POSTER PRESENTATIONS
BMFMS: Labour and Delivery
PLD.01 COST COMPARISON OF CAESAREAN SECTION FOR ABNORMAL PLACENTATION WITH AND WITHOUT USE OF INTERVENTIONAL RADIOLOGY
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PLD.01 COST COMPARISON OF...
PLD.02 CAN A NEW...S. Nallapeta, R. Arya, S. Vause. Central Manchester NHS Trust, Manchester, UK
Postpartum haemorrhage remains a significant cause of maternal morbidity and mortality. Fourteen deaths are attributed directly to haemorrhage in the most recent CEMACH report. At least two major surveys have shown that approximately two-thirds of all cases of severe maternal morbidity, so called "near misses", are related to severe haemorrhage. Of women requiring hysterectomy, 38% had a morbidly adherent placenta: placenta accreta, percreta or increta.
Interventional radiology can be used as a prophylactic measure to reduce blood loss when there is a known or suspected case of placenta accreta or placenta praevia associated with a previous Caesarean section scar.
Balloons are placed in the internal iliac or uterine arteries before delivery. The balloons can be inflated to occlude the vessels when required. Embolisation can be performed via the balloon catheters if bleeding continues despite inflation.
It has been reported that while blood loss during routine Caesarean section averages 1000 ml, haemorrhage during Caesarean hysterectomy for associated placental abnormalities may require up to 70 units of replacement blood products.
We have looked at the cost incurred by our trust when we do elective section along with interventional radiology (£2601) and compared this with similar cases in which elective section was associated with major postpartum haemorrhage (£4510). This is based on 12 cases in which we used interventional radiology and cost analysis included inpatient stay, total cost of procedure, blood products and uterotonics.
We recommend that interventional radiology is effective in achieving haemostasis during Caesarean section performed for placental abnormalities and is also cost effective.
PLD.02 CAN A NEW OXYTOCIN ANALOGUE REDUCE THE NEED FOR ADDITIONAL OXYTOCICS AFTER CAESAREAN SECTION? THE RESULTS OF A DOUBLE-BLIND RANDOMISED TRIAL
G. Attilakos1, D. Psaroudakis1, J. Ash1, R. Buchanan1, C. Winter1, F. Donald1, L. Hunt2, T. Draycott1. 1Southmead Hospital, North Bristol NHS Trust, Bristol, UK, 2University of Bristol, Bristol, UK
Introduction: NICE currently recommends 5 IU syntocinon to prevent postpartum haemorrhage (PPH) after Caesarean section. However, additional oxytocics may be required. Carbetocin is an oxytocin analogue, with a longer half life, which may reduce the requirement for additional treatment.
Methods: We conducted a double-blind randomised study of carbetocin versus syntocinon (1 : 1 ratio). The anaesthetist administered either the licensed dose (100 µg) of carbetocin intravenously after the delivery of the fetus or 5 IU syntocinon, from blinded ampoules. The surgeon was permitted to ask for additional oxytocics when required clinically. Elective and emergency Caesarean sections were included. We excluded women with multiple gestation, placenta praevia, placental abruption, gestation less than 37 weeks or undergoing general anaesthesia.
Results: 377 women were randomly assigned in the study. Both study groups had similar demographic and antenatal data. More women in the syntocinon arm needed additional oxytocic interventions (45.5% versus 33.5%, p = 0.02). A large proportion of women received a 4-h infusion of syntocinon (30.2% versus 22.3%, p = 0.1). There were no differences in the estimated blood loss, side-effect profile, intra and postoperative blood pressure and pulse readings or between pre and postoperative haemoglobin.
Conclusions: More than 40% of women required additional oxytocics following 5 IU syntocinon, but this was significantly reduced in the carbetocin arm. There was also a trend towards significance for a reduction in the use of a 4-h syntocinon infusion post-Caesarean section after carbetocin. This decrease in pharmacological intervention may reduce delay in transferring women to the postnatal wards postoperatively.
PLD.03 CONTRACTILE PROPERTIES OF MYOMETRIUM IN TWIN PREGNANCIES
P. A. Turton1, S. Wray1, J. Neilson2, S. Quenby2. 1School of Biomedical Sciences, University of Liverpool, Liverpool, UK, 2School of Reproductive and Developmental Medicine, University of Liverpool, Liverpool, UK
Twin pregnancies present greater risks to both the mother and fetuses. The major clinical risk is that of preterm labour, with 40–70% of multiple pregnancies ending with preterm delivery (before 37 weeks).
Increased uterine stretch may play a role in this. There have, however, been no studies of the contractile properties of myometrium from multiple pregnancies and so we have investigated this and compared them with singleton pregnancies.
Following informed consent and ethical approval, myometrial biopsies were obtained at Caesarean section, from women having either singleton (n = 11) or twin (n = 7) pregnancies. Strips of myometrium were dissected, attached to a force transducer and mounted in a bath perfused with physiological solution. The force of contraction (relative to high-K depolarisation), duration and frequency of contractions were measured in both groups, as well as their response to 10 nmol oxytocin.
Myometrium from twin pregnancies contracted more frequently than singletons (p = 0.02), and there was a non-significant decrease in duration (p = 0.06), although when gestation was accounted for there was a significant decrease in duration (p = 0.05). Contractions from myometria of twin pregnancies were non-significantly more augmented by oxytocin (p = 0.07).
This first insight into the differences in myometria, showing increased contraction frequency in twin pregnancies, provides the basis for further work, such as oxytocin receptor and potassium channel expression, which may provide us with targets for tocolytics in pre-term multiple pregnancy.
Funding: This work has been supported by the Wolfson Foundation and the Jean Shanks Foundation.
PLD.04 THE ROLE OF CERVICAL ELECTRICAL IMPEDANCE SPECTROSCOPY IN THE PREDICTION OF THE COURSE AND OUTCOME OF INDUCED LABOUR
R. P. Jokhi1, B. H. Brown2, D. O. C. Anumba1. 1Academic Department of Obstetrics and Gynaecology, Jessop Wing, Sheffield, UK, 2Department of Medical Physics, University of Sheffield, Sheffield, UK
Background: We sought to compare the predictive value of cervical electrical impedance spectroscopy with clinical assessment by the Bishop Score (BS) for the course and outcome of induced labour.
Methods: 205 women undergoing indicated induction of labour were assessed by BS and cervical resistivity was measured using four probes of 3, 6, 9 and 12 mm diameter, before prostaglandin or amniotomy. The association of measured parameters with labour characteristics and outcomes (time to onset of labour, duration of labour, requirement for augmentation of labour and mode of delivery) were tested by correlation statistics, multilinear regression and receiver operator characteristic curve analysis.
Results: Compared with cervical resistivity the BS score better predicted time to onset of labour >12 h but neither correlated with the duration of labour nor predicted delivery by Caesarean section (CS). Conversely pre-induction cervical resistivity, measured with the 12 mm probe, between 19 and 156 kHz, better predicted labour duration and delivery by CS, being significantly increased in women who delivered by CS versus those who delivered vaginally and in labours >24 h. Prediction of CS was best at 78 kHz, with an optimal cut-off cervical resistivity of 2.24 
.m (area under the curve (AUC) 0.66, sensitivity 71.0%, specificity 56.5%). Prediction of labour duration was best at 39 kHz, with an optimal cut-off of 2.25 .m (AUC 0.623, sensitivity 72.7%, specificity 55.4%).
Conclusions: Cervical electrical impedance spectroscopy predicts the duration and mode of delivery following induced labour better than the BS. Probe design may enhance the potential clinical utility of this technique.
PLD.05 RANDOMISED CONTROLLED TRIAL TO COMPARE THE EFFECTIVENESS OF PROSTAGLANDIN GEL VERSUS TABLETS IN LABOUR INDUCTION AT TERM
S. Taher1, J. Inder Riden2, S. Soltan2, J. Elihoo1, V. Terzidou1, P. Bennett1. 1Imperial College, London, UK, 2Queen Charlotte’s and Chelsea Hospital, London, UK
Objective: To compare the effectiveness of prostaglandin gel versus tablets in term labour induction.
Design: Prospective randomised controlled trial.
Setting: Patients attending for induction of labour at term.
Participants: 172 women aged 15–47 years (38–42 weeks of pregnancy).
Interventions: Women were randomly allocated to either prostin gel or tablets.
Main Outcome Measures: Time interval between induction to delivery. Other outcome measures: mode and indication of delivery, frequency of epidural usage, oxytocin used, epidural as analgesia, meconium staining in labour, uterine hyperstimulation, need for fetal blood sampling and admission to neonatal unit.
Results: 165 patients were randomly assigned, 83 to the gel arm and 82 to the tablet arm. Induction to delivery interval was significantly shorter in the gel group, 1400 versus 1868 minutes (p = 0.04).
Conclusions: Prostin gel is more effective and has cost-benefit compared with tablets.
