Sophie E.M. Truijens

Prevalence, course and determinants of carpal tunnel syndrome symptoms during pregnancy: a prospective study.

To investigate the prevalence, severity and relation to fluid retention of self‐reported pregnancy‐related carpal tunnel syndrome (CTS) symptoms in a large sample of pregnant women.

Fear for external cephalic version and depression: predictors of successful external cephalic version for breech presentation at term?

BackgroundObjective was to determine whether fear for external cephalic version (ECV) and depression are associated with the success rate of ECV in women with a breech presentation at term.MethodsProspective study conducted in the Catharina Hospital Eindhoven between October 2007 and May 2012. Participants fulfilled The Edinburgh Depression Scale (EDS) questionnaire and expressed their degree of fear on a visual analogue scale from one to ten before ECV. Obstetric factors were evaluated as well. Primary outcome was the relation between psychological factors (fear for ECV and depression EDS scores) and ECV success rate. Secondary outcome was a possible relation between fear for ECV and increased abdominal muscle tension.ResultsThe overall success rate was 55% and was significantly lower (p < 0.001) in nulliparous women (44.3%) compared with parous women (78.0%). Fear for ECV and depression EDS-scores were not related with ECV success rate. Parity, placental location, BMI and engagement of the fetal breech were obstetric factors associated with ECV outcome. There was no relation between fear for ECV and abdominal muscle tone.ConclusionFear for ECV and depression were not related with ECV success rate in this study. Engagement of the fetal breech was the most important factor associated with a successful ECV.Trial registrationEBIS: The Eindhoven Breech Intervention Study, NCT00516555.

Development of the Childbirth Perception Scale (CPS) : Perception of delivery and the first postpartum week

Some caregivers suggest a more positive experience of childbirth when giving birth at home. Since properly developed instruments that assess women’s perception of delivery and the early postpartum are missing, the aim of the current study is to develop a Childbirth Perception Scale (CPS). Three focus groups with caregivers, pregnant women, and women who recently gave birth were conducted. Psychometric properties of 23 candidate items derived from the interviews were tested with explorative factor analysis (EFA) (N = 495). Confirmatory factor analysis (CFA) was performed in another sample of women (N = 483) and confirmed a 12-item CPS. The EFA in sample I suggested a two-component solution: a subscale ‘perception of delivery’ (six items) and a subscale ‘perception of the first postpartum week’ (six items). The CFA in sample II confirmed an adequate model fit and a good internal consistency (α = .82). Multivariate linear regression showed a positive effect of home delivery on perception of delivery in multiparous but not in primiparous women. The 12-item CPS with two dimensions (perception of delivery and perception of first postpartum week) has adequate psychometric properties. In multiparous women, home delivery showed to be independently related to more positive perception of delivery.

Determinants of pain perception after external cephalic version in pregnant women

OBJECTIVE A considerable proportion of pregnant women with a fetus in breech position refuses external cephalic version (ECV), with fear of pain as important barrier. As a consequence, they are at high risk for caesarean section at term. The current study investigated determinants of pain perception during ECV, with special attention to maternal mental state such as depression and fear of ECV. DESIGN Prospective study of 249 third-trimester pregnant women with breech position with a request for an ECV attempt. SETTING Department of Obstetrics and Gynaecology in a large teaching hospital in the Netherlands. METHODS Prior to the ECV attempts, obstetric factors were registered, participants fulfilled the Edinburgh Depression Scale (EDS) and reported fear of ECV on a 10-point visual analog scale. Perception of pain intensity was measured with a 10-point visual analog scale, immediately after ECV. FINDINGS Multivariate linear regression analyses showed success of ECV to be the strongest predictor of pain perception. Furthermore, scores on the depression questionnaire and degree of fear of ECV independently explained pain perception, which was not the case for obstetrical or ECV related factors. CONCLUSION Apart from ECV outcome, psychological factors like depression and fear of ECV were independently related to pain perception of an ECV attempt. IMPLICATION FOR PRACTICE Maternal mood state should be taken into account when offering an ECV attempt to women with a fetus in breech position. Due to the painful experience and the importance of successful outcome, ECV should only be attempted in institutions with experienced practitioners and with careful attention to maternal mood and the way a woman is coping with the ECV attempt.

