Anna J.M. Aabakke

Subcuticular suture compared with staples for skin closure after cesarean delivery: a randomized controlled trial.

OBJECTIVE: To compare subcuticular sutures with staples for skin closure after cesarean delivery in a randomized trial in which each woman was her own control. METHODS: Women undergoing cesarean delivery (primary, n=32; repeat, n=31) were randomized to side distribution of skin closure methods with one side of the skin incision closed with staples and the other side closed with subcuticular suture. The primary outcome was the overall preferred side of the scar 6 months postoperatively. Additional outcomes were womens preferred method of closure and cosmetically preferred side of the scar, difference in objective cosmetic scores (assessed by two plastic surgeons), and pain between the two sides of the scar and infection rate. RESULTS: Significantly more women preferred the stapled side, both overall (odds ratio [OR] 2.55; 95% confidence interval [CI] 1.18–5.52) and cosmetically (OR 2.67; 95% CI 1.24–5.74), and reported staples as their preferred technique (OR 2.00; 95% CI 1.10–3.64). There were no significant differences in pain scores at any time. One plastic surgeon preferred the stapled side (OR 2.8; 95% CI 1.01–7.78) and scored it significantly higher on a cosmetic visual analog scale (P=.031); the other found no significant difference. There were four (6.8%) cases of infection—three on the sutured side and one bilateral. CONCLUSION: Staples were preferred to subcuticular suture for skin closure by women after cesarean delivery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; www.clinicaltrials.gov; NCT01217567. LEVEL OF EVIDENCE: I

European trainees support the new European curriculum in Obstetrics and Gynaecology

The development of a new European training curriculum in Obstetrics and Gynaecology (OBGYN) has been initiated by the European Board and College of Obstetricians and Gynaecologists (EBCOG) [1]. The European Network of Trainees in Obstetrics and Gynaecology (ENTOG) has been involved in the project from the beginning. We hereby wish to emphasise the importance of the EBCOG – Project for Achieving Consensus in Training (EBCOGPACT) by presenting data on the current differences in training across Europe. ENTOG is an independent association with national trainee societies as its members. ENTOG currently has 30 member countries representing more than 6000 trainees [2]. Its objective is to harmonise and achieve the highest possible standards of training in OBGYN thereby improving women’s healthcare in Europe [3]. A survey carried out by ENTOG in 2014 explored the conditions of OBGYN training from medical school to specialisation and it showed considerable variations throughout Europe (unpublished):

Incidence of Incisional Hernia after Cesarean Delivery: A Register-Based Cohort Study

Objective To estimate the incidence of incisional hernias requiring surgical repair after cesarean delivery over a 10-year period. Methods This population- and register-based cohort study identified all women in Denmark with no history of previous abdominal surgery who had a cesarean delivery between 1991 and 2000. The cohort was followed from their first until 10 years after their last cesarean delivery within the inclusion period or until the first of the following events: hernia repair, death, emigration, abdominal surgery, or cesarean delivery after the inclusion period. For women who had a hernia repair, hospital records regarding the surgery and previous cesarean deliveries were tracked and manually analyzed to validate the relationship between hernia repair and cesarean delivery. Data were analyzed with a competing risk analysis that included each cesarean delivery. Results We identified 57,564 women who had had 68,271 cesarean deliveries during the inclusion period. During follow-up, 134 of these women had a hernia requiring repair. Of these 68 (51% [95% CI 42–60%]) were in a midline incision although the transverse incision was the primary approach at cesarean delivery during the inclusion period. The cumulated incidence of a hernia repair within 10 years after a cesarean delivery was 0.197% (95% CI 0.164–0.234%). The risk of a hernia repair was higher during the first 3 years after a cesarean delivery, with an incidence after 3 years of 0.157% (95% CI 0.127–0.187%). Conclusions The overall risk of an incisional hernia requiring surgical repair within 10 years after a cesarean delivery was 2 per 1000 deliveries in a population in which the transverse incision was the primary approach at cesarean delivery.

