Learning From Experience: Qualitative Analysis to Develop a Cognitive Task List for Vaginal Breech Deliveries.

OBJECTIVE: Achieving clinical competence in managing safe vaginal breech delivery (VBD) is challenging in contemporary obstetrics. Novel educational strategies are required, as exposure of obstetric trainees to VBD remains limited. The aim of this study was to identify the verbal and non-verbal skills required to manage VBD through filmed demonstration by experts. METHODS: Labour and delivery nursing staff at three large university-affiliated hospitals identified clinicians whom they considered skilled in VBD. Obstetricians consistently identified were invited to participate in the study. Participants were filmed performing a VBD on a birth simulator while discussing their assessment, technique, and providing clinical pearls based on their experience. Two study members reviewed all videos and documented verbal and non-verbal components of the assessment, grouped them into common themes, and produced an integrated summary. This was circulated to all participants and reviewed by senior obstetricians from outside Canada. RESULTS: Seventeen clinicians were identified; 12 (70%) consented to participation. Themes identified were meticulous assessment and pre-pregnancy counselling; roles of the multidisciplinary team; need for careful and appropriate communication with parents; specific techniques of the delivery; and postpartum care and documentation. A clinical task list was generated based on this analysis. CONCLUSION: Derived from clinicians with extensive experience, we have developed a comprehensive task list outlining the important features involved in safe VBD. Common themes in the experts' teaching for safe VBD included rigorous antepartum selection and counselling, appreciation for when to convert to Caesarean section, and a "hands off" delivery technique.

Objectif : De nos jours, dans le domaine de l'obstétrique, il est difficile d'acquérir les compétences cliniques nécessaires à la tenue d'un accouchement vaginal du siège (AVS) en toute sûreté. Des stratégies pédagogiques novatrices sont requises, puisque l'exposition des stagiaires en obstétrique à l'AVS demeure limitée. Cette étude avait pour objectif d'identifier, au moyen de démonstrations filmées par des spécialistes, les compétences verbales et non verbales nécessaires à la prise en charge de l'AVS. Méthodes : Les membres du personnel infirmier de la salle de travail et d'accouchement de trois importants hôpitaux universitaires ont identifié les cliniciens qu'ils considéraient comme étant compétents en matière d'AVS. Les obstétriciens les plus souvent identifiés ont été conviés à participer à l'étude. Les participants ont été filmés alors qu'ils procédaient à un AVS sur un simulateur d'accouchement; à ces occasions, nous leur avons également demandé de nous entretenir de leur évaluation et de leur technique, ainsi que de nous fournir des conseils cliniques issus de leur expérience. Deux membres de l'étude ont passé en revue toutes les vidéos et ont documenté les composantes verbales et non verbales de l'évaluation, les ont groupées en thèmes communs et en ont rédigé une synthèse. Cette synthèse a été transmise à tous les participants et a été analysée par des obstétriciens expérimentés de l'étranger. Résultats : Dix-sept cliniciens ont été identifiés; 12 (70 %) ont consenti à participer à l'étude. Parmi les thèmes identifiés, on trouvait les suivants : évaluation méticuleuse et counseling prégrossesse; rôles de l'équipe multidisciplinaire; nécessité d'une communication attentive et adéquate avec les parents; techniques d'accouchement particulières; et documentation et soins postpartum. Une liste des tâches cliniques a été générée en fonction des résultats de cette analyse. Conclusion : En nous inspirant de cliniciens vastement expérimentés, nous avons élaboré une liste exhaustive de tâches soulignant les caractéristiques importantes de la tenue d'un AVS en toute sûreté. Parmi les thèmes courants relevés par ces spécialistes à ce sujet, on trouvait la tenue antepartum d'une sélection et d'un counseling rigoureux, les connaissances requises pour savoir quand convertir l'intervention en césarienne et l'utilisation d'une technique d'accouchement « passive ¼ (hands off).

Learning From Experience: Development of a Cognitive Task List to Perform a Safe and Successful Non-Rotational Forceps Delivery.

