Oral and Poster Presentations - Obstetrics and Gynecology

Abstracts

DOI: 10.1111/1471-0528.15493 www.bjog.org

Oral and Poster Presentations

0001 The therapeutic effects of hydroxychloroquine in combating the detrimental endothelial effects of cell-free haemoglobin (fHbF) in fetal growth restriction

Noor, M The University of Manchester, Manchester, UK Introduction Fetal growth restriction (FGR) is the failure of a fetus

to achieve its predetermined growth potential. Inadequate blood flow through the placenta has been found to be a major cause. Free fetal haemoglobin (fHbF) increases vascular resistance in the placenta, disrupting adequate blood flow. The aim of our study was to determine if hydroxychloroquine (HCQ) reduces free fetal haemoglobin-induced increase in placental vascular resistance. Methods Pregnant women at term, meeting the inclusion criteria, were recruited from the delivery unit at St Mary’s Hospital, Manchester; written informed consent was obtained. Ethical clearance was obtained from the North West Regional Ethics Committee (08/H1010/55(+5)). Ex vivo dual perfusion studies of the human placental cotyledon were utilised to assess the increase in fetal-side inflow hydrostatic pressure (FIHP) when fHbF was used alone compared with fHbF with HCQ. Results A lower rise in FIHP was seen when fHbF was administered in the presence of HCQ than fHbF on its own (significance at 10% level, P = 0.085). The mean increase in absolute FIHP using fHbF alone and fHbF with HCQ was 35.07 8.79 and 20.77 4.32, respectively. Conclusion HCQ is effective in reducing fHbF-induced rise in placental vascular resistance. This has positive implications for FGR, a disease in which fHbF is elevated along with vascular resistance. Further experiments need to be conducted to increase the significance of the data, which can then be taken further in the form of clinical trials in high risk for FGR pregnancies.

0007 Operative delivery: transforming skin-to-skin contact, reducing stress and improving birthing partner experience. A patient education approach

Saba, S1; Davies, M1; Johns, N2; Cullis, K3 1

Russells Hall Hospital, Dudley, UK; 2Department of Obstetrics, Birmingham Women’s Hospital, Birmingham, UK; 3Department of Anaesthetics, Birmingham Women’s Hospital, Birmingham, UK Introduction The benefits of early skin-to-skin contact are clear.

These can be overlooked in the operating theatre. Theatre delivery

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is stressful for all. We utilised a patient education approach to improve awareness and skin-to-skin following operative delivery, and reduced stress and improved experience amongst birthingpartners. Methods Birthing partners of women who underwent operative delivery were surveyed. Twenty birthing partners were surveyed regarding the occurrence and awareness of skin-to-skin in theatre and overall experience. An information poster was produced to outline events which occur in theatre. Posters have been placed in key areas of patient contact. Re-survey was undertaken to evaluate their impact. Results A skin-to-skin rate of 25% was initially identified, with a 30% partner-awareness rate. High levels of stress amongst birthing partners were identified, with 90% of partners indicating a lack of information as a factor. Following poster installation, re-survey identified a 78% increase in provision of skin-to-skin, with an improved awareness rate of 71%. 89% of partners reported a stress-reducing effect of reading the poster, with 82% reporting an overall improvement in their birthing experience. Conclusion Our work demonstrates an effective method in improving operative skin-to-skin rates, highlighting education as a tool for reducing stress. Our posters provide an excellent resource for the preparation of patients, family and staff regarding events which occur in an obstetric theatre.

0008 The role of simulation in obstetric emergencies for non-speciality trainees

Athey, R Sheffield Teaching Hospitals, Sheffield, UK Introduction At SHO level, labour ward is covered by a mixture

of speciality trainees, GP speciality trainees and F2s. As an F2, I was an obstetric SHO on call at a busy tertiary centre when I experienced a critical event. An otherwise uncomplicated delivery on the midwifery-led unit had resulted in a shoulder dystocia. Despite the best efforts of the consultant, senior registrar and senior midwife, the time between delivery of the head to delivery of the body was over 9 minutes. As a non-speciality trainee, I had very limited knowledge of obstetric complications and my expected role in this scenario which made for a very difficult experience. As a direct result of this incident, I developed a simulation training afternoon for common obstetric emergencies to be delivered for all rotating SHOs as a part of their induction.

ª 2018 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2018 RCOG


Methods We ran five simulation stations with part task trainers, utilising a facilitator of ST3 or above at each station. The stations covered shoulder dystocia; post-partum haemorrhage; eclamptic seizure; adult resuscitation; and emergency caesarean (Category 1). This was delivered as an afternoon session at the end of their two day induction. Results Feedback sheets asking participants to self assess their knowledge and confidence were distributed before and after the pilot session. This demonstrated a qualitative improvement in both areas. Conclusion After the initial pilot was demonstrated to be a success, the simulation teaching sessions have been incorporated in the standard induction for all rotating SHOs.

0009 Current evidence on the efficacy and safety of treatments for a symptomatic cyst or abscess of the Bartholin’s gland: a systematic review

Illingworth, B1; Stocking, K2; Showell, M3; Kirk, E4; Duffy, J5 1 University College London, London, UK; 2Manchester University NHS Foundation Trust, Manchester, UK; 3University of Auckland, Auckland, New Zealand; 4The Royal Free Hospital, London, UK; 5 Balliol College, University of Oxford, Oxford, UK

Introduction Different treatments are frequently used in the

management of Bartholin’s cyst or abscess. As no national or international guidelines exist to inform the management of Bartholin’s cyst or abscess, we undertook a systematic review of randomised trials to assess the effectiveness and safety of potential treatments to inform clinical practice recommendations. Methods We searched bibliographical databases, from inception to February 2018. Randomised trials evaluating any treatment for Bartholin’s cyst or abscess were included. Two researchers independently assessed studies for, inclusion, methodological quality, and extracted relevant data. We used the fixed effect (Mantel–Haenszel method) to calculate summary estimates. Results Seven randomised controlled trials, reporting data from 545 women with Bartholin’s cyst or abscess, were included. There was trials were insufficiently powered to demonstrate differences in the recurrence of a Bartholin’s cyst or abscess within twelve months when comparing marsupialisation with Word catheter (RR 0.83; 95% CI 0.35–2.00), incision, drainage, and silver nitrate insertion (RR 0.92; 95% CI 0.54–1.57), and incision, drainage, and cavity closure (RR 0.25; 95% CI 1.01 to 2.89). There was limited reporting of secondary outcomes, including haematoma, infectious morbidity, and persistent dyspareunia. Conclusion There is no high-quality evidence to support the use of any single intervention for the treatment of Bartholin’s cyst or abscess. Other commonly used interventions including aspiration, alcohol sclerotherapy, and rubber ring catheter have not been sufficiently evaluated in randomised trials.

0010 Validation of the Welch Allyn Connex Spot BP monitor on the accuracy of blood pressure measurements in pregnant and preeclamptic women

Geddes-Barton, D; Palaniappan, V Queen Elizabeth Hospital, Woolwich, UK Introduction The aim of the study is to evaluate the accuracy of

the Welch Allyn Connex Spot device on pregnant women with and without preeclampsia using the British Hypertension Society validation protocol. Methods Blood pressure was measured sequentially in 30 women of any gestation. Trained observers took six sequential same arm measurements alternating between the Connex Spot and taking the blood pressure manually. Results The Welch Allen Connex Spot achieved an overall A/B grade with a mean of the device–observer difference being 5.1 3.7 and 5.2 4.7 and therefore overall passed the validation criteria of the BHS protocol for pregnancy. However when looking at the women with a blood pressure greater than 140/90, it achieved a D/D rating and therefore failed to meet the validation criteria. Conclusion The Welch Allyn Connex Spot monitor cannot be recommended for measurements of blood pressure in women with blood pressure greater than 140/90 who are at risk of having preeclampsia.

0013 Integration of research into clinical practice – vaginal cleansing pre-caesarean section to improve infection rates: a quality improvement project

Mulji, Y; Yousuf, A; Page, L West Middlesex University Hospital, London, UK Introduction Post-partum endometritis occurs in about 27% of

caesarean deliveries. Research confirms that the simple, low cost procedure of vaginal cleansing halves the risk of post-partum endometritis. The main aim of this project was to integrate evidence-based research into clinical practice. The secondary aims were to audit the number of infections and to gather staff feedback on the change of practice. Methods Initiation of new practice requires careful planning and collaboration with a multidisciplinary team. We raised awareness via meetings and visual reminders, created a standard operating procedure and added cleansing to the surgical checklist. An audit was undertaken for 4 weeks before and after introduction of vaginal cleansing with a subsequent survey to gain staff insight. Results A total of 355 patients were included. 6% versus 4% of pre- versus post-intervention patients presented postnatally with infection (45% versus 27% of whom required admission for IV antibiotics respectively). Initial compliance with vaginal cleansing was 65%, which subsequently improved to 81%. All members of


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staff who performed vaginal cleansing accepted that it was easily performed. Conclusion Despite various challenges, vaginal cleansing precaesarean section was successfully integrated into everyday clinical practice. This was due to careful planning and inclusion of various multidisciplinary members. Improved compliance was a reflection of staff understanding of the importance of vaginal cleansing as well as integration of this new practice into the presurgical checklist for all patients undergoing caesarean sections.

0018 Telephone reviews following major gynaecological surgery – a pilot study

Wylie, J; Johnston, L Causeway Hospital, Coleraine, UK Introduction Whilst waiting list initiatives have impacted on the

time patients wait for a new appointment in outpatients, reviews have not been included. Patients are waiting longer than their supposed interval to be seen. To reduce the waiting time for gynaecology clinics in Causeway, a pilot was launched to review uncomplicated post-op major gynaecology cases by telephone. It was hoped this would free up appointments enabling patients needing reviewed for chronic conditions to be seen in a more timely manner. Methods A proforma questionnaire was created and released for consultation and amendment by involved parties. Senior nurses on the gynae ward kindly offered their time to perform the reviews and their input has been key to the early, apparent success of the project. The questionnaire has been amended according to highlighted queries from patients and staff. Results 95% of patients receiving phone reviews were able to be discharged without a face to face clinic review. During the six month pilot, the total number of overdue review appointments was reduced from 71 to 13 for general gynaecology (urogynaecology excluded). Patient satisfaction surveys showed 80% of patients believed the phone review to be more convenient whilst also meeting their needs. All participants felt able to ask questions were satisfied with the information provided. Conclusion A simple intervention has the ability to revolutionise the way in which we can provide care to patients. Whilst providing patient-centred, convenient and safe follow-up to our post-op patients we have also facilitated the release of more outpatient appointments.

0019 Detection rate of major congenital cardiac anomalies in East Sussex Healthcare NHS Trust

Dickinson, O; Roberts, N East Sussex Healthcare NHS Trust, Hastings, UK Introduction Congenital heart disease (CHD) is the leading cause

of major congenital defects and is the leading cause of infant

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mortality. Breakthroughs in cardiovascular diagnostics and cardiothoracic surgery led to an increased survival with patients reaching adulthood; therefore, evaluation of the fetal heart and careful documentation of pathologic anatomy have become a critical component of fetal ultrasonography. In the UK, the Fetal Anomaly Screening Programme (FASP) set out a standard for 50% detection rate of serious cardiac anomalies at the 18 + 0 to 20 + 6/40 anomaly scan. Early detection reduces pre-diagnosis neonatal collapse and deaths from critical CHD; improves longterm outcomes; allows early referrals and counselling; and gives parents earlier choice over the pregnancy options and logistics of care. Methods This was a retrospective audit of recorded cases of CHD at East Sussex Healthcare NHS Trust between 2013 and 2016. Over the 4-year period there were 46 cases of major cardiac anomalies recorded in the local Fetal anomaly register. After the relevant exclusions 31 cases were reviewed. Results The audit showed overall detection rate of 74.5% with 40% detection in 2015 and 100% in 2016. The overall rate met the FASP standard of 50% detection. Conclusion Although the overall average detection rate exceeded the set National standard, year on year the rate varied. Audit limitations included a single source of data (local Fetal anomaly register), recent migration to paperless notes, and lack of formal method for alerting the department of cases subsequently diagnosed by GP practices, Tertiary Paediatric Cardiology Centres, etc.

0020 Management of monochorionic diamniotic twins at Jessops wing

Halley, B Jessops Wing, Sheffield, UK Introduction A service review to establish whether patients with

MCDA twins are receiving appropriate care at Jessops wing. The incidence of twin pregnancy is approx. 3% and is increasing due to assisted conception. Monochorionic twins are high risk for twin-to-twin transfusion syndrome (TTTS), preterm birth, selective fetal growth restriction, and pre-eclampsia. RCOG recommends 2 weekly scans from 16 weeks to identify patients at risk of TTTS and growth restriction. Scans should cover 4 key areas – (i) estimated fetal weight (EFW), (ii) liquor volume, (iii) Doppler and (iv) fetal bladders. Methods 125 sets of twins were identified covering a one-year period. Booking scans were reviewed to determine chorionicity. Late fetal loss/stillbirths were identified via MBRRACE report. Exclusion criteria: DCDA twins, transfers from out of area, patients who did not have their full antenatal care at Jessops. Results 36% of scans met all 4 key criteria. 80% of patients saw a consultant/senior Spr on booking. 60% had risks of TTTS, preterm birth, and birth plan discussed. 45% of patients referred to FMU, using 55 clinic slots. Conclusion Care of women with MCDA twins at Jessops wing appears substandard. A specific twins clinic with MDT care would improve patient experience and could improve outcomes. A scan



proforma for sonographers should be implemented to ensure all 4 scan criteria are being met at each scan. A booking visit proforma for twins should be implemented to ensure all risks are discussed. A specific twins clinic would also reduce the burden on FMU appointments.

0021 Barriers to exception reporting: improving the working environment for junior doctors

Damodaram, M; Khan, S East and North Hertfordshire NHS Trust, Stevenage, UK Introduction The 2016 junior doctors’ contract features exception

reporting as a tool to enable doctors in training to report concerns. Anecdotal evidence however suggests the doctors who exception report remain in the minority. Methods A trust trainee survey was run from January to February 2018. Seventy-six trainees from all specialities, ranging from FY1 to ST8 responded. Results 65% of trainees reported working beyond their rostered hours at least monthly. Of the doctors who worked late, 8% submitted an exception report. The top five reasons given for not doing so were: being required to stay for a period of time that was perceived as non-significant (0.5–1.5 hours; cited by 21%), lack of clarity on it (cited by 15%), a perception that it is negative (cited by 15%), an agreement for informal time off in lieu (cited by 8.9%), and out of choice for training reasons (cited by 8.9%). Conclusion We tried to address barriers to exception reporting by having guidance on the intranet homepage and having a teaching session for trainees and education supervisors covering exception reporting. The measures undertaken above have attempted to address barriers to exception reporting caused by lack of guidance, it is however unlikely to address the barriers that are due to the apprenticeship style training model in some specialities. Exception reporting has the potential to highlight unsafe working patterns which in turn has implications for patient and staff safety, and removing barriers to it should remain a high priority for all trainers in the NHS.