Mindfulness skills during pregnancy: Prospective associations with mother's mood and neonatal birth weight

OBJECTIVES Mindfulness skills have been associated with better mood and several health related outcomes. Because depressed mood during pregnancy has been related to worse child outcomes, the aim was to examine the association of mindfulness skills during pregnancy with the mothers depressive symptoms, gestational age, and neonatal birth weight. METHODS A subsample of 905 pregnant women who participated in the longitudinal cohort HAPPY study (Holistic Approach to Pregnancy and the first Postpartum Year) completed the 12-item Three Facet Mindfulness-Questionnaire-Short Form at 22weeks of gestation. The Edinburgh Depression Scale was completed to assess depressive symptoms at 12, 22 and 32weeks. The obstetric medical records were examined for gestational age and birth weight. RESULTS Mindfulness skills Acting with Awareness and Nonjudging at 22weeks were associated with less depressive symptoms at 22weeks and at 32weeks. When controlled for depressive symptoms at 22weeks, the association was still significant for Nonjudging predicting depressive symptoms at 32weeks (Beta=-0.12, p<0.01). Regarding the obstetric medical records, only Nonreacting was (positively) associated with birth weight (Beta=0.09, p<0.01). Controlling for gestational age, sex, parity, depressive symptoms, and health behavior, Nonreacting predicted a normal birth weight (OR=1.12, 95% CI=1.06-1.19), in contrast to low birth weight. CONCLUSION It seems that different mindfulness skills during pregnancy are important in predicting mothers depressive symptoms compared to the prediction of childs birth weight. Potential mechanisms are discussed.

Comparison of the psychological and physiological effects on students of a video-assisted or text introduction to a simulated task

Introduction The use of different methods for introducing the scenario in simulation-based medical education has not been investigated before and may be a useful element to optimise the effectiveness of learning. The aim of this study was to compare an immersive video-assisted introduction to a minimal text-based one, with regard to emotional assessment of the situation. Methods In this pilot study, 39 students participated in a medical simulated scenario. The students were randomly assigned to an experimental group (video-assisted introduction) or a control group (minimal textual introduction) and both were followed by performing surgery on LapSim (Surgical Science, Gothenburg, Sweden). The emotional assessment of the situation, cognitive appraisal, was defined as the ratio of the demands placed by an individual’s environment (primary appraisal) to that person’s resources to meet the demands (secondary appraisal). Secondary outcomes were anxiety (State-Trait Anxiety Inventory), physiological parameters (heart rate, heart rate variability, skin conductance, salivary cortisol), engagement (Game Engagement Questionnaire), motivation (Intrinsic Motivation Inventory) and performance (mean score in percentage calculated by LapSim of predefined levels). Results Participants in the immersive video group (n=17) were overloaded in terms of their perceived demands (a ratio of 1.17, IQR 0.30) compared with those in the control group (a ratio of 1.00, IQR 0.42, n=22) (P=0.01). No significant differences were found between the groups in secondary outcomes. Both groups showed an increase of anxiety after the introduction method. In the experimental group, this score increased from 9.0 to 11.0, and in the textual group from 7.5 to 10.5, both P<0.01. Discussion This study shows that the method of introducing a simulated scenario may influence the emotional assessment of the situation. It may be possible to make your simulation introduction too immersive or stimulating, which may interfere with learning. Further research will be necessary to investigate the impact and usefulness of these findings on learning in simulation-based medical education.

