Progress testing in postgraduate medical education.

BACKGROUND: The role of knowledge in postgraduate medical education has often been discussed. However, recent insights from cognitive psychology and the study of deliberate practice recognize that expert problem solving requires a well-organized knowledge database. This implies that postgraduate assessment should include knowledge testing. Longitudinal assessment, like progress testing, seems a promising approach for postgraduate progress knowledge assessment. AIMS: To evaluate the validity and reliability of a national progress test in postgraduate Obstetrics and Gynaecology training. METHODS: Data of 10 years of postgraduate progress testing were analyzed on reliability with Cronbach's alpha and on construct validity using one-way ANOVA with a post hoc Scheffe test. RESULTS: Average reliability with true-false questions was 0.50, which is moderate at best. After the introduction of multiple-choice questions average reliability improved to 0.65. Construct validity or discriminative power could only be demonstrated with some certainty between training year 1 and training year 2 and higher training years. CONCLUSION: Validity and reliability of the current progress test in postgraduate Obstetrics and Gynaecology training is unsatisfactory. Suggestions for improvement of both test construct and test content are provided.

Carbohydrate solution intake during labour just before the start of the second stage: a double-blind study on metabolic effects and clinical outcome.

OBJECTIVE: To study the effects of oral carbohydrate ingestion on clinical outcome and on maternal and fetal metabolism. DESIGN: Prospective, double-blind, randomised study. SETTING: Leyenburg Hospital, The Hague, The Netherlands. POPULATION: Two hundred and two nulliparous women. METHODS: In labour, at 8 to 10 cm of cervical dilatation, the women were asked to drink a solution containing either 25 g carbohydrates or placebo. In a subgroup of 28 women, metabolic parameters were measured. MAIN OUTCOME MEASURES: Number of instrumental deliveries, fetal and maternal glucose, free fatty acids, lactate, pH, Pco2, base excess/deficit and beta-hydroxybutyrate. RESULTS: Drinking a carbohydrate-enriched solution just before starting the second stage of labour did not reduce instrumental delivery rate (RR 1.1, 95% CI 0.9-1.3). Caesarean section rate was lower in the carbohydrate group, but the difference did not reach statistical significance (1% vs 7%, RR 0.2, 95% CI 0.02-1.2). In the carbohydrate group, maternal free fatty acids decreased and the lactate increased. In the umbilical cord there was a positive venous-arterial lactate difference in the carbohydrate group and a negative one in the placebo group, but the differences in pH and base deficit were comparable. CONCLUSION: Intake of carbohydrates just before the second stage does not reduce instrumental delivery rate. The venous-arterial difference in the umbilical cord suggested lactate transport to the fetal circulation but did not result in fetal acidaemia.

Students' perceptions of relationships between some educational variables in the out-patient setting.

BACKGROUND: Medical education uses the cognitive apprenticeship model of student learning extensively. Students rotate among different hospitals and out- patient clinics where they are exposed to a range of professionally relevant contexts. Here they learn to think and act in different domains under the supervision of experts. Previous research has shown that these learning situations involve little teaching. Students see a narrow range of patient problems and feedback is limited. The aim of this study is to investigate relationships among some educational variables in the out-patient clinic. METHOD: This paper provides a theoretical model that specifies the factors influencing the effectiveness of student rotations at out-patient clinics. The model makes distinctions between input variables, such as organizational quality, number of students contemporaneously involved and available space, and process variables, such as patient mix and supervision, and the output variable of the effectiveness of rotations in out-patient clinics. RESULTS: The model was tested against empirical data from evaluative surveys and showed a reasonable fit. The model offers suggestions for improving the learning environment of clinical rotations. DISCUSSION: The strength of this study lies in its process evaluation perspective which investigates interactions between intervening variables rather than the influence of particular variables in isolation from other variables.

[Physical diagnostics--bimanual vaginal examination]. / Fysische diagnostiek--het vaginaal toucher.