0022 Audit of cell salvage practice over a 4-year period in patients undergoing caesarean section in a District General Hospital

Badger, E; Boyes, Z; Yoxall, P St Helens and Knowsley Trust, Prescot, UK Introduction Transfusion of allogenic blood products has

recognised adverse effects. Due to the risks, cost and relative short supply of blood products there is an incentive to use an alternative and cost-effective process of managing intraoperative blood loss. Cell salvage can significantly reduce the use of transfusion by 38% and offers a safe alternative with physiological benefits for the patient.

Methods All patients undergoing caesarean section from 2012 to 2016 were identified. Data were obtained from Medway and Maxims computer systems. Results There were 3955 deliveries in 2016. Of these, 1061 delivered by caesarean section. This gave a 26.2% caesarean section rate. The average BMI was 28.2 and average pre-operative haemoglobin was 115 g/l. The average intraoperative blood loss was 523 mL. Cell salvage blood was collected in 481 patients and returned in 248 giving an overall efficiency rate of 52%. A total of 26 patients received a transfusion of blood. Of these, the average blood loss was 929 mL and 10 of these patients also received cell salvaged blood. Of the 26 patients receiving a transfusion, 15 had a starting haemoglobin of 100 g/l (52%). Those with a starting haemoglobin of 90 g/l or less were at significant risk of requiring transfusion of allogenic blood (32%). Conclusion Our audit demonstrated the success that can be achieved with a dedicated cell salvage service. We recommend that cell salvage is utilised routinely with a starting haemoglobin of 110 g/l or less and more frequent use of cell salvage will be costeffective in the long term.

0024 Management of cardiac pacemaker in pregnant patients

Kamal, B1,2; Ejaz, H2; Shearer, K2 1 Aberdeen Royal Infirmary, Aberdeen, UK; 2Aberdeen Maternity Hospital, Aberdeen, UK

Introduction In terms of management of pacemaker in pregnancy

very little data is available worldwide. As the number of younger people having cardiac pacemaker is increasing, there is growing need to know more about the basic knowledge of pacemaker technology and monitoring for surgical intervention during pregnancy. To recognise the importance of multidisciplinary approach for the care of pregnant patients with cardiac pacemaker. Awareness of the basic principles related to management of pregnant patients with pacemaker. Method Retrospective audit. Out of 46 patients only 13 patients were pregnant with cardiac pacemaker. Standards were identified using NHS Grampian protocol “Permanent pacemaker patient: pre/post operative protocol”. Variables identified and compared include preconception counselling, cardiac assessment, labour, mode of delivery, type of procedure, diathermy and magnet use. Results We found that cautery was avoided in all surgical procedures. No anticoagulation was used apart from routine thromboprophylaxis. Route of delivery was based on obstetric indications. The results were in accordance to the standards identified. Pre-conception counselling (100%), cardiac assessment (100%), spontaneous labour (69%), PPROM (15%), IOL (8%), caesarean section (54%), SVD (30%), NVB (8%), KFD (8%), emergency caesarean (39%), elective caesarean section (15%), diathermy and magnet use (100%) avoided Conclusions Avoid using electro cautery if at all possible. Bipolar modes only should be used if needed. Restrict the output to


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2 seconds bursts and leave 10 seconds between each output for electro cautery.

0026 Outpatient induction of labour with the Cook Cervical Ripening Balloon: a pilot study

Sampson, V; Mazzocchi, E; Kropiwnicka, Z; Samy, A; Otigbah, C Queen’s Hospital, Romford, UK Introduction Induction of labour is an intervention that is

increasing. The majority of inductions occur with prostaglandins which have the known side effect of hyperstimulation and foetal heart rate changes. These tend to take place on an inpatient basis. Outpatient induction has been gaining favour as it reduces the workload for staff and reduces cost as a result of reduced length of stay. However, the use of prostaglandins restricts birth options, by excluding birth centre. The Cook Cervical Ripening Balloon (CCRB) has been shown to reduce the incidence of hyperstimulation making it an ideal agent for a trial of outpatient induction. Methods An extensive training programme was developed for safe insertion of CCRB. Strict criteria were developed to ensure only appropriate women were selected. Data on outcomes were gathered daily to monitor for any adverse events. Patient satisfaction was collated post-delivery. Results One hundred women were recruited. 69% were primips. Postdates was the commonest indication (70%). 20% delivered on the birth centre – compared to 0% previously. Modal time from insertion to delivery was 36 to 48 hours. Approximately 50% of this time was spent at home. The CS rate was 22%, an improvement from 30%. Patients reported high acceptability of the outpatient CCRB process. Conclusion The results are promising: higher vaginal delivery rate and significant reduction in length of stay and cost alongside good maternal/neonatal outcomes. Using the CCRB has improved capacity without impacting on safety. We recommend ongoing usage of the CCRB in this capacity to continue assessing its suitability.

0027 Does medicalisation of pregnancy and childbirth promote good birth outcomes for mothers and infants? A review of narratives from developing and developed countries

Sunil, S Lancaster Medical School, Lancaster, UK Introduction Medicalisation occurs when non-medical problems

are treated as medical problems. It is particularly controversial in pregnancy and childbirth, as in the last few decades it has strongly been influenced by the feminist movement.

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Methods A literature review was conducted exploring the three discussion topics by comparing the similarities and differences between developed and developing countries. Research was carried out using findings from a pilot study of 121 women, a crosssectional study, narratives by sociologists and 47 qualitative interviews. Results Estimations made by the World Health Organization in 2015 indicated that the average maternal mortality ratio was 239 per 100,000 live births in developing countries and 12 per 100,000 live births in developed countries. In developing countries, there is a smaller number of women that receive antenatal care visits or any contact with skilled healthcare professionals. Inadequate services and the lack of resources appear to be an important factor that contributes to the high mortality rate. The negative effects of medicalisation felt by women in developed countries neglects the freedom of opportunity they have, in order to decide where and how they want to give birth. Conclusion Medicalising pregnancy can have different outcomes on women in developed versus developing countries. For the latter, the benefits seen are more straightforward where there is a reduction in the maternal and infant mortality rates. Yet, for women in developed countries, medicalisation causes problems that are more spiritual in nature where the ability to feel empowered during this process is impeded through the involvement of obstetricians in their birth.

0028 Should a planned elective caesarean section be the first option for a breech presentation from 37 weeks’ gestation during labour in a multiparous woman? A review of the current methods of management

Sunil, S Lancaster Medical School, Lancaster, UK Introduction It is recommended by the RCOG to offer a planned

caesarean section for breech babies. The publication of the Term Breech Trial has led to an increase in elective caesarean rates from 24% to 60%; however, there are still even more stipulations as to how a breech baby should be delivered. Methods Comparison of mortality/morbidity rates was made between external cephalic version, vaginal delivery and caesarean section by conducting a literature review. Research was carried out using findings from 14 RCTs, 241 articles, a retrospective cohort study and a qualitative study. The search was conducted using PubMed and Cochrane Library. Results The TBT indicates an increase in the difference of 3.6% in neonatal health problems in the planned VD group. However, there are conflicting studies to this trial which indicate delayed recovery after birth through VD but with no significant harm to the mother or the baby after a 2 year follow-up. Conducting an ECV on breech babies older than 34 weeks has shown to increase the rates of cephalic presentation at birth, therefore reducing the need for a CS. Studies indicating that VDs are more harmful have



limitations in their study design such as a small sample size, inability to predict the outcomes in practice in the UK due to some of the studies being conducted in other countries and the lack of blinding in the trials. Conclusion VD should be considered in mothers who meet the criteria for a successful ECV; this should be encouraged to carry out in mothers who present with breech.

0031 Service evaluation of antenatal guidance for monitoring fetal movements: effects on maternal understanding and reassurance

Chan, A1; Hughes, S2 1 Manchester Medical School, Manchester, UK; 2Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK

Introduction Maternal perception of reduced fetal movements

0029 The relationship between race and risk factors for recurrent miscarriage. A retrospective cohort study

Sunil, S1; Quinn, S2 1

Imperial College London, London, UK; 2Imperial College Healthcare NHS Trust, London, UK Introduction Recurrent miscarriage (RM) is the loss of a uterine

pregnancy on more than three consecutive occasions. Maternal factors such as advanced age, obesity, smoking and alcohol consumption are associated with an increased risk of RM. Thrombophilias such as factor V Leiden mutation, prothrombin G20210A mutation and antiphospholipid syndrome increase bleeding risk at the uteroplacental site resulting in fetal loss. Thromboelastogram (TEG) is a measure of an individual’s haemostatic capabilities, and it can be used to assess the thrombotic state of a patient. This study is unique in assessing ethnic variations in TEG parameters and thrombophilias in the RM population. (i) To assess the relationship between ethnicity and risk factors for RM; and (ii) to assess interracial variations in TEG parameters in the pre-pregnant and the early pregnancy stages. Methods This is a retrospective cohort study of 1612 women that attended the RM clinic at St Mary’s Hospital, London, between July 2014 and January 2018. A Kruskal–Wallis test was used to identify significance in continuous variables and a chi-squared test was used for categorical variables. Mann–Whitney tests were used to identify interracial variations across the variables. Statistical significance was evaluated as P < 0.05. Results There were significant interracial variations across all risk factors: maternal age (P = 0.002), BMI (P < 0.001), smoking (P = 0.004) and alcohol consumption (P < 0.001). There were significant variations in the pre-pregnancy TEG parameters: maximum amplitude (P < 0.001), LY30 (P = 0.003) and LY60 (P < 0.001). Conclusion There is a significant South Asian dominance in certain risk factors for RM which includes reduced smoking and low pre-pregnancy LY30 and LY60.

(RFM) is associated with poor pregnancy outcomes, including stillbirth. The objectives of this service evaluation were to explore how women understand guidance for fetal movement (FM) monitoring and how reassurance is achieved for presentations of perceived RFM. Methods Structured interviews were conducted with 60 women receiving care in the maternity unit at Royal Preston Hospital. Qualitative responses for women’s experiences of FM and the maternity services were analysed by thematic analysis. Women indicated agreement to statements regarding maternal understanding and reassurance on Likert-type scales. Results 93.3% of women had received professional information about FM during routine care; participants demonstrated good understanding and accurate recall of instructions. Women avoided using negative words such as ‘death’ in responses; it was unclear if there was true understanding of the association with stillbirth. 66.7% of women had RFM concerns at least once prior to interview. Immediate reassurance was best achieved if the woman attended maternity triage to hear the fetal heartbeat and receive explanation from an experienced midwife. Conclusion Women at Royal Preston Hospital are satisfied with the guidance and management they receive for RFM. Clinicians should continue to emphasise evidence-based recommendations to clarify maternal understanding. The training of midwives to perform ultrasound scans independently could also be considered. There may be potential to raise public awareness by encouraging professionals to discuss the topic of stillbirth, particularly with women who do not engage with FM monitoring or fail to seek further assessment of RFM.

0032 Review of success and morbidity from mid-urethral tapes – audit for the Gynaecology Department at Sunderland Royal Hospital

Longden, E Newcastle University Medical School, Newcastle upon Tyne, UK Introduction Mid-urethral tapes (MUT) are used to improve

urodynamic stress incontinence. These are minimally invasive and have a high success rate; however, in certain cases, complications such as tape erosion and pelvic pain can occur. Methods The aims were to assess pre-procedure counselling, decision-making, procedural success and follow-up through adherence to NICE guidance. This was a retrospective audit of patients who underwent a MUT at Sunderland Royal Hospital between 2012 and 2017. Data were collected using paper record


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retrieval, including consent forms, operation notes and discharge letters, and evaluated against standards based on NICE guidance. Results Prior to analysis, patients under the care of Urology were excluded, giving a sample size of 60 patients. Prior to surgery, 86% of patients (n = 52) were offered physiotherapy and all patients had urodynamic assessment. Fewer patients were offered a range of continence surgeries (55%, n = 33) or discussed at multidisciplinary team meetings (12%, n = 7). The main complications documented were chronic pain 34%, mesh erosion 62%, overactive bladder 80% and voiding difficulty 91% (mean = 67%). 46 women had the outcome of their procedure documented, and 36 were satisfied, giving a success rate of 78%. At follow-up, half of patients had a speculum examination to exclude erosion, and an average of 71% were asked about complications. Conclusion Adherence to NICE guidance is below standards in almost all domains; areas for improvement are counselling and follow-up. Professionals should use the standardised consent proforma to document risk. Complications should be assessed using a pre- and post-procedure questionnaire.

0033 An audit of fetal scalp blood sampling procedures at St Mary’s Hospital

Abid, Z1; Heazell, A2 1 University of Manchester, Manchester, UK; 2Tommy’s Stillbirth Research Centre, University of Manchester, Manchester, UK

Introduction An audit of the practice of fetal scalp blood

sampling (FSBS) in St Mary’s Hospital (SMH) was conducted against set standards derived from the National Institute for Health and Care Excellence (NICE) Intrapartum Clinical Guidelines, last updated in February 2017. Methods A prospective study was conducted of 90 women who underwent 139 FSBS procedures during a one-month time period. Interventions were set to see whether practice can be improved immediately. Data required to fulfil audit requirements were collected along with data relating to maternal age, neonatal outcome and mode of delivery. Audit summaries of the last eight years were also analysed and a comparison of audits were made. Results There was a net improvement in audit standards set against NICE Intrapartum guidelines in comparison with previous years. An increase in FSBS procedures from 1 to 3 during labour resulted in a decrease in spontaneous vaginal birth from 49% to 35% to 25% respectively. A 4th FSBS procedure in labour resulted in a 50% chance of the labour progressing to spontaneous vaginal birth. One of two interventions was successful in improving practice of reviewing CTGs according to set time interval. A correlation was also identified between advancing maternal age and caesarean sections. Conclusion The re-audit of FSBS procedures at SMH demonstrated an improvement in standards. Continual re-audit should be conducted to maintain standards of quality of care of mothers and babies in the UK.

