Vaginal delivery: An argument against requiring consent.

Birth by vaginal delivery is an evolutionary process refined over millennia to create a sustainable and safe method of human reproduction. A key argument against requiring consent for vaginal birth acknowledges that from an evolutionary point of view, vaginal delivery has successfully accompanied human development and remains the natural and default form of human birth. Concern has been raised by the Montgomery court case in the United Kingdom; however, the ruling does not mean consent is required for normal birth. What it does reaffirm is the need to engage patients in their care decisions when complications occur in pregnancy and delivery. Effective communication, rather than a legalistic consent pathway, is required for positive healthcare outcomes.

Attitudes of pregnant women towards personally controlled electronic, hospital-held, and patient-held medical record systems: a survey study.

BACKGROUND: On July 1, 2012 the Australian Government launched the personally controlled electronic health record (PCEHR). This article surveys obstetric patients about their medical record preferences and identifies barriers to adoption of the PCEHR. MATERIALS AND METHODS: A survey study was conducted of antenatal patients attending a large Australian metropolitan hospital. Consecutive patients completed questionnaires during the launch phase of the PCEHR system. Quantitative and qualitative data were collected on demographics, computer access and familiarity, preference for medical record system, and perceived benefits and concerns. RESULTS: Of 528 women eligible to participate, 474 completed the survey (89.8%). Respondents had high levels of home access to a computer (90.5%) and the Internet (87.1%) and were familiar with using computers in daily life (median Likert scale of 9 out of 10). Despite this, respondents preferred hospital-held paper records, and only one-third preferred a PCEHR; the remainder preferred patient-held records. Compared with hospital-held paper records, respondents felt a PCEHR would reduce the risk of lost records (p<0.0001) and improve staff communication (p<0.0001). However, there were significant concerns about confidentiality and privacy of the PCEHR (p<0.0001) and lack of control (p<0.0001). CONCLUSIONS: Consumers see advantages and disadvantages with the PCEHR, although the majority still prefer existing record systems. To increase uptake, confidentiality, privacy, and control concerns need to be addressed.

Barriers to the 4-h rule: what causes delays for gynaecology patients in the emergency department?

OBJECTIVES: To explore factors that led to noncompliance with the 4-h rule for gynaecology patients in a general emergency department. METHODS: A cross-sectional cohort study was performed at a general emergency department. The files of all female patients aged from birth to 100 years presenting from 1 January 2009 to 31 December 2010 were screened. Those patient's files where a coded gynaecological diagnosis was made were reviewed. A time flow analysis was then undertaken of 580 consecutive files to evaluate barriers to admission or discharge of patients within the 4-h period. A further 300 files were audited to determine whether suboptimal management by emergency department staff contributed towards delays. RESULTS: There were 134 438 presentations to the emergency department, of which 2968 were gynaecology presentations (2.2%). The overall compliance with the 4-h rule was 66%. Patients with acute triage status, who were pregnant or who were eventually admitted, were more likely to be managed in compliance with the 4-h rule. The main barriers to compliance were incomplete examinations by emergency department staff; waiting for ultrasound examinations and blood test results; delays waiting for specialty review; and delays caused by initial review by surgical teams. CONCLUSION: Specific barriers to compliance with the 4-h rule can be identified in gynaecology patients. Strategies specific to overcome these barriers can be developed to improve compliance.

The impact of molar pregnancy on the male partner.

