Evaluating Acquisition of Knowledge about Infertility Using a Whiteboard Video.

OBJECTIVE: Myths about fertility are commonplace in society. Few studies have investigated educational approaches to bridge gaps in knowledge among consumers. We evaluated the effectiveness of an animated, 15-minute whiteboard video to effect change in knowledge about infertility. METHODS: We recruited medical students in their first or second year of training for participation. The students completed the study before their formal lectures on infertility issues. Participants completed questionnaires assessing infertility knowledge immediately before and one week after watching the educational video. Before and after scores (maximum = 50 points) were compared using paired t tests. RESULTS: The study cohort included 101 medical students; 69% (70/101) were female and 31% (31/101) were male. Overall, students increased their score by 4.0/50 (95% CI 3.2 to 4.8, P < 0.001) from 36.5/50 to 40.5/50. Female students improved slightly more in their responses than did male students (mean improvement 4.7/50 vs. 2.5/50). CONCLUSION: A whiteboard video presentation on infertility resulted in short-term improvement in medical students' knowledge of basic reproductive biology, infertility risk factors, treatments, and common myths associated with infertility.

The Use of Intermittent Auscultation in Parturients of Varying BMI Categories: Experience From a Mid-Sized Tertiary Care Obstetrical Unit.

OBJECTIVES: The aim of this quality assurance project was to determine how many patients who qualified for intermittent auscultation (IA) in labour were actually monitored by intermittent auscultation. A secondary objective was to assess whether the rate of IA use depended on maternal BMI. METHODS: We performed a retrospective chart review in a sample of women who received obstetrical care at Kingston General Hospital over one year from July 31, 2012. Eligibility was determined using the inclusion and exclusion criteria outlined by the hospital's guideline on intermittent auscultation. RESULTS: Two hundred seven of 244 charts analyzed in this review qualified for IA. The mean age of women in the study was 29.3 (range 17 to 41) years. Their mean gestational age was 39.6 (range 37 to 42) weeks. Fifty-six percent (116/207) of the eligible women actually had IA. Forty-seven percent of obese women who were eligible (47/100) had IA, compared with 64.4% of overweight women (58/90). This difference (17.4%) was statistically significant (P = 0.019, Fisher exact test). CONCLUSION: Fifty-six percent (116/207) of women with low risk pregnancies who were deemed eligible to have IA rather than electronic fetal heart rate monitoring actually had IA. Obese women were less likely to have IA than overweight women. More research is required regarding barriers to using IA in eligible women in our institution and elsewhere.

Objectifs : Ce projet d'assurance de la qualité avait pour but de déterminer le nombre des patientes répondant aux critères nécessaires à la mise en œuvre d'une auscultation intermittente (AI) pendant le travail qui ont bel et bien fait l'objet d'un tel monitorage. Son objectif secondaire était de déterminer si le taux d'utilisation de l'AI dépend de l'IMC maternel. Méthodes : Nous avons mené une analyse de dossiers rétrospective auprès d'un échantillon de femmes ayant reçu des soins obstétricaux au Kingston General Hospital sur une période d'un an à partir du 31 juillet 2012. L'admissibilité a été déterminée au moyen des critères d'inclusion et d'exclusion décrits par les lignes directrices de l'hôpital sur l'auscultation intermittente. Résultats : Deux cent sept des 244 dossiers analysés dans le cadre de cette analyse ont répondu aux critères nécessaires à la mise en œuvre d'une AI. L'âge moyen des femmes étudiées était de 29,3 ans (plage : de 17 à 41 ans). Leur âge gestationnel moyen était de 39,6 semaines (plage : de 37 à 42 semaines). Cinquante-six pour cent (116/207) des femmes admissibles ont bel et bien fait l'objet d'une AI. Quarante-sept pour cent des femmes obèses admissibles (47/100) ont fait l'objet d'une AI, par comparaison avec 64,4 % des femmes présentant une surcharge pondérale (58/90). Cette différence (17,4 %) était significative sur le plan statistique (P = 0,019, test exact de Fisher). Conclusion : Cinquante-six pour cent (116/207) des femmes qui connaissaient une grossesse exposée à de faibles risques et que l'on estimait être admissibles à la mise en œuvre d'une AI plutôt qu'à celle d'un monitorage fœtal électronique ont bel et bien fait l'objet d'une AI. Les femmes obèses étaient moins susceptibles de faire l'objet d'une AI que les femmes présentant une surcharge pondérale. La tenue d'un plus grand nombre de recherches s'avère requise au sujet des obstacles à l'utilisation de l'AI chez les femmes admissibles, tant au sein de notre établissement qu'ailleurs.