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0034 The effect of probiotic supplementation on gestational diabetes mellitus and metabolic outcomes: a randomised controlled trial

Charles, D1; Drymoussi, Z2; Thangaratinam, S2 1 Barts and The London School of Medicine and Dentistry, London, UK; 2Women’s Health Research Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK

Introduction Gestational diabetes mellitus (GDM) is an important

complication in pregnancy associated with adverse effects for the mother and infant. Probiotic supplementation has been proposed as a novel treatment. We present a secondary analysis of an additional outcome of the PrePro pilot study, to assess the effects of probiotic supplementation on the risk of acquisition of GDM and serum glucose in pregnant women and to determine suitable criteria and parameters for the assessment of GDM in future studies. Methods 304 pregnant women were randomised into two groups which received either probiotic or placebo capsules. Capsules which contained Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-1 were given daily from early pregnancy till the end of pregnancy. Participants in this analysis were then given a 75 g oral glucose tolerance test (OGTT) with measurements at 0 hour and 2 hours. GDM status was determined according to several international criteria. Results 110 pregnant women were assessed for GDM by OGTT. No difference in the rate of GDM was seen between those given probiotics and those given controls under the NICE (RR 0.80, 95% CI 0.41–1.57, P = 0.52), WHO (RR 1.04, 95% CI 0.50–2.18, P = 0.91) and IADPSG definitions (RR 1.16, 95% CI 0.54–2.49, P = 0.70). Similarly, mean fasting plasma glucose (FPG) did not significantly differ between those given probiotics and those given placebo capsules (MD -0.18, 95% CI 0.42 to 0.06, P = 0.15). Conclusion In a secondary analysis, the provision of probiotic capsules containing Lactobacillus did not significantly influence FPG in pregnant women.

0035 An audit of external cephalic version success rates

Wylie, S; Modder, J University College London Hospital, London, UK Introduction Breech presentation complicates 3–4% of deliveries.

External cephalic version (ECV) is successful in approximately 50% depending on parity, and reduces rates of caesarean section (CS). The aim was to investigate the success rate of ECV at UCLH and possible contributors to the success rate. The standards used were taken from local UCLH guidelines and the RCOG Green Top Guidelines. Both guidelines highlighted all women with breech presentation at term should be offered an ECV. Methods Reviewing 6 months of retrospective ECV cases; a total of 48 notes (of which 31 notes, 64.5%) were retrieved. Booked ECV procedures identified from outlook calendar. Outcome of



ECV and clinical data were obtained from maternity notes and local CDR. Results A total of 23 notes were analysed. Local UCLH success rates are 39.1% (Multips 50%, Nullips 30%). Tocolysis was used in 95.6% cases (22/23). Flexed breech and AFI>10 were more common amongst our successful ECVs. Success rates by operator were: Consultants 36.4%; Senior Registrars ST6-7 50%; and Specialist Registrars ST3-5 25%. Outcome modes of delivery were vaginal cephalic, CS cephalic, vaginal breech, elective CS breech (ElCS) and emergency CS (EmCS) breech (30.4%, 13%, 0%, 26.1%, 30.4% respectively). Conclusion UCLH ECV success rates are lower than the national average. The majority of successful ECVs had a flexed breech, AFI>10 and progressed to a vaginal cephalic delivery. The importance of continual analysis of local success rates is to provide our women with enough information to make an informed choice of having an ECV at our hospital.

0036 An evaluation of the multiple scan pathway in predicting small-for-gestational-age babies: a retrospective study

Morrall, J University of Manchester, Manchester, UK Introduction Small-for-gestational-age refers to a baby born

underweight compared to others born at the same gestation and carries increased obstetric risk. The multiple scan pathway aims to monitor pregnancies at risk of SGA. This study aimed to evaluate the relationship between risk factors in the pathway and the incidence of small-for-gestational-age births. Methods A retrospective study of 996 births over a 3-month period at Lancashire Teaching Hospitals. Analysis was run to determine the effect of maternal risk factors (age, BMI, smoking, cocaine and comorbidities), previous pregnancies (previous SGA births and stillbirths) and current pregnancy complications (low PAPP-A and multiple pregnancies) on SGA births. Results The following risk factors were found to be statistically significant: smoking ≥11 cpd (P = 0.044), previous SGA (P = 0.016), >1 SGA births (P = 0.004), PAPP-A ≤ 0.4 (P = 0.007) and multiple pregnancy (P = 0.036). The following did not show significance, maternal age ≥40 (P = 0.514), cocaine use (P = 0.797), diagnosis of comorbidities (hypertension P = 0.289, diabetes P = 0.797, renal disease P = 0.797, antiphospholipid syndrome P = 0.711) or maternal BMI ≥35 (P = 0.357). Conclusion There is high variability in the relationship between risk factors and SGA births. Previous pregnancy outcomes, maternal risk behaviours & current complications appear to be the most clinically significant. More data collection is required for risk factors with an insufficient study size. Maternal age and BMI may be causing an overuse of the pathway and as a result overconsumption of time and staff capital. As pressures within the NHS continue to rise, it is imperative to appraise current guidelines to improve both patient care and reduce unnecessary resource utilisation.

0039 Induction of labour for post-dates re-audit of York and Scarborough sites

Robinson, M; Riaz, T York Teaching Hospital NHS Foundation Trust, Scarborough, UK Introduction Induction of labour (IOL) is a common procedure;

20% of pregnant women require IOL for various reasons. Only consider when vaginal delivery is appropriate delivery mode IOL decision is made by either: - Consultant team the woman is booked under - Community midwife if woman post-dates + pregnancy low risk IOL offered for low-risk pregnancies from 40 + 12 to 40 + 14 weeks If patient requests IOL prior 40 + 12 - Discuss with consultant Method Retrospective audit Audit proforma included: - 3 standards, age, BMI, parity, gestation - Outcome, Apgars, EBL, total inpatient stay - IOL timings, IOL method used, complications Audit period: - 1 July 2017 to 31 July 2017 on 40x patients Patients identified with audit department assistance Data collection via clinic notes and IOL proforma Results IOL dates offered in York and Scarborough was both at 41 + 5/40. Membrane sweep offered to 100% of patients in both sites. 68% of patients in York and 82% in Scarborough had propess. 44% of patients in York and 38% in Scarborough had SVD. 25% of patients in York and 33% in Scarborough had instrumental delivery. 31% of patients in York and 29% in Scarborough had urgent LSCS. 9 patients in York and 7 patients in Scarborough had PPH. Conclusions Every patient offered membrane sweep across both sites - B/w 40 + 0–41 + 0 weeks’ gestation Standard of 100% was achieved 95% accepted membrane sweep - 37.5% accepted, were unable to have membrane sweep 5% declined membrane sweep No change identified from previous audit’s results.

0042 Improving objective assessment during inpatient bladder training for overactive bladder

Roper, J; Byrne, V; Bach, F; Toozs-Hobson, P Birmingham Women’s Hospital, Birmingham, UK Introduction Inpatient bladder training is offered to patients

with symptoms of overactive bladder in whom routine treatments have failed, those with complex symptoms or to those with additional physical or social needs. It is provided as a tertiary service and involves in-depth, multidisciplinary assessment and treatment for the 5-day in-patient stay. The mainstay of treatment is carefully tailored bladder retraining by increasing set times between voids with adjuncts of medication,


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Botox and PTNS. Our previous study found positive Results for inpatient bladder training but it was noted that the documentation had little structure and did not focus on patientreported outcomes and experience. A new inpatient bladder training booklet was developed to improve documentation during admission and a re-audit performed. Methods A retrospective case-note review of 8 patients admitted in the 3 months after booklet introduced. Results The booklet improved documentation by

average increase of 23.3% in DDX4-expressing germ cells compared to vehicle control (n = 3, P = 0.71). Conclusion As key events in establishing female fertility occur during fetal life, these results indicate that exposure to paracetamol in utero could have consequences for subsequent fertility and reproductive lifespan.

Structured doctor review Designated area for daily nurse comment Specific patient feedback

0044 Reduced fetal movements: a cohort observational study at the Royal Surrey County Hospital

Objective outcomes showed incontinence frequency was cured or improved in 75% of patients and 88% of patients had cure or improvement in frequency of nocturia. 50% of patients made positive comments about their experience. Conclusion Since the booklet has been introduced objective outcomes have improved but this may reflect improved documentation rather than an enhanced service. There is still improvement needed in documenting subjective outcomes and this can be addressed with encouragement to staff using the booklet. The booklet empowers nurses and patients to have more input into the bladder training process.

Yong, N; Morton, K

0043 The effect of analgesics on the germ cell population in the developing fetal ovary

Blyth, UE; Dunlop, CE; Anderson, RA MRC Centre for Reproductive Health, The Queens Medical Research Institute, University of Edinburgh., Edinburgh, UK Introduction Paracetamol is the recommended analgesic in

pregnancy, and over half of pregnant women will use paracetamol. Germ cells replicate by mitosis through the first trimester, with progressive entry into meiosis and initiation of follicle formation during the second trimester. During this period, germ cells may be particularly sensitive to their external environment. Our aim was to investigate the effect of paracetamol on the germ cell population within the human fetal ovary. We hypothesised that exposure to paracetamol will affect germ cell numbers in comparison with control groups. Methods Ethical approval was gained, women gave informed consent, and fetal ovaries were obtained following medical termination of pregnancy. Gestations ranged between 9 and 19 weeks. Ovaries were cultured for seven days in medium containing 100 lmol/L paracetamol or its vehicle DMSO. The samples were processed for immunohistochemistry for LIN28 and DDX4 to enable germ cell quantification: these label premeiotic and later stages of germ cell development respectively. Data were then statistically analysed. Results The first trimester sample cultured in paracetamol had 26.4% fewer LIN28-expressing germ cells than vehicle controls (P = 0.048). Second trimester tissues showed considerable variability, which limited analysis. There was an average decrease of 46.8% in LIN28-expressing germ cells (n = 3, P = 0.39) and an

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Royal Surrey County Hospital, Guildford, UK Introduction Perception of fetal movement is a way for mothers

and clinicians to assess fetal well-being. Reduced fetal movement (RFM) has correlated with several negative perinatal measures including placental insufficiency, fetal hypoxia, intrauterine growth restriction (IUGR), admission to NICU, and intrauterine death (IUD). 55% of mothers who experienced a stillbirth have RFM prior to demise. However, there is no high-power evidence for the management of RFM. Methods We aim to evaluate the outcome of women attending the antenatal unit with RFM. Inclusion criterion was women who had a delivery in the calendar year of 2016 who experienced RFM beyond 28/40 gestation. Results 238 women were included, representing 8.0% of the total population (n = 3044). 20% had high-risk factors including diabetes or hypertension in pregnancy, multiple pregnancy, IUGR, or previous IUD. 50% were nulliparous. 43% presented with multiple episodes of RFM. 63% of women in the cohort ultimately underwent induction of labour (IOL) or was scheduled for Caesarean section. 10.5% of total number of women induced (n = 947) was due to RFM. Of the cohort there were 239 live births and 0 IUD/stillbirth. Three neonates were delivered prematurely and 5 required SCBU admission. Conclusion Women who experienced RFM are likely to have further episodes during pregnancy. Large proportion of women with RFM required intervention to expedite delivery; this poses a significant burden for maternity services. RFM is a serious concern for women which require careful management to ensure fetal well-being is safeguarded.



0045 Surgical outcome, survival and morbidity associated with cytoreduction surgery for ovarian cancer

McMulan, J1; Beirne, J1,2; McComiskey, M1 1 Belfast City Hospital, Belfast, UK; 2Queens University Belfast, Belfast, UK

Introduction Extensive surgery is often required to achieve

complete cytoreduction (R0) and patients are at risk of perioperative and post-operative morbidity. The purpose of this project was to ascertain surgical outcomes, intra-operative and post-operative complications and long-term morbidity of ovarian cancer patients. Methods A retrospective cohort study examined all patients who had cytoreduction surgery in Northern Ireland in 2016. A proforma was completed using electronic and paper records. The data were then interrogated. Results 65 women were studied with mean age of 60 years, mean BMI of 28, 78% of them had 2 or more significant co-morbidities. 26% had stage 1 disease, 15% stage 2, 49% stage 3 and 9% stage 4. R0 rates were 100%, 70%, 36% and 50% for stage 1, 2, 3, and 4 disease, respectively. Optimal cytoreduction rates for stage 2, 3 and 4 disease were 10%, 31% and 33% respectively. Overall suboptimal cytoreduction rate was 15% with primary surgery having a rate of 13% and interval surgery a suboptimal cytoreduction rate of 20%. The most common intra-operative complication was estimated blood loss >1000 mL followed by cystotomy. Post-operative complications included ileus and nausea/vomiting. There were 6 grade 3 complications and 1 grade 4 complication. Mean length of stay was 10 days. Complete primary cytoreduction had the longest survival rate. Conclusion Ovarian cancer patients are elderly, overweight and have significant co-morbidities. However, high R0 rates can be achieved with an acceptable risk profile. These data suggest a survival benefit to patients of maximal surgical effort.

0049 Healthcare services for pregnant women in Chilaweni, Malawi. Results from a cross-sectional questionnaire survey

Geddes-Barton, D; Alexander, D; Kuhrt, K; Stead, G; Yoward, F; Florman, K; Ryan, G Croydon University Hospital, London, UK Introduction To conduct a questionnaire survey of pregnant

woman to investigate current provision of contraception and maternity services to inform a proposal to build a new maternity unit. Methods Meeting with District Health Officer in Blantyre and visited existing Health Clinic. 1 Designed a questionnaire to collect qualitative and quantitative data 2 Employed field officers for translation 3 Met with the Chiefs 4 2 weeks collecting data

Results

60 pregnant women; age range 14–45, average age 24, response rate 100% (60/60) All women planned to give birth in healthcare centre (>6 km away) or hospital A fifth reported previously giving birth en route to health centre 66% unplanned pregnancies 62% using Depo-Provera contraception 92% of women had left school before completing secondary education – 37% due to pregnancy The majority of women wanted fewer children than the number of siblings they had Conclusion

Birthing facilities High maternal death rate A fifth reported giving birth en route to clinic (6–10 km walk) No women reported planning to give birth at home with traditional birth attendant Contraception 66% unplanned pregnancies but 62% reported using Depo-Provera contraception Difficulty attending health clinic? Unaware contraception only lasted 3 months/ difficulty keeping track of time? Lack of resources at the clinic? Education Improved family planning? Further educational level for women

0050 The treatment effect and re-intervention rate following MRI-guided focused ultrasound treatment of uterine fibroids since 2011 at St Mary’s Hospital

Finch, E-L; Taheri, M; Gedroyc, W; Regan, L; Quinn, S St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK Introduction Uterine fibroids are a common gynaecological

abnormality arising from the myometrium. Several options exist for the treatment of symptomatic fibroids; however, few fulfil all the needs and expectations of women. Magnetic resonance-guided focused ultrasound (MRgFUS) is a novel treatment option that holds appealing prospects, despite limited data on long-term effectiveness. Since its introduction in 2003 at St Mary’s Hospital, London, refinements to the patient selection for this treatment have been made with the aim of improving outcomes. The aim of this study was to establish whether stricter patient selection criteria for the MRgFUS treatment of fibroids resulted in an improvement in treatment outcomes. Methods This was a retrospective cohort analysis of all patients undergoing MRgFUS treatment of symptomatic fibroids at St Mary’s Hospital since 2011 (n = 54). The volume of fibroid that was not perfused after treatment (non-perfused volume, NPV)


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was used as a measure of treatment success and analysed against data on patient demographics, outcomes and prior cohorts. Results An apparent increase in mean NPVs achieved was observed since the 2011 criteria change. Mean NPVs appeared to be higher in patients treated who met the criteria (61.46%) compared to patients who did not (54.43%). Higher mean NPVs corresponded to better symptomatic outcomes and lower re-intervention rates. Conclusion The refined patient criteria appears to have led to better ablation and an improvement in subsequent outcomes in MRgFUStreated fibroids; however, a lack of statistically significant results warrants a broader, multi-centre study to establish more conclusive evidence on the viability of this treatment modality.

