Comparison of pre and post Foley catheter Bishop's Score: A retrospective record review at Aga Khan University Hospital Karachi, Pakistan.

Objective: To compare pre and post Foley's catheter Bishop Score during labour induction. Methods: This study was a retrospective study conducted at the Aga Khan University Hospital Karachi, Pakistan after approval from ethical review board. All women who underwent induction of labour with Foley's Catheter at gestation of 37 weeks or more from September 2014-October 2015 were included. Data was entered and analyzed in Statistical Package for Social Sciences (SPSS) version 19.0. The comparison between pre and post Foley's catheter Bishop Score during labour induction will be calculated by Wilcoxon sign test. Results: There were 981 cases of inductions of labour, 749 (76.3%) received Foley's catheter, in combination with prostaglandins and oxytocin. About 68% were vaginal deliveries while 32% underwent C-section. Two third of women had bishop <4. Overall, Bishop score improved significantly in all patients with the catheter however, maximum benefit was seen in patients where the catheter was placed for 10-12 hours. Conclusion: Foley's is the better and safer option. In view of our results, It has been recommended to keep the Foley's for 10-12 hours to get significant improvement in bishop score.

From tradition to Simulation: An experience of team training on management of shoulder dystocia.

OBJECTIVE: To determine if simulation-based team training improves the management of shoulder dystocia compared to traditionally taught obstetrical emergencies. METHODS: The prospective mixed-method study was conducted at the Centre for Innovation in Medical Education at the Aga Khan University, Karachi, from June to August 2018, and comprised doctors and nurses having up to five years of labour and delivery experience. The subjects were divided into two equal groups which were further subdivided into four equal teams. Group 1 was taught to manage shoulder dystocia using traditional lectures and hands-on pelvic models, while group 2 was trained in a simulated environment with a simulated scenario of shoulder dystocia. After two weeks, the performance of both teams were assessed and compared. Data was analysed using SPSS 19. A focus group discussion was subsequently conducted on the quality of the simulation experience. RESULTS: Of the 32 subjects, 16(50%) each were doctors and nurses. They were divided into groups having 16(50%) members each, and each group had 4 teams having 4(25%) subjects. The overall mean age of the sample was 31.9±2.8 years (range: 28-38 years). The mean score for performance on technical and communication task of group 2 was 10.25±1.258 compared to 5.7±2.500 in group 1 (p=0.028). Focus group participants agreed that training in a simulated environment was far superior than being traditionally taught. CONCLUSIONS: Simulation-based team training in shoulder dystocia management was associated with better feedback than traditional-style teaching.

Pregnancy outcomes amongst adolescents/young adults at tertiary-care hospital in a low-middle-income country: Ten-year retrospective record review.

OBJECTIVE: Adolescent pregnancies are known to be associated with adverse outcomes. Our objective was to compare pregnancy outcomes amongst adolescents (young adolescents YA: 15-17 years; older adolescents OA: 18- 19 years) and young adults (20 to 25 years). METHODS: Study was conducted at the Aga Khan University Hospital, Karachi. Ten-year retrospective record review was done through convenience sampling. Data was collected on predesigned proforma. Participants were 396 primiparous adolescents (15-19 years) with singleton low-risk pregnancy. Reference-group included 410 primiparous, low-risk, young adults. Pregnancies complicated with preexisting diabetes mellitus, chronic hypertension, renal disorders or cardiac diseases were excluded. Maternal /neonatal outcomes were compared amongst groups. RESULTS: Out of 806 charts reviewed, 75 (9.3%) were YA, 321 (39.8%) were OA and 410 (50.9%) were 20-25 years old young adults. Most of the un-booked cases were in young adolescents; 17 (22.7% YA), 41 (12.8% OA) and 33 (8.0% reference -group) (p-value 0.001). This group also booked at a later gestational age; YA (19.6±10.4 weeks), OA (17.2±9.3 weeks) and controls (15.5n±8.8 weeks) (p-value 0.002). Gestational age at delivery was not significantly different among the groups. Adolescents had a decreased likelihood of Caesarian section with youngest group having 29% less chance of Caesarian delivery (OR 95% CI 0.41, 0.2) compared to women of 20-25 years of age. Difference in maternal/neonatal outcomes remained insignificant between groups at univariate and multivariate analysis. CONCLUSIONS: Maternal/neonatal outcomes in adolescents were comparable to young adults. Good antenatal care, evidence-based protocols and strong family backing may reduce risks to mothers/babies in adolescent pregnancies.

Hybrid simulation training: An effective teaching and learning modality for intrauterine contraceptive device insertion.