Bimanual examination is frequently done for the evaluation of internal female genitals in gynaecologic and obstetric patients. Reliability of bimanual examination is influenced by several factors such as the woman's age and physique, but also by the experience of the examiner. Additional transvaginal sonographic assessment increases both the sensitivity and specificity of the diagnostic procedure, especially where the ovaries are concerned. However, transvaginal sonography is not an alternative to bimanual examination. In obstetrics, bimanual examination is an essential diagnostic procedure at parturition. Bimanual examination is unpleasant for most patients and not without risks. This underscores the importance of adequate skills in performing the technique, and the importance of accurate consideration of the necessity of the procedure.

Eating and drinking in labor: the influence of caregiver advice on women's behavior.

BACKGROUND: Although there is much debate about eating and drinking during labor, little scientific data about its influence on the course of labor exist. In The Netherlands, most midwives and obstetricians allow women to eat and drink during normal labor. The objective of this study was to examine whether or not women were actively advised to eat and drink and if this advice affected eating and drinking behavior. METHODS: A randomly selected group of midwives and obstetricians from across The Netherlands identified 211 consecutive nulliparous women to participate in the study. In a questionnaire with open-ended questions, women were asked after their delivery whether or not they were advised about eating and drinking during labor, and if so, about the nature of this advice and what they had consumed. Data were analyzed at the Leyenburg Hospital in The Hague. RESULTS: Sixty-six percent of the women were not given advice about eating and drinking during labor. Women who were given advice usually followed it. In the total group, 37 percent of the women had intake other than water and of these, 75 percent ate solid food. After adjusting for other prognostic factors, the incidence of an instrumental delivery due to a nonprogressing second stage was lower in women with caloric intake (13% vs 24%, p = 0.04). CONCLUSION: The study design did not enable us to draw conclusions about the cause and effect between caloric intake and labor progress. Scientific data with respect to the giving of evidence-based advice about eating and drinking during labor are lacking. Should such advice become available, women are likely to follow it.

Students' perceptions of time spent during clinical rotations.

Some rotations during clinical education are characterized by a high number of hours spent per week in the hospital because students panicipate in a hospital on-call system, i.e. hours beyond usual working hours, e.g. at night. However, students complain about spending too many hours in the hospital on non-instructive activities. This study was undertaken to investigate differences among rotations in time spent in hospital, in on-call hours, in self-study and in non-instructive activities and to investigate the relationship between time spent on the various activities and the overall effectiveness as perceived by students. A questionnaire was administered to students at the end of various clinical rotations. Rotations differ considerably in time spent in hospital, on call (i.e. beyond usual working hours), on self-study and on non-instructive activities. In some rotations students report spending on average 18-20% of their time in the hospital on non-instructive activities. Furthermore, the numbers of hours spent in hospital do not correlate with the overall effectiveness as perceived by students, unless the numbers of hours spent in non-instructive activities are taken into account. The effectiveness of a rotation does not automatically improve if students spend more hours in hospital. The number of hours spent on non-instructive activities should be reduced in some rotations and should be kept as low as possible. Further research is needed to find out which activities are perceived as non-instructive.

Fetal and maternal energy metabolism during labor in relation to the available caloric substrate.

AIM: To discuss maternal and fetal metabolic events during labor and the possible role of glucose administration. RESULTS: The oxidative pathway covers the largest part of the energy demand of labor, although in the second stage or, in polysystolic labor, the non-oxidative pathway becomes important as well. Glucose is the main maternal energy source, but the rise in ketobodies, even during normal labor, suggests a relative shortage. In the first stage of labor, a combination of a respiratory alkalosis, and to a lesser extent, a metabolic acidosis, result in a rise in the maternal pH. In the second stage of labor, the maternal pH decreases due to an increasing metabolic acidosis. Glucose is also the main fetal energetic fuel. In fetal hypoxia, lactate is produced, which in most cases is transferred to the maternal circulation. High maternal lactate concentrations, however, may interfere with this process. Furthermore, fetal hyperglycemia may lead to an increased fetal lactate production. CONCLUSIONS: Maternal hyperglycemia, may lead to an increase in maternal and fetal lactate production resulting in metabolic acidosis. Unlike high dosage intravenous glucose administration, it is not likely that oral intake of carbohydrates leads to maternal and fetal hyperglycemia and subsequently to metabolic acidosis, but studies are rare.

Short interpregnancy intervals and unfavourable pregnancy outcome: role of folate depletion.

