with an expected risk reduction of 50% and power of 80%, our calculation showed a sample size of 195 036 deliveries. Using Apgar score <7 at 5 minutes or emergency cesarean section as the outcome, 16 254 and 818 deliveries, respectively, were required. In tentative cohort studies, the required sample sizes were larger due to the unequal proportion of exposed/non-exposed women. CONCLUSIONS: Most adverse obstetric outcomes occur rarely; thus, very large sample sizes are required to achieve adequate statistical power in randomized controlled trials. Multicenter studies, international collaborations or alternative study designs to randomized controlled trials could be considered.

The impact of a national cardiotocography education program on neonatal and maternal outcomes: A historical cohort study.

INTRODUCTION: Studies indicate an association between errors in cardiotocography (CTG) management and hypoxic brain injuries among newborns. Continuing professional education is recommended. We aimed to examine whether the implementation of a national interprofessional CTG education program in Denmark was associated with a decrease in risk of fetal hypoxia measured by umbilical cord pH < 7.00, 5-minute Apgar score <7 or neonatal therapeutic hypothermia. As a secondary aim, we assessed whether the educational intervention was associated with an increase in operative deliveries. MATERIAL AND METHODS: We conducted a historical cohort study from 2009 to 2015 including all intended vaginal deliveries with liveborn singletons in cephalic presentation and gestational age ≥37 weeks. Data were retrieved from the Medical Birth Register and the National Patient Register. The study period was divided in three: pre-implementation (2009-2012), implementation (2013) and post-implementation (2014-2015). Using logistic regression we estimated odds ratios (OR) of fetal hypoxia outcomes using the pre-implementation period as reference. Analyses were adjusted for potential maternal, neonatal and delivery-associated confounders. Missing data were accounted for by multiple imputation. RESULTS: In all, 331 282 deliveries were included. Overall risks of pH < 7.00, Apgar score <7 and therapeutic hypothermia were respectively 0.45%, 0.58% and 0.06%. Adjusted OR in the post-implementation period were 1.12 (95% confidence interval [CI] 1.00-1.26), 0.99 (95% CI 0.90-1.10) and 1.34 (95% CI 0.99-1.82) for the three outcomes, respectively. The pH missingness equaled 12.4%. Odds of emergency cesarean section was unaltered, whereas the odds of assisted vaginal delivery decreased by 14% (0.86, 95% CI 0.84-0.89). CONCLUSIONS: Healthcare professionals are considered the weakest link of CTG technology. We did not find that increasing healthcare professionals' CTG interpretation skills affected the risk of fetal hypoxia. Missing data for pH values were substantial and represent a limitation of the study. We cannot with certainty rule out that missingness masked a true effect of the intervention. Our study indicates that assisted vaginal deliveries can be decreased without an increased risk of fetal hypoxia. Dilution of effect in a complex clinical setting, rare outcomes, insufficient intervention and a possible overestimation of the impact of errors in CTG management might explain the lack of effect.

Cardiotocography interpretation skills and the association with size of maternity unit, years of obstetric work experience and healthcare professional background: a national cross-sectional study.

INTRODUCTION: We aimed to examine whether cardiotocography (CTG) knowledge, interpretation skills and decision-making measured by a written assessment were associated with size of maternity unit, years of obstetric work experience and healthcare professional background. MATERIAL AND METHODS: A national cross-sectional study in the setting of a CTG teaching intervention involving all 24 maternity units in Denmark. Participants were midwives (n = 1260) and specialists (n = 269) and residents (n = 142) in obstetrics and gynecology who attended a 1-day CTG course and answered a 30-item multiple-choice question test. Associations between mean test score and work conditions were analyzed using multivariable robust regression, in which the three variables were mutually adjusted. RESULTS: Participants from units with > 3000 deliveries/year scored higher on the test than participants from units with < 1000 deliveries/year (3000-3999 deliveries/year: mean difference 0.8, p < 0.0001; > 4000 deliveries/year: mean difference 0.5, p = 0.006). Participants with < 15 years of work experience scored higher than participants with > 15 years of experience (15-20 years of experience: mean difference - 0.6, p = 0.007; > 20 years experience: mean difference - 0.9, p < 0.0001). No differences were detected concerning professional background. CONCLUSIONS: CTG knowledge, interpretation skills and decision-making measured by a written assessment were positively associated with working in large maternity units and having < 15 years of obstetric work experience. This might indicate a challenge in maintaining CTG skills in small units and among experienced staff but could also reflect different levels of motivation, test familiarity and learning culture. Whether the findings are transferable to the clinical setting was not examined.