Antenatal mother–infant bonding scores are related to maternal reports of infant crying behaviour

Abstract Objective: To assess the relation between antenatal mother–infant bonding scores and maternal reports of infant crying behaviour. Background: Crying is normal behaviour and it is important for parent–infant bonding. Even though bonding starts antenatally, the relation between antenatal bonding scores and infant crying behaviour has never been studied. Method: A secondary analysis was performed on data that were gathered in a large prospective study within our region. Bonding was assessed using an antenatal bonding questionnaire at 32 weeks gestational age. The crying behaviour of infants was assessed with three questions at six weeks postpartum. Crying was termed excessive (EC+) when mothers perceived the crying to be ‘every day’, ‘often’ or ‘very often’, and with ‘crying episodes lasting more than 30 minutes’; in other words, when mothers scored high on all three questions. The relation between bonding and crying was examined using a multiple logistic regression analysis, including adjustment for relevant variables, especially maternal depression as measured with the Edinburgh Depression Scale. Results: In total, 894 women were included of whom 47 reported EC+ infants (5.3%). Antenatal bonding scores were significantly related to the reporting of crying behaviour, even after adjustment for relevant variables (p = 0.02). Each extra point on the bonding scale reduced the EC+ risk with 14% (OR = 0.86, 95% CI [0.76–0.97]). Conclusion: Mothers with lower antenatal bonding scores were more likely to report an EC+ infant. Future research should further explore the concept of antenatal bonding, its relation with EC and risks associated with EC.

Assessing teamwork performance in obstetrics: A systematic search and review of validated tools

Teamwork performance is an essential component for the clinical efficiency of multi-professional teams in obstetric care. As patient safety is related to teamwork performance, it has become an important learning goal in simulation-based education. In order to improve teamwork performance, reliable assessment tools are required. These can be used to provide feedback during training courses, or to compare learning effects between different types of training courses. The aim of the current study is to (1) identify the available assessment tools to evaluate obstetric teamwork performance in a simulated environment, and (2) evaluate their psychometric properties in order to identify the most valuable tool(s) to use. We performed a systematic search in PubMed, MEDLINE, and EMBASE to identify articles describing assessment tools for the evaluation of obstetric teamwork performance in a simulated environment. In order to evaluate the quality of the identified assessment tools the standards and grading rules have been applied as recommended by the Accreditation Council for Graduate Medical Education (ACGME) Committee on Educational Outcomes. The included studies were also assessed according to the Oxford Centre for Evidence Based Medicine (OCEBM) levels of evidence. This search resulted in the inclusion of five articles describing the following six tools: Clinical Teamwork Scale, Human Factors Rating Scale, Global Rating Scale, Assessment of Obstetric Team Performance, Global Assessment of Obstetric Team Performance, and the Teamwork Measurement Tool. Based on the ACGME guidelines we assigned a Class 3, level C of evidence, to all tools. Regarding the OCEBM levels of evidence, a level 3b was assigned to two studies and a level 4 to four studies. The Clinical Teamwork Scale demonstrated the most comprehensive validation, and the Teamwork Measurement Tool demonstrated promising results, however it is recommended to further investigate its reliability.

Board 437 - Research Abstract Psychological and Physiological Effects of Briefing Videos in Simulation-Based Medical Training (Submission #980)

