College Of Obstetricians Research Articles

Non-indicated use of prophylactic antibiotics in gynaecological surgery at an academic tertiary medical centre

Surgical site infections (SSI) are the most common surgical complication. Perioperative antibiotics can reduce SSI when used properly. Despite guidelines from The American College of Obstetrics and Gynecology, non-indicated antibiotic use is widespread which exposes women to unnecessary risks. This study represents a quality improvement analysis assessing surgeon compliance with established guidelines regarding antibiotic use in gynaecological surgery. This is a single centre, retrospective study examining gynaecological procedures over two years. Cases were identified using Current Procedure Terminology codes. Perioperative antibiotics were used contrary to published guidelines in 199 of 1046 cases. Three variables were independently associated with inappropriate administration of perioperative antibiotics: entrance into abdominal cavity, higher EBL, and longer procedures.Impact statementOveruse of antibiotics has unintended consequences including allergic sequelae, extended length of hospital stay, increased healthcare costs, and the formation of antibiotic-resistant organisms.Antibiotic stewardship programmes have been shown to reduce the number of resistant pathogens, decrease incidence of Clostridium difficile colitis, and decrease length of hospital stay without increasing infection rates.Further outcomes-based research is needed regarding the use of antibiotic stewardship programmes in gynaecological surgery.

Analysis and development of mobile perinatal mental health system

Perinatal depression includes major and minor depressive episodes during pregnancy or in the first 12 months after birth. The American College of Obstetricians and Gynecologists recommends that clinicians screen patients at least once during pregnancy for depression and anxiety symptoms using a standardised tool. This paper attempts to consolidate current depression screening tools into an electronic application that can be accessed from a computer, tablet or cell phone and can be sent directly to the primary care physician's office for review. The object-oriented approach was used to analysis and design the system. The systems requirements are first gathered using questionnaire and interviews with practitioners; then, analysed based on unified modelling language techniques such as use case, class, and sequence diagrams. This system will aid healthcare providers in identifying patients who are at risk of perinatal depression.

Strip of the Month: Marked Variability: To Worry or Not?

Electronic fetal monitoring is a popular technology used to establish fetal well-being. Despite its widespread use, the terminology used to describe patterns seen on the monitor has not been consistent until recently. In 1997, the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop published guidelines for interpretation of fetal tracings. This publication was the culmination of 2 years of work by a panel of experts in the field of fetal monitoring and was endorsed in 2005 by both the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). In 2008, ACOG, NICHD, and the Society for Maternal-Fetal Medicine reviewed and updated the definitions for fetal heart rate (FHR) patterns, interpretation, and research recommendations. Following is a summary of the terminology definitions and assumptions found in the 2008 NICHD workshop report. Normal values for arterial umbilical cord gas values and indications of acidosis are defined in Table 1. View this table: Table 1. Arterial Umbilical Cord Gas Values ### Assumptions from the NICHD Workshop ### Baseline FHR

Comparison of efficacy of different concentration of bupivacaine in ultrasound-guided transversus abdominis plane (TAP) block for postoperative pain relief in lower segment cesarean section

Comparison of efficacy of different concentration of bupivacaine in ultrasound-guided transversus abdominis plane (TAP) block for postoperative pain relief in lower segment cesarean section

What European gynaecologists need to master: Consensus on medical expertise outcomes of pan-European postgraduate training in obstetrics & gynaecology

ObjectiveEuropean harmonisation of training standards in postgraduate medical education in Obstetrics and Gynaecology is needed because of the increasing mobility of medical specialists. Harmonisation of training will provide quality assurance of training and promote high quality care throughout Europe. Pan-European training standards should describe medical expertise outcomes that are required from the European gynaecologist. This paper reports on consensus development on the medical expertise outcomes of pan-European training in Obstetrics and Gynaecology. Study designA Delphi procedure was performed amongst European gynaecologists and trainees in Obstetrics & Gynaecology, to develop consensus on outcomes of training. The consensus procedure consisted of two questionnaire rounds, followed by a consensus meeting. To ensure reasonability and feasibility for implementation of the training standards in Europe, implications of the outcomes were considered in a working group thereafter. We invited 142 gynaecologists and trainees in Obstetrics & Gynaecology for participation representing a wide range of European countries. They were selected through the European Board & College of Obstetrics and Gynaecology and the European Network of Trainees in Obstetrics & Gynaecology. ResultsSixty people participated in round 1 and 2 of the consensus procedure, 38 (63.3%) of whom were gynaecologists and 22 (36.7%) were trainees in Obstetrics & Gynaecology. Twenty-eight European countries were represented in this response. Round 3 of the consensus procedure was performed in a consensus meeting with six experts. Implications of the training outcomes were discussed in a working group meeting, to ensure reasonability and feasibility of the material for implementation in Europe. The entire consensus procedure resulted in a core content of training standards of 188 outcomes, categorised in ten topics. ConclusionEuropean consensus was developed regarding the medical expertise outcomes of pan-European training in Obstetrics and Gynaecology. The outcomes will be described in core trainings standards, aimed at harmonising training in Obstetrics and Gynaecology in Europe to promote high quality care.