OBJECTIVE: Increased rates of delivery by Caesarean section have resulted in a reduction in rates of instrumental deliveries. This has led to a new educational challenge for teaching and development of skills. In teaching trainees, there are subconscious tasks that the supervising staff may not review because they are automatic. This study aimed to create a new tool to meet this challenge: to identify the core steps required to perform a non-rotational forceps delivery safely and successfully. METHODS: Labour and delivery nursing staff of three large teaching hospitals were asked to identify clinicians they considered to be particularly skilled in non-rotational forceps deliveries. Obstetricians who were identified consistently in this way were invited to participate in the study. After providing written consent, participants were then filmed performing a non-rotational forceps delivery on a model. Two clinicians reviewed all videos and documented verbal and non-verbal components of the assessment. Thematic analysis combined findings into an integrated summary. The initial summary was then circulated to all participants for their approval. RESULTS: Seventeen clinicians were identified and consented. Themes identified included the need for careful assessment of suitability for operative delivery, the role of the multidisciplinary team, the need for careful and appropriate communication with the parents, the technique of delivery itself, and postpartum care and documentation. CONCLUSION: In the core steps identified, the clinicians balanced respect for the "elegant technique" of non-rotational forceps deliveries with careful assessment and knowing when to stop if safety criteria were not met.

Objectif : La hausse des taux d'accouchement par césarienne a entraîné une baisse des taux d'accouchement instrumental. Cette situation a donné lieu à un nouveau défi sur le plan pédagogique en ce qui concerne l'enseignement et l'acquisition de compétences. Dans le cadre de l'enseignement offert aux stagiaires, certaines tâches menées par le subconscient pourraient passer inaperçues (car elles sont automatiques) et donc ne pas être abordées par le personnel de supervision. Cette étude avait pour but de créer un nouvel outil pour relever ce défi : identifier les étapes de base requises pour la réussite d'un accouchement par forceps non rotationnels en toute sûreté. Méthodes : Les membres du personnel infirmier de la salle de travail et d'accouchement de trois hôpitaux universitaires d'envergure ont identifié les cliniciens qu'ils considéraient comme étant particulièrement compétents en matière d'accouchements par forceps non rotationnels. Les obstétriciens dont les noms revenaient les plus souvent ont été conviés à participer à l'étude. Après avoir offert leur consentement par écrit, les participants ont été filmés pendant l'exécution d'un accouchement par forceps non rotationnels sur un modèle. Deux cliniciens ont passé en revue toutes les vidéos et ont documenté toutes les composantes verbales et non verbales de l'évaluation. Une analyse thématique a combiné les résultats en un résumé intégré. Le résumé initial a par la suite été distribué aux participants pour que l'on obtienne leur approbation. Résultats : Dix-sept cliniciens ont ainsi été identifiés et ont consenti à participer à l'étude. Les thèmes identifiés ont été les suivants : la nécessité de procéder à une évaluation rigoureuse de l'admissibilité de la patiente à un accouchement opératoire, le rôle de l'équipe multidisciplinaire, la nécessité d'une communication rigoureuse et adaptée avec les parents, la technique d'accouchement en tant que telle et les soins et la documentation pendant le postpartum. Conclusion : Au moment d'identifier les étapes de base, les cliniciens ont mis en balance leur respect envers « l'élégance de la technique ¼ utilisée pour les accouchements par forceps non rotationnels avec la nécessité de procéder à une évaluation rigoureuse et le fait de savoir quand mettre fin à l'intervention lorsque les critères de sûreté ne peuvent être satisfaits.

Learning From Experience: Qualitative Analysis to Develop a Cognitive Task List for Kielland Forceps Deliveries.

OBJECTIVE: Fetal malposition is a common indication for Caesarean section in the second stage of labour. Rotational (Kielland) forceps are a valuable tool in select situations for successful vaginal delivery; however, learning opportunities are scarce. Our aim was to identify the verbal and non-verbal components of performing a safe Kielland forceps delivery through filmed demonstrations by expert practitioners on models to develop a task list for training purposes. METHODS: Labour and delivery nurses at three university-affiliated hospitals identified clinicians whom they considered skilled in Kielland forceps deliveries. These physicians gave consent and were filmed performing Kielland forceps deliveries on a model, describing their assessment and technique and sharing clinical pearls based on their experience. Two clinicians reviewed the videos independently and recorded verbal and non-verbal components of the assessment; thematic analysis was performed and a core task list was developed. The algorithm was circulated to participants to ensure consensus. RESULTS: Eleven clinicians were identified; eight participated. Common themes were prevention of persistent malposition where possible, a thorough assessment to determine suitability for forceps delivery, roles of the multidisciplinary team, description of the Kielland forceps and technical aspects related to their use, the importance of communication with the parents and the team (including consent, debriefing, and documentation), and "red flags" that indicate the need to stop when safety criteria cannot be met. CONCLUSION: Development of a cognitive task list, derived from years of experience with Kielland forceps deliveries by expert clinicians, provides an inclusive algorithm that may facilitate standardized resident training to enhance education in rotational forceps deliveries.

