Developing the TeamOBS-vacuum-assisted delivery checklist to assess clinical performance in a vacuum-assisted delivery: a Delphi study with initial validation.

Introduction: In Northern Europe, vacuum-assisted delivery (VAD) accounts for 6-15% of all deliveries; VAD is considered safe when conducted by adequately trained personnel. However, failed vacuum extraction can be harmful to both the mother and child. Therefore, the clinical performance in VAD must be assessed to guide learning, determine a performance benchmark, and evaluate the quality to achieve an overall high performance. We were unable to identify a pre-existing tool for evaluating the clinical performance in real-life vacuum-assisted births. Objective: We aimed to develop and validate a checklist for assessing the clinical performance in VAD. Methods: We conducted a Delphi process, described as an interactive process where experts answer questions until answers converge toward a "joint opinion" (consensus). We invited international experts as Delphi panelists and reached a consensus after four Delphi rounds, described as follows: (1) the panelists were asked to add, remove, or suggest corrections to the preliminary list of items essential for evaluating clinical performance in VAD; (2) the panelists applied weights of clinical importance on a Likert scale of 1-5 for each item; (3) each panelist revised their original scores after reviewing a summary of the other panelists' scores and arguments; and (4) the TeamOBS-VAD was tested using videos of real-life VADs, and the Delphi panel made final adjustments and approved the checklist. Results: Twelve Delphi panelists from the UK (n = 3), Norway (n = 2), Sweden (n = 3), Denmark (n = 3), and Iceland (n = 1) were included. After four Delphi rounds, the Delphi panel reached a consensus on the checklist items and scores. The TeamOBS-VAD checklist was tested using 60 videos of real-life vacuum extractions. The inter-rater agreement had an intraclass correlation coefficient (ICC) of 0.73; 95% confidence interval (95% CI) of [0.58, 0.83], and that for the average of two raters was ICC 0.84 95% CI [0.73, 0.91]. The TeamOBS-VAD score was not associated with difficulties in delivery, such as the number of contractions during vacuum extraction delivery, cephalic level, rotation, and position. Failed vacuum extraction occurred in 6% of the video deliveries, but none were associated with the teams with low clinical performance scores. Conclusion: The TeamOBS-VAD checklist provides a valid and reliable evaluation of the clinical performance of vaginal-assisted vacuum extraction.

Healthcare providers' perceptions and expectations of video-assisted debriefing of real-life obstetrical emergencies: a qualitative study from Denmark.

OBJECTIVES: Video-assisted debriefing (VAD) of real-life obstetrical emergencies provides an opportunity to improve quality of care, but is rarely used in clinical practice. A barrier for implementation is the expected mental reservations among healthcare providers. The aim of this study was to explore healthcare providers' perceptions and expectations of VAD of real-life events. SETTING: Participants were recruited from two Labour and Delivery Units in Denmark. In both units, VAD of real-life obstetrical emergencies had never been conducted. PARTICIPANTS: 22 healthcare providers (10 physicians, 9 midwives and 3 nursing assistants). During the study period (August-October 2021), semi-structured, individual interviews were conducted. Interviews were analysed using thematic analysis. PRIMARY AND SECONDARY OUTCOME MEASURES: A qualitative description of healthcare providers' perceptions and expectations of VAD of real-life events. RESULTS: Three major themes were identified: (1) Video-assisted debriefing (VAD) as an opportunity for learning: All participants expected VAD to provide an opportunity for learning and improving patient care. All participants expected the video to provide a 'bigger picture', by showing 'what was actually done' instead of 'what we believed was done'. (2) Video-assisted debriefing (VAD) as a cause for concern: The primary concern for all participants was the risk of being exposed as less competent. Participants were concerned that being confronted with every minor detail of their clinical practice would enhance their self-criticalness. (3) Preconditions for video-assisted debriefing (VAD): Participants emphasised the importance of organisational support from management. In addition, creating a safe environment for VAD, for example, by using only expert debriefers was considered an essential precondition for successful implementation. CONCLUSIONS: The risk of being exposed as less competent was a barrier towards VAD of real-life events. However, the majority found the educational benefits to outweigh the risk of being exposed.

Women and partners' experience of major postpartum haemorrhage: a qualitative study.

