Christy Burden

Stillbirths: economic and psychosocial consequences.

Despite the frequency of stillbirths, the subsequent implications are overlooked and underappreciated. We present findings from comprehensive, systematic literature reviews, and new analyses of published and unpublished data, to establish the effect of stillbirth on parents, families, health-care providers, and societies worldwide. Data for direct costs of this event are sparse but suggest that a stillbirth needs more resources than a livebirth, both in the perinatal period and in additional surveillance during subsequent pregnancies. Indirect and intangible costs of stillbirth are extensive and are usually met by families alone. This issue is particularly onerous for those with few resources. Negative effects, particularly on parental mental health, might be moderated by empathic attitudes of care providers and tailored interventions. The value of the baby, as well as the associated costs for parents, families, care providers, communities, and society, should be considered to prevent stillbirths and reduce associated morbidity.

From grief, guilt pain and stigma to hope and pride – a systematic review and meta-analysis of mixed-method research of the psychosocial impact of stillbirth

BackgroundDespite improvements in maternity healthcare services over the last few decades, more than 2.7 million babies worldwide are stillborn each year. The global health agenda is silent about stillbirth, perhaps, in part, because its wider impact has not been systematically analysed or understood before now across the world. Our study aimed to systematically review, evaluate and summarise the current evidence regarding the psychosocial impact of stillbirth to parents and their families, with the aim of improving guidance in bereavement care worldwide.MethodsSystematic review and meta-summary (quantitative aggregation of qualitative findings) of quantitative, qualitative, and mixed-methods studies. All languages and countries were included.ResultsTwo thousand, six hundred and nineteen abstracts were identified; 144 studies were included. Frequency effect sizes (FES %) were calculated for each theme, as a measure of their prevalence in the literature.Themes ranged from negative psychological symptoms post bereavement (77 · 1) and in subsequent pregnancies (27 · 1), to disenfranchised grief (31 · 2), and incongruent grief (28 · 5), There was also impact on siblings (23 · 6) and on the wider family (2 · 8).They included mixed-feelings about decisions made when the baby died (12 · 5), avoidance of memories (13 · 2), anxiety over other children (7 · 6), chronic pain and fatigue (6 · 9), and a different approach to the use of healthcare services (6 · 9).Some themes were particularly prominent in studies of fathers; grief suppression (avoidance)(18 · 1), employment difficulties, financial debt (5 · 6), and increased substance use (4 · 2). Others found in studies specific to mothers included altered body image (3 · 5) and impact on quality of life (2 · 1). Counter-intuitively, Some themes had mixed connotations. These included parental pride in the baby (5 · 6), motivation for engagement in healthcare improvement (4 · 2) and changed approaches to life and death, self-esteem, and own identity (25 · 7).In studies from low/middle income countries, stigmatisation (13 · 2) and pressure to prioritise or delay conception (9) were especially prevalent.ConclusionExperiencing the birth of a stillborn child is a life-changing event. The focus of the consequences may vary with parent gender and country. Stillbirth can have devastating psychological, physical and social costs, with ongoing effects on interpersonal relationships and subsequently born children. However, parents who experience the tragedy of stillbirth can develop resilience and new life-skills and capacities. Future research should focus on developing interventions that may reduce the psychosocial cost of stillbirth.

Usability of virtual‐reality simulation training in obstetric ultrasonography: a prospective cohort study

To assess the usability of virtual‐reality (VR) simulation for obstetric ultrasound trainees.

Current pregnancy outcomes in women with cystic fibrosis

OBJECTIVES Women with cystic fibrosis (CF) now achieve a greater life expectancy and therefore have greater expectations from life. Literature reporting pregnancy outcomes in CF is still sparse. There remains a legacy of advising women with significant disease to avoid pregnancy. We aimed to assess current maternal and fetal outcomes in women with CF with varied pre-pregnancy lung function. STUDY DESIGN Retrospective case note review of data from 15 pregnancies in 12 women with CF receiving care at a specialist centre between 2003 and 2011. Descriptive statistics were used for the quantitative data. The forced expiratory volume (FEV₁) and forced vital capacity (FVC) were calculated and shown as the percentage of their predicted values for BMI, height and age. Changes in lung function pre, 6, and 24 months post delivery were calculated with the paired t-test. RESULTS Mean maternal age was 28.9 (range 21-36, CI 26.8-31). Maternal FEV₁ at booking ranged from 27 to 80% predicted (mean=63.6%, CI 54.62-71.38%). Cystic fibrosis-related diabetes (CFRD) was present in 8 of 14 (live birth) pregnancies. Average gestation at delivery was 38 weeks. There was a 100% vaginal delivery rate (11 spontaneous vertex, 2 ventouse, 1 forceps). Average fetal birth weight was 2.97 kg (range 2.2-3.83 kg, CI 2.72-3.23). The differences between the maternal pre- and 6 months post-pregnancy mean FEV₁ (p=0.136) and FVC (p=0.225) were not statistically significant. CONCLUSION With careful multidisciplinary antenatal and intrapartum management, successful outcomes have been obtained in this group of women with CF.

