Search

Background: Diabetes in pregnancy is associated with an increased risk to the woman and to the developing fetus. Currently, there is no consensus on the optimal management strategies for the follow-up and the timing of delivery of pregnancies affected by gestational and pregestational diabetes, with different international guidelines suggesting different management options., Materials and Methods: We conducted a retrospective cohort study from January 2017 to January 2021, to compare maternal and neonatal outcomes of pregnancies complicated by gestational and pregestational diabetes, followed-up and delivered in a third level referral center before and after the introduction of a standardized multidisciplinary management protocol including diagnostic, screening, and management criteria., Results: Of the 131 women included, 55 were managed before the introduction of the multidisciplinary management protocol and included in group 1 (preprotocol), while 76 were managed according to the newly introduced multidisciplinary protocol and included in group 2 (after protocol). We observed an increase in the rates of vaginal delivery, rising from 32.7% to 64.5% (<0.001), and the rate of successful induction of labor improved from 28.6% to 86.2% ( P < 0.001). No differences were found in neonatal outcomes, and the only significant difference was demonstrated for the rates of fetal macrosomia (20% versus 5.3%, P : 0.012). Therefore, the improvements observed in the maternal outcomes did not impact negatively on fetal and neonatal outcomes., Conclusion: The introduction of a standardized multidisciplinary management protocol led to an improvement in the rates of vaginal delivery and in the rate of successful induction of labor in our center. A strong cooperation between obstetricians, diabetologists, and neonatologists is crucial to obtain a successful outcome in women with diabetes in pregnancy., Competing Interests: All the authors declare no conflicts of interest., (Copyright © 2021 Maddalena Morlando et al.)

Background: Clinical practice guidelines on uncomplicated birth provide clinical practice guidance and help to reduce unnecessary, non-evidence-based and potentially harmful intrapartum care practices. Little is known about the trustworthiness and consistency of these guidelines., Objectives: To appraise guidelines relevant to uncomplicated birth, and summarise consensus and non-consensus recommendations., Search Strategy: Eight literature databases and the websites of guideline development institutions and organisations of obstetricians, gynaecologists and midwives were searched from January 2008 to October 2018., Selection Criteria: Guidelines that: reported in Chinese or English; labelled guideline, or recommendation, or consensus, or practice parameter, or position paper/stand; with uncomplicated birth being the primary objectives or comprised chapter(s); and were the most recently published or updated versions., Data Collection and Analysis: Two reviewers independently assessed guideline quality using the AGREE II instrument, and synthesised consensus and non-consensus recommendations using the content analysis approach., Main Results: Eleven guidelines met the inclusion criteria. The WHO and NICE guidelines were deemed to have the highest methodological quality. Twenty-three discrepant recommendations and 39 groups of unanimous recommendations (containing 113 individual ones) were identified, among which 14 recommendations including eating and drinking as desired, prophylactic uterotonics, routine amniotomy and episiotomy were included in five or more guidelines. Perineal massage, uterine massage, active or expectant management at the third stage and use of hands-on or hands-poised technique were identified as the main discrepant recommendations., Conclusions: Two guidelines with higher methodological quality and key clinical guideline recommendations, including both consensus and non-consensus ones, on uncomplicated birth were identified., Tweetable Abstract: Clinical guidelines of uncomplicated birth agree and disagree on several key recommendations., (© 2019 Royal College of Obstetricians and Gynaecologists.)

In the United States, there is a widespread belief that the overall cesarean birth rate is higher than necessary. Efforts are being directed toward decreasing the number of these procedures, in part by encouraging physicians to make changes in their management practices. Because breech presentations are associated with a high rate of cesarean birth, there is renewed interest in techniques such as external cephalic version (ECV) and vaginal breech delivery. The purpose of this document is to provide information about ECV by summarizing the relevant evidence presented in published studies and to make recommendations regarding its use in obstetric practice.

In the United States, there is a widespread belief that the overall cesarean birth rate is higher than necessary. Efforts are being directed toward decreasing the number of these procedures, in part by encouraging physicians to make changes in their management practices. Because breech presentations are associated with a high rate of cesarean birth, there is renewed interest in techniques such as external cephalic version (ECV) and vaginal breech delivery. The purpose of this document is to provide information about ECV by summarizing the relevant evidence presented in published studies and to make recommendations regarding its use in obstetric practice.

Objective: To compare midwife and obstetrician labor practices and birth outcomes in women with low-risk pregnancies delivered in the hospital., Methods: We conducted a retrospective cohort study of singleton births of 37 0/7-42 6/7 weeks of gestation at 11 hospitals between January 1, 2014, and December 31, 2018. Exclusions included intrapartum transfer from home-birth center, antepartum stillbirth, previous cesarean delivery, practitioner other than midwife or obstetrician, prelabor cesarean, prepregnancy maternal disease, and pregnancy complications or risk factors. Interventions (induction, artificial rupture of membranes, epidural, oxytocin, and episiotomy), mode of delivery, maternal outcomes (third- or fourth-degree laceration, postpartum hemorrhage, blood transfusion, and severe maternal morbidity), and newborn outcomes (shoulder dystocia, 5-minute Apgar score less than 7, resuscitation at delivery, birth trauma, and neonatal intensive care unit admission) were examined by practitioner type. We used modified Poisson regression models adjusted for individual confounders to assess risk ratios, stratified by parity, for health care provider type and perinatal outcomes., Results: The study cohort comprised 23,100 births (3,816 midwife and 19,284 obstetrician). Compared with obstetricians, midwifery patients had significantly lower intervention rates, an approximately 30% lower risk of cesarean delivery in nulliparous patients (adjusted relative risk [aRR] 0.68; 95th% CI 0.57-0.82), and an approximately 40% lower risk of cesarean in multiparous patients (aRR 0.57; 95th% CI 0.36-0.89). Operative vaginal birth was also less common in nulliparous patients (aRR 0.73; 95th% CI 0.57-0.93) and multiparous patients (aRR 0.30; 95th% CI 0.14-0.63). Shoulder dystocia was more common in multiparous patients receiving midwifery care (aRR 1.42; 95th% CI 1.04-1.92)., Conclusions: In low-risk pregnancies, midwifery care in labor was associated with decreased intervention, decreased cesarean and operative vaginal births, and, in multiparous women, an increased risk for shoulder dystocia. Greater integration of midwifery care into maternity services in the United States may reduce intervention in labor and potentially even cesarean delivery, in low-risk pregnancies. Larger research studies are needed to evaluate uncommon but important maternal and newborn outcomes.

