Operative vaginal delivery: practice patterns and outcomes at a tertiary general hospital.

Introduction: There has been a global decrease in operative vaginal deliveries, with a marked shift towards the vacuum extractor. However, little is known about the trends in operative vaginal delivery in Singapore. Methods: A retrospective study was conducted on all operative vaginal deliveries performed from 2012 to 2017 at Singapore General Hospital (SGH). Maternal outcomes in terms of postpartum haemorrhage and obstetric anal sphincter injuries were compared between forceps- and vacuum-assisted deliveries. Neonatal outcomes in terms of neonatal intensive care unit (NICU) admission and clinically significant neonatal events were compared. The instrument preference of obstetricians was analysed. Results: A total of 906 consecutive operative vaginal deliveries were included in the study, comprising 461 forceps- and 445 vacuum-assisted deliveries. The rate of operative vaginal delivery was maintained at approximately 10% from 2012 to 2017. Neonatal cephalohematomas were more common after vacuum-assisted deliveries. Other maternal and neonatal outcomes did not differ significantly between the two groups. Clinically significant neonatal events were mostly due to shoulder dystocia, whereas all cases of NICU admissions were not directly related to the mode of delivery. Obstetricians' choice of instrument appeared to reflect personal preference and was not affected by the year of graduation. Conclusion: The rates of neonatal and maternal morbidity were low at SGH. Overall instrument use of forceps and vacuum was balanced, and proficiency in both was demonstrated by all operators. Operative vaginal delivery remains an essential skill in facilitating safe vaginal delivery, which should be maintained to keep Caesarean section rates in check.

Pharmacokinetics of oral versus intravenous ibuprofen for closure of patent ductus arteriosus: A pilot randomised controlled study.

AIM: This pilot study aimed to compare the pharmacokinetic profiles of oral (PO) and intravenous (IV) ibuprofen for treatment of patent ductus arteriosus (PDA) in preterm neonates. METHODS: In a single-centre, parallel, randomised open-label trial, neonates ≤35 weeks, weight <1800 g with haemodynamically significant PDA during the first week of life were recruited between June 2017 and February 2019 and randomised to receive either PO or IV ibuprofen at standard dosage of 10, 5 and 5 mg/kg every 24 h for three consecutive days. Plasma concentrations of ibuprofen were quantified using a validated high-performance liquid chromatography method and pharmacokinetic parameters were calculated. Treatment outcomes were recorded. RESULTS: Eleven neonates participated in the trial, six and five patients receiving PO and IV ibuprofen, respectively. Pharmacokinetic analysis reveals similar ibuprofen exposure levels in treatment groups. Median dose- and weight-normalised Cmax values of PO and IV groups were 2.12 and 2.53 g/mL respectively (P = 0.082) and median AUC0-24 levels were comparable (PO: 34.6 g*h/mL vs. IV: 50.7.6 g*h/mL, P = 0.25). CONCLUSION: This exploratory study demonstrates comparable pharmacokinetics of PO and IV formulations of ibuprofen in preterm neonates. Larger prospective studies are required to validate these findings.

Varying clinical presentations of umbilical venous catheter extravasation: A case series.

Umbilical venous catheter insertion is a common procedure in the neonatal units performed for rapid vascular access. Though relatively safe and easy to perform, suboptimal position of the catheter tip is frequently encountered and can lead to wide range of complications from venous thrombosis, catheter extravasation with extravasation of infusate to intraperitoneal or intrapericardial space, liver injury and cardiac arrhythmias. Identification of catheter extravasation may be difficult and often confused with catheter related infection or necrotising enterocolitis. We present a series of three cases of intraperitoneal extravasation of umbilical venous catheter in the premature neonate with widely varying presentation from subtle biochemical changes to critical clinical signs with rapid and progressive deterioration.

Use of web-based game in neonatal resuscitation - is it effective?

BACKGROUND: Knowledge and skills decline within months post simulation-based training in neonatal resuscitation. To empower 'Millennial' learners to take control of their own learning, a single-player, unguided web-based Neonatal Resuscitation Game was designed. The present study investigates the effectiveness of the game on retention of resuscitation knowledge and skills. METHODS: The study evaluated 162 healthcare professionals who attended simulation-based training in neonatal resuscitation. Following standard simulation-based training, participants were assigned to either a gaming group (Gamers) with access to the web-based Neonatal Resuscitation Game or a control group (Controls) with no access to the game. Although Gamers were given access, game utilization was completely voluntary and at will. Some Gamers chose to utilize the web-based game (Players) and others did not (Non-players). Knowledge and skills in neonatal resuscitation were assessed upon completion of training and 6 months post-training using a multiple-choice question test and a manikin-based skills test. Changes in scores were compared statistically between Gamers vs Controls, Players vs Controls, and Players vs Controls + Non-players using two-sample t-tests. RESULTS: At the final assessment, declines in knowledge scores were seen in all groups. Mean change from baseline in knowledge and skill performance scores at 6 months, adjusted for baseline skill performance and MCQ test scores, did not differ significantly between Players vs Controls and Players vs Controls + Non-players. CONCLUSION: The web-based game in its current format may not be effective in facilitating retention of knowledge and technical skills in neonatal resuscitation.

Reducing radiation hazard opportunities in neonatal unit: quality improvement in radiation safety practices.

AIM: Guided by the ALARA - "As Low As Reasonably Achievable" principle in radiation safety, a quality improvement project to optimise the bedside diagnostic imaging process to the best standards of care was conducted over a six month period. The goal was too reduce the radiation hazard opportunities in the neonatal intensive care unit by at least 75% from the existing level at Q2/2015, within 6 months. METHODS: The existing bedside imaging process was critically analysed and the following quality improvement initiatives were implemented namely, mandatory lead protective gear to healthcare staff, gonadal shield for neonates, guidelines for optimal collimation of X-ray beam and optimal positioning of neonates. Radiation dosimetry results, regular staff awareness sessions and strong collaboration between neonatologists, radiologists, radiographers and neonatal nurses helped to ensure compliance to the revised imaging process. Radiation hazard opportunities were measured by analysing all radiographs done during the period under baby exposure and healthcare staff exposure categories. SUMMARY OF RESULTS: Radiation hazard opportunities were reduced by 100% to healthcare staff and 75% to neonates, and the overall reduction was 83%. The rate of discordance between radiograph request forms and images taken was measured as a surrogate marker for compliance to the project initiatives and it declined by 77%. Mandatory orientation of staff to the revised policy on the standardised diagnostic imaging process, regular radiation awareness talks and staff feedback sessions are among several measures taken to sustain the project.