Perineal resuturing versus expectant management following vaginal delivery complicated by a dehisced wound (PREVIEW): a pilot and feasibility randomised controlled trial.

OBJECTIVE: To establish the feasibility of conducting a definitive randomised controlled trial (RCT) comparing the effectiveness of resuturing versus expectant management for dehisced perineal wounds. DESIGN: A multicentre pilot and feasibility RCT. SETTING: Ten UK maternity units from July 2011 to July 2013. POPULATION: Eligible women with a dehisced perineal wound within 2 weeks of childbirth. METHODS: The interventions were resuturing or expectancy. Randomisation was via web or telephone, stratified by participating centre. Blinding was not possible due to the nature of the interventions. Analysis was by intention-to-treat. OUTCOME: The primary outcome measure was wound healing at 6-8 weeks. RESULTS: The study revealed a number of feasibility issues, particularly strong patient and clinician preference for treatment options at recruiting centres and the timing of the primary outcome measure. Thirty-four women were randomised (17 in each arm). Data from 33 women were analysed on an intention-to-treat analysis to obtain preliminary estimates of effect size. There was a difference in wound healing at 2 weeks favouring resuturing (OR 20.00, 95% CI 2.04 to 196.37, p=0.004). However, by 6-8 weeks all but one wound in both groups had healed. CONCLUSIONS: PREVIEW revealed a number of feasibility issues, which impacted on recruitment rate. These will have to be taken into account in the design of any future definitive study. In this feasibility study, resuturing was associated with quicker wound healing and women reported higher satisfaction rates with the outcome at 3 months. TRIAL REGISTRATION NUMBER: ISRCTN05754020.

Evaluation of accuracy of mediolateral episiotomy incisions using a training model.

BACKGROUND: Episiotomy is one of the most commonly performed surgical procedures worldwide. In the UK the use of episiotomy is selective, rather than routine, and a right mediolateral episiotomy (RMLE) is considered standard practice. According to The National Institute of Health and Care Excellence (NICE, 2007) guideline for intrapartum care such an episiotomy should be cut at an angle between 45° and 60° to the vertical axis. Recent evidence suggests that the angle of incision of mediolateral episiotomy (MLE) is associated with risk of obstetric anal sphincter injury (OASIS). OBJECTIVE: to assess the accuracy of individual practitioner's techniques when performing a RMLE. DESIGN: an audit of practice against nationally set standards. SETTING: at a national midwifery conference and prior to three multiprofessional perineal repair training workshops in the West Midlands region of the UK. PARTICIPANTS: 144 midwives and 53 obstetric trainees. MEASUREMENTS: practitioners were asked to perform a RMLE incision on a bespoke training model, which is designed to give a realistic representation of a stretched perineum at crowning of the baby's head. Four parameters were measured: (1) distance of the starting point from the midline; (2) angle subtended to the perpendicular; (3) length and (4) shape of the incision (curved, straight or J-shaped). FINDINGS: of the 197 incisions performed only 12.7% (14.6%, n=21/144 of midwives and 7.5%, n=4/53 of obstetricians) complied with the defined technique of a RMLE for correctness of angle and placement. A 2-sided Fisher's exact test showed no significant difference between previous attendance at perineal management training and incision accuracy.

Developing Objective Metrics for Unit Staffing (DOMUS) study.

OBJECTIVE: Safe midwifery staffing levels on delivery suites is a priority area for any maternity service. Escalation policies are tools that provide an operational response to emergency pressures. The aim of this study was to assess the feasibility of using a scoring system to contemporaneously assess the required staffing level based on demand and use this to determine delivery suite escalation level and utilise the information generated regarding clinical activity (Demand) and staffing levels (Capacity) to generate unit-specific calculation for the actual number of midwifery staff required. SETTING: A maternity unit of a university-affiliated tertiary referral hospital. DESIGN: Over a 12-month period, specifically designed scoring sheets were completed by delivery suite shift co-ordinators four times a day (04:00, 10:00, 16:00 and 22:00). Based on the dependency score (Demand) and the number of midwifery staff available (Capacity), an escalation level was determined for each shift. The 80th centile of the demand was used to determine optimal capacity. RESULTS: A total of 1160 scoring sheets were completed. Average staff number throughout the year on any shift was 7 (range 3-11). Average dependency score was 7 (range 1-14). The 80th centile for demand was calculated to be 11. CONCLUSIONS: This study stresses the importance and usefulness of a simple tool that can be used to determine the level of escalation on delivery suite based on an objective scoring system and can also be used to determine the appropriate staffing on delivery suite.

Cervical cerclage and type of suture material: a survey of UK consultants' practice.

