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Background: Surgical site infections (SSIs) are common, occurring in up to 25% of > 4 million operations performed in England each year. Previous trials of the effect of wound dressings on the risk of developing a SSI are of poor quality and underpowered., Methods/design: This study is a feasibility and pilot trial to examine the feasibility of a full trial that will compare simple dressings, no dressing and tissue-glue as a dressing. It is examining the overall acceptability of trial participation, identifying opportunities for refinement, testing the feasibility of and validating new outcome tools to assess SSI, wound management issues and patients' wound symptom experiences. It is also exploring methods for avoiding performance bias and blinding outcome assessors by testing the feasibility of collecting wound photographs taken in theatre immediately after wound closure and, at 4-8 weeks after surgery, taken by participants themselves or their carers. Finally, it is identifying the main cost drivers for an economic evaluation of dressing types. Integrated qualitative research is exploring acceptability and reasons for non-adherence to allocation. Adults undergoing primary elective or unplanned abdominal general surgery or Caesarean section are eligible. The main exclusion criteria are abdominal or other major surgery less than three months before the index operation or contraindication to dressing allocation. The trial is scheduled to recruit for nine months. The findings will be used to inform the design of a main trial., Discussion: This pilot trial is the first pragmatic study to randomise participants to no dressing or tissue-glue as a dressing versus a simple dressing. Early evidence from the ongoing pilot shows that recruitment is proceeding well and that the interventions are acceptable to participants. Combined with the qualitative findings, the findings will inform whether a main, large trial is feasible and, if so, how it should be designed., Trial Registration: ISRCTN49328913 . Registered on 20 October 2015.

Third-trimester stillbirth affects approximately 2.6 million women worldwide each year. Although most stillbirths (98%) occur in low- and middle-income countries, most of the research on the impact of stillbirth and bereavement care has come from high-income countries. The impact of stillbirth ranges from stigma to disenfranchised grief, broken relationships, clinical depression, chronic pain, substance use, increased use of health services, employment difficulties, and debt. Appropriate bereavement care following a stillbirth is essential to minimise the negative socio-economic impact on parents and their families. This article presents the best practice points in stillbirth bereavement care, including taking an individualised and flexible approach. The latest published research, guidelines, and best practice points from high-income countries will be used and will highlight the gaps in the research which urgently need to be addressed. Research and investment in appropriate, respectful aftercare is needed to minimise the negative impact for parents., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: With no evidence to guide management of the gastric band in pregnancy, we aim to compare outcomes according to band management., Methods: Data were collected on all women pregnant (November 2011-October 2012) following gastric banding, using the UK Obstetric Surveillance System surveillance system. We compared outcomes between band management groups and with national data., Results: Band management was variable; deflation 43.4%, inflation maintained 56.6%. The deflation group had lower risk of small for gestational age infants (no cases vs. 11.3%; risk ratio = 0.14, p  = 0.05). There was greater gestational weight gain (deflation 15.4 kg, inflation 7.6 kg; adjusted p  = 0.05), and perhaps higher risk of gestational hypertension (deflation 10.5%, inflation no cases; p  = 0.08) in the deflation group. Other maternal outcomes were similar between management groups but overall worse than national data., Conclusions: Deflation is associated with better outcomes for babies but worse outcomes for mothers than maintained inflation.