Patient blood management in obstetrics: management of anaemia and haematinic deficiencies in pregnancy and in the post-partum period: NATA consensus statement.

Patient blood management (PBM) is the timely application of evidence-informed medical and surgical concepts designed to maintain haemoglobin concentration, optimise haemostasis and minimise blood loss in an effort to improve patient outcomes. The aim of this consensus statement is to provide recommendations on the management of anaemia and haematinic deficiencies in pregnancy and in the post-partum period as part of PBM in obstetrics. A multidisciplinary panel of physicians with expertise in obstetrics, anaesthesia, haematology, policymaking and epidemiology was convened by the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA) in collaboration with the International Federation of Gynaecology and Obstetrics (FIGO) and the European Board and College of Obstetrics and Gynaecology (EBCOG). Members of the task force assessed the quantity, quality and consistency of the published evidence and formulated recommendations using the system developed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group. The recommendations in this consensus statement are intended for use by clinical practitioners managing the perinatal care of women in all settings and by policymakers in charge of decision making for the update of clinical practice in health-care establishments. They need to be tailored for application in individual patients or any population after consideration of the values and preferences of both health-care providers and patients, as well as equity issues; explicit assessment of harms and benefits of each recommendation; feasibility including resources, capacity and equipment; and implementability.

Committee Opinion No. 704 Summary: Human Papillomavirus Vaccination.

Human papillomavirus (HPV) is associated with anogenital cancer (including cervical, vaginal, vulvar, penile, and anal), oropharyngeal cancer, and genital warts. The HPV vaccination significantly reduces the incidence of anogenital cancer and genital warts. Despite the benefits of HPV vaccines, only 41.9% of girls in the recommended age group, and only 28.1% of males in the recommended age group have received all recom-mended doses. Compared with many other countries, HPV vaccination rates in the United States are unacceptably low. The U.S. Food and Drug Administration has approved three vaccines that are effective at preventing HPV infection. These vaccines cover 2, 4, or 9 HPV serotypes, respectively. Safety data for all three HPV vaccines are reassuring. The HPV vaccines are recommended for girls and boys aged 11-12 years and can be given to females and males up to age 26 years. The Advisory Committee on Immunization Practices and the American College of Obstetricians and Gynecologists recommend routine HPV vaccination for girls and boys at the target age of 11-12 years (but it may be given from the age of 9 years) as part of the adolescent immunization platform in order to help reduce the incidence of anogenital cancer and genital warts associated with HPV infection. Obstetrician-gynecologists and other health care providers should stress to parents and patients the benefits and safety of HPV vaccination and offer HPV vaccines in their offices.

The Maternal Quality Improvement Program: A Clinical Data-Driven National Registry for Maternity Care.

Advancing the quality and safety of maternity care should be data-driven. Defining a standard set of clinical data elements, across electronic health record platforms and facilities, could accelerate performance measurement, benchmarking, and identification of better practices. In 2014, the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists launched the Maternal Quality Improvement Program, a data-driven national clinical registry for maternity care. Having an agreed-on set of discrete data elements related to labor and delivery will set the stage for analysis of this care. Through the use of clinical performance measures and data quality metrics, the Maternal Quality Improvement Program will provide an opportunity for health care providers to better understand the overall quality and safety of the maternity care provided within their institution.

Practice Bulletin No. 176 Summary: Pelvic Organ Prolapse.

