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Introduction: This study explores the scope of practice of Obstetrics and Gynaecology specialists in Italy, Belgium and England, in light of the growth of professional and patient mobility within the EU which has raised concerns about a lack of standardisation of medical speciality practice and training., Methods: Semi-structured qualitative interviews were conducted with 29 obstetricians and gynaecologists from England, Belgium and Italy, exploring training and scope of practice, following a common topic guide. Interviews were recorded, transcribed and coded following a common coding framework in the language of the country concerned. Completed coding frames, written summaries and key quotes were then translated into English and were cross-analysed among the researchers to identify emerging themes and comparative findings., Results: Although medical and specialty qualifications in each country are mutually recognised, there were great differences in training regimes, with different emphases on theory versus practice and recognition of different subspecialties. However all countries shared concerns about the impact of the European Working Time Directive on trainees' skills development. Reflecting differences in models of care, the scope of practice of OBGYN varied among countries, with pronounced differences between the public and private sector within countries. Technological advances and the growth of co-morbidities resulting from ageing populations have created new opportunities and greater links with other specialties. In turn new ethical concerns around abortion and fertility have also arisen, with stark cultural differences between the countries., Conclusion: Variations exist in the training and scope of practice of OBGYN specialists among these three countries, which could have significant implications for the expectations of patients seeking care and specialists practising in other EU countries. Changes within the specialty and advances in technology are creating new opportunities and challenges, although these may widen existing differences. Harmonisation of the training and scope of practice of OBGYN within Europe remains a distant goal. Further research on the scope of practice of medical professionals would better inform future policies on professional mobility., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objectives: To explore the effect of obstetric emergency training on knowledge. Furthermore, to assess if acquisition of knowledge is influenced by the training setting or teamwork training., Design: A prospective randomised controlled trial., Setting: Training was completed in six hospitals in the South West of England, UK and at the Bristol Medical Simulation Centre, UK., Population: Midwives and obstetric doctors working for the participating hospitals were eligible for inclusion in the study. A total of 140 participants (22 junior and 23 senior doctors, 47 junior and 48 senior midwives) were studied., Methods: Participants were randomised to one of four obstetric emergency training interventions: (1) 1-day course at local hospital, (2) 1-day course at simulation centre, (3) 2-day course with teamwork training at local hospital and (4) 2-day course with teamwork training at simulation centre., Main Outcome Measures: Change in knowledge was assessed by a 185 question Multiple-Choice Questionnaire (MCQ) completed up to 3 weeks before and 3 weeks after the training intervention., Results: There was a significant increase in knowledge following training; mean MCQ score increased by 20.6 points (95% CI 18.1-23.1, P < 0.001). Overall, 123/133 (92.5%) participants increased their MCQ score. There was no significant effect on the MCQ score of either the location of training (two-way analysis of variants P = 0.785) or the inclusion of teamwork training (P = 0.965)., Conclusions: Practical, multiprofessional, obstetric emergency training increased midwives' and doctors' knowledge of obstetric emergency management. Furthermore, neither the location of training, in a simulation centre or in local hospitals, nor the inclusion of teamwork training made any significant difference to the acquisition of knowledge in obstetric emergencies.

The provision of safe high-quality care in obstetrics and gynaecology is a key target in the UK National Health Service (NHS), in part because of the high cost of litigation in this area. Good risk management processes should improve safety and reduce the cost of litigation to the NHS. This chapter looks at structures and processes for improving quality and patient safety, using the stepwise approach described by the National Patient Safety Authority (NPSA). This encompasses building a safety culture, leading and supporting staff, integrating risk management activity, promoting reporting, involving and communicating with patients and the public, learning and sharing safety lessons, and implementing solutions to prevent harm. Examples from the Liverpool Women's NHS Foundation Trust are used to illustrate these steps, including how they were developed, what obstacles had to be overcome, ongoing challenges, and whether good risk management has translated into better, safer health care.

