UK O&G trainees' attitudes to caesarean delivery for maternal request.

We assessed the attitudes of UK Obstetrics and Gynaecology (O&G) trainees towards a caesarean delivery for maternal request (CDMR); and identified differences in attitude towards patients requesting CDMR and preferences for their own mode of delivery. An internet survey was constructed with questions covering trainees' personal preferences towards and experience of CDMR; attitudes to CDMR; and how they might treat patients making this request. From 02/2013 to 06/2013, the survey was sent electronically via email to all UK Deaneries to be forwarded to O&G trainees. Two hundred and forty O&G trainees participated; 78% female. 6/101 (6%) respondents had opted for CDMR in their first pregnancy. 28/131 (21%) would choose CDMR in their first pregnancy. Reasons for CDMR included concerns about pelvic floor/perineum, safety of the baby and convenience. 105/226 (46.4%) disagreed or strongly disagreed, and 67 (29.6%) agreed or strongly agreed with CDMR. 75/128 (58.6%) of respondents would grant CDMR to a patient; reasons included maternal choice, psychological concerns of the mother, perineal injury, pelvic floor. Our results are encouraging: positive attitudes of trainees towards vaginal delivery may help to reduce the rising caesarean rate. Impact Statement What is already known on this subject: Over the last 30 years, the rate of caesarean section in the UK has trebled and currently accounts for 25% of all deliveries. The rate of caesarean section in the UK has risen to 25% of all deliveries, incurring a financial burden and an excess clinical risk. With pressure to keep the caesarean rates low, understanding the attitudes and experience of obstetricians in training is important. What the results of this study add: Six percent of obstetric trainees, or their partners who had children had chosen a caesarean delivery for maternal request (CDMR), consistent with the population average. Twenty one percent of those who had not had children would choose CDMR. Both groups cited concerns over the pelvic floor as the predominant reason. Fifty nine percent of respondents would grant patients' request for CDMR. 29.6% of respondents agreed, and 46.4% disagreed with CDMR. Trainees' attitude to CDMR does not appear to be associated with whether or not they have had children, but does appear to be associated with whether they had experienced, or were planning to choose CDMR themselves in the future. What the implications are of these findings for clinical practice and/or further research: Training for obstetric trainees regarding the optimum way to manage patients' requests for, and clearer guidance on CDMR may be of benefit. It is important that obstetricians discuss the reasons behind such requests in order to individualise management.

Single-knot versus multiple-knot technique of perineal repair: a randomised controlled trial.

PURPOSE: An important factor influencing the outcome of perineal repair is the repair technique. This study was done to determine if there is a difference in post perineal repair pain scores following the use of the standard multiple-knot technique (MKT) of perineal repair and a single-knot technique (SKT). METHODS: We randomised 260 women who sustained a second-degree perineal tear at the University of Benin Teaching Hospital, Benin City, Nigeria and had perineal repair using either a SKT or a MKT between 1 July 2014 and 28 February 2015. Primary outcome measure was pain assessed with a numerical rating scale (0 = no pain, 10 = worst imaginable pain) on day two, day 10 and at 3 months. Secondary outcome measures were pain scores during basic activities of daily living, analgesia use, dyspareunia and patient satisfaction. RESULTS: Mean pain scores were significantly lower in the SKT group on day two (2.8 versus 5.6; P < 0.001) and day 10 (1.8 versus 3.3; P < 0.001). Significantly fewer women in the SKT group reported pain on day two (90/126, 71.4 % versus 122/128, 95.3 %; Relative Risk [RR] 0.6, 95 % Confidence Interval [CI] 0.6-0.8; P < 0.001), and day 10 (69/126, 54.8 % versus 107/128, 83.6 %; RR 0.7, 95 % CI 0.5-0.7; P < 0.001)]. Women in the SKT group were more likely to be satisfied with outcome of repair at three months (RR 1.4, 95 % CI 1.2-1.5; P < 0.001). No difference in pain scores and dyspareunia at 3 months. CONCLUSIONS: SKT of perineal repair is associated with significantly less pain in the first 10 days postdelivery and a higher patient satisfaction rate at 3 months.