Pelvic organ prolapse (POP) is a common, benign condition in women. For many women it can cause vaginal bulge and pressure, voiding dysfunction, defecatory dysfunction, and sexual dysfunction, which may adversely affect quality of life. Women in the United States have a 13% lifetime risk of undergoing surgery for POP (1). Although POP can occur in younger women, the peak incidence of POP symptoms is in women aged 70-79 years (2). Given the aging population in the United States, it is anticipated that by 2050 the number of women experiencing POP will increase by approximately 50% (3). The purpose of this joint document of the American College of Obstetricians and Gynecologists and the American Urogynecologic Society is to review information on the current understanding of POP in women and to outline guidelines for diagnosis and management that are consistent with the best available scientific evidence.

Premenstrual Syndrome Is Associated With a Higher Frequency of Female Sexual Difficulty and Sexual Distress

Few prospective studies have evaluated the impact of premenstrual symptoms (PMS) on female sexual function and sexuality-related distress. The purpose of the present study was therefore to find out risk factors of PMS for female sexual function and sexuality-related personal distress. This prospective cohort study was conducted at the Süleymaniye Women and Children's Health Training and Research Hospital in Istanbul, Turkey, between February 2014 and March 2016. The study group consisted of women admitted to the general gynecology outpatient clinic aged 18 to 40 years who met the inclusion criteria. The American College of Obstetricians and Gynecologists criteria were used for the initial diagnosis of PMS and the participants were allocated to PMS(+) and PMS(−) groups (healthy subjects). All participants completed the Beck Depression Inventory to exclude those at risk for depression. The patients with an initial diagnosis of PMS then completed the PMS Daily Record of Severity of Problems form prospectively for two consecutive menstrual cycles to confirm PMS diagnosis. Lastly, both sexual function and sexual distress of eligible PMS(+) (n = 143) and PMS(−) (n = 143) participants were assessed with both the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale-Revised (FSDS-R). According to the FSFI cutoff value, 77.6% of patients in the PMS(+) group and 27.3% of patients in the PMS(−) group had sexual concerns (p < 0.05). The sexuality-related personal distress rate was 51.7% in the PMS(+) group and 24.5% in the PMS(−) group (p < 0.05). Overall, 51.7% of the PMS(+) and 24.5% of the PMS(−) group were recognized as having sexual difficulties based on the presence of sexual distress and the low FSFI scores (p < 0.05). We concluded that women with PMS are likely to have sexual difficulties and a higher level of sexual distress, emphasizing the importance of the sexual aspects of PMS in clinical practice.

Psychiatric Disorders during Pregnancy and Postpartum

Pregnancy is the most beautiful and memorable time in a woman’s life. Apart from medical and obstetrical challenges it involves a of lot emotional, psychological and social aspects too. Although women having medical and obstetrical disorders commonly seek treatment, psychological problems are often not addressed. A female may continue to live in a state of emotional turmoil and may attribute these changes to the hormonal changes in the body due to pregnancy. Psychiatric disorders which remain untreated can disrupt the social life and can have undesirable effects on fetal and neonatal development, so it becomes important to identify women at risk for developing psychiatric disorders during pregnancy and postpartum and initiate timely management. Although the American College of Obstetrics and Gynaecology recommended strongly considering screening pregnant women for depression in 2006, it is not done as a routine. Recently we came across two interesting cases of ante partum and post-partum mental disorders. Which led us to write a review article on Psychiatric disorders in pregnancy? Let’s review the two cases in brief.

Strip of the Month: January 2017

* Abbreviations: ACOG, : American College of Obstetricians and Gynecologists AWHONN, : Association of Women's Health, Obstetric and Neonatal Nurses EFM, : electronic fetal monitoring FHR, : fetal heart rate IUPC, : intrauterine pressure catheter NICHD, : National Institute of Child Health and Human Development OR, : operating room TOLAC, : trial-of-labor-after-cesarean VABC, : vaginal birth after cesarean Electronic fetal monitoring (EFM) is a popular technology used to establish fetal well-being. Despite its widespread use, the terminology used to describe patterns seen on the monitor has not been consistent until recently. In 1997, the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop published guidelines for interpretation of fetal tracings. This publication was the culmination of 2 years of work by a panel of experts in the field of fetal monitoring, and was endorsed in 2005 by both the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). In 2008, ACOG, NICHD, and the Society for Maternal-Fetal Medicine reviewed and updated the definitions for fetal heart rate patterns, interpretation, and research recommendations. Following is a summary of the terminology definitions and assumptions found in the 2008 NICHD workshop report. Normal values for arterial umbilical cord gas values and indications of acidosis are defined in Table 1. View this table: Table 1. Arterial Umbilical Cord Gas Values ### Assumptions from the NICHD Workshop ### Baseline Fetal Heart Rate

