Royal College Of Obstetricians And Gynaecologists Research Articles

National inpatient diagnostic hysteroscopy survey

This survey was undertaken to determine the common practise patterns of how hysteroscopy is carried out in the UK. We believe this will help to develop a consensus and set national guidelines in accordance with the way we undertake this procedure. In addition; we aim to assess the operators understanding of hysteroscope optics related to this procedure. The study was conducted in a teaching hospital in the southwest of England, UK. Postal questionnaires were sent within the first week of June 2007 to 1,000 consultant gynaecologists in the UK. The surveyed gynaecologists were selected from the Royal college of Obstetricians and Gynaecologists (RCOG) register of Fellows and Members. The questionnaire included questions regarding common preoperative preparation, operative techniques, post-operative management, and follow-up. Four hundred seventy-five (47.5%) responses were returned. Four hundred forty (44%) consultant gynaecologists completed the survey and 35 (3.5%) incomplete questionnaires were returned by consultants who currently do not undertake hysteroscopy. It appears that there is some consensus in with the way we undertake this procedure. However, the results showed a wide variation in the understanding of the hysteroscopes angled optics and how this relates to surgical technique for inpatient hysteroscopy. It seems that setting up a national guideline is feasible. However, there was a clear lack of understanding of the optics used during a hysteroscopic procedure between gynaecologists. Optics-related surgical techniques should be included into training programmes. Professional societies are able to develop a general consensus for this procedure. We are pleased that the practical skills courses run by the RCOG include clear training in this area.

Shoulder Dystocia: Comparison of the ACOG Practice Bulletin with Another National Guideline

Our objective was to compare national guidelines regarding shoulder dystocia. Along with the American College of Obstetricians and Gynecologists (ACOG) practice bulletin on shoulder dystocia, guidelines from England, Canada, Australia, and New Zealand were reviewed. The Royal College of Obstetricians and Gynaecologists (RCOG) guideline agrees with the ACOG definition of shoulder dystocia, but there are variances in the management of suspected macrosomia and resolution of impacted shoulders. How recommendations are categorized differ also. Only 53% (20 of 38) of eligible references are cited by both publications. The two national guidelines on shoulder dystocia have differences and disagreements with each other, raising concerns about how the literature is synthesized and which is more comprehensive.

Intrauterine growth restriction: comparison of American College of Obstetricians and Gynecologists practice bulletin with other national guidelines

The objective of the study was to compare national guidelines regarding small for gestational age (SGA). Along with American College of Obstetricians and Gynecologists (ACOG) practice bulletin on abnormal growth, guidelines from England, Canada, Australia, and New Zealand were reviewed. There are no guidelines on SGA from Canada, Australia, and New Zealand. The Royal College of Obstetricians and Gynaecologists (RCOG) guideline agrees with ACOG's definition of abnormal growth, but there are noticeable variances in the diagnosis and management of SGA. RCOG has more recommendations than ACOG (18 vs 4, respectively). The articles referenced varied, with only 13 similar articles being cited by the both committees. The differences in the 2 guidelines suggest that there is variance in how 2 committees synthesize the literature and issue recommendations.

Homebirths in a modern setting – a cautionary tale

In Western societies, homebirth instead of facility delivery pinpoints the essence of obstetrics: supporting and overseeing an uncomplicated delivery and providing timely intervention for a complic...

Where do we go now with low molecular weight heparin use in obstetric care?

The use of low molecular weight heparins (LMWH) in obstetric care has grown considerably since their introduction into clinical practice in the early 1990s. However, because of the physiological changes of pregnancy, the predictable pharmacokinetic profile of LMWH is lost and some uncertainty exists around the optimal dosing regimen for LMWH in obstetric care. Two recent United Kingdom prospective surveys of the management of acute venous thromboembolism (VTE) suggest that despite recommendations from the Royal College of Obstetricians and Gynaecologists (RCOG) for a twice daily LMWH regimen, a once daily regimen is acceptable for the treatment of venous thromboembolism; and that accepted thromboprophylactic doses licensed for non-pregnant individuals may not be applicable during the second and third trimester for VTE thromboprophylaxis. Accepting that randomized clinical studies are difficult in obstetric care, future advances could be made through population-based multi-center studies, coupled with pharmacokinetic modeling studies, which have the potential to determine the optimal dosing regimen for the various obstetric indications.