Introduction: The objective of these clinical practice guidelines was to analyse all of the interventions during pregnancy and childbirth that might prevent obstetric anal sphincter injuries (OASIS) and postnatal pelvic floor symptoms., Material and Methods: These guidelines were developed in accordance with the methods prescribed by the French Health Authority (HAS)., Results: A prenatal clinical examination of the perineum is recommended for women with a history of Crohn's disease, OASIS, genital mutilation, or perianal lesions (professional consensus). Just after delivery, a perineal examination is recommended to check for OASIS (Grade B); if there is doubt about the diagnosis, a second opinion should be requested (Grade C). In case of OASIS, the injuries (including their severity) and the technique for their repair should be described in detail (Grade C). Perineal massage during pregnancy must be encouraged among women who want it (Grade B). No intervention conducted before the start of the active phase of the second stage of labour has been shown to be effective in reducing the risk of perineal injury. The crowning of the baby's head should be manually controlled and the posterior perineum manually supported to reduce the risk of OASIS (Grade C). The performance of an episiotomy during normal deliveries is not recommended to reduce the risk of OASIS (Grade A). In instrumental deliveries, episiotomy may be indicated to avoid OASIS (Grade C). When an episiotomy is performed, a mediolateral incision is recommended (Grade B). The indication for episiotomy should be explained to the woman, and she should consent before its performance. Advising women to have a caesarean delivery for primary prevention of postnatal urinary or anal incontinence is not recommended (Grade B). During pregnancy and again in the labour room, obstetrics professionals should focus on the woman's expectations and inform her about the modes of delivery., (Copyright © 2019 CNGOF. Published by Elsevier Masson SAS.. All rights reserved.)

Objective: To assess the existing knowledge and skills relating to Emergency Obstetrics Care (EMOC) among health providers in eight referral maternity hospitals in Nigeria., Study Design: A cross-sectional study of skilled health providers (doctors, nurses and midwives) working in the hospitals during the period., Setting: Six general hospitals (4 in the south and 2 in the north), and two teaching hospitals (both in the Northern part) of the country., Population: All skilled providers offering EMOC services in the hospitals during the study., Methods: A pre-tested self-administered questionnaire was used to obtain information relating to socio-demographic characteristics, the respondents' knowledge and skills in offering specific EMOC services (as compared to standard World Health Organization recommendations), and their confidence in transferring the skills to mid-level providers. Data were analyzed with univariate, bivariate, binary and multinomial logistic regression analyses. Main outcome measures: knowledge and skills in EMOC services by hospital and overall., Results: A total of 341 health providers (148 doctors and 193 nurses/midwives) participated in the study. Averagely, the providers scored less than 46% in a composite EMOC knowledge score, with doctors scoring considerable higher than the nurses/midwives. Similarly, doctors scored higher than nurses/midwives in the self-reporting of confidence in carrying out specific EMOC functions. Health providers that scored higher in knowledge were significantly more likely to report confidence in performing specific EMOC functions as compared to those with lower scores. The self-reporting of confidence in transferring clinical skills was also higher in those with higher EMOC knowledge scores., Conclusion: The knowledge and reported skills on EMOC by health providers in referral facilities in Nigeria was lower than average. We conclude that the in-service training and re-training of health providers should be included in national policy and programs that address maternal mortality prevention in referral facilities in the country., Trial Registration: Nigeria Clinical Trials Registry 91540209., Competing Interests: The authors have declared that no competing interests exist.

Background: The aim of the study was to assess whether a more context-specific modified version of WHO Safe Childbirth Checklist (mSCC) would result in improved adoption rate., Methods: A prospective observational study was conducted in University Obstetrics Unit at De Soysa Hospital for Women (DSHW), Colombo and two Obstetric Units at Teaching Hospital, Mahamodara, Galle (THMG), Sri Lanka. Study was conducted over 8 weeks at DSHW and over 4 weeks at THMG after introduction of the mSCC in 2017. The WHO SCC was in use at DSHW from 2013 until its replacement by the mSCC. Checklists were kept attached at admission and collected on discharge. Level of acceptance was assessed using a self-administered questionnaire at the end. Outcome measures were adoption rate (percentage of deliveries where mSCC was used and could be found), adherence to practices (mean percentage of items checked), response rate (percentage of staff members responded to questionnaire) and level of acceptance (percentage of "strongly agree/agree" in Likert scale to five questions regarding acceptance of mSCC). Responses were also taken to the open-ended question on barriers to implementation., Results: In DSHW, out of 606 births during study period, there were 329 live births in which the mSCC was used and could be found giving an adoption rate of 54.3%. In THMG adoption rate was 153/814 (18.8%). In DSHW, response rate for the questionnaire was 40.5% and in THMG, 40.0%. Level of acceptance was good among those who responded to the questionnaire. Mean (95% CI) adherence to the Checklist practices was 52.7% (44.1-58.5) in DSHW and 32.2% (24.5-39.1) in THMG with a range of 1-100% in both settings. Majority mentioned the lack of staff, lack of enthusiasm, inadequate training and advice on use of mSCC and lack of supervision from Ministry/institutional level. Majority suggested the involvement of medical doctors, removal of the need to place the signature and separate accountability to each 27-items and the desirability of proper training sessions regarding the mSCC., Conclusion: Checklist-based interventions in maternity care cannot be expected to improve by merely making them context-specific. Other approaches should be explored to maximize its benefits.

