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.

Predictive and prognostic values of cancer-associated serum antigen (CASA) and cancer antigen 125 (CA 125) levels prior to second-look laparotomy for ovarian cancer.

CA 125 and cancer-associated serum antigen (CASA) were measured prior to second-look laparotomy (SLL) to investigate their predictive and prognostic values in 93 patients treated for epithelial ovarian cancer FIGO stage II, III, or IV. Residual tumor was diagnosed at the SLL in 58 patients (62%). The optimal cutoff level was 15 U/ml for CA 125 and 8 U/ml for CASA. Using these levels, the sensitivity for detection of residual tumor was 40% for CA 125 and 22% for CASA. The combined use of the markers resulted in a sensitivity of 47% (diagnostic gain 6.9%; 95% confidence interval (CI), 0.14-13.44%). Microscopic tumor volumes were equally diagnosed by CASA and CA 125. The independent prognostic value of CA 125 (RR = 2.6; 95% CI, 2.0-3.2) and CASA (RR = 2.2; CI, 1.5-2.9) was established by means of Cox regression analysis of the covariation between survival, age, FIGO stage, histopathology, tumor grade, and bulk of residual tumor at the primary operation and CA 125 and CASA before the SLL. In conclusion, we found that CASA could supplement CA 125 measurement prior to SLL and reduce the number of SLLs. Furthermore, CASA had an independent prognostic value for survival which may be used together with other information in the planning of further treatment of the individual patient.

Association between colposcopic findings and histology in cervical lesions: the significance of the size of the lesion.

The relation between eight specific colposcopic diagnostic findings and the histologic grade of a cervical lesion in 896 women was evaluated. The size of the transformation zone (TZ), the size of the lesion, the intensity of the color tone, distinct margins, the pathology of the vessels, and the presence of micropapillae as single findings were highly statistically correlated to the histologic grade (P < 0.0001). By logistic regression analysis the risk for a higher histologic grade when assessed by colposcopy was greatest in women with variation of the acetowhite color (odds ratio (OR) = 16.0; 95% CI, 10.0-26.0) followed by coarse vessels (OR = 10.0; CI, 3.2-34.0). Lesion-size larger than 50% of the visible cervix had an OR of 3.6 (CI, 2.1-6.3). Extention beyond TZ had an OR of 0.4 (CI, 0.2-0.4) and larger TZ had an OR of 0.5 (CI, 0.3-0.9). In conclusion we found that the size of the cervical lesion had some independent predictive value and should be considered in future trials.

Diagnostic accuracy of cytology and colposcopy in cervical squamous intraepithelial lesions.

OBJECTIVE: To evaluate the diagnostic accuracy of cytology and colposcopy in women with an abnormal cervical smear using histology as the 'gold standard'. DESIGN: Survey of consecutively referred women with abnormal smear. SETTING: The out-patient colposcopical clinic of Herning Hospital, Denmark. PATIENTS: 813 women with a median age of 29.0 years (range 15-71 years) with their first abnormal smear. RESULTS: For detecting cervical high-grade lesions (HGL) the sensitivity of cytology was 41% (36-47%), of colposcopy 67% (62-72%) and in combination 75% (70-80%), so at least 25% of HGL were underestimated. Colposcopy underestimated more CIN-2 than CIN-3 lesions and more small lesions and lesions in smaller transformation zones. Cytology underestimated more CIN-2 lesions but equal numbers of small and large lesions and transformation zones. CONCLUSIONS: Colposcopy was a better tool for diagnosing HGL than cytology, but even in combination too many HGL were missed. All women with abnormal cytology should therefore have colposcopical and histological investigation and prospective studies of the natural history of cervical squamous lesions should include histological evidence.

Effect of previous frequency of headache, duration of fasting and caffeine abstinence on perioperative headache.

We have examined the relationship between perioperative headache and various factors in 219 patients who fasted from midnight and underwent minor surgery under general anaesthesia. Four to six hours after operation all patients completed a questionnaire on previous frequency of headache, daily consumption of caffeine and occurrence of perioperative headache. The duration of fasting, type of surgery, premedication and anaesthetic agents used were obtained from the anaesthetic record. After multivariate logistic regression analysis a significant risk of preoperative headache was found in patients who normally experienced headache more than twice a month (odds ratio (OR): 7.7; confidence interval (CI): 2.9-20.1), had a daily caffeine consumption > 400 mg/24 h (OR: 5.0; CI: 1.6-14.8) and who were anaesthetized after 12:00 (OR: 3.7; CI: 1.4-9.8). The risk of postoperative headache was significantly greater in patients with preoperative headache (OR: 16.9; CI: 6.5-43.8), daily caffeine consumption > 400 mg/24 h (OR: 3.9; CI: 1.5-9.6) and in those patients who received atracurium, which was similar to the risk of tracheal intubation.