Determinants of late presentation for induced abortion care.

OBJECTIVE: To determine whether demographic or patient factors contribute to later presentation (10 to 12 weeks' gestational age) for induced abortion in a Canadian abortion clinic. METHODS: Women attending a hospital-based abortion clinic between April and September 2012 were asked to complete a survey. The characteristics of women who presented early (EPs; gestational age < 10 weeks) were compared with those of late presenters (LPs; gestational age ≥ 10 weeks) using t tests for means and Fisher exact tests for rates. RESULTS: Among women referred to the clinic by a primary care provider, LPs were more likely than EPs to report "a delay in obtaining a referral" (20.8% vs. 6.1%; P = 0.007). While there was no significant difference between the groups in reporting that "someone tried to discourage [them] from having an abortion" (26.45% for EPs, 32.4% for LPs; P = 0.421), LPs were more likely to report that discouragement "caused a delay in making arrangements" (45.5% vs. 16.7%; P = 0.019). Of women who had access to a primary care provider, it was more common for the primary care provider to be aware of the pregnancy among LPs than among EPs (80.6% vs. 63.1%; P = 0.015). CONCLUSION: Some women delay presenting for abortion because of discouragement from friends and family. It is unclear whether there are educational or policy interventions that can have an impact on this delay, and this warrants further study. There may be ways of addressing the delay in referral by primary care providers. Further study into the causes for delay in referral for abortion is warranted.

Objectif : Déterminer si des facteurs démographiques ou liés à la patiente contribuent au fait de se présenter tardivement (âge gestationnel : 10-12 semaines) dans une clinique d'avortement canadienne pour l'obtention d'un avortement provoqué. Méthodes : Nous avons demandé aux femmes ayant fréquenté une clinique d'avortement en milieu hospitalier entre avril et septembre 2012 de remplir un questionnaire. Les caractéristiques des femmes s'étant présentées tôt (âge gestationnel < 10 semaines) ont été comparées aux caractéristiques des femmes s'étant présentées tard (âge gestationnel ≥ 10 semaines) au moyen de tests t (pour les moyennes) et de tests exacts de Fisher (pour les taux). Résultats : Chez les femmes orientées vers la clinique par un fournisseur de soins primaires, les femmes s'étant présentées tard étaient plus susceptibles que les femmes s'étant présentées tôt de signaler « un délai quant à l'obtention d'une orientation ¼ (20,8 % vs 6,1 %; P = 0,007). Bien qu'aucune différence significative n'ait été constatée entre les groupes pour ce qui est du fait de signaler que « quelqu'un avait tenté de les convaincre de ne pas subir un avortement ¼ (26,45 % des femmes s'étant présentées tôt, 32,4 % des femmes s'étant présentées tard; P = 0,421), les femmes s'étant présentées tard étaient plus susceptibles de signaler qu'une telle intervention « avait causé un délai pour ce qui est de la prise des mesures nécessaires ¼ (45,5 % vs 16,7 %; P = 0,019). Chez les femmes qui avaient accès à un fournisseur de soins primaires, il était plus fréquent que ce dernier soit au courant de la grossesse dans le cas des femmes s'étant présentées tard que dans celui des femmes s'étant présentées tôt (80,6 % vs 63,1 %; P = 0,015). Conclusion : Certaines femmes tardent à chercher à obtenir un avortement en raison des efforts qui sont déployés par des amis et des membres de la famille pour chercher à les en dissuader. La question de savoir s'il existe des interventions pédagogiques ou de politique pouvant exercer un effet sur ce délai demeure sans réponse, ce qui justifie la tenue d'autres études. Il pourrait y avoir des façons d'aborder ce délai en matière d'orientation lorsqu'il est lié aux fournisseurs de soins primaires. La tenue d'autres études quant aux causes de délai pour ce qui est de l'orientation vers des services d'avortement s'avère justifiée.