PLD.06 A RANDOMISED TRIAL OF EPIDURAL VERSUS SPINAL ANAESTHESIA FOR CAESAREAN SECTION IN THE POTENTIALLY COMPROMISED FETUS
V. Ashton, N. Steen, V. Bythell, S. Robson. Newcastle University, Newcastle upon Tyne, UK
Background: Spinal anaesthesia provides rapid and effective anaesthesia for elective Caesarean section. In healthy fetuses, spinal anaesthesia is associated with a statistically significant, but clinically irrelevant, reduction in umbilical arterial pH compared with epidural anaesthesia. We hypothesised that in the potentially compromised fetus, spinal anaesthesia would result in a clinically significant reduction in umbilical artery pH (defined as a fall of 0.05).
Methods: 60 women with severe pre-eclampsia, a small-for-gestational-age fetus or both were randomly assigned to spinal (SA: 12.5 mg bupivacaine 0.5% + 300 µg diamorphine) or epidural (EA: 50 mg bupivacaine 0.5% + 50 µg fentanyl) anaesthesia stratified by umbilical artery Doppler. An intravenous infusion of phenylephrine was used to prevent hypotension in all women. Haemodynamic measurements included maternal cardiac output (measured by Doppler and cross-sectional echocardiography) and umbilical artery pulsatility index.
Results: Three women were randomly assigned but not studied. Mean gestational age at randomisation was 33 weeks and mean (SD) umbilical artery pulsatility index was 1.86 (1.37). Baseline mean (SD) umbilical artery pH and base excess was similar in the two groups (SA 7.26 (0.07), –3.80 (2.94) versus EA 7.25 (0.11), –4.36 (4.39), respectively). Despite greater falls in systolic blood pressure (SA (23 (27) versus EA 14 (17) mm Hg, p = 0.004) and diastolic blood pressure (SA 14 (17) versus EA 5 (14) mm Hg, p = 0.02), there were no differences in cardiac output and umbilical artery Doppler after anaesthesia.
Conclusions: Spinal anaesthesia, with optimum hypotension prophylaxis, does not adversely affect acid base status in the potentially compromised fetus.
PLD.07 CHILDBIRTH IN A STAND-ALONE MIDWIFE-LED UNIT: TRANSFERS AND OUTCOMES
A. S. Hammerton, P. Jacobs, P. K. Eedarapalli. The Royal Bournemouth Hospital, Bournemouth, UK
Background: The midwife-led maternity unit at the Royal Bournemouth Hospital (BMU) was opened in February 1992, the first in the United Kingdom. Patients requiring consultant care during labour have to be transferred to the consultant-led unit at Poole Hospital (PCU), 9 miles away. Despite the existence of midwife units in the United Kingdom for over 15 years, there remains a lack of good quality evidence on the safety of these units.
Objectives: To establish the incidence of intra and postpartum patient transfers between BMU and Poole Hospital and the reasons for transfer. To assess the time taken for interhospital transfers and potential problems. To determine the incidence of any maternal or neonatal adverse events.
Design: A retrospective, descriptive study of all patients transferred in labour or after delivery from BMU to PCU between 1 January 2007 and 30 June 2007.
Main Results: 238 women were admitted to BMU in labour. Of these, 31% (74) were transferred, of which 67% (60) were primigravidas. The mean time for transfer between the two units was 56 minutes. There were seven (9%) adverse neonatal events and 25 (20%) adverse maternal events, with an 8.4% emergency Caesarian section rate.
Conclusions: Midwife units are promoted as a way of offering choice to low-risk patients. However, patients should be made aware of their risk of transfer as well as possible adverse outcomes. This will only be possible if all units undergo continuous audit and participate in a national reporting system, which includes serious adverse maternal and neonatal events.
PLD.08 FETAL DISTRESS: A MYOMETRIAL PERSPECTIVE
A. J. G. Matthew, S. Quenby, S. Wray. University of Liverpool, Liverpool, UK
Fetal distress (FD) occurs when the fetus is deprived of oxygen. During labour, the uterus contracts in order to expel the fetus. This contraction compresses the vasculature supplying the placenta with oxygenated blood and the supply of oxygenated blood to the uterus and fetus is reduced. The resultant decrease in blood supply gives rise to an accumulation of acidic carbon dioxide and lactate. This acidification inhibits uterine contraction, helps to relax the uterus and therefore protects the fetus. If this inhibitory feedback system is altered, then it may give rise to problems in labour and increase the risk of FD. We investigated whether patients with FD had altered uterine contractility and if they respond differently to uterine acidification.
Uterine biopsies were obtained with patients’ consent during Caesarean delivery. Contractility of uterine strips was measured at physiological and acidic pH (pH 7.5 and pH 7.3, respectively). Expression of lactate dehydrogenase was measured in biopsies by Western blot, and lactate dehydrogenase isoenzyme activity was assayed using the Helena Biosciences SAS-1plus electrophoresis system.
Contractility of uterine strips was significantly increased (p = 0.0002) in FD (6.726 ± 0.903 mN, n = 18) when compared with control labouring strips (2.878 ± 0.289 mN, n = 19). Upon acidification, the FD strips were significantly (p = 0.02) more inhibited by acidification to pH 7.3 compared with labouring control strips (1.524 ± 0.918 mN, n = 5 and 0.346 ± 0.257 mN, n = 5, respectively).
This study shows that FD is strongly associated with high uterine contractility. Also, uterine biopsies from patients with FD respond differently to changes in pH, suggesting an altered metabolic process.
PLD.09 UK SURVEY OF ANTIBIOTIC TREATMENT OF WOMEN WITH SPONTANEOUS PRETERM LABOUR OR PRETERM RUPTURE OF THE MEMBRANES
S. Kenyon1, D. Jones1, P. Brocklehurst2, N. Marlow3, A. Salt4, D. Taylor1. 1University of Leicester, Leicester, UK, 2University of Oxford, Oxford, UK, 3University of Nottingham, Nottingham, UK, 4Great Ormond Street Hospital for Sick Children, London, UK
Objective: To determine practice regarding antibiotic treatment of women with spontaneous preterm labour (SPL) or preterm rupture of the membranes (PROM) before publication of ORACLE Children Study (expected spring 2008).
Design: Questionnaire survey of practice in 2007.
Setting: All obstetric units.
Population: Clinical directors of obstetric units.
Methods: Questionnaire regarding practice of antibiotic treatment for women with either SPL or PROM. Reminders are sent after one month.
Main Outcome Measures: Number of obstetric units offering treatment based on Cochrane systematic reviews.
Results: Response rate of 76% (163/214). SPL 78.5% (128/163) reported they did not treat these women and the majority stated that the evidence of benefit was not conclusive 71% (72/101). 21.4% (35/163) stated they did treat these women, with erythromycin (16/35), penicillin (15/35), or ampicillin (2/35). Reasons given included Guillain-Barré syndrome prophylaxis (10/29) and evidence of benefit (9/29). PROM 97.5% (159/163) prescribe antibiotics for these women, with 97% (154/159) using erythromycin. The majority stated there was evidence of benefit 82% (93/113).
Conclusions: Evidence from the Cochrane reviews suggests that antibiotic treatment is of no benefit with SPL.1 Whereas the majority (78.5%) of obstetric units stated they do not offer antibiotics, over 20% stated they did treat these women. Evidence suggests that antibiotic treatment (erythromycin) is of benefit with PROM;2 the majority of UK women received this treatment.
PLD.10 THE LONGITUDINAL STUDY OF THE OUTCOMES OF OPERATIVE BIRTHS FOR MALPOSITION IN THE SECOND STAGE
A. Cope1, S. Brigham1, S. A. Walkinshaw1, D. K. Hapangama2. 1Liverpool Women’s Hospital NHS Trust, Liverpool, UK, 2University of Liverpool, Liverpool, UK
Introduction: Malposition of the fetal head is a major cause of operative birth during the second stage of labour. Liverpool Women’s Hospital has available expertise in all approaches for this indication—Kjelland’s forceps (KF), rotational ventouse (VEN) or manual rotation (MR) and careful case selection is emphasised.
Methodology: A retrospective case note audit has been performed for deliveries between 2002 and 2008 at Liverpool Women’s Hospital. Deliveries were grouped by initially intended method for rotation delivery. Successful rotational delivery was defined as completion of vaginal delivery using a single instrument for VEN/KF or by successful rotation followed by the use of a single traction instrument for MR.
Results: 605 deliveries have been examined. Demographic features of groups were similar. The technique initially chosen to achieve birth was KF in 239, VEN in 117, MR in 48 and primary Caesarean section in 201. KF (85.4%) was significantly more likely to be successful than MR (64.6%) and VEN (45.3%). MR was associated with the highest percentage of neonatal morbidity (admission to neonatal intensive care unit, pH <7.0, 5-minute Apgar score <6) and maternal morbidity (major postpartum haemorrhage or trauma) (14.6% and 14.6%, respectively). The results show that only a small number of rotational deliveries that failed proceeded to Caesarean section (54/404 13.4%).
Conclusions: Careful choice of the appropriate technique for each woman achieves high success rates for vaginal birth for delay in the second stage secondary to malposition without exposure to high morbidity for either woman or baby.
