Poster Presentations

E-Poster Presentations

NEP7469 Baby up depression down: Babywearing and postpartum depression: ancient wisdom for the modern mom

Jerip, A Obstetrics & Gynecology, University Malaysia Sarawak, Kuching, Malaysia

Maternal depression is a public health issue with important links to children health development. Highly prevalent yet treatable, 1:11 women died from mental health-related causes during or up to 6 weeks postpartum. Almost 1:4 deaths occurring from 6 weeks-1 year after birth were related to mental health problems (1:7 by suicide). This manuscript aims to shed light on babywearing and postpartum depression (PPD). Not a paper with a P-value and NNT conclusion, this compiles experience of babywearing mothers and evidence-based practices naturally facilitated by babywearing. Babywearing is gaining traction amongst modern mothers as evidence shows calmer babies with more carrying and skin-to-skin contact (SSC). Mothers report that carriers ease SSC, keep infants warm and encourage breastfeeding. They also report less infantcrying, a strong trigger for postpartum depression. Supplementary carrying reduces crying and fussing by 41–50% and babywearing facilitates ‘hands-free’ carrying, allowing the mother to perform chores and attend elder children. Mothers of special-needs and medically-fragile infants are at higher risk for PPD. Experiencing heightened relationship difficulties, family and financial stress, they are doubly predisposed. Already a delicate demographic, NICU infants of mothers with PPD are fussier, exhibiting more discontent and avoidant behavior with less positive facial expressions and vocalizations SSC for premature babies remarkably improve physiological, emotional and cognitive regulatory capacities. Babywearing builds parenting confidence as they attune-finely to their babies’ nuances, an interaction that enhances the mutual learning. This cycle of positive interaction deepens reciprocal parent-child attachment, fundamental for mothers at-risk or with PPD. New evidence supports antidepressant effects of exercise. One study reported a halving of Edinburgh Post Depression Scale (EPDS) scores in their exercise group. Thus, pairing babywearing with exercise should be introduced postnatally. Prams are expansive and cumbersome, requiring good weather and infrastructure. Carriers, on the other hand, are lightweight, easyto-pack and accommodate for small spaces and public transportation. Requiring no additional childcare, babywearing exercise fits comfortably around infant nap times. Under correct supervision, babywearing exercise is secure and can be safely taught at health clinics. It takes a village to raise a child, and the babywearing community is one that reaches beyond the divides of race and class. One can subscribe to any parenting-style and still babywear. It is vital for healthcare providers to recognize its potential despite its simplicity and support babywearing educators who aid mother-child bonding with this ancient practice.

Category O: E-Poster Presentations: Quality Improvement, Medical Legal, Patient Safety OEP5430 Closed loop audit: How competent and compliant are surgeons (obstetrics) at surgical hand antisepsis prior to elective and emergency surgical procedures?

Ooi, R1; Griffiths, A2 1

Obstetrics and Gynaecology, Cardiff University, Cardiff, UK; Obstetrics and Gynaecology, University Hospital Wales, Cardiff, UK