The aim of this commentary is to describe changes in women's care at an obstetric department that made it possible to reduce the number of beds from 40 to 29. Patient pathways were reviewed and revised using lean methodology. The mean length of stay was reduced from 70 to 59 h and the mean numbers of hospitalizations per woman from 1.26 to 1.20. At the organizational level, we introduced a Family Department, home management of newborns, home monitoring of the women with cardiotocography and blood samples, and intrapartum Group B Streptococcus-PCR. Additionally, an After Birth Clinic and network meetings for vulnerable women were established. In patient pathway, we reduced the hospitalization indicated by preterm premature rupture of membranes, preeclampsia and observation after birth laceration. According to National Patient Satisfaction surveys, there was no decrease in women's satisfaction after reducing the number of beds., (© 2018 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: Since publication of the Term Breech Trial in 2000 only 15% of term breech presentations is delivered vaginally in the Netherlands. This declined exposure to vaginal breech deliveries (VBD) is a problem for those who still need to be trained. The aim of this study was to evaluate the level of training of the Dutch gynecological residents, and their intentions on guiding VBDs during their careers., Study Design: Via an online questionnaire Dutch residents and starting gynecologists, were asked about their training, exposure and confidence in guiding VBDs during their residency., Main Outcome Measures: Number of VBDs performed, level of entrustment of independent practice in guiding VBDs, courses in guiding VBDs, confidence in guiding VBDs after finishing their residency., Results: The response rate was 64% (N = 294). Thirteen per cent performed less than three VBDs, 15% more than 15. Of sixth year residents 65% has not yet obtained entrustment for personally guiding VBDs. The residents are trained in VBDs at least once during a national mandatory course. Further training is strongly dependent on local hospital policy: 34% are trained every quarter versus 29% who never receive a local training., Conclusion: Our survey showed that more than half of the respondents judge the current residency program to be insufficient for guiding VBDs. This seems to be related to the low overall exposure to VBDs and the lack of quantity and quality of attended courses., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: To provide guidance on the implementation of a surgical safety checklist in the practice of obstetrics and gynaecology., Outcomes: Outcomes evaluated include the impact of the surgical safety checklist on surgical morbidity and mortality., Evidence: Medline databases were searched for articles on subjects related to "surgical safety checklist" published in English from January 2001 to January 2011. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to January 2012., Values: The quality of evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described by the Task Force (Table)., Benefits, Harms, and Costs: Implementation of the guideline recommendations will improve the health and well-being of women undergoing obstetrical or gynaecologic surgery., Summary Statements: RECOMMENDATIONS., (Copyright © 2018. Published by Elsevier Inc.)

There has been an emphasis on redesigning our health care system to eliminate medical errors and create a culture of safety. The American College of Obstetrics and Gynecologists defines a culture of safety as an environment in which all care providers are empowered to identify errors, near misses, risky behaviors and broader systems issues while engaging in active collaboration to improve and resolve processes and system failures. This article reviews key components that promote a culture of safety and help to implement safer, more effective, evidence-based quality care on labor and delivery units., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Approximately 0.5% of all births occur before the third trimester of pregnancy, and these very early deliveries result in the majority of neonatal deaths and more than 40% of infant deaths. A recent executive summary of proceedings from a joint workshop defined periviable birth as delivery occurring from 20 0/7 weeks to 25 6/7 weeks of gestation. When delivery is anticipated near the limit of viability, families and health care teams are faced with complex and ethically challenging decisions. Multiple factors have been found to be associated with short-term and long-term outcomes of periviable births in addition to gestational age at birth. These include, but are not limited to, nonmodifiable factors (eg, fetal sex, weight, plurality), potentially modifiable antepartum and intrapartum factors (eg, location of delivery, intent to intervene by cesarean delivery or induction for delivery, administration of antenatal corticosteroids and magnesium sulfate), and postnatal management (eg, starting or withholding and continuing or withdrawing intensive care after birth). Antepartum and intrapartum management options vary depending upon the specific circumstances but may include short-term tocolytic therapy for preterm labor to allow time for administration of antenatal steroids, antibiotics to prolong latency after preterm premature rupture of membranes or for intrapartum group B streptococci prophylaxis, and delivery, including cesarean delivery, for concern regarding fetal well-being or fetal malpresentation. Whenever possible, periviable births for which maternal or neonatal intervention is planned should occur in centers that offer expertise in maternal and neonatal care and the needed infrastructure, including intensive care units, to support such services. This document describes newborn outcomes after periviable birth, provides current evidence and recommendations regarding interventions in this setting, and provides an outline for family counseling with the goal of incorporating informed patient preferences. Its intent is to provide support and guidance regarding decisions, including declining and accepting interventions and therapies, based on individual circumstances and patient values.

Approximately 0.5% of all births occur before the third trimester of pregnancy, and these very early deliveries result in the majority of neonatal deaths and more than 40% of infant deaths. A recent executive summary of proceedings from a joint workshop defined periviable birth as delivery occurring from 20 0/7 weeks to 25 6/7 weeks of gestation. When delivery is anticipated near the limit of viability, families and health care teams are faced with complex and ethically challenging decisions. Multiple factors have been found to be associated with short-term and long-term outcomes of periviable births in addition to gestational age at birth. These include, but are not limited to, nonmodifiable factors (eg, fetal sex, weight, plurality), potentially modifiable antepartum and intrapartum factors (eg, location of delivery, intent to intervene by cesarean delivery or induction for delivery, administration of antenatal corticosteroids and magnesium sulfate), and postnatal management (eg, starting or withholding and continuing or withdrawing intensive care after birth). Antepartum and intrapartum management options vary depending upon the specific circumstances but may include short-term tocolytic therapy for preterm labor to allow time for administration of antenatal steroids, antibiotics to prolong latency after preterm premature rupture of membranes or for intrapartum group B streptococci prophylaxis, and delivery, including cesarean delivery, for concern regarding fetal well-being or fetal malpresentation. Whenever possible, periviable births for which maternal or neonatal intervention is planned should occur in centers that offer expertise in maternal and neonatal care and the needed infrastructure, including intensive care units, to support such services. This document describes newborn outcomes after periviable birth, provides current evidence and recommendations regarding interventions in this setting, and provides an outline for family counseling with the goal of incorporating informed patient preferences. Its intent is to provide support and guidance regarding decisions, including declining and accepting interventions and therapies, based on individual circumstances and patient values.