The knowledge, practice and opinion of midwives' in the UK on their training in obstetric perineal repair.

PURPOSE: To investigate the knowledge and practice of perineal repair by midwives' in the UK, as well as their perception of the adequacy of their training. METHODS: An anonymous structured questionnaire survey was conducted. Standard statistical comparative analysis was performed between groups. Significant differences were quantified by calculating odds ratios and 95% confidence intervals. P < 0.05 was considered significant. RESULTS: Analysis of 592 responses revealed that midwives who believed that they had adequate training were ten times more likely to report that they have an adequate knowledge of pelvic floor anatomy (OR 9.8, 95% CI 6.4-14.9, P < 0.001), six times more likely to be aware of recommended techniques of perineal repair (OR 6.1, 95% CI 3.8-9.7, P < 0.001) and 16 times more likely to feel competent to perform a repair (OR 16.1, 95% CI 9.3-27.2, P < 0.001). Midwives who had formal hands-on perineal repair training were four times more likely to report that they have an adequate knowledge of pelvic floor anatomy (OR 4.1, 95% CI 2.8-5.8, P < 0.001) and four times more likely to feel competent enough to perform a repair (OR 3.6 95% CI 2.4-4.9, P < 0.001). CONCLUSION: The majority of midwives in the study sample report that they were unable to identify key perineal anatomy and believed that their pre-qualification training on perineal repair was inadequate. They also believed that midwives should routinely repair simple second-degree perineal tears.

Consent for gynaecological procedure: what do women understand and remember?

PURPOSE: To determine patients' understanding and recall of consent information and risks associated with their procedure following gynaecological surgery. METHOD: Patients planned for routine gynaecological surgery were invited to participate in the study by completing a self-administered questionnaire 4-6 h after day-surgery and 24 h after in-patient surgery. Collated data were analysed using standard statistical methods. RESULT: 544 women participated in the study. 321 (57.9 %) were day-cases and 233 (42.1 %) were in-patients. 33 % and 30.8 % of in-patients and day-cases, respectively did not recall any risk associated with their procedure. Among in-patients, women who did not recall any risk were less likely to have post primary education (84.2 vs. 96.2 %, P = 0.008), understood an information leaflet (79.5 vs. 95.1 %, P = 0.002), understood the consent counselling (85.5 vs. 98 %, P = 0.001), or remember the explanation of procedure and risks (85.5 vs. 98 %, P = 0.001). Among women who did not recall any risk, the day-case women were less likely to have read the information leaflet (86.4 vs. 96.2 %, P = 0.002), understood the information leaflet (79.5 vs. 98.9 %, P = 0.007), or understood the consent counselling (85.5 vs. 98.9 %, P < 0.001) when compared to in-patients. CONCLUSION: A third of women who had planned gynaecology procedure do not recall any risk associated with the procedure. Provision of information leaflet did not make any consistent difference.

Understanding and recollection of the risks associated with cesarean delivery during the consent process.

OBJECTIVE: To investigate women's recall of information provided during the consent process for cesarean delivery, specifically the associated risks, 24 hours after the procedure. METHODS: A prospective questionnaire-based study was conducted at the Barnet and Chase Farm Hospitals NHS Trust between May 2009 and August 2010. Women who had undergone a cesarean delivery (planned or emergency) completed a self-administered questionnaire 24 hours after delivery. Women who did not recall the risks associated with the procedure (group 1) were compared with those who did recall this information (group 2). RESULTS: A total of 554 women participated in the study. Group 1 (n=140) were 4 times more likely to have undergone an emergency cesarean than group 2 (n=414) (OR 4; 95% CI, 2.5-6.2). Group 2 were more to likely to have higher than secondary level education, 7 times more likely to have understood the explanation of the procedure (OR 6.9; 95% CI, 3.3-14.2), and 9 times more likely to recall that the risks had been explained (OR 9.4; 95% CI, 5.2-17.1). More women in group 1 reported that they would have liked to receive an information leaflet about cesarean delivery at the first prenatal visit. CONCLUSION: One in 4 women did not recall any risks associated with cesarean delivery shortly after the procedure and this group of women were less likely to understand or recall the details of the consent discussion.