Development of a written assessment for a national interprofessional cardiotocography education program.

BACKGROUND: To reduce the incidence of hypoxic brain injuries among newborns a national cardiotocography (CTG) education program was implemented in Denmark. A multiple-choice question test was integrated as part of the program. The aim of this article was to describe and discuss the test development process and to introduce a feasible method for written test development in general. METHODS: The test development was based on the unitary approach to validity. The process involved national consensus on learning objectives, standardized item writing, pilot testing, sensitivity analyses, standard setting and evaluation of psychometric properties using Item Response Theory models. Test responses and feedback from midwives, specialists and residents in obstetrics and gynecology, and medical and midwifery students were used in the process (proofreaders n = 6, pilot test participants n = 118, CTG course participants n = 1679). RESULTS: The final test included 30 items and the passing score was established at 25 correct answers. All items fitted a loglinear Rasch model and the test was able to discriminate levels of competence. Seven items revealed differential item functioning in relation to profession and geographical regions, which means the test is not suitable for measuring differences between midwives and physicians or differences across regions. In the setting of pilot testing Cronbach's alpha equaled 0.79, whereas Cronbach's alpha equaled 0.63 in the setting of the CTG education program. This indicates a need for more items and items with a higher degree of difficulty in the test, and illuminates the importance of context when discussing validity. CONCLUSIONS: Test development is a complex and time-consuming process. The unitary approach to validity was a useful and applicable tool for development of a CTG written assessment. The process and findings supported our proposed interpretation of the assessment as measuring CTG knowledge and interpretive skills. However, for the test to function as a high-stake assessment a higher reliability is required.

Curriculum development for a national cardiotocography education program: a Delphi survey to obtain consensus on learning objectives.

OBJECTIVE: To define learning objectives for a national cardiotocography (CTG) education program based on expert consensus. DESIGN: A three-round Delphi survey. POPULATION AND SETTING: One midwife and one obstetrician from each maternity unit in Denmark were appointed based on CTG teaching experience and clinical obstetric experience. METHODS: Following national and international guidelines, the research group determined six topics as important when using CTG: fetal physiology, equipment, indication, interpretation, clinical management, and communication/responsibility. In the first Delphi round, participants listed one to five learning objectives within the predefined topics. Responses were analyzed by a directed approach to content analysis. Phrasing was modified in accordance with Bloom's taxonomy. In the second and third Delphi rounds, participants rated each objective on a five-point relevance scale. Consensus was predefined as objectives with a mean rating value of ≥ 3. MAIN OUTCOME MEASURES: A prioritized list of CTG learning objectives. RESULTS: A total of 42 midwives and obstetricians from 21 maternity units were invited to participate, of whom 26 completed all three Delphi rounds, representing 18 maternity units. The final prioritized list included 40 objectives. The highest ranked objectives emphasized CTG interpretation and clinical management. The lowest ranked objectives emphasized fetal physiology. Mean ratings of relevance ranged from 3.15 to 5.00. CONCLUSIONS: National consensus on CTG learning objectives was achieved using the Delphi methodology. This was an initial step in developing a valid CTG education program. A prioritized list of objectives will clarify which topics to emphasize in a CTG education program.

[Serious complications to a weight loss programme with HCG]. / Alvorlig komplikation i forbindelse med slankekur med humant choriongonadotropin.

A 28-year-old woman presented with abdominal pain. Prior to admission she had injected human chorionic gonadotropin (hCG) intramuscularly as part of a weight loss programme. A computed tomography detected a thrombosis of the superior mesenteric vein and with a gynaecologic scan she was found to be six weeks pregnant despite using oral contraception. Treatment with anticoagulant therapy was started, and a surgical abortion was performed. hCG bought illegal is used as a part of a weight loss program. Whether HCG injected in small amounts is a risk factor of venous thrombosis and whether it is able to reduce the effect of oral contraception is unknown.