Inappropriate Use of Antibiotics in Patients Undergoing Gynecologic Surgery

We retrospectively examined prophylactic antibiotic use and documentation of wound classification in patients having gynecologic surgery at a tertiary hospital. Of the 326 cases reviewed, 175 (54%) received prophylactic antibiotics when not indicated according to guidelines of the American College of Obstetricians and Gynecologists. Antibiotic administration varied significantly (P < 0.02) among the different types of surgery, being given in 82% of laparoscopic cases, 35% of nonobstetrical dilation and curettage and operative hysteroscopy procedures, and 51% of open abdominal procedures. There were no recorded episodes of anaphylaxis or pseudomembranous colitis. In conclusion, antibiotic use is high among gynecologic surgeons at a tertiary hospital, but this use was unnecessary.

Physicians' Perspectives and Practice Patterns Toward Opportunistic Salpingectomy in High- and Low-Risk Women

ABSTRACTBackground: Opportunistic bilateral salpingectomy (OBS) has been proposed as an ovarian cancer risk-reducing strategy. Methods: A survey was emailed to 300 members of the American College of Obstetricians and Gynecologists. Results: 125 (42%) surveys were returned: 60% female, 88% generalists, 67% private practice. Only 36% correctly identified the lifetime risk of ovarian cancer, only 23% understood the risk-reducing benefit of bilateral salpingo-oophorectomy. 75% perform salpingectomy during hysterectomy, 26–53% use for sterilization depending on approach. Concerns were increased operative time and complications. For BRCA mutations, 64% recommend BSO, 12% recommend a two-step risk-reducing strategy, and 14% refer to gynecologic oncology. Conclusions: We identified broad support and factors limiting willingness to perform OBS.

Evidence based considerations regarding the new ACOG labor guidelines

Recent guidelines issued jointly by the American College of Obstetrics and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine for assessing labor differ substantially from those described initially by Friedman, who led obstetric practice for decades. The new recommendations are based on results achieved by the analysis of patterns of cervical dilation and fetal descent. They argue that labor models originally described by Friedman are no longer applicable to modern obstetrical practice. The main changes proposed to the Friedman curve are considered to be that the beginning of the active phase is from 6 cm opposed to 4 cm. The diagnosis of dystocia is established for a progression of dilatation under 0.5 cm/h opposed to 1.5-1.2 cm. Accepted duration of the expulsion is amended: over 3 hours for nulliparous and over 2 hours for mulliparous. The new ACOG guidelines revised birth periods favoring a more permissive in terms of time factor.

European Network of Trainees in Obstetrics and Gynaecology: experiences from the 2016 exchange programme in Turin, Italy.

The European Network of Trainees in Obstetrics and Gynaecology (ENTOG) is an organization representing trainees from 30 European member countries. Together with the European Board and College of Obstetrics and Gynaecology (EBCOG), it seeks to achieve the highest possible standards of training and consequently to improve the quality of medical care in the field of gynaecology and obstetrics. Every year, the ENTOG council meets and holds a scientific meeting in a different European country. To coincide with this, the host country arranges an exchange, to which each member country can send two trainees. This exchange allows trainees to gain insight into both daily clinical work and the structure of the health care system. This article reports the experiences of participants in the May 2016 ENTOG exchange to Turin, Italy. The aim is to outline differences in training between Germany and Italy as well as some striking differences with other European countries. The participants' personal benefit from this unique experience was not only to get familiar with the Italian trainee programme and health care system, but also to exchange experiences among representatives from other European countries and build up a young gynaecological network within Europe.

Mesh removal after vaginal surgery: what happens in the UK?

There is little objective evidence regarding complication rates for mesh procedures outside clinical trials. Current coding poorly collects complications of prolapse and continence surgery using mesh. This survey was designed to identify surgeons performing mesh removal and reporting patterns in the UK. An electronic questionnaire was sent to all members of the Royal College of Obstetricians and Gynaecologists and members of the Section of Female Neurological and Urodynamic Urology of the British Association of Urologists in the UK. The questionnaire aimed to identify the number of procedures performed for mesh complications and whether they were reported to the Medicines and Healthcare products Regulatory Agency (MHRA) and the patterns of referral and treatment RESULTS: Referral to a colleague in the same hospital was common practice (69%). Only 27% of respondents stated that they reported all removals to the MHRA. The numbers of surgical procedures were low, with most respondents performing between one and three procedures each year and many not performing any surgery for a specific mesh complication in the previous year. Removal of exposed, eroded and/or painful vaginally inserted mesh is performed by many different surgeons in a variety of hospital settings in the UK.