Accurate and consistent classification of causes and associated conditions for perinatal deaths is essential to inform strategies to reduce the five million which occur globally each year. With the majority of deaths occurring in low- and middle-income countries (LMICs), their needs must be prioritised. The aim of this paper is to review the classification of perinatal death, the contemporary classification systems including the World Health Organization's International Classification of Diseases - Perinatal Mortality (ICD-PM), and next steps. During the period from 2009 to 2014, a total of 81 new or modified classification systems were identified with the majority developed in high-income countries (HICs). Structure, definitions and rules and therefore data on causes vary widely and implementation is suboptimal. Whereas system testing is limited, none appears ideal. Several systems result in a high proportion of unexplained stillbirths, prompting HICs to use more detailed systems that require data unavailable in low-income countries. Some systems appear to perform well across these different settings. ICD-PM addresses some shortcomings of ICD-10 for perinatal deaths, but important limitations remain, especially for stillbirths. A global approach to classification is needed and seems feasible. The new ICD-PM system is an important step forward and improvements will be enhanced by wide-scale use and evaluation. Implementation requires national-level support and dedicated resources. Future research should focus on implementation strategies and evaluation methods, defining placental pathologies, and ways to engage parents in the process., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: Rotational forceps and manual rotation followed by direct forceps are techniques used in the management of malposition of the fetal head in the second stage of labor. However, there is widespread debate regarding their relative safety and utility. We aimed to compare the effectiveness and safety of rotational forceps with manual rotation followed by direct forceps, for management of fetal malposition at full dilation., Study Design: A retrospective cohort study in a single tertiary obstetric unit with >6000 births per year. We recorded and analysed outcomes of 104 sequential rotational forceps births over 21 months (Jan 2010-Sept 2012) and 208 matched chronologically sequential attempted manual rotations and direct forceps births (1:2 by number). Univariable and multivariable approaches used for statistical analysis. The main outcome measure was vaginal birth., Results: The rate of vaginal birth was significantly higher with rotational forceps than with manual rotation followed by direct forceps (88.5% vs 82.2%, RR 1.17, 95% CI 1.04-1.31, p=0.017). Births by rotational forceps were associated with a significantly higher rate of shoulder dystocia (19.2% vs 10.6%, RR 2.35, 95% CI 1.23-4.47, p=0.012), but not of neonatal injury. There were no significant differences in all other maternal and neonatal outcomes between the two modes of birth., Conclusions: The use of rotational forceps was associated with a statistically significantly higher rate of vaginal birth, but also of shoulder dystocia, compared to manual rotation followed by direct forceps. This is the first study to demonstrate a statistically significant increase in the rate of shoulder dystocia following rotational forceps birth., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Introduction: Simulation-based, multiprofessional team training (SBMPTT) is used widely in healthcare, with evidence that it can improve clinical outcomes and be associated with a positive safety culture. Our aim was to explore the impact of introducing this type of training to a gynaecological team., Methods: In this interrupted time-series study, 'Safety Attitudes Questionnaire' (SAQ) data was collected both before and after SBMPTT was introduced to a gynaecological team., Results: Low baseline SAQ scores coincided with difficulty in establishing the training, meaning that at the end of our study period only a small proportion of staff had actually attended a training session. Despite trends towards improvement in scores for safety climate, teamwork climate and job satisfaction, no statistically significant difference was observed. There was however an improved perception of the level of collaboration between nursing staff and doctors after the introduction of training., Conclusions and Discussion: In this paper we explore a hypothesis that low baseline SAQ scores may highlight that the multiprofessional teams most in need of training work in environments where it is more challenging to implement. There is evidence from other specialties that multiprofessional team training works, now we need to understand how to address the barriers to getting it started. In this paper we suggest how the SAQ could be used as a directive tool for improvement; using the detailed analysis of the local safety culture it provides to both inform future training design and also provide management with an objective marker of progress., Competing Interests: Competing interests: DS is a member of the PROMPT Maternity Foundation. He has no financial interest from this association., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objective: To determine the economic impact of the introduction of carbetocin for the prevention of postpartum haemorrhage (PPH) at caesarean section, compared to oxytocin., Study Design: The model is a decision tree conducted from a UK National Health Service perspective. 1500 caesarean sections (both elective and emergency) were modelled over a 12 month period. Efficacy data was taken from a published Cochrane meta-analysis, and costs from NHS Reference costs, the British National Formulary and the NHS electronic Medicines Information Tool. A combination of hospital audit data and expert input from an advisory board of clinicians was used to inform resource use estimates. The main outcome measures were the incidence of PPH and total cost over a one year time horizon, as a result of using carbetocin compared to oxytocin for prevention of PPH at caesarean section., Results: The use of carbetocin compared to oxytocin for prevention of PPH at caesarean section was associated with a reduction of 30 (88 vs 58) PPH events (>500ml blood loss), and a cost saving of £27,518. In probabilistic sensitivity analysis, carbetocin had a 91.5% probability of producing better outcomes, and a 69.4% chance of being dominant (both cheaper and more effective) compared to oxytocin., Conclusion: At list price, the introduction of carbetocin appears to provide improved clinical outcomes along with cost savings, though this is subject to uncertainty regarding the underlying data in efficacy, resource use, and cost., (Crown Copyright © 2017. Published by Elsevier B.V. All rights reserved.)

Multidisciplinary training has improved maternity outcomes when the training has been well attended, regular, in house, used high-fidelity simulators, and integrated teamwork training. If these principles were used in other settings, better clinical care may result. This before-after study sought to establish whether a short multidisciplinary training intervention can improve recognition of the deteriorating patient using an aggregated physiological parameter scoring system (Early Warning Score [EWS]). Nursing, medical, and allied nursing staff participated in an hour-long training session, using real-life scenarios with simple tools and structured debriefing. After training, staff were more likely to calculate EWS scores correctly (68.02% vs 55.12%; risk ratio [RR] = 1.24, 95% confidence interval [CI] = 1.07-1.44), and observations were more likely to be performed at the correct frequency (78.57% vs 68.09%; RR = 1.20, 95% CI = 1.09-1.32). Multidisciplinary training, according to core principles, can lead to more accurate identification of deteriorating patients, with implications for subsequent care and outcome., (© The Author(s) 2015.)