BACKGROUND: Molar pregnancy is a complication of 1 in 200-2000 pregnancies whereby abnormal placental tissue proliferates in the absence of a fetus and may lead to metastases. The disease origin lies in dispermy or dual fertilisation of the egg. The aim of this study was to explore the impact of molar pregnancy upon the male partner. METHODS: Institutional ethics committee approval and individual consent were obtained. All women listed on the state molar pregnancy database who were receiving active follow-up (n = 102) and a random sample of women who had been registered in the previous 30 years (n = 56) were sent a postal survey outlining the purpose of the study and an invitation for their partner to participate. Sixty-six women gave permission for their partner to participate in the study. Questionnaires included the Hospital Anxiety and Depression Scale, Satisfaction with Life Scale and Sexual History Form 12. Responding partners were also invited to make comments about any aspect of particular concern. A reminder mail out was issued after 6 weeks. RESULTS: The response rate was 62% (N = 41). The key findings were that 32.5% and 12.5% of men met the case criteria for anxiety and depressive disorder, respectively. These figures represent a doubling of usual community rates for anxiety disorder. However, overall quality of life and sexual functioning outcomes were consistent with community samples. The presence of children played a protective role and was associated with significantly better psychological function and quality of life in univariate and multivariate analysis. Qualitative results complemented the quantitative data, with anxiety as the dominant emotional theme. CONCLUSION: There are high persisting levels of anxiety in male partners of women with molar pregnancy. Partners may benefit from therapy where anxiety disorders are detected.

Prevalence and associations of domestic violence at an Australian colposcopy clinic.

OBJECTIVE: Domestic violence is associated with significant mortality and morbidity including gynecological morbidity. We report the prevalence and associations of domestic violence in an Australian colposcopy service. MATERIALS AND METHODS: A prospective study was performed from consecutive patients attending colposcopy clinics at a major metropolitan hospital in Australia. Key outcomes were the prevalence of intimate partner violence and its key demographic associations. RESULTS: Consent was obtained from 574 and domestic violence status was ascertained in 566 of 581 women approached. Overall, 33% of responders reported violence within 12 months. In 14.5%, the female reported being sole recipient of violence; in a further 16.6%, violence was bidirectional, and in 1.9% of cases, a woman was the sole perpetrator. Key associations of violence were younger age at presentation (32 vs 35 y; p = .01), higher rates of smoking (51.3% vs 38.2%; p = .0004), higher rates of housing instability (32.2% vs 12.2%; p < .0001), a positive Beck Depression Inventory screen (50.0% vs 24.6%; p < .0001), and higher rates of default to initial attendance (15.5% vs 4.7%, p < .0001). CONCLUSIONS: Domestic violence is common in women presenting to colposcopy services and may be associated with poor housing stability and higher default rates.

HPV genotype prevalence in women with abnormal pap smears in Melbourne, Australia.

Carcinoma of the cervix and its precursor, high-grade cervical intraepithelial neoplasia (CIN2/3), are associated with persistent oncogenic Human papillomavirus (HPV) infection, particularly HPV 16 and 18. HPV genotype distribution varies with severity of cervical disease, patient demographics such as age, as well as geographical location. In this study, HPV genotype prevalence was determined, using the Roche Linear Array genotyping test, among a cohort of 1,676 women being managed with ablative or excisional treatment following colposcopically directed biopsies, who were referred initially due to cytological abnormalities. HPV genotype prevalence, including presence of single and multiple infections was assessed against both histological diagnosis and age. Overall, 83.9% of women were identified as HPV positive, comprising of 32.2% single and 51.7% multiple HPV infections. Of those with an available histological diagnosis at time-of-treatment (n = 899), HPV positivity increased significantly with disease severity: 62.4% (normal), 77.6% (CIN1), 92.6% (CIN2), and 97.9% (> or =CIN3) (P < 0.006). Similarly, a significant increase in high-risk (HR) HPV detection was observed with severity of disease (P < 0.005). The five most prevalent genotypes were HPV 16 (35.1%), 31 (12.6%), 51 (11.1%), 52 (9.9%), and 18 (8.5%). HPV 16 was the only genotype to demonstrate a significant increase in prevalence with increasing severity of histological or cytological disease (P < 0.0001). Multiple HPV infections, including multiple HR-HPV infections, declined significantly with age (P < 0.02). These findings provide the largest dataset of HPV genotype prevalence rates within Australian women, though are not representative of the general population.

Early stress predicts age at menarche and first birth, adult attachment, and expected lifespan.