PLD.11 OXYTOCIN-INDUCED MYOMETRIAL CONTRACTIONS IN THE PRESENCE OF NIFEDIPINE, TOWARDS UNDERSTANDING THE MECHANISM
J. E. Gullam, S. Thornton, A. Shmygol. University of Warwick Medical School, Coventry, UK
Background: Oxytocin-induced release of calcium ions (Ca2+) from sarcoplasmic reticulum (SR) and sensitisation of contractile proteins to Ca2+ have been suggested to mediate the oxytocin-induced potentiation of myometrial contractions.
Objective: We investigated the effects of oxytocin in the presence of nifedipine, a known inhibitor of the L-type calcium channel.
Methods: Samples of myometrium were obtained from women undergoing term Caesarean section with the approval of the local ethics committee. A standard organ bath system (AD Instruments, UK) was employed to analyze contractile activity. Stable spontaneous contractions were recorded for 40 minutes before addition of nifedipine.
Results: In agreement with our previous findings, application of oxytocin to spontaneously active strips produced a two-component effect: a transient tetanus-like contraction, followed by prolonged augmentation of phasic contractions. Nifedipine (1 µmol) rapidly abolishes spontaneous contractions; the subsequent addition of 100 nmol oxytocin produced an initial, transient rise in force followed by high frequency oscillations in >50% of strips. Calcium-free solutions confirm these oscillations are due to Ca2+ entry. No inhibition of oscillations was seen by either disabling the SR store with thapsigargin, T-type calcium-channel blockade by mibefradil (1 µmol) or 2-aminoethyldiphenylborate 50 µmol inhibition of the IP3 receptor and store-operated calcium channel. Partial inhibition was seen with the store-operated calcium channel inhibitor SKF-96365 (50 µmol). The gap-junction inhibitor carbenoxolone (200 µmol) showed rapid abolition of oscillations.
Conclusions: Based on these results, we believe that gap junctions between myometrial cells are important in the maintenance of these oscillations. Further work needs to be completed for clarification of the mechanism.
PLD.12 HIGH DEPENDENCY CARE PROVISION IN THE MATERNITY UNITS OF THE UNITED KINGDOM
N. Rawal2, A. Carlin2, H. Scholefield2, M. K. Whitworth1. 1University of Liverpool, Liverpool, UK, 2Liverpool Women’s NHS Foundation Trust, Liverpool, UK
No national data exist as to what high dependency (HD) facilities exist in maternity units in the United Kingdom. However, the latest confidential enquiry suggested that HD facilities within labour wards are absorbing the rise in the number of women with major haemorrhage. Successive enquiries have recommended that critically ill patients should be cared for in a HD unit with adequate staff and facilities. Our aim was to assess HD provision and staffing in UK maternity units.
We carried out a self-report survey of 235 maternity units in the United Kingdom between September and December 2007.
159 questionnaires were returned (67.6% response rate). The mean number of deliveries per year is 3451 (240–8000). 56% of units have designated HD beds. Median provision is one bed per unit. In units with no specific maternity HD facilities, care is provided either in a room on the delivery suite (44%), in a separate HD unit used by surgical patients (34%) or in the obstetric theatre recovery area (22%).
Patients in obstetric HD beds are nursed, almost exclusively, by midwives (95%), but less than a third of these have any formal HD training. Joint medical care, by obstetricians and anaesthetists, is provided in 71.6% of units.
The main issues identified by responding units were: (1) the need for HD facilities in the delivery suite; (2) formal training for those providing frontline care; (3) improved midwifery staffing levels.
This survey clearly demonstrates major, and potentially life-threatening, deficiencies in the organisation and provision of HD care in UK maternity units.
PLD.13 INTRAPARTUM STILLBIRTHS: 10-YEAR ANALYSIS BY RECODE
N. Beamish, J. Gardosi. Perinatal Institute, Birmingham, UK
Background: The number of stillbirths during labour and delivery has remained fairly constant over recent years and many remain unexplained. In his annual report published in 2007, the Chief Medical Officer called for renewed efforts to identify the factors associated with intrapartum-related deaths.
Methods: A 10-year database (1997–2006) of stillbirths in the West Midlands was investigated, using the ReCoDe classification1 to determine the relevant conditions at death.
Results: There was a total of 3802 stillbirths over the 10-year period, including 386 intrapartum deaths (10.2%). 41.2% of deaths occurred after term (37+ weeks). According to ReCoDe, the main categories of intrapartum deaths were fetal growth restriction (<10th customised percentile) 33.2%; intrapartum asphyxia 26.4%; placental abruption 24.6% and cord accident 8.0%.
Conclusions: The results suggest that many intrapartum deaths are potentially avoidable with better awareness and care. Antepartum recognition of fetal growth restriction is important as an alert of potentially diminished intrapartum fetal reserve.
PLD.14 ASSESSING THE HUMAN CERVIX BY IMPEDANCE SPECTROSCOPY: WHAT HISTOLOGICAL TISSUE CHANGES ACCOUNT FOR THE CLINICAL HUMAN OBSERVATIONS
C. E. Milward, C. Hill, G. Cope, D. O. C. Anumba. University of Sheffield, Sheffield, UK
Background: Electrical impedance spectroscopy (EIS) has demonstrated differences in resistivity between the pregnant and non-pregnant cervix. However, the tissue morphological characteristics that inform the resistivity spectra obtained are unclear. We hypothesised that several epithelial and stromal components that change during pregnancy would influence cervical resistivity to different degrees. We therefore sought to determine what cervical tissue elements correlated with cervical resistivity over 30 electrical frequencies.
Methods: Cervical biopsies of fresh hysterectomy specimens from non-pregnant women were assessed for epithelial layer thickness, epithelial cell sizes, connective tissue (collagen), fibroblast and blood vessel content. Additional samples were treated with collagenase in Hanks balanced salt solution (vehicle) or vehicle alone for 2 h. Cervical resistivity was measured using a 5 mm probe in all fresh samples before light microscopy and compared with histological findings.
Results: Compared with untreated tissue, collagenase treatment reduced cervical resistivity at low frequencies. Epithelial thickness and cell widths showed medium correlation with cervical resistivity at lower frequencies (coefficient 0.56, p<0.001 at 8 kHz and 0.414, p<0.05 at 6.3 kHz, respectively). Blood vessel proportions and collagen content affected impedance (correlation coefficient 0.48, p<0.05 at 4 kHz and 0.60, p<0.05 at 812 kHz, respectively). Fibroblast content had no significant correlation with impedance.
Conclusions: The key tissue determinants of cervical resistivity values are connective tissue content, epithelial thickness and cell width and blood vessel content. Information regarding these characteristics following cervical remodelling prelabour may enable probe design enhancements that optimise the assessment of cervical resistivity as a clinical tool for prelabour cervical assessment.
PLD.15 "SAFE" TRAINING TO SAVE MOTHERS’ LIVES AND BABIES FROM INJURY
D. Siassakos2, J. Crofts1, J. Clark1, C. Winter1, T. Sibanda1, T. Draycott1. 1Southmead Hospital, Bristol, UK, 2University of Bristol, North Academy, Bristol, UK
Investigators for the Confidential Enquiries into Maternal and Child Health have repeatedly identified substandard care, with inadequate communication and poor teamwork as major contributors, in a significant proportion of maternal, fetal and neonatal deaths in the United Kingdom. This has been reflected in the Clinical Negligence Scheme for Trusts standards and the "Safer Childbirth—Minimum Standards for the Organisation and Delivery of Care in Labour" paper, which recommend specific training in obstetric emergencies and group dynamics for all those who are involved in the management of women in labour or their babies.
We designed the multicentre Simulation and Fire-Drill Evaluation (SaFE) study to evaluate the effectiveness of multiprofessional obstetric emergencies training. The results demonstrate that training improves knowledge, communication, team behaviour scores and other markers of care during the management of simulated obstetric emergencies, such as shoulder dystocia or eclampsia, even without additional teamwork training. This translated into safe practice; in our unit and others where mandatory training was introduced, neonatal outcomes significantly improved. Following the training intervention, the risk of babies delivered with low Apgar scores, hypoxic ischaemic encephalopathy or brachial plexus injury was reduced by at least 50%.
Not all courses have been able to demonstrate an improved outcome after obstetric emergency training. We suggest that effective training programmes should include: (1) institution level incentives to train; (2) relevant and situated training; (3) team working principles integrated into the course; (4) realistic training tools; (5) multiprofessional involvement and 100% staff participation; (6) peer monitoring and (7) continuous monitoring of outcomes.
PLD.16 WITHDRAWN
PLD.17 EPIDURAL ANALGESIA: THE ASSOCIATION WITH MATERNAL AND FETAL URATE
N. A. Richards, Z. S. Maharaullee, S. M. Yentis, P. J. Steer. Chelsea and Westminster Hospital, London, UK
Introduction: Epidural analgesia in labour is associated with a rise in maternal and fetal temperature.1 Unpublished work in our department indicated a concomitant rise in umbilical cord urate levels. It was hypothesised that this might represent a fetal antioxidant response to the oxidative stress of labour. One aim of our follow-up study was to investigate the relationship between maternal and fetal urate levels, duration of epidural and temperature.