Objectif : La malposition fœtale constitue une indication courante menant à la tenue d'une césarienne au cours du deuxième stade du travail. Les forceps de Kielland sont un outil utile dans certaines situations pour assurer la réussite de l'accouchement vaginal; toutefois, les occasions d'en apprendre l'utilisation se font rares. Nous avions pour objectif d'identifier les composantes verbales et non verbales de la tenue en toute sûreté d'un accouchement au moyen de forceps de Kielland en filmant des démonstrations menées par des praticiens spécialisés sur des modèles, et ce, dans le but de rédiger une liste de tâches à des fins pédagogiques. Méthodes : Les infirmières du service d'obstétrique de trois hôpitaux universitaires ont identifié les cliniciens qu'elles considéraient comme étant compétents en ce qui concerne les accouchements par forceps de Kielland. Ces médecins ont consenti à l'entreprise et ont été filmés pendant l'exécution d'un accouchement par forceps de Kielland sur un modèle; pendant cette simulation, ils ont pris soin de décrire leur évaluation et leur technique, en plus de partager des conseils cliniques fondés sur leur expérience. Deux cliniciens ont passé en revue les vidéos de façon indépendante et ont consigné les composantes verbales et non verbales de l'évaluation; une analyse thématique a été menée et une liste de tâches de base a été élaborée. L'algorithme a été distribué aux participants afin d'assurer un consensus. Résultats : Onze cliniciens ont été identifiés; huit d'entre eux ont consenti à participer au projet. Les thèmes communs ont été la prévention de la malposition persistante (dans la mesure du possible), une évaluation exhaustive visant à déterminer la pertinence de la tenue d'un accouchement par forceps, les rôles de l'équipe multidisciplinaire, la description des forceps de Kielland et les aspects techniques associés à leur utilisation, l'importance de la communication avec les parents et l'équipe (y compris le consentement, le débreffage et la documentation), et les « signaux d'alarme ¼ qui indiquent la nécessité de mettre fin à l'intervention lorsque les critères d'innocuité ne peuvent être assurés. Conclusion : L'élaboration d'une liste de tâches cognitives, tirée des années d'expérience de cliniciens spécialisés en ce qui a trait à la tenue d'accouchements par forceps de Kielland, offre un riche algorithme qui pourrait faciliter la standardisation de la formation des résidents, de façon à améliorer l'enseignement de tels accouchements.

Learning from experience: development of a cognitive task-list to assess the second stage of labour for operative delivery.

OBJECTIVE: Ensuring the availability of operative vaginal delivery is one strategy for reducing the rising Caesarean section rate. However, current training programs appear inadequate. We sought to systematically identify the core steps in assessing women in the second stage of labour for safe operative delivery, and to produce an expert task-list to assist residents and obstetricians in deciding on the safest mode of delivery for their patients. METHODS: Labour and delivery nursing staff of three large university-associated hospitals identified clinicians they considered to be skilled in operative vaginal deliveries. Obstetricians who were identified consistently were invited to participate in the study. Participants were filmed performing their normal assessment of the second stage of labour on a model. Two clinicians reviewed all videos and documented all verbal and non-verbal components of the assessment; these components were grouped into overarching themes and combined into an integrated expert task-list. The task-list was then circulated to all participants for additional comments, checked against SOGC guidelines, and redrafted, allowing production of a final expert task-list. RESULTS: Thirty clinicians were identified by this process and 20 agreed to participate. Themes identified were assessment of suitability, focused history, physical examination including importance of an abdominal examination, strategies to accurately assess fetal position, station, and the likelihood of success, cautionary signs to prompt reassessment in the operating room, and warning signs to abandon operative delivery for Caesarean section. Communication strategies were emphasized. CONCLUSION: Having expert clinicians teach assessment in the second stage of labour is an important step in the education of residents and junior obstetricians to improve confidence in managing the second stage of labour.