Variation in stillbirth rates across high-income countries and large equity gaps within high-income countries persist. If all high-income countries achieved stillbirth rates equal to the best performing countries, 19,439 late gestation (28 weeks or more) stillbirths could have been avoided in 2015. The proportion of unexplained stillbirths is high and can be addressed through improvements in data collection, investigation, and classification, and with a better understanding of causal pathways. Substandard care contributes to 20-30% of all stillbirths and the contribution is even higher for late gestation intrapartum stillbirths. National perinatal mortality audit programmes need to be implemented in all high-income countries. The need to reduce stigma and fatalism related to stillbirth and to improve bereavement care are also clear, persisting priorities for action. In high-income countries, a woman living under adverse socioeconomic circumstances has twice the risk of having a stillborn child when compared to her more advantaged counterparts. Programmes at community and country level need to improve health in disadvantaged families to address these inequities., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Despite the frequency of stillbirths, the subsequent implications are overlooked and underappreciated. We present findings from comprehensive, systematic literature reviews, and new analyses of published and unpublished data, to establish the effect of stillbirth on parents, families, health-care providers, and societies worldwide. Data for direct costs of this event are sparse but suggest that a stillbirth needs more resources than a livebirth, both in the perinatal period and in additional surveillance during subsequent pregnancies. Indirect and intangible costs of stillbirth are extensive and are usually met by families alone. This issue is particularly onerous for those with few resources. Negative effects, particularly on parental mental health, might be moderated by empathic attitudes of care providers and tailored interventions. The value of the baby, as well as the associated costs for parents, families, care providers, communities, and society, should be considered to prevent stillbirths and reduce associated morbidity., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Introduction: Performing a pelvic examination is a core skill for all medical undergraduates. The use of hybrid simulation, manikin with patient actress, to attain technical and communication skills competencies and to improve the quality of care we offer women, has not been compared to other teaching methods before. Outcome measures were technical skills, communication skills and confidence in completing a pelvic examination., Methods: A cluster randomised control trial was conducted over an academic year. Forty-eight medical students who completed an 8-week obstetrics and gynaecology attachment were recruited. Clusters were randomly assigned for initial training on hybrid or manikin only models and attended an end of attachment Objective Structured Clinical Assessment., Results: Outcome data were received for 43/48 students (89.5%). Following the objectively structured clinical examination, the hybrid trained cohort had higher technical scores (mean 23 (95% CI 20.1 to 25.8) vs 16.7 (CI 14.7 to 18.6); mean difference 6.3, CI 3.0 to 9.6) and communication skills scores (mean 22.6 (CI 21.2 to 23.8) vs 15.9 (CI 14.4 to 17.3); mean difference 6.7, CI 4.8 to 8.5) compared to the manikin only trained participants. Confidence in undertaking future pelvic examinations were similar in the control and intervention groups; (p=0.10, r=0.18)., Conclusions: This study demonstrates the value of hybrid simulation compared to manikins alone in improving the short-term acquisition of competence in simulated pelvic examinations at an undergraduate level. Future research should focus on whether hybrid models lead to long-term acquisition of skill and comparison of these models with other innovative methods such as clinical teaching associates., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: 2.7 million babies were stillborn in 2015 worldwide; behind these statistics lie the experiences of bereaved parents. The first Lancet series on stillbirth in 2011 described stillbirth as one of the "most shamefully neglected" areas of public health, recommended improving interaction between families and frontline caregivers and made a plea for increased investment in relevant research., Methods: A systematic review of qualitative, quantitative and mixed-method studies researching parents and healthcare professionals experiences of care after stillbirth in high-income westernised countries (Europe, North America, Australia and South Africa) was conducted. The review was designed to inform research, training and improve care for parents who experience stillbirth., Results: Four thousand four hundred eighty eight abstracts were identified; 52 studies were eligible for inclusion. Synthesis and quantitative aggregation (meta-summary) was used to extract findings and calculate frequency effect sizes (FES%) for each theme (shown in italics), a measure of the prevalence of that finding in the included studies. Researchers' areas of interest may influence reporting of findings in the literature and result in higher FES sizes, such as; support memory making (53%) and fathers have different needs (18%). Other parental findings were more unexpected; Parents want increased public awareness (20%) and for stillbirth care to be prioritised (5%). Parental findings highlighted lessons for staff; prepare parents for vaginal birth (23%), discuss concerns (13%), give options & time (20%), privacy not abandonment (30%), tailored post-mortem discussions (20%) and post-natal information (30%). Parental and staff findings were often related; behaviours and actions of staff have a memorable impact on parents (53%) whilst staff described emotional, knowledge and system-based barriers to providing effective care (100%). Parents reported distress being caused by midwives hiding behind 'doing' and ritualising guidelines whilst staff described distancing themselves from parents and focusing on tasks as coping strategies. Parents and staff both identified the need for improved training (parents 25% & staff 57%); continuity of care (parents 15% & staff 36%); supportive systems & structures (parents 50%); and clear care pathways (parents 5%)., Conclusions: Parents' and healthcare workers' experiences of stillbirth can inform training, improve the provision of care and highlight areas for future research.

