Team performance during vacuum-assisted vaginal delivery: video review of obstetric multidisciplinary teams.

Introduction: Vacuum extraction is generally considered an operator-dependent task, with most attention directed toward the obstetrician's technical abilities (1-3). Little is known about the effect of the team and non-technical skills on clinical outcomes in vacuum-assisted delivery. This study aimed to investigate whether the non-technical skills of obstetricians were correlated with their level of clinical performance via the analysis of video recordings of teams conducting actual vacuum extractions. Methods: We installed between two or three video cameras in each delivery room at Aarhus University Hospital and Horsens Regional Hospital and obtained 60 videos of teams managing vacuum extraction. Appropriate consent was obtained. Two raters carefully reviewed the videos and assessed the teams' non-technical skills using the Assessment of Obstetric Team Performance (AOTP) checklist, rating all items on a Likert scale score from 1 to 5 (1 = poor; 3 = average; and 5 = excellent). This resulted in a total score ranging from 18 to 90. Two different raters independently assessed the teams' clinical performance (adherence to clinical guidelines) using the TeamOBS-Vacuum-Assisted Delivery (VAD) checklist, rating each item (0 = not done, 1 = done incorrectly; and 2 = done correctly). This resulted in a total score with the following ranges (low clinical performance: 0-59; average: 60-84; and high: 85-100). Interrater agreement was analyzed using intraclass correlation (ICC), and the risk of high or low clinical performance was analyzed on a logit scale to meet the assumption of normality. Results: Teams that received excellent non-technical scores had an 81% probability of achieving high clinical performance, whereas this probability was only 12% among teams with average non-technical scores (p < 0.001). Teams with a high clinical performance often had excellent behavior in the non-technical items of "team interaction," "anticipation," "avoidance fixation," and "focused communication." Teams with a low or average clinical performance often neglected to consider analgesia, had delayed abandonment of the attempted vaginal delivery and insufficient use of appropriate fetal monitoring. Interrater reliability was high for both rater-teams, with an ICC for the non-technical skills of 0.83 (95% confidence interval [CI]: 0.71-0.88) and 0.84 for the clinical performance (95% CI: 0.74-0.90). Conclusion: Although assisted vaginal delivery by vacuum extraction is generally considered to be an operator-dependent task, our findings suggest that teamwork and effective team interaction play crucial roles in achieving high clinical performance. Teamwork helped the consultant anticipate the next step, avoid fixation, ensure adequate analgesia, and maintain thorough fetal monitoring during delivery.

The importance of non-technical performance for teams managing postpartum haemorrhage: video review of 99 obstetric teams.

OBJECTIVE: Little is known about how teams' non-technical performance influences clinical performance in obstetric emergencies such as postpartum haemorrhage. DESIGN: Video review - observational study. SETTING: A university hospital (5000 deliveries) and a regional hospital (2000 deliveries) in Denmark. POPULATION: Obstetric teams managing real-life postpartum haemorrhage. METHODS: We systematically assessed 99 video recordings of obstetric teams managing real-life major postpartum haemorrhage. Exposure was the non-technical score (AOTP); outcomes were the clinical performance score (TeamOBS) and the delayed transfer to the operating theatre (defined as blood loss >1500 ml in the delivery room). RESULTS: Teams with an excellent non-technical score performed significantly better than teams with a poor non-technical score: 83.7 versus 0.3% chance of a high clinical performance score (P < 0.001), 0.2 versus 80% risk of a low clinical performance score (P < 0.001), and 3.5 versus 31.7% risk of delayed transfer to the operating theatre (P = 0.008). The results remained robust when adjusting for potential confounders such as bleeding velocity, aetiology, time of day, team size, and hospital. The specific non-technical skills associated with high clinical performance were vigilance, role assignment, problem-solving, management of disruptive behavior, and leadership. Communication with the patient and closing the loop were of minor importance. All performance assessments showed good reliability: the intraclass correlation was 0.97 (95% CI 0.96-0.98) for the non-technical score and 0.84 (95% CI 0.76-0.89) for the clinical performance score. CONCLUSION: Video review offers a new method and new perspectives for research in obstetric teams to identify how teams become effective and safe; the skills identified in this study can be included in future obstetric training programmes. TWEETABLE ABSTRACT: Non-technical performance is important for teams managing postpartum haemorrhage; video review of 99 obstetric teams.