Hysteroscopy training in the UK: the trainees’ perspective

The advanced hysteroscopy special skills module has been developed by the Royal College of Obstetricians and Gynaecologists (RCOG) in association with the British Society of Gynaecologic Endoscopists (BSGE). It is mainly aimed at senior specialist registrars in obstetrics and gynaecology in their final two years of training, but it can also be undertaken by non-training posts in the same field. By completion of the module, ideally within a year, trainees are expected to have reached independent competence in performing both diagnostic, as well as operative hysteroscopy. A survey was done on trainees attending the mandatory course at the RCOG (intermediate/advanced hysteroscopic surgery course in 2006), which is part of the requirement for obtaining the Advanced hysteroscopy special skills module. Feedback was obtained from 44 trainees who were either already registered for the special skills module in advanced hysteroscopy or were planning on registering. Overall, 50% of candidates found the one-year target difficult to achieve. The majority attended at least one hysteroscopy outpatient clinic per week (85%) and/or one hysteroscopy theatre list per week (87%). This suggested the adequate attendance of hysteroscopy sessions; however, the problem was with operative hysteroscopy, which comprised 0–20% of training for the majority of trainees (59%). The conclusion was that the one-year target for obtaining the special skills module was difficult to achieve, with the most evident cause being the inability to acquire the expected operative hysteroscopy standard within the intended time.

The Local Adaptation of National Recommendations for Preventing Early-Onset Neonatal Group B Streptococcal Disease in Uk Maternity Units

To evaluate how UK maternity unit protocols conformed to national recommendations for preventing early-onset neonatal Group B Streptococcal (GBS) disease. In December 2005, all UK obstetric maternity units were contacted and asked to provide a copy of their protocol on preventing GBS disease. Information was extracted on the protocol's recommendations, its development date and the evidence cited. The protocol's recommendations were then compared against the recommendations in the Royal College of Obstetricians and Gynaecologists (RCOG) guideline. Protocols were obtained for 171 of the 227 units (75%), of which 120 were developed after the guideline has been published. There were 134 protocols (78%) that followed the RCOG prevention strategy, recommending a risk-based approach to selecting women for intrapartum antibiotic prophylaxis (IAP). However, the sets of risk factors named as indications for IAP differed between the protocols and only 34 of these 134 protocols were entirely consistent with the guideline. The 37 protocols (22%) that did not follow the RCOG prevention strategy recommended IAP for some risk factors but only if a bacteriological test was also GBS positive. There are considerable differences in the GBS protocols used in maternity units in the UK despite the availability of a national guideline. Consequently, some high-risk women may not receive IAP while some women without risk factors are treated needlessly. While local adaptation may be for legitimate reasons, the processes used in some units seem to require improvement.

Avoiding over diagnosis of shoulder dystocia

SummaryIn this study, we aimed to distinguish true shoulder dystocia from mere difficulty with delivery of the shoulder, by investigating the risk factors that lead to shoulder dystocia. Shoulder dystocia is a bony problem which occurs when either the anterior or, less commonly, the posterior fetal shoulder impacts on the maternal symphysis pubis or sacral promontory. Failure to apply the Royal College of Obstetricians and Gynaecologists (RCOG) clinical diagnostic criteria for shoulder dystocia has made it susceptible to over-diagnosis due to inclusion of all difficult shoulder deliveries, including those related to an inappropriate maternal position. This was a retrospective analysis of risk factors associated with 56 cases of shoulder dystocia which occurred in West Middlesex University Hospital between 2003 and 2004. The cases were analysed in two categories, good outcome and poor outcome, and compared with each other. The poor outcome had represented true shoulder dystocia. The incidence of shoulder dystocia increased from 0.94% in 2003 to 1.37% in 2004. However, the incidence of those with a poor outcome decreased from 45.4% of the whole shoulder dystocia group in 2003, to 17.6% in 2004 (p = 0.03). There were no clear diagnostic criteria documented in the notes for the condition other than the birth attendants' opinion and the turtle sign. This may either reflect over-diagnosis from increased awareness or possibly improvement in the outcome due to training and education. Interestingly, at least four risk factors were identified in each of the cases with poor outcome. A registrar conducting the delivery, forceps delivery for delayed second stage and the turtle sign were significantly common findings among the true shoulder dystocia group. Multiple risk factors can be a good predictor for the occurrence of shoulder dystocia. Applying the RCOG diagnostic criteria for shoulder dystocia may lead to improvement in diagnosis and therefore a better understanding of the risk factors and future management of shoulder dystocia.