Life history theory suggests that in risky and uncertain environments the optimal reproductive strategy is to reproduce early in order to maximize the probability of leaving any descendants at all. The fact that early menarche facilitates early reproduction provides an adaptationist rationale for our first two hypotheses: that women who experience more risky and uncertain environments early in life would have (1) earlier menarche and (2) earlier first births than women who experience less stress at an early age. Attachment theory and research provide the rationale for our second two hypotheses: that the subjective early experience of risky and uncertain environments (insecurity) is (3) part of an evolved mechanism for entraining alternative reproductive strategies contingent on environmental risk and uncertainty and (4) reflected in expected lifespan. Evidence from our pilot study of 100 women attending antenatal clinics at a large metropolitan hospital is consistent with all four hypotheses: Women reporting more troubled family relations early in life had earlier menarche, earlier first birth, were more likely to identify with insecure adult attachment styles, and expected shorter lifespans. Multivariate analyses show that early stress directly affected age at menarche and first birth, affected adult attachment in interaction with expected lifespan, but had no effect on expected lifespan, where its original effect was taken over by interactions between age at menarche and adult attachment as well as age at first birth and adult attachment. We discuss our results in terms of the need to combine evolutionary and developmental perspectives and the relation between early stress in general and father absence in particular.

Australian Fathers' Study: What Influences Paternal Engagement With Antenatal Care?

This mixed-methods study explores factors associated with and levels of engagement of fathers in antenatal care. One hundred expectant fathers were recruited from antenatal clinics and community settings in Western Australia. They completed validated questionnaires. Eighty-three percent of expectant fathers reported a lack of engagement with antenatal care. Factors significantly associated with lack of engagement in multivariate analysis were working more than 40 hours a week and lack of adequate consultation by antenatal care staff. In qualitative analysis, 6 themes emerged in association with a lack of engagement. They were role in decision making, time pressures, the observer effect, lack of knowledge, barriers to attendance, and feeling unprepared or anxious. Care providers should involve fathers in consultations to improve paternal engagement.

What Factors Impact upon a Woman's Decision to Undertake Genetic Cancer Testing?

INTRODUCTION: The advent of human genome project has lead to genetic tests that identify high-risk states for certain cancers. Many are privately marketed on the Internet. Despite the availability of tests, limited data has evaluated factors that lead to test uptake. The aim of the present study was to explore the attitudes of a cohort of new mothers toward uptake of a genetic cancer test with a 50% predictive value of cancer. METHODS: A cross-sectional survey was undertaken. The project targeted women who had recently given birth at an Australian tertiary referral hospital. Women were asked about a theoretical blood test that detected an increased risk for the development of cancer. Attitudes and knowledge questionnaires were completed. RESULTS: Of 232 consecutive women approached, 32 declined, giving a response rate of 86.2%. Only 63 (31.5%) women stated they would have the test. Absence of religious belief, higher level of education, better knowledge of terms used in genetics, an absence of concern over emotional, employment, and insurance discrimination, and previous acceptance of Down syndrome screening in pregnancy were each associated with significantly higher rate of test uptake in univariate analysis (all p < 0.03). In multivariate analysis, a lack of concern over discrimination and a history of having accepted Down syndrome screening in the previous pregnancy remained significantly associated with test uptake (all p < 0.0001). CONCLUSION: Concern over discrimination and having made a prior decision to have genetic testing were the principal factors associated with decision-making.

Pandemic (H1N1) 2009 influenza vaccine uptake in pregnant women entering the 2010 influenza season in Western Australia.

OBJECTIVE: To audit the uptake of pandemic (H1N1) 2009 influenza vaccine in pregnant women entering the 2010 influenza season in Western Australia, and to identify why some women did not receive the vaccine. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional study of consecutive patients attending the Joondalup Health Campus public antenatal clinics in WA in January 2010. INTERVENTION: Audit of uptake of the H1N1-specific vaccine. MAIN OUTCOME MEASURES: Rate of H1N1-specific vaccination, and reasons for not being the vaccinated. RESULTS: 479 of 541 women who attended the clinics (88.5%) were included in the audit. Three women had been infected with pandemic influenza in the preceding influenza season, leaving 476 women who were eligible for vaccination in pregnancy. Of these 476 women, only 33(6.9%) had been vaccinated. Of the remaining 443 women who were eligible to receive the vaccine but had not been vaccinated, 63.9% had not been offered vaccination despite multiple visits to their general practitioners during pregnancy, 19.6% had been advised by their GPs against vaccination in pregnancy, and 61.6% stated that they would decline vaccination if offered because of safety concerns. CONCLUSIONS: Uptake of H1N1-specific influenza vaccine in pregnant women was poor. Reasons for this relate both to vaccination not being offered to or actively sought by the women, as well as concerns - of both the women and their GPs - about vaccine safety in pregnancy. Uptake in this setting may improve if vaccination is offered through public antenatal clinics with concurrent safety education for obstetricians and vaccination providers.