0051 Botulinum toxin for pelvic floor muscle pain

Roper, JR; Brair, A; Bach, F; Toozs-Hobson, P Birmingham Women’s Hospital, Birmingham, UK Introduction Botulinum toxin is a potent neurotoxin produced by

Clostridium botulinum. Botulinum toxin serotype A is used for several disorders which involve muscle spasm; however, there are few reports on the effectiveness of injecting botulinum toxin into the pelvic floor muscles for the treatment of pelvic pain. The mechanism of pain may be due to prolonged muscle contractions leading to ischaemia by compressing the blood supply and increasing the oxygen demand leading to release of inflammatory substances resulting in hyperalgesia. Botulinum toxin relaxes the muscles to reduce spasticity, increase blood flow, and therefore help pain. Aim to assess the outcome of Botox injections to pelvic floor pain due to spastic levator ani muscles. Methods This is a retrospective cohort study of patients who underwent Botox injections to the pelvic floor muscles from January 2013 – September 2016. Trigger points were identified pre-operatively and Botox (50, 100 or 200 units) was injected into the pelvic floor muscles. Results Thirty patients were identified with 3 (10%) being lost to follow-up. 21 (78%) had improvement in their symptoms (felt better, much better, very much better or pain free), 6 (22%) had no change and no patients reported worsening of symptoms. One patient (4%) developed post-operative faecal incontinence which resolved after physiotherapy. There appeared to be no difference in outcome between the doses. Conclusion Our study suggests that Botox to the pelvic floor for pain is successful and safe. Further studies are required to assess differing dosages and longer term follow-up.

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0052 Exploring the outcomes of breast cancer patients who underwent fertility preservation

Raval, H1; Gould, D2; Fitzgerald, C2 1 University of Manchester, Manchester, UK; 2St Mary’s, Manchester, UK

Introduction Breast cancer is the most common cancer in young

women. Due to the long-term effects of cytotoxic cancer treatment, many patients’ fertility and thus quality of life are affected. This project aimed to explore the outcomes of breast cancer patients who underwent fertility preservation at St Mary’s Hospital from 2009 to 2017. Methods A retrospective analysis was performed on the medical records of 115 patients, 57 of whom were >2 years post-diagnosis. Demographics of the patients attending, their response to stimulation and their outcomes following treatment such as pregnancies and deaths were noted. Results The mean age of patients undergoing treatment was 32.5 years, and 64% of patients had an oestrogen receptor positive tumour. Pre-chemotherapy AMH levels were 19.2 pmol/l, and the mean number of oocytes retrieved was 11.6. Of the women who are 2 years post-diagnosis, 12 (21%) have conceived, 10 of which were spontaneous conceptions. Of the 7 patients who have returned to use their cryopreserved embryos, only 2 have had successful live births. Furthermore, 9 patients (8% of the cohort) have since died, at least 7 of which were due to cancer recurrence. Conclusion Overall, breast cancer patients responded well to ovarian stimulation for fertility preservation. Despite the gonadotoxic effect of chemotherapy, many have conceived naturally, demonstrating the importance of fertility for this cohort and the value of fertility consultations to enhance awareness about natural fecundity. Further long-term follow-up studies are required to establish the overall safety of fertility preservation in breast cancer patients.

0053 Novasure device endometrial ablation – Western Sussex Hospitals NHS Foundation Trust (Worthing) outcomes audit

Chowdhury, M; Ellabany, R Western Sussex Hospitals NHS Foundation Trust, Worthing, UK Introduction Menorrhagia is a relatively common presentation.

The World Health Organization reports that 18 million women aged 30–35 years report their menstrual bleeding to be heavy majorly affecting quality of life, accounting for 12% of all gynaecology referrals. After conservative medical management, endometrial ablation is the primary surgical option. Novasure (bipolar impedance-controlled) – which delivers suction ensuring proper contact with the endometrium to remove vaporised tissue – was approved in 2001 by the FDA. Methods A retrospective audit from April 2016 to April 2017 to assess the efficacy of Novasure ablation (compared against the standards set out by Hologic, manufacturing arm of Novasure).



Patients who had hysterectomies after ablation therapy were also recorded. Standard: 91% have lower levels of menstrual bleeding following endometrial ablation. Results A total of 24 patients had Novasure ablation in Worthing Hospital from April 2016 to April 2017. One set of notes was excluded due to failure of the pre-procedure cavity check. Only 10 patients attended follow-up appointment. Mean treatment time was found to be 79.2 s (Hologic average time 90 s). 91.6% (22/24) of patients did not require a hysterectomy. Clinic note entries, lack of follow-up were used as evidence of reduction in menstrual bleeding. Conclusion In comparison with Hologic standards, more patients – 91.6% – had lower levels of menstrual bleeding in this audit. Standard patient satisfaction questionnaires, at the convenience of the patient, were recommended to reduce follow-ups in outpatients clinic as well as more patients being discharged after surgery. This has been demonstrated effectively in other units.

0056 Introducing a Restorative Practice approach to the Birth Reflection Clinic

Reisel, D; Hoesch, D; McCabe, M; Whitten, M UCLH, London, UK Introduction The Birth Reflection Clinic is a vital part of the

maternity service, enabling women to explore and discuss aspects of their birth experience. However, there is little guidance as to how to best conduct the birth reflection clinics available. Over the last thirty years, Restorative Practice (RP) has been successfully applied in the criminal justice system, schools and elsewhere. RP is considered an effective and accessible way to speak about the needs of all impacted parties, a view to seeing concerns fairly addressed and, if possible, resolved. RP has not yet been applied within the healthcare setting, despite there being considerable scope for its implementation, especially within Maternity. Methods We interviewed midwives facilitating the Birth Reflection Clinics, establishing their current practices and learning needs. We then offered them a 3-day intensive training course on how to conduct RP sessions. Outcome measures were twofold: (i) exit interviews for women attending the clinic and (ii) metrics of efficiency of clinic appointments and provider satisfaction. Results Initial results uncovered a desire on the part of many to learn resolution skills that could be useful in this setting, and early Results suggest a high degree of provider satisfaction and session times that are shorter in length, with positive feedback from clients. Conclusion As a first foray into health care, this project shows that the RP approach might have much to offer the speciality. Further work should be undertaken to establish best practice and recommendations for use in other clinical settings.

0057 Characteristics of those followed up/not followed up at three colleges participating in the NIHRfunded ‘Test and Treat’ feasibility trial of rapid chlamydia tests

Alam, F; Chaudry-Daley, Z; Green, A; Oakeshott, P; Kerry-Barnard, S; Fleming, C Population Health Research Institute, St George’s University of London, London, UK Introduction The Test and Treat trial is an NIHR-funded

feasibility trial of rapid on-site chlamydia tests in three further education colleges in London. All participants were followed up 7 months after recruitment with repeat tests and questionnaires. This study aimed to compare the characteristics of participants from three further education colleges, who were or were not followed up. Methods 257 students were recruited across 3 colleges – of these students, 123 (48%) were followed up successfully at their colleges while 134 (52%) were not. To increase the response rate, the trial manager called and texted the 134 students a link to the questionnaire asking them to provide details of their sexual health, mobile numbers and if they were willing to provide a urine sample by post for testing (£10 incentive provided). The option of providing samples at college was offered. Results Age and gender of participants followed up by each method or not followed up were broadly similar. However, of 135 black students, 53% (n = 72) were followed up at college, 7% (n = 9) were followed up via phone/online and 40% (n = 54) were lost to follow-up. Therefore, it was found that students of black ethnicity were more likely to be followed up at college or lost to follow-up than to be followed up via phone/online (chisquare test for trend P < 0.001). Conclusion Although this was a small study, it is possible that outreach to those of black ethnicity is more effective in person rather than via phone/online.

0058 Audit of fetal cardiac anomaly detection at six obstetric units in the South West

Hein, C; Liversedge, H Centre for Women’s Health Royal Devon and Exeter Hospital, Exeter, UK Introduction Antenatal detection of fetal cardiac conditions is

audited by NICOR (National Institute of Cardiovascular Outcomes), FASP (Fetal Anomaly Screening Programme) with the National Congenital Anomaly and Rare Disease Registration Service. In the recent report Devon and Cornwall diagnosis rate was 26.5% (target 50%). In response, we have completed an audit of cardiac anomalies diagnosed at 6 units in the South West. Methods Fetal scanning departments were contacted under the auspice of the South West Congenital Cardiac Anomaly Network.


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We requested EDD, gestation at diagnosis, diagnosis and outcome of all cardiac anomalies detected in a 13-month period. Results 89.7% fetal cardiac anomalies are detected antenatally, the latest gestation was 23 + 2. 15.4% of these were made outside of FASP criteria (18 + 0 20 + 6), and 50% of those were made at 16 + 5 weeks providing parents with an earlier diagnosis. 10.3% cardiac anomalies were not detected until the postnatal period. 7.7% diagnoses would have been missed by both FASP and NICOR criteria. 32% fetal outcomes were unknown after referral to tertiary units. Conclusion This audit cannot be directly compared with the national audit owing to differences in timeframe and units involved. However, it does question parameters used by the national audit to create a performance review of fetal cardiac scanning. This audit has also illuminated the lack of communication between secondary and tertiary referral units regarding neonatal outcome. We will share our findings with FASP and working with the South West Congenital Cardiac Network to improve communication and target training for fetal scanning units.

0060 Piloting the Introduction of Cook Ripening Balloons (CRB) for induction of labour in multiparous women: a quality improvement project.

Medland, V; Park, C; Ficquet, J Maternity Services, Royal United Hospital, Bath, UK 1

Introduction Du et al meta-analysis 2017 demonstrated the

double-balloon catheter (CRB) to have greater safety and costeffectiveness than PGE2 for labour induction (IOL), with similar efficacy profiles. We piloted the Introduction of CRB use in all multiparous women, aiming for improved patient flow, but no change in delivery or neonatal outcomes. Methods A 3-month IOL audit was undertaken prior (2017–PGE2 group) and following CRB Introduction (2018–CRB group). An educational program of midwifery and medical staff was undertaken prior to piloting. Feedback was sought from staff and women undergoing the CRB IOL during the pilot and disseminated via handover, email and text groups, allowing several PDSA cycles, optimising patient flow and experience. Results Demographic characteristics were similar for the two groups with 47 having PGE2 and 49 having CRB. Similar delivery outcomes were achieved with PGE2 versus CRB; SVD 68% versus 70%, operative vaginal delivery 13% versus 12% and LSCS 19% versus 18%. However, SVD was achieved within 24 hours in only 38% with PGE2 versus 63% with CRB. Whilst unexpected NICU admissions were similar (PGE2 4% versus 6% with CRB), a greater proportion of women who had an emergency LSCS had a pathological CTG with PGE2 88% (7/8) versus CRB 55% (5/9). Conclusion IOL with CRB improved patient flow without compromising neonatal or delivery outcomes, proving popular with women and medical staff. We are planning on offering IOL

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with CRB as an outpatient and fully midwifery delivered, further improving women’s experience.

0062 Audit of operative vaginal deliveries carried out within East Kent University Foundation Trust

Kasaven, L1; Herridge, D2; Alabi, C3; Othayoth, N4 1 East Kent University Hospitals, Ashford, UK; 2East Kent Hospital, Ashford, UK; 3East Kent Hospital, Ashford, UK; 4East Kent University Hospital, Margate, UK

Introduction The purpose of operative vaginal delivery (OVD) is

to expedite delivery with a minimum of maternal or neonatal morbidity. The rate within the UK remains 10–13%. We have audited OVD practice within East Kent Hospital in reference to local trust guidelines. Methods 50 patients in total had an OVD between 1 January and 28 February 2018 within the trust. Data were collected using hospital notes and E3 software. Simple statistical analysis was performed on the data using Excel. Results Of the total 50 patients, 14 patients had a BMI >30. Indications for instrumental delivery included fetal (n = 25), maternal factors (n = 5) and inadequate progress of labour (n = 20). Forty-two cases were performed by an obstetrician deemed competent. Of the 8 cases performed by junior trainees not competent, 7 were supervised appropriately by senior staff. The rate of sequential instrument use was 16% (n = 8), all of which were forceps following failed ventouse. The most common reason for sequential instrument use was detachment of the suction cup with evidence of descent (n = 4). 44% of patients had a primary post-partum haemorrhage (PPH > 500 mL). Six babies were born with Apgars 97th centile using INTERGROWTH21 and 7.5% (EFW) and 8.9% (BW) >90th centile and 3.4% (EFW) and 3.4% (BW) >97th centile using WHO. Conclusion Using INTERGROWTH21 increased the antenatal SGA detection rate from 33% to 50%. However, the LGA detection rate was overestimated at 15.9% (>90th centile) and better predicted by WHO. We propose the use of INTERGROWTH21 EFW charts for antenatal detection of SGA fetuses, in units of similar populations and financial means, with use of >97th centile to minimise overestimating LGA fetuses.


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0066 Venous thromboembolism prevention during pregnancy

Phillips, E Newcastle University, Newcastle upon Tyne, United Kingdom. North Tees and Hartlepool Foundation Trust, Stockton-on-Tees, UK Introduction Venous thromboembolism (VTE) remains the

leading cause of direct maternal death in the UK. Last year 78% of women in North Tees and Hartlepool Trust were scored correctly on their postpartum VTE risk assessment and 78% were managed correctly. This audit aims to assess the accuracy of VTE risk assessments and management choice for patients at booking, 28 weeks and postpartum at North Tees and Hartlepool Foundation Trust hospitals. Methods A prospective cohort study of 50 women seen in antenatal clinic in January 2018 combined with a retrospective reaudit of 50 women who gave birth between November 2017 and January 2018. Data collected from trust VTE risk assessments and patients notes were recorded on a proforma and interpreted in Excel. Results 66% of antenatal booking patients, 73% of 28 weeks’ gestation and 90% of postpartum risk assessments were scored accurately. Leading to 92% of booking patients, 93% 28 weeks’ gestation and 76% of postpartum patients being managed correctly. Scoring inaccuracies were primarily due to missed risk factors (47% antenatal and 100% postpartum inaccuracies) or undocumented scoring (41% of antenatal inaccuracies). Conclusion Since last year’s audit, documentation of postpartum scoring has improved from 92% to 100%; however, due to risk factor identification absences, completion falls below the 100% accuracy RCOG standard putting women at risk. This indicates a need for an update of knowledge of common risk factors for VTE during pregnancy and re-audit in 2019 to assess whether accuracy has improved.