Is induced labour in the nullipara associated with more maternal and perinatal morbidity?

PURPOSE: To ascertain any differences in foetomaternal outcomes in induced and spontaneous labour among nulliparous women delivering at term. METHODS: A retrospective matched cohort study consisting of 403 nulliparous women induced at ≥ 292 days and 806 nulliparous women with spontaneous labour at 285-291 days. RESULTS: Compared to those in spontaneous labour, women who had induction of labour were three times more likely to have a caesarean delivery (OR 3.1, 95% CI 2.4-4.1; P < 0.001). Women who had induction of labour were 2.2 times more likely to have oxytocin augmentation (OR 2.2, 95% CI 1.7-2.8; P < 0.001), 3.6 times more likely to have epidural anaesthesia (OR 3.6, 95% CI 2.8-4.6; P < 0.001), 1.7 times more likely to have uterine hyperstimulation (OR 1.7, 95% CI 1.1-2.6), 2 times more likely to have a suspicious foetal heart rate trace (OR 2.0, 95% CI 1.5-2.6), 4.1 times more likely to have blood loss over 500 ml (OR 4.1, 95% CI 2.9-5.5; P < 0.001), and 2.9 times more likely to stay in hospital beyond 5 days (OR 2.9, 95% CI 1.5-5.6; P < 0.001). Babies born to mothers who had induction of labour were significantly more likely to have an Apgar score of <5 at 5 min and an arterial cord pH of <7.0. CONCLUSION: Compared to those with spontaneous labour, nulliparous women with induced labours are more likely to have uterine hyperstimulation, caesarean delivery, and babies with low Apgar scores. Nulliparous women should be made aware of this, as well as potential risks of expectant management during counseling.

Clinico-pathological study of cervical polyps.

OBJECTIVE: To determine the incidence of malignancy in cervical polyps and determine the effect of age and parity on clinical presentation. METHODS: A retrospective analysis of histological diagnosis and demographic information relating to 294 polyps was undertaken. Comparison was made between premenopausal and postmenopausal women as well as women with and without recurrent polyps. RESULTS: There was no case of malignancy. Majority of the women were parous (71.8%), asymptomatic (65.9%) and had their polyps removed in the outpatient setting (69.9%). The recurrence rate was 12.6%. The predominant symptom was IMB/PCB. Women with recurrent polyps were 10 times more likely to be parous (OR = 10.1, 95% CI 1.4-74.8), 7.9 times more likely to have symptoms (OR = 7.9, 95% CI 3.5-17.1) and 4.8 times more likely to have polyps removed under general anaesthesia (OR = 4.8, 95% CI 2.4-9.9). Postmenopausal women were 2.2 times more likely to have symptoms (OR = 2.2, 95% CI 1.6-4.7) and 1.7 times more likely to have general anaesthesia (OR = 1.7, 95% CI 1.0-3.1). CONCLUSION: Cervical polyps are mainly benign, asymptomatic lesions and recur in about 12.6% of women. They are more likely to be symptomatic in postmenopausal women.

Impact of a structured, hands-on, surgical skills training program for midwives performing perineal repair.

OBJECTIVE: To evaluate the effect of structured hands-on training for midwives performing perineal repair. METHODS: The training was performed using models and ox tongues. A total of 719 midwives completed an anonymous questionnaire prior to and immediately after training. Out of 300 participants, 151 completed a follow-up questionnaire 4 months later. Participants rated their knowledge and skills in the domains of instrument handling, knot tying, and subcuticular perineal repair. RESULTS: Compared with the situation before receiving the training, there was a significant increase in the use of the recommended evidence-based technique for perineal repair 4 months after training (28% vs 100%; P<0.001), and in the mean scores for knowledge and skills in all the domains (P<0.001). Participants believed that their patients were happier with the new technique. CONCLUSIONS: Structured hands-on training is an effective way of improving the skills of midwives performing perineal repair and leads to modification of clinical practice.