Introduction/Background Team performance and medical technical skills may improve after multi-professional obstetric team training in a medical simulation center.1 Suspension of disbelief is necessary to create an effective training. To achieve suspension of disbelief, various introductions and briefing Methods can be used. In our medical simulation center in the Netherlands (medsim, Eindhoven) briefing videos are used in order to enlarge engagement of trainees and thereby the efficacy of the training. Our research question is whether briefing videos have an advantage over textual briefings. We hypothesized that the combination of visual and auditory stimuli is more likely to activate brain structures (priming), resulting in increased sympathetic activity. This activity may lead to better and faster engagement in medical simulation. The aim of this study is to measure the effect of an immersive briefing video on psychological stress, physiological activity, performance and suspension of disbelief, in comparison to a textual briefing. Methods Randomized controlled trial in which medical students were asked to participate in a medical simulation experiment. The students were randomly assigned to an experimental group (video briefing) or a control group (textual briefing). The scenario comprises of a resuscitation of an adult. The simulator used for this scenario was Resusci Anne® (Laerdal, Norway). Physiological parameters (heart rate (HR), HR variability and skin conductance) were measured with an ECG-necklace and wristband. This equipment is especially designed for measuring stress parameters by an open innovation center (Holst Centre, Belgium – the Netherlands). The Dutch (shortened) Profile of Mood States (POMS) was fulfilled before and after the briefing and at the end of the training.2 The six-item stress subscale of the POMS was used to measure emotional stress. Furthermore, a questionnaire about suspension of disbelief was accomplished at the end of the experiment. The scenarios were videotaped and performance was independently scored by two researchers, who were blinded to the allocation group. For assessment of medical performance a checklist, based on Dutch resuscitation guidelines was developed. Results Before entering the simulation scenario, the experimental group (N=14) saw a briefing video while the control group (N=14) read a textual briefing. Prior to the briefing, scores on the stress subscale were similar in both groups. Immediately after the briefing there was no significant difference between the experimental and control group (M(SD): 13.0(3.7) versus 14.0(4.1), p=.53). At the end of the experiment, the experimental group scored significantly higher on the stress subscale than the control group (M(SD): 8.1(2.0) versus 6.9(1.0), p=.04). The experimental group reported to feel more nervous (p=.03). The physiological parameters (HR, HR variability and skin conductance) showed an increase in sympathetic and a decrease in parasympathetic activity, from baseline to briefing and from briefing to evaluation. However, there were no differences in physiological parameters between the groups. We found no significant difference in items about suspension of disbelief between the two groups. Resuscitation was better performed in the control group (M(SD): 23.5(4.2) versus 18.7(4.1), p<.01)). Conclusion Briefing videos in medical simulation settings seem to contribute to increased stress. Not immediately after the briefing, but after the evaluation, differences in emotional stress were found between the groups, suggesting a delay in emotional response. However, there is no difference in achieving suspension of disbelief between video and textual briefing. The control group showed a better resuscitation performance than the experimental group. However, this performance does not automatically represent the efficacy of the training. To optimize efficacy, cognitive and physiological processes should be appropriately challenged, inducing a risk of failure.3,5 This could possibly explain the difference in performance between the groups. Future research will focus on the contribution of briefing videos to learning effects of simulation training. References 1. Fransen AF, van de Ven J, Merién AE, de Wit-Zuurendonk LD, Houterman S, Mol BW, Oei SG: Effect of obstetric team training on team performance and medical technical skills: a randomised controlled trial. BJOG 2012; 119:1387-93 2. McNair DM, Lorr M, Droppleman LF: Profile of mood states. San Diego, CA: educational and Industrial Testing Services 1992. 3. Guadagnoli M, Morin M, Dubrowski A: The application of the challenge point framework in medical education. Medical education 2012:46:447-53. 4. Yerkes RM, Dodson JD: The relation of strength of stimulus to rapidity of habit formation. Journal of Comparative Neurological psychology 1908; 18:459-82. 5. Rudolph JW, Repenning NR: Disaster dynamics: understanding the role of stress and interruptions in organizational collapse. Science Quarterly 2002; 47:1–30. Disclosures None.

Board 433 - Research Abstract Changes in Satisfaction with Team Functioning after Multi-Professional Simulation-Based Medical Team Training (Submission #1109)