0067 Feedback in medical education: the perspective of Obstetric and Gynaecology Trainees in the West Midlands

Stevenson, H University of Birmingham, Birmingham, UK Introduction Use of feedback is well documented as a method of

improving performance when learning new skills. When good quality feedback is delivered, it should help learners develop their skills and improve; however, this is not necessarily reflected in student satisfaction. A lack of trainee satisfaction with feedback is reflected in the opinion of trainer’s as well. The aim of this study was to determine the attitude of O&G trainees’ towards feedback. Methods A structured questionnaire was delivered to all current obstetrics and gynaecology trainees in the West Midlands. Results Twenty-six trainees completed the questionnaire. 64% were grade ST3 and above. 46% were happy with the amount of feedback they received and 44% felt they received regular feedback

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more than once per month. 32% reported getting feedback consistently from the same supervisor. When asked how they prefer to have feedback delivered 68% preferred immediate feedback after the event and 48% found structured workplacebased assessments useful as a tool for feedback sessions. However, 36% of trainee’s felt these assessments were a tick-box exercise and not useful. 68% said feedback was delivered in an appropriate environment Conclusion Most west midlands O&G trainees prefer immediate feedback on clinical skills, given by a consistent individual within an appropriate environment. Trainees generally want more feedback. The majority prefer using reflective discussion rather than structured ePortfolio forms. This follows Pendleton’s rules for effective feedback which suggests a structure that involves the learner reflecting on positive elements and areas for improvement before agreeing an action plan for future learning.

0068 Audit of datix completion for unexpected gynaecology readmissions after surgery at University Hospitals North Midlands

Ali, N1; Todd, R2 1

University Hospital North Midlands, Stoke-on-Trent, UK; University Hospital North Midlands, Stoke-on-Trent, UK

2

Introduction Datix is an incident reporting system that is used to

measure our gynaecology morbidity, investigate the care we have provided, identify if there has been any associated learning and demonstrate what measures we have taken done to mitigate this in the future. We looked to see if datixs were appropriately completed for unexpected post-operative gynaecological readmissions. Methods Data were retrospectively obtained on all unexpected gynaecology readmissions following surgery to all areas within 30 days of discharge over 3 months. The trusts electronic patient information system was used to examine reason for readmission, primary procedure, post-operative day readmitted, investigations undertaken, management, discharge diagnosis and length of stay. The trust’s “datix system” was used to identify patients with completed datixs. Results There were a total of 56 readmissions in gynaecology with 47 unexpected readmissions after surgery. Only 1 datix was completed out of 47 readmissions and 3 patients had 2nd readmission with no datix completion. 79% of patients had had elective surgery and 21% of patients had had emergency surgery. 80% of patients re-presented within 2 weeks of surgery. 71% presented with pain, infection or bleeding. 30% needed overnight admission. 36% needed reassurance, 36% needed antibiotics and 7% needed analgesia. Non-specific abdominal pain was the commonest discharge diagnosis. Conclusion There is significant under reporting with only one datix completed, consequently there is under investigation from risk management. No patients returned to theatre and most patients were discharged following no invasive investigation and reassurance only but they still need a datix completing.



Results 50.5% were primip. Propess was used in 202 patients, rest

0069 Better than blood: an aggressive pharmacologic and surgical protocol for avoiding transfusion in treating molar pregnancy

Marchand, G1; Rials, L1; Ware, K1,2; King, A1; Anderson, S1; Cieminski, K1; Sainz, K1,3 1 Marchand OBGYN, Mesa, AZ, USA; 2The University of Science, Arts and Technology, Olveston, Montserrat; 3Washington University of Health and Science, San Pedro, Belize

Introduction Molar pregnancy remains one of the most bloody

obstetrical procedures performed by OB/GYNs in the world with many sources quoting average blood loss is in the range of 1000 cc. Using an aggressive protocol of intravenous uterotonics, as well as proper surgical technique and the judicious avoidance of uterine softening agents, we were able to reduce blood loss in three dilation and curettage procedures to only 50 cc each. In this case, although in a very limited set, we were able to prove that the patient’s blood loss can be approximately 50 cc if this aggressive protocol of surgical and pharmacologic management is undertaken. Methods We compared three cases of molar pregnancy treated by our protocol, which coincided with the only three cases of molar pregnancy treated by the researchers in a one-year period. We compared our blood loss with estimations of blood loss in similar procedures based on data from common published sources. Results Our initial evidence leads us to believe our protocol is an effective tool against molar pregnancy, both reducing the need for transfusion as well as effectively treating the disease. Conclusion While more experience will clearly be needed in order to prove the protocols dramatic benefits, we believe that our findings add to the evidence of the value of intravenous uterotonics at time of dilation and curettage for first trimester pathologies. We believe that this protocol will prove to be an effective weapon in avoiding blood transfusions in patients with gestational trophoblastic disease.

0070 Outcomes of induction of labour at term

Welch, T; Elfituri, A; Gulghotay, I; Ganapathy, R Epsom and St Helier University Hospitals NHS Trust, Epsom, UK Introduction Around 1 in 5 labours are started using induction. It

is associated with higher rates of assisted delivery (17–19%) compared to 12% with spontaneous labour. IOL has a large impact on the health of women and their babies and so needs to be clearly clinically justified. We did a big study to see the outcome of different methods of induction in our trust and to compare with the national standards (NICE) and local guidelines. Methods It was a large retrospective study for 3 months. Out of 1226 deliveries, a total of 368 Induction of labour, we analysed 270 (73% of cases).

was ARM and syntocinon. 55.5% of patient using propess was primip. Commonest indication was reduced fetal movement. Nearly 2/3rd patient needed only 1 propess. Only 10.3% Asian, Afro Caribbean had IOL after 40 weeks. Two-thirds of IOL was between 37 and 39 + 6 weeks’ gestation. Conclusion 30% had IOL, caesarean 18.8%, SVD 62.7%, and instrumental 18.4%, all of which corroborates with National figures. Greater than 15% had syntocinon started after 5–6 hours of ARM. Postdate induction has an ethnic variation. IOL at 41 weeks was 14%, and 4% at 42 weeks. Induction at 42 weeks had 50% caesarean and majority required 2 propess. Consider earlier IOL at around 40 weeks for Asian and Afro-Caribbean women. Consider IOL at around 41 weeks rather than 42 weeks to reduce perinatal mortality and good outcome. Monitor delay in start of syntocinon infusion after ARM. Re-audit in 2 years.

0072 Lichen sclerosus management – gynaecology versus dermatology and vulval specialty clinics

Daly, C1; Murphy, B2; Hutchinson, S2 1

Craigavon Area Hospital, Craigavon, UK; 2Royal Victoria Hospital, Belfast, UK Introduction In the Standards of Care for women with vulval

conditions, patients with less complex needs do not need to be referred to a vulval service – if their condition can be managed effectively within primary and secondary care (1). Methods Retrospective data collection was performed on 41 patients based on the new 2018 British Association for Dermatologists Guidelines (2). Results In the General Gynaecology clinic, 42% of women were asked specifically about vulval itch in the history. 80% of women had a detailed examination description. A diagram was present in just 5/21 patients. A psychosexual enquiry was documented in 3/ 21. 19% had documented evidence of receiving a general vulval care leaflet. In comparison, all patients within the General Dermatology and Specialist Vulval clinics had a full history and examination detailed (a proforma is routinely used). Patients without a diagram of examination findings were all seen in the Dermatology clinic. A psychosexual enquiry was performed in all patients attending the Specialist Vulval clinic. All but one patient received a patient information leaflet. Conclusion High concordance with the guideline was seen within the specialist Vulval clinic. Psychosexual morbidity is potentially being missed within the secondary care setting. A proforma is being drafted for use within the Gynaecology clinic and re-audit planned in 6 months.


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0073 Introduction of the laparoscopic approach to sacrocolpopexy and sacrocervicopexy in a District General Hospital

Daly, C; Boggs, E Craigavon Area Hospital, Portadown, UK Introduction Guidelines on the use of mesh in gynaecological

procedures have been recently updated (1). A laparoscopic approach to sacrocolpopexy was introduced to Craigavon District General Hospital, Northern Ireland, on 9 March 2015. Methods Retrospective data were collected between 9 March 2015 and 17 October 2017. Demographics, operative details and postprocedure follow-up were recorded and analysed. Ten patients were identified; 1 patient had the procedure abandoned due to dense bowel adhesions, 1 patient had a missing chart and 1 patient awaits the procedure. Six laparoscopic sacrocolpopexies and 1 laparoscopic sacrocervicopexy were identified. Results Average age and parity were 57 years and para 2 respectively. Of note, all patients were consented by a consultant urogynaecologist. Average operation time was 2 hours 31 minutes and no intra-operative complications were noted. A statistically significant improvement in anterior (P = 0.016) and cervical/ cuff compartment (P = 0.003) prolapse was seen (Pelvic Organ Prolapse Quantification (Paired t-test used)). A higher rate of new urgency and urge urinary incontinence were noted (both 29% in our group, 1000 babies/year are stillborn, have a neonatal brain injury or die within 7 days and 75% are potentially avoidable. We must do better. Methods Drawing on experience in this field, published evidence was sought which demonstrates the scale of the problem, highlights areas for improvement and describes recent initiatives to reduce future harm. Results Inadequate involvement of parents is endemic with 60– 95% of investigations not involving parents. Investigations are often poor quality and up to 91% use root cause analysis methodology inappropriately. Use of independent experts is low (12%), multi-professional reviews rare (3%) and investigations

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often blame individuals rather than identify system or organisational issues (75%). Other deficiencies include a perceived lack of independence and no standardised, or mandated, national training for those conducting the investigations. Errors in maternity care contribute 50% of the NHS litigation bill. Conclusion New initiatives, recently implemented but possibly not well understood and not yet evaluated are seeking to improve this area. NHS Resolutions’ Early Notification Scheme, the RCOG Each Baby Counts programme and the Healthcare Safety Investigation Branch independent maternity investigations are all welcome improvements that should help make maternity care safer. However, it is proposed that there is still scope to introduce a national, mandatory and standardised training programme for healthcare investigators.

0075 An audit of induction of labour at the Whittington Hospital

Rayner, C; Mayers, K; Mellon, C Whittington Health NHS Trust, London, UK Introduction Induction of labour (IOL) is relatively common.

Approximately 1 in 5 labours are induced every year in the UK. The decision to induce labour may be based on maternal or foetal factors, or both. IOL impacts on the overall birth experience, as well as putting pressure on the labour ward. Therefore, it is important that our clinical decisions are justified and that we provide a safe induction process. Methods 76 women undergoing IOL at the Whittington Hospital in October 2017 were identified using the IOL booking diary. We performed a retrospective review of the notes. After exclusions, 72 were included in the final data. Results Overall, our induction rate is less than the national average at 21%. Prior to IOL, 97% were offered a cervical sweep, though rate of uptake was lower. 82% of IOLs were appropriately indicated, and 79% were at an appropriate gestation for the indication. On admission, 100% had a CTG, 91% had a Bishop’s Score recorded, and 94% received appropriate first line prostaglandin according to trust guidance. 98% of women proceeded to labour following IOL, though 64% of women had to wait over two hours for transfer. 96% of women delivered on the labour ward. Conclusion This audit identified areas for improvement including more consultant-led decisions on “off-guidance” indications for IOL with clear documentation, more timely transfer to labour ward and use of the birth centre where appropriate. We plan to review our trust guideline and to look at ways of improving the patient experience.



0076 An audit of thyroid disease in pregnancy

Demertzidou, E; Mcgoldrick, E; Davies, J; Rao, U Countess Of Chester Hospital NHS Foundation Trust, Chester, UK Introduction Thyroid dysfunction affects 2–3% of pregnancies;

moreover, poorly controlled hypo-/hyperthyroidism has been associated with adverse maternal/fetal outcomes. The aim of the audit is to compare the management of women with thyroid disease against the departmental guidelines at the Countess of Chester Hospital (COCH). Methods Retrospective case-note analysis of women with thyroid dysfunction before/during pregnancy booked at COCH between 1/ 1/2015 and 31/12/2015. Results 90 cases were identified. Fifty-six patients were hypothyroid and 6 hyperthyroid. 48 of patients with hypothyroidism were diagnosed before pregnancy, 49 had TFTs taken at booking and 40 were referred to shared-care at 20 weeks. Only 7 had documentation regarding the cause of the disease. Eight experienced a miscarriage. Twenty-six remained stable throughout pregnancy. Sixteen of the latter were discharged to midwifery-led care and 10 stayed under the medical disorders clinic (MDC), due to medical complications. Seventeen had abnormal TFTs requiring dose adjustments. Of the patients with hyperthyroidism, all were referred to the MDC and had TFTs checked at booking. Four of them had Graves’ disease. Four patients remained euthyroid. One experienced a miscarriage. Three had antibodies and needed FH-auscultation from 24 weeks. None required referral to the Fetal-Medicine-Unit. None required early delivery for thyroid disease. The documentation of postnatal management for both mother and baby was poor. Conclusion 67% of hypothyroid and 80% of hyperthyroid patients were managed in accordance with the COCH guideline. 75% of miscarriages occurred in women with unstable TFT results, suggesting the importance of good control and close monitoring of women with thyroid disease in pregnancy.

0077 Post-operative coffee consumption for accelerated resolution of ileus following abdominal surgery: a systematic review and meta-analysis of randomised controlled trials

Cornwall, HL1; Edwards, B1; Curran, JF2; Boyce, S3 1

Division of Medical Sciences, University of Oxford, Oxford, UK; Oxford University Hospitals, Oxford, UK; 3Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, UK 2

Introduction Ileus following abdominal surgery is a common

post-operative complication. It is a source of considerable morbidity to patients and prolongs hospital stay. Despite its ready availability, there is limited evidence to support the use of coffee to promote resolution of post-operative ileus.

Methods We performed a systematic review, a risk of bias assessment (ROB), and meta-analysis of randomised controlled trials (RCT) identified using search criteria ‘coffee’, ‘ileus’, ‘bowel’, ‘colon’, ‘gastrointestinal motility’, derivatives and MeSH terms in PubMed, EMBASE, CINAHL, ISI Web of Science, ClinicalTrials.gov, Cochrane Library, CENTRAL, WHO ICTRP, and Google Scholar, from inception to 24 February 2018. Results Data from seven RCT were extracted (606 patients). 31% were men. 69% were women. A total of 342 underwent colorectal surgery (CRS), 114 gynaecological surgery (GS) and 150 elective caesarean section (CS). Coffee consumption reduced (95% confidence interval) time to flatus by 0.5 hours (11.3-(-) 10.3 hours) in CRS, 11.9 hours (8.8–15.0 hours) in GS, and 3.0 hours (7.2-(-)1.1 hours) in CS. Time to defecation was reduced by 14.8 hours (11.9–17.7 hours) in CRS, 17.8 hours (13.6–22.0 hours) in GS, and 0.6 hours (0.4-(-)1.6 hours) in CS. Complications and length of hospital stay were similar for coffee and control groups. Coffee was well-tolerated with no adverse effects. Cost was low. Conclusion ROB was unclear or high across studies. Assessed with GRADE criteria, there is low to moderate quality evidence that coffee accelerates post-operative recovery of gastrointestinal function, particularly after CRS and GS.