Knowledge of prenatal screening and psychological management of test decisions.

OBJECTIVES: To study associations between pregnant women's knowledge of prenatal screening and decisional conflict in deciding whether to participate in first-trimester screening for Down syndrome in a setting of required informed consent, and to study associations between knowledge and personal wellbeing, and worries in pregnancy. METHODS: A population-based cross-sectional study with 6427 pregnant women consecutively included before the time of a nuchal translucency scan. Participants were recruited from three Danish obstetric departments offering prenatal screening free of charge. The results presented are based on 4111 pregnant women (64%). Knowledge was measured using 15 questions. The primary outcomes were measured using pre-existing validated scales, i.e. The Decisional Conflict Scale, the WHO Well-Being Index and the Cambridge Worry Scale. Associations were analyzed by multivariate logistic and linear regression analyses. RESULTS: A higher level of knowledge was associated with less decisional conflict when deciding whether to participate in first-trimester Down syndrome screening (adjusted odds ratio 1.31 (95% CI, 1.26-1.37)). An increased level of knowledge was also associated with higher levels of wellbeing (adjusted linear coefficient 0.51 (95% CI, 0.26-0.75), P < 0.001). Knowledge was not associated with worries, either in general or specifically about something being wrong with the baby. CONCLUSION: The results of this study indicate the importance of ensuring a high level of knowledge for pregnant women making choices about participation in prenatal screening for Down syndrome in order to improve the psychological management of test decisions.

First-trimester Down syndrome screening: pregnant women's knowledge.

OBJECTIVES: The primary aim of this study was to assess pregnant women's knowledge of first-trimester combined Down syndrome screening in a setting of required informed consent. As the secondary aim, we wanted to identify relevant differences in knowledge level among subgroups of pregnant women, including those informed in different ways about prenatal examinations. METHODS: Data stem from a population-based cross-sectional questionnaire study including 15 multiple-choice questions assessing knowledge of different aspects of screening. Included were 6427 first-trimester pregnant women from three Danish obstetric departments offering prenatal screening free of charge. Both participants and non-participants in the screening program were included. The results are based on 4095 responders (64%). Differences between subgroups were examined using chi-squared tests and logistic regression analysis. Estimates are stated with 95% CI. RESULTS: The majority of the participants (87.6 (86.6-88.6)% to 92.6 (91.7-93.3)%) correctly identified the test concept and the main condition being screened for. Fewer participants (16.4 (15.3-17.6)% to 43.3 (41.8-44.8)%) correctly recognized test accuracy and the potential risk of adverse findings other than Down syndrome. Knowledge level was positively associated with length of education (adjusted ORs 1.0 (0.8-1.4) to 3.9 (2.4-6.4)) and participation in the screening program (adjusted OR 0.9 (0.6-1.3) to 5.9 (3.9-8.8)). Participation in an individual information session was weakly associated with more knowledge. CONCLUSION: The majority of the pregnant women correctly identified the test concept and the main condition being screened for. The pregnant women were found less knowledgeable on test accuracy and drawbacks.

Randomised trial of structured antenatal training sessions to improve the birth process.

OBJECTIVE: To compare the birth process in nulliparous women enrolled in a structured antenatal training programme, the 'Ready for Child' programme, with women allocated to routine care. DESIGN: A randomised controlled trial. SETTING: A Danish university hospital. PARTICIPANTS: Thousand hundred and ninety-three nulliparous women, recruited before week 22 + 0. Methods Compliance to the protocol was monitored by questionnaires sent to the women by email, and by data from the local birth cohort database. Data were analysed according to the 'intention-to-treat' principle. INTERVENTION: Women were randomised to receive 9 hours of antenatal training or no formalised training. Of the 1193 women, 603 were randomised to the intervention group and 590 were allocated to the reference group. MAIN OUTCOME MEASURES: Cervix dilatation on arrival at the maternity ward, use of pain relief and medical interventions during the birth process, and the women's birth experience. RESULTS: Women who attended the 'Ready for Child' programme arrived at the maternity ward in active labour more often than the reference group [relative risk (RR) 1.45, 95% confidence interval (95% CI) 1.26-1.65, P < 0.01], and they used less epidural analgesia during labour (RR 0.84, 95% CI 0.73-0.97, P < 0.01) but not less pain relief overall (RR 0.99, 95% CI 0.94-1.04, P < 0.72). Medical interventions and the women's self-reported birth experiences were similar in the two groups. We found no adverse effects of the intervention. CONCLUSION: Attending the 'Ready for Child' programme may help women to cope better with the birth process. Adverse effects are few, if any.