A complete audit cycle of management of third/fourth degree perineal tears

SummaryWe present a complete audit cycle of the management of third/fourth degree perineal tears in the three Glasgow maternity hospitals measured against the recommendations of the Royal College of Obstetricians and Gynaecologists (RCOG) Guideline No. 29 (www.rcog.org.uk). Following an initial 6-month data collection period, shortcomings in the practice were identified, circulated and an operative proforma was designed and introduced. A re-audit demonstrated improved compliance with the RCOG guidelines. We recommend the introduction of an operative proforma to aid management and documentation of third/fourth degree tear repairs.

Admission cardiotocography screening of high risk obstetric patients

Background: To predict the neonatal outcome in high risk obstetric cases by admission cardiotocography (CTG) testing. Methods: A total of 150 consecutive high risk obstetric patients meeting the inclusion criteria were subjected to admission CTG testing in this prospective study. The CTG tracing was categorized based on Royal College of Obstetricians and Gynaecologists (RCOG) criteria. Specific foetal and neonatal outcome measures were studied and correlated with the admission CTG testing. Result: Foetal distress during labour developed in 15% of patients with a normal test and in 73% of patients with an abnormal test. The admission test had a sensitivity of 66.7%, specificity of 93.3% and a positive predictive value of 53.3% for predicting an Apgar score < 5 at birth. Neonatal admission to neonatal intensive care unit was required in 1% of patients with a normal test and 33% of patients with an abnormal test (p < 0.01). Conclusion: The result of admission cardiotocography testing could be used to identify patients likely to develop adverse foetal outcomes and help in optimal utilization of labour room resources.

Amniocentesis counselling: a role for the midwife-practitioner

SummaryRecent publication of an evidence-based clinical guideline by the Royal College of Obstetricians and Gynaecologists (RCOG ) for invasive testing in pregnancy stimulated a review of our prenatal diagnosis counselling service. This coincided with a reduction in the hours worked by obstetric trainees and a need to streamline antenatal care. We arranged for a senior midwife (KE) with extensive experience in general midwifery and fetal medicine to undergo additional training in counselling for amniocentesis. She then took over the running of the counselling service supported by an in-house care pathway. She had open access to a consultant (RF) for advice. A review of the case notes of 60 consecutive women who attended for counselling showed that the midwife followed the guidelines extremely closely both in terms of process and quality of the documentation. A total of 58 of the women were counselled solely by the midwife-practitioner. Only two required additional counselling by the consultant. Of a subset of 27 women surveyed by telephone questionnaire, only two (7.4%) were surprised to have been counselled by a midwife; 25 (93%) said the counselling was excellent or good; 17 (63%) said they would prefer to see a midwife in any future pregnancy and only one woman said she would prefer to see a doctor.