Can online learning adequately prepare medical students to undertake a first female pelvic examination?

OBJECTIVE: To determine whether a novel web-based learning module could adequately prepare first-year undergraduate medical students to skilfully perform their first female pelvic examination. METHODS: First-year Queen's University medical students without prior training or experience in female pelvic examination were recruited for this study. After viewing key segments of the learning module, students were evaluated while performing a pelvic examination on a female volunteer using a standardized assessment checklist (total score = 30 points). Descriptive and comparative statistics were generated. RESULTS: Forty-five students participated with a mean age of 24 years (range 20 to 40). The mean score (±SD) on the assessment checklist was 23.9 ± 3.6 points, (range 17 to 30). All study participants received a passing grade of ≥ 50% (15/30 points), and 53.3% (24/45) received an honours grade of ≥ 80% (24/30 points). Of the participants, 88.9% (40/45) agreed that they were well prepared for their first female pelvic examination after viewing the training video. Mean scores were similar for male students (23.9, n = 22) and female students (23.8, n = 23) (P = 0.90, t test). Mean scores were not higher in those who watched key segments of the learning module more than once. CONCLUSION: This learning module viewed immediately prior to a simulated clinic session afforded first-year medical students the necessary knowledge and skills to perform a first female pelvic examination. This was accomplished with as little as one viewing, and could lead to savings in organizational costs and instruction time for medical school curricula.

Characteristics and concerns of women choosing an online contraception selection tool ("choosing wisely").

BACKGROUND: Choosing Wisely, a user-friendly and interactive application developed and tested at Queen's University, is a self-administered computer-based questionnaire that aims to assist women, their partners, and their health care providers in deciding among contraceptive options. The application asks specific, direct questions regarding a patient's preferences, health, and lifestyle, and it then generates three lists: (1) indicated contraceptive methods, (2) options that may be suitable, and (3) contraindicated methods. OBJECTIVE: To report statistics on the users of Choosing Wisely in the first 13 months since the launch of the program on the award-winning SOGC website Sexualityandu.ca in June, 2007. METHODS: At the end of the program module, each user's answers were logged anonymously in a Microsoft Excel spreadsheet along with the time and date of completion. Descriptive statistics were generated in SPSS version 16.0. RESULTS: Between June 21, 2007, and July 25, 2008, 9775 users completed the Choosing Wisely program. Of these users, 8942 (91.5%) were female, and 8745 (89.5%) were under 35. At least one concern regarding contraceptive options was reported by 7359 users (75.3%), and the most common of these was weight gain, selected by 4806 (65.3%). CONCLUSION: Choosing Wisely has attracted an average of 24 users per day seeking more information on birth control methods. The responses gathered from the program will likely allow for both a better understanding of the characteristics of women who desire birth control and refinement of the program, with the aim of better serving those who are seeking contraceptive advice.

Gender preference for a female physician diminishes as women have increased experience with intimate examinations.

OBJECTIVES: To determine the importance of seven statements encouraging medical student participation in the health care team with respect to the effect they would have on a woman's decision to allow a medical student to participate in an intimate physical examination, and to explore factors associated with gender bias. METHODS: Questionnaires were administered to women attending outpatient clinics in obstetrics and gynaecology at Kingston General Hospital and to students at two local secondary schools. RESULTS: Responses from 683 clinic patients and 192 secondary school students were analyzed. The mean age (range) was 42 years (17- 85) and 16 years (15- 22) for the respective samples. More clinic patients rated each of the statements as important or very important than did students (P < 0.01, Fisher exact tests). The largest differences between the sample groups were seen for the statements pertaining to the potential for enhanced understanding (81.0% vs. 60.2%), quality of health care (87.4% vs. 69.8%), and affording medical students the opportunity to participate (92.7% vs. 77.0%); 72.8% (485/666) of clinic patients reported they would accept an intimate examination by a medical student of either gender, compared with 32.1% (61/190) of secondary school students, and 22.2% (148/666) of clinic patients indicated they would only accept a female student compared with 55.3% (105/190) of secondary school students. The proportion of students preferring female medical students was inversely related to the number of previous breast or pelvic examinations (P = 0.031, chi-square test for trend). CONCLUSIONS: Educational statements designed to encourage women to allow students to participate in their medical care had less effect on the secondary school students than on the women in a clinic setting. Although secondary school students express a preference for female physicians, it appears that with increasing experience with intimate examinations other factors take precedence in determining choice of health care provider.