Validation of virtual reality simulation for obstetric ultrasonography: a prospective cross-sectional study.

Introduction Ultrasonography is an important skill for obstetricians and gynecologists; however, trainees have highlighted ultrasonography as an area of deficiency in their training. We undertook a prospective cross-sectional comparative study to assess content and construct validity of an ultrasound virtual reality (VR) simulator (UltraSim). Methods Twenty-six physicians and sonographers of varied ultrasonography experience were recruited and divided into trainees (no formal ultrasonography training) and expert (certified) categories. They performed a VR simulation crown-rump length (CRL) ultrasound scan and growth ultrasound scan measuring biparietal diameter, occipitofrontal diameter, abdominal anteroposterior and transverse diameters, and femur length. Maximum pool depth (MPD), placental site, and fetal presentation were also assessed. Outcome measures included the mean absolute deviation and the variance of the absolute deviation from true measurements. Accuracy of determining placental site, fetal presentation, and MPD was assessed. The time taken to perform each type of scan was recorded. Results Trainees had significantly greater variation of measurement of CRL (P = 0.025) than the expert group. For late-pregnancy fetal biometry, the absolute deviation and the degree of variability for all measurements differed. These differences were statistically significant (P < 0.05) for all measurements except abdominal diameters and MPD. Trainees took significantly longer time to obtain CRL and fetal biometric scans (P < 0.001). All subjects correctly identified fetal presentation and placental site. Conclusions Clinicians with differing ultrasonography expertise showed differing skill with the UltraSim VR simulator, demonstrating construct validity for skills needed in simulation. Consideration should be given to investigating whether trainees with minimal scanning experience can improve their clinical skills and efficiency with VR simulation.

Curriculum development for basic gynaecological laparoscopy with comparison of expert trainee opinions; Prospective cross-sectional observational study

OBJECTIVE To develop content for a basic laparoscopic curriculum in gynaecology. STUDY DESIGN Prospective cross-sectional observational study. Modified Delphi method with three iterations undertaken by an invited group of national experts across the United Kingdom (UK). Two anonymous online surveys and a final physical group meeting were undertaken. Junior trainees in gynaecology undertook a parallel iteration of the Delphi process for external validation. Population included: expert panel - certified specialists in minimal-access gynaecological surgery, RCOG national senior trainee representatives, and medical educationalists, junior trainees group - regional trainees in gynaecology in first and second year of speciality training. RESULTS Experts (n=37) reached fair to almost complete significant agreement (κ=0.100-0.8159; p<0.05) on eight out of nine questions by the second iteration. Trainees (n=19) agreed with the experts on 89% (51/57) of categories to be included in the curriculum. Findings indicated that 39 categories should be included in the curriculum. Port placement, laparoscopic equipment and patient selection were ranked the most important theoretical categories. Hand-eye co-ordination, camera navigation and entry techniques were deemed the most valuable skills. Diagnostic laparoscopy, laparoscopic sterilisation, and laparoscopic salpingectomy were the operations agreed to be most important for inclusion. Simulation training was agreed as the method of skill development. The expert panel favoured box trainers, whereas the junior trainee group preferred virtual reality simulators. A basic simulation laparoscopic hand-eye co-ordination test was proposed as a final assessment of competence in the curriculum. CONCLUSION Consensus was achieved on the content of a basic laparoscopic curriculum in gynaecology, in a cost- and time-effective, scientific process. The Delphi method provided a simple, structured consumer approach to curriculum development that combined views of trainers and trainees that could be used to develop curricula in other areas of post-graduate education.

Laparoscopic simulation training in gynaecology: Current provision and staff attitudes – a cross-sectional survey

The objectives of this study were to explore current provision of laparoscopic simulation training, and to determine attitudes of trainers and trainees to the role of simulators in surgical training across the UK. An anonymous cross-sectional survey with cluster sampling was developed and circulated. All Royal College of Obstetricians and Gynaecologists (RCOG) Training Programme Directors (TPD), College Tutors (RCT) and Trainee representatives (TR) across the UK were invited to participate. One hundred and ninety-six obstetricians and gynaecologists participated. Sixty-three percent of hospitals had at least one box trainer, and 14.6% had least one virtual-reality simulator. Only 9.3% and 3.6% stated that trainees used a structured curriculum on box and virtual-reality simulators, respectively. Respondents working in a Large/Teaching hospital (p = 0.008) were more likely to agree that simulators enhance surgical training. Eighty-nine percent agreed that simulators improve the quality of training, and should be mandatory or desirable for junior trainees. Consultants (p = 0.003) and respondents over 40 years (p = 0.011) were more likely to hold that a simulation test should be undertaken before live operation. Our data demonstrated, therefore, that availability of laparoscopic simulators is inconsistent, with limited use of mandatory structured curricula. In contrast, both trainers and trainees recognise a need for greater use of laparoscopic simulation for surgical training.