Operative vaginal delivery and the use of episiotomy—A survey of practice in the United Kingdom and Ireland

Objective To establish the views and current practice of obstetricians with regard to operative vaginal delivery and the use of episiotomy. Study design A national survey of consultant obstetricians and specialist registrars practising in the United Kingdom and Ireland registered with the Royal College of Obstetricians and Gynaecologists (RCOG), London. A postal questionnaire was sent to all obstetricians with two subsequent reminders to non-responders. The choice of procedure for specific circumstances, instrument preference, use of episiotomy and views on the relationship between episiotomy use and anal sphincter tears at operative vaginal delivery were explored. Results The response rate was 80.4%. Instrument preference varied according to the fetal position and station and the grade of operator. Vacuum and forceps were both used for mid-cavity non-rotational deliveries (64% and 56% reported frequent use respectively). Rotational vacuum was preferred for a mid-cavity mal-position (69%) followed by equal numbers using rotational forceps or manual rotation and forceps (34% and 36%, respectively). Inexperienced operators were more likely to proceed directly to caesarean section (35%). A restrictive approach to use of episiotomy was preferred for vacuum delivery (72%) and a routine approach for forceps (73%). Obstetricians varied greatly in their perception of the relationship between episiotomy use and anal sphincter tears at operative vaginal delivery. Conclusion There is wide variation in the use of episiotomy at operative vaginal delivery with uncertainty about its role in preventing anal sphincter tears. A randomised controlled trial would address this important aspect of obstetric care.

Trials and tribulations of operative vaginal delivery

The notion that operative vaginal delivery has declined in the wake of escalating caesarean section rates is not evidence based. In England, despite a progressive increase in caesarean deliveries over the past 20 years, reaching 23% of births in 2004, the instrumental delivery rate has remained relatively stable at 10–11% of all births.1 Similar trends are evident throughout the UK and North America.2 In Australia, in 2004, more than 29% of women across the nation had their babies delivered by caesarean section; yet, the instrumental delivery rate has remained steady at 11% for the past 10 years.3 The increase in caesarean deliveries, therefore, cannot be explained by a shift from instrumental-assisted births. During the same period, operative vaginal delivery has undergone a dramatic change in practice manifested by a decline in the number of forceps deliveries and a concomitant increase in vacuum extractions. In most reports, the vacuum extractor has now become the preferred instrument for assisted delivery.1,3 The Royal College of Obstetricians and Gynaecologists (RCOG) has issued evidence-based guidelines to increase safety of operative vaginal delivery for mothers and babies and to reduce the likelihood of litigation for medical practitioners and health institutions.4 One of the key recommendations of the guideline (section 5.2) is that ‘operative vaginal births that have a higher rate of failure should be considered a trial and conducted in the operating theatre where immediate recourse to caesarean section can be undertaken’. The rationale behind this recommendation is that fetal injuries have been attributed to the time delay between failed operative vaginal delivery and caesarean section. The benefits should be obvious yet, as the guideline admits, evidence to support this practice is limited. Olagundoye and MacKenzie in this issue of the journal (pages 603–8) report the findings of their evaluation of the impact of a trial of instrumental delivery in the operating theatre in terms of the decision-to-delivery intervals (DDI), mode of delivery and neonatal condition at birth.5 They concluded that on average, the DDI for instrumental procedures in the operating theatre were some two to three times longer than for deliveries undertaken in the labour ward room. Either way, their data showed no significant differences in short-term neonatal or maternal outcomes and do not provide support for the recommendation in the RCOG guideline. The DDI have been studied extensively in relation to emergency caesarean section, where delivery within 30 minutes has generally been accepted as the benchmark. Nevertheless, this recommendation is not achieved in up to 50% of emergency caesarean sections and is therefore an unrealistic target for clinical practice.6 Furthermore, large national and multicentre studies have reported no differences in neonatal or maternal outcomes for emergency caesarean sections when the delivery interval was less than 30 minutes compared with the intervals of longer than 30 minutes and up to 75 minutes.7,8 For forceps delivery and vacuum extraction, the DDI and its effects on neonatal outcome are less clear. A prospective analysis of 90 forceps and 135 vacuum deliveries reported that in cases of fetal distress, the mean DDI for forceps delivery (23 minutes) was significantly shorter than that for vacuum extraction (29 minutes).9 In the Portsmouth study, the mean interval from time of application of the forceps to delivery was shorter than that for vacuum extraction, but the interval from the decision to delivery was the same for both instruments.10 This is plausible when considering the number of steps involved in performing an operative vaginal delivery prior to application of the device.11 The preoccupation with DDI has diverted the focus from problems related to instrumental delivery that need urgent attention. Of particular importance are the high failure rates reported for vacuum extraction and the potential for injury associated with a failed instrumental delivery.12 In the analysis by Olagundoye and MacKenzie, 30 (22%) of the vacuum extractions were unsuccessful at the initial attempt, whereas

