George Attilakos

Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double‐blind randomised trial

Please cite this paper as: Attilakos G, Psaroudakis D, Ash J, Buchanan R, Winter C, Donald F, Hunt L, Draycott T. Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double‐blind randomised trial. BJOG 2010;117:929–936.

A randomised controlled trial of a new handheld vacuum extraction device

Objective  To evaluate the effectiveness of a new handheld vacuum delivery device.

The SAFE project: towards non-invasive prenatal diagnosis.

After the revolutionary detection of ffDNA (free fetal DNA) in maternal circulation by real-time PCR in 1997 and advances in molecular techniques, NIPD (non-invasive prenatal diagnosis) is now a clinical reality. Non-invasive diagnosis using ffDNA has been implemented, allowing the detection of paternally inherited alleles, sex-linked conditions and some single-gene disorders and is a viable indicator of predisposition to certain obstetric complications [e.g. PET (pre-eclampsia)]. To date, the major use of ffDNA genotyping in the clinic has been for the non-invasive detection of the pregnancies that are at risk of HDFN (haemolytic disease of the fetus and newborn). This has seen numerous clinical services arising across Europe and many large-scale NIPD genotyping studies taking place using maternal plasma. Because of the interest in performing NIPD and the speed at which the research in this area was developing, the SAFE (Special Non-Invasive Advances in Fetal and Neonatal Evaluation) NoE (Network of Excellence) was founded. The SAFE project was set up to implement routine, cost-effective NIPD and neonatal screening through the creation of long-term partnerships within and beyond the European Community and has played a major role in the standardization of non-invasive RHD genotyping. Other research using ffDNA has focused on the amount of ffDNA present in the maternal circulation, with a view to pre-empting various complications of pregnancy. One of the key areas of interest in the non-invasive arena is the prenatal detection of aneuploid pregnancies, particularly Downs syndrome. Owing to the high maternal DNA background, detection of ffDNA from maternal plasma is very difficult; consequently, research in this area is now more focused on ffRNA to produce new biomarkers.

A simple tool to measure patient perceptions of operative birth

Objective  To assess the feasibility and validity of a maternal satisfaction measurement tool, the SaFE study Patient Perception Score (PPS), after operative delivery.

Amniotic fluid index in low-risk, post-dates pregnancies.

Objective: To determine normal values for amniotic fluid index (AFI) in uncomplicated post-dates singleton pregnancies and compare it to current reference ranges. Population: Four hundred and forty-eight women with singleton, uncomplicated pregnancies, presenting for post-dates assessment (gestation 40+0 to 42+0 weeks) between January 1, 2004 and June 30, 2005. Methods: Ultrasound assessment of liquor to calculate the AFI. Results: The mean and standard deviation for AFI in the sample was 9.86 (SD 3.4), which is significantly different to the mean of the currently used reference range (mean 11.6, SD 3.9, p < 0.0001). The 5th percentile in this population was 4.6 cm. Conclusions: This study has demonstrated lower mean and 5th percentile values for AFI in post-dates pregnancies than current reference ranges. It has the largest published UK study population, and can therefore be used as a reference range in similar populations, which is likely to reduce unnecessary obstetric interventions.

A randomised trial of a new handheld vacuum extraction device

Sir, Thank you for giving us the opportunity to reply to these interesting letters. Our study demonstrated that in the ‘study population of 194 women requiring vacuum extraction the KIWI Omnicup was associated with a significantly higher failure rate than standard (metal or silastic) cups’. Dr Vacca questioned the external validity of our results, in particular, the apparently high failure rates. Our results were similar to the results of a study involving another large UK hospital, which demonstrated similar failure rates (31% for the Omnicup and 19% for the standard cups).1 Our study employed a pragmatic design and the deliveries were not performed just by our most junior doctors but by the whole team, four of whom hadmore than 4 years experience in obstetrics, which would qualify them as specialists in many other European countries. Certainly the ‘lack of skill’ has not been translated to an increased incidence of significant maternal trauma (significant maternal injury was higher than 10% in previous meta-analyses2 and 7–8% in our study). Furthermore, any ‘collective inexperience’ was equally distributed between the two groups. We agree that training maybe a significant factor affecting current failure rates, but it would be simplistic to assume that it is the only factor. In the Cochrane review of soft versus rigid vacuum extractor cups,2 six out of nine included studies demonstrate failure rates >15% and four out of nine studies show failure rates >20%. This Cochrane review demonstrated that the soft cups are associated with a higher failure rate than the rigid cups; yet, the soft cups are used more often as they are associated with a lower rate of significant scalp trauma. In the Staffordshire/Wigan assisted delivery trial3 (forceps versus vacuum), the failure rate for the vacuum group (Kobayashi silicone cup) was 27%, and in the Portsmouth trial,4 where only metal cups were used, the failure rate was 13.4%. Professor Mola’s suggestion of a ‘failure rate of less than 10% with whatever instrument’ is perhaps a target that all units should aim for, rather than a description of current UK practice. Professor Mola also suggests that transverse and posterior positions of the fetal occiput should not be associated with higher incidence of failure. While this again would be ideal, it has been previously demonstrated that occipitoposterior (OP) position increases the likelihood of delivery by caesarean section after prolonged second stage.5 The majority of OP deliveries in our study were performed in theatre precisely because of the increased likelihood of failure. It is plausible that the Kiwi Omnicup has a longer ‘learning curve’. We have used cumulative sums charts to analyse the trend of failures with the Omnicup during the study period,6 and we demonstrated that the Omnicup failure rate did not decrease over the study period. This may reflect the true performance of the Omnicup or that the learning curve may be longer for the Omnicup; each obstetrician performed on average less than ten Omnicup deliveries during the study period. Dr Kotaska’s comments provide a very interesting North American perspective to the debate. Contrary to his hypothesis, the Omnicup performed better for nonrotational deliveries. The failure rate for occipitanterior (OA) deliveries in the Omnicup group was 23.7% and for OP/occipit-transmerse (OT) deliveries it was 56.7%. The admission rate to neonatal intensive care unit (NICU) was not apparently increased after anterior metal cup deliveries. There were three admissions to NICU after anterior metal cup deliveries: one baby was admitted for a sepsis screen and twobabies for observation following lowApgar scores. A ‘tailored’ approach, similar to the one described by Johanson et al.,7 is used in most UK hospitals. When the Bird cup is not available, using the Kiwi Omnicup for malpositions is a reasonable alternative but women need to be informed of the expected higher failure rates (approximately 50% in the twoUK studies).j