OBJECTIVE: The main aim of the survey was to explore current practices with regards to cervical cerclage procedures amongst UK consultants with particular emphasis on the type of suture material used. METHODS: An electronic survey of UK consultant members and fellows of the Royal College of Obstetricians and Gynaecologists and who previously agreed to be contacted for survey purposes. RESULTS: There were 261 respondents to the survey and 88% routinely performed cerclage. The majority performed the procedure between 12 and 16 weeks' gestation (88.7%; n = 180/203), following the McDonald technique (83.4%; n = 166/199) and using a braided suture material (86.6%; n = 175/202). Although only 27 of the 202 responders (13.4%) used a monofilament suture for cerclage (75%; n = 149/201) of clinicians stated that they were not sure what is the best suture material to be used. CONCLUSION: There is considerable variation in practice amongst Consultant obstetricians with regards to cervical cerclage. Although most respondents use the traditional braided suture material, a significant proportion of them were not sure what is the best suture material to use. The "gestation at delivery" rate was judged to be the most important outcome for a future study.

Pregnancy outcome after elective cervical cerclage in relation to type of suture material used.

Cervical weakness is an important cause of late miscarriage and extreme preterm labour. Women have been traditionally offered a cervical cerclage procedure, though studies failed to demonstrate a therapeutic effect. None of these studies has addressed the effect of non-braided to braided suture material on cerclage outcome. Type of suture material is an important determinant of surgical outcomes. This issue is of particular relevance to cerclage because the traditionally braided suture has been associated with increased risk of infection in other surgical procedures. Indeed, infection is an important underlying cause for cerclage failure. It is for this reason that some surgeons use non-braided suture material. Therefore, we hypothesise that the unrealised benefit of cervical cerclage is at least in part due to the type of suture material used. In this article, we present the rationale behind our hypothesis and a proposed way of testing it.

Prioritisation of teaching topics in obstetrics and gynaecology: a Delphi survey of postgraduate trainees.

Topics for theoretical teaching during the obstetrics and gynaecology specialty training programme are often chosen by tutors, with little input from the trainees. However, it is important to actively involve adults in their learning process to maintain their learning ownership and motivation. The Delphi methodology is a generic social science technique used to aggregate views and opinions of experts, the community and service users. In this study, we conducted a two generational Delphi study to achieve consensus between a group of trainees in obstetrics and gynaecology, regarding what they considered important topics for inclusion in their protected teaching programme. A total of 25 trainees from one deanery, participated in this study. We were able to produce a list of 26 topics in obstetrics and 30 in gynaecology, prioritised according to their importance for inclusion in the specialty protected teaching programme, as viewed by these trainees.

Epigenetic control of fetal gene expression.

Each differentiated cell type has its own epigenetic signature, which reflects its genotype, developmental history, and environmental influences, and is ultimately reflected in the phenotype of the cell and organism. Some cells undergo major epigenetic 'reprogramming' during fetal development. The proper, or improper, handling of these highly sensitive periods may have significant short-term and long-term effects on the newborn and his/her progeny. This review highlights the impact of environmental and nutritional factors on the epigenome and the potential effect of epigenetic dysregulation on maternal and fetal pregnancy outcomes, as well as possible long-term implications.

Continuous versus interrupted sutures for repair of episiotomy or second degree tears.

BACKGROUND: Millions of women worldwide undergo perineal suturing after childbirth and the type of repair may have an impact on pain and healing. For more than 70 years, researchers have been suggesting that continuous non-locking suture techniques for repair of the vagina, perineal muscles and skin are associated with less perineal pain than traditional interrupted methods. OBJECTIVES: To assess the effects of continuous versus interrupted absorbable sutures for repair of episiotomy and second degree perineal tears following childbirth. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (June 2007). SELECTION CRITERIA: Randomised trials comparing continuous versus interrupted sutures for repair of episiotomy and second-degree tears after vaginal delivery. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed trial quality. Two of the three authors independently extracted data and a third author checked them. We contacted study authors for additional information. MAIN RESULTS: Seven studies, involving 3822 women at point of entry, from four countries, have been included. The trials were heterogeneous in respect of operator skill and training. Meta-analysis showed that continuous suture techniques compared with interrupted sutures for perineal closure (all layers or perineal skin only) are associated with less pain for up to 10 days postpartum (relative risk (RR) 0.70, 95% confidence interval 0.64 to 0.76). Subgroup analysis showed that there is a greater reduction in pain when continuous suturing techniques are used for all layers (RR 0.65, 95% CI 0.60 to 0.71). There was an overall reduction in analgesia use associated with the continuous subcutaneous technique versus interrupted stitches for repair of perineal skin (RR 0.70, 95% CI 0.58 to 0.84). Subgroup analysis showed some evidence of reduction in dyspareunia experienced by participants in the groups that had continuous suturing for all layers (RR 0.83, 95% CI 0.70 to 0.98). There was also a reduction in suture removal in the continuous suturing groups versus interrupted (RR 0.54, 95% CI 0.45 to 0.65), but no significant differences were seen in the need for re-suturing of wounds or long-term pain. AUTHORS' CONCLUSIONS: The continuous suturing techniques for perineal closure, compared to interrupted methods, are associated with less short-term pain. Moreover, if the continuous technique is used for all layers (vagina, perineal muscles and skin) compared to perineal skin only, the reduction in pain is even greater.