Background: Despite improvements in maternity healthcare services over the last few decades, more than 2.7 million babies worldwide are stillborn each year. The global health agenda is silent about stillbirth, perhaps, in part, because its wider impact has not been systematically analysed or understood before now across the world. Our study aimed to systematically review, evaluate and summarise the current evidence regarding the psychosocial impact of stillbirth to parents and their families, with the aim of improving guidance in bereavement care worldwide., Methods: Systematic review and meta-summary (quantitative aggregation of qualitative findings) of quantitative, qualitative, and mixed-methods studies. All languages and countries were included., Results: Two thousand, six hundred and nineteen abstracts were identified; 144 studies were included. Frequency effect sizes (FES %) were calculated for each theme, as a measure of their prevalence in the literature. Themes ranged from negative psychological symptoms post bereavement (77 · 1) and in subsequent pregnancies (27 · 1), to disenfranchised grief (31 · 2), and incongruent grief (28 · 5), There was also impact on siblings (23 · 6) and on the wider family (2 · 8). They included mixed-feelings about decisions made when the baby died (12 · 5), avoidance of memories (13 · 2), anxiety over other children (7 · 6), chronic pain and fatigue (6 · 9), and a different approach to the use of healthcare services (6 · 9). Some themes were particularly prominent in studies of fathers; grief suppression (avoidance)(18 · 1), employment difficulties, financial debt (5 · 6), and increased substance use (4 · 2). Others found in studies specific to mothers included altered body image (3 · 5) and impact on quality of life (2 · 1). Counter-intuitively, Some themes had mixed connotations. These included parental pride in the baby (5 · 6), motivation for engagement in healthcare improvement (4 · 2) and changed approaches to life and death, self-esteem, and own identity (25 · 7). In studies from low/middle income countries, stigmatisation (13 · 2) and pressure to prioritise or delay conception (9) were especially prevalent., Conclusion: Experiencing the birth of a stillborn child is a life-changing event. The focus of the consequences may vary with parent gender and country. Stillbirth can have devastating psychological, physical and social costs, with ongoing effects on interpersonal relationships and subsequently born children. However, parents who experience the tragedy of stillbirth can develop resilience and new life-skills and capacities. Future research should focus on developing interventions that may reduce the psychosocial cost of stillbirth.

Effective and coordinated teamworking is key to achieving safe birth for mothers and babies. Confidential enquiries have repeatedly identified deficiencies in teamwork as factors contributing to poor maternal and neonatal outcomes. The ingredients of a successful multi-professional team are varied, but research has identified some fundamental teamwork behaviours, with good communication, proficient leadership and situational awareness at the heart. Simple, evidence-based methods in teamwork training can be seamlessly integrated into a core, mandatory obstetric emergency training. Training should be an enjoyable, inclusive and beneficial experience for members of staff. Training in teamwork can lead to improved clinical outcomes and better birth experience for women., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Training for intrapartum emergencies is a promising strategy to reduce preventable harm during birth; however, not all training is clinically effective. Many myths have developed around such training. These principally derive from misinformed beliefs that all training must be effective, cheap, independent of context and sustainable. The current evidence base for effective training supports local, unit-based and multi-professional training, with appropriate mannequins, and practice-based tools to support the best care. Training programmes based on these principles are associated with improved clinical outcomes, but we need to understand how and why that is, and also why some training is associated with no improvements, or even deterioration in outcomes. Effective training is not cheap, but it can be cost-effective. Insurers have the fiscal power to incentivise training, but they should demand the evidence of clinical effect; aspiration and proxies alone should no longer be sufficient for funding, in any resource setting., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Pregnancies are increasingly seen in women with a gastric band, but no guidance exists on band management during pregnancy. Although band inflation can prevent excessive gestational weight gain and its associated complications, it might have detrimental effects on fetal growth. We compared maternal and perinatal outcomes according to band management strategy-keeping the band inflated throughout pregnancy versus deflation., Methods: Data were collected by means of the UK Obstetric Surveillance System (UKOSS) on all pregnancies in women with a laparoscopic adjustable gastric band, booking in UK maternity units (Nov 1, 2011, to Oct 31, 2012). Maternal and perinatal outcomes were compared according to band management strategy, with women in a control group who had not undergone the procedure and with national data. Multivariable regression analyses were used to adjust for potential confounders., Findings: 109 cases were reported (prevalence 1·7 per 10 000 maternities), of whom 42 underwent band deflation and 54 had inflation maintained (remainder unknown). Mean weight gain was higher with deflation than inflation (15·4 kg [95% CI 10·8-20·0] vs 7·6 [3·7-11·5], p=0·047). Some evidence of a higher risk of gestational hypertension with deflation than with inflation was noted (relative risk [RR] 6·86, p=0·07). There was strong evidence of a high risk of gestational hypertension with deflation compared with controls and national data (RR 4·74, p=0·001). Mean birth weight was significantly lower in the inflation group than in the deflation group (3380 g [95% CI 3255-3505] vs 3712 [3572-3851], p=0·002). Infants of women with deflation had a high risk of macrosomia compared with controls (adjusted RR 0·40, p=0·002) and national data (RR 2·04, p=0·01)., Interpretation: Pregnant women with a laparoscopic adjustable gastric band are high risk; the monitoring of both fetal and maternal wellbeing is essential. Maintainance of band inflation during pregnancy reduces gestational weight gain and associated complications, but affects fetal growth. Therefore, maintainance of band inflation throughout pregnancy cannot be recommended. However, inflation for part of the pregnancy might improve some maternal outcomes. Further studies are needed to define the optimum timing of band adjustment., Funding: Bristol Bariatric Pregnancy Research Hub., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