0078 Isolated fetal echogenic bowel: risk factor or red herring?

Headen, K1; Dornan, S2 1 Croydon University Hospital, London, UK; 2Royal Victoria Hospital, Belfast, UK

Introduction Fetal echogenic bowel is often dismissed as an

incidental finding. We aimed to establish whether isolated fetal echogenic bowel on second trimester ultrasound has a risk association with cystic fibrosis (CF), genetic abnormality, congenital infection, intrauterine growth restriction (IUGR) and intrauterine fetal demise (IUFD). Methods A retrospective study of all patients presenting in The Belfast trust with a finding of isolated fetal echogenic bowel on second trimester ultrasound scan between 2007 and 2016. We identified 219 women from a 9-year period using the ViewPoint database and then used electronic records to identify prevalence of each risk association. Results Due to low uptake of amniocentesis we were unable to accurately estimate the number of pregnancies affected by CF and genetic abnormalities. Instead, we established rates of CF carriers in the population. Of 219 patients, we identified 56 (25.5%) pregnancies had at least one CF carrier parent, compared to just 5% in the general population. We identified 11 (5%) pregnancies affected by IUGR and 6 (2.7%) cases of IUFD, which represents a 6x incidence in comparison with the general obstetric population. We identified 6 (2.7%) pregnancies with positive TORCH results. Twenty-nine (13%) pregnancies required paediatric follow-up.


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Conclusion There is an increased incidence of CF carrier status in

parents as well as increased rates of IUGR, IUFD, and positive TORCH screen results in those pregnancies found to have isolated fetal echogenic bowel on second trimester ultrasound. Serial growth assessments, comprehensive counselling and genetic testing where desired may be warranted in these patients.

0080 Introduction of midwife-led discharge of obstetric patients from the postnatal wards – implementing effective change and enhancing patient flow

Slater, A; Thomson, N; Ficquet, J Royal United Hospital, Bath, UK Introduction Complaints about delays and problems with patient

flow through the maternity unit highlighted the need to streamline the postnatal discharge process for mothers in our maternity unit. ‘Routine’ medical review for many postnatal women was duplicating work performed by midwives and delaying discharges. Methods Our aim was to introduce a discharge process led by midwives for suitable obstetric patients, eliminating the need for medical review, and expediting discharge. Through close collaboration with the midwifery leadership team and a multidisciplinary working party, we developed a discharge proforma that served as an ‘aide memoir’ to ensure standardised patient assessments. Amendments were made to the postnatal-care guidelines and a standard operating procedure was created to support midwife-led discharge. A training package including a video was developed and shown to all midwives. Results A daily average of 7 postnatal reviews, with a mode of 9, were performed by the SHO prior to the implementation of our project. The barriers we faced included midwives feeling under confident about making the decision to discharge patients. The implementation of the project has served to reduce the number of postnatal reviews performed by the medical teams by 60% and has reduced the time to discharge. Conclusion Achieving change is challenging, and for implementation to be successful the concerns and expectation of all stakeholders must be considered. The key to the successful introduction of our project was the involvement of pivotal midwives who championed the change, delivered the training and provided peer support to those experiencing difficulties.

0085 Induction of labour with Cooke’s cervical ripening balloon in women with previous lower segment caesarean section

Smyth, S; Singh, S Basingstoke and North Hampshire NHSFT, Basingstoke, UK Introduction Labour induction using prostaglandins in vaginal

of 2.4%; hence, rupture of fetal amniotic membranes (ARM) followed occasionally by oxytocics is preferred (risk 0.8%). In women with an unfavourable cervix (Bishop score 75 nmol/L), insufficient (50–75 nmol/L) and deficient (30 and 83% were 35 years. Conclusion If we manage to discharge these patients sooner, on an average, we could save £2000 per patient.

0216 The management of failure to progress due to malposition in the 2nd stage of labour

Antoun, L; Buduru, I; Mahboob, A Good Hope Hospital NHS Foundation Trust, Birmingham, UK Introduction To review the factors associated with selection of

rotational instrumental versus C-section delivery when managing failure to progress at 2nd stage of labour due to persistent fetal malposition, and to assess differences in adverse neonatal and



maternal outcomes following delivery by rotational instruments versus C-section. Methods We conducted a prospective study over a 6-month period in a DGH. Thirty-five women with vertex-presenting, single, live-born infants at term with persistent malposition in the second stage of labour were included. Selection bias where there is a possibility that obstetricians may systematically select more difficult cases for caesarean section was considered. Maternal and neonatal outcomes for delivery by rotational forceps or ventouse versus caesarean section were reported including admission to SCBU. Results Rotational instrumental delivery was associated with lower maternal age, lower BMI, and lower birth-weight. The time of delivery, delivery during the daytime, and delivery by a more experienced obstetrician made no significant difference in terms of the outcome when the decision to delivery by a rotational instrument was made. There was no difference by delivery method in the rates of delayed neonatal respiration, reported critical incidents, or low fetal arterial pH. Maternal blood loss was higher in the caesarean group. Conclusion Although rotational instrumental delivery is often regarded as unsafe by many trainees, we find that neonatal and maternal outcomes are no worse, once the likelihood of severe obstetric haemorrhage is reduced. More training in rotational instrumental delivery should be considered, particularly in light of rising caesarean section rates.

0217 The effects of maternal smoking and BMI on the first and second trimester human fetal kidney

Banh, S1; Mulhern, J1; Walker, N1; Robertson, L1; Brown, P2; Wilson, H1; Fowler, P1 1 School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK; 2Pathology Department, NHS Grampian, Aberdeen, UK

overall podocyte density. Expression of 11/23 transcripts significantly increased with fetal age, while the erythropoietin (EPO) transcript was undetectable. Renin (REN), involved in blood pressure and fluid balance control, was significantly increased in fetal male kidneys if maternal BMI was ≥25 (P < 0.04). Conclusion Retarded fetal renal development is a known major contributor to hypertension and kidney diseases in adulthood. Our data show that maternal smoking and high maternal BMI are associated with phenotypic and molecular changes in fetal kidney development.

0220 Antibiotic misuse in maternity – a re-audit

Thava, S; Giacchino, T; Gupta, A Darent Valley Hospital, Dartford, UK Introduction Whilst reviewing intrapartum notes it became

evident that there was scope for improvement in antibiotic prescribing. An audit undertaken at Darent Valley Hospital in 2016 revealed. That only 35% of cases had a well-documented, clinical and guideline based explanation for prescribing intravenous antibiotics. Non-adherence to antibiotic guidelines. Incidental raised inflammatory markers are being acted on without clinical acumen. Inconsistencies in prescription of step down oral antibiotic and their duration of use. Methods To complete the audit cycle, data were collected prospectively between April and July 2018 from 50 postnatal labour notes. A proforma was filled in which highlighted. Why antibiotics were prescribed. Any clinical signs of sepsis, i.e. fever >38°C, tachycardia, high WBC and evidence of confusion. Which IV antibiotics were prescribed and duration. Which step down oral antibiotic was prescribed and duration. If local guidelines were adhered to. Results 52% of cases had a clinical and guideline based

Introduction The study aimed to characterise and identify

phenotypic and molecular changes to the human fetal kidney in relation to either maternal smoking or pregnancy BMI status. Methods Human fetal kidneys (n = 145) were collected from elective terminations of normally progressing pregnancies (7– 20 weeks of gestation, Scottish Advanced Fetal Research Study, REC 15/NS/0123). All kidneys were weighed and whole kidney extracts prepared from 58 fetuses. Twenty-three transcripts of key renal developmental genes, renin-angiotensin system (RAS), and kidney injury markers were quantified by qPCR. Whole kidneys were processed for histomorphological analysis to assess podocyte density. Statistical analysis was performed by ANOVA, linear regression and non-parametric tests as appropriate. Results Female smoke-exposed fetuses have slightly accelerated increase in kidney weight (P = 0.037). Preliminary data show podocyte density tends to be higher in female smoke-exposed fetuses. High maternal BMI significantly increases the relative ratio of kidney weight to total fetal body weight in male fetuses (P = 0.02), but maternal BMI has no significant association with

explanation for antibiotic prescription. There is almost complete non-adherence to the local protocol and the wrong antibiotic is being prescribed in almost all cases. 96% of patients are prescribed the correct oral antibiotic on discharge but there are inconsistencies with the duration of use. Conclusion There has been improvement in correct antibiotic prescribing but some patients are still being given antibiotics without a good clinical reason. Increased awareness of local guidelines and correct indication for starting IV treatment needs to be encouraged. Junior doctors need to be informed regarding oral antibiotic step-down regimes and course duration.


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0221 Diabetes and pregnancy: an audit of HbA1c at booking and pregnancy outcomes at City Hospital, Birmingham

Cotton, Z1; Lahiri, S2; Bleasdale, J3 1 University of Birmingham, Birmingham, UK; 2 Obstetrics and Gynaecology, Sandwell and West Birmingham Hospitals, Birmingham, UK; 3Intensive Care Medicine and Anaesthesia, Sandwell and West Birmingham Hospitals, Birmingham, UK

Introduction Pre-existing diabetes affects approximately 4,300

pregnancies in England and Wales each year. It can lead to complications for both the mother and the foetus, including macrosomia, polyhydramnios and the mode of delivery. NICE recommends that women with diabetes planning to conceive aim for a HbA1c value of less than 48 mmol/mol. Furthermore, those with a HbA1c of greater than 85 mmol/mol should be strongly advised to not conceive. This study aims to investigate whether women with pre-existing diabetes complied with NICE recommendations, and whether HbA1c closest to conception was a determinant of pregnancy outcomes. Methods Recorded electronic data from Birmingham City Hospital of women with diabetes who delivered between October 2015 and October 2017. Only patients with diabetes diagnosed prior to conception were included. Results Sixty-three patients met the inclusion criteria. Of this population, 30% complied with the NICE guidelines and had a HbA1c less than 48 mmol/mol at booking. 10% had a HbA1c greater than 85 mmol/mol. Having a HbA1c greater than 48 mmol/mol was associated with a 10% increased risk of having either macrosomia or polyhydramnios. In this population, 89% of babies within the 97–100% birth percentile were in pregnancies with a HbA1c >48 mmol/mol. Conclusion This audit provides evidence that women with preexisting diabetes need to improve their HbA1c at conception to reduce the chance of complications during the pregnancy. To achieve this, there should be an improvement in optimising HbA1c prior to conception in women with diabetes who are at child-bearing age.

0222 MedNav – technological decision support helping clinicians manage neonatal resuscitation in resource poor settings

Powell, H1; Gbadamosi, J1; MacLaren, E1; Letchworth, P1; Duffy, S2 1 Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; 2Chelsea and Westminster Hospital NHS Trust, London, UK

Introduction A quarter of neonatal deaths worldwide are

secondary to birth asphyxia. Adequate neonatal resuscitation could prevent many of these deaths. Resuscitation guidelines are algorithm driven, and deviation is associated with poor outcomes. Neonatal resuscitation is interprofessional relying upon doctors, midwives and birth attendants. Limited access to training,

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equipment, refreshers and qualified staff can unfortunately prevent familiarity with appropriate algorithms in resource poor settings. We developed MedNav, a step-by-step interactive app to assist clinical decision-making during a real-time neonatal resuscitation. It uses word, image and audio prompts, based upon accepted guidelines with contemporaneous timer. The intuitive app is downloaded to a device to assist clinicians in real-time resuscitation immediately after birth, and was studied in Kitovu Hospital, Uganda. Methods Midwives were compared using MedNav (n = 20) and not using MedNav (n = 26), for neonatal resuscitation following caesarean section over 6 months in Uganda. Results Twelve key steps in resuscitation were identified, and clinician consideration of these in resuscitation was compared with or without MedNav. Using A/B testing a mean of 94% versus 46% showed MedNav users were more compliant with resuscitation guidelines. A system usability score of 84.5/100 provided positive feedback on interface. Feedback identified the app was popular with younger staff. Others felt MedNav use undermined senior staffs experience. Conclusion MedNav improves neonatal resuscitation compliance in a resource poor setting. Further study is planned to identify effectiveness at reducing neonatal morbidity and mortality. Methods to culturally integrate MedNav are required.

0223 Comparison of metformin versus insulin in females presenting with gestational diabetes during third trimester of pregnancy

Tahseen, S Lady Willingdon Hospital, Lahore, Pakistan Introduction GDM affects 15% pregnancies worldwide and is

associated with increased risk of maternal and perinatal complications. Insulin is treatment of choice when lifestyle measures do not maintain glycemic control during pregnancy. Recent studies have suggested that certain oral hypoglycemic agents; i.e., metformin may be a safe alternative. We compared frequency of macrosomia in females with GDM managed with metformin versus insulin during third trimester of pregnancy. Methods A total of 490 females fulfilling inclusion criteria (18– 35 years with GDM at >24 weeks) were enrolled after informed consent (January 2016–June 2016) from OPD. Females were randomly divided in two groups (M & I, 245 each) by lottery method. Group M received 750 mg metformin once daily during first week increasing up to 3000 mg depending upon disease severity. Group I, received two insulin shots daily as per standard protocol before meals. Patients were followed fortnightly between 28 and 36 weeks and weekly till delivery. At delivery, birthweight of neonate was assessed for presence or absence of macrosomia (>4000 g). Results Mean age: metformin group: 26.85 4.66 years; and insulin group: 27.39 4.59 years. Mean gestational age at delivery: metformin group: 39.49 1.72 weeks; and insulin group: 39.50 1.70 weeks. In the metformin group 48 (19.6%)



and in the insulin group 59 (24.1%) had macrosomia. There was no statistically significant association (P-value = 0.229) between treatment groups and macrosomia. Conclusion There was no statistically significant difference for frequency of macrosomia with metformin and insulin treatment in gestational diabetes during third trimester of pregnancy.