Methods: After regional ethics committee approval and written consent, 30 women in labour with epidural analgesia were randomly assigned to one of two cooling groups or a control group. Hourly oral temperatures were recorded and maternal venous blood samples taken at epidural insertion and delivery, plus an umbilical venous sample for the measurement of urate levels. Regression analysis was performed using SPSS with p<0.05 indicating statistical significance.
Results: There was significant correlation between the duration of epidural and maternal urate (R2 = 0.131, p = 0.049) but no independent correlation with the rise in maternal temperature. The cord urate was closely correlated with the maternal urate levels (Pearson correlation 0.953).
Discussion: Our findings confirm that maternal and fetal urate levels increase in parallel with the duration of epidural anaesthesia but that this rise is not associated with the rise in maternal temperature. The very close correlation between maternal and cord urates suggests that the rise in the fetus is likely to be an infusion effect from the mother.
PLD.18 RISK OF LATE INTRAUTERINE FETAL DEATH IN UNCOMPLICATED MONOCHORIONIC TWINS: A RETROSPECTIVE COHORT STUDY
J. Ogah, A. Oboh, E. Ferriman. Leeds University Teaching Hospitals, Leeds, UK
Background: Monochorionic twins have an increased risk of morbidity and mortality. Recent reports suggest that even in uncomplicated monochorionic diamniotic (MCDA) twins there is an increased risk of late intrauterine fetal death (IUD) predominantly after 32 weeks, leading to a recommendation in some units for elective delivery at 34 weeks.
Aim: We aimed to determine the risk of unexpected IUD in uncomplicated MCDA pregnancies beyond 24 weeks in our unit.
Methods: Data were collected on all MCDA twin pregnancies presenting to the Leeds General Infirmary from January 2005 to January 2008. MCDA twins were scanned every 2 weeks from diagnosis. "Complicated" MCDA gestations (twin-to-twin transfusion syndrome (TTTS), intrauterine growth restriction (IUGR), structural anomalies and delivery <24 weeks) were excluded.
Results: 281 twin pregnancies were delivered in the time period; 63 were MCDA twins with seven TTTS, six IUGR, three structural anomalies, three <24 weeks. 44 were "uncomplicated" MCDA twins. There were no intrauterine fetal deaths.
Discussion: Some studies quote unexplained fetal death rates of up to 4.6% in "uncomplicated" MCDA pregnancies leading to a policy of delivery at 34 weeks.1 Our study does not support this. Delivery at 34 weeks carries increased neonatal and maternal morbidity. In view of our findings "uncomplicated" MCDA twins are not delivered until 37–38 weeks in our unit.
- Barigye O, et al. High risk of unexpected late fetal death in monochorionic twins despite intensive ultrasound surveillance: a cohort study. Pics Med 2005;2:0521–6; e172.
PLD.19 PERINEAL TRAUMA IN OPERATIVE VAGINAL DELIVERY WITHOUT EPISIOTOMY
F. J. Watson1, A. McReady1, P. Owen2. 1Glasgow University, Glasgow, UK, 2Princess Royal Maternity Unit, Glasgow, UK
Introduction: Operative vaginal delivery (OVD) increases the risk of perineal trauma. Traditionally, episiotomy is performed at the time of OVD in an effort to reduce the severity of perineal trauma. Omitting to perform an episiotomy is becoming more commonplace but the consequences of this are not well described.
Aims: To determine the frequency of "no episiotomy" among women undergoing OVD. To describe the perineal trauma associated with "no episiotomy".
Study Design: Clinical data from the Princess Royal Maternity Unit, Glasgow, were collected retrospectively for the 326 women undergoing OVD between 1 February 2007 and 30 July 2007. Variables included: type of OVD, use of episiotomy, degree of perineal trauma and requirement for suturing.
Results: Delivery was by non-rotational forceps (58%), non-rotational ventouse (33%), rotational forceps (7%) and rotational ventouse (2%). Episiotomy was not performed in 13%. Group with no episiotomy: intact perineum (24%); first degree tear (19%); second degree tear (50%); third/fourth degree tear (7%); proportion requiring suturing (67%). Group with episiotomy: first degree tear (4%); second degree tear (87%); third/fourth degree tear (9%); proportion requiring suturing (99%).
Conclusions: 24% of women having OVD without episiotomy have an intact perineum and there is no increase in the incidence of severe perineal trauma. There is a reduction in the incidence of suturing when an episiotomy is not performed. This non-randomised comparison supports the selective use of episiotomy at OVD.
PLD.20 DIGIT PREFERENCE AND THRESHOLD AVOIDANCE: A COMMON CAUSE OF ERROR IN ESTIMATED BLOOD LOSS ASSESSMENT?
A. L. Briley1, P. T. Seed1, S. Bewley2. 1Kings College London, London, UK, 2Guys and St Thomas’ NHS Foundation Trust, London, UK
Objective: Postpartum haemorrhage (PPH) complicates 5–12% of all deliveries and is increasing. Current local policy is to document estimated blood loss (EBL). Digit preference and threshold avoidance are acknowledged confounders in other areas, but have not been assessed or described with EBL. This dataset afforded the opportunity to examine practice at a large inner-city London teaching hospital.
Methods: Data were obtained for all deliveries between 2000 and 2005 (n = 31 776).
Results: 76% of women had EBL 
499 ml, 20% >500–999 ml, 2% 
1000–1499 ml and 1.6% 1500 ml. Digit preference was demonstrated with most EBL ending in 0, 00 and 50. Threshold avoidance was apparent, particularly in blood loss up to 1 litre. Both these factors were most apparent at 500 ml, the worldwide definition of PPH. EBL around 500 ml are shown in the table. The overall PPH rate was 24%. If 499 ml and 450–498 ml represent threshold avoidance, it could have been as high as 25 or 30%. Defining PPH as or >500 ml would make a difference of 24% or 14%.
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Conclusions: The reporting of digit preference and threshold avoidance in this context is original, inclining towards underestimation. Threshold preference (choosing 500 ml) is novel and unexplained. Digit bias could adversely influence management. It cannot help patients or data collection for managerial, audit or research purposes. Future work should focus on accurate estimation, direct measurement, psychological responses to emergencies, maternity culture and training.
PLD.21 OPERATIVE DELIVERY IN SECOND STAGE IN THEATRE: A COMPARISON IN OUTCOME WITH AND WITHOUT CONSULTANT VAGINAL ASSESSMENT PREOPERATIVELY
S. Mwenechanya, D. Tuffnell, K. Wilkinson. Bradford Royal Infirmary, Bradford, UK
Background: Second stage Caesarean section is associated with high maternal and neonatal morbidity. This risk is further increased by failed multiple use of trial of instrumental delivery. Vaginal examination findings help in decision making on whether to proceed to Caesarean section or try an instrumental vaginal delivery and also which instrument is more likely to achieve a vaginal delivery.
Aim: To compare outcomes after registrar and consultant vaginal examination preoperatively with registrar vaginal examination only and consultant informed over the phone (out of hours).
Methods: After the registrar assessed the patient and made the decision to take to theatre, the consultant reassessed patient and findings and further management plans were compared. If out of hours then the consultant was informed by phone before proceeding with operative delivery.
Results: Data for 82 women over a 5-month period were analyzed. 22 women had both registrar and consultant assessment preoperatively. There were differences in vaginal examination findings in 11 (50%) cases; this led to a change in management plans in four women (18.2%). In the registrar-only group 52 (86.7%) of the 60 had trial with 38 (73%) successes. In the consultant vaginal examination group 17 (72%) had trial with 12 (71%) successes. Maternal and fetal morbidity were 18% and 0.9%, respectively (with consultant vaginal examination), 17% and 1%, respectively (without consultant vaginal examination).
Conclusions: There was a difference in vaginal examination findings in 50% of the cases and this necessitated a change in planned mode of delivery in 18% of the women. There was no difference in success rate of trial of instrumental deliveries, maternal and fetal morbidity.
PLD.22 PROSPECTIVE STUDY OF INTRAPARTUM FETAL BLOOD SAMPLING
E. J. Ferguson, K. A. Brogan, A. M. Mathers. Princess Royal Maternity Hospital, Glasgow, UK
Intrapartum fetal blood sampling (FBS) is an important adjunct to electronic fetal monitoring in assessing the potentially hypoxic fetus. Our aims were to assess the time taken from decision to result for FBS and any factors influencing this.
Methods: From 1 June to 31 July 2007, 125 samples were taken from 42 women. The operator, the time of decision, the time of result, maternal BMI and cervical dilatation were recorded.