This interrupted time-series study evaluated the impact of multiprofessional scenario-based training on the safety culture and teamwork climate of 3 surgical wards during a time of reduced financial resources. The authors ran 22 team training sessions for teams of 4 to 5 medical and nursing staff over a 4-month period on 3 surgical wards, using 2 scenarios based on a previously successful obstetric training program. Safety culture was measured before and after training using a validated psychometric questionnaire. After training there was a statistically significant improvement in safety culture (P = .036) on the wards. Teamwork climate improved, but the evidence was not as strong (P = .052). Perceptions of hospital management and adequacy of staffing levels showed significant deterioration. Simple, low-resource interventions can have a significant positive impact on safety culture and possibly teamwork climate on surgical wards. This could be of great value in maintaining patient safety at times of financial constraint.

We describe lessons for safety from a synthesis of seven studies of teamwork, leadership and team training across a healthcare region. Two studies identified successes and challenges in a unit with embedded team training: a staff survey demonstrated a positive culture but a perceived need for greater senior presence; training improved actual emergency care, but wide variation in team performance remained. Analysis of multicenter simulation records showed that variation in patient safety and team efficiency correlated with their teamwork but not individual knowledge, skills or attitudes. Safe teams tended to declare the emergency earlier, hand over in a more structured way, and use closed-loop communication. Focused and directed communication was also associated with better patient-actor perception of care. Focus groups corroborated these findings, proposed that the capability and experience of the leader is more important than seniority, and identified teamwork and leadership issues that require further research., (© 2013 Nordic Federation of Societies of Obstetrics and Gynecology.)

Poor teamwork results in preventable morbidity and mortality for mothers and babies. Suboptimal communication and lack of leadership cost not only lives but also money that is diverted from clinical care to insurance and litigation. Avoidable harm is usually not the result of staff failing their duty of care, it is the result of poor training failing hard-worked staff. A few simple teamwork and leadership behaviours can make a huge difference to outcome and experience for women and their companions, yet they are often missing from maternity care. Recent research has identified the problems and solutions, including the best way to train maternity teams to make a palpable difference. We describe simple yet evidence-based methods to improve teams and leaders., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Effective training has been shown to improve perinatal care and outcome, decrease litigation claims and reduce midwifery sick leave. To be effective, training should be incentivised, in a realistic context, and delivered to inter-professional teams similar to those delivering actual care. Teamwork training is a useful addition, but it should be based on the characteristics of effective teamwork as derived from the study of frontline teams. Implementation of simulation and teamwork training is challenging, with constraints on staff time, facilities and finances. Local adoption and adaptation of effective programmes can help keep costs down, and make them locally relevant whilst maintaining effectiveness. Training programmes need to evolve continually in line with new evidence. To do this, it is vital to monitor outcomes and robustly evaluate programmes for their impact on patient care and outcome, not just on participants., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: In line with the rise in the prevalence of obesity, an increasing number of women of childbearing age are undergoing laparoscopic adjustable gastric banding (LAGB), resulting in an increasing number of pregnancies with a band in place. Currently, there is no consensus on optimal band management in pregnancy. Some clinicians advocate leaving the band balloon inflated to reduce gestational weight gain and associated adverse perinatal outcomes. However, there are concerns that maintaining balloon inflation during pregnancy might increase the risk of band complications and adversely affect fetal development and/or growth as a result of reduced nutritional intake., Objectives: To compare maternal and perinatal outcomes for elective gastric band balloon deflation versus intention to maintain balloon inflation during pregnancy., Search Methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2012) and the Web of Science database (1940 to September 2012)., Selection Criteria: Randomised-controlled trials comparing elective deflation of the gastric band balloon with intention to maintain balloon inflation in pregnant women who have undergone LAGB., Data Collection and Analysis: Two review authors independently assessed studies for inclusion., Main Results: No studies met the criteria for inclusion in the review., Authors' Conclusions: To date no randomised controlled trials exist that compare elective deflation of the gastric band balloon in pregnancy versus intention to maintain balloon inflation. Further research is needed to define the optimum management of the gastric band balloon in pregnancy.

Our purpose was to investigate health care professionals' beliefs about effective teamwork in medical emergencies based on their experiences. We used framework analysis of interprofessional focus groups in four secondary and tertiary maternity units. The participants were randomly selected senior and junior doctors, senior and junior midwives, and health care assistants, in five groups of 5 to 7 participants each. We found that optimal teamwork was perceived to be dependent on good leadership and availability of experienced staff. The participants described a good leader as one who verbally declares being the leader, communicates clear objectives, and allocates critical tasks, including communication with patients or their family, to suitable individual members. We triangulated the results with evidence from simulation to identify convergent findings and issues requiring further research. The findings will inform the development of teaching programs for medical teams who manage emergencies to improve patient safety and experience.