There is no generally accepted explanation for the excess risk of adverse pregnancy outcome after short interpregnancy intervals. In this paper, we present a hypothesis that is both biologically plausible, empirically testable, and able to explain many observations. Maternal serum and erythrocyte concentrations of folate decrease from the fifth month of pregnancy onwards and remain low for a fairly long time after delivery. Women who become pregnant before folate restoration is complete have a raised risk of folate insufficiency at the time of conception and during pregnancy. As a consequence, their offspring have higher risks of neural tube defects, intrauterine growth retardation, and preterm birth. We make several predictions based on our hypothesis and suggest ways of testing them empirically. The proposed mechanism implies, among other things, that postpartum supplementation with folic acid might prevent excess risk of unfavourable pregnancy outcome in women with short interpregnancy intervals.

Aspects of food and fluid intake during labour. Policies of midwives and obstetricians in The Netherlands.

OBJECTIVE: This study outlines the current policies on food and fluid intake during labour in The Netherlands and discusses the pro's and con's of food-restriction. STUDY DESIGN: 50 midwives and 30 obstetricians were asked about their actual policy on food and fluid-intake during labour. RESULTS: A restrictive policy during normal labour is followed by 20% of the midwives and 14% of the obstetricians. About 75% leaves the decision on food and fluid-intake to the women themselves. CONCLUSIONS: Despite the non-restrictive policy in The Netherlands, the mortality due to the Mendelson-syndrome is not higher than in countries where a restrictive policy is followed. During normal labour there are no conclusive reasons for food or fluid-restriction. From a metabolic point of view it is hypothesized that the intake of energy-rich substrates may have a positive influence on labour progression. Further study on the subject seems indicated.

[Optimal world-wide obstetrical care; a WHO report]. / Optimale verloskundige zorg wereldwijd; een WHO-rapport.

'Safe motherhood; care in normal birth: a practical guide' is a document produced by an international technical working group of the World Health Organization. This report addresses issues of care during normal birth irrespective of country or region. Routine interventions and non-interventions in the physiological processes of pregnancy and labour are analysed and assessed for their scientific validity. Scientific foundation of obstetric practice is considered an important step towards worldwide demystification of obstetric practice, which now often relies on authority, culture and habit. For risk assessment, the cornerstone of the Dutch system of obstetric care, an evidence-based strategy is imperative. This requires scientific training in schools of midwifery.

Smoking in Dutch pregnant women and birth weight.

In this study 796 ambulatory singular pregnant women were questioned about their smoking habits both before and during pregnancy (ambispective). Important covariates such as parity, blood pressure, maternal weight gain, salt- and alcohol consumption and length of gestation were taken into account. At the beginning of pregnancy 52% of the questioned women smoked; 36% smoked in the seventh/eighth month of pregnancy. A dose-response relationship was found between the number of cigarettes smoked per day and birth weight. For those pregnant women who still smoked after 7 months of pregnancy an average birth weight loss of 24 g was found per cigarette per day. Even after controlling for covariates, there still remains an independent influence of smoking on birth weight loss on the average of 19 g for each cigarette smoked per day.

Blues and depression during early puerperium: home versus hospital deliveries.

OBJECTIVE: To investigate whether women who give birth at home are less prone to mood disturbances during the early puerperium than those who give birth in hospital. DESIGN: A prospective study of 303 pregnant women who registered for antenatal care. SETTING: The antenatal clinic at St Joseph's Hospital, Veldhoven, The Netherlands, and five antenatal consultation programmes of local midwives working in the surrounding region. SUBJECTS: Three hundred and eighty-two consecutive caucasian women registering for antenatal care were approached. Of these, 303 consented to participate and 293 completed the study. MAIN OUTCOME MEASURE: The predictor variable was the way in which the women gave birth: spontaneous vaginal parturition at home or in hospital as follows: spontaneously; vaginal parturition after stimulation with medication; vaginal parturition with forceps/vacuum extraction; or caesarean section. The outcome variables were blues and depression. The occurrence of blues was assessed at 4 weeks postpartum, using Pitt's criteria. The occurrence of depression was assessed at 4 weeks postpartum using the Research Diagnostic Criteria. The possible confounding effects of a set of obstetrical and psycho-social variables relating to the early puerperium were investigated using logistic regression analysis. RESULTS: Of the 293 women who completed the study, 52% gave birth at home. Significantly more nullipara gave birth in hospital. Parturition occurred where it had been planned in 77% of women; referral occurred later on in pregnancy in 11% and during labour in 12%. Nullipara had to be referred significantly more often than multipara. In general, there was no difference in the incidence of blues and depression between women who gave birth at home and those who gave birth in hospital. Obstetric factors were not related to the occurrence of blues or depression in the early puerperium. CONCLUSIONS: Women who gave birth in hospital are no more prone to postpartum mood disturbances, such as blues and depression, than women who give birth at home.