2

Introduction Surgical hand antisepsis is known to effectively

remove or destroy transient microorganisms and inhibit the growth of resident microorganisms. Hand hygiene is so critical as newborns are more susceptible to infections because of their immature immune system. This also leads to an increase risk of maternal sepsis postpartum surgery. Aim We aim to assess how competent and compliant are surgeons at hand scrubbing prior to elective and emergency surgical procedures by video-surveillance before and after the revision of the AFPP and WHO guidelines. Methods Involved staff were notified through email and microcamera was assembled. Micro-camera was turned on at random to capture hand scrubbing footage over a period of 7 days. Video recordings collected were compared with AFPP and WHO guidelines. Each recording was graded with a binary variable 1 = Obey and 0 = Disobey, scoring over 13 principal steps and 12 key steps into 3 categories (Excellent, Satisfactory, Unsatisfactory). An updated interventional poster was created and strategically placed above all scrubbing stations in all obstetric theatres. Importance of surgical hand antisepsis too was addressed during the UHW Quality and Safety meeting. A re-audit was performed 2 weeks after. All footages were being analyzed anonymously and deleted. Descriptive statistics [mean (SD), frequency (%)] and charts were being used to demonstrate any change post-intervention. Results 80 observations of surgical hand antisepsis were recorded. 40% of recordings showed compliance with 2-minute hand scrubbing time of which surgeons’ performance were 31.3%. A slight improvement was seen in elective procedures in the reaudit. Unsatisfactory rates were higher in the night (initial audit, 57%; re-audit, 36%) compared to observations made during the day (initial audit, 46%; re-audit, 24.1%). Unsatisfactory rates dropped after the intervention period from 50% to 27.5% overall; and 75% to 31.6% among surgeons. Conclusion Our results demonstrate that there is much need for improvement of hand-scrubbing compliance. Video surveillance combined with real-time feedback produced a significant and sustained improvement in hand hygiene compliance. Use of the surgical hand antisepsis guidelines increased following the initial audit and intervention.

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

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OEP5680 Insuring maternity safety: Exploring models of clinical-insurer engagement

Yau, C1,2; Quick, O3; Draycott, T1 1

Obstetrics and Gynaecology, Southmead Hospital, Bristol, UK; Translational Health Sciences, University of Bristol, Bristol, UK; 3Law School, University of Bristol, Bristol, UK 2

Introduction Across the world, birth is not as safe as it could, and

should, be. Preventable harm is not only a tragedy for the families affected, but with rising litigation costs, it is a significant drain of financial resources from healthcare systems. These are payments that no one wants to have to receive, or pay. It is money lost to the healthcare service and ultimately, patient care. Preventing these payouts may release funds to help replenish health systems facing perpetual financial constraints. Whilst insurers are not patient safety organisations, they have a key role in reducing harm and avoiding litigation which has yet to be fully realised. There has been little empirical research to understand state insurers’ different strategies of engagement with clinical teams. In this study, we explored different models of clinical-insurer engagement, with a focus on maternity care. The aim was to understand how insurers could and should work with clinical staff to improve outcomes and prevent harm. Methods We conducted semi-structured interviews with senior representatives from the following state insurers: NHS Resolution (England) Welsh Risk Pool Services (Wales) Central Legal Office (Scotland) State Claims Agency (Republic of Ireland) Victorian Managed Insurance Authority (Victoria, Australia) € Landstingens Omsesidiga F€ ors€akringsbolag (Sweden) Results A variety of clinical engagement activities were undertaken by the insurers. These included training clinical staff on claims and risk management, hospital site visits, facilitating multi-professional network meetings and working with clinical experts to develop best practice recommendations. Some insurers engaged with frontline clinical teams through collaborative patient safety programmes. These projects were supervised by clinical experts from the start and some appear to have had beneficial effects on outcomes or litigation. Insurers should focus on supporting translational improvement initiatives to maximise impact in a variety of healthcare settings. Claims data could be better utilised as a learning resource and would complement clinical data. Insurers and clinicians should work in partnership to carefully design an accessible system that will facilitate, rather than hinder, the analysis of claims and clinical data together. This will result in more data being converted into meaningful information. Conclusion Insurers are not only focussed on claims management and the litigation process. They also have an interest in patient safety. Insurers can be important allies to clinical teams in their pursuit of safer patient care. Clinical staff should collaborate more closely with insurers to achieve their common goals: improving patient outcomes and reducing litigation.

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OEP5697 Hysteroscopy audit in LNWH: Results between September 2015–September 2016. Do we need to set a cut-off for endometrial thickness in order to refer for hysteroscopy?