During a 5-year period there were 32 cases where the vaginal assessment performed by a specialist registrar in the second stage of labour was re-assessed within 15 minutes by a consultant obstetrician. The examination was prompted by a request for permission to perform a caesarean section in the second stage of labour. The results suggest a significant discrepancy between the consultants and the specialist registrar's findings, with 44% of the cases indicating a difference in the position of the head, and 81% a difference in the station of the head. No comment was made about caput or moulding in the majority of cases (94%). The study findings suggest that vaginal examination, like instrumental delivery, is a skill that is being eroded and will require formal instruction to address this problem.

Objective: The objective of this study was to assess the use and efficacy of delivery by vacuum extraction or ventouse in routine clinical practice and to assess some aspects of the procedure that may reflect the quality of training in this technique., Materials and Methods: Women's demographic profiles and delivery details were collected in both the prospective (B) and retrospective (A) arm of the study. In addition, in the prospective arm of the study two custom-designed forms were used: the obstetrician recorded their perception of where the vacuum cup had been placed on one form while on a second form the pediatrician indicated the actual site of the cup placement as observed from the position of the chignon. All the diagrams of cup placement were reviewed by one of the authors, who was blinded to the outcome of the procedure., Results: The vacuum extractor was the first instrument to be used in 79% and 87% of the instrumental deliveries in groups A and B, respectively, with corresponding failure rates of 20% and 21%. Although an occipito-posterior position was diagnosed in 11% of cases of group A and 14% of cases of group B, the specifically designed occipito-posterior cup was not used at all. The vacuum cup was considered to have been applied suboptimally in 40% of the cases where attempted vacuum delivery failed., Conclusion: The high rate of inappropriate positioning of the cup may reflect difficulty in accurately applying the cup, perhaps due to caput or malposition, but may also represent poor assessment of the orientation and position of the fetal skull and therefore be indicative of a need for improvement in training methods.

Objective: Aim of the study was to assess whether different birth management of an english and german department can influence the maternal and neonatal outcome., Material and Methods: The database consisted of routinely published data from 1986-95 for two clinical units in Solihull (England) and Ibbenbueren (Germany) comprising 34 820 and 9 053 deliveries respectively. In order to standardise the obstetric risk profiles the heterogeneous primary groups were subdivided into "standard primip groups". A statistical comparison using the "binomial confidence interval method" was carried out., Results: In the standardised comparison induction of labour, duration of labour 1-6 hours, vaginal delivery from cephalic presentation, elective caesarean section, both for cephalic and breech presentation, transfer to the childrens hospital were less frequent in Solihull. On the other hand, Solihull showed more frequent oxytocin administration, fetal blood analysis, epidural anaesthesia, episiotomies, duration of labour > 13 hours, forceps, ventouse and emergency caesarean section deliveries from cephalic presentation, vaginal deliveries or emergency caesarean sections from breech presentation, resuscitation of the newborn using mask and/or drugs, maternal blood loss > 1 000 ml as well as abnormalities of placental separation. Despite the different management of the departments being compared no significant differences in the incidence of perinatal hypoxia as determined by Apgar scores at 5 minutes nor in the fetal mortality rate between the units could be identified., Conclusion: Using standardised data the quality of obstetric and perinatal care in England and Germany can be reliably compared. Different birth management does not significantly influence the neonatal outcome.

Objectives: to gain an insight into how health professionals in the maternity services define evidence and how they perceive different types of evidence are valued in maternity care., Design: using a qualitative approach data were collected by semi-structured interviews: the content of each was analysed thematically., Setting: England., Participants: a purposeful sample of ten midwives, two obstetricians and one research nurse., Findings: definitions of evidence vary widely among health practitioners. These definitions are affected by individuals' own beliefs and give rise to a hierarchy in which some types of evidence are valued above others. All the participants made direct or indirect reference to cultural beliefs inherent within the health service, and indicated that these beliefs determine the extent to which different types of evidence are seen as legitimate., Implications for Practice: the concept of evidence-based practice is not value-free. Evidence that reinforces notions of authoritative knowledge may be transposed into clinical practice quickly and easily. Conversely, health practitioners may have difficulty putting evidence into practice that challenges the cultural norms of the profession. There is a need for further work to make explicit the values that underpin different sources of knowledge and expose the hierarchies of evidence that exist., (Copyright 2001 Harcourt Publishers Ltd.)