Objectif : Le fait d'assurer la disponibilité de l'accouchement vaginal opératoire constitue l'une des stratégies pouvant permettre d'atténuer la hausse des taux de césarienne. Toutefois, les programmes de formation actuels semblent inadéquats. Nous avons cherché à identifier, de façon systématique, les étapes de base de l'évaluation des femmes en étant au deuxième stade du travail afin de déterminer si la tenue d'un accouchement opératoire sûr s'avère possible dans leur cas, ainsi qu'à formuler une liste de tâches spécialisée visant à aider les résidents et les obstétriciens à déterminer le mode d'accouchement le plus sûr pour leurs patientes. Méthodes : Les membres du personnel infirmier de la salle de travail et d'accouchement de trois hôpitaux universitaires d'envergure ont identifié les cliniciens qu'ils considéraient comme étant particulièrement compétents en matière d'accouchements vaginaux opératoires. Les obstétriciens dont les noms revenaient les plus souvent ont été conviés à participer à l'étude. Les participants ont été filmés pendant l'exécution d'une évaluation normale du deuxième stade du travail sur un modèle. Deux cliniciens ont passé en revue toutes les vidéos et ont documenté toutes les composantes verbales et non verbales de l'évaluation; ces composantes ont été groupées en thèmes généraux et combinées sous forme d'une liste de tâches spécialisée intégrée. Cette liste de tâches a par la suite été remise à tous les participants pour qu'ils puissent formuler des commentaires additionnels, vérifiée en fonction des directives cliniques de la SOGC et reformulées, ce qui a permis la production d'une liste de tâches spécialisée finale. Résultats : Trente cliniciens ont ainsi été identifiés et 20 d'entre eux ont consenti à participer à l'étude. Les thèmes identifiés ont été les suivants : évaluation du caractère adéquat de l'intervention, anamnèse ciblée, examen physique (y compris l'importance de la tenue d'un examen abdominal), stratégies permettant de déterminer avec précision la position et la station fœtales (et la probabilité de réussite), signes de mise en garde devant mener à une réévaluation immédiate en salle d'opération et signes d'avertissement devant mener à l'abandon de l'accouchement opératoire au profit de la césarienne. Des stratégies de communication ont été soulignées. Conclusion : Le fait de pouvoir compter sur l'apport de cliniciens spécialisés pour l'enseignement de l'évaluation au cours du deuxième stade du travail constitue un facteur important dans l'éducation des résidents et des obstétriciens débutants, de façon à ce qu'ils puissent gagner en confiance pour ce qui est de la prise en charge du deuxième stade du travail.

Ectopic prolactin-producing pituitary adenoma in a benign ovarian cystic teratoma.

We report the presence of pituitary tissue in a benign ovarian cystic teratoma removed surgically from a 43-year-old woman. The pituitary consisted of non-tumorous neurohypophysis and adenohypophysis containing mainly prolactin (PRL)-immunopositive cells (80 % of cells) and a small PRL-producing adenoma. The ultrastructure of the tumor cells differed significantly from PRL cells in the non-tumorous and adenomatous intrasellar pituitary. It appears that cells differing in ultrastructure from intrasellar pituitary PRL cells can also produce PRL.

Pasteurella multocida bacteremia and tuboovarian abscess.

BACKGROUND: Tuboovarian abscess is commonly associated with sexually transmitted pathogens. We report a tuboovarian abscess caused by a rare pathogen, Pasteurella multocida, which was managed conservatively. CASE: A 50-year-old sexually inactive woman presented with suprapubic pain and fever. Cat scratches were seen on her hand. Ultrasonography showed a 7.9-cm complex cystic adnexal structure. Her fever persisted despite broad-spectrum parenteral antibiotics. After placement of a transvaginal drain, the patient defervesced, and her pain improved. Both blood cultures and cyst aspirates grew Pasteurella multocida. CONCLUSION: Tuboovarian abscess secondary to rare pathogens must be considered in the differential diagnosis of acute febrile pelvic illness in a non-sexually active woman. Minimally invasive drainage procedures may avoid surgery in patients failing initial antibiotic therapy.