Spyroulis, C; Abdel-aal, M; Yousri, N; Kyaw, A Obstetrics and Gynaecology, Northwick Park Hospital, North West London, UK Introduction Hysteroscopy with endometrial biopsy is a

recognised method to diagnose endometrial cancer in case of bleeding in premenopausal and postmenopausal women. Unfortunately, there is no specific cut-off setting from NICE or RCOG. NICE recommends that, in case of postmenopausal bleeding women who receive HRT should be referred for hystteroscopy, even if the endometrial thickness is 2 mm. Methods We did a retrospecrtive analysis of the hysteroscopic data which was held in LNWH hospitals (Ealing, Central Middlesex and Northwick Park hospital) between September 2015-September 2016. During this period, we undergone 150 hysteroscopies; outpatient and inpatient for different reason. The reasons of hysteroscopies were: (a) 130 bleeding (premenopausal and postmenopausal bleeding), (b) 10 infertility cases, when the HSG or ultrasound scan shown a submucoisal fibroid, (c) to 7 identify the Mirena (Bayer plc, Reading, UK) coil and (d) 3 due to pain. 110/130 bleeding cases, had a scan prior to hysteroscopy. Results 10/130 were premenopausal and 120 were postmenopausal women. From those that they had a scan prior to hysteroscopy (110 in total), 5 had endometrial thickness 11 mm. On time of hysteroscopy, we wouldn’t be able to receive an endometrial sample in 40 cases, due to obvious atrophic endometrium. From the rest; 70 cases we received an endometrial sample and we sent it for biopsy. 5/70 had confirmed endometrial cancer. All 5 endometrial cancer patients had an endometrial thickness of more than 11 mm. Discussion It is universally accepted that, the golden standard diagnostic tool for endometrial cancer is hysteroscopy and biopsy. NICE states that, 10% of women with postmenopasal women will be diagnosed with endometrial cancer. Also, we know that the thicker the endometrium it is, the higher potential to diagnose a postmenopausal woman with cancer. Obesity is a well-recognised risk factor for endometrial cancer, since the adipose tissue is metabolised to estrione which is a weak estrogen, but capable to increase the endometrial thickness and further, to increase the risk for endometrial cancer. By looking our data, but also an epidemiological study from the University of Hong Kong we set up as a cut off referring point of endometrial thickness to hysteroscopy and biopsy. This cut off point is 5 mm. This cut off was based on our data, the referring cut off point in Scotland and the epidemiological study from the University of Hong Kong, which analysed the risk of endometrial cancer based on the ET in ultrasound



OEP5918 The importance of documentation and guidelines in Electronic Fetal Monitoring

Gnanasambanthan, S; Uchil, D; Andrews, V Obstetrics and Gynaecology, University Hospital Lewisham, London, UK

OEP6097 Woman-Centred Induction of Labour (the WOCIL Project) – A Quality Improvement Project and experience of introducing Misoprostol Vaginal Insert to reduce in-patient stay and improve women’s experiences

Clarke, A; Taggert, H; Noori, M; O’Dwyer, S Introduction Intrapartum hypoxia occurs in 1% of all labours,

and can cause fetal and neonatal concerns including long-term neurological disability, and fetal demise. Electronic fetal monitoring (EFM) combined with clinical judgement are used to assess for fetal hypoxia. A previous audit in April 2015 showed deficiencies in documentation, which was only correct in 69% of cases. A structured programme for midwives and doctors consisting of mandatory CTG masterclasses, weekly teaching on EFM with input from midwives who are trained in fetal wellbeing, and obstetricians, were introduced to address this. Objectives To assess whether this structured education program and mandatory CTG masterclass had an impact on documentation of CTGs. Methods Prospective audit of documentation of EFM was conducted in November 2015. Results

36 patients were investigated representing 1% of the total deliveries. All CTGs were correctly labelled with the date, time and patient identification details. The gestation was recorded in 69% of cases, an improvement from 53% previously. ‘Fresh-eyes’ approach where EFM interpretation is checked by a second health care professional every two hours improved to 60% compared with 11% previously. Documentation of CTG interpretation improved from an average of 69% to 80%. An action plan if the trace was classified as suspicious or pathological, in keeping with local guidelines was implemented in 95% of cases, compared with 91%.