The objective of this study was to investigate the judgements of British doctors, nurses and midwives about behaviour which complies with a protocol, violates a protocol, or constitutes an improvisation where no protocol exists. Primary data were collected on the judgments of hospital healthcare professionals (N = 310) from three specialties in each of three hospitals. Respondents were required to judge the appropriateness of the behaviour of a fellow professional in each of nine hypothetical scenarios generated on the basis of previous focus group discussions. They were also asked how likely they would be to report this professional to a senior member of staff. Within the scenarios, both behaviour with respect to the relevant clinical protocol and outcome for the patient were experimentally manipulated. Data were collected using a survey questionnaire. The three professional groups studied (doctors, nurses and midwives) were found to make significantly different judgements. Crucially, doctors judged the violation of a protocol as less inappropriate than did nurses or midwives. Midwives were disapproving of violations, even when the patient outcome was good. These differences were reflected in the ratings of reporting likelihood. The proliferation of clinical protocols likely to occur in Britain in the coming years will need to be managed with great care if the regulation of clinical behaviour is the goal. Particular care will be needed to avoid the exacerbation of professional tensions.

Objective: To compare the outcome of care given to women 'booking' for delivery in a midwife-led maternity unit with that for comparable women 'booking' for care in a consultant obstetric unit., Design and Method: Prospective cohort study with a quasi-experimental design and data extracted from case notes., Setting: East Dorset, midwife-led maternity unit at Royal Bournemouth Hospital and consultant-led maternity unit at Poole General Hospital., Subjects: Two cohorts of women who satisfied the criteria for 'booking' at the Royal Bournemouth Hospital. Of these 794 'booked' at Bournemouth from 1 November 1992 to 30 June 1993 and 705 'booked' at Poole over the same period. MAIN PROCESS AND OUTCOME MEASURES: Care given, morbidity in women and their babies, transfers during the antenatal period and in labour., Findings: Of the women who initially 'booked' for Bournemouth, 62.3% actually delivered there, 27.1% transferred before labour and a further 9.2% transferred during labour. No differences were seen between those 'booked' for Bournemouth or Poole in the proportions of low birthweight babies, babies who were transferred to special care or babies who had congenital abnormality. Higher proportions of babies whose mothers 'booked' for delivery in Poole were resuscitated and had one minute Apgar scores below seven but there was no difference in the five minute scores. Similar proportions of women had perineal tears but fewer of the women 'booked' for delivery in Bournemouth had an episiotomy. 'Booking' for Poole was associated with higher rates of induction and augmentation of labour and greater use of anesthesia. 'Booking' for Bournemouth was associated with a shorter first stage and a longer third stage of labour. Women 'booked' for delivery in Bournemouth were no more likely to be delivered by a midwife than those 'booked' for Poole., Conclusions: There was very little difference between the groups of women who initially 'booked' for delivery at the two units. There were differences in the patterns of care received, but no major differences in the outcome for the women or their babies were detected.

