Andrea N. Simpson

Learning from Experience: Development of a Cognitive Task-List to Assess the Second Stage of Labour for Operative Delivery

OBJECTIVE Ensuring the availability of operative vaginal delivery is one strategy for reducing the rising Caesarean section rate. However, current training programs appear inadequate. We sought to systematically identify the core steps in assessing women in the second stage of labour for safe operative delivery, and to produce an expert task-list to assist residents and obstetricians in deciding on the safest mode of delivery for their patients. METHODS Labour and delivery nursing staff of three large university-associated hospitals identified clinicians they considered to be skilled in operative vaginal deliveries. Obstetricians who were identified consistently were invited to participate in the study. Participants were filmed performing their normal assessment of the second stage of labour on a model. Two clinicians reviewed all videos and documented all verbal and non-verbal components of the assessment; these components were grouped into overarching themes and combined into an integrated expert task-list. The task-list was then circulated to all participants for additional comments, checked against SOGC guidelines, and redrafted, allowing production of a final expert task-list. RESULTS Thirty clinicians were identified by this process and 20 agreed to participate. Themes identified were assessment of suitability, focused history, physical examination including importance of an abdominal examination, strategies to accurately assess fetal position, station, and the likelihood of success, cautionary signs to prompt reassessment in the operating room, and warning signs to abandon operative delivery for Caesarean section. Communication strategies were emphasized. CONCLUSION Having expert clinicians teach assessment in the second stage of labour is an important step in the education of residents and junior obstetricians to improve confidence in managing the second stage of labour.

Learning From Experience: Development of a Cognitive Task List to Perform a Caesarean Section in the Second Stage of Labour

OBJECTIVE Caesarean section at full cervical dilatation is a challenging procedure with a higher risk of fetal and maternal morbidity. We wished to elicit the essential clinical components of a CS at full dilatation performed skilfully and safely. METHODS We conducted a prospective study with both qualitative (individual interviews) and quantitative (questionnaire) components. In the qualitative components, senior clinicians were interviewed using open-ended questions regarding techniques used for performance of CS at full cervical dilatation. Interviews were recorded and thematic analysis was performed until saturation was achieved. In the second (quantitative) component of the study, clinicians completed a questionnaire regarding tips and techniques to perform a CS at full cervical dilatation. RESULTS For the qualitative component, 15 clinicians agreed to participate. There was a 90% (n = 27) response rate to the questionnaire. Common themes from both components of the study included the advice to routinely re-examine the patient (with abdominal and vaginal examinations) in the operating room after induction of anaesthesia to determine pelvic architecture, fetal size, and the station of the presenting part, and especially to assess for progress since the initial decision to perform a CS in the labour room. When the decision is made to proceed with CS, the following modifications to a standard CS technique were suggested: first, to make a more superior transverse uterine incision than usual, and second, to secure each uterine angle separately before uterine closure is commenced in order to identify and manage angle extension and thereby minimize blood loss. Other modifications, such as vaginal disimpaction of the fetal head before beginning the operation, were more controversial. Participants developed their own techniques by combining teaching from senior obstetricians, watching others operate, and learning from their own clinical experience. CONCLUSION There is an increasing role for good quality clinical training programs on how best to perform complex deliveries such as CS at full cervical dilatation. After identifying the essential components of CS at full cervical dilatation reported by multiple skilled clinicians, these can then be translated into a useful educational tool.

Uterine Full Thickness Multifocal Dehiscence Associated With a History of Cho Uterine Compression Sutures

At operation, there was blood in the abdomen, but the lower uterine segment was intact. A single infant was delivered in good condition. The patient had completed childbearing and agreed to undergo hysterectomy. The uterus had multiple areas of full thickness dehiscence anteriorly and posteriorly (Figure 1), with placenta accreta (Figure 2). There have been few reports of pregnancies after use of compression sutures; partial thickness uterine wall necrosis has been described.2

PLD.53 Using clinical experience to elicit the components of a skilled and safe operative delivery

Reduced working hours and increased caesarean delivery rates have resulted in less exposure to intricate deliveries by obstetrics trainees. Though trainees may not be exposed to these deliveries as part of their training, conversely they may be expected to be proficient in them once starting independent clinical practice. This study aims to identify the verbal and non-verbal components of three intricate deliveries – Kiellands, non-rotational and assisted breech. Labour and delivery nursing staff were asked to identify those clinicians who they considered to be particularly skilled in intricate deliveries. Those identified consistently were invited to participate in the study. With written consent participants were then videoed performing each type of delivery on a model in order to identify the verbal and non-verbal components of the delivery. Two clinicians reviewed videos. The initial summary was then circulated to all participants for their approval. Themes identified included the need for careful assessment of suitability, the role of the multidisciplinary team, need for careful and appropriate communication with the parents, the technique of delivery itself and postpartum care and documentation. Overall the clinicians balanced respect for the “elegant technique” of intricate deliveries with careful assessment and when to stop should safety criteria not be met. There is still a role for intricate deliveries in modern obstetric practice, and a need for good quality holistic training programs on how best to perform such deliveries. By identifying verbal and non-verbal components of skilled deliveries these can then be translated into an useful educational tool.

Improving Communication in Obstetrics Practice

Andrea Simpson, MD, Ryan Hodges, MB BS, PhD, FRANZCOG, Mary Higgins, MB BCh, MD, MRCOG Department of Obstetrics and Gynaecology, University of Toronto, Toronto ON The Ritchie Centre, Monash Institute of Medical Research, Department of Obstetrics and Gynaecology, Monash University, Victoria, Australia Department of Obstetrics and Gynaecology, University College Dublin, National Maternity Hospital, Ireland

Déhiscence utérine totale multifocale associée à des antécédents de sutures Cho de compression utérine

U femme de 41 ans (gravida 2, para 1) presentait, a 37 semaines de gestation, des contractions et des douleurs abdominales que le mouvement aggravait. Trois ans auparavant, elle avait subi une cesarienne qui avait donne lieu a une hemorragie postpartum ayant ete prise en charge au moyen d’uterotoniques, de la ligature des arteres uterines et de multiples sutures Cho de compression uterine1 (utilisant du #1 Biosyn).