Postpartum perineal repair performed by midwives: a randomised trial comparing two suture techniques leaving the skin unsutured.

OBJECTIVE: To compare a continuous suture technique with interrupted stitches using inverted knots for postpartum perineal repair of second-degree lacerations and episiotomies. DESIGN: A double-blind randomised controlled trial. SETTING: A Danish university hospital with more than 4800 deliveries annually. POPULATION: A total of 400 healthy primiparous women with a vaginal delivery at term. METHOD Randomisation was computer-controlled. Structured interviews and systematic assessment of perineal healing were performed by research midwives blinded to treatment allocation at 24-48 hours, 10 days and 6 months postpartum. Pain was evaluated using a visual analogue scale and the McGill Pain Questionnaire. Wound healing was evaluated using the REEDA scale and by assessment of gaping wounds >0.5 cm. Analysis complied with the intention-to-treat principle. MAIN OUTCOME MEASURES: The primary outcome was perineal pain 10 days after delivery. Secondary outcomes were wound healing, patient satisfaction, dyspareunia, need for resuturing, time elapsed during repair and amount of suture material used. RESULTS: A total of 400 women were randomised; 5 women withdrew their consent, leaving 395 for follow up. The follow-up rate was 98% for all assessments after delivery. No difference was seen in perineal pain 10 days after delivery. No difference was seen in wound healing, patient satisfaction, dyspareunia or need for resuturing. The continuous suture technique was significantly faster (15 versus 17 minutes, P = 0.03) and less suture material was used (one versus two packets, P < 0.01). CONCLUSION: Interrupted, inverted stitches for perineal repair leaving the skin unsutured appear to be equivalent to the continuous suture technique in relation to perineal pain, wound healing, patient satisfaction, dyspareunia and need for resuturing. The continuous technique, however, is faster and requires less suture material, thus leaving it the more cost-effective of the two techniques evaluated.

Risk of postpartum urinary incontinence associated with pregnancy and mode of delivery.

AIM: The aim was to estimate the postpartum urinary incontinence (PP UI) impact of precursory UI during pregnancy (PR UI) and delivery performed by cesarean section (CS) vs. vaginal childbirth (VC). METHODS: Among the members of two population samples, in total 8610 women aged 20-59 years, 1232 had their first childbirth and 642 their second childbirth within 13-120 months prior to responding to a questionnaire that included information on PR UI occurrence, mode of delivery and PP UI occurrence. RESULTS: CS was applied in 12.2% of first childbirths, and 87.8% thus delivered vaginally; PR UI during the pregnancy leading to the first childbirth was reported by 15.6%, and a total of 26.3% reported PP UI. An increased PP UI occurrence was reported following VC (28.3% vs. 12.0% in women undergoing CS, p < 0.001) and after PR UI (first childbirth, 66.7% vs. 18.8% in women not reporting PR UI, p < 0.0001). Among cases of PP UI following the first childbirth, 56.1% and 69.5% of cases could be attributed to PR UI and VC, respectively. CONCLUSIONS: The highest PP UI risks were found among women complaining of PR UI, which manifested itself as a crucial, independent precursor of PP UI. Because of the high frequency of VC, more than seven out of 10 cases of UI following the first childbirth, however, seemed to be attributable to VC. The present data did not lend significant support to the assumption that the PP UI risk is also lowered after a subsequent delivery by CS.

Menstrual cycle, female hormone use and urinary incontinence in premenopausal women.

Our aim was to study the association between menstrual cycle characteristics, the use of female hormones and urinary incontinence (UI) in an age-stratified random population sample of 2158 premenopausal women who answered a questionnaire on urinary incontinence. Episodes of UI during 1997 were reported by 18.3% and one or more episodes of UI the preceding year by 3.9%. Based on multiple logistic regression, self-reported UI the day before answering the questionnaire was found to be associated with current hormone use for menstrual disorders (OR 2.7, 95% CI 1.2-6.6), a recent decrease in bleeding duration (OR 2.2, 95% CI 1.3-3.7), being on days 11-15 before the expected end of the menstrual cycle the preceding day (OR 2.6, 95% CI 1.3-5.0), and with general UI risk factors, i.e. vaginal childbirth, childhood enuresis, BMI >/=530 and exposure to abdominal and/or gynecologic surgery. The findings are in accordance with a hypothesis of hormonal variation being a risk indicator of UI in premenopausal women.