0228 Enhanced recovery for obstetric surgery (EROS): an effective and proactive new ethos for managing low-risk elective caesarean sections

Lockley, S; Demitry, A City Hospital, Birmingham, UK Introduction Enhanced recovery (EROS) is a programme of

optimising a patient’s peri-surgical care. This is increasingly used within obstetrics to reduce post-caesarean section length of stay (LOS). There have, however, been concerns raised about whether early discharge results in increased readmission rates. The programme utilises patient education, a carbohydrate supplement and efficient, pre-emptive postnatal care. This retrospective audit aims to evaluate the effects of the introduction of EROS at City Hospital. Methods Patients meeting local criteria for EROS undergoing elective caesarean section (ELCS) were entered into the programme. These patients had data collected from digital notes including individual LOS, prolonged LOS causes and readmissions. A control group of patients meeting inclusion criteria and delivered prior to the EROS programme had the same data collected. A comparison of these data was made. Results Fifty four EROS patients were identified over a 6-month period with a similar number of matched controls. EROS patients demonstrated a mean LOS 1.38 days versus 2.7 in the control group. The primary reason for prolonged LOS in both groups was a passive approach to achieving a proposed early discharge. There was no evidence of increased rates of readmission in the EROS group versus control group. Conclusion This audit suggests benefits of enhanced recovery can be demonstrated in low-risk ELCS patients without perceivable complication or increased readmission rates. By reducing LOS there will be an obvious financial benefit and it is hoped that birth by caesarean section will be de-medicalised and the overall postnatal experience improved.

0230 Preconception care clinics for women with diabetes in Manchester – a review of literature and audit (St Mary’s Hospital)

Handa, N University of Manchester, Manchester, UK Introduction Entering pregnancy with poorly managed diabetes

can be detrimental to birth outcomes. Preconception care (PCC) for women with types 1 and 2 diabetes at one women’s hospital

was assessed. This ascertained whether PCC delivered was in line with updated NICE guidelines and what impact this care may be having on assisting women with diabetes preparing for safe pregnancy, conceiving and managing pregnancy. The key aim is thus to demonstrate the value of PCC and the clinic outcomes. Methods Data were collected for all women attending their first diabetes PCC appointment within a 12-month period (46 women) or were also pregnant in this period having attended for PCC (13 women). This was compared to data collected for the National Pregnancy in Diabetes (NPID) audit. Whether patients were treated as per guidelines and the outcomes of this for their fertility and health in pregnancy was recorded. The number of follow-ups to achieve these outcomes and pregnancy was also recorded. Results Guidance on removal of teratogenic medications had been adhered to. Significantly more women were on the recommended folic acid dose than those not in PCC (P = 0.027). HbA1c changes between first PCC contact and conception were also statistically significant (P ≤ 0.05). On average women attended 3 follow-ups within 12 months. Conclusion Practice was being conducted according to guidelines and benefits of this on improvement in glycaemic control and medication status were significant. Improvements can now be made in how women are referred to the service and addressing barriers to PCC uptake.

0231 Management and outcomes of shoulder dystocia at Luton and Dunstable University Hospital

Marshall, D1; Pann, M2; Awais, S2; Barnfield, L2 1 Luton and Dunstable University Hospital, Dunstable, UK; 2Luton and Dunstable University Hospital, Dunstable, UK

Introduction Shoulder dystocia (SD) is an obstetric emergency

caused by impaction of the fetal shoulder against the maternal pelvis, requiring additional manoeuvres to deliver the body, occurring in 0.58–0.7% of cephalic vaginal deliveries. SD may cause significant neonatal morbidity, including brachial plexus injury (4–16% SD cases), fractures and hypoxia. There is increased risk of maternal anal sphincter injury and post-partum haemorrhage (PPH). Method We analysed records of SD retrospectively at Luton and Dunstable University Hospital occurring within a year, noting whether manoeuvres were utilised followed RCOG guidelines; neonatal and maternal morbidity; and documentation. Results 58 cases were identified. Mean head-to-body delivery time was 2 minutes. 81% delivered with McRoberts suprapubic pressure. 84% followed the RCOG recommended sequence of manoeuvres. 5.2% of babies had suspected humeral fracture (later excluded). 3.4% of babies sustained BPI, all resolving prior to discharge. PPH occurred in 38% of cases, with blood loss exceeding a litre in 32%. Obstetric anal sphincter injury affected 7% of women. Despite a Trust documentation tool, only 47% met our standard for documentation (>75% completion). Conclusion Most cases of SD resolved quickly with simple manoeuvres. There was no neonatal mortality, and infrequent morbidity. Overall, regular PROMPT training leads to effective


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management. Regular audit of guideline compliance, neonatal and maternal outcomes should identify areas to improve. Incidence of PPH exceeds the RCOG’s recorded 11%, suggesting staff education should focus on preparing for and managing this complication. Staff should be aware of the importance of recordkeeping in this potentially life-threatening situation.

0233 Completion of consent forms in gynaecology

Khera, T Diana, Princess of Wales Hospital, Grimsby, UK Introduction Patients have a fundamental legal and ethical right

to decide what happens to their bodies. It is therefore essential that patients have given valid consent for all treatments and investigations. Consent refers to the right of patients to decide what, if any, clinical care they are to receive and the duty of surgeons to ensure that patients have given their permission prior to any treatment, examination or intervention and ensure that the appropriate information is given to patients. The aim of my project was to assess the completion of the consent form which is completed to support the consent process and evidence discussions with patients. Methods A random sample of 20 patients who had a surgical procedure during June 2018 in the Gynaecology department of Diana, Princess of Wales, Grimsby, was selected. Data collection was undertaken using a criteria-based data form designed from RCOG Obtaining Valid Consent, Clinical Governance Advice No. 6, January 2015. Results In general there was a 100% compliance except only 75% of patients received the pink copy of the form, only 55% of patients received additional information (e.g. leaflets) and only 25% of patients were given a contact telephone number. Conclusion Consent form compliance as a whole is very good. But on the areas that we are less compliant we perform below acceptable standards. I recommend that patients receive additional information in the form of reliable and agreed patient information websites and also that we put telephone contact numbers on pre-printed consent forms.

0234 Water birth for DCDA twins: how confident are we?

Calvia, A; Damodaram, M Lister Hospital, Stevenage, UK Introduction Dichorionic diamniotic (DCDA) twin pregnancies

are considered high-risk; therefore, women are often not given the option of a water birth. Giving women choice leads to better birth experiences, but do healthcare professionals feel confident in offering water birth to high-risk patients? Methods A questionnaire regarding attitudes towards water birth in women carrying DCDA twins was designed and distributed to

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doctors and midwifes who work on the Consultant Led Unit, Lister Hospital. Results 30 filled questionnaires were obtained. Overall only 43% of healthcare professionals felt confident to support labour in the pool and 20% felt confident to support delivery. 91% of doctors were not confident to deliver in the pool, compared to 44% of senior midwifes who felt confident to. The main concerns were monitoring foetal well-being (80%), stabilising lie of second twin (76%), scanning for position (80%) manipulation of second twin (80%) and manoeuvring patient in an emergency (60%). Healthcare professionals felt more confident to facilitate delivery if cephalic/cephalic presentation (86%), if previous vaginal delivery (83%), or if second twin is delivered out of the pool (73%). 75% of doctors felt seeing more water births would increase their confidence. 100% of doctors and 67% of midwifes felt that water birth for twin pregnancies should not be routinely offered. Conclusion Although only a minority of DCDA twin pregnancies opt for water birth in the department, healthcare professionals do not feel confident in offering it. Increased familiarity and confidence with water birth techniques may enable the department to facilitate patient choice.

0235 Retrospective review of laparoscopic and histological findings in cases where the ESSURE device was removed due to device attributed symptoms

Redford, K Midyorkshire Trust Pinderfields Hospital, Wakefield, UK Introduction ESSURE is a minimally invasive technique for

providing permanent sterilization associated with low risk of complication and a high rate of patient satisfaction. Methods Between 2013 and 2017, 218 women underwent hysteroscopic sterilization with the ESSURE device. Seven (3%) women have represented to services with pelvic pain attributable to ESSURE device. These women underwent bilateral laparoscopic salpingectomy hysterectomy. A retrospective case note review of the operative and histological findings was performed. Results All the women experienced symptom resolution following surgery. Five of the seven women represented within 12 months following insertion. Only one of the seven women who represented had an operative finding and histological confirmation of endometriosis. Migration of the ESSURE coils was seen in three (1.3%) cases despite correct placement being noted at the USS 3 months following insertion. Four of the cases were noted to have normal fallopian tube histology. Paratubal cysts were noted in two cases although the significance is questionable. Ectatic blood vessels were noted in two cases, and one case had inflammatory changes identified. Conclusion This is a small cohort of patients but a significant number (42%) had migration of the coils. However, coil migration following ESSURE appears a lower risk (1.3%) than at laparoscopic sterilization with Filshie clips (5%) in cohorts of



patients with post-procedure pain. ESSURE device does not appear to lead to post-placement pain in the majority of women and is safe, effective and economic. In the few where pain was a problem laparoscopic salpingectomy was an effective treatment.

0237 Use of antenatal corticosteroids prior to term elective caesarean sections in order to reduce unplanned special care baby unit admissions

Evans, R1,2 1 Hampshire Hospitals Foundation Trust, Winchester, UK; 2Waikato District Health Board, Hamilton, New Zealand

Introduction Term infants born by elective caesarean section

(ELCS) are more likely to develop respiratory morbidity than those born vaginally. Betamethasone administration prior to ELCS has been shown to reduce both respiratory distress and admission to special care baby unit (SCBU) by more than 50%. RCOG and RANZCOG guidelines state that ELCS should ideally be performed at or after 39 + 0 weeks, but that corticosteroids should be given to reduce neonatal respiratory morbidity in ELCS prior to this gestation. Methods Review of all ELCS prior to 39 weeks over 12 months at Waikato Hospital, New Zealand. Ninety-three patients were identified and the notes assessed to determine corticosteroid administration and neonatal outcome. Results 24% of mothers did not receive antenatal corticosteroids, 60% received two doses of corticosteroids in the week prior to ELCS and 16% received steroids but greater than one week prior to ELCS. 13% of babies whose mothers did not receive corticosteroids were admitted to the SCBU compared to 9% in those receiving two doses of corticosteroids (Relative Risk 0.69). The number needed to treat (NNT) to prevent one newborn unit admission was 25. Conclusion Antenatal corticosteroids are effective in reducing admissions to SCBU, demonstrating that where necessary to perform an ELCS prior to 39 weeks steroids should be given. We can see that the NNT is small and so closer adherence to national guidelines could have a large impact on care provided and help to reduce the financial and health burden of admissions to the SCBU.

0240 Rotational deliveries: how can we manage them better?

Nijjar, S; Usman, S; Tay, J; Akmal, S Queen Charlotte’s and Chelsea Hospital, London, UK Introduction Rotational deliveries are associated with increased

maternal and fetal morbidity. Failed or non-attempted instrumental deliveries (ID) can be associated with malposition.

70% of fetal head positions are inaccurate on vaginal examination. Ultrasound is the gold standard for determining fetal head position, but knowing fetal spine is also important for successful rotational deliveries. Methods Scan in the sagittal plane; assess the position of the fetal spine at the level of the four-chamber view of the fetal heart. Identify the fetal head, looking for landmarks, e.g. fetal orbits (OP) and cerebellum (OT-OA). Never rely on midline horizontal lines; they can be misleading. Results A fetal spine away from 6 o’clock indicates a fetus more likely to rotate during pushing and ID. Seeing one orbit and the thalami horizontally with the spine on either side of the mother indicates OT position; these fetuses will rotate to OA easily. In most cases the head is expected to rotate up to 90 degrees on either side of the spine from its neutral position without moving the body, to bring the head to DOA. If the fetal spine is posterior this is more challenging, as head and body have to rotate almost 180 degrees to bring the head to DOA. Conclusion The complexity of a rotational delivery is determined by the degree of rotation of fetal head to achieve DOA in relation to the fetal spine. RCOG recommends knowing correct fetal head position at ID, but we propose knowing spine position is just as important.

0241 Management of sepsis in pregnancy

Bevington, L Queens Hospital Burton, Burton on Trent, UK Introduction Sepsis is currently the 4th leading direct cause of

maternal death in the UK. With prompt recognition, investigation and management in a timely manner it can help to reduce patient morbidity and mortality. Methods A retrospective study of patients diagnosed with sepsis during the antenatal or postnatal time over a two-year period from January 2016 and January 2018 were identified. Data from patient handheld and computer notes were then analysed using a proforma to review the care and outcomes of patients diagnosed with sepsis and assess compliance with local hospital guidelines and RCOG national guidelines and highlight areas for improvement. Results 28 patients were identified with a diagnosis of sepsis. The majority of patients (79%) presented in the postnatal period, 18% in the antenatal period and 3% intrapartum. 75% of patients had blood cultures taken prior to intravenous antibiotics. Of the 28 patients 54% received intravenous antibiotics within 1 hour of triggering for and identification of sepsis. Lactate levels within six hours of diagnosis were performed in 86% of patients. Of the antenatal patients, 3 were delivered due to sepsis, one was induced and two patients had an emergency caesarean section. Conclusion Patients with severe sepsis were monitored closely on enhanced care pathways with multidisciplinary review. However, improvements must be made as only 58% of patients had antibiotics within sixty minutes of triggering for sepsis and patient


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review by a senior clinician tended to be after multiple hours on most occasions.

0242 A retrospective audit of the use of root cause analysis in achieving a culture of learning and reflective practice, leading to improved outcomes in neonates with hypoxic ischaemic encephalopathy treated with therapeutic hypothermia

Charlesworth, D1; Cunningham, S1; Oguntimehin, J2; Dudley, L1; Bentley, F1; Moore, A1 1 University Hospitals of North Midlands, Stoke-on-Trent, UK; 2Keele University, Stoke-on-Trent, UK

Introduction In 2014, the Royal College of Obstetricians and

Gynaecologists (RCOG) launched the ‘Each Baby Counts’ (EBC) initiative which included the aim of reducing the number of neonates who are left severely disabled by preventable incidents in labour. The initial report concluded that a different outcome may have been achieved in 76% of cases if different care had been received. Methods In 2015, we launched a series of measures inspired by EBC to reduce our rates of neonates requiring therapeutic hypothermia. One key component of our programme was a change in how our root cause analysis (RCAs) were undertaken. We changed RCA leads to junior staff, promoted a reflective journey and thematic analysis, changed our meetings to include staff recommended by the EBC report, promoted team learning, and fed back via case based, reflective teaching. We then undertook a 40-month retrospective audit from 01/2015 to 04/ 2018 to see if we had improved care. Results In 2015 our therapeutic hypothermia annual incidence was 12, 7 in 2017, and none by the end of 04/2018. We also significantly reduced our HIE grades, and increased the proportion of cases in which we concluded we could not improve the end outcome (though learning was identified in all), staff empowerment, and our ability to identify key targeted improvements. All cases were analysed by EBC and NHSr. Conclusion If conducted with reflection as a key component, and the aim to achieve flattened hierarchies and promote a culture of learning and becoming, RCA can be used as a powerful teaching tool in training and to promote improved patient care.