Background: Maternity care is facing increasing intervention and iatrogenic morbidity rates. This can be attributed, in part, to higher-risk maternity populations, but also to a risk culture in which birth is increasingly seen as abnormal. Technology and intervention are used to prevent perceived implication in adverse outcomes and litigation., Question: Does midwives' and obstetricians' perception of risk affect care practices for normal birth and low-risk women in labour, taking into account different settings?, Methods: The research methods are developed within a qualitative framework. Data were collected using semi-structured interviews and analysed thematically. A purposive sample of 25 midwives and obstetricians were recruited from three maternity settings in Ireland. This included obstetric-led hospitals, an alongside midwifery-led unit and the community., Findings: Midwifery is assuming a peripheral position with regard to normal birth as a progressive culture of risk and medicalisation affects the provision of maternity care. This is revealed in four themes; (1) professional autonomy and hierarchy in maternity care; (2) midwifery-led care as an undervalued and unsupported aspiration; (3) a shift in focus from striving for normality to risk management; and (4) viewing pregnancy through a 'risk-lens'., Discussion: Factors connected to the increased medicalisation of birth contribute to the lack of midwifery responsibility for low-risk women and normal birth. Midwives are resigned to the current situation and as a profession are reluctant to take action., Conclusion: Improved models of care, distinct from medical jurisdiction, are required. Midwives must take responsibility for leading change as their professional identity is in jeopardy., (Copyright © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Recent policy and service provision recommends a woman-centred approach to maternity care. Midwife-led models of care are seen as one important strategy for enhancing women's choice; a core element of woman-centred care. In the Republic of Ireland, an obstetric consultant-led, midwife-managed service model currently predominates and there is limited exploration of the concept of women centred care from the perspectives of those directly involved; that is, women, midwives, general practitioners and obstetricians. This study considers women's and clinicians' views, experiences and perspectives of woman-centred maternity care in Ireland., Methods: A descriptive qualitative design. Participants (n = 31) were purposively sampled from two geographically distinct maternity units. Interviews were face-to-face or over the telephone, one-to-one or focus groups. A thematic analysis of the interview data was performed., Results: Five major themes representing women's and clinicians' views, experiences and perspectives of women-centred care emerged from the data. These were Protecting Normality, Education and Decision Making, Continuity, Empowerment for Women-Centred Care and Building Capacity for Women-Centred Care. Within these major themes, sub-themes emerged that reflect key elements of women-centred care. These were respect, partnership in decision making, information sharing, educational impact, continuity of service, staff continuity and availability, genuine choice, promoting women's autonomy, individualized care, staff competency and practice organization., Conclusion: Women centred-care, as perceived by participants in this study, is not routinely provided in Ireland and women subscribe to the dominant culture that views safety as paramount. Women-centred care can best be facilitated through continuity of carer and in particular through midwife led models of care; however, there is potential to provide women-centred care within existing labour wards in terms of consistency of care, education of women, common approaches to care across professions and women's choice. To achieve this, however, future research is required to better understand the role of midwife-led care within existing labour ward settings. While a positive view of women-centred care was found; there is still a difference in approach and imbalance of power between the professions. More research is required to consider how these differences impact care provision and how they might be overcome.

Background: In recent years, the role of intrapartum sonography has expanded in childbirth management, in subjective clinical situations such as arrested deliveries, or prior to instrumental deliveries., Objectives: To assess the current use of intrapartum ultrasound by obstetricians in Israel., Methods: An anonymous questionnaire was completed by 79 obstetricians in second- and third level- hospitals in Israel. The results were analyzed according to main subspecialty (sonography, delivery), experience and gender., Results: A questionnaire was completed by 56 senior obstetricians and 23 interns with an average experience of 14.3 and 2.4 years, respectively. All obstetricians performed ultrasound examinations in the delivery room for basic indications such as fetal presentation during twin delivery and to rule out placenta previa. Sonographers consistently reported advanced indications as compared to senior members of delivery teams and interns in the assessment of prolonged first (52% vs. 14% vs. 14%) and second stage of labor (88% vs. 52% vs. 62%) and in assessment of fetal head station (60% vs. 30% vs. 22%), head progression during descent (48% vs. 23% vs. 11%), diagnosis of head position (88% vs. 68% vs. 60%), spine direction (92% vs. 59% vs. 53%) and asynclytism (41% vs. 20% vs. 29%)., Conclusions: Ultrasound is currently used by all physicians in the delivery room for basic indications. However, obstetric teams report a low use of advanced intrapartum ultrasound and prefer to rely on their clinical experience. Advanced intrapartum sonographic imaging should be an integral part of obstetric qualifications. A steep learning curve, along with high reproducibility, suggests that ultrasound devices will become a common tool in labor and delivery management.

Obstetrician-gynecologists, in collaboration with midwives, nurses, patients, and those who support them in labor, can help women meet their goals for labor and birth by using techniques that are associated with minimal interventions and high rates of patient satisfaction. Many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor. For women who are in latent labor and are not admitted, a process of shared decision making is recommended. Admission during the latent phase of labor may be necessary for a variety of reasons. A pregnant woman with term premature rupture of membranes (also known as prelabor rupture of membranes) should be assessed, and the woman and her obstetrician-gynecologist or other obstetric care provider should make a plan for expectant management versus admission and induction. Data suggest that in women with normally progressing labor and no evidence of fetal compromise, routine amniotomy is not necessary. The widespread use of continuous electronic fetal heart-rate monitoring has not improved outcomes when used for women with low-risk pregnancies. Multiple nonpharmacologic and pharmacologic techniques can be used to help women cope with labor pain. Women in spontaneously progressing labor may not require routine continuous infusion of intravenous fluids. For most women, no one position needs to be mandated nor proscribed. Nulliparous women who have an epidural and no indication for expeditious delivery may be offered a period of rest for 1-2 hours before initiating pushing efforts. Obstetrician-gynecologists and other obstetric care providers should be familiar with and consider using low-interventional approaches for the intrapartum management of low-risk women in spontaneous labor.

Shoulder dystocia is an obstetrical emergency that may result in significant neonatal complications. It requires rapid recognition and a coordinated response. Standardization of care, teamwork and communication, and clinical simulation are the key components of patient safety programs in obstetrics. Simulation-based team training and institutional protocols for the management of shoulder dystocia are emerging as integral components of many labor and delivery safety initiatives because of their impact on technical skills and team performance.

Shoulder dystocia is an unpredictable obstetric emergency that requires prompt interventions to ensure optimal outcomes. Proper technique is important but difficult to train given the urgent and critical clinical situation. Simulation training for shoulder dystocia allows providers at all levels to practice technical and teamwork skills in a no-risk environment. Programs utilizing simulation training for this emergency have consistently demonstrated improved performance both during practice drills and in actual patients with significantly decreased risks of fetal injury. Given the evidence, simulation training for shoulder dystocia should be conducted at all institutions that provide delivery services.