Practice Bulletin No. 173 Summary: Fetal Macrosomia.

Suspected fetal macrosomia is encountered commonly in obstetric practice. As birth weight increases, the likelihood of labor abnormalities, shoulder dystocia, birth trauma, and permanent injury to the neonate increases. The purpose of this document is to quantify those risks, address the accuracy and limitations of methods for estimating fetal weight, and suggest clinical management for a pregnancy with suspected fetal macrosomia.

Alcohol, pregnancy and the precautionary principle

British Journal of MidwiferyVol. 24, No. 10 CommentAlcohol, pregnancy and the precautionary principleGeorge F WinterGeorge F WinterSearch for more papers by this authorGeorge F WinterPublished Online:7 Oct 2016https://doi.org/10.12968/bjom.2016.24.10.684AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References European Board and College of Obstetrics and Gynaecology (2016) EBCOG Position Paper on Alcohol and pregnancy. Eur J Obstet Gynecol Reprod Biol 202: 99–100. doi: https://doi.org/10.1016/j.ejogrb.2016.04.020 Crossref, Google ScholarLeppo A, Hecksher D (2010) The rise of the total abstinence model. Recommendations regarding alcohol use during pregnancy in Finland and Denmark. Nord Stud Alcohol Dr 28(1): 7−27. doi: https://doi.org/10.2478/v10199-011-0002-7 Google ScholarLeppo A, Hecksher D, Tryggvesson K (2014) ‘Why take chances?’ Advice on alcohol intake to pregnant and non-pregnant women in four Nordic countries. Health Risk Soc 16(6): 512–29. doi: https://doi.org/10.1080/13698575.2014.957659 Crossref, Google ScholarMidgley M (1992) Science as Salvation: A modern myth and its meaning. Routledge, London Google ScholarMurphy M (2016) Maternal autonomy. British Journal of Midwifery 24(5): 371−3. doi: https://doi.org/10.12968/bjom.2016.24.5.371 Link, Google ScholarPeterson M (2007) Should the precautionary principle guide our actions or our beliefs? J Med Ethics 33(1): 5–10. doi: https://doi.org/10.1136/jme.2005.015495 Crossref, Google Scholar FiguresReferencesRelatedDetailsCited byContinuity of carer and application of the Code: how student midwives can be agents of changeAmy Corrigan2 August 2017 | British Journal of Midwifery, Vol. 25, No. 8 2 October 2016Volume 24Issue 10ISSN (print): 0969-4900ISSN (online): 2052-4307 Metrics History Published online 7 October 2016 Published in print 2 October 2016 Information© MA Healthcare LimitedPDF download

Guideline choice for CTG analysis influences first caesarean decision

Objective: To compare intrapartum cardiotocography (CTG) analysis in case of first caesarean section (CS) for non-reassuring CTG according to international guidelines.Methods: Four ObGyns retrospectively analysed first CS for non-reassuring CTG during labour blind to neonatal outcome. CTG were analysed according to French National College of Obstetricians and Gynaecologists (CNGOF) and to the FIGO guidelines. First, CTG analysis was done without obstetrical context, then secondly, it was given. ObGyns stated if CS was justified or not. Inter-operator ObGyn agreement was analysed.Results: Among 587 CS, 100 women met the inclusion criteria with a first CS for non-reassuring CTG. The overall inter observer agreement was low but fair. ObGyns were significantly more concordant using the FIGO than the CNGOF guidelines (kappa coefficient = 0.331 [0.27–0.39] versus 0.209 [0.16–0.26] p < 0.001). Without obstetrical context 70% of CS were considered as unjustified. This rate decreased to 16% with the knowledge of the obstetrical context and the use of a classification (p < 0.001). Two-third of the unjustified CS were carried out during night hours (p = 0.026).Conclusion: The FIGO guidelines are more reproducible than CNGOF guidelines. The overall inter-observer agreement was low but fair. The guideline choice could have an impact on first CS decision.