Selecting medical students for academic and attitudinal outcomes in a Catholic medical school.

OBJECTIVES: To evaluate whether the four criteria used by the University of Notre Dame Australia (UNDA) to select medical students are successful in selecting for graduates with the desired outcomes of academic excellence and Catholic "mission fit". DESIGN, SETTING AND PARTICIPANTS: Prospective cohort study of medical students selected for 2008 and 2009 entry to UNDA in Sydney, New South Wales. MAIN OUTCOME MEASURES: The statistical association between the two academic selection criteria of the Graduate Australian Medical School Admissions Test (GAMSAT) and grade point average (GPA) compared with the outcome of medical school examination performance, and the two mission selection criteria of a portfolio score and interview score compared with the outcome of a positive attitude towards serving underserved communities as measured using the Medical Student Attitudes Toward the Underserved (MSATU) test. RESULTS: A total of 223 students were enrolled. GAMSAT section 3, GPA and the interview scores were significantly positively associated with academic performance (P < 0.05). However, none of the selection variables were significantly associated with a positive attitude towards serving underserved communities, as measured by the MSATU score. CONCLUSION: None of the four selection tools used were significantly associated with medical students who had a positive attitude towards serving underserved communities.

Human papillomavirus genotype detection from archival papanicolaou-stained cervical tests.

BACKGROUND: Archival Papanicolaou (Pap)-stained cervical cytology tests may be the only source of a clinical sample for the evaluation of previous human papillomavirus (HPV) infection. Pap tests are ideal because the majority of women in countries with comprehensive screening programs would have had several collected and stored. METHODS: In the current study, HPV detection and genotyping were compared in samples collected from a conventionally fixed Pap test with those collected using an endocervical brush and collected in PreservCyt (liquid-based) in 87 women undergoing management for a high-grade Pap test abnormality. Cytology slides were scanned to create high-resolution digital images before the removal of cells because the DNA extraction process resulted in the destruction of the cells from the original sample. RESULTS: All previously identified high-grade abnormalities on the Pap tests were detectable on the digital images. ß-globin was detected in all extracted Pap tests, indicating the presence of recoverable, amplifiable DNA. A total of 62 (71.3%) and 59 (67.8%) tests were found to have high-risk (HR) HPV detected on PreservCyt and fixed Pap test slides, respectively, with >87% concordance for the detection of HR HPV genotypes. Complete HPV genotyping concordance was observed in 62% and was partial in 26% of sample pairs, with very good agreement for HPV types 16 and 18 (κ = 0.850 and 0.903, respectively). Only 1 Pap test slide was found to be positive whereas the PreservCyt had no detectable HPV DNA, demonstrating a low false-positive rate (1%). CONCLUSIONS: The results of the current study confirm that imaging and subsequent HPV detection and genotyping in archival cervical smears can offer accuracy in HPV detection that is comparable to endocervical brush-collected PreservCyt samples.

Prevalence of Chlamydia trachomatis in a public colposcopy clinic population.