Results: Only 61/125 samples (49%) yielded results. The average decision-to-FBS result interval was 20 minutes (range 6–65). In 82% of cases, decisions were made with a single result. If delivery was indicated, the FBS decision-to-delivery interval was 49 minutes (range 43–58). Machine malfunctions accounted for 58% of the failures to obtain results. Maternal BMI >30 significantly increased the risk of failure to obtain a result (overall relative risk 4, 95% CI 1.8 to 9) and the time taken to achieve a result (15 versus 28 minutes, p<0.001). Cervical dilatation <5 cm yielded a success rate of 57% and >5 cm yielded 70%. Grade of operator did not significantly affect the success rate.
Conclusions: The decision-to-result interval should be considered when undertaking FBS or planning a repeat test, especially with high BMI. Maternal BMI >30 increases the time to obtain a sample and the failure rate. FBS at cervical dilatation <5 cm is achievable and should be considered if indicated. Practical education with simulators to improve collection techniques and alternative blood collection systems may reduce procedure time and failure rates.
PLD.23 CAESAREAN SECTION RATES AMONG FEE AND NON-FEE-PAYING NULLIPARAS ARE SIMILAR WHEN THE MANAGEMENT OF LABOUR IS MIDWIFERY LED
C. M. Murphy1, M. E. Foley2, M. Murphy1, M. R. Robson1. 1National Maternity Hospital, Dublin, Ireland, 2UCD School of Medicine and Medical Science, Dublin, Ireland
Objective: Comparison of the Caesarean rates in fee and non-fee-paying single cephalic term nulliparous patients.
Methods: Data were collated prospectively for 2005–7 and analyzed for groups 1 and 2 of Robsons’ classification.1
Results: The overall Caesarean section rate was 15.4% (1460/9472). The onset of labour was spontaneous in 67.5% (6390/9472), induced in 30% (2850/9472) and there were 232/9472 pre-labour Caesarean sections (2.5%). The overall Caesarean section rate in spontaneous labour was 6.6% (425/6390) and was similar for non-fee 6.4% (342/5301) and fee-paying 7.6% (83/1089) patients (p = 0.2) and in induced labour 28.3% (2213/4982) and 27.3% (196/718), respectively. The Caesarean section rates for pre-labour Caesarean sections were higher in private patients (2.1% versus 3.8%) The Caesarean section rate among non-fee patients was 14.6% (1109/7593) and was significantly less compared with fee-paying patients 18.7% (351/1879) (p<0.001); this difference is explained by a significantly lower induction rate among public patients (26.8%; 1301/7593 versus 38%; 718/1879, p<0.001) resulting in fewer Caesarean deliveries. The overall Caesarean section rate for spontaneous and induced labour combined was significantly higher in the fee-paying cohort (15.4%; 279/1807 versus 12.8%; 949/7430, p<0.001).
Conclusions: Midwifery-led management of spontaneous and induced labour results in similar Caesarean delivery rates for fee and non-fee-paying patients. The higher Caesarean rate among fee-paying patients reflects decisions (selection for induction of labour) made before the onset of labour.
PLD.24 TRIAL OF LABOUR IN PATIENTS WITH ONE PREVIOUS CAESAREAN SECTION: DOES MATERNAL AGE AFFECT THE OUTCOME?
S. Gul, N. Farah, M. J. Turner. Coombe Women’s and Infants’ University Hospital, Dublin, Ireland
Objective: To evaluate the effect of maternal age on the rate of vaginal delivery in patients undergoing trial of labour after one previous lower segment Caesarean delivery.
Design: The study included all women with a live singleton pregnancy over 37 weeks’ gestation undergoing a trial of labour after one previous Caesarean delivery between January 2002 and December 2006. Patients were divided into four groups depending on the maternal age (<30, 30–34, 35–39 and >40 years). Women with no previous vaginal delivery and at least one previous vaginal delivery were analyzed seperately. The rate of vaginal delivery and the rate of uterine rupture were analyzed using binominal logistic regression. SPSS 14 was used.
Results: There were 6387 patients who met the study criteria (see 
tables 1 and 2).
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View this table: Abstract PLD.24 Table 1 Total number of patients in each subgroup
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View this table: Abstract PLD.24 Table 2 Vaginal birth after Caesarean rate in each subgroup
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Conclusions: Increased maternal age had an impact on delivery outcomes. Previous vaginal delivery increases the vaginal birth after Caesarean rate. Women over 40 years were more likely to have repeat Caesarean delivery.
PLD.25 NEONATAL OUTCOMES OF THE SECOND TWIN BASED ON MODE OF DELIVERY
V. Agarwal1, R. Agarwal2, A. Gornall1, M. Mohajer1. 1Royal Shrewsbury Hospital, Shrewsbury, UK, 2University of Pennsylvania, Philadelphia, Pennsylvania, USA
Background: The decision about mode of delivery for twin pregnancy is challenging, especially in the light of the fact that one or both twins frequently have malpresentation. In the absence of limited evidence, clinical opinion is frequently divided on choosing the mode of delivery.
Methods: A retrospective review of 132 twin deliveries was conducted for 2005–6. Data were extracted on type of delivery, patient age, body mass index, parity, type of twin, gestational age, presentation (cephalic/non-cephalic) and neonatal outcomes for the second twin (admission to neonatal unit, arterial pH and Apgar scores). Multivariate regression analysis was performed for each neonatal outcome adjusting for the variables mentioned. Analyses were conducted separately for the type of delivery planned (intention-to-treat) and actually conducted (per-protocol).
Results: Vaginal delivery was planned in 102 cases and Caesarean section in 30 cases. Admission to the neonatal unit for the second twin was not significantly different comparing Caesarean section and vaginal delivery on both intention-to-treat (adjusted odds ratio (OR) 0.21; 95% CI 0.01 to 4.74) and per-protocol analyses (adjusted OR 1.63; 95% CI 0.15 to 18.40). There was no significant difference in arterial pH between the two groups in either analysis. The Apgar score at 1 minute was significantly higher in the Caesarean section group on both intention-to-treat (2.28 points; 95% CI 0.73 to 3.82) and per-protocol analyses (1.32 points; 95% CI 0.05 to 2.60), but there were no significant differences in the Apgar score at 5 minutes.
Conclusions: The neonatal outcomes for the second twin are similar regardless of the mode of delivery.
PLD.26 THE PATERNAL PERSPECTIVE OF CHILDBIRTH
F. Hogg1, D. Siassakos1, T. Draycott2. 1University of Bristol, Bristol, UK, 2Southmead Hospital, Bristol, UK
Background: As the role of the father has extended from breadwinner to a full domesticated involvement, it is unsurprising that their presence at childbirth is now an accepted part of western culture. The father, often present from booking appointment to cutting of the cord, is often overlooked. This is reflected by the scarcity of research into their perceptions of birth.
Objective: To assess paternal attendance at antenatal classes and examine whether they influenced fathers’ satisfaction with labour.
Methods: A Likert-style health service evaluation questionnaire, developed from literature, was completed by 45 new fathers who had attended normal births.
Results: 45 fathers (27 first-time (FT), 18 existing (E), age 22–26 years) completed the questionnaire. 55% (25) had attended antenatal classes (67% FT, 39% E). Mean paternal satisfaction score was 78% (SD 9.44 range 56–100%). There was no statistically significant difference in the satisfaction of those who had attended antenatal classes (FT 78% and E 83%) with those who had not (FT 74% and E 79%). The majority strongly agreed that it was their decision to attend (FT 70%, E 88%) and had felt prepared for birth but still felt scared by it. Most had no concerns about their future sex life and were pleased to have attended.
Conclusions: High levels of paternal satisfaction were found to be independent of antenatal class attendance. Further studies are necessary to assess the benefits and cost effectiveness of antenatal classes and investigate the paternal perspective of childbirth.
PLD.27 PREDICTIVE MODEL FOR SHOULDER DYSTOCIA
A. Swaminathan, D. Roberts, M. Whitworth, Z. Alfirevic. Liverpool Women’s Hospital Foundation NHS Trust, Liverpool, UK
The majority of studies suggesting that shoulder dystocia (SD) is associated with prolonged second stage are retrospective. We aimed to assess 5 years of prospective births to determine which intrapartum factors are important in predisposing to SD.
Methods: Computerised medical records of all patients who delivered in Liverpool Women’s Hospital (a tertiary care university teaching hospital) for a 5-year period were obtained from MEDITECH. Inclusion criteria were singleton, cephalic, 37+ weeks with vaginal birth. Univariate and then a stepwise logistic regression analysis were done using SPSS.
Results: Out of 23 762 births that fulfilled the criteria 426 had SD (see table).
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View this table: Abstract PLD.27
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Conclusions: Of all factors studied, birthweight and length of second stage were most significant. A predictive model has been devised. Receiver operator characteristic curves have been devised for the model and will be presented.