Compliance with the published RCOG guidelines in women undergoing hysterectomy for menorrhagia in a district general hospital

SummaryThe Royal College of Obstetricians and Gynaecologists (RCOG) published guidelines describing the management of menorrhagia in primary and secondary care. In this study, we reviewed retrospectively, the compliance with these guidelines in women who underwent a hysterectomy for menorrhagia over a 3-year period in a District General Hospital. Case notes were reviewed for 22 women in whom the uterus was reported normal on histology. There was a high level of compliance in clinical assessment before hysterectomy. Nearly 70% of women received some form of medical treatment, however only 50% were offered endometrial ablation. Compliance was high in imparting information about the risk factors of hysterectomy and in administering thromboprophylaxis.

The birth of perinatal medicine in the United Kingdom

Slow but steady progress in the medical care of mothers and their infants during the 16th-19th centuries received a setback early in the 20th century following a shift of focus from the baby towards gynaecological surgery. The development of paediatrics after 1928 and the formation of a national health service in 1948 led to a renewed interest in the fetus and newborn infant. Special care baby units (SBCUs) were created in the 1960s. At this time, too, obstetric technology arrived in the delivery room and domiciliary birth largely gave way to hospital delivery. Neonatal intensive care arrived in the 1970s. However, a severe lack of resources retarded progress. Many medical reports in the 1970s drew attention to the deplorable situation. In 1980 a House of Commons working party called for the establishment of a sound perinatal service. In 1982 the Government recognized all newborn infants as NHS patients from the moment of birth rather than after their registration. That year too the Royal College of Obstetricians and Gynaecologists (RCOG) acknowledged the need for a subspecialty in maternal and fetal medicine. Meanwhile, a paediatric perinatal pressure group, arising in 1976, became a multidisciplinary association of perinatal medicine in 1981. By 1983 the new discipline of perinatal medicine had become firmly established.

Editorial

I have recently had cause to review the clinical practice guidelines of a number of Australasian clinical units, along with the statements of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Royal College of Obstetricians and Gynaecologists (RCOG) and the National Institute of Clinical Excellence (NICE). As evidence-based medicine (EBM) is supposed to be replacing eminence-based medicine (? also EBM), I am struck by the slightly preposterous thought that all the clinical practice guidelines that I look at should say the same thing. But then, in a country of just over 20 million people, which even more preposterously has eight health departments, I guess that such a possibility is too much to hope for. What is it about clinicians that we must all have our own set of guidelines for care, yet we expect our trainees to always come up with uniform management options in an examination? How is it that we do not have one set of agreed guidelines? I believe that there is a light in the tunnel that I am peering down. A National Working Group, reporting to the health ministers and the community and disability services ministers, has commissioned a Women's Hospitals of Australasia-facilitated ‘Consortium on Evidence-Based Guidelines in Women's Health’** The ‘Consortium’ is managed by Women's Hospitals of Australasia, and includes the Australian College of Midwives Inc., the Australian and New Zealand Neonatal Network, the Centre for the Study of Mothers’ and Children's Health La Trobe University, the Health Advisory Committee NH and MRC, the National Perinatal Statistics Unit AIHW, the New Zealand Guidelines Group, the National Institute of Clinical Studies, the Royal Australian College of General Practitioners, the Royal New Zealand College of General Practitioners, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the 3Centres Collaboration Victoria (including consumer inputs), and the Maternity Coalition. to undertake a review of existing guidelines in an effort to develop national evidence-based guidelines for antenatal care as a first step to develop a single guideline set and to identify areas that still require evidence to be developed. I commend this project as one that we should all support.