Midline versus transverse incision for cesarean delivery in low‐income countries

While transverse incision is the recommended entry technique for cesarean delivery in high‐income countries, it is our experience that midline incision is still used routinely in many low‐income settings. Accordingly, international guidelines lack uniformity on this matter. Although evidence is limited, the literature suggests important advantages of the transverse incision, with lower risk of long‐term disabilities such as wound disruption and hernia. Also, potential extra time spent on this incision appears not to impact neonatal outcome. Therefore, we suggest that it is time for a change in guidelines for low‐income settings in which resources are limited for treating complications that may be life threatening.

Sharp compared with blunt fascial incision at cesarean delivery: a randomized controlled trial with each case as her own control

OBJECTIVE To compare patient preference for either sharp incision with scissors or blunt manual cleavage of the fascia at cesarean delivery in a randomized controlled trial in which each woman was her own control. STUDY DESIGN Women undergoing primary cesarean delivery (n=34) were randomized to side distribution of sharp or blunt incision of the fascia (sharp right and blunt left or blunt right and sharp left) and followed three months postoperatively. The primary outcome was patient preference for the right or left side of the scar 3 months postoperatively and modeled by polytomous logistic regression. The secondary outcome was difference in pain between the two sides measured on a 0.0-10.0 numerical rating scale at 1, 3, and 7 days and 1 and 3 months postoperatively. Pain scores were analyzed with a Wilcoxon signed rank test. RESULTS 28 cases were analyzed and no significant difference was found in preference after three months. Nine women preferred the sharp (32%, 95% CI 16-52%) and 7 the blunt side (25%, 95% CI 11-45%) (P=0.804). Pain scores did not differ significantly between the two sides at any time postoperatively either at rest or during mobilization. CONCLUSION No significant difference was found in patient preference with regard to sharp or blunt incision of the fascia, nor was there a significant difference in postoperative pain scores. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov: www.clinicaltrials.org;NCT01297725.

Workforce planning and training in Obstetrics and Gynaecology across Europe: A survey of national trainee societies

OBJECTIVE(S) To describe the infrastructural differences in training in Obstetrics and Gynaecology (ObGyn) across Europe. STUDY DESIGN Descriptive web-based survey of 31 national ObGyn trainee societies representing the 30 member countries of the European Network of Trainees in Obstetrics and Gynaecology. Answers were verified in a telephone interview and only countries which had completed the telephone interview were included in the final analysis. RESULTS The final analysis included 28 of 31 societies representing 27 countries (response rate 90%). The median formal duration of training was 5 years (range 4-7). There were mandatory requirements in addition to medical school graduation before specialisation could be started in 20 (71%) countries. The job opportunities after completion of training varied and included academic fellowships (n=21 [75%]), clinical fellowships/junior consultancy (n=21 [75%]), consultancy (n=11 [40%]), and private practice (n=23 [82%)]. Training and working as a specialist abroad was uncommon (≤20% in 21 [78%] and 26 [96%] countries respectively). Exams during ObGyn training were offered in 24 (85%) countries. Unemployment after completion of training was rare (<5% in 26 [93%] countries). Assessment of ObGyn specialists took place in 20 (71%) countries. CONCLUSION(S) The study illustrates that there are organisational variations in ObGyn training in Europe; A) The requirements to obtain a training post vary causing differences in the qualifications of trainees starting training. B) The duration of training varies. And C) newly trained specialists carry varying levels of responsibility. The results suggest that the content, organisation, and outcome of training differ across Europe. Differences due to political, social and cultural reasons are expected. However, further harmonisation of training across Europe still seems desirable in order to improve womens healthcare and facilitate the mobility of ObGyn trainees and specialists across Europe. There are currently several European initiatives, however, national and local measures are essential for training to improve.