There is little scientific evidence to support the majority of simulation-based maternity training programmes, but some characteristics appear to be associated with sustainability. Among these are a clear institutional-level commitment to the course, strong leadership in course organisation, a curriculum relevant to clinical practice, a nonthreatening learning environment, the establishment of multiprofessional training and the use of simulators appropriate to the learning objectives. There is still some debate on whether simulation-based sessions should be carried out in dedicated training time outside normal working hours or in ad-hoc drills that are run during clinical sessions, whether they should be located in clinical areas, simulation centres, or both, and whether or not they should include standardised generic teamwork training sessions. In this review, we discuss the main characteristics that appear to make a simulation-based training programme a sustainable initiative., (© 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2011 RCOG.)

Introduction: Patient satisfaction is an important healthcare outcome and communication with clinical staff is an important determinant. Simulation could identify problems and inform corrective action to improve patient experience., Methods: One hundred eight randomly selected maternity professionals in 18 teams were videoed managing a patient-actor with a simulated emergency. The trained patient-actor assessed the quality of staff-patient interaction. Clinicians scored teams for their teamwork skills and behaviors., Results: There was significant variation in staff-patient interaction, with some teams not having exchanged a single word and others striving to interact with the patient-actor in the heat of the emergency. There was significant correlation between patient-actor perceptions of communication, respect, and safety and individual and team behaviors: number, duration, and content of communication episodes, as well as generic teamwork skills and teamwork behaviors. The patient-actor perception of safety was better when the content of the communication episodes with them included certain items of information, but most teams failed to communicate these to the patient-actor., Conclusion: Some aspects of staff-patient interaction and teamwork during management of a simulated emergency varied significantly and were often inadequate in this study, indicating a need for better training of individuals and teams.

Objective: To identify specific aspects of teamworking associated with greater clinical efficiency in simulated obstetric emergencies., Design: Cross-sectional secondary analysis of video recordings from the Simulation & Fire-drill Evaluation (SaFE) randomised controlled trial., Setting: Six secondary and tertiary maternity units., Sample: A total of 114 randomly selected healthcare professionals, in 19 teams of six members., Methods: Two independent assessors, a clinician and a language communication specialist identified specific teamwork behaviours using a grid derived from the safety literature., Main Outcome Measures: Relationship between teamwork behaviours and the time to administration of magnesium sulfate, a validated measure of clinical efficiency, was calculated., Results: More efficient teams were likely to (1) have stated (recognised and verbally declared) the emergency (eclampsia) earlier (Kendall's rank correlation coefficient τ(b) = -0.53, 95% CI from -0.74 to -0.32, P=0.004); and (2) have managed the critical task using closed-loop communication (task clearly and loudly delegated, accepted, executed and completion acknowledged) (τ(b) = 0.46, 95% CI 0.17-0.74, P=0.022). Teams that administered magnesium sulfate within the allocated time (10 minutes) had significantly fewer exits from the labour room compared with teams who did not: a median of three (IQR 2-5) versus six exits (IQR 5-6) (P=0.03, Mann-Whitney U-test)., Conclusions: Using administration of an essential drug as a valid surrogate of team efficiency and patient outcome after a simulated emergency, we found that more efficient teams were more likely to exhibit certain team behaviours relating to better handover and task allocation., (© 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2011 RCOG.)

The objective of this study was to identify any residual challenges in a unit with a track record of good clinical performance. A cross-sectional survey of frontline caregiver attitudes was conducted using a validated psychometric instrument. A total of 69% (91 of 132) of eligible participants completed questionnaires. The results indicated positive safety culture, teamwork climate, and job satisfaction. Perceptions of high workload and insufficient staffing levels were the most prominent negative observations but not to the detriment of job satisfaction or perception of work conditions. Male staff had consistently better safety attitudes in multivariate analyses. The authors identified 24-hour consultant (attending) presence and better support by management as prerequisites for further improvement. Teamwork and safety attitudes are positive in a unit with established interprofessional team training. Establishing better support by senior clinical and management leaders was identified as a necessary intervention to improve attitudes and safety.

