Obstetric emergency training was associated with improved teamwork, as evidenced by the improved documentation post-training in this study, but not with improved diagnosis to delivery interval. Long-term follow-up studies are required to ascertain whether training has an impact on longer-term paediatric outcomes, such as cerebral palsy rates.
Background: Following the Term Breech Trial, vaginal breech deliveries are rarely undertaken in Australia. Some women choose to have a breech delivery following counselling, while others will present in labour with an undiagnosed breech. Clinicians need to be skilled in vaginal breech delivery despite this being a rare clinical situation. Simulation training provides a means by which uncommon clinical situations can be practised. Aim: This study aims to determine if the introduction of a simulation-based training course is associated with an improvement in the management of vaginal breech delivery and neonatal outcomes. Methods: Cases of term vaginal breech delivery five years prior to introduction of In Time training (2001-2005) and five years after In Time training (2007-2011) were identified in a tertiary obstetric hospital (King Edward Memorial Hospital, Perth). There were 136 women identified in the pre-training (2001-2005, n = 56) and post-training (2007-2011, n = 80) groups. Case note review was undertaken to gather information. Results: Apgar scores of <7 at five minutes were higher in the post-training cohort (8.8% vs 0%, P = 0.041). Arterial and venous pH readings were similar between cohorts, with a non-significant trend toward improvement in the post-training cohort. Special care nursery admissions and length of hospital stay were unchanged. The primary accoucheur was more likely to be a consultant (35.0% vs 16.4%) in the post-training cohort. Appropriate manoeuvres were more likely to be used in the post-training cohort (52.5% vs 44.6%). Conclusions: Obstetric In Time simulation training improved seniority of accoucheur and documented appropriate manoeuvres in the management of term vaginal breech delivery.
Background
Suspected appendicitis is the most common indication for surgery for non‐obstetric conditions during pregnancy. Delay in management increases the risk of appendiceal perforation and pregnancy loss. Stand‐alone specialty obstetric hospitals often don’t have surgical teams on site. It has been suspected that this may be a factor that leads to delayed diagnosis and management of non‐obstetric surgical conditions in pregnancy.
Aims
To assess the differences in time to diagnosis, imaging, surgical management and outcomes between a stand‐alone tertiary obstetric hospital and a tertiary general hospital for pregnant patients presenting with suspected appendicitis who underwent an appendicectomy.
Materials and Methods
A retrospective study of all women who underwent appendicectomy in pregnancy for suspected appendicitis over a four‐year period.
Results
Women who attended the specialist hospital were later in gestation (medians 29 weeks vs 18 weeks, P = 0.004) and less likely to have imaging (84% vs 56%, P = 0.047) with no difference in the rates of confirmation of diagnosis of appendicitis using imaging. Women who presented to the specialist hospital were more likely to be managed with a laparotomy, admitted to high dependency unit, have a longer hospital stay and tended to be later in gestation. There was no difference in rates of positive appendicectomies, appendiceal perforation or management in under the recommended 24 h.
Conclusions
The specialty obstetric hospital has a much higher rate of laparotomy and longer length of stay. The majority of patients presenting to both hospitals did not undergo surgery within 24 h and delay in imaging was a major contributor.
Introduction
Preoperative imaging of patients with endometriosis allows adequate counselling, referral to appropriate centres of expertise and workforce planning. The objective of this study was to assess the feasibility of simplified three‐category preoperative endometriosis MRI morphological descriptors to predict subsequent surgical management.
Methods
A single‐centre observational study in 76 patients (median age 38 years, range 18–55) with preoperative endometriosis mapping MRI between 1 Jan 2015 and 31 Dec 2019. MRI studies were prospectively re‐read blind‐to‐surgical outcome to categorise rectosigmoid morphology as normal, spider‐shaped (linear T2‐dark fibrotic bands) superficial endometriosis or typical crescentic or mushroom‐shaped deep infiltrating endometriosis (DIE). Bowel motility was similarly categorised as normal, tethered or distorted/fixed. The reference standard was subsequent surgery within 3 years of MRI, categorised as no bowel surgery, adhesiolysis only or more complex surgeries.
Results
Despite three‐quarters of surgical cases having normal bowel morphology on preoperative MRI (72%, 55/76; 12% linear superficial endometriosis, 10% crescentic and 5% mushroom‐shaped DIE) more than half showed bowel tethering (54%, 41/76) or distortion/fixation (10%, 8/76) and most patients underwent adhesiolysis (79%, 60/76). Complex surgery such as bowel resection, laparotomy conversion or complex adhesiolysis is predicted by morphology (crescentic or mushroom‐shaped DIE, P < 0.001) and motility (tethered or distorted bowel, P = 0.002) descriptors.
Conclusions
Comprehensive and clinically relevant diagnostic reporting does not have to be convoluted to have clinical impact: in our study population, categorising bowel morphology as normal, spider‐shaped (superficial) or crescentic/mushroom‐(DIE) shaped and motility as normal, tethered (superficial) or distorted/fixed (deep endometriosis) correlates to subsequent surgical complexity.
(Aust N Z J Obstet Gynaecol. 2017;57(3):327–333)
Although the overall incidence of cord prolapse is 0.1% to 0.6%, it often appears in perinatal mortality inquiries, with a perinatal mortality rate of 91 in 1000 in the setting of cord prolapse. Cord prolapse is also significantly associated with spastic quadriplegic or dyskinetic cerebral palsy in both term and preterm infants. In order to optimize perinatal outcome in cases of cord prolapse where there is evidence of fetal distress, a diagnosis to delivery interval (DDI) of <30 minutes has been recommended, but there is no evidence that demonstrates an association between a more rapid DDI and improved neonatal outcomes below this 30-minute interval. On the basis of previous studies, it has also been recommended that all staff involved in maternity care receive training in the management of cord prolapse, in order to avoid the poor communication and confusion about roles and responsibilities shown to be associated with poor outcomes.
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