Objectives: To describe the relation between research evidence and local obstetric unit policy for specific areas of care and to explore clinicians' views about the reasons for any discrepancies identified., Design: An independent evaluation of a project undertaken by a district maternity services liaison committee (MSLC) to promote evidence based maternity care in specific areas of care. The evaluation involved a combination of qualitative methodologies including documentary analysis, non-participant observation, semi-structured interviews, and self completed open ended questionnaires., Setting: One English health district with three obstetric units., Main Measures: Congruence between unit policies and research evidence in specific areas of care. Views expressed by unit staff concerning the reasons for any discrepancies identified. Consistency between staff views within and between units. Unit attitudes to modification of discrepant policies and details of any subsequent changes made., Results: Of the 12 unit policies considered, seven were consistent with the research evidence. In all cases in which unit policy did not reflect the evidence, provider unit staff thought that the differences were justified. In several cases there were substantive differences of view between staff in different units. No differences of view were expressed between staff in the same unit. There were three different types of concern about the research evidence and the problems of using it as a basis for deciding unit policy. These were: concerns about the adequacy or completeness of the evidence; concerns about the applicability of the evidence in the local setting; and concerns about local capacity to act on the evidence. At the time of the project, none of the units expressed any intention of modifying the policies under discussion. Subsequently, two of them did make changes of this sort., Conclusion: The results suggest the need for further research to ascertain what factors may produce such varying assessments of the validity and adequacy of particular sets of research findings as were found between clinicians in this study and to understand what considerations other than views about evidence may affect decisions to alter clinical policy., Implications: When clinicians have clear reasons for not following research evidence, two contrasting responses are possible. One is to take the view that the clinicians are mistaken, and seek to change their attitudes or persuade them to change their behaviour regardless of their views. An alternative response is to accept that the concerns they express may be legitimate and consider how their doubts may be addressed. The challenge is to recognise which response is preferable in any particular situation.

Objective: To investigate women's experience of transfer from community-based to consultant obstetric care., Design: Semi-structured interviews three to eight weeks postnatally, which were taped, transcribed and analysed according to grounded theory., Setting: Community-based maternity service, Sheffield, England., Participants: Twelve women who had been transferred to consultant care in late pregnancy or labour., Main Outcome Measures: Categories which described and explained women's experience and that could be validated by checking back against the interview data., Findings: There was a strong potential for disappointment with their labours, but this could be ameliorated by certain aspects of care, namely information and explanation, debriefing, and continuity of care., Conclusion: Transfer is an inevitable consequence for a proportion of community-booked women but need not be a negative experience, with appropriate care.

Objective: To formulate consensus based guidelines for antenatal care in a health district., Design: Prospective formulation of draft guidelines by a working group of consultant obstetricians and general practitioners with an obstetric interest, canvassing opinions of all GPs in the district by questionnaire, and revision and final circulation of the guidelines., Setting: One health district., Subjects: All 160 GPs in the district and members of the working party., Main Measures: Questionnaire responses to specific proposals within the draft guidelines for managing anaemia, antepartum haemorrhage, and hypertension., Results: 136 GPs responded (response rate 85%); responders and nonresponders did not differ in age, sex, or presence on obstetric list. Overall they favoured more conservative management than suggested in the guidelines. For example, only 38% (44/116) prescribed iron routinely and 34% (38/113) referred to hospital for haemoglobin concentration of < or = 10 g/l; 10% referred women unnecessarily for oedema unassociated with proteinuria; and 20% managed active bleeding progressing to old brown staining as an urgent admission. The guidelines were revised according to the relative weight of the views obtained., Conclusion: Establishing guidelines is mainly a political process. Canvassed views influenced guidelines most when internal disagreement existed within the working party., Implications and Action: Regular revising of the guidelines is planned, which, in conjunction with repeating the questionnaire to monitor changing practice, will allow a long term district wide clinical review.

Objective: To examine the use of routinely collected computerised data in clinical audit., Design: Retrospective review of all analyses of obstetric practice based on a computerised data system from January 1983 to June 1988., Setting: Maternity department of the regional referral hospital in Oxford., Main Outcome Measures: Congruence with the principles of clinical audit; that is, comparing clinical practice with previously agreed standards and changing practice to meet these standards if necessary., Results: Over the five and a half years of the study the data formed the basis of 130 special inquiries into different aspects of obstetric practice. Most inquiries seemed to be aimed only at describing current activities and identifying trends. Genuine clinical audit was rare. Simple audits--for example, concerning induction for pregnancy after term--could be supported by the computerised data, but for detailed and wide ranging audits--for example, reducing antenatal clinic visits for low risk multiparas--the data had to be supplemented from other sources., Conclusions: Routinely collected computerised data enable ongoing clinical audit, but it becomes a reality only when clinicians agree on standards of practice and have a flexible attitude towards change. Even then, genuine clinical audits of obstetric practice demand more detailed and comprehensive data than are generally available on such systems.