Clinical performance indicators at hysterectomy.

The short-term complications of hysterectomy in 184 women have been documented over 12 months against a panel of clinical performance indicators in a district general hospital. One hundred and fifty-nine operations (159/184, 86·4%) were performed by the abdominal route; 25/184 (13·6%) by the vaginal route. Clinical indications for hysterectomy varied from menorrhagia (75/184, 40·7%) to Stage III/IV endometriosis (10/184, 5·4%). Clinical performance indicators (cPI) were triggered in 32/184 (17·4%) cases; 19/ 184 (10·3%) triggered a single performance indicator, 9/184 (4·9%) triggered two performance indicators and 4/184 (2·2%) triggered three performance indicators. Combining the number of hysterectomies performed per annum (HYST 1), with the proportion of cases triggering three or more clinical performance indicators (HYST 2) and the rate of hysterectomy for histologically normal uteri weighing less than 120 g excluding genital prolapse (HYST 3) provides a profile of the operation for comparison with other clinical services.

Three babies, two cavities, one incision: a case of a triplet pregnancy in a septate uterus.

We present a unique, successful, triplet pregnancy in a septate uterus. At a dating scan, a triplet pregnancy was found – with monochorionic diamniotic (MCDA) twins in the left cavity and a singleton in the right – in a woman with one previous delivery, by emergency caesarean section, when uterus didelphys with vaginal septum was diagnosed. Fortnightly scans from 16 weeks showed symmetrical, steady growth. At 26 weeks, the abdominal circumference (AC) of twins 1 and 2 had dropped from the 50th to the 5th centile and to below the 5th, respectively. At 28 weeks, no further growth was seen in either twin, with normal liquor volumes and umbilical artery (UA) Doppler studies. The singleton showed normal growth and liquor volume. Twin 2 developed intermittently absent UA end-diastolic flow (EDF) at 29þ 3 weeks and persistently absent EDF by 29þ5, with signs of cerebral redistribution. The other fetuses had normal liquor and Doppler studies. During scanning, a uterine contraction was associated with bradycardia in twin 2, so lower segment caesarean section was undertaken that day. Three female infants were born: triplet 1 (twin 1) 1,080 g with Apgars 910; triplet 2 (twin 2) 900 g with Apgars 89; and triplet 3 (singleton) 1,282 g with Apgars 89. A full-length uterine septum was found and incised during entry and the triplets delivered through one uterine incision. There was no obvious fundal indentation, a cervix on the right, and no apparent cervix on the left (Figs. 1 and 2). Magnetic resonance imaging performed at 7 months postpartum showed a septate uterus, with two cavities, no fundal notch, a septum running the full length of the uterus and two cervical canals. Septate uterus is a Müllerian duct abnormality with a prevalence of between 0.1% and 3.2%. It is associated with significant pregnancy complications (Acien 1993; Grimbizis et al. 2001; Raga et al. 1997), including miscarriage (23–30%), pre-term labour (15–23%) and malpresentation. Prior to delivery, thinking this was a case of uterus didelphys, we were planning to deliver the triplets through two separate uterine incisions, one on each uterine half. At operation, there was a single lower uterine segment and therefore a single transverse uterine incision was made, with the uterine septum incised at entry and the triplets delivered without difficulty. This unique case demonstrates the possibility of delivery of multiple fetuses through a single uterine incision in cases of septate uterus and highlights the value of clarifying the uterine anatomy by pelvic imaging in the non-pregnant state.

Evaluation of a shoulder dystocia training model

Shoulder dystocia is unpredictable and can result in unacceptably high morbidity. Currently there are no high fidelity training models available and this project evaluates a realistic mannequin which can be used to train midwives and doctors to correctly manage shoulder dystocia so as to reduce morbidity. Thirty-eight midwives and obstetricians in two South West hospitals were evaluated using the high fidelity training mannequin we developed. Practical skills required to deliver the baby were assessed using a validated checklist which assessed the timing and the execution of the manoeuvres. Force data were collected using a real-time force monitoring system, anatomically designed to simulate brachial plexus forces. There was a statistically significant increase in the total scores obtained by both groups after training (P-values <0.003). The data on force were obtained from only 10 participants, but still showed clinically significant findings. Peak traction forces ranged from 7 N to 379 N (95% CI of −2.3–163.9 N) before training, and 14 to 81 N (95% CI of 29.0–64.9 N) after training. Time to delivery also tended to be shorter (95% CI of 120.3–222.9 seconds before training and 88.0–154.4 seconds after training).