Objectives: To determine whether team performance in a simulated emergency is related to generic teamwork skills and behaviours., Methods: Design - Cross-sectional analysis of data from the Simulation and Fire-drill Evaluation (SaFE) randomised controlled trial. Setting - Six secondary and tertiary Maternity Units in Southwest England. Participants - 140 healthcare professionals, in 24 teams. Assessment - Blinded analysis of recorded simulations. Main outcome measures - Correlation of team performance (efficiency conducting key clinical actions, including the administration of an essential drug, magnesium), and generic teamwork scores (using a validated tool that assesses skills and behaviours, by Weller et al.)., Results: There was significant positive correlation between clinical efficiency and teamwork scores across all three dimensions; skills (Kendall's tau(b)=0.54, p<0.001), behaviours (tau(b)=0.41, p=0.001), and overall score (tau(b)=0.51, p<0.001). Better teams administered the essential drug 2½min more quickly (Mann-Whitney U, p<0.001)., Conclusions: The clinical conduct of a simulated emergency was strongly linked to generic measures of teamwork. Further studies are needed to elucidate which aspects of team working are critical for team performance, to better inform training programs for multi-professional team working., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: To assess whether team performance in simulated eclampsia is related to the knowledge, skills and attitudes of individual team members., Design: Cross-sectional analysis of data from the Simulation and Fire Drill Evaluation randomised controlled trial., Setting: Six secondary and tertiary maternity units in south-west England., Participants: One hundred and fourteen maternity professionals in 19 teams of six members; one senior and one junior obstetrician; two senior and two junior midwives., Methods: We validated a team performance ranking scheme with respect to magnesium administration (Magnesium Administration Rank, MAR) by expert consensus (face validity) and correlation with clinical measures (construct validity). We tested for correlation between MAR and measures of knowledge, skills and attitudes., Main Outcome Measures: Correlation between team performance (MAR) and scores in validated multiple-choice questionnaires (MCQs) (knowledge), a measure of individual manual skill to manage an obstetric emergency (skill) and scores in a widely used teamwork/safety attitude questionnaire (attitude)., Results: There was no relationship between team performance and cumulative individual MCQs, skill or teamwork/safety attitude scores., Conclusions: The knowledge, manual skills and attitudes of the individuals comprising each team, measured by established methods, did not correlate in this study with the team's clinical efficiency in the management of simulated eclampsia. The inference is that unidentified characteristic(s) play a crucial part in the efficiency of teams managing emergencies. Any emphasis of training programmes to promote individual knowledge, skills and attitudes alone may have to be re-examined. This highlights a need to understand what makes a team efficient in dealing with clinical emergencies.

Background: Introducing novel methods in undergraduate teaching of obstetrics and gynecology has been recommended. High-fidelity simulation of shoulder dystocia has been shown to improve skills of qualified maternity staff. We aimed to assess whether simulation is also useful for improving medical students' skills., Methods: Twenty-four medical students were recruited. Training consisted of a high-fidelity simulation teaching session for all 24 students and a refresher session for which the same students were randomly allocated to two groups. Half attended a small-group tutorial (SGT) and half a simulation session with a patient-actor (hybrid simulation, HYB). Afterward, they were asked to deliver a baby with simulated shoulder dystocia. We assessed their practical skills and compared communication skills between SGT and HYB. Primary outcome measure was their communication score, using a validated scale. Secondary measure was the students' ability to deliver the baby appropriately., Results: Posttraining, all students managed delivery appropriately. Group HYB had significantly higher median total patient perception scores (11 simulation versus 9 tutorial, P = 0.0239, Mann-Whitney) than SGT., Conclusion: High-fidelity simulation can be used to train and evaluate learning. The use of patient-actors during simulation improves students' communication skills. Future research should assess whether this translates into better communication with real patients.

Objective: To assess the feasibility and validity of a maternal satisfaction measurement tool, the SaFE study Patient Perception Score (PPS), after operative delivery., Design: Cross-sectional survey., Setting: A large maternity unit in England., Sample: 150 women who had had an operative birth., Methods: We recruited women within 24 hours of birth and quantified their satisfaction with two questionnaires: PPS, and the Mackey Childbirth Satisfaction Rating Scale (CSRS; modified)., Main Outcome Measures: Participation rate to determine feasibility; Cronbach's alpha as measure of internal consistency; PPS satisfaction scores for groups of accoucheurs of different seniority to assess construct validity; correlation coefficient of PPS scores with total scores from the CSRS questionnaire to establish criterion validity., Results: Participation rate approached 85%. We observed high scores for most births except a few outliers. Internal consistency of the PPS was high (Cronbach's alpha=0.83). Total PPS scores correlated strongly with total CSRS scores (Spearman's r=0.64, P<0.001)., Conclusions: The PPS is a simple and valid tool for patient-centred assessments. High scores were observed for most births but there were a small minority of accoucheurs who consistently scored poorly and these data could be used during appraisal and training.

Objective: Our objective was to evaluate a prospective monitoring and quality improvement system for studying trends in the rates of an adverse neonatal outcome, the low Apgar scores (Apgar score <7)., Study Design: A cumulative sum (CUSUM) chart-based system was used to monitor the rate of low Apgar scores over 2 years. Root cause analysis (RCA) was used to investigate for causes of periods of increased low Apgar score rates., Results: A period of deteriorated outcome (increased rates of low Apgar) occurred in August 2006. RCA identified deficiencies in cardiotocograph education, which were addressed by targeted training and mentoring. Prompt resolution followed, with the rates returning to baseline and staying within acceptable limits through to the end of evaluation in December 2007., Conclusion: Prospective and continuous monitoring of clinical outcomes using the CUSUM chart method is feasible and may be beneficial. Early detection of an adverse trend allows for timely corrective action, and may lead to overall improvements in performance.