OBJECTIVE: To examine women and their partners' experience of major postpartum haemorrhage (PPH). DESIGN: A qualitative interview study. SETTING: Two Labour and Delivery Units in Denmark. POPULATION: Women who experienced major PPH (≥1 litre within 2 hours after vaginal birth). METHODS: Semi-structured interviews were conducted with 15 women and nine partners (nine joint interviews, six individual interviews). Interviews were analysed using thematic analysis. MAIN OUTCOME MEASURES: A qualitative description of women and their partners' experiences. RESULTS: Three major themes were identified. (1) 'From birth to emergency' included factors that increased concern in women and their partners, such as 'incomprehensible' medical terminology, a tense atmosphere, and alarm call. Transfer to the operating theatre was experienced as the most devastating part of major PPH. (2) 'Feeling safe during an emergency' described factors that supported the women and their partners' management of the situation such as brief explanations from a few healthcare professionals and reassurance that the healthcare professionals were in control of the situation. The pain was experienced as severe, but acceptable. (3) 'Family unity challenged' described how family bonding was supported by positioning the partner at the head of the bed and by keeping the baby on the woman's chest. CONCLUSIONS: Several factors such as small gestures from healthcare professionals and appropriate organisation of the PPH can make a difference to the woman and her partner's experience of major PPH. Particularly, efforts that support family bonding are greatly valued by women and their partners.

Teamwork and Adherence to Guideline on Newborn Resuscitation-Video Review of Neonatal Interdisciplinary Teams.

Background: Little is known about the importance of non-technical skills for the adherence to guidelines, when teams of midwives, obstetricians, anesthesiologists, and pediatricians resuscitate and support the transition of newborns. Non-technical skills are competences underpinning successful teamwork in healthcare. These are usually referred to as leadership, situational awareness, communication, teamwork, decision making, and coping with stress and fatigue. Objective: By review of videos of teams managing newborns with difficult transition, we aimed to investigate whether the level of the teams' non-technical skills was associated with the degree of adherence to guidelines for newborn resuscitation and transitional support at birth. Methods: Four expert raters independently assessed 43 real-life videos of teams managing newborns with transitional difficulties, two assessed the non-technical score and two assessed the clinical performance. Exposure was the non-technical score, obtained by the Global Assessment Of Team Performance checklist (GAOTP). GAOTP was rated on a Likert Scale 1-5 (1 = poor, 3 = average and 5 = excellent). The outcome was the clinical performance score of the team assessed according to adherence of the European Resuscitation Counsel (ERC) guideline for neonatal resuscitation and transitional support. The ERC guideline was adapted into the checklist TeamOBS-Newborn to facilitate a structured and simple performance assessment (low score 0-60, average 60-84, high 85-100). Interrater agreement was analyzed by intraclass correlation (ICC), Bland-Altman analysis, and Cohen's kappa weighted. The risk of high and low clinical performance was analyzed on the logit scale to meet the assumptions of normality and constant standard deviation. Results: Teams with an excellent non-technical score had a relative risk 5.5 [95% confidence interval (CI) 2.4-22.5] of high clinical performance score compared to teams with average non-technical score. In addition, we found a dose response like association. The specific non-technical skills associated with the highest degree of adherence to guidelines were leadership and teamwork, coping with stress and fatigue, and communication with parents. Inter-rater agreement was high; raters assessing non-technical skills had an interclass coefficient (ICC) 0.88 (95% CI 0.79-0.94); the neonatologists assessing clinical performance had an ICC of 0.81 (95% CI 0.66-0.89). Conclusion: Teams with an excellent non-technical score had five times the chance of high clinical performance compared to teams with average non-technical skills. High performance teams were characterized by good leadership and teamwork, coping with stress, and fatigue and communication with parents.

Cardiopulmonary Resuscitation Training for Healthcare Professionals: A Scoping Review.

SUMMARY STATEMENT: The optimal strategy for training cardiopulmonary resuscitation (CPR) for healthcare professionals remains to be determined. This scoping review aimed to describe the emerging evidence for CPR training for healthcare professionals.We screened 7605 abstracts and included 110 studies in this scoping review on CPR training for healthcare professionals. We assessed the included articles for evidence for the following topics: training duration, retraining intervals, e-learning, virtual reality/augmented reality/gamified learning, instructor-learner ratio, equipment and manikins, other aspects of contextual learning content, feedback devices, and feedback/debriefing. We found emerging evidence supporting the use of low-dose, high-frequency training with e-learning to achieve knowledge, feedback devices to perform high-quality chest compressions, and in situ team simulations with debriefings to improve the performance of provider teams.