Objective: To develop and test the validity of an Objective Structured Assessment of Technical Skills (OSATS) tool for breech presentation delivery., Materials and Methods: Monocentric prospective study conducted in the Department of Gynecology, Obstetrics, Fetal Medicine and Reproductive Medicine at the University Hospital of Nice. The study consisted of two parts, the development of the OSATS scoring system and its objective validation. Several experts in obstetrics from university hospital centers and private French hospitals were invited to participate in the development phase of the scoring system. For the validation phase, we formed a group of 20 novices and a group of 20 experts, who had to perform a breech presentation delivery on a simulator, according to a standardized scenario. Each participant was filmed and two experts would then evaluate their performance by viewing anonymized videos and using the OSATS score., Results: The scores obtained by the expert group were significantly higher than those of the novice group, with a total score of 21.73/25 versus 6.95/25 (p < 0.0001), a task-specific score of 87.2/110 versus 44.3/110 (p < 0.0001) and an overall score of 108.93/135 versus 51.25/135 (p < 0.0001), respectively., Conclusion: The OSATS score developed in this study for breech presentation delivery is a reliable model to assess the competence level in procedural skills using a simulator.

Background: Satisfaction with birth care is part of quality assessment of care. The aim of this study was to investigate possible differences in satisfaction with intrapartum care among low-risk women, randomized to a midwifery unit or to an obstetric unit within the same hospital., Methods: Randomized controlled trial conducted at the Department of Obstetrics and Gynecology, Østfold Hospital Trust, Norway. A total of 485 women with no expressed preference for level of birth care, assessed to be at low-risk at onset of spontaneous labor were included. To assess the overall satisfaction with intrapartum care, the Labour and Delivery Satisfaction Index (LADSI) questionnaire, was sent to the participants 6 months after birth. To assess women's experience with intrapartum transfer, four additional items were added. In addition, we tested the effects of the following aspects on satisfaction; obstetrician involved, intrapartum transfer from the midwifery unit to the obstetric unit during labor, mode of delivery and epidural analgesia., Results: Women randomized to the midwifery unit were significantly more satisfied with intrapartum care than those randomized to the obstetric unit (183 versus 176 of maximum 204 scoring points, mean difference 7.2, p = 0.002). No difference was found between the units for women who had an obstetrician involved during labor or delivery and who answered four additional questions on this aspect (mean item score 4.0 at the midwifery unit vs 4.3 at the obstetric unit, p = 0.3). Intrapartum transfer from the midwifery unit to an obstetric unit, operative delivery and epidurals influenced the level of overall satisfaction in a negative direction regardless of allocated unit (p < 0.001)., Conclusion: Low-risk women with no expressed preference for level of birth care were more satisfied if allocated to the midwifery unit compared to the obstetric unit., Trial Registration: The trial is registered at www.clinicaltrials.gov NCT00857129 . Initially released 03/05/2009.

Perineal lacerations are a common occurrence with vaginal delivery. Although perineal lacerations are tracked easily from coding data, there are a variety of problems with using rates of such tears as a quality measure. The rate of severe perineal lacerations should not be used as a measure of obstetric quality for the following three reasons: 1) third-degree and fourth-degree perineal lacerations may not be defined uniformly; 2) severe perineal lacerations are associated strongly with nonmodifiable risk factors; and 3) diminishing the use of operative vaginal delivery, in an effort to decrease severe perineal lacerations, likely would result in an increased rate of cesarean delivery. Measuring the rate of episiotomy with unassisted vaginal deliveries is an alternative candidate for quality measurement, but it requires validation before widespread implementation.

This month we focus on current research in the management of acute preterm labor. Dr. Malone discusses four recent publications, which are concluded with a "bottom line" that is the take-home message. The complete reference for each can be found in on this page, along with direct links to the abstracts.

Perineal lacerations are a common occurrence with vaginal delivery. Although perineal lacerations are tracked easily from coding data, there are a variety of problems with using rates of such tears as a quality measure. The rate of severe perineal lacerations should not be used as a measure of obstetric quality for the following three reasons: 1) third-degree and fourth-degree perineal lacerations may not be defined uniformly; 2) severe perineal lacerations are associated strongly with nonmodifiable risk factors; and 3) diminishing the use of operative vaginal delivery, in an effort to decrease severe perineal lacerations, likely would result in an increased rate of cesarean delivery. Measuring the rate of episiotomy with unassisted vaginal deliveries is an alternative candidate for quality measurement, but it requires validation before widespread implementation.

Perineal lacerations are a common occurrence with vaginal delivery. Although perineal lacerations are tracked easily from coding data, there are a variety of problems with using rates of such tears as a quality measure. The rate of severe perineal lacerations should not be used as a measure of obstetric quality for the following three reasons: 1) third-degree and fourth-degree perineal lacerations may not be defined uniformly; 2) severe perineal lacerations are associated strongly with nonmodifiable risk factors; and 3) diminishing the use of operative vaginal delivery, in an effort to decrease severe perineal lacerations, likely would result in an increased rate of cesarean delivery. Measuring the rate of episiotomy with unassisted vaginal deliveries is an alternative candidate for quality measurement, but it requires validation before widespread implementation.

Background: Quality of care provided during childbirth is a critical determinant of preventing maternal mortality and morbidity. In the studies available, quality has been assessed either from the users' perspective or the providers'. The current study tries to bring both perspectives together to identify common key focus areas for quality improvement. This study aims to assess the users' (recently delivered women) and care providers' perceptions of care to understand the common challenges affecting provision of quality maternity care in public health facilities in India., Methods: A qualitative design comprising of in-depth interviews of 24 recently delivered women from secondary care facilities and 16 health care providers in Uttar Pradesh, India. The data were analysed thematically to assess users' and providers' perspectives on the common themes., Results: The common challenges experienced regarding provision of care were inadequate physical infrastructure, irregular supply of water, electricity, shortage of medicines, supplies, and gynaecologist and anaesthetist to manage complications, difficulty in maintaining privacy and lack of skill for post-delivery counselling. However, physical access, cleanliness, interpersonal behaviour, information sharing and out-of-pocket expenditure were concerns for only users. Similarly, providers raised poor management of referral cases, shortage of staff, non-functioning of blood bank, lack of incentives for work as their concerns., Discussion: The study identified the common themes of care from both the perspectives, which have been foundrelevant in terms of challenges identified in many developing countries including India. The study framework identified new themes like management of emergencies in complicated cases, privacy and cost of care which both the group felt is relevant in the context of providing quality care during childbirth in low resource setting. The key challenges identified by both the groups can be prioritized, when developing quality improvement program in the health facilities. The identified components of care can match the supply with the demand for care and make the services truly responsive to user needs., Conclusion: The study highlights infrastructure, human resources, supplies and medicine as priority areas of quality improvement in the facility as perceived by both users and providers, nevertheless the interpersonal aspect of care primarily reported by the users must also not be ignored.

