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Surgical site infection (SSI) is an important cause of postoperative morbidity and, in severe cases, mortality. The epidemiology of SSIs varies depending on the type of surgery and the country. It is influenced by patient-related, preoperative, intraoperative and postoperative risk factors. Prevention strategies target these risk factors and include measures taken before, during and after surgery. Learning objectivesTo understand how SSIs can be prevented, depending on the type of wound, especially perioperative measures including antibiotic prophylaxis, and when to institute repeat antibiotics or alter dosages. To understand the bases of and approaches to perioperative antibiotics in women with incidental infections (for example, lower genital and urinary tract) and in women with comorbidities, such as those who are immunosuppressed or with mechanical valvar heart diseases.To understand what specific measures to take to reduce the risk of SSIs in special cases in obstetrics and gynaecology, such as in morbidly obese women, those undergoing cancer surgery, or those with cardiac conditions or transplants. Ethical issuesShould perioperative antibiotics be given to every woman undergoing surgery? What is the risk of antibiotic resistance as a result of administration of perioperative antibiotics?

The incidence of placenta praevia and accreta has been increasing with rising caesarean section rates. We highlight the increasing incidence of severe post-partum haemorrhage due to placenta accreta. Four cases occurred within 3 years (2002--2004) in a small District General Hospital (DGH) with a delivery rate of 1,800 per year. All of the cases had previous caesarean sections and three had an associated anterior low-lying placenta. These patients were diagnosed to have placenta accreta in the third stage of labour, as the placenta was completely adherent and was difficult to remove. However, two of them had a provisional diagnosis made of placenta accreta and prophylactic measures had been taken in the form of counselling and consent for possible hysterectomy. Patients were counselled regarding this condition, and the possible need for hysterectomy was discussed. Two of them had to be managed by post-partum hysterectomy and the other two were treated conservatively. The purpose of writing these case reports is to warn others of the need for vigilance, particularly in keeping their primary caesarean section rates down and being prepared for long-term complications.

Introduction Diabetes is the most common pre-existing medical condition in pregnancy in the UK. The global obesity epidemic has led to an increase in the incidence of Type 2 Diabetes in pregnancy and gestational diabetes. Obesity may also affect susceptibility to Type 1 Diabetes.1 Children of diabetic mothers are in turn pre-disposed to Type 2 Diabetes in adult life.2 Objective To determine the prevalence of obesity in diabetics and correlate body mass index (BMI) with pregnancy outcomes. Results 103 cases were identified. Age range was 15 to 43 years. Gestational diabetes n=45, Type 1 Diabetes n=50 and Type 2 Diabetes n=8. BMI was not recorded in 10 cases. BMI range 22–54. 67% were clinically obese. (Class 1 obesity=30%, Class 2 obesity=23% and Class 3 obesity=14%). 20.4% were overweight. Only 12.6% had BMI of 25 or less. In the Obese group the caesarean section rate was 57% (30% Elective and 27% Emergency). Spontaneous vaginal delivery rate was 31% and 12% had assisted vaginal delivery compared to a caesarean section rate of 50%, Vaginal delivery rate of 38.2% and assisted vaginal delivery rate of 11.8% in the non-obese group. 8% of all babies had intra uterine growth restriction. 45% were normal centile for gestation and 47% were above the 95th centile. (Range 1.7–5.4 kg). Conclusion Obesity is strongly associated with both pre-existing and gestational diabetes in pregnancy. It appears to confer an even greater risk of operative delivery. A significant proportion of babies were macrosomic.

Background Ultrasound surveillance remains one of the main stay in the management of the high risk antenatal patient. However, it contributes significantly to the burden of most Scan departments. The National institute for clinical excellence states that evidence does not support the routine use of ultrasound scanning after 24 weeks. Methodolgy Retrospective Audit of fetal surveillance performed in a Teaching Hospital. Objectives To assess how fetal surveillance scan assisted in the management of selected high risk patients. Results 500 scans were performed in 202 patients. In 54.5% birth weights did not correlate with scan. Findings did not influence care in 78.2% and did not affect timing or mode of delivery in 86%. In 43 patients scan affected antenatal care. 15 patients had further scans. 6 had OGTT and 1 Gestational diabetes was diagnosed. 5 patients required admission. 26 women (13%) were delivered as a result of scan findings including 1 EMCS. 1 ECV was performed for undiagnosed breech presentation. 69% of babies with IUGR had not been picked up by scan. 38% of the 56 smokers had babies whose birth weight was on or below the 10th centile. 75% of women scanned serially for booking late were of ethnic minority origin. Conclusion Ultrasound surveillance is by no means infallible in the assessment of fetal wellbeing. Over half of estimated fetal weights as predicted by scan was inaccurate however it made a significant impact on antenatal care in a good proportion of patients.

Background The Audit of antenatal ultrasound scans in England and Wales in 2007 concluded that largest contribution to workload with potential for rationalisation was from the scans perform ed after the anomaly scan. They accounted for 27% of all scans and 63% of non-routine scans Methodolgy Retrospective Audit of Growth scans performed in a Teaching Hospital. May 2011 Objectives To determine amount, indications and frequency and to formulate a guideline for referral Results Total number of scan was 500 in 202 patients. Range 1 to 11 scan per patient. Most scans were performed by Sonographers. In 46.5% scan had been planned as part of antenatal care while in 53.5% scans were unplanned. Indication was maternal in 105 cases and fetal in 97 cases. Average frequency interval was 2-4 weeks. Maternal indications varied from Medical disorders, antepatum haemorraghe and BMI issues to anxiety, cervical suture and abdominal trauma. Fetal indications varied from suspected IUGR and fetal abnormality to previous macrosomia, suspected polyhydramnios and suspected oligohydramnios Scan did not influence antenatal care in 78.2% and did not affect timing or mode of delivery in 86% Conclusion The decision to perform growth scans poses a dilemma when the indication does not fall into a well defined category. Many of the growth scans performed did not fall under accepted indications. Appropriate use with careful consideration about frequency helps in the management of high risk women but random indications contributes significantly to the burden in most units

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Background Diabetes remains the most common pre-existing medical disorder complicating pregnancy in the UK. In 1989 the St Vincent Declaration suggested that outcomes of pregnancy should be similar in women with and without diabetes.1 Method Retrospective study using maternal records. All women were managed in a multidisciplinary clinic. Scottish Intercollegiate guideline recommendations were followed for their care.2 Objective To analyse the outcomes of pregnancy in the diabetic population over a 2 year period. Results 103 cases were identified. Gestational diabetes n=45, Type 1 diabetes n=50 and Type 2 diabetes n=8. Median age was 29 years. There were 102 live births and only 1 stillbirth at 24 weeks. Caesarean section rate was 50% (25% emergency and 25% elective). Vaginal delivery rate was 38% and instrumental delivery rate 12%. There were eight growth restricted infants and 47% had birth weights greater than the 90th centile. 30% required SCBU admission. There was 1 case of severe shoulder Dystocia and 1 severe Hypoxic Ischemic encephalopathy. Congenital malformations included 1 renal anomalie, 1 congenitally short femur and 1 polydactyly (rate 2.9%). Conclusion The congenital anomaly and perinatal mortality were similar to that of normal controls. Caesarean section rate and neonatal morbidity were high compared to the background rate. Optimal outcome is possible in diabetic pregnancies with good glycaemic control in women managed in a multidisciplinary clinic.