PLD.28 OUTCOME FOLLOWING A THIRD DOSE OF VAGINAL PROSTAGLANDIN TABLETS (3 MG PGE2) FOR INDUCTION OF LABOUR
L. Michie, F. Mackenzie. Princess Royal Maternity Hospital, Glasgow, UK
Introduction: The NICE guideline for induction of labour (IOL) recommends the use of vaginal prostaglandin (PGE2) tablets. The recommended regimen is 3 mg PGE2 6–8-hourly with a maximum dose of 6 mg. If the cervix remains unfavourable, our practice has been to consider a further 3 mg PGE2.
Methods: A retrospective review of all women receiving a third 3 mg PGE2 tablet for IOL between January 2005 and December 2006 was undertaken.
Results: Of the 1149 women who were induced with vaginal PGE2 tablets over the study period, 100 received three PGE2 tablets. The mean gestational age at IOL was 40–41 weeks and the commonest indication "post-dates" (48%). Cervical assessment before a third dose of PGE2 was performed by a middle-grade or above in 97% of cases but the Bishop score was only documented in 40%. The mode of delivery is documented in the table. The overall Caesarean section rate was 49% in this group of women—54% for primigravid women and 24% for parous women. This compares with a section rate of 27% for all women undergoing IOL with prostaglandins during the study period (35% for primigravid and 16% for parous).
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View this table: Abstract PLD.28
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Conclusions: The delivery outcomes for those women receiving a third 3 mg dose of PGE2 show that just over 50% of these women achieve a vaginal delivery. The actual figures could allow more accurate counselling in the decision-making process during IOL.
PLD.29 OUTCOME OF EXTERNAL CEPHALIC VERSION AT A DISTRICT GENERAL HOSPITAL: OUR 1-YEAR EXPERIENCE
P. Jain1, S. Kalla2. 1Gloucester Royal Hospital, Gloucester, UK, 2Wexham Park Hospital, Slough, Berkshire, UK
Background: Vaginal breech delivery is associated with increased perinatal morbidity and mortality.1 The RCOG recommends that all women with an uncomplicated breech at term should be offered external cephalic version (ECV).2 ECV significantly reduces the Caesarean section rate. It is a cost effective, although underused, procedure with variable success. There appears to be a resurgence in the past two decades, with a national success rate of approximately 50%.
Aim: To assess the outcome of ECV at our unit in order to identify educational/training needs.
Materials and Methods: A prospective questionnaire-based study over a 1-year period from September 2004 to September 2005 at Wexham Park Hospital, Slough. During this period 40 eligible women with breech presentation at term had ECV attempted. Women with contraindications for ECV were excluded. Relevant data were obtained at the time of the procedure. Data regarding mode of delivery after successful ECV were obtained from the maternity database.
Results: The audit showed an ECV success rate of 62.5% (25/40) in our hospital. None of the women had procedure-related complications. More than 95% (24/25) of women with successful ECV delivered vaginally. There was a positive correlation of success rate with higher parity. Success rate was almost equal between 37 and 40 weeks’ gestation.
Conclusions: The outcome of ECV at Wexham Park Hospital is encouraging. As recommended by RCOG we suggest that all women with uncomplicated breech at term should be offered ECV. Specialty trainees should actively participate to acquire counselling and procedural skills.
PLD.30 LIVING WITH STAN: EARLY EXPERIENCE OF INTRAPARTUM FETAL SURVEILLANCE USING FETAL ECG ST SEGMENT ANALYSIS
K. Ragupathy, A. E. Nicoll. Ninewells Hospital, Dundee, UK
Aims: Our aims were to assess the frequency of ST events and obstetric outcomes after the introduction of fetal ECG ST analysis (STAN) to Ninewells Hospital, Dundee, in October 2007.
Methods: Data were collected prospectively from all women who had STAN between 1 October 2007 and 31 December 2007. Following an ST event, the cardiotocograph (CTG) was reviewed and classified as normal, intermediary or abnormal. Action was required if the STAN guideline criteria were met.
Results: 142/721 (20%) women who received continuous intrapartum electronic fetal monitoring had STAN. There were 400 ST events (median 3, range 1–32) and 338/400 (84%) were associated with a normal CTG. 80/142 (56%) women had at least one ST event. 68/80 (85%) with an ST event required no immediate action. 4/80 (5%) required immediate delivery. 24/142 (17%) had fetal blood sampling, 34/142 (24%) required operative vaginal delivery and 43/142 (30%) required emergency Caesarean section. 24/142 (17%) had operative delivery for suspected fetal distress. 2/142 (1.4%) were delivered for an ST event with a normal CTG. 3/142 (2.1%) had severe neonatal metabolic acidosis. All three cases were not managed according to STAN guidelines.
Conclusions: ST events are common but most require no action. The rate of obstetric intervention was higher than anticipated but the majority of operative deliveries were for reasons other than suspected fetal distress. We were initially concerned that an ST event with a normal CTG might lead to inappropriate delivery, but this occurred infrequently. We are now concerned that the high incidence of "false positive" ST events might lead to complacency and failure to act when a significant ST event occurs.
PLD.31 ASSESSING THE IMPACT OF TRAINING DRILLS IN THE MANAGEMENT OF MASSIVE POSTPARTUM HAEMORRHAGE
F. Dawood1, H. Schofield1, K. Mills2, K. Boyce2, S. Quenby2. 1Liverpool Women’s Hospital, Liverpool, UK, 2University of Liverpool, Liverpool, UK
Massive postpartum haemorrhage (PPH) is defined as blood loss of >1500 ml 24 h after delivery and is an important cause of maternal morbidity and mortality. The aim of this study was to determine the effectiveness of training drills in the management of PPH.
Methodology: A cohort study comparing adherence to our unit PPH guideline was conducted in two time-frames: a retrospective study in 1 April 2002–31 March 2003 and then a prospective study in 1 April 2005–31 March 2006 following the implementation of PPH training drills.
Results: The total number of deliveries was 5842 in 2002/3 and 7895 in 2005/6. Similar predisposing risk factors and causes of PPH were present in both periods, the commonest cause being uterine atony. A marked improvement in the usage of first-line medical treatments and a significant reduction in the need for surgical interventions was observed in the second period (see table).
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View this table: Abstract PLD.31
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Conclusions: Regular training drills improved adherence to guidelines, reduced maternal morbidity and are effective tools for clinical practice and risk management.
PLD.32 ANAESTHETIC CONSIDERATIONS FOR THE MORBIDLY OBESE WOMAN: ANTEPARTUM, INTRAPARTUM AND POSTPARTUM RECOMMENDATIONS
J. J. Arnold1, A. E. Loughnan1, J. J. S. Waugh2, N. Redfern3. 1Newcastle Medical School, Newcastle University, Newcastle upon Tyne, UK, 2Directorate of Womens Services, NUTH NHS Foundation Trust, Newcastle upon Tyne, UK, 3Directorate of Anaesthesia, NUTH NHS Foundation Trust, Newcastle upon Tyne, UK
The CEMACH report recommends that all morbidly obese women should be referred antenatally for anaesthetic assessment; trainees should be directly supervised when dealing with these patients and all morbidly obese parturients should receive prophylactic low molecular weight heparin post-delivery. Our audit considered whether this was current practice in out unit.
4% (125) of mothers who delivered in Newcastle upon Tyne over a 6-month period with a BMI >35 were retrospectively reviewed. The number requiring anaesthetic intervention, technical difficulties encountered, grade of anaesthetist, labour outcome and prophylactic low molecular weight heparin dose were studied.
We found that 35 primiparous women (54%) and 24 multiparous women (34%) required anaesthetic intervention (25 epidurals, 15 spinals, two combined spinal epidurals, one general anaesthetic). 66% of emergency Caesarean sections were done using spinal anaesthesia. Early data indicate that 50% of regional blocks were reported as being technically difficult. According to current hospital protocol, only women undergoing Caesarean section receive heparin (>100 kg, 50 IU/kg tinzaparin). Only 30% received the correct dose.
Referral is worthwhile because 54% of primiparous obese women need some form of anaesthetic intervention. Our data confirm that regional blockade is technically difficult in obese patients. Early epidural siting may avoid the need for technically difficult urgent spinal anaesthesia. A tinzaparin dosage chart could be provided in theatre rather than relying on the anaesthetist to calculate the dose.
PLD.33 PREGNANCY IN WOMEN WITH SCOLIOSIS AND PREVIOUS SPINAL SURGERY: A CHALLENGE FOR OBSTETRICIANS AND ANAESTHETISTS
O. Navti, N. Potdar, V. Kalathy, M. Khare, E. Howarth, C. Elton. University Hospitals of Leicester NHS Trust, Leicester, UK
Introduction: Pregnant women with scoliosis and previous spinal surgery present challenges to the obstetrician and anaesthetist, particularly with regard to counselling for appropriate analgesia for labour and delivery.
Methodology: Observational, retrospective study of women with scoliosis or previous spinal surgery reviewed in the maternal medicine and obstetric anaesthesia clinics in a large teaching hospital. Outcomes of these pregnancies including type of analgesia for labour and delivery and the mode of delivery were reviewed.