Obstetric safety and quality is an emerging and important topic not only as a result of the pressures of patient and regulatory expectations, but also because of the genuine interest of caregivers to reduce harm, improve outcomes, and optimize care. Although each seeks to improve care by using scientific approaches beyond human physiology and pathophysiology, patient safety methodologies seek to avoid preventable adverse events, whereas health care quality projects aim to achieve the best possible outcomes. It is well-documented that an increasingly complex medical system controlled by human workers is a circumstance subject to recurrent failure. A safety culture encourages a proactive approach to mitigate failure before, during, and after it occurs. This article highlights the key concepts in health care safety and quality and reviews the background of the quality improvement sciences with particular emphasis on obstetric outcomes and quality measures.

Background: High quality care is crucial in ensuring that women and newborns receive interventions that may prevent and treat birth-related complications. As facility deliveries increase in developing countries, there are concerns about service quality. Observation is the gold standard for clinical quality assessment, but existing observation-based measures of obstetric quality of care are lengthy and difficult to administer. There is a lack of consensus on quality indicators for routine intrapartum and immediate postpartum care, including essential newborn care. This study identified key dimensions of the quality of the process of intrapartum and immediate postpartum care (QoPIIPC) in facility deliveries and developed a quality assessment measure representing these dimensions., Methods and Findings: Global maternal and neonatal care experts identified key dimensions of QoPIIPC through a modified Delphi process. Experts also rated indicators of these dimensions from a comprehensive delivery observation checklist used in quality surveys in sub-Saharan African countries. Potential QoPIIPC indices were developed from combinations of highly-rated indicators. Face, content, and criterion validation of these indices was conducted using data from observations of 1,145 deliveries in Kenya, Madagascar, and Tanzania (including Zanzibar). A best-performing index was selected, composed of 20 indicators of intrapartum/immediate postpartum care, including essential newborn care. This index represented most dimensions of QoPIIPC and effectively discriminated between poorly and well-performed deliveries., Conclusions: As facility deliveries increase and the global community pays greater attention to the role of care quality in achieving further maternal and newborn mortality reduction, the QoPIIPC index may be a valuable measure. This index complements and addresses gaps in currently used quality assessment tools. Further evaluation of index usability and reliability is needed. The availability of a streamlined, comprehensive, and validated index may enable ongoing and efficient observation-based assessment of care quality during labor and delivery in sub-Saharan Africa, facilitating targeted quality improvement.

Objective: To evaluate the quality and content of nurse and physician shoulder dystocia delivery documentation before and after MORE training in shoulder dystocia management skills and documentation., Methods: Approximately 384 charts at the Ottawa Hospital General Campus involving a diagnosis of shoulder dystocia between the years of 2000 and 2006 excluding the training year of 2003 were identified. The charts were evaluated for 14 key components derived from a validated instrument. The delivery notes were then scored based on these components by 2 separate investigators who were blinded to delivery note author, date, and patient identification to further quantify delivery record quality., Results: Approximately 346 charts were reviewed for physician and nurse delivery documentation. The average score for physician notes was 6 (maximum possible score of 14) both before and after the training intervention. The nurses' average score was 5 before and after the training intervention., Conclusions: Negligible improvement was observed in the content and quality of shoulder dystocia documentation before and after nurse and physician training.

An increase in Cesarean section birth rate is evident worldwide, especially in developed and developing countries. Since this trend is rapidly gaining epidemic status with unpredictable consequences regarding the reproductive and overall women's health, there is a need for systematic collection and analysis of Cesarean section occurrence data. At this moment, there is no standardized, internationally accepted classification that would be easy to understand and simple to apply. In 2001, Robson Cesarean section classification in ten groups, which might satisfy good classification criteria, was published. In this paper, we have retrospectively collected and sorted the data on Cesarean section births from the "Dr. Fra Mato Nikolić" Croatian Hospital in Nova Bila, according to Robson classification, for the period from January 1st, 1998 to December 31st, 2007. During this period, 6603 women have given birth. Of these, 1010 opted for Cesarean sec- tion (15.30%). The largest group of women giving birth belongs to group 3 (multiparous, single pregnancy, head down, 37 weeks gestation age or more, spontaneous labor), where 49.74% of all the analyzed births belong. The largest group for those with Cesarean sections is group 5 (previous Cesarean section) with 26.93% of all the Cesarean sections. Our results are similar to the results of studies done elsewhere in the world. Robson classification identifies the risk groups with high Cesarean section percentage and is appropriate for long-term tracking and international comparison of the recognized increase of the Cesarean section trend.

Background: Although the evaluation of caesarean delivery rates has been suggested as one of the most important indicators of quality in obstetrics, it has been criticized because of its controversial ability to capture maternal and neonatal outcomes. In an "ideal" process of labor and delivery auditing, both caesarean (CD) and assisted vaginal delivery (AVD) rates should be considered because both of them may be associated with an increased risk of complications. The aim of our study was to evaluate maternal and neonatal outcomes according to the outlier status for case-mix adjusted CD and AVD rates in the same obstetric population., Methods: Standardized data on 15,189 deliveries from 11 centers were prospectively collected. Multiple logistic regression was used to estimate the risk-adjusted probability of a woman in each center having an AVD or a CD. Centers were classified as "above", "below", or "within" the expected rates by considering the observed-to-expected rates and the 95% confidence interval around the ratio. Adjusted maternal and neonatal outcomes were compared among the three groupings., Results: Centers classified as "above" or "below" the expected CD rates had, in both cases, higher adjusted incidence of composite maternal (2.97%, 4.69%, 3.90% for "within", "above" and "below", respectively; p = 0.000) and neonatal complications (3.85%, 9.66%, 6.29% for "within", "above" and "below", respectively; p = 0.000) than centers "within" CD expected rates. Centers with AVD rates above and below the expected showed poorer and better composite maternal (3.96%, 4.61%, 2.97% for "within", "above" and "below", respectively; p = 0.000) and neonatal (6.52%, 9.77%, 3.52% for "within", "above" and "below", respectively; p = 0.000) outcomes respectively than centers with "within" AVD rates., Conclusions: Both risk-adjusted CD and AVD delivery rates should be considered to assess the level of obstetric care. In this context, both higher and lower-than-expected rates of CD and "above" AVD rates are significantly associated with increased risk of complications, whereas the "below" status for AVD showed a "protective" effect on maternal and neonatal outcomes.