The effect of maneuvers for shoulder delivery on perineal trauma: a randomized controlled trial

Approximately 85% of vaginal deliveries are accompanied by perineal trauma. The objective of this trial was to compare the incidence of perineal trauma after primary delivery of either the anterior or posterior shoulder during vaginal delivery.

Sexual Health During Postgraduate Training—European Survey Across Medical Specialties

Background Sexual health problems are common. Therefore, training in sexual health is relevant for the clinical practice of trainees and early-career specialists in several specialties who deal with patients with sexual health problems. However, little is known about how sexual health training is provided across countries and specialties. Aim To assess (i) sexual health training during postgraduate training programs in psychiatry, obstetrics and gynecology, urology, and endocrinology across Europe; (ii) the confidence of trainees and early-career specialists in dealing with patients with sexual health problems; and (iii) their need for further training in sexual health during postgraduate training programs. Methods The study was based on a collaboration among European societies of trainees in these 4 specialties. An online survey was developed and conducted from January 2015 through June 2016. Main Outcome Measures Self-reported questionnaire. Results We collected 366 completed surveys from 40 countries. Sexual health training was considered an important or very important part of specialty training by 78.7% of participants. Overall, 62.3% of participants had not received any training in sexual health. Especially in obstetrics and gynecology, the large majority did not have training in sexual health (82.8%), followed by psychiatry (59.8%), urology (58.4%), and endocrinology (56.1%). There were statistically significant differences among specialties in the confidence of participants in managing patients with sexual health problems. In general, trainees and early-career specialists who had received sexual health training felt more confident in dealing with patients with gender dysphoria (P = .011), need for sexual therapy (P = .0004), paraphilic disorders (P = .0003), and sexual dysfunction (P = .0017). Conclusions Trainees and early-career specialists found sexual health training important for their future medical practice; however, less than half received it during their postgraduate training. Participants felt more confident in managing patients with sexual health problems when sexual health training was included in the postgraduate training program. Kristufkova A, Pinto Da Costa M, Mintziori G, et al. Sexual Health During Postgraduate Training—European Survey Across Medical Specialties. Sex Med 2018;6:255–262.

The effect of a preoperative single-dose methylprednisolone on postoperative pain after abdominal hysterectomy: a randomized controlled trial

OBJECTIVE Methylprednisolone has been shown to have analgesic effects after orthopedic surgery. The objective of this trial was to compare the effect of 125 mg methylprednisolone with placebo on postoperative pain after abdominal hysterectomy. STUDY DESIGN In this randomized double-blinded placebo-controlled trial women scheduled for elective abdominal hysterectomy (n=59) were randomized to preoperatively receive either 125 mg methylprednisolone or saline intravenously. Primary outcome was postoperative pain measured on a 0.0-10.0 visual analog scale and assessed at rest and during mobilization repeatedly the first 24h and daily on the 2nd to 7th postoperative day. Secondary outcomes were postoperative use of opioids and antiemetics, vomiting, C-reactive protein levels, and time to mobilization and discharge. Repeated measures including the primary outcome were analyzed with linear mixed models. RESULTS Forty-nine cases were analyzed (methylprednisolone n=25, placebo n=24). Pain scores were significantly higher in the methylprednisolone group compared to the placebo group during mobilization (0.79 [95% confidence intervals (CI) 0.07-1.50] P=0.03) but not at rest (0.55 [95% CI: -0.06 to 1.16] P=0.08). There was no difference between the methylprednisolone and placebo group regarding use of opioids (P=0.24) and antiemetics (P=0.14), number of vomits (P=0.26), and time to mobilization (P=0.24) and discharge (P=0.28). C-reactive protein levels were significantly higher in the placebo group (P=0.01). CONCLUSIONS This trial showed no beneficial effect of methylprednisolone on postoperative pain after abdominal hysterectomy. Methylprednisolone significantly lowered postoperative CRP levels. CLINICAL TRIAL REGISTRATION ClinicalTrial.gov: www.clinicaltrials.gov: NCT01106547.