Background: Hybrid simulation training (HST) is a teaching modality that combines patient interaction using simulated patient (SP) with pelvic model. This provides realism to learners, lacking in manikins alone. This study was designed to compare knowledge, procedural, and communication skills of medical students regarding intrauterine contraceptive device (IUCD) insertion before and after introducing HST and to assess learner satisfaction with this methodology. Methods: This quasi-experimental mixed-method study was conducted at Aga Khan University Hospital, Karachi, from October 2016 to September 2017, for third-year medical students (n = 90). IUCD insertion was introduced to students through interactive session and provision of literature/video clip on IUCD insertion. Students were pretested on objectively structured clinical examination -station (IUCD insertion) using SP and manikin simultaneously. This was followed by practice on manikin and subsequent posttest on same OSCE-station. Learner evaluation of activity was through validated pro forma with both, Likert scale and open-ended questions. Results: Out of the 90 students, 73 completed pre/posttest and evaluation survey. There was significant increase in pre- and post-simulation mean scores for all clinical skills; history taking (5.1 pretest, 8.8 posttest, P ≤ 0.0005), counseling (40.11 pretest, 57.85 posttest, P ≤ 0.0005), procedural (15.16 pretest, 49.09 posttest, P ≤ 0.0005) and total scores (60 pretest, 115.6 posttest, P ≤ 0.0005), when compared using two-sided Wilcoxon signed rank sum test. Overall, activity was assessed as "very good" to "excellent" by 83.5% participants. Themes generated from open-ended questions of evaluation forms were "Process-descriptors," "Teaching-utility," "Pedagogic-efficacy" and "Way-forward." Discussion: HST is an effective teaching strategy with potential to improve competency of medical students. Students acknowledged it, as innovative learning strategy that increased their satisfaction and confidence in performing IUCD insertion.

Comparison of neonatal outcomes between category-1 and non-category-1 Primary Emergency Cesarean Section: A retrospective record review in a tertiary care hospital.

OBJECTIVE: To compare neonatal outcomes between Category-1 and Non-Category-1 Primary Emergency Cesarean Section. METHODS: This was a retrospective analysis, conducted at Aga Khan University Hospital Karachi from January 1st 2016 till December 31st 2016. Non-probability purposive sampling technique was used. A sample size of 375 patients who had primary Emergency Caesarean Section (Em-CS) was identified by keeping CS rate of 41.5% and 5% bond on error. Data was collected from labor ward, operating theatre and neonatal ward records by using structured questionnaire. RESULTS: In the current study, out of 375 participants who underwent primary Em-CS; majority (89.3%) were booked cases. Two-hundred-eighty-two (75.2%) were primiparous women. Two hundred and thirty (61.3%) were at term and 145(38.7%) were preterm. The main indication among Category-1 CS was fetal distress (15.7%). For Non-Category-1 CS, non-progress of labour (45.1%) was the leading cause of abdominal delivery. Except for APGAR score at one minute (p value = 0.048), no other variables were statistically significant when neonatal outcomes were compared among Category-1 and Non-Category-1 CS. CONCLUSION: In this study, fetal distress and non-progress of labor were the main indications for Category-1 and Non-Category-1 CS respectively. We did not find statistically significant association between indications of Em CS and neonatal outcomes. However further prospective studies are required to confirm this association.

Caesarean Section rate amongst Obstetricians at a tertiary-care hospital of Karachi.

OBJECTIVE: To analyze the Caesarean Section (CS) rate among different groups of consultants dealing with Nulliparous Term Singleton pregnancy with Vertex (NTSV) presentation delivering at a tertiary care hospital of Karachi over four months. METHODS: This is a secondary analysis of a retrospective data that analyzed factors affecting the CS-rate of NTSV patients. Patients with CS (n=106) were taken as cases and vaginal deliveries (n=106) as controls. This was an unmatched retrospective case-control study. RESULTS: Mean age of patients was 26.6(SD: 4.2) years. Mean gestational-age was 38.6(SD: 1.0) weeks. Likelihood of CS was slightly less in patients who were attended by feto-maternal consultants(OR:0.81 CI:0.38-1.07) and was slightly more in patients managed by non-full-time faculty (OR:1.04 CI:0.59-1.85). Odds of CS was highest amongst consultants having average monthly volumes of 21-30 patients/month (OR:1.069 CI:0.48-2.34). However none of the above findings were statistically significant. A non-significant increase in risk of CS was observed with increase in experience of physicians (p=0.787). CONCLUSION: The results did not show statistically significant difference in CS rate among different groups of Obstetricians. This might indicate that managing labour according to standard guidelines can eliminate physicians' bias. This can be further evaluated with larger multicenter prospective studies.