Richard Pittini

Evaluating teamwork in a simulated obstetric environment

Background:The National Confidential Enquiry into Maternal Deaths identified “lack of communication and teamwork” as a leading cause of substandard obstetric care. The authors used high-fidelity simulation to present obstetric scenarios for team assessment. Methods:Obstetric nurses, physicians, and resident physicians were repeatedly assigned to teams of five or six, each team managing one of four scenarios. Each person participated in two or three scenarios with differently constructed teams. Participants and nine external raters rated the teams’ performances using a Human Factors Rating Scale (HFRS) and a Global Rating Scale (GRS). Interrater reliability was determined using intraclass correlations and the Cronbach &agr;. Analyses of variance were used to determine the reliability of the two measures, and effects of both scenario and rater profession (R.N. vs. M.D.) on scores. Pearson product–moment correlations were used to compare external with self-generated assessments. Results:The average of nine external rater scores showed good reliability for both HFRS and GRS; however, the intraclass correlation coefficients for a single rater was low. There was some effect of rater profession on self-generated HFRS but not on GRS. An analysis of profession-specific subscores on the HFRS revealed no interaction between profession of rater and profession being rated. There was low correlation between externally and self-generated team assessments. Conclusions:This study does not support the use of the HFRS for assessment of obstetric teams. The GRS shows promise as a summative but not a formative assessment tool. It is necessary to develop a domain specific behavioral marking system for obstetric teams.

Factors Affecting Academic Promotion in Obstetrics and Gynaecology in Canada

OBJECTIVE (1) To determine if women faculty members in departments of Obstetrics and Gynaecology were less likely than men to achieve promotion; and (2) to assess gender differences in attitudes towards promotion. METHODS Department chairs at the 16 medical schools in Canada were approached to participate in this study. A questionnaire was mailed to the obstetricians/gynaecologists in faculties of medicine at the 15 Canadian medical schools that agreed to participate. Likelihood of promotion for women and men was compared using survival analysis, controlling for other factors. Survival (event) time was the time in years between completion of residency and achieving promotion. RESULTS The response rate was 72% (376/522). Overall, 37% of respondents were women, and 63% were men. The women respondents were younger than the men, with a mean age of 43.4 +/- 7.9 years compared to 52.8 +/- 8.9 years. Of those in an academic stream, 39% of women (29/75) and 62% of men (90/145) had attained senior academic ranks. Completing residency more recently was associated with a higher likelihood of promotion to Assistant Professor (hazard ratio [HR], 1.05; P <0.001). The likelihood of promotion to Professor was lower for women than for men (HR, 0.40; P = 0.05). Having a mentor was associated with a higher likelihood of promotion to Professor (HR, 2.33; P = 0.002). Women were more likely to perceive barriers to promotion, such as family care responsibilities (P <0.001). CONCLUSION Independent of the respondents gender, recent completion of residency and having a mentor were the most significant factors increasing the likelihood of promotion in Canadian medical school departments of Obstetrics and Gynaecology. As women were found to be less likely than men to achieve promotion to Professor, mentoring and strategies that focus on facilitating promotion for women should be encouraged to ensure there are academic leaders in obstetrics and gynaecology in the future.

The Relationship between Sexual Functioning and Depressive Symptomatology in Postpartum Women: A Pilot Study