Objective: To determine whether the introduction of multi-professional simulation training was associated with improvements in the management of cord prolapse, in particular, the diagnosis-delivery interval (DDI)., Design: Retrospective cohort study., Setting: Large tertiary maternity unit within a University Hospital in the United Kingdom., Sample: All cases of cord prolapse with informative case record: 34 pre-training, 28 post-training., Methods: Review of hospital notes and software system entries; comparison of quality of management for umbilical cord prolapse pre-training (1993-99) and post-training (2001-07)., Main Outcome Measures: Diagnosis-delivery interval; proportion of caesarean section (CS) in whom actions were taken to reduce cord compression; type of anaesthesia for CS births; rate of low (<7) 5-minute Apgar scores; rate of admission to neonatal intensive care unit (NICU) (if birthweight >2500 g)., Results: After training, there was a statistically significant reduction in median DDI from 25 to 14.5 minutes (P < 0.001). Post-training, there was also a statistically significant increase in the proportion of CS where recommended actions had been performed (from 34.78 to 82.35%, P = 0.003). There was a nonsignificant increase in the use of spinal anaesthesia for CS, from 8.70 to 17.65%, and a nonsignificant reduction in the rate of low Apgar scores from 6.45 to 0% and in the rate of admission to NICU from 38.46 to 22.22%., Conclusions: The introduction of annual training, in accordance with national recommendations, was associated with improved management of cord prolapse. Future studies could assess whether this improved management translates into better outcomes for babies and their mothers.

Confidential enquiries into poor perinatal outcomes have identified deficiencies in team working as a common factor and have recommended team training in the management of obstetric emergencies. Isolated aviation-based team training programmes have not been associated with improved perinatal outcomes when applied to labour ward settings, whereas obstetric-specific training interventions with integrated teamwork have been associated with clinical improvements. This commentary reviews obstetric emergency training programmes from hospitals that have demonstrated improved outcomes to determine the active components of effective training. The common features identified were: institution-level incentives to train; multi-professional training of all staff in their units; teamwork training integrated with clinical teaching and use of high fidelity simulation models. Local training also appeared to facilitate self-directed infrastructural change.

Context: Poor interprofessional relationships in maternity units have resulted in a number of suboptimal outcomes: students are reluctant to pursue careers in obstetrics and gynaecology (O & G); trainees feel bullied, and poor communication between professionals results in avoidable adverse events. Interprofessional learning has been advocated to improve interprofessional relationships, but recent interventions have not been successful at undergraduate level. This study aimed to address this issue locally and then to disseminate our lessons, successes and challenges., Methods: A strategy for interprofessional team-working was developed in a large maternity unit in the UK, with a variety of interprofessional interventions spanning the attachment and opportunities to participate in specific task or research teams. These interventions were evaluated before the strategy proceeded to large-scale implementation, with a validated attitudes questionnaire (Pollard) and a reaction survey., Results: Interprofessional relationships improved significantly (P < 0.05) after the O&G attachment. There was also some improvement of borderline significance (P = 0.05) in interprofessional teamwork and communication, as well as a non-significant improvement in perceptions of interprofessional interactions. Most (17/27, 63%) students stated that O&G was their primary career intention after the attachment. They did not witness any bullying or interprofessional difficulties., Conclusions: Contrary to findings in other studies, in which initial idealism has been reported to have collapsed after working with students from other professions, we achieved a positive reaction to the O&G attachment, harnessing students' initial positivity towards interprofessional learning and cementing it into real optimism. Our promising initial results suggest that more work is needed to further increase the impact of such strategies and to determine whether the improvements in attitudes translate to improved clinical behaviour and thence patient outcomes.

Introduction: We aimed to retrospectively assess the prevalence of microcarcinoma in thyroidectomy specimens from a Greek population and the role of histopathology in determining management of these patients., Methods: We used histopathological reports of thyroidectomies performed in a Greek general district hospital. The samples consisted of 191 thyroidectomies performed between January 1997 and July 2001. The female:male ratio was approximately 2:1 and the follow-up period was 327 weeks., Results: There were 29 microcarcinomas (15.2 percent) with a female:male ratio of 6:1. The prevalence rate in cases with Hashimoto's thyroiditis was significantly higher compared to cases with other benign thyroid pathology (26.8 percent versus 11.9 percent, p-value equals 0.02). Eight microcarcinomas (27.6 percent) were multifocal. The histological type was that of papillary tumour in ten cases (34.5 percent) and follicular in 18 cases (62.1 percent). There were no deaths, recurrences or metastases during the follow-up period., Conclusion: Our results suggest that incidental microcarcinomas are low-risk tumours that do not require routine further intervention. The latter may be necessary for tumours with poor differentiation or for non-incidental microcarcinomas.