Accuracy of serum uric acid in predicting complications of pre-eclampsia: a systematic review.

BACKGROUND: Pre-eclampsia is one of the largest causes of maternal and fetal mortality and morbidity. Hyperuricemia is often associated with pre-eclampsia. OBJECTIVE: To determine the accuracy with which serum uric acid predicts maternal and fetal complications in women with pre-eclampsia. STUDY DESIGN: Systematic quantitative review of test accuracy studies. SEARCH STRATEGY: We conducted electronic searches in MEDLINE (1951-2004), EMBASE (1980-2004), the Cochrane Library (2004:4) and the MEDION database to identify relevant articles. A hand-search of selected specialist journals and reference lists of articles obtained was then carried out. There were no language restrictions for any of these searches. SELECTION CRITERIA: Two reviewers independently selected the articles in which the accuracy of serum uric acid was evaluated to predict maternal and fetal complications of pre-eclampsia. DATA COLLECTION AND ANALYSIS: Data were extracted on study characteristics, quality and accuracy to construct 2 x 2 tables with maternal and fetal complications as reference standard. Summary likelihood ratios for positive (LR+) and negative LR(-) test results are generated for various threshold levels of uric acid. MAIN RESULTS: There were 18 primary articles that met the selection criteria, including a total of 3913 women and forty-one 2 x 2 tables. In women with pre-eclampsia, a positive test result of uric acid greater than or equal to a 350-micromol/l threshold predicted eclampsia with a pooled likelihood ratio (LR) of 2.1 (95% CI 1.4-3.5), while a negative test result had a pooled LR of 0.38 (95% CI 0.18-0.81). For severe hypertension as the outcome measure, the LRs were 1.7 (95% CI 1.3-2.2) and 0.49 (95% CI 0.38-0.64) for positive and negative test results, respectively, and for caesarean section the LRs were 2.4 (95% CI 1.3-4.7) and 0.39 (95% CI 0.20-0.76). For stillbirths and neonatal deaths the respective LRs were 1.5 (95% CI 0.91-2.6) and 0.51 (95% CI 0.20-1.3). For the prediction of small-for-gestational-age fetus, the pooled LRs were 1.3 (95% CI 1.1-1.7) and 0.60 (95% CI 0.43-0.83) for positive and negative results, respectively. AUTHOR'S CONCLUSION: Serum uric acid is a poor predictor of maternal and fetal complications in women with pre-eclampsia.

Fetal magnetic resonance imaging in prenatal diagnosis of central nervous system abnormalities: 3-year experience.

OBJECTIVE: To evaluate the comparative merits of ultrasound and fetal magnetic resonance imaging (MRI) in the correct antenatal diagnosis of suspected central nervous system abnormalities. METHODS: A retrospective review of 27 consecutive pregnancies referred for fetal MRI for suspected central nervous system abnormalities between July 1998 and July 2001. Women were referred for the MRI examination when further anatomical and/or pathological clarification of the ultrasound scan findings was needed. Antenatal ultrasound scan and MRI were reviewed in relation to the findings on postpartum investigations. RESULTS: Data were complete for 26 pregnancies. The median gestational age at the time of the ultrasound examination was 26 weeks (95% CI 24 weeks 2 days to 28 weeks 1 day). The median gestational age at the time of magnetic resonance imaging was 27 weeks' gestation (95% Cl 26 weeks 1 day to 29 weeks 2 days). Eight fetuses had associated skeletal, renal and/or cardiac abnormalities previously noted on ultrasound examination. MRI confirmed the ultrasound diagnosis in 15/26 cases (58%). It changed the diagnosis to the correct one in 7/26 (27%) and misdiagnosed four cases (15%). Three of the four cases that were misdiagnosed on MRI occurred in the first 18 months of our 36-month experience. CONCLUSION: Ultrasound remains the primary imaging modality for prenatal diagnosis. Fetal MRI appears to be a useful adjunct to ultrasound to confirm or exclude certain abnormalities; this will consequently help in the counselling of parents and assist in planning further management. However, like any imaging technique, the sensitivity and specificity of the test are likely to improve with experience.