A community-based intervention to increase screening mammography among disadvantaged women at an inner-city drop-in center.

PURPOSE: To determine the effectiveness of a community- based intervention to increase the use of screening mammography among disadvantaged women at an inner-city drop-in center. METHODS: This study involved women 50 to 70 years old who were clients of an inner-city drop-in center in Toronto, Canada, during the years 1995-2002 (N = 158 in 1995-2001 and N = 89 in 2002). In 2002, the drop-in center and a nearby hospital initiated a collaborative breast cancer screening project in which a staff member of the drop-in center accompanied small groups of women for mammography visits at a weekly pre-arranged time. Interrupted time series analysis was used to examine the effect of this intervention on the annual rate of screening mammography, as determined by review of medical records. RESULTS: More than half of the women 50 to 70 years old who used the drop-in center in 2002 had been diagnosed with a major mental illness, and one-third were either homeless or living in supportive housing. In the 7 years before the introduction of the intervention, annual mammography rates among women using the drop-in center averaged 4.7%. During the intervention year, 26 (29.2%) of 89 women underwent mammography (p = 0.0001 for the change from pre-to post-intervention). CONCLUSIONS: The introduction of accompanied small-group visits was associated with significantly increased use of mammography in a group of disadvantaged women who were clients of an inner-city drop-in center. This approach may be useful to promote breast cancer screening among women affected by mental illness or homelessness who have contact with community-based agencies.

Pregnancy after uterine artery embolization for leiomyomata: the Ontario multicenter trial.

OBJECTIVE: To report on pregnancies and deliveries occurring in a large cohort of women who underwent uterine artery embolization instead of surgery for symptomatic leiomyomata. METHODS: A total of 555 women underwent uterine embolization in a multicenter clinical trial. The primary embolic agent was 355-500 microm polyvinyl alcohol particles with treatment end-point as bilateral stasis in the uterine arteries. Women desiring pregnancy were informed of the uncertain effect of embolization on fertility and pregnancy. Average age at embolization was 43 years (range 18-59 years). Thirty-one percent were younger than age 40 years. Women were followed up prospectively by telephone, and obstetric records of the women who conceived were reviewed. RESULTS: Twenty-one women of average age 34 years (range 27-42 years) conceived, (3 of these twice), and 13 women were nulliparous. Twenty-three of the 24 pregnancies were conceived spontaneously (1 woman had in vitro fertilization). There were 4 spontaneous abortions (16.7%, 95% confidence interval 5.4-41.9%) and 2 elective pregnancy terminations. Fourteen of the 18 live births were full term and 4 were preterm. There were 9 vaginal deliveries and 9 cesarean deliveries, 4 of which were elective. Abnormal placentation occurred in 3 cases, all nulliparas (12.5% 95% confidence interval 3.1-36.3%). Two cases developed placenta previa (1 had a clinical partial accreta) and the third developed a placenta membranacea with accreta resulting in cesarean hysterectomy. Three postpartum hemorrhages all secondary to placental abnormalities occurred. Four newborns were small for gestational age (< or = 5th percentile); 2 of these pregnancies were complicated by gestational hypertension. CONCLUSION: Women are able to achieve pregnancies after uterine artery embolization, and most resulted in term deliveries and appropriately grown newborns. Close monitoring of placental status, however, is recommended.

Tolerance, hospital stay, and recovery after uterine artery embolization for fibroids: the Ontario Uterine Fibroid Embolization Trial.