Correlates of urinary incontinence in pregnancy.

In a population sample, the period prevalence of urinary incontinence (UI) during pregnancy was found to be 19.9% and 24.1% among 352 nulliparous and 290 primiparous women, respectively. The first UI episode ever was experienced by 16.7% and 7.0% during the two last trimesters of the first and second pregnancies, respectively. None of the pregnancy-specific risk factors, such as emesis and birthweight, was significantly associated with UI during pregnancy. Previous UI was a significant risk factor for period prevalent UI during pregnancy, explaining 34% and 83% of pregnancy UI for the nulliparous and the primiparous, respectively. The present data suggest pregnancy UI not to be provoked by the mere onset of pregnancy, but by increasing hormonal concentrations or local tissue changes caused by hormones, whereas there was no support for a theory based on increasing pressure on the bladder caused by the weight of the fetus.

[The use of Doppler-ultrasound in obstetrics]. / Anvendelsen af Doppler-ultralyd i obstetrikken.

Several investigations have suggested an association between intrauterine growth retardation or an adverse neonatal outcome and increased vascular resistance in the fetal and maternal uteroplacental circulation assessed by Doppler-ultrasound. Meta-analysis of nine randomized controlled trials showed that the use of Doppler-ultrasound in the surveillance of high-risk pregnancies reduced the perinatal mortality considerably. Taken together, there is evidence to suggest that Doppler-ultrasound is a valuable tool for discriminating between normal small and "sick" small fetuses. Screening in unselected populations of low-risk pregnancies, however, seems to be without any benefit.

All-trans retinoic acid in acute promyelocytic leukemia in late pregnancy.

All-trans retinoic acid (ATRA) was used in a case of acute promyelocytic leukemia (APL) in late pregnancy. A very prompt maternal risk reduction was achieved with subsequent complete remission and spontaneous delivery of two live children in whom no fetal damage seems to have occurred.

All-trans retinoic acid in acute promyelocytic leukemia in late pregnancy.

All-trans retinoic acid (ATRA) was used in a case of acute promyelocytic leukemia (APL) in late pregnancy. A very prompt maternal risk reduction was achieved with subsequent complete remission and spontaneous delivery of two live children in whom no fetal damage seems to have occurred.

Normal serum relaxin in women with disabling pelvic pain during pregnancy.

As part of a case control within cohort study 472 pregnant women answered a questionnaire post partum. Serum relaxin concentrations were measured by a homologous ELISA in samples collected from the women in the 30th week of pregnancy. Serum relaxin concentrations were not associated with pregnancy-associated pelvic pain. Thus, normal pregnant women without pelvic pain (n = 118) had mean concentrations of 343 pg/ml compared to 332 pg/ml in women (n = 59) with pelvic pain and some restriction in daily activities and to 349 pg/ml in women (n = 9) with severe pregnancy-induced pelvic pain. The present results do not suggest a role for relaxin in symptom-giving pelvic relaxation during human pregnancy.

Placental abruption. A case-control investigation.

The course of pregnancy and labour, neonatal outcome and social circumstances, were compared between 87 women with placental abruption and a control group of 5697 women. First and second trimester haemorrhage, amniocentesis, congenital malformations, maternal smoking and a job involving much standing or walking were associated with placental abruption.

Iron supplementation during pregnancy.

192 pregnant women were consecutively randomized to either a vitamin-mineral pill or a vitamin mineral pill with a high iron content in a prospective, open, randomized investigation. The participants were advised about iron-rich foodstuffs twice during pregnancy. Iron status of the mother proved to be without any significance for the outcome of pregnancy. A serum ferritin level of 80 pmol/l in mid-pregnancy followed by a control in the last trimester was suggested as a guide in deciding of whether or not to prescribe supplementary iron during pregnancy.

No effect of intralesional injection of interferon on moderate cervical intraepithelial neoplasia.