Introduction/Background Many preventable medical errors are caused by failure in communication or because the team has not anticipated on each other.1-5 Multi-professional simulation-based medical training is internationallyadvocated to improve medical team performance.1,6,7 Grogan et al. 8 demonstrated that team training in Crew Resource Management (CRM) Results in a positive attitude of trainees towards teambuilding and communication and that this improvement in attitude is the initial step toward a substantive and sustainable organizational transformation. The positive reactions of trainees towards teambuilding, as represented by the first level of Kirkpatrick’s model for the evaluation of training, should result in implementation of the learned skills and behavior into clinical practice (level three) and finally be reflected in clinical outcomes as measured in the fourth level of Kirkpatrick’s model.9 The aim of this study is to determine the effect of simulation-based obstetric team training on satisfaction with team functioning after the training and to measure the changes over time. It is hypothesized that the training will have a positive effect on satisfaction with team functioning in the first weeks after the training but that this positive effect may decrease over time. Methods A prospective follow-up study with stepwise enrollment of an intervention. Between October 2012 and January 2013, the obstetric department of the Máxima Medical Center (Veldhoven, The Netherlands) was trained in a medical simulation center (medsim, Eindhoven, The Netherlands). Divided in 11 groups, 96 obstetric care providers participated in a one day, multi-professional simulation-based medical team training, focusing on both Crew Resource Management (approximately 80%) and medical technical skills (approximately 20%). Satisfaction with team functioning was evaluated three times for each group: prior to the training, two weeks after the training and three months after the training. The questionnaire consisted of questions about satisfaction with communication and collaboration between care providers in both general and emergency situations and evaluated workplace ambience as perceived in the last two weeks. Trainees evaluated satisfaction with several aspects of team functioning with a grade from one to ten. Explorative factor analyses and internal reliability analyses were used to test the internal consistency of the questionnaire and to explore whether the questions contained a main factor or several subscales. Paired samples T-tests and Repeated Measures ANOVA were used to analyze changes in satisfaction with team functioning (dependent variable) over time. Results Explorative factor analyses showed one main factor ‘team functioning’ consisting of five items (total score range 5-50), with a Cronbach’s alpha of 0.80 indicating good internal reliability. In the total sample there is a significant increase (n=66, p<0.001) in satisfaction with team performance from baseline (M(SD)=36.6(2.1)) to two weeks after the training (M(SD)=38.0(2.4)). Around three moments after the training, there is still an increase (M(SD)=37.7(2.4), n=47, p<0.001) compared to baseline. There is no significant change in satisfaction from two weeks to three months after training (p=0.34). Repeated Measures ANOVA in 37 trainees (without missing data) confirmed previous Results (Figure 1). Conclusion Multi-professional simulation-based team training has a positive effect on satisfaction with team functioning, persisting at least three months after the training. References 1. Centre for Maternal and Child Enquiries (CMACE): Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011; 118:1-203. 2. Van de Ven J, Houterman S, Steinweg RAJQ, Scherpbier AJJA, Wijers W, Mol BWJ, Oei SG: Reducing errors in health care: cost-effectiveness of multidisciplinary team training in obstetric emergencies (TOSTI study); a randomized controlled trial. BMC Pregnancy and Childbirth 2010; 10:59. 3. Kohn LT, Corrigan JM, Donaldson MS (Committee on Quality of Health Care in America, Institute of Medicine): To err is human: Building a safer health system. Washington DC: National Academy Press, 1999. 4. Dutch medical safety report: ‘Onbedoelde schade in Nederlandse ziekenhuizen’ EMGO Instituut/VUmc en NIVEL, Nederlands Instituut voor onderzoek van de gezondheidszorg in opdracht van de Orde, April 2007. 5. Dutch medical safety report: ‘Veiligheidsprogramma, voorkom schade, werk veilig in de Nederlandse ziekenhuizen’, June 2007. 6. Fransen AF, van de Ven J, Merién AE, de Wit-ZuurendonkLD, Houterman S, Mol BW, Oei SG: Effect of obstetric team training on team performance and medical technical skills: a randomised controlled trial. BJOG 2012; 119(11);1387-93. 7. Oei SG, Koops W, van Uytrecht C, Porath M, Mulders LGM: Op elkaar inspelen. Multidisciplinaire teamtraining verbetert patiëntveiligheid. Medisch Contact 2006; 61:904-6. 8. Grogan EL, Stiles RA, France DJ, Speroff T, Morris JA, Nixon B, et al: The impact of aviation-based teamwork training on the attitudes of health-care professionals. J Am Coll Surg 2004; 199(6):843–8. 9. Kirkpatrick D: Evaluating Training Programmes; the Four Levels. San Francisco, CA: Berrett-Kochler Publishers, 1994. Disclosures None.