Results: Over the 3-year period, 49 patients with scoliosis and 13 patients with previous spinal surgery attended the clinics. In the cohort with scoliosis, vaginal delivery was achieved in 34 (69%), whereas 15 (31%) had Caesarean sections. Successful regional anaesthesia was achieved in 12 (35%) of the women delivering vaginally and 93% (14) of women requiring Caesarean sections. In the 13 women with previous spinal surgery, six (43%) had Caesarean sections, a third of which were emergencies. All patients requiring Caesarean sections and one (8%) of those delivering vaginally had successful regional blocks. Overall, only three women had a general anaesthetic for elective sections. These included patients with Klippel–Feil syndrome, previous spinal meningioma and spina bifida.
Conclusions: With appropriate antepartum counselling and planning in a multidisciplinary setting the majority of patients with scoliosis or previous spinal surgery can have successful regional anaesthesia for delivery.
PLD.34 FACILITATING PLACENTAL TRANSFUSION: A SURVEY OF CARE DURING THE THIRD STAGE OF LABOUR IN A UK HOSPITAL
D. Farrar, L. Duley. Bradford Institute for Health Research, Bradford, UK
Background: Early cord clamping is widely practised as part of active management of the third stage of labour. Delaying cord clamping, by just a few minutes, may allow continued transfusion from the placenta to the newborn infant. Other factors that may influence this placental transfusion include the position of the baby at delivery and timing and choice of uterotonic. Whether early clamping has advantages over late clamping remains unclear.1
Methodology: Delivery suite midwives at the Bradford Royal Infirmary were invited to complete a questionnaire about their third-stage practice. Practice was observed for 100 normal deliveries.
Results: See table.
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View this table: Abstract PLD.34
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Discussion: Current views and practice of delivery suite midwives in Bradford are to clamp the cord early. Although there is some variation in practice during the third stage, for most deliveries it seems likely that placental transfusion is restricted. Practice in our hospital appears typical within the United Kingdom.2
This study was conducted as part of the preparation for a multicentre trial comparing early with late cord clamping.
PLD.35 A WEB-BASED INFORMATION PACKAGE FOR PARENTS EXPECTING A MULTIPLE PREGNANCY
H. Jones1, E. Ferriman2. 1University of Leeds, Leeds, UK, 2Leeds General Infirmary, Leeds, UK
Introduction: 280 multiple pregnancies were managed at the Leeds General Infirmary between January 2005 and January 2008.1 Prospective parents face a much medicalised pregnancy with intensive monitoring. It is well documented that these parents require additional support both from the medical and midwifery team. We have devised a web-based information package for parents expecting a multiple pregnancy. The package details all aspects of pregnancy care including diagnosis, screening, antenatal monitoring and delivery options. It was felt that a web-based guide for multiple gestations would provide an accessible medium for parents to answer their questions and provide some practical advice and support.
Aim: To produce a web-based package to guide prospective parents through their multiple pregnancy at Leeds General Infirmary.
Methods: Initial responses to the idea were considered alongside RCOG recommendations2 and United Leeds Teaching Hospitals guidelines3 for the management of multiple gestations. The software "Articulate presenter 5 pro" was chosen to produce a package allowing ease of use and the option to include narration to provide an alternative means of learning. A pilot study of the package is currently being evaluated by parents and health professionals.
Results: A questionnaire has been constructed to evaluate the usefulness of the package among parents and health professionals.
Conclusions: The web-based information package is easily accessible to most parents and provides them with immediately available information. We believe that this will provide an alternative method of advice and information in a group of parents who can feel isolated and unsupported in pregnancy.
PLD.36 CHANGES IN MYOMETRIAL "PERFUSION" DURING NORMAL LABOUR AS VISUALISED BY 3-DIMENSIONAL POWER DOPPLER ANGIOGRAPHY
N. W. Jones1, H. A. Mousa1, N. J. Raine-Fenning2, G. J. Bugg1. 1Queen’s Medical Centre, Nottingham, UK, 2University of Nottingham, Nottingham, UK
Objective: Myometrial contraction is one of the most important aspects of effective labour. For cells within the myometrium to work efficiently they need to be well oxygenated by an adequate blood supply. This is the first study to use three-dimensional (3D) power Doppler angiography to attempt to describe myometrial perfusion in terms of "fractional moving blood volume" (FMBV) during a relaxation–contraction–relaxation cycle of active labour.
Methods: 3D transabdominal ultrasound in the power Doppler angiography mode was performed in the first stage of spontaneous labour in 20 term, nulliparous women. 3D datasets were acquired during a single cycle of uterine relaxation, contraction and subsequent relaxation for each subject. The resultant datasets were independently analyzed, using VOCAL within four-dimensional view by two investigators on two occasions each.
Results: Myometrial FMBV, the percentage change in indices compared with the initial uterine relaxation (taken as the local maximum of 100%), fell significantly during the uterine contraction and returned during the subsequent relaxation of the cycle. During contraction the vascularisation index fell to 44%, flow index to 86% and vascularisation–flow index to 41%. The intraclass correlation coefficients in blood flow measurements of 0.910–0.999 between the two investigators were indicative of good interobserver reliability.
Conclusions: This study confirms that FMBV within the myometrium falls during uterine contraction and returns during relaxation and demonstrates that this reduction can be quantified using 3D power Doppler angiography.
PLD.37 DELAYED UMBILICAL CORD CLAMPING, A PRACTICAL OPTION IN JAMAICA?
T. Bugembe1, B. Brabin1, M. Thame2, H. Fletcher2, P. van Rhaenan3. 1University of Liverpool, Liverpool, UK, 2University of West Indies, Kingston, Jamaica, 3University Medical Centre, Gronigen, The Netherlands
Introduction: Despite 30 years of public health measures, iron deficiency anaemia (IDA) in Jamaica’s children has remained at a prevalence of 40%.1–4 Delayed umbilical cord clamping (DCC) has been shown to reduce the risk of anaemia in infancy.5–8 Evidence-based guidelines on delayed cord clamping for low-resource settings were recently published.9 10 The aim of this study was to assess whether DCC was a practical option for reducing IDA in Jamaican infants.
Methods: The study was conducted at the University Hospital of West Indies (UHWI), Kingston, Jamaica. A cross-sectional observational study described cord clamping practices. A questionnaire survey assessed the knowledge and training of medical staff on umbilical cord clamping and requested their opinions on the current BMJ guidelines.
Results: This is the first study describing cord clamping practices and attitudes in the developing world. The mean time of clamping the umbilical cord at UHWI was 21.9 s (range 4–96). Midwives clamped significantly later than other professional groups (33 s versus medical students at 11.5 s, p = 0.04). 82% of staff were taught to clamp the cord early, with 70% receiving no training on cord clamping since qualifying. Half the staff were aware that DCC reduced anaemia in infancy, yet only 41.7% supported the implementation of the BMJ guidelines in Jamaica.
Conclusions: Early cord clamping is normal practice at UHWI, arising from a lack of awareness of the evidence-based benefits. These knowledge gaps can be used to direct training and promote a standard DCC policy at UHWI.
PLD.38 ONE HUNDRED AND SEVENTY-THREE CONSECUTIVE TWIN DELIVERIES: A 2-YEAR REVIEW
O. Subair, K. Kannan, M. Coker. Watford General Hospital, Watford, UK
Background: Vaginal twin births are associated with a fourfold increase in perinatal mortality and depressed Apgar scores usually due to intrapartum asphyxia of twin 2.1 Caesarean section for twin 2 occurred in 3.5% of deliveries in the United Kingdom.2
Materials and Methods: A retrospective audit looking at the birth records of all twin deliveries in our unit between January 2006 and December 2007 (2 years) totalling 175. Two sets were excluded, as they were less than 24 weeks’ gestation. In the same period there were 10 611 total deliveries, giving a twin birth rate of 1.6%.
Results: We had a 36% (62/173) elective Caesarean section and 36% (63/173) emergency Caesarean section rate. 17.5% (30/173) spontaneous vaginal deliveries and 10.5% (18/173) instrumental deliveries. Among the successful vaginal deliveries, 30/48 (64%) were multiparous. In vertex/breech twins, multiparous women were 2.5 times more likely to have a successful vaginal delivery. Twin 2 was 2.4 times more likely to have a cord pH <7.20 if vaginal delivery was successful and there were eight times more emergency Caesarean sections for twin 2 at nighttime. 9/173 (5.2%) of our deliveries required an emergency Caesarean section for twin 2, with 8/9 having a non-vertex presentation of twin 2 and 7/9 having a cord pH <7.20 at delivery.
Conclusions: The mode of delivery in twins remains controversial and counselling should include a frank discussion of the uncertainties and the small absolute risk of adverse events at term.3
PLD.39 FETAL FIBRONECTIN BEDSIDE TESTING: COSTLY KIT OR COST-SAVING INTERVENTION?
L. M. Page, C. Biswas, TG Teoh. St Mary’s Hospital, London, UK
Prematurity is a major contributor to perinatal morbidity and mortality. Fetal fibronectin (fFN) is found in cervicovaginal secretions. Its detection between 24 and 34 weeks is associated with preterm delivery. Before the introduction of fFN testing, the management of women presenting with threatened preterm labour (tPTL) included admission, steroids, tocolysis (atosiban) and possible in-utero transfer.