BACKGROUND: Chlamydia trachomatis is a major public health issue, with notifications of this sexually transmitted disease continuing to rise in Australia. Women attending colposcopy clinics are referred for treatment of cervical abnormalities often associated with human papilloma virus (HPV) infection. There is evidence that women who have acquired one sexually transmitted infection, such as HPV, are at higher risk of acquiring another. Women attending colposcopy clinics may therefore be at risk of undiagnosed infection with C. trachomatis. AIM: To determine the prevalence of C. trachomatis in women attending a public metropolitan colposcopy clinic in Victoria. METHODS: A cross-sectional study was performed. Institutional ethics committee approval and informed consent were obtained. Consecutive women attending the colposcopy clinic completed a questionnaire and had a swab collected from the endocervix for analysis by polymerase chain reaction for C. trachomatis. Positive screens were treated in accordance with best practice. Data were analysed with Minitab Version 2004 (Minitab Inc, State College, PA, USA). RESULTS: Of 581 women approached to participate in the trial, consent was obtained from 568 women (98%) and final outcome data was available on 560 women (99%). The overall rate of chlamydial infection was 2.1% (95% CI 1.5-2.7%). However, in women aged 25 years or less the rate was 5.8% (95% CI 3.8-7.8%) and in women over 25 years it was only 0.9% (95% CI 0.4-1.4%). Apart from age, no other demographic factor was significantly associated with chlamydial infection. CONCLUSION: Although the prevalence of chlamydial infection in the colposcopy clinic population as a whole does not warrant a policy for routine screening, screening directed at women aged 25 years or less would gain the greatest yields in terms of cost efficacy. Such a policy should be implemented as standard practice.

Psychologic changes after a gynecologic cancer.

AIM: The aim of this study was to explore the wider psychologic symptomatology experienced by women with a new diagnosis of a gynecologic cancer at the point of diagnosis and 6 weeks later. METHODS: A prospective cohort study was carried out with ethics committee approval and informed consent. Women were recruited from three tertiary hospitals in Australia over an 8-month period. In order to cover a diverse range of potential symptomatology, we utilized the Hopkins Symptom Checklist (HSCL)-90, which covers 90 separate psychologic symptoms that can then be coded into eight domains. Women also completed questions relating to their perceived level of social support, and demographic data were collated separately. RESULTS: Key findings were that levels of symptomatology remained uniform across the first 6 weeks following the diagnosis of the cancer regardless of the site of the cancer. Across the spectrum of symptomatology domains, the median scores were all higher in women with poor social supports compared with those with higher social support levels at 6 weeks. Statistically significant differences were observed in the domains of phobic-anxiety, retarded depression, and agitated depression at 6 weeks' follow up. CONCLUSION: Women with a new diagnosis of a gynecologic cancer experience diverse psychologic symptomatology. Symptoms persist over the first 6 weeks and are higher in women with poor social supports. Screening of women for adequate social support structure and targeted interventions to resolve symptomatology need to be tailored to the type of symptoms experienced.

The impact of molar pregnancy on psychological symptomatology, sexual function, and quality of life.

BACKGROUND: Molar pregnancy is an unusual complication of pregnancy whereby abnormal placental tissue proliferates in the absence of a fetus. There is usually a protracted follow-up period where pregnancy is contra-indicated. Whilst the medical outcomes of the disease have been well explored, limited data have evaluated the impact on psychological symptomatology, sexual function, and quality of life. METHODS: Institutional ethics approval and individual consent were obtained. All women listed on the hospital molar pregnancy register receiving active follow-up (n = 102) and a random sample of women who had been registered in the previous 30 years (n = 56) were sent a postal survey outlining the purpose of the study and an invitation to participate. Questionnaires included the Hospital Anxiety and Depression Scale (HADS), Satisfaction with Life Scale (SWLS), and Sexual History Form 12 (SHF-12). RESULTS: The response rate was 54%. The key findings were that 60%, 55%, and 18% of women scored > or =10 on the total HADS, > or =8 on HADS-A, and >8 on HADS-D, respectively. The presence of children played a protective role and was associated with significantly better psychological function and quality of life. SWLS were in the lower end of ranges reported for community controls (mean of 23.9). Chemotherapy had an adverse impact on quality of life ratings (SWLS for chemotherapy yes = 21.7, no = 25). Sexual dysfunction was similar to community samples and was independent of age, time since diagnosis, chemotherapy requirement, and presence of children. Qualitative results complemented the quantitative data with similar emotional themes identified as well as issues related to the medical condition, care, and support networks. CONCLUSION: Women with a molar pregnancy may benefit from a multidisciplinary approach to management that addresses their psychological and sexual needs in addition to medical aspects of care.