INTRODUCTION Previous research on postpartum sexuality has primarily focused on the impact of physical factors on the resumption and frequency of sexual intercourse; fewer studies have focused on the impact of psychological factors on womens sexual functioning. AIM The aim of this study is to assess current sexual functioning and sexual behavior in women with and without symptoms of postpartum depression using validated measures of postpartum depression and sexual functioning. METHODS Women attending postpartum appointments were consecutively recruited over a 12-month period and completed questionnaires assessing sexual functioning, current sexual behavior, and mental health. MAIN OUTCOME MEASURES The Female Sexual Function Index (FSFI), the Edinburgh Postnatal Depression Scale (EPDS), and items assessing current sexual behaviors. RESULTS A total of 77 women returned completed questionnaire packages (mean postpartum weeks: 13, range 3-24). Of these, 57 women (74%) had engaged in sexual activity with a partner in the 4 weeks prior to completing the questionnaire. The mean FSFI score was 23.0 (range 6-34), with 37 women (65%) scoring in the range associated with clinical sexual dysfunction. Women with elevated EPDS scores had significantly lower total FSFI, arousal, orgasm, and satisfaction FSFI subscale scores (all P values <0.005) than nondepressed women, suggesting more problematic sexual functioning. Desire, lubrication, and pain FSFI subscale scores were not significantly associated with depression status. CONCLUSIONS A substantial proportion of women experience sexual problems in the postpartum period; these problems are particularly pronounced among women with symptoms of postpartum depression. Longitudinal research is needed to better understand the relationship between sexual dysfunction and depression among postpartum women, and to identify implications for prevention and treatment of both conditions.

Development and usability of a behavioural marking system for performance assessment of obstetrical teams

Background: Teamwork and communication have been identified as root causes of sentinel events involving infant death and injury during delivery. However, despite the emphasis on team training as a way to improve maternal and fetal safety outcomes, valid and reliable markers of obstetrical team performance are not available to assess curricular efficacy. Objectives: The objective of this study was to develop and assess the usability of two obstetrical behavioural marking systems for use with simulation entitled Assessment of Obstetrical Team Performance (AOTP) and Global Assessment of Obstetrical Team Performance (GAOTP). Methods: In a previous study, obstetrical teams were videotaped managing simulated emergency obstetrical scenarios. In the current study, 13 reviewers reviewed these videotapes and generated a list of behaviours judged to negatively or positively affect the teams’ performances. Qualitative analysis using research team consensus and NVivo generated themes and subthemes. Research team members developed descriptors for poor and excellent team performance for each of the behaviours. Subsequently, the usability of the prototypes was assessed by an additional 14 reviewers. Results: In total, the reviewers identified 1294 items, which were sorted into 6 themes and 18 subthemes of obstetrical team performance. In terms of usability, the median amount of time that participants spent completing the AOTP was 7.5 min (range 1.5 to 50 min) and 75% thought the time requirement was moderate and manageable. Conclusion: Feedback regarding usability suggests that the AOTP allows for an accurate reflection of raters’ assessments of the performance of the team, and as a whole, it is comprehensive, quick and easy to use. Studies are underway to establish the validity and reliability of the AOTP and GAOTP.

Does surgical "warming up" improve laparoscopic simulator performance?

Introduction The objective of this study was to determine if preoperative warming up by obstetrics and gynecology trainees, using a validated bench model for intracorporeal suturing, improves efficiency, precision, and quality of laparoscopic suturing. Methods A randomized crossover design was used. Fourteen obstetrics and gynecology residents were randomized [3 junior (year 2) and 11 senior (years 3–5) residents]. Participants were randomized to warm-up or no warm-up and then acted as their own controls at least 2 weeks later. Warm-up consisted of the use of a laparoscopic bench model to practice intracorporeal suturing for 15 minutes. All participants performed a prevalidated intracorporeal suturing task (after either warm-up or no warm-up), which was scored based on time, precision, and knot strength. Each participant also completed a questionnaire anonymously to determine if they believed that warming up improved their performance, regardless of the score they received. Results Thirteen participants completed the study. There was no difference in score when warm-up was compared with no warm-up for the group as a whole. When the junior residents were excluded from the analysis, however, analysis of variance showed a significant improvement in score only when a warm-up was completed in the second session (P = 0.022). The questionnaire revealed that 81.8% of participants felt that warming up subjectively improved their ability, independent of their actual score. Conclusions This study demonstrates that a preoperative warm-up, combined with repetition, is beneficial in improving senior obstetrics and gynecology residents’ laparoscopic suturing performance. This demonstrates a novel approach to resident education for teaching advanced laparoscopic skills.

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.

Using a situational awareness global assessment technique for interprofessional obstetrical team training with high fidelity simulation.