A randomised controlled trial of amniotomy and immediate oxytocin infusion versus amniotomy and delayed oxytocin infusion for induction of labour at term.

BACKGROUND: There is uncertainty as to the optimal time interval between amniotomy and oxytocin administration when inducing labour. The aim of this study was to compare the efficacy of amniotomy and immediate oxytocin infusion with amniotomy and delayed oxytocin infusion for induction of labour at term. METHOD: A total of 123 women were randomly chosen to receive either amniotomy and immediate oxytocin infusion (referred to as the 'immediate group') or amniotomy and delayed oxytocin infusion (referred to as the 'delayed group'). The main outcome measure was the proportion of women in established labour at 4 h as well as the proportion that delivered within 12 h of amniotomy. Data were analysed using standard statistical methods. RESULTS: Women in the immediate group were more likely to be in established labour 4 h post-amniotomy [relative risk (RR) 12.8; 95% CI 55.1-111.7], have a shorter amniotomy to delivery interval (P < 0.001) and achieve vaginal delivery within 12 h (RR 1.5; 95% CI 1.2-12.6). There was no difference between the groups with regards to the mode of delivery, incidence of uterine hyperstimulation and abnormal foetal heart rate recording. Compared to the delayed group, women in the immediate group were more likely to be satisfied with the induction process (RR 4.1, 95% CI 1.1-16.1) and the duration of labour (RR 1.8 95% CI 1.0-3.3). CONCLUSION: In induction of labour at term, amniotomy and immediate oxytocin infusion is associated with the establishment of active labour at 4 h, a shorter amniotomy-delivery interval and greater maternal satisfaction.

Preferred and actual delivery mode after a cesarean in London, UK.

OBJECTIVE: To determine the delivery mode preferred by pregnant women with 1 previous cesarean delivery and to investigate the relationship between preferred and actual mode of delivery. METHOD: We reviewed the records of 215 women who were delivered in a London hospital with a history of 1 cesarean delivery. Women who planned an elective repeat cesarean section (ERCS) were compared with those who planned a vaginal birth after cesarean (VBAC). RESULTS: Although 55.3% chose VBAC overall, only 37.8% of those who chose it were delivered by it, whereas 94.8% of those who chose ERCS were delivered by ERCS. Nonwhite women were more likely to choose VBAC than white women (odds ratio, 3.5; 95% confidence interval, 1.9-6.1) but less likely to be deliver by it (odds ratio, 0.31; 95% confidence interval, 0.14-0.68). CONCLUSION: In this study, VBAC was the method of delivery preferred by most women. Nonwhite women were more likely to choose VBAC over ERCS but less likely to be delivered by VBAC.

Caesarean delivery at full cervical dilatation versus caesarean delivery in the first stage of labour: comparison of maternal and perinatal morbidity.

OBJECTIVE: To compare perinatal and maternal morbidity associated with caesarean sections performed in the first with that performed in the second stages of labour. PATIENTS AND METHODS: Comparative analyses between nulliparous women with singleton term pregnancies who had a caesarean section in the first stage of labour and those who had a second stage caesarean section were completed using standard statistical methods. A subgroup analysis, according to indication for caesarean section, was also performed. RESULTS: Of 627 women, 81% had caesarean delivery in the first stage and 19% had caesarean delivery in the second stage of labour. Women undergoing caesarean delivery at full cervical dilatation were 1.9 times more likely to have an augmented labour (95% CI 1.2-3.4, P < 0.001) and 2.8 times more likely to have epidural anaesthesia in labour (95% CI 1.5-5.2, P < 0.001) than those in the first stage. Compared with caesarean delivery in the first stage of labour, women undergoing caesarean delivery at full cervical dilatation were 4.6 times more likely to have composite intraoperative complications (95% CI 2.7-7.9, P < 0.001), 3.1 times more likely to have blood loss greater than 1,000 ml (95% CI 1.3-7.4, P = 0.01), and 2.9 times more likely to have a blood transfusion (95% CI 1.5-5.6, P < 0.001). The risk of neonatal morbidity was higher in first stage caesareans when they were performed for presumed fetal compromise (66.3 vs. 26.3%, P = 0.002), and lower when they were performed for failure to progress (18.4 vs. 42%, P = 0.02). CONCLUSION: Caesarean section in the second stage of labour is associated with a higher risk of maternal but not perinatal morbidity.