Resident consultant cover may become part of 21st century maternity care, but it is not a panacea

Resident consultant cover has long been proposed as a solution to a wide variety of current intrapartum issues: poor clinical outcomes; high intervention rates, particularly increasing rates of caesarean section; middle-grade rota gaps; and decreased training opportunities. As has been the case for many previous well-intentioned, apparently simple and plausible interventions introduced into maternity care, however, there may be little or no benefit when robustly tested. The recent systematic reviews from the National Perinatal Epidemiology Unit and Reid et al. conclude that there is no clear evidence of different intrapartum outcomes and safety of care with 24-hour resident consultant presence on the labour ward. Reid et al. found that increased hours per week of rostered consultant presence significantly reduced the likelihood of emergency caesarean sections and increased the likelihood of non-instrumental vaginal deliveries; however, an effect on mortality and morbidity was not identified. The authors accept that the quality of the existing data was low; however, the introduction of a resident labourist model of care in the USA has similarly failed to demonstrate any tangible benefits in intrapartum process measures or clinical outcomes (Srinivas et al. Am J Obstet Gynecol 2016;215:770.e1–9). Although intrapartum outcomes are important direct markers of patient safety, it is crucial to consider other drivers behind the push for resident consultant cover, particularly the increasing number of middle-grade rota gaps in UK maternity units: heads of school reported 30% rota gaps in a 2014 survey. This is likely to be exacerbated by the recent call for a reduction in training numbers by Health Education England (HEE). In response to these rota gaps, the Royal College of Obstetricians and Gynaecologists (RCOG) have recommended resident consultant working (http://www.rcog.org.uk/globalassets/ documents/guidelines/working-party-re ports/ogworkforce.pdf), and a recent RCOG commentary concluded that some resident consultant care in most units was inevitable (http://www.rcog. org.uk/globalassets/documents/news/ membership-news/og-magazine/Dece mber-2016/feature.pdf). RCOG also recognises that there may be difficulties with the sustainable implementation of resident consultant working, however. A Kings Fund review of maternity staffing concluded that the skill mix, experience, and deployment of available staff were of greater importance and were more amenable to change, and that the costs of continuous consultant presence was prohibitive (Sandall et al. The King’s Fund, 2011). Moreover, issues with perceived junior status and reduced opportunities to practice independently have been raised by other Medical Royal Colleges. This may be a timely opportunity for a wider review of the structure of maternity units in the UK. Some centralisation of obstetric services may be useful, with a networked approach to provide all models of maternity care in the most efficient manner possible, including formally matching and classifying obstetric units with neonatal units (levels 1, 2, and 3). Certainly, different level obstetric units are likely to use different models of staff provision. We agree that there is unlikely to be a single solution across all maternity units, and more research in this area is imperative; however, we consider that the call for a future cluster of randomised trials may provide too narrow a focus, and there should also be mixedmethods studies investigating the sustainability of different models of care provision, including health economics evaluation, perceptions of patients and doctors, as well as clinical outcomes. Finally, it is the current generation of junior obstetricians that will be most affected by these changes, and their opinions need to be actively sought as part of any sustainable solution for the future.

Care following stillbirth in high-resource settings: latest evidence, guidelines, and best practice points

Third-trimester stillbirth affects approximately 2.6 million women worldwide each year. Although most stillbirths (98%) occur in low- and middle-income countries, most of the research on the impact of stillbirth and bereavement care has come from high-income countries. The impact of stillbirth ranges from stigma to disenfranchised grief, broken relationships, clinical depression, chronic pain, substance use, increased use of health services, employment difficulties, and debt. Appropriate bereavement care following a stillbirth is essential to minimise the negative socio-economic impact on parents and their families. This article presents the best practice points in stillbirth bereavement care, including taking an individualised and flexible approach. The latest published research, guidelines, and best practice points from high-income countries will be used and will highlight the gaps in the research which urgently need to be addressed. Research and investment in appropriate, respectful aftercare is needed to minimise the negative impact for parents.

Fetal head position and perineal distension associated with the use of the BD Odon Device™ in operative vaginal birth: a simulation study

To investigate (1) the placement of the BD Odon Device on the model fetal head and (2) perineal distention during simulated operative vaginal births conducted with the BD Odon Device.