Women with histologically confirmed cervical intraepithelial neoplasia grade 2 (CIN 2) were treated in a double blind investigation of treatment with intralesioneal interferon alpha-2b (Intron a). Before treatment commenced, the existence and the types of human papilloma-virus (HPV) were assessed in [35S] methionine-labelled cervical biopsies by the determination of specific protein markers. Pronounced side effects occurred in all the women treated with interferon and the trial was stopped when it became apparent that there were no obvious beneficial effects. No positive benefits of interferon treatment were detected on either the CIN 2 or on the persistence of HPV types. It is concluded that intralesioneal injection of interferon has no place in the treatment of CIN.

[The relation of birth weight and gestational age in a group of infants in Jutland with special reference to diagnosing infants with intrauterine growth retardation]. / Sammenhaengen mellem fødselsvaegt og gestationsalder blandt en gruppe jyske børn med henblik på at diagnosticere intrauterint vaekstretarderede børn.

The relationship between birthweight (BW) and gestational age (GA) in 14,276 Danish children with GA of 35 to 42 completed weeks was illustrated employing 10%, 50% and 90% percentile curves. The curves were sex-specific. The number of light for dates (LFD) children defined by means of the 10% percentile (BW below 10th percentile) was 1,351 compared to 848 children when using the curve currently employed. The latter curve was based upon foreign children and moreover was not sex-specific. It is concluded that sex-specific and updated curves representing the population studied are mandatory in the diagnosis of LFD-children.

[The course of delivery in a group a low-risk primipara women]. / Fødselsforløb hos en gruppe lavrisiko-primiparae.

The course of delivery in 1,545 primiparae who were considered to be in the low-risk group at the commencement of labour as assessed by the previous directives issued by the Danish Ministry of Health (1976) were reviewed. 2/3 were delivered normally as episiotomy was not regarded as a complication. 1/3 had complicated deliveries. In 350, the contractions were abnormal and intervention was required. 1/3 of these were delivered instrumentally. Haemorrhage of more than 500 ml, intrauterine asphyxia and Apgar score less than or equal to 7 at 1 minute occurred frequently in this group. A total of 1,195 did not receive treatment to improve contractions and, in this group, instrumental delivery was undertaken in 10%. Following normal labour pains and spontaneous delivery, complications in the third stage were observed in 77 out of 1,075 patients, including haemorrhage of more than 500 ml in 38 patients. Six infants in this group had Apgar scores less than or equal to 7 at 5 minutes. In the group with abnormal contractions and/or instrumental delivery, haemorrhage of more than 500 ml, retention of the placenta and signs of perinatal asphyxia occurred, however, significantly more frequently. The authors consider that home deliveries in primiparae cannot be recommended. Primiparae should be advised to be delivered in hospital as it is not always possible to predict complications.

[Breech presentation deliveries]. / Fødsel med foster i underkropspraesentation.

A total of 5,519 consecutive single deliveries at term were analysed for maternal and foetal factors associated with breech presentation (UK). The protocol in this department for breech deliveries which permits vaginal delivery of foetuses estimated to be between 2,400 and 3,800 g in cases where the pelvis was considered to be clinically normal, was also evaluated. Breech presentation was found in 173 cases. In 102 of these circumstances were present which permitted trial of vaginal delivery. Seventy-seven were delivered vaginally. An increased frequency of low Apgar scores (less than 8) after one minute was demonstrated among infants delivered vaginally in the breech presentation on comparison with infants delivered by Caesarean section, whereas low scoring after five minutes occurred with the same frequency. One infant died during delivery. Follow-up of infants delivered in breech presentation (mean period of observation two years) showed developmental disturbances in three of the vaginally delivered infants and in five of those delivered abdominally. Two of the infants delivered abdominally had severe cerebral paresis and psychomotor retardation without evidence of intrauterine or severe neonatal asphyxia. On comparison with the population delivered in cephalic presentation (HST), significantly increased frequencies of primiparity and light-for-dates infants were found in the breech presentations. Low Apgar score after one minute was significantly more frequent in breech presentations while low Apgar scoring after five minutes occurred with the same frequency. The perinatal mortality rates in breech and cephalic presentations were 17.3 and 4.7 per 1,000 respectively. Following correction for lethal malformations, the rates were 5.8 and 3.8 per 1,000, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)