Following the introduction of a new tPTL protocol that incorporated fFN testing, an audit was designed to investigate compliance with the protocol and whether fFN testing could reduce admission rates, steroid and atosiban use and in-utero transfers.
30 symptomatic women were tested for fFN. Nine women tested fFN positive. These women received steroids. Two received atosiban and none required in-utero transfer. The median length of inpatient stay was 3 days. The median gestation at delivery was 33 weeks. 44% of women delivered within 14 days of a positive test.
21 women tested fFN negative. One woman received steroids for another indication. No women received atosiban or required an in-utero transfer. The mean length of inpatient stay was less than one day. The mean gestation at delivery was 39 weeks.
Before the introduction of fFN testing the cost of atosiban per month was £1886. After introduction of fFN testing the cost of atosiban and fFN kits per month was £1021.
After introducing fFN testing there were savings of £865 per month due to a reduction in the use of atosiban. Further cost savings are associated with reduced inpatient episodes. Moreover, unnecessary anxiety for women and their families was avoided.
PLD.40 OBSTETRIC AND NEONATAL OUTCOMES OF TWIN PREGNANCIES IN A GLASGOW HOSPITAL
V. A. Mackay, J. Gibson. Southern General Hospital, Glasgow, UK
Introduction: Evidence suggests an increased risk of fetal mortality in vaginally delivered second twins from intrapartum anoxia, proposing delivery of twin gestations by planned Caesarean section (CS). We investigated the neonatal outcome of labouring twin pregnancies.
Methods: A retrospective analysis of twin deliveries (January 2005–January 2007). Neonatal outcome was evaluated by Apgar score, special care baby unit (SCBU)/neonatal intensive care unit (NICU) admission and mortality.
Results: Of 79 cases, 52 twin pregnancies (65.8%) had twin 1 vertex presentation at delivery; 11 had elective Caesarean section (21.2%) and 41 were allowed to labour (78.8%). Of the labourers, 25 were induced (61%), six had emergency (E) Caesarean section (14.6%), 33 had a vaginal delivery (80.5%) and two had vaginal delivery of twin 1 and emergency Caesarean section for twin 2 (4.9%). Median labouring inter-twin delivery interval was 12 minutes (range 6–20 minutes). 31.7% of deliveries occurred from 09:00 to 17:00 hours; a consultant was present in five cases (38.5%). Of first twins, there were no Apgars <5. Of second twins, one had Apgars of 5 at 1 and 8 at 5 minutes (E Caesarean section delivery) and one had Apgars of 3 at 1 and 5 at 5 minutes (mid-cavity forceps delivery E Caesarean section). Six twin pairs were admitted to the SCBU (14.6%; median gestation 35 weeks, 34–37 weeks). Three pairs of twins were admitted to the NICU (7.3%; 37 weeks, 24.0–38 weeks). One twin pair, delivered at 24 weeks’ gestation, died in the NICU.
Conclusions: In our unit, the delivery and neonatal complication rate is low despite a high percentage of labouring twin pregnancies. We cannot justify delivering all twin pregnancies by elective Caesarean section.
PLD.41 CASE REPORT: PSOAS ABSCESS AND SACROILIAC JOINT INFECTION POST-CAESAREAN SECTION
K. R. Savage, A. P. Chaudhuri, A. S. Parveen, D. A. Rich. Gwent Healthcare NHS Trust, Gwent, UK
Introduction: This is the second reported case of a psoas abscess related to a Caesarean section. There are now many reports of psoas abscesses or sacroiliac joint infections in pregnancy and the postpartum period and there is only one other report of a psoas abscess post-Caesarean section.
Case Report: A 31-year-old primigravida woman attended with an Escherichia coli urinary tract infection, she was 12 days post-emergency Caesarean section at full dilatation after a failed ventouse extraction. Three days later she presented with severe abdominal, sacroiliac joint and left leg pain. On examination she was tachycardic, pyrexial with left loin tenderness. There was no neurological deficit identified. Computed tomography imaging revealed a psoas abscess and subsequent magnetic resonance imaging showed a sacroiliac joint infection with a small left-sided gluteal abscess. The surgeons elected to drain the psoas abscess by an open approach.
Discussion: Psoas abscess can be primary following haematogenous spread of pathogens, or secondary to direct spread from abdominal, retroperitoneal or lumbar spine infections. A sacroiliac joint infection is also commonly caused by haematogenous spread, but may also occur secondary to local infection or chronic joint disease. The vague symptoms and poorly localised signs can lead to a delay in diagnosis so extra consideration is needed in these complex cases. The cause of this psoas abscess is most likely to be secondary to the urinary tract infection; no intra-abdominal collection or dilation of the upper urinary tract was identified so haematogenous spread was the most likely cause.
PLD.42 DECISION TO INCISION: HOW LONG DID IT TAKE TO DELIVER THE BABY?
E. A. Simm, A. Stock. Department of Obstetrics and Gynaecology, Milton Keynes General Hospital, Milton Keynes, UK
Objective: To assess potential errors, secondary to inaccurate clocks and watches, in documentation of decision to delivery time interval (DDTI) for emergency Caesarean sections.
Methods: Times displayed on clocks in the labour ward were compared with a digital watch set to Greenwich mean time (GMT). Absolute time differences were then calculated using the clock in the main obstetric theatre and secondary obstetric theatre as reference points. Differences were expressed in seconds, with a positive value indicating that a clock was fast relative to the time displayed in theatre. The watches/fob watches of the midwives and doctors present on the labour ward at the time were similarly assessed. The study was conducted one month after the clocks had been altered from British summer time to GMT.
Results: For main theatre average time errors (in seconds) were: labour ward clocks 207 (range 72–266), midwives watches 167 (89–221) and doctors’ watches 179 (–12–508). For the secondary theatre the corresponding results were labour ward 47 (–112–82), midwives 38 (–36–95) and doctors 118 (–196–324). In the worst case scenarios the most inaccurate timepieces could therefore add 196 s to the documented DDTI or reduce it by 508 s.
Conclusions: Inaccurate watches and clocks could introduce significant errors in determining the DDTI. In the context of the recommended 30-minute interval, this degree of inaccuracy is unacceptable. Protocols are required to ensure the accurate setting of all timepieces used in calculating the DDTI.
PLD.43 POSTNATAL RE-ADMISSIONS: THE INCIDENCE, CAUSES AND LENGTH OF STAY IN A LARGE ANTENATAL POPULATION
M. Geisler1, C. M. Murphy1, C. Brophy1, F. M. McAuliffe2. 1National Maternity Hospital, Dublin, Ireland, 2UCD School of Medicine and Medical Science, Dublin, Ireland
Objective: To ascertain the incidence, causes and length of stay for maternal re-admissions in the puerperium.
Methods: A retrospective and prospective study of re-admissions over a 6-month period in a tertiary referral hospital. A retrospective chart review was performed over 3 months as a pilot study and then continued for three consecutive months prospectively. The study group included all women who delivered a singleton infant >37 weeks’ gestation and who subsequently required re-admission for at least one night during the puerperium.
Results: There were 4270 deliveries. We identified 69 re-admissions with two patients re-admitted twice. The main reason for re-admission was mastitis 15, then secondary postpartum haemorrhage 12, followed by endometritis eight and wound infections or haematoma 10 and hypertension four. The mean length of stay was 3.4 days (range 2–6). Of those re-admitted 44 patients were discharged routinely and 14 were planned early discharges. There was no difference between primiparous (n = 44) and multiparous (n = 23) patients. 22 of 67 patients were delivered by emergency Caesarean section and 33/67 vaginally p<0.01. Mean BMI was 26 and six patients had BMI >30; four had wound infections. The commonest intervention was intravenous antibiotics. The majority of re-admissions were public patients 43/67 (64%) with a minority 24/67 (35%) fee-paying. The expected proportions were 52.2% and 47.7%, respectively.
Conclusions: The rate of re-admission after Caesarean delivery is 26/1000 (22/807), after instrumental 18/1000 and spontaneous vaginal delivery 11/1000. Sepsis was the commonest cause of re-admission. Admission rates appear higher among public rather than private patients. The reasons for this deserve further study.
PLD.44 CHORIOAMNIONITIS OR VILLITIS: WHICH POSES THE GREATEST RISK TO MATERNAL AND FETAL WELLBEING?
S. M. Cooley, J. Donnelly, T. Walsh, U. Durnea, A. O’Malley, J. Gillan, M. P. Geary. Rotunda Hospital, Dublin, Ireland
Objective: The fetus is at risk from ascending infection and the haematogenous spread of pathogens from its mother. The definitive diagnosis of chorioamnionitis is histological and requires the presence of neutrophils in the amniotic and chorionic tissues. Parenchymal infection or villitis is the histological presence of maternal mononuclear cell infiltrate around or within the villous structure. We aimed