Demographic variables routinely collected at colposcopic examination do not predict who will default from conservative management of cervical intraepithelial neoplasia I.

OBJECTIVE: As a result of the low incidence of progression from low grade epithelial abnormalities to cervical intraepithelial neoplasia (CIN) 3 or cervical cancer, a conservative approach to management is supported, especially in young women. Loss to follow-up is a recognised problem with a conservative approach however, with women defaulting known to experience higher rates of cancer. AIM: To determine if any routinely collected demographic variables could predict which Australian women would subsequently default from care having initially elected to have conservative management of CIN 1 lesions. METHODS: Prospectively collected data was audited on 279 women with a colposcopically directed biopsy diagnosis of CIN 1, confirmed on external review, who were enroled by their own choice into a conservative management program and monitored until a definitive lesion outcome was determined. Women who defaulted from follow-up and were lost to care providers despite follow-up appointments and reminder letters were compared to women who completed follow-up with either lesion resolution or progression requiring treatment, to establish if there were any demographic variables to predict default from care. RESULTS: Fifty-two (18.5%) women subsequently defaulted from follow-up. There were no significant differences in age, parity, proportion of women who were pregnant at diagnosis, smoking status, immunosuppressed or had a 'human papillomavirus (HPV) effect' reported on Pap-smear or colposcopic examination. CONCLUSION: We cannot easily identify a subgroup of women who are more likely to default from follow-up of CIN 1 using routinely collected demographic data. Default from follow-up is a major risk with conservative approaches and further research to reduce default rates are required.

Preventing anxiety and depression in gynaecological cancer: a randomised controlled trial.

OBJECTIVE: To examine the effect of counselling and relaxation intervention on psychological symptoms in patients with gynaecological cancer between the post-operative period and the six-week review. DESIGN: Randomised controlled trial. PARTICIPANTS: Fifty-three patients with gynaecological cancer. SETTING: Three Australian tertiary referral hospitals. METHODS: Fifty-three patients were randomised to control or intervention and completed the baseline Hospital Anxiety and Depression Scale (HADS) and General Health Questionnaire-28 (GHQ-28) questionnaires. The intervention consisted of a relaxation and counselling session performed by a senior doctor. Follow up questionnaires were completed at six weeks. Demographic and tumour data were collated independently. RESULTS: Complete data were available on 50 patients. There were no significant differences in demographic, social support or tumour characteristics between the two groups. Multivariate analysis determined that only the intervention and baseline score were significant predictors of outcome. The intervention was associated with a significant reduction in total HADS score (P = 0.002). The reduction was seen in both anxiety and moderate depression subscales (P = 0.001 and P = 0.02). The intervention was also associated with a significant reduction in total GHQ-28 score and in three of the four subscale scores (somatisation, anxiety and personality development; all P < 0.02). However, no significant difference was found in the fourth subscale of major depression. CONCLUSION: A relaxation and counselling intervention performed by a treating doctor reduces psychological symptoms in women with a new diagnosis of gynaecological cancer.

Small intestinal volvulus following laparotomy for endometrial clear cell carcinoma in a woman with a past history of total gastrectomy and Roux-en-Y anastomosis for gastric carcinoma.

BACKGROUND: Small intestinal volvulus is a rare complication following Roux-en-Y anastomosis. CASE REPORT: A 63-year-old woman was diagnosed with small intestinal volvulus following laparotomy for clear cell carcinoma of the endometrium. Her past medical history included a total gastrectomy and antecolic Roux-en-Y anastomosis for Duke's B gastric carcinoma. Operative findings were of transmesenteric herniation of the ileum through the Roux-en-Y small intestinal mesenteric window, with metastatic deposits fixing the hernia at its base to create a volvulus. The proximal transverse colon was very dilated and thin due to partial obstruction by the volvulus. Her treatment involved adhesiolysis and unraveling of the small intestinal volvulus. CONCLUSIONS: This is the first case report of a small intestinal volvulus following a Roux-en-Y anastomosis involving a metastatic gynacological malignancy.