Impact of prolonged referral interval on colposcopic outcomes in women with moderate or severe dysplasia.

OBJECTIVE: To ascertain the impact of long referral to first colposcopy interval on disease outcome in women with high-grade cervical smear tests. METHODS: Data from 316 women categorized into Group 1 (seen 180 days after referral) and Group 2 (seen within 180 days of referral) were analyzed using chi2 test with Yates correction. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: Women in Group 1 were less likely to need treatment (33.8% [25/74] vs 55.8% [135/242]; OR=0.45; 95% CI, 0.25-0.78; P=0.0004) and less likely to have high-grade disease (24.3% [18/74] vs 45.9% [111/242]); OR=0.37; 95% CI, 0.21-0.68; P=0.001) than women in Group 2. There was no significant difference between the groups in proportion of women with invasive disease. CONCLUSION: In women with high-grade smears the need for excisional treatment and the risk of invasive disease may be reduced by prolonged referral interval.

Post-coital bleeding: a rare and unusual presentation of cervical endometriosis.

INTRODUCTION: Often due to benign conditions such as cervical ectopy, post-coital bleeding is a distressing symptom for the patient. However, for the clinician, the identification of the etiology is important in order to effect proper treatment. CASE REPORT: We present a case referred to the colposcopy clinic because of post-coital bleeding and a smear report of 'groups of benign glandular cells of endometrial origin'. Colposcopy was normal but histology of an excised haemorrhagic nodule revealed endometriosis with resolution of symptoms. CONCLUSION: Cervical endometriosis should be considered in the differential diagnosis of post-coital bleeding with no obvious ectopy or malignancy.

Emergency peripartum hysterectomy in a tertiary London hospital.

OBJECTIVE: The objective was to review all emergency peripartum hysterectomies performed at a tertiary hospital in London, UK, and to identify the risk factors for emergency peripartum hysterectomy. METHOD: A retrospective case control study. The cases consisted of all women who had emergency peripartum hysterectomy between 1 January 1993 and 31 December 2003. Controls were women who delivered immediately before and after the indexed case. Demographic data, medical and surgical histories, pregnancy, intrapartum and postpartum data were collected. Differences between cases and controls were compared with chi2, Fisher exact and Student t tests. Multiple logistic regression analysis was performed to identify independent risk factors for emergency peripartum hysterectomy. RESULTS: There were 15 cases of emergency peripartum hysterectomy in 31,079 deliveries, giving a rate of 0.48 per 1,000. Women who had emergency peripartum hysterectomy were significantly older (mean age 37 years vs. 29 years, P<0.001) and multiparous (P=0.02). More of the cases had a history of uterine surgery (67 vs. 30%, P=0.01), placenta praevia (60 vs. 3%, P<0.0001) and were delivered by caesarean section (86.7 vs. 30%, P=0.003). Eighty percent of the hysterectomies were performed in the daytime and all were done by consultants. Haemorrhage due to placenta praevia was the main indication for emergency peripartum hysterectomy (47%). Independent risk factors for emergency peripartum hysterectomy were older age (odds ratios [OR] 1.2, 95% confidence interval [95% CI] 1.2-1.6), multiparity (OR 2.6, 95% CI 1.3-10.2), history of previous caesarean section (OR 13.5, 95% CI 2.7-65.4), caesarean delivery in index pregnancy (OR 11.6, 95% CI 2.1-68.6) and caesarean delivery in index pregnancy for placenta praevia (OR 18, 95% CI 3.6-69). CONCLUSION: Caesarean deliveries, especially repeat caesareans in women with placenta praevia, significantly increase the risk of emergency peripartum hysterectomy.