[Ambulatory labor--experience from the first 2 years]. / Ambulante fødsler--erfaringer fra de første to år.

A trial arrangement for mandatory early discharge for all normal multiparae in 1990 and 1991 was evaluated. 63.4 percent of 1661 multiparous women were discharged within 24 hours of giving birth. During the period the mean time to discharge rose from 6 1/2 to 10 1/2 hours. Only 2.6 per cent of the children were readmitted to hospital, as were 1.2 percent of the mothers. The purpose of the trial was to save money, but in the trial period no money was saved from the early discharged women, the savings came from deductions in the perinatal service to the non-early discharged women.

[Duration of breast feeding after mandatory early discharge]. / Ammeperiodens varighed efter tvungen ambulant fødsel.

A trial arrangement for mandatory early discharge for all normal multiparae was started in 1990 and the duration of breastfeeding was investigated by a questionnaire. 89 mothers who stayed at the hospital were compared to 113 mothers who were discharged within 24 hours after delivery. The latter group was also compared to 122 early discharged mothers who delivered 14-17 months after the trial arrangement had started. The three groups were comparable in all aspects. After four weeks a large proportion of the later discharged mothers were still breastfeeding compared to the other two groups (p < 0.001). This difference disappeared later, hence when comparing the total duration of breastfeeding no differences were found between the three groups.

Ring chromosome 20 with loss of telomeric sequences detected by multicolour PRINS.

A ring chromosome 20 in a male infant with epileptic seizures, mental and somatic growth retardation, and behavioural disturbances is described. Conventional cytogenetics revealed the karyotype to be 46,XY,r(20)(pter-->qter) and no signs of mosaicism were found. Fluorescence in situ hybridisation using the clone p20Z1 identified the ring to be derived from chromosome 20. By counting 111 metaphases, only 7% were found to be missing the ring. The absence of telomeric sequences in the ring chromosome was demonstrated by multicolour PRINS: a three-step PRimed IN Situ labelling technique, using unlabelled primers. A terminal deletion of both arms thus seems to be the cause of the ring formation in the proband. Bivariate flow-analysis of chromosomes verified a deletion of the ring chromosome. The clinical and cytogenetic findings are compared with previous cases. A specific ring 20 syndrome seems justified.

[Prognosis for infants with birth weights less than 1,501 g treated in a central hospital]. / Prognosen for børn med fødselsvaegt under 1.501 g behandlet på et centralsygehus.

The mortality, morbidity and major sequelae for children with very low birth weight (< 1501 grams) born in the county of Ringkoebing, from 1981 to 1990 were reviewed retrospectively. Ventilator treatment was not used in the neonatal period. Neonatal survival was 63% (143 of 227 infants); the excess mortality compared with contemporary investigations was found in the group 1251-1500 grams and was mainly due to respiratory distress syndrome, which, in the whole population, was an important factor in 62% of neonatal deaths. Among 11 with bronchopulmonary dysplasia and six with Wilson-Mikity syndrome, only three died from Wilson-Mikity syndrome and three had minor pulmonary symptoms, but were healthy at one year of age. Twenty eight per cent of neonatal survivors received supplementary oxygen for more than 28 days. Six per cent of neonatal survivors had major neurological sequelae; i.e. higher neonatal mortality but probably lower incidence of chronic lung disease and major neurological sequelae than reported from contemporary Danish and foreign centres.

[Efficiency of a screening program for gestational diabetes]. / Effektiviteten af screening for gestationel diabetes.

From 1.1.1991-31.5.1989, we evaluated a selective screening system for detection of diabetes in pregnancy in an unselected consecutive population of 665 pregnant women. The screening procedure was carried out by the general practitioners and the midwives. The screening was based on clinical criteria for potential diabetes consisting of previous delivery of a large baby, a family history of diabetes and obesity combined with examination for glucosuria and determination of the fasting blood glucose concentration. Only 2% of the pregnant women were examined correctly and only two out of 665 women were found to have diabetes in pregnancy. The screening procedure failed when it was organised by general practitioners and midwives.

[Screening for gestational diabetes in Denmark]. / Screening for gestationel diabetes i Danmark.