Fetal heart rate response to maternal hypocapnia and hypercapnia in late gestation.

OBJECTIVE: To examine the effects of acute maternal hypocapnia and hypercapnia on electronic fetal heart rate (FHR) patterns in late gestation. METHODS: Thirty-five women with healthy singleton pregnancies performed a modified carbon dioxide (CO2) rebreathing procedure between 34 and 38 weeks of pregnancy. Prior to rebreathing, subjects hyperventilated for five minutes to reduce end-tidal CO2 tensions (PETco2) below 23 Torr (hypocapnia). During rebreathing, PETco2 progressively increased from hypocapnia to hypercapnia (PETco2 = 40-60 Torr) at a constant hyperoxic end-tidal O2 tension of 150 Torr. FHR responses were classified using standardized guidelines over four periods: 20 minutes before rebreathing (pretest), during hypocapnia and hypercapnia, and 20 minutes after rebreathing (post-test). RESULTS: Mean baseline FHR measures (SD) over the four test periods were 138(8), 144(10), 132(11), and 137(9) beats per minute (bpm). All pairwise comparisons were statistically significant except the pretest versus post-test comparison (P < 0.05, Tukey-Kramer multiple comparisons test). A single tachycardia episode of 170 bpm was recorded in the post-test period. In 20 subjects FHR variability changed from moderate in the pretest period to minimal during hypocapnia and/or hypercapnia. All but two returned to moderate FHR variability in the post-test period. One other fetus with minimal post-test variability had moderate values in the three preceding test periods. CONCLUSION: Electronic FHR parameters remained within normal limits for third-trimester fetuses with the exception of one fetus that experienced tachycardia. Acute maternal hypocapnia and hypercapnia over the range studied had no adverse effects on fetal well-being. These results support the safety of the modified CO2 rebreathing procedure for research in healthy, low-risk pregnancy.

Peptide YY(3-36)-induced inhibition of food intake in female monkeys.

Peptide YY (PYY) is produced in L cells of the intestine and is released after eating. PYY circulates in a truncated form designated PYY(3-36). PYY(3-36) is thought to be a physiologic anorexigenic peptide. The objective of the current study was to test the effect of exogenous PYY(3-36) on food intake in non-human primates exposed to different ovarian steroid milieus. The study was conducted in four ovariectomized cynomolgus monkeys replaced with estrogen alone for 2 weeks followed by estrogen in combination with progesterone for 2 weeks to mimic the menstrual cycle. The effect of PYY(3-36) on food intake was tested during each week of the simulated menstrual cycle by comparing the 2 h food intake following intracerebroventricular (icv) injection of artificial cerebrospinal fluid (aCSF) or PYY(3-36). Despite considerable variation in food intake following aCSF, PYY(3-36) consistently inhibited food consumption, except during week 2 of estrogen plus progesterone replacement. PYY(3-36) reduced food consumption by 16.2 g (95% confidence interval (CI)=4.5-27.9 g) and 26.6 g (95% CI=7.3-45.9 g) in weeks 1 and 2 respectively of estrogen only treatment and by 38.2 g (95% CI=26.1-50.2 g) in week 1 of estrogen plus progesterone treatment. In contrast, PYY(3-36) injected in week 2 of estrogen plus progesterone did not consistently inhibit food intake (13.1 g; CI=-49.5-75.7). This is the first study to report the effect of PYY(3-36) on food consumption in female monkeys. We conclude that icv administration of PYY(3-36) has a strong anorexic effect in female cynomolgus monkeys and that sensitivity to PYY(3-36) may be influenced by the ovarian steroid milieu.

The acceptance of medical students by women with gynaecology appointments.