Surgical management of ectopic pregnancy in a district general hospital

SummaryThe mainstay of management of ectopic pregnancies is laparoscopic surgery. Other treatment options include open laparotomy, methotrexate or expectant approach. Recently the Royal College of Obstetricians and Gynaecologists (RCOG) revised its guidelines regarding management of suspected ectopic pregnancies. We undertook a retrospective study looking at management of ectopic pregnancies over a defined 12-month period (1 October 2003 – 30 September 2004) in a district general hospital to the north of London and compared this with the recommended RCOG guidelines . Cases of ectopic pregnancy were identified from the theatre, ward log, and cross-referenced with histopathological reports. The case notes of these women were reviewed and data extracted according to a drawn-up questionnaire. A total of 64 cases met the diagnostic criteria and were included in the study. Nine of the 64 cases were haemodynamically unstable and seven underwent rapid laparotomy. All of the stable 55 cases underwent laparoscopy, which was converted to open laparotomy in 13 cases (23.6%). Three patients were treated with methotrexate all of whom had been previously managed surgically. The majority of cases of ectopic pregnancy were managed according to the RCOG recommendations. Further changes in practice will be required to incorporate expectant and primary medical management as proposed by the recent guidelines (RCOG ). This study reveals progress achieved in management of ectopic pregnancies in UK with the introduction of RCOG guidelines .

Termination of pregnancy in South Tyneside

SummaryWe evaluated prospectively, compliance with the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines on termination of pregnancy (TOP) in a cohort of 340 women referred for termination of pregnancy in 2003 at South Tyneside Foundation Trust. The number of referrals represented one-fifth of all births in our unit during the study period. Teenagers were the largest single group of women requesting termination of pregnancy and the majority were nulliparous. There were 85 women who were seeking a repeat termination of pregnancy. The RCOG minimum referral standard was met in 80% of cases. A good number of women were unsure of their menstrual dates and only 5% had used emergency contraception. A total of 96% were either not using contraception, using condoms or taking oral contraceptives irregularly. A total of 50% of the women attended hospital without a Certificate A being completed by the referring practitioner. Surgical termination was preferred over medical termination in the cohort of women who could exercise a choice. It is possible to comply with the RCOG Termination of Pregnancy guidelines to a large extent in a District General Hospital, with some innovation. Close liaison between General Practitioners, Family Planning Clinics and Acute Hospitals is required. The adoption of agreed referral requirements and pathways would help in the delivery of a high quality service as advocated by the guideline.

Learning lessons from ‘Why Mothers Die’

The ‘Why Mothers Die’ Report (2000 – 2002) from the Confidential Enquiry into Maternal and Child Health (CEMACH) (RCOG, 2004), was launched on 12 November 2004 at the Royal College of Obstetricians and Gynaecologists (RCOG). This is the latest report by the Confidential Enquiry into Maternal Deaths (CEMD), the first having been published in 1957 when the risk of a mother dying was 1 in 1500.

Management of genital chlamydial infections at termination of pregnancy services in England and Wales: where are we now?

To determine the range of policies and practices related to the management of genital chlamydial infection employed at termination of pregnancy services in England and Wales. Cross-sectional descriptive study. England and Wales. Termination of pregnancy providers. Survey questionnaire administered to termination of pregnancy providers. Policies and practices for the management of genital chlamydial infection in women seeking termination of pregnancy with comparison to the national guidelines of the chief medical officer (CMO) and the Royal College of Obstetricians and Gynaecologists (RCOG). One hundred and thirty-eight (48%) practices responded to the survey, with representation across England and Wales. Policies for screening and/or treatment of chlamydial infection existed for 70% of providers. We found three practice patterns for the management of genital chlamydial infection among termination of pregnancy attenders: 70% of providers tested their own attenders prior to termination and treated if necessary; about 25% of providers administered prophylaxis without testing; and a small number of providers (< 5%) neither tested nor treated attenders. These patterns may be the result of differences in the CMO and RCOG guidelines. Given the impact of untreated genital chlamydial infection in women attending for termination, consistent recommendations from the CMO and RCOG may encourage uniform practice for the management of chlamydial infection in this vulnerable population.