1. Table comparing improvements before and after structured training. Discussion

There was a five-fold increase in fresh-eyes. Improvement in documentation and action plans. Conclusion A structured programme reinforced with weekly CTG

training and masterclass significantly improved a second healthcare professional reviewing electronic fetal monitoring and had an impact on documentation and appropriate action plans. Consideration for similar structured programmes should be considered for all maternity units.

Obstetrics and Gynaecology, Imperial College Healthcare NHS Trust, London, UK Introduction In response to increasing Induction of Labour (IOL)

rates (32% in our unit), and concerns raised by women and staff regarding our IOL process, the WOCIL team was formed. Methods We used Quality Improvement (QI) methodology to engage staff, conduct a root cause analysis, and implement changes using Plan-Do-Study-Act cycles. Problems identified include: delays starting/continuing IOL due to capacity and flow issues; unrealistic patient expectations; staff burnout.

Data was collected prospectively from November 2016 to September 2017, with constant review and revision of improvement strategies at various stages. 371 cases were examined. Qualitative data from women and staff were collected via surveys and engagement events. Interventions included: outpatient inductions (OPIOL) being performed on Day Unit; new information leaflet, including an explanation video; introduction of misoprostol vaginal insert (MVI) for in-patient IOL (from July-September 2017).

We performed a comparison of women receiving dinoprostone (by vaginal insert or gel) and women receiving MVI (172 and 128 women respectively). Results Over the study period, we achieved the following: reduction in average time taken to commence IOL and concomitant reduction in upper process control limits; increase in OPIOL rate from 0% to 10%; positive feedback from staff and women.

We found that our experience of using MVI mirrored the findings of the EXPEDITE study (Wing et al 2013): Median IOL duration was reduced in the MVI group: 15 h 52 m versus 29 h 50 m; reduction in amount of variation in total IOL time (upper process control) with MVI; less use of oxytocin (43% in MVI versus 66% in dinoprostone); of those requiring oxytocin, duration was reduced (6 h 44 m in MVI versus 9 h 39 m in dinoprostone); MVI is associated with an increased risk of tachysystole/hyperstimulation (45% in MVI versus 9% in dinoprostone). Fetal heart rate changes were associated with 21% of MVI group. no difference in neonatal apgar, acidosis and admission for neonatal care.

We found a lower caesarean section rate in women receiving MVI compared to dinoprostone (20% versus 26%) and a trend towards a reduction in maternal and neonatal antibiotic use. Conclusion Our experience with MVI has confirmed that it is an effective method of induction. There exists a learning curve with


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use of MVI and timely removal is important in preventing excessive hyperstimulation/tachysystole rates. We recommend considering MVI in high volume units experiencing challenges with patient flow in IOL, as part of a robust QI strategy to ensure staff engagement and education.

OEP6177 Asymptomatic bacteriuria in pregnancy: Diagnosis and management in an UK maternity unit

Roberts, R1; Chan, D; Chiu, S; Teoh, TG; Hatcher, J; Arulkumaran, S Obstetrics and Gynaecology, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK

OEP6107 Transversus abdominis plane block for postoperative pain of caesarean section

Introduction Asymptomatic bacteriuria defined as positive urine

Maung Maung, P; Kler Ku, S; Yee, HH; Pe, A Department of Obstetrics and Gynaecology, University of Medicine, Mandalay, Burma (Myanmar) Objective Transversus abdominis plane (TAP), a neurofascial plane between rectus abdominis and transversus abdominis muscles, block is a relatively new regional anaesthetic technique that provides analgesia after surgery. The purpose of this study was to study the analgesic effect of TAP block after caesarean section