OBJECTIVES: To determine the proportion of women unwilling to see medical students for their upcoming gynaecologic appointments and to determine whether information about medical student training could influence their decisions. METHODS: Questionnaires were mailed to 1230 women with outpatient gynaecology specialist appointments. The women were asked if they would be willing to see a medical student at their upcoming appointment. Those who declined were asked to indicate the reason(s) for their decision. After reading the survey's information section on medical students, patients who initially rejected student involvement were asked if they would reconsider. Mean differences were analyzed with t tests and associations with Fisher exact tests. RESULTS: Thirty percent (367/1230) of the surveys were returned and analyzed. The mean age was 48.4 years (range 17-90). Fifty-three percent (189/358) reported a positive past experience with medical students, and 7% (25/358) reported a negative past experience. Twenty-six percent (96/367) indicated that they would not be willing to be seen by a medical student. Sixty-three percent (60/96) did not wish to have a gynaecologic examination performed by a student. One-third (32/96) identified this as a concern particularly if the examination involved a male student. After reading the information section of the survey, 17% (16/96) of the respondents who initially indicated they were unwilling to see a medical student indicated that they would reconsider. Those who would reconsider were younger than those who remained unwilling (mean age 41.9 vs. 52.1 years, P= 0.045). CONCLUSION: The information about medical students embedded in our survey positively influenced one in six unwilling patients to reconsider and accept medical students as part of their health care team.

Maternal hemodynamics after oxytocin bolus compared with infusion in the third stage of labor: a randomized controlled trial.

OBJECTIVE: To assess the effects of oxytocin bolus or infusion on maternal hemodynamics in the third stage of labor. METHODS: In a randomized, double-blind, double-dummy fashion, 99 women received an intravenous oxytocin bolus (10 IU push) and 102 women received an infusion (10 IU in 500 mL saline at 125 mL/h) at delivery of the anterior shoulder. Mean arterial pressure and heart rate were measured every minute for 10 minutes, then every 5 minutes for the next 20 minutes. These serial measurements were analyzed using a 2-factor analysis of variance for repeated measures. RESULTS: Serial mean arterial pressure measures varied significantly between groups (interaction effect, P = .002). Mean arterial pressure (+/- standard deviation) nadirs were reached after 10 minutes, 80.9 (+/- 11.0) mm Hg in the bolus group compared with 77.0 (+/- 12.1) mm Hg in the dilute infusion group. The mean difference (95% confidence interval) between groups was 4.0 (0.7-7.2) mm Hg. Serial heart rate measures also varied between groups (interaction effect, P < .001). Mean heart rate (+/- standard deviation) peaked 1 minute after the oxytocin infusion, 115 (+/- 27) beats per minute (bpm) in the bolus group compared with 109 (+/- 21) bpm in the dilute infusion group. The mean difference (95% confidence interval) between groups was 6.6 bpm (-0.1 to 13.3). The dilute oxytocin infusion group experienced a greater mean estimated blood loss (423.7 mL compared with 358.1 mL, P = .029, t test), increased use of additional oxytocics (35.3% compared with 22.2%, P = .044, Fisher exact test) and a greater drop in hemoglobin (admission minus postpartum) (17.4g/L compared with 11.4g/L, P = .002, t test) compared with the oxytocin bolus group. CONCLUSION: Bolus oxytocin of 10 IU is not associated with adverse hemodynamic responses and can safely be administered to women with intravenous access in the third stage of labor for postpartum hemorrhage prophylaxis. LEVEL OF EVIDENCE: I.

Bioavailability of the Yuzpe and levonorgestrel regimens of emergency contraception: vaginal vs. oral administration.