The standard of obstetrics care by general practitioners in Bradford was assessed by reviewing the case records of all women who in 1988 were booked for delivery under their general practitioner but subsequently required transfer to consultant care. A total of 5885 women were delivered in Bradford during 1988. Of 1289 booked under their general practitioner, 637 required transfer to consultant care. In 259 cases transfer occurred during labour; only 37 of these women were visited by their general practitioner. Many of the problems that precipitated transfer were predictable and some were considered preventable: 263 of the women transferred were considered unsuitable for booking by general practitioners. The perinatal mortality among women booked under their general practitioner was 10.1/1000 and the stillbirth rate 7.8/1000. These figures are high and suggest a need for tighter controls over the qualifications and experience of doctors participating in a fully integrated system of obstetric care.

The high perinatal mortality among infants of women transferred from general practitioner to consultant care is well known, the implication being that if these women had been booked for consultant care several of the deaths might not have occurred. The findings of this study indicate that booking into a consultant unit did not reduce perinatal mortality and suggest that, where liaison between hospital and general practitioners is good and transfer easy, booking into a general practitioner maternity unit can be as safe for low-risk women as booking into a consultant unit.

Between 1976 and 1981 some 939 perinatal deaths occurred to women living in Leicestershire, of which 128 (14%) were to Asian women. The qualifications of the general practitioners, the gestation at which women start antenatal care, and perinatal death were used as structural, process, and outcome measures for evaluating the services provided to Asian immigrants within this population. Perinatal deaths were divided into four groups: congenital malformation, macerated stillbirth, asphyxia in labour, and immaturity. Asian mothers had one and a half times the risk of perinatal mortality when social class, parity, height, legitimacy, and the general practitioner's qualifications were taken into account. Asian and non-Asian mothers with general practitioners who were not on the obstetric list had more than twice the risk of a perinatal death when a similar adjustment was made. Recommendations include priority allocation of community midwives to practitioners not on the obstetric list, the establishment of postgraduate courses for such doctors, and the continued evaluation of the effect of such proposals on perinatal mortality.

This paper reviews national data on obstetric and neonatal practices in England and Wales, and in France between 1970 and 1980. The data have been derived from national statistics and surveys on national samples of births in 1970, 1975 and 1980 in England and Wales, and 1972, 1976 and 1981 in France. The analysis shows that there was no major difference in pregnancy outcome, but wide variations in medical practices, and their trend over time. The main differences were: in England and Wales a higher number of antenatal visits, a higher percentage of inpatient admissions during pregnancy, a higher rate of induction, more episiotomies, a higher rate of resuscitation at birth, and admission to neonatal special care units; in France, a higher rate of caesarean sections before and during labour, some evidence of a more active management of labour, and a longer hospital post-natal stay. These differences in practice reflect differences in objectives and assessment of the effectiveness of care between the two countries: they point out the need for better monitoring and evaluation of obstetric and neonatal practices.

To assess the feasibility and quality of general practitioner obstetrics an audit of 1223 consecutive obstetric deliveries over 26 years was carried out with standard clinical records. The perinatal mortality of 9.0 per 1000 births was significantly better than the national average of about 19.0 per 1000 for the overall period. During the audit home deliveries virtually stopped. The proportion of consultant bookings and deliveries more than doubled because of more stringent booking arrangements despite relocation of the previously isolated general practitioner unit to beneath the consultant unit. Abnormal deliveries also rose significantly. A "steady state" was achieved during the final 11 years in which 73% of women booked to be delivered by their general practitioner, 64% were admitted to the general practitioner unit, and 54% were delivered by their general practitioner. Though this is enough to sustain obstetric experience, the proportion might safely be increased.