0243 Do labour ward staff know the location of equipment and necessary contact numbers in the event of an obstetric emergency? A questionnaire in Ipswich Hospital to establish knowledge of emergency equipment location, how to instigate the major obstetric haemorrhage protocol and crash bleep numbers for the obstetric and neonatal teams

Davies, R; Farrakh, S Ipswich Hospital NHS Trust, Ipswich, UK Introduction Familiarity with drills and timely instigation of

treatment is paramount in obstetric emergencies. This study investigated obstetric staff’s awareness of contact numbers and the location of equipment. Methods The questionnaire asked staff to free-text the location of six specific emergency items and the bleep numbers needed to contact the obstetric crash team, neonatal crash team and to activate the Major Obstetric Haemorrhage (MOH) Protocol, with the alternative option of selecting ‘I don’t know’. Results N = 35. results were tabulated as a whole and also stratified by job title. Total correct response to location of equipment was: Scalpel 68.6%, Magnesium Sulphate 82.9%, PPH box 82.9%, Intralipid 40%, Resus trolley 88.6%, Terbutaline 71.4%. 11.4% knew how to activate the MOH: midwives 10.5%, student midwives 0%, core-trainees 0%, registrars 33% and consultants 16.7%. 100% and 78.9% of midwives, 50% and 0% of core-trainees, and 50% and 16.7% of consultants could contact the obstetric and neonatal crash teams respectively. 100% of registrars could contact neither. Whilst midwives cumulatively indicated the correct emergency bleep numbers more commonly than doctors (63.6% versus 20.5%), doctors were more likely than midwives to select ‘I don’t know’ (74.4% versus 0%) than give an incorrect answer (5.1% versus 36.6%). Conclusion The results showed inadequate knowledge which requires remedial action. The greater rate of correct answers amongst midwives and their students likely represents the delegation of tasks within the emergency team. Of note, compared with midwives, doctors were more inclined to admit not knowing than give an incorrect response.

0245 Induction of labour: how can we improve the patient experience?

Nijjar, S; Cox, P; O’Dwyer, S Queen Charlotte’s and Chelsea Hospital, London, UK Introduction In the UK, 20% of labours are induced. This is a

very important part of the pregnancy journey, but can be challenging. In previous work we have reduced total IOL time by using new induction agents, but high-risk groups of women are still likely to wait for IOL due to need to go to LW.

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Methods We sent out an ‘IOL Questionnaire’ to patients on the postnatal ward at QCCH. We focused on patients undergoing ‘high-risk inductions’ and concentrated on several key areas: quality of staff communication, timing to start of IOL and delays, and overall satisfaction with IOL. Results So far, we have collected 12 patient responses. 33% of women underwent IOL for rupture of membranes prior to labour, 17% for diabetes requiring sliding scale, 25% for VBAC and 25% for small babies. On average women had to wait: 10 hours (25%) from arriving in hospital until their induction was started. When there was a delay, 67% of women received an apology from staff, and in 67% of cases this was due to lack of space on LW and in 33% of cases there was a lack of trained staff to start induction. 58% of women were very satisfied with the IOL process. Conclusion There are areas for improvement, and we will explore strategies for minimising delays and improving staff communication, including training midwives to insert balloon catheters for VBAC in triage.

0246 Developing a ‘Return to Clinical Practice’ course in the West Midlands

Shields, R1; Roper, J2; Knox, E2 1

University Hospital Coventry and Warwickshire, Coventry, UK; Birmingham Women’s Hospital, Birmingham, UK

2

Introduction Returning to clinical practice following a break in

training for maternity leave, sickness or research can be difficult. The Academy of Medical Royal Colleges recognises that there is likely to be a decrease in skills and knowledge after a period of absence of 3 months or more. It suggests assessment prior to recommencing work in order to ensure patient safety is not compromised. The RCOG is currently aiming to develop a programme to aid return to work. Currently there is no such standardised programme. Within the West Midlands we have been running a successful ‘Return to clinical practice’ course for the past 2 years and have helped other regions set up similar programmes. Methods All participants in the biannual ‘Return to Clinical Practice’ course were asked to complete a standardised pre- and post-workshop questionnaire. Following analysis feedback was used to aid further development of the course and provide information to Educational Supervisors to help them provide appropriate support to trainees. Results Twenty two trainees have attended over four workshops. 85.4% of trainees were returning from maternity leave; however, 13.6% were returning from research (n = 2/22) or long-term illness (n = 1/22). Three participants were yet to commence ST1; however, the majority were ST3-5. All trainees expressed feelings of unease and anxiety about returning to work which reduced following attendance at the workshop. Conclusion Trainees highly value the workshop, its content and being able to develop a personal support network with those in a similar situation.

0248 Audit: indications and outcomes of induction of labour at a District General Hospital

Aung, C; Moy, L; Neales, K East Kent Hospitals University NHS Foundation Trust, Ashford, UK Introduction Induction of labour (IOL) has a significant impact

on the birth experience of women and places a strain on labour wards. IOL should be performed only when there is a clear medical indication and the expected benefits are known to outweigh the potential harm. An audit in East Kent Trust, UK, was carried out to create a consistent approach to IOL, required to standardise care. Methods A retrospective audit was conducted for all women induced in April 2017. The indications for IOL and outcome were ascertained by using the computerised notes system and the IOL booking book. Results The decision to induce was made by consultants in 68% of cases, and registrars in the remaining cases. Only 70% of patients were reviewed by a consultant on the labour ward. 63% achieved spontaneous vaginal delivery, 22% had instrumental deliveries and 15% were emergency C-sections, with assisted deliveries being more common in primips. IOL to delivery was more than 48 hours in 45% of cases. Conclusion In response, a strategy was developed to categorise IOL into “hard” and “soft” indications. Hard indications are distinct recommendations by NICE UK guidelines while soft indications are less clear cut and based on individual patient assessment by the obstetrician. In Conclusion an IOL booking form has been created in East Kent, with agreed guidelines across the Trust, to help standardise the indications for induction of labour with the goal of improving maternal outcomes and reducing pressure on the labour ward.

0249 Case series of gastrointestinal surgical emergencies in pregnancy

Shenoy, V; Dalmia, S; Smyth, M James Cook University Hospital, Middlesbrough, UK Introduction Gastrointestinal emergencies are rare in pregnancy

but can lead to significant morbidity and mortality. Methods We present three cases requiring surgical exploration

including first ever case of laparoscopic repair of duodenal perforation in pregnancy. Results Case 1 – A G2P1 presented at 26 weeks with generalised abdominal pain and vomiting. Her abdomen was soft but diffusely tender. Her CXR and USS were normal but had raised inflammatory markers. She continued to deteriorate clinically. Diagnostic laparoscopy revealed purulent peritonitis with perforated duodenal ulcer that was repaired. Case 2 – A G4P1, BMI 45 presented at 31 + 5 weeks with severe central abdominal pain and nausea. There was localised tenderness over the umbilicus with possible lump. Due to suspicion of an


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incarcerated paraumbilical hernia, surgical review was requested. She had a laparotomy and repair of this hernia. Case 3 – A G1P0 presented at 28 + 6 weeks with severe vomiting. She had a laparotomy previously for perforated appendix. The initial diagnosis was gastroenteritis as her abdomen was soft and not distended. As vomiting persisted, she had a CT scan that showed small bowel obstruction which was initially managed conservatively. She had a laparotomy at 31 weeks that revealed extensive adhesions with features of long-standing bowel obstruction. Thirty centimetres of bowel was resected and took over an hour to reach the uterus. Conclusion It is challenging to arrive at an accurate diagnosis when dealing with surgical emergencies in obstetrics often delaying treatment. We report these cases to draw attention to their occurrence requiring a high index of suspicion and multidisciplinary approach.

0250 Introducing electronic discharge summaries into maternity

Murphy, L1; Ali, O1,2; Quilliam, R1; Chard, S1,2; Bowman, C1; Armstrong, H1; Hughes, S1; Wood, N1 1

Lancashire Teaching Hospitals, Preston, UK; 2University of Manchester, Manchester, UK Introduction Maternity services in the United Kingdom rely on a

hybrid of paper and electronic notes. At a large teaching hospital in Northern England, electronic notes were used intrapartum, but paper notes in the antenatal and postnatal periods. This included the discharge summary to the GP arriving days to weeks later if at all, with obvious implications for patient safety and no audit trail. Two junior doctors and a pharmacist set about introducing an electronic discharge system similar to that used in the rest of the trust, to provide secure email communication. Methods Consultants and midwives were involved early on and together with the IT department a discharge summary form was created. An educational campaign was launched and midwives created a visual step by step guide. Results The number of discharges going to GPs instantly rose from 0% in August to 33% in November, 66% two months later, then 75%. Compliance with completion of electronic discharges is 100%. Training issues have been identified and are in progress. Conclusion Simplifying the discharge process resulted in an instant rise in the numbers of discharges sent to the GPs. Awareness in itself does not drive behaviour and by using a “nudge” approach with midwives, we have doubled this figure and hope to reach 100% soon. This introductory phase of electronic discharges was intended to provide prescription information to GPs; the system will also be utilised to provide clinical information in future.

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0253 Total laparoscopic hysterectomy – a 3-year experience and audit at a District General Hospital

Smotra, G; Riad, M; Kumar, M Good Hope Hospital, Sutton Coldfield, UK Introduction Total laparoscopic hysterectomy (TLH) is gaining

popularity amongst gynaecological surgeons and patients because of its benefits of minimally invasive approach, shorter hospital stay and minimal blood loss. TLH is a laparoscopic hysterectomy in which all the surgical pedicles are taken laparoscopically, specimen is retrieved from the vagina followed by closure of the vaginal vault laparoscopically. The objective of this audit was to evaluate patient care and outcome following TLH. Methods Retrospective case notes review of 100 patients who had TLH from June 2013 to February 2016. Results TLH was being done is varied age group from 26– 81 years. It was successfully done on women with BMI ranging from 21–48. 18% of the women who had TLH had previous caesarean. 22% had previous abdominal surgery. Menorrhagia was the most common indication for TLH followed by endometrial cancer. Direct optic entry was done in all the 100 cases. 60% of the women had adhesions. Conversion to laparotomy was done in 6%. Bladder injury was 1% and haemorrhage more than 500 ml was seen in 3%. All of these were below the national standards. 59% of patients went home on day-1. None of the patients returned to theatre. Conclusion Our audit results reiterate that TLH is a safe procedure with low complication rates when done by trained professionals. It leads to quicker recovery and is a cost-effective procedure.

0254 An audit of infection post-hysteroscopy at a District General Hospital

Naik, A; Taki, F; Wong, CY; Kothari, A; Syed, S The Hillingdon Hospital, London, UK Introduction 3.8% of patients undergoing hysteroscopy have

complications. The RCOG identifies infection post-hysteroscopy as a frequently occurring complication (0.18–1.5%). The use of routine prophylactic antibiotics is not recommended as demonstrated in the RCOG, ACOG and a Cochrane review. Local guidelines do not recommend the use of routine antibiotics in inpatient hysteroscopy. Patients undergoing outpatient hysteroscopy who are either premenopausal or have risk factors for infection receive a stat dose of azithromycin. Methods We reviewed hysteroscopies over 1 month (n = 57) and readmissions over 6 months (n = 8). We assessed the demographics, menopausal status, risk factors for infection, antibiotic prescription, and complications. Results were audited against local guidelines. Results 66% of pre-menopausal women undergoing outpatient hysteroscopy received azithromycin as recommended. 54% of women undergoing inpatient hysteroscopy received various



antibiotics based on the surgeon’s preference and additional procedures carried out. They had other risk factors such as high BMI and diabetes, but no clear history of PID. Of the eight readmissions, three received antibiotics during the primary procedure, only 1 of whom had previous PID. Another had T2DM and raised BMI. Five required antibiotics and three required additional surgery on re-admission for hydrosalpinx or pyosalpinx. Two women required ITU admission. Conclusion Re-admissions with sepsis can be a cause of significant morbidity and it is worth considering risk factors other than only PID when choosing candidates for prophylactic antibiotics. Further, our local antibiotic guidelines for outpatient and inpatient hysteroscopy are inconsistent and we have suggested that this be corrected.

0256 Impact of the fetal pillow device on maternal morbidity

Kalburgi, S1; Oyekan, E2; Bagtharia, S1; Ikomi, A1 1

Basildon Hospital, Basildon, UK; 2Queen Elizabeth Hospital, Woolwich, London, UK Introduction Second-stage caesarean sections are associated with

difficulty in the delivery of the head, uterine angle extension and haemorrhage. Fetal pillow is a balloon device which when inserted in the vagina and inflated with saline, disimpacts and facilitates delivery of a deeply engaged fetal head. We conducted two separate studies on the fetal pillow to evaluate the benefits of its use. Our NHS trust in Essex, England looked into the efficacy and sustainability of the device. Methods Data were collected retrospectively from the electronic medical records of 18 cases in 2014 and then a second analysis of 38 cases in 2017 to close the audit loop. The following parameters were compared: BMI, gestation at delivery, indications for caesarean, difficulty in insertion and fetal pH. Results In 2017, the device was used appropriately in 84% of cases. In 5% of cases, the head was at station +2. There were no uterine angle extensions in 63% of cases, an 8% improvement from 2014. A shift in grade 2 extensions towards grade 1 was seen. 5% of cases showed blood loss of more than 1500 ml with no increase in maternal morbidity. Comparative results between the two audits when the data were normalised showed that despite deeper engagement of the fetal head, good performance of the fetal pillow was maintained. This supports the sustainability of the device. Conclusion We recommend the fetal pillow in second-stage caesarean sections where we expect difficulties in delivery, deeply engaged head and following unsuccessful instrumental deliveries.

0257 Retrospective study of the management of cervical glandular intraepithelial neoplasia

Merzougui, S1; Srinivasan, J2 1 Birmingham Women’s Hospital, Birmingham, UK; 2Burton Hospitals NHS Trust, Burton-on-Trent, UK

Introduction Invasive cervical adenocarcinoma is the second most

common malignancy of the cervix. The incidence of this cancer as well as its precursor cervical glandular intraepithelial neoplasia (CGIN) has increased, especially in young women. Detection of glandular abnormalities on cervical cytology is more difficult than the detection of changes in squamous cells. The prevalence of invasive disease among women with glandular abnormalities is 40%. Indicators of glandular abnormalities at colposcopy lack sensitivity. Methods The aims of our study were to review the management of patients with glandular abnormalities on smear and histology results. A total of 69 women over a 10-year period with abnormal glandular smears and CGIN on histology were identified. 61% had glandular abnormalities, 8% had abnormal vaginal bleeding and 6% described as ectropion. Results At the first colposcopy visit, 70% of patients had large loop excision of cervix (LLETZ). 10% had invasive adenocarcinoma of cervix. Four women had endometrial cancer. 64% had CGIN; 70% of those were associated with CIN. 9% of CGIN had only borderline nuclear changes on squamous cells or mild dyskaryosis on the referral smear (nearly 1:10). A third of LLETZ specimens had a depth