There is an increasing awareness of maternal somatic birth trauma, which affects many more women than previously thought, primarily in the form of anal sphincter and levator ani tears. Given that such trauma occurs in about one-third of all women giving birth vaginally for the first time, and given that it has serious long-term consequences, it should be audited by all maternity services with a view to providing remedial therapy to delay or prevent subsequent morbidity, and to facilitate practice improvement. The increasing availability of modern imaging equipment and the skills of using it for pelvic floor assessment means that it is now becoming possible to provide such services postnatally.

Of the approximately four million women who give birth each year in the United States, nearly 13 percent experience one or more major complications. But the extent to which the rates of major obstetrical complications vary across hospitals in the United States is unknown. We used multivariable logistic regression models to examine the variation in obstetrical complication outcomes across US hospitals among a large, nationally representative sample of more than 750,000 obstetrical deliveries in 2010. We found that 22.55 percent of patients delivering vaginally at low-performing hospitals experienced major complications, compared to 10.42 percent of similar patients delivering vaginally at high-performing hospitals. Hospitals were classified as having low, average, or high performance based on a calculation of the relative risk that a patient would experience a major complication. Patients undergoing a cesarean delivery at low-performing hospitals had nearly five times the rate of major complications that patients undergoing a cesarean delivery at high-performing hospitals had (20.93 percent compared to 4.37 percent). Our finding that the rate of major obstetrical complications varies markedly across US hospitals should prompt clinicians and policy makers to develop comprehensive quality metrics for obstetrical care and focus on improving obstetrical outcomes., (Project HOPE—The People-to-People Health Foundation, Inc.)

Background: The importance of non-technical skills (NTS) is a growing area for training and assessment in medicine. Currently there is little formal assessment of these skills in obstetrics and gynaecology., Context: Non-technical Skills for Surgeons (NOTSS) is perhaps the most psychometrically robust tool for assessing individual NTS in the surgical environment. It has previously been evaluated in our specialty alongside objective structured assessments of technical skills, with promising results., Innovation: By removing rankings, NOTSS was adapted for use as a formative feedback tool. This article describes the subsequent Royal College of Obstetricians and Gynaecologists (RCOG) usability pilot of the adapted version of NOTSS in the real delivery suite environment using minimally trained assessors. Twenty-six trainee evaluations and 25 trainer evaluations were completed after 55 assessments., Implications: The number of assessments and evaluations completed was disappointing. However, NOTSS appears promising as a formative NTS assessment tool for use on the delivery suite. Overall satisfaction with NOTSS was high (an average score of 4.5 on a scale of 1-5 for trainers and trainees). Both trainers and trainees consider that it is accep and straightforward to deliver, and that the form takes an average of 10 minutes to complete, including time for feedback (range 5-20 min). There will be considerable challenges to achieving the successful implementation of the NOTSS tool, and its inclusion in the RCOG training matrix: primarily, in training those using it to recognise the behaviours under observation and to give feedback appropriately, and also engaging trainees, although they obviously appreciated the NOTSS process when used., (© 2014 John Wiley & Sons Ltd.)

Objective: To evaluate whether current Joint Commission (JC) exclusion criteria for measure PC-01, "Elective Delivery" before 39 weeks of gestation, accurately identify valid, codeable indications for planned early-term delivery., Methods: We performed a review and critical analysis of all cases recorded as noncompliant for the measure in a large health care system during the second half of 2012., Results: During the study period, of 107,145 total deliveries, 205 cases were reported as noncompliant with PC-01. Ten percent of compliance fallouts (ie, cases coded as noncompliant) resulted from valid indications for delivery identifiable by International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding not included on the JC exclusion list; these were primarily unusual or extreme variations of these conditions. Twenty-five percent of fallouts represented valid indications not represented by an ICD-9-CM code. Eight percent of cases were reported as fallouts as a result of imprecise physician charting; only 2% represented chart abstraction errors. Fifty-five percent of cases involved stated indications for early-term delivery not generally recognized as such by the medical community. Compliance rates of 98% are achievable across a large population using the current ICD-9-CM-based metric for compliance assessment used by the JC (PC-01). The current exclusion list does not appear to be amenable to further improvement by inclusion of more or different ICD-9-CM codes. However, given the low volumes generated using the current PC-01 denominator definition, approximately 60% of facilities would have compliance rates below a 95% benchmark with even a single justified outlier if analyzed on a quarterly basis., Conclusion: Our data validate the current JC exclusion criteria for this measure, which identify the vast majority of valid indications for early-term delivery used by obstetrician-gynecologists and identifiable with ICD-9-CM codes., Level of Evidence: III.

Recent reports observe poorer healthcare outcomes during the weekend. Many attribute this weekend effect to a reduced consultant presence. This study evaluates differences in labour management on weekends vs weekdays. A total of 20,187 deliveries, all resulting from spontaneous labour, in the same large U.K. maternity hospital were examined. Labour management was analysed both for the department as a whole, and separately for each consultant, for differences in weekend and weekday practice. Results showed no statistically significant results of a difference in any of the measures analysed. On a weekend, deliveries were no more likely to be vaginal, p = 0.485, assisted, p = 0.771 or by caesarean section, p = 0.526. There was also no difference between individual consultants. It was concluded that for spontaneous labour, there is no difference in patient management on weekends vs weekdays, either in the department as a whole, or between individual consultants in our study.