PURPOSE: Uterine artery embolization (UAE) is gaining popularity as an alternative to hysterectomy for the treatment of fibroids. Although minimally invasive treatments such as UAE offer the potential of fewer complications, shorter hospital stay, and quicker recovery than surgery, there have been few published data on tolerance and recovery in patients undergoing UAE. MATERIALS AND METHODS: This was a multicenter prospective single-arm clinical treatment trial involving the practices of 11 interventional radiologists in eight Ontario university-affiliated and community hospitals. Between November 1998 and November 2000, 555 women underwent UAE for symptomatic uterine fibroids. Follow-up included ultrasound examinations and telephone interviews. UAE was performed under conscious sedation. Polyvinyl alcohol particles (355-500 micro m) were the primary embolic agent, and the procedural endpoint involved stasis in the uterine arteries. Pain protocols included antiinflammatory medications and narcotics and a planned overnight hospital admission. Tolerance and recovery were measured by patient-reported pain intensity (10-point numeric rating and five-point descriptor scale), hospital length of stay (LOS), and time until return to work. RESULTS: Intraprocedural pain was reported by 30% of patients and postprocedural pain was reported by 92% of patients (mean pain rating +/- SD, 7.0 +/- 2.47). The mean hospital LOS was 1.3 nights. Postprocedural pain was the most common indication for an LOS greater than 1 night (18%) or 2 nights (5%). Return visits to the hospital (10%) and readmissions (3%) were primarily for pain. The overall postprocedural complication rate was 8.0% (95% CI: 5.9%-10.6%). Of the 44 complications, 32 (73%) were pain-related. The mean recovery time after UAE was 13.1 days (median, 10.0 d). CONCLUSION: The majority of patients had a 1-night LOS after UAE and recovered within 2 weeks. Postprocedural pain varied considerably and was the major indication for extended hospital stay and recovery.

Hysterectomy for complications after uterine artery embolization for leiomyoma: results of a Canadian multicenter clinical trial.

STUDY OBJECTIVE: To determine the complication-related hysterectomy rate after uterine artery embolization (UAE) for symptomatic uterine leiomyomas. DESIGN: Prospective, multicenter, nonrandomized, single-arm clinical trial (Canadian Task Force classification II-2). SETTING: Eight Ontario University-affiliated teaching and community hospitals. PATIENTS: Five hundred fifty-five women. INTERVENTION: Polyvinyl alcohol particles were delivered through a catheter into uterine arteries under fluoroscopic guidance. MEASUREMENTS AND MAIN RESULTS: Prospective follow-up investigations consisted of telephone interviews, ultrasound examinations, and reviews of pathology and surgery reports. Median follow-up was 8.1 months, and all but five patients had complete 3-month follow-up. At 3 months, eight women (1.5%, 95% CI 0.6-2.8) underwent complication-related hysterectomy. Half of the surgeries were performed at institutions other than where UAE had been performed. Indications for hysterectomies were infections (2), postembolization pain (4), vaginal bleeding (1), and prolapsed leiomyoma (1). CONCLUSIONS: The 3-month complication rate resulting in hysterectomy after UAE in a large cohort of women was low. Hysterectomy after UAE is an important measure of safety and a key outcome measure of this new therapy.

Pathologic features of uteri and leiomyomas following uterine artery embolization for leiomyomas.

The objectives of this study were to identify the presence/absence and location of any embolic material and to describe the morphologic appearance of the leiomyoma and adjacent tissues of cases undergoing surgical intervention following uterine artery embolization (UAE) for leiomyomas. A total of 555 women underwent UAE using polyvinyl alcohol particles (PVA) in a multicenter clinical trial. The histopathologic slides from 17 of 18 women who subsequently underwent myomectomy or hysterectomy in the follow-up period (median 8.2 months) were reviewed without knowledge of the indication for surgery or time elapsed since UAE. The presence/absence and distribution of PVA emboli, associated inflammatory response, and necrosis were noted. Necrosis of leiomyoma(s) was classified as hyaline-type, coagulative tumor cell necrosis, and/or acute suppurative necrosis. In all cases PVA emboli were identified within smooth muscle tumors of the uterine body, its periphery, cervix, uterine body, myometrium, and/or the adnexa. A florid foreign body giant cell type of chronic inflammatory reaction was seen within 1 week of UAE and persisted with visible PVA for up to 14 months post-UAE. Typically, post-UAE leiomyomas showed hyaline-type, but rarely coagulative tumor cell necrosis and acute suppurative necrosis could be seen as well. Five of eight cases coming to surgery for complications showed necrotizing endomyometritis with tissue infarction. PVA particles are recognizable in post-UAE specimens. Leiomyoma necrosis is typically of the hyaline type; coagulative tumor cell necrosis was rarely seen. In some cases with complications, uterine and/or cervical necrosis occurred. The applicability of these findings for UAE patients who have been successfully treated and not resected is uncertain.