Separate crossover studies compared the bioavailability of oral vs. vaginal routes of administration for the Yuzpe (n=5) and levonorgestrel regimens (n=4) of emergency contraception. Twice the standard dose of the Yuzpe regimen (200 microg of ethinyl estradiol, 1000 microg of levonorgestrel) or the levonorgestrel regimen (1500 microg of levonorgestrel) was self-administered vaginally. One week later, each subject received orally the standard dose of the assigned medication. Serial blood samples were collected over 24 h and assayed for levonorgestrel and ethinyl estradiol (for the Yuzpe regimen only). Paired t tests were used to compare oral vs. vaginal administration for maximum concentration (Cmax), time to maximum concentration (Tmax) and area under the curve over 24 h (AUC0-24). Relative bioavailability (vaginal/oral) was derived from AUC0-24. Vaginal administration of double the standard dose of the Yuzpe regimen resulted in a lower Cmax (vaginal=5.4 vs. oral=14.6 ng/mL, p=.038) and a later Tmax (5.9 vs. 2.0 h, p=.066) for levonorgestrel, compared to oral administration. Corresponding ethinyl estradiol concentrations were higher (786 vs. 391 pg/mL, p=.039) and peaked later (4.0 vs. 1.9 hr, p=.154) with vaginal administration. Relative bioavailabilities for levonorgestrel and ethinyl estradiol were 58% and 175%, respectively. Similarly, vaginal administration of the levonorgestrel regimen resulted in a lower Cmax (vaginal=5.4 vs. oral=15.2 ng/mL, p=.006) and a later Tmax (7.4 vs. 1.3 h, p=.037) for levonorgestel, compared to oral administration. The relative bioavailability was 62%. Our preliminary data suggest that vaginal administration of these emergency contraception regimens appears to require at least three times the standard oral dose to achieve equivalent systemic levonorgestrel concentrations.

What women believe about oral contraceptives and the effect of counseling.

OBJECTIVES: To evaluate Canadian women' s knowledge of the risks, benefits and side effects of oral contraceptives (OCs) and the effect of counseling. STUDY DESIGN: Six-hundred and forty-nine Canadian women filling an OC prescription at Shopper's Drug Mart stores completed the survey. Respondents recorded whether or not they had discussed 12 separate issues about OC use with their healthcare provider. Optimal responses to multiple-choice questions were compared between those reporting counseling to those reporting no counseling, using Fisher's Exact Tests. Women were also questioned on what they were told about associated cancer risks. RESULTS: Eighty percent or more of the women selected the optimal response for the questions relating to dysmenorrhea, leg pain and co-medication. Less than half of survey respondents identified the optimal response for nausea, breakthrough bleeding, breast tenderness, acne, headaches and weight change. Counseling made a significant impact on selection of the optimal response for 7 of the 12 questions (p < 0.004, adjusted significance level). Fifty-two percent indicated that they did not know what they were told about the risk of uterine and ovarian cancer when on the pill. A significant proportion of women said they would phone their physician for relatively minor problems such as breakthrough bleeding (65%), breast tenderness (55%) and acne (54%). CONCLUSIONS: The knowledge level of Canadian women on the pill regarding risks, benefits and side effects of the pill remains deficient in several key areas. Adequate counseling by healthcare providers can help women recognize the pill's positive health benefits, and may result in fewer unnecessary physician contacts and unwanted pregnancies.

A survey of recommendations by gynecologists in Canada regarding oral contraceptive use in the perioperative period.

OBJECTIVE: This survey was conducted to determine the practice patterns of gynecologists in Canada regarding the discontinuation of oral contraceptives before gynecologic surgical procedures. STUDY DESIGN: In May and June of 1997, surveys were sent to all obstetricians and gynecologists on the mailing list of the Society of Obstetricians and Gynaecologists of Canada. RESULTS: Of the 1472 surveys that were sent, 702 of the surveys were completed and returned, for a response rate of 48%. More than 90% of the gynecologists who were surveyed would advise their patients to continue using oral contraceptives before relatively minor surgical procedures and <1% of them would use low-dose heparin before these procedures. Rates of oral contraceptive discontinuation increased as the extent of the surgical intervention increased: Prolonged laparoscopy (39.8%), vaginal repairs and hysterectomy (54.7%), and abdominal hysterectomy or adnexectomy (56.1%). Just over one half of the gynecologists (56.1%) indicated that they would advise discontinuation > or =4 weeks before the surgical procedure, which is the minimum time required for the prothrombotic changes that are associated with oral contraceptive use to return to baseline. Less than 10% of the surgeons indicated that they would use low-dose heparin even when the patient was advised to continue taking oral contraceptives before major surgical procedures. CONCLUSION: The controversy over whether young healthy women should discontinue oral contraceptive use before major surgical procedures that are associated with immobility is reflected by a lack of consensus among gynecologists in Canada.