Composition of cervical smears in patients with and without a cervical ectropion.

AIMS: To test the hypothesis that absence of squamous cells in cervical smears obtained by an endocervical sampling technique is more prominent in patients with a cervical ectropion. METHODS: Prospective study exploring the relation between the composition of cervical smears obtained using an endocervical cotton swab in patients with (n = 188) and without (n = 341) a cervical ectropion. Subjects were 529 consecutive patients from whom a cervical smear was prepared at a university gynaecological clinic. RESULTS: In 7% of the endocervical samples no squamous cells were found. There was no correlation, however, between the presence or the size of an ectropion and the absence of squamous cells in those samples. CONCLUSIONS: It was confirmed that endocervical sampling alone is insufficient to obtain good quality cervical smears. The presence of an ectropion proved to be an unreliable predictor of the absence of squamous cells.

Long-term effect of feedback and peer comparison on the sampling quality of cervical smears--a randomized controlled trial.

In a randomized controlled trial the effect of feedback and peer review directed at the sample-taking doctor (n = 179) on the sampling quality of cervical smears (n = 21,240) was studied. This paper reports the impact 6 and 12 months after the end of the intervention. Monthly feedback with peer comparison was related to a net improvement in the proportion of cervical smears without endocervical cells during the intervention period, as well as during a follow-up period lasting until 15 months after the end of the intervention. This improvement seemed to be related to a minimum of 50 or even 100 smears performed each year and was therefore not confirmed on clustered data analysis. There is a strong suggestion that the intervention also related to an increase of the number of smears showing cytological pathology, although this study lacked sufficient power to test this hypothesis.

The effect of different sampling devices on the presence of endocervical cells in cervical smears. A systematic literature review.

A literature search examined 39 reports on the relationship between the absence of endocervical cells in a cervical smear and the sampling technique used. Using (pooled) ratios we compared the results for different pairs of sampling devices, thereby controlling for the design of each study when appropriate. The Cytobrush appears the most efficient sampling method with regard to the presence of endocervical cells. Combining the results of this review with the results of a previous meta-analysis on the effect of the sampling technique on the detection of pathology, the combined spatula and Cytobrush technique seems to be the best sampling method.

Role of the baroreflex in beta 2-sympathomimetic induced tachycardia in male rats.

The aim of the study was to determine whether tachycardia which is associated with the use of beta 2-sympathomimetic tocolytic agents is caused by baroreflex activation or by direct stimulation of cardiac beta-adrenoceptors. In conscious male rats, tachycardiac responses following intravenous injection of hexoprenaline, ritodrine and fenoterol were compared following (i) bilateral sinoaortic denervation (SAD) or (ii) sham-operation, and (iii) ganglionic-blockade using hexamethonium. Dose-ranges were chosen to result in similar reductions in diastolic blood pressure (DAP). Furthermore, following ganglionic blockade, the relative contribution of beta 1-adrenoceptor stimulation was assessed using the selective beta 2-receptor antagonist ICI 118,551. In intact rats, increases in HR induced by all beta-adrenoceptor agonist were comparable. In SAD and ganglion-blocked rats, DAP fell more pronounced at even lower doses. The corresponding increases in HR were approximately 3 times smaller than in intact rats but not different between agents. During ganglionic blockade ICI 118,551 significantly inhibited HR responses to fenoterol and hexoprenaline but not ritodrine. The conclusion is that in intact male rats, baroreflex activation is the major determinant of tachycardia following injection of ritodrine, fenoterol or hexoprenaline. Increasing the beta 2-selectivity of these drugs will not limit the tachycardic effects.