Objectives: during 2007 the Chilean Ministry of Public Health introduced the Model of Integrated and Humanized Health Services, in addition to the Clinical Guide for Humanized Care during Delivery. Three years after its implementation, a study was conducted (i) to describe selected clinical outcomes of women who received care within this model, (ii) to identify the degree of maternal-newborn well-being and (iii) to explore the perception of this humanised attention during labour and delivery by both the professional staff (obstetricians and midwives) and consumers., Design and Method: a cross-sectional, descriptive study using both quantitative and qualitative methods was conducted with 508 women who delivered in two major hospitals within the National Health System in the metropolitan area of Santiago, Chile, from September 2010 until June 2011. The quantitative methods included a validated survey of maternal well-being and an adapted version of the American College of Nurse-Midwives (ACNM) standardised antepartum and intrapartum data set. The qualitative methods included six focus groups discussions (FGDs), with midwives, obstetricians and consumers. Additionally, two in depth interviews were carried out with the directors of the maternity units., Findings: the quantitative findings showed poor implementation of the guidelines: 92.7% of the women had medically induced labours (artificial rupture of the membranes and received oxytocin and epidural anaesthesia), and almost one-third of the women reported discontent with the care they received. The qualitative findings showed that the main complaint perceived by the midwives was that the health system was highly hierarchical and medicalised and that the obstetricians were not engaged in this modality of assistance. The women (consumers) highlighted that professionals (midwives and obstetricians) were highly technically skilled, and they felt confident in their assistance. However, women complained about receiving inadequate personal treatment from these professionals. The obstetricians showed no self-critique, stating that they always expressed concern for their patients and that they provided humanised professional assistance., Conclusions and Implications for Practice: by illuminating the main strengths and weakness with regard to the application of the model, these findings can help to inform strategies and actions to improve its implementation., (© 2013 Elsevier Ltd. All rights reserved.)

Published in 1981, "The Maximin Strategy in Modern Obstetrics" offered two claims: first, that obstetrical interventions ought to be assessed not singly, but rather as packages of interconnected measures that could cumulatively increase risks of harm; and second, that many of these interventions, considered either singly or as a package, lacked a sound evidence base. The first claim has been well supported by later literature, although the term "cascade effect" has proven a more felicitous descriptor for the phenomenon of interventions that trigger the use of other interventions to monitor, prevent, or treat possible side-effects. The second claim was initially supported in a very inadequate way, since the "Maximin" article appeared before an understanding of the methods of systematic reviews of medical evidence had been widely promulgated. Despite these defects, subsequent, rigorously conducted systematic reviews have tended to confirm the impression first offered in 1981, that practices that support physiologic childbearing and the innate, hormonally driven capacities of childbearing women and their fetuses/newborns are much more in keeping with the available evidence than practices involving common or routine high-technology interference with physiologic processes. Harm may occur either directly, through high-technology interventions, or when such procedures distract attention and resources from safe, effective biological processes and lower-technology measures. Surveys indicate a lack of knowledge of this evidence among childbearing women, signaling a serious ethical deficiency in shared decision-making processes and perhaps the skills and knowledge of maternity care clinicians.

Planned home birth has been considered by some to be consistent with professional responsibility in patient care. This article critically assesses the ethical and scientific justification for this view and shows it to be unjustified. We critically assess recent statements by professional associations of obstetricians, one that sanctions and one that endorses planned home birth. We base our critical appraisal on the professional responsibility model of obstetric ethics, which is based on the ethical concept of medicine from the Scottish and English Enlightenments of the 18th century. Our critical assessment supports the following conclusions. Because of its significantly increased, preventable perinatal risks, planned home birth in the United States is not clinically or ethically benign. Attending planned home birth, no matter one's training or experience, is not acting in a professional capacity, because this role preventably results in clinically unnecessary and therefore clinically unacceptable perinatal risk. It is therefore not consistent with the ethical concept of medicine as a profession for any attendant to planned home birth to represent himself or herself as a "professional." Obstetric healthcare associations should neither sanction nor endorse planned home birth. Instead, these associations should recommend against planned home birth. Obstetric healthcare professionals should respond to expressions of interest in planned home birth by pregnant women by informing them that it incurs significantly increased, preventable perinatal risks, by recommending strongly against planned home birth, and by recommending strongly for planned hospital birth. Obstetric healthcare professionals should routinely provide excellent obstetric care to all women transferred to the hospital from a planned home birth.The professional responsibility model of obstetric ethics requires obstetricians to address and remedy legitimate dissatisfaction with some hospital settings and address patients' concerns about excessive interventions. Creating a sustained culture of comprehensive safety, which cannot be achieved in planned home birth, informed by compassionate and respectful treatment of pregnant women, should be a primary focus of professional obstetric responsibility.

Assessment of progress in labor is one of the foremost problems in obstetrics. Obstructed labor increases danger to maternal and fetal life and health, and may be caused by birth canal pathologies, as well as inefficient uterine contractions or failure of cervical dilation. Such obstructions require the use of vacuum extraction, forceps, or a Caesarean section. Operative delivery should be performed only when specifically indicated. Conversely postponing an operative delivery when the procedure is necessary is detrimental to the neonatal outcome. Therefore, it is advisable to make the decision on the basis of objective, measurable parameters. Methods of evaluating the risk of labor disorders have evolved over the years. Currently ultrasonography is used for fetal biometric measurements and weight estimation. It helps to evaluate the risk of labor disorders. This method, however is limited by a relatively large measurement error At present, vaginal examination is still the primary method of evaluating labor progress, although the technique is known to be operator-dependent and poorly reproducible. Recent publications suggest that intrapartum translabial ultrasonography is more accurate and allows for an objective assessment of labor progress. Recent studies have evaluated fetal head engagement based on the following parameters: angle between the pubic symphysis and fetal head, distance between the presenting point and the interspinous line and fetal head direction in the birth canal. Each of the described parameters allowed for an objective assessment of head engagement but no advantage of any particular parameter has been revealed so far.

Despite the availability of professional guidelines for the pregnancy management of women affected by female genital mutilation (FGM), this study demonstrated major deficits in identification, management and safeguarding.

Background: It is commonly believed that the experience of practitioners (time spent in delivery ward) may be helpful in aiding the spontaneous vaginal birth., Aim: To check if this opinion is true., Methods: In 995 low-risk, full-term, pregnancies resulting in spontaneous labour, multivariate logistic regression analysis was performed, which considered the age, the years of service of the obstetrician and of the midwife, and of both as independent variables. Results The longer the obstetrician (odds ratio 0.779, C.I. 95% 0.653-0.930, p = 0.006) or the midwife has been practising (odds ratio 0.609, C.I. 95% 0.408-0.909, p = 0.015) the less likely is the occurrence of a spontaneous vaginal birth. The combined years of service of the caring doctor/midwife pair appears to have no influence on the outcome of delivery. The chances of an operative vaginal birth increase with the age of the caring obstetrician (odds ratio 1.362, C.I. 95% 1.138-1.630, p = 0.001)., Conclusion: The experience of the staff assisting women in labour definitely does not determine the success of deliveries. The skills of each professional category are based on theoretical knowledge that is possibly not being put to use during routine duties, especially by the 'more experienced' practitioners. Additionally, it appears that there is no team work, and decisions are not taken together.