Abstract Evidence suggests that breakdowns in communication and a lack of situation awareness contribute to poor performance of medical teams. In this pilot study, three interprofessional obstetrical teams determined the feasibility of using the situation awareness global assessment technique (SAGAT) during simulated critical event management of three obstetrical scenarios. After each scenario, teams were asked to complete questionnaires assessing their opinion of how their performance was affected by the introduction of questions during a SAGAT stop. Fifteen obstetrical professionals took part in the study and completed the three scenarios in teams consisting of five members. At nine questions per stop, more participants agreed or strongly agreed that there were too many questions per stop (57.1%) than when we asked six questions per stop (13%) and three questions per stop (0%). A number of interprofessional differences in response to this interprofessional experience were noted. A team SAGAT score was determined by calculating the proportion of correct responses for each individual. Higher scores were associated with better adherence to outcome times, although not statistically significant. A robust study design building on our pilot data is needed to probe the differing interprofessional perceptions of SAGAT and the potential association between its scores and clinical outcome times.

Omega-3 Supplements in Pregnancy: Are We Too Late to Identify the Possible Benefits?

OBJECTIVE Postpartum depression (PPD) is a common and recurring illness. Most women who experience PPD do not seek professional help; for those who do, the available treatment options are not supported by extensive research evidence. Several lines of research have linked omega-3 fatty acids (omega-3) supplementation with a reduced risk of PPD. Although it has been suggested that women in the perinatal period consume sufficient omega-3 to potentially prevent PPD, there is a lack of definitive research evidence. This pilot study surveyed pregnant womens current use of omega-3, multivitamin, and other supplements, as well as their attitudes toward omega-3 research during pregnancy, to assess the feasibility of pregnant womens participation in a large randomized controlled trial evaluating omega-3 supplementation. METHODS Women attending prenatal clinics over a three-week period were invited to participate in a survey. The survey contained an information letter that was followed by a brief questionnaire assessing the use of nutritional supplements and opinions regarding the likelihood of participating in a clinical trial during pregnancy. RESULTS Of the 176 women who completed the survey, six women were in the first trimester of pregnancy, 82 were in the second trimester, and 87 were in the third trimester. One hundred fifty-nine respondents (90.3%) reported taking a multivitamin supplement but none were taking a supplement that contained omega-3; only 20 (11.4%) were taking omega-3. Seventy-eight women (44.4%) responded that they would participate in a clinical study evaluating the effects of fish oil on their health. CONCLUSION The results of our study indicate that many pregnant women take prenatal multivitamins and nutritional supplements, that there are currently few pregnant women attending clinics at our hospitals who are supplementing with omega-3, and that pregnant women would be willing to participate in a clinical trial evaluating the effects of omega-3.

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

Reliability Study of the Laparoscopic Skills Index (LSI): A New Measure of Gynaecologic Laparoscopic Surgical Skills

OBJECTIVE To construct and test the reliability of the Laparoscopic Skills Index (LSI) as a new, multi-item, objective measure of laparoscopic skills in gynaecology. METHODS Construction of the LSI involved (1). item selection, (2). choosing a method to scale responses, (3). design, and (4). choosing a scoring method. Internal consistency and rater reliability were tested. One community-based gynaecologist (rater A) and 3 teaching faculty gynaecologists (raters B, C, and D) reviewed 20 videotaped gynaecologic laparoscopy operations and scored operator (subject) performance. RESULTS Cronbachs a was 0.95, indicating a high level of internal consistency. The intraclass correlation coefficient (ICC) for all 4 raters was 0.51 (95% confidence interval [CI], 0.20-0.76), indicative of moderate interrater reliability. A systematic observer bias was seen wherein rater As scores closely paralleled, but were consistently higher than, those of raters B, C, and D. The ICC for raters B, C, and D only was 0.77 (95% CI, 0.56-0.90), which is consistent with very good rater agreement. CONCLUSION The LSI appears to have the properties of a reliable, unidimensional index, in which the item variables are true components of the overall attribute, that is, laparoscopic skill.