A questionnaire regarding the screening procedure for gestational diabetes was sent to all maternity hospitals in Denmark in 1990. Only 15 out of 51 departments used the screening procedure as proposed by Guttorm & Pedersen. Glucosuria was a clinical risk factor in 49 of 51 departments. There was no agreement about the histories and clinical risk factors. The factors used were family history of diabetes, obesity, a previous infant weighing 9 lbs or more, a previous infant born with low gestational age, habitual abortion, previous perinatal deaths, previous preterm delivery, hydramnios, excessive fetal growth or glucosuria in the present pregnancy. No department used universal screening.

[Sick-leave during pregnancy--focusing on textile workers]. / Sygemelding i graviditeten--med fokus på tekstilarbejdere.

In order to illustrate the conditions involved in sick-leave during pregnancy, 593 consecutive parturient women received a questionnaire on the day after delivery. 48% of the pregnant women were certified as sick and 16% were admitted to hospital during pregnancy. The most common reasons for sick-leave were threatening abortion (19%), haemorrhage (18%) and threatening premature delivery (15%). The duration of sick-leave averaged 15 weeks as compared with 7.3 weeks in Denmark as a whole. In the subgroup of textile workers, 71% considered that the work was physically stressing and 70% were certified sick. Compared with all of the other occupationally active women, textile workers were more frequently certified sick, considered that their work was more physically stressing and had more frequently required sick-leave but were more rarely admitted to hospital. Similarly, textile workers had a greater risk for sick-leave on account of threatening abortion, pelvic loosening or pain in the locomotor system.

[The course of postpartum period after mandatory ambulatory labor]. / Barselsperiodens forløb efter tvungen ambulant fødsel.

Mandatory early discharge for all normal multiparae was introduced as a trial arrangement in the County of Ringkøbing from 1.1.1990. A total of 113 early discharged women and 90 patients who remained in hospital participated in a questionnaire investigation comprising 41 questions about problems and need for support during the first postpartum period and about satisfaction with the postpartum period. A total of 64% of all the multiparae were early discharged and were discharged 4.2 hours after the delivery. On the whole, the women were satisfied with the postpartum period and only few problems in infants or mothers occurred. The early discharged group, however, as compared with the control group, stated that they had received less satisfactory support concerning breast-feeding (p less than 0.005) and that, in general, they had received less support from friends (p less than 0.01) and hospital staff (p = 0.04). The group of early discharged felt that they had received less satisfactory information (p less than 0.005) and, on the whole, they were less satisfied with the postpartum period (p less than 0.005). In addition, the group who were early discharged had 67% more telephone conversations with and 127% more visits from the midwife, health nurse or practitioner.

[Morbidity among mothers and infants after ambulatory deliveries]. / Morbiditet hos mødre og børn efter ambulant fødsel.

Postpartum early discharge programs are reviewed. Few programs were mandatory and both primi- and multiparae were included. Discharge varied from two to 72 hours after delivery. Nearly all programs had prenatal preparation and all patients had postpartum follow-up at home. Approximately one per cent of the infants were readmitted mostly on account of hyperbilirubinemia and infections, and half as many mothers were readmitted mostly for hemorrhage and endometritis. Infants discharged very early were readmitted more frequently than others. There were no statistical significant difference in mortality or morbidity between mothers or infants in early discharge groups and control groups.

[Prognosis of patients with rectal cancer treated in a department of general surgery]. / Prognosen for patienter med cancer recti behandlet på en almen kirurgisk afdeling.

The results of treatment of 355 patients with adenocarcinoma of the rectum treated during the period 1973-1982 in a department for general surgery were compared with the results obtained in other more specialized departments. The 5 year survival rate, corrected for deaths from other causes than cancer of the rectum, was calculated retrospectively to be 35% which was comparable with certain departments. Some highly specialized departments had, however, better results. The postoperative mortality was high (14%). Highly differentiated tumours resulted in better prognoses than poorly differentiated tumours (p less than 0.001). The median age was relatively high (67 years) and relatively many of the patients were men (62%). Patients in whom haemorrhage was the first symptom had better prognoses than patients with other symptoms (p = 0.018). The prognoses were similar regardless of the durations of symptoms.

[Upper abdominal pain and pre-eclampsia--HELLP syndrome]. / Ovre abdominalsmerter og praeeklampsi--HELLP-syndrom.

A 26 year old primiparous woman in the 30th gestational week presented with upper right abdominal pain. Clinical examination revealed direct tenderness under the right curverture, oedema, hypertension and proteinuria. Ultrasound scanning showed a normal gallbladder. Laboratory findings revealed Hemolysis, Elevated Liver enzymes and Low Platelet count. On account of suspected HELLP-syndrome cesarean section was performed. We suggest screening of all pregnant with upper abdominal symptoms suspected for preeclampsia by measuring platelet count and liver enzymes.