The effects of obstetric emergency team training on patient outcome: A systematic review and meta-analysis.

INTRODUCTION: Little is known about the optimal simulation-based team training in obstetric emergencies. We aimed to review how simulation-based team training affects patient outcomes in obstetric emergencies. MATERIAL AND METHODS: Search Strategy: MEDLINE, Embase, Cochrane Library, and Cochrane Central Register of Controlled Trials were searched up to and including May 15, 2021. SELECTION CRITERIA: randomized controlled trials (RCTs) and cohort studies on obstetric teams in high-resource settings comparing the effect of simulation-based obstetric emergency team training with no training on the risk of Apgar scores less than 7 at 5 min, neonatal hypoxic ischemic encephalopathy, severe postpartum hemorrhage, blood transfusion of four or more units, and delay of emergency cesarean section by more than 30 min. DATA COLLECTION AND ANALYSIS: The included studies were assessed using PRISMA, EPCO, and GRADE. RESULTS: We found 21 studies, four RCTs and 17 cohort studies, evaluating patient outcomes after obstetric team training compared with no training. Annual obstetric emergency team training may reduce brachial plexus injury (six cohort studies: odds ratio [OR] 0.47, 95% CI 0.33-0.68; one RCT: OR 1.30, 95 CI% 0.39-4.33, low certainty evidence) and suggest a positive effect; but it was not significant on Apgar score below 7 at 5 min (three cohort studies: OR 0.77, 95% CI 0.51-1.19; two RCT: OR 0.87, 95% CI 0.72-1.05, moderate certainty evidence). The effect was unclear for hypoxic ischemic encephalopathy, umbilical prolapse, decision to birth interval in emergency cesarean section, and for severe postpartum hemorrhage. Studies with in situ multi-professional simulation-based training demonstrated the best effect. CONCLUSIONS: Emerging evidence suggests an effect of obstetric team training on obstetric outcomes, but conflicting results call for controlled trials targeted to identify the optimal methodology for effective team training.

Women's body mass index and oral administration of Misoprostol for induction of labor - A retrospective cohort study.

Pregnant women who are obese are at greater risk of pregnancy complications, including preeclampsia, gestational diabetes, and macrosomia, leading to an increased likelihood of induced labor. Little is known about pregnant women with obesity and the dose of Misoprostol needed for induction of labor (IOL). To investigate whether the cumulative dose of Misoprostol needed for induction of labor (IOL) is associated with women's body mass index (BMI), we conducted a retrospective study of the use of oral Misoprostol for IOL at the Department of Obstetrics and Gynecology, Aarhus University Hospital - a tertiary referral delivery unit with 4800 deliveries a year. Data on IOL among 1637 women with singleton pregnancies was collected in the period January 1st, 2014, to October 4th, 2017. Low-risk women were induced in an outpatient setting. Primary outcomes were Misoprostol dose, time between start of induction (first dose of Angusta®) and completed delivery, and mode of delivery. Secondary outcomes were neonatal data as Apgar score and pH of the umbilical artery. In this study, we found the total dose of Misoprostol needed for induction increased significantly with increasing BMI (p < 0.005). The time to delivery and the risk of Cesarean section increased with rising BMI class. However, 76% of inductions among the women with obesity ended in a vaginal delivery. For the neonatal outcomes, a total of 16 children had an Apgar score below 7 at five minutes and 14 had a pH less than 7.0; none of these results differed significantly between BMI classes. The perinatal and maternal mortality rate was 0%.

Can ultrasound 10 days after obstetric anal sphincter injury predict anal incontinence at long-term follow-up?

INTRODUCTION AND HYPOTHESIS: The objective was to investigate whether endoanal ultrasound (EAUS) performed 10 days after a primary repaired obstetric anal sphincter injury (OASIS) can predict the severity of anal incontinence (AI) in the long term. METHODS: This prospective cohort study included women with a primary repaired 3b-degree tear, 3c-degree tear or fourth-degree tear at Aarhus University Hospital, Denmark, from 1 September 2010 to 31 May 2011. Clinical assessment and EAUS were performed on day 2, day 10, and day 20 after delivery. Functional outcomes were assessed using a questionnaire at the time of all clinical visits and at the long-term follow-up, 7 years after delivery. AI was graded according to the Wexner score and EAUS defects were graded according to the Starck score. RESULTS: Ninety-six out of 99 women consented to participate. Five women had a secondary sphincter repair and were subsequently excluded from follow-up. Fifty-seven women underwent both EAUS 10 days after delivery and answered the long-term follow-up questionnaire. Median follow-up time was 7.7 years (IQR 7.4-7.8). Mean Wexner score was 4.4 ± 4.8 10 days after delivery and 2.5 ± 2.8 at follow-up; thus, the Wexner score improved over time (p = 0.01). Ultrasound sphincter defects were found in 82.6% of the women. Mean Starck score was 3.0 ± 1.8. The risk of AI was 0% (95% CI 0.0-30.8) if the Starck score was 0. No correlation was found between the Starck score and the Wexner score at follow-up. CONCLUSIONS: We found that performing EAUS in the puerperium following OASIS has limited value in predicting long-term AI.

[Christmas article: Please put your pants on - an RCT].

INTRODUCTION: It is common practice after a pelvic exam to ask a woman to put her pants on, before she is given verbal information. We aimed to compare short-term memory in undressed versus dressed women. METHODS: Thirty-six female Ob/Gyn doctors were randomised to receive verbal information while undressed and still in a lithotomy position, or once dressed again. The primary outcome was the proportion of items recalled from a 20-item list. RESULTS: We found no significant difference in recall; 58% in dressed women versus 62% in undressed women (p = 0.26). CONCLUSION: The memory of women is not affected by, whether or not they are dressed. FUNDING: none. TRIAL REGISTRATION: none.

Noise as a risk factor in the delivery room: A clinical study.

INTRODUCTION: We aimed to investigate whether noise in delivery rooms is associated with impaired performance of obstetric teams managing major (≥1000 mL) postpartum hemorrhage. MATERIAL AND METHODS: We included video recordings of 96 obstetric teams managing real-life major postpartum hemorrhage. Exposure was noise defined as the occurrence of sound level pressures (SPL) above 90 dB. The outcome was high clinical performance assessed through expert ratings using the TeamOBS-PPH tool. RESULTS: The 23 teams unexposed to noise had a significantly higher chance of high clinical performance than the 73 teams exposed to noise: 91.3% (95% CI; 72.0-98.9) versus 58.9% (95% CI; 46.8-70.3) (p < 0.001). The results remained significant when adjusting for the following possible confounders: team size, non-technical performance, bleeding velocity, hospital type, etiology of bleeding, event duration and time of day. Typical sources of noise above 90 dB SPL were mother or baby crying, dropping of instruments, and slamming of cupboard doors. CONCLUSION: Noise in delivery rooms may be an independent source of impaired clinical performance.

Development of the TeamOBS-PPH - targeting clinical performance in postpartum hemorrhage.

INTRODUCTION: This study aimed to develop a valid and reliable TeamOBS-PPH tool for assessing clinical performance in the management of postpartum hemorrhage (PPH). The tool was evaluated using video-recordings of teams managing PPH in both real-life and simulated settings. MATERIAL AND METHODS: A Delphi panel consisting of 12 obstetricians from the UK, Norway, Sweden, Iceland, and Denmark achieved consensus on (i) the elements to include in the assessment tool, (ii) the weighting of each element, and (iii) the final tool. The validity and reliability were evaluated according to Cook and Beckman. (Level 1) Four raters scored four video-recordings of in situ simulations of PPH. (Level 2) Two raters scored 85 video-recordings of real-life teams managing patients with PPH ≥1000 mL in two Danish hospitals. (Level 3) Two raters scored 15 video-recordings of in situ simulations of PPH from a US hospital. RESULTS: The tool was designed with scores from 0 to 100. (Level 1) Teams of novices had a median score of 54 (95% CI 48-60), whereas experienced teams had a median score of 75 (95% CI 71-79; p < 0.001). (Level 2) The intra-rater [intra-class correlation (ICC) = 0.96] and inter-rater (ICC = 0.83) agreements for real-life PPH were strong. The tool was applicable in all cases: atony, retained placenta, and lacerations. (Level 3) The tool was easily adapted to in situ simulation settings in the USA (ICC = 0.86). CONCLUSION: The TeamOBS-PPH tool appears to be valid and reliable for assessing clinical performance in real-life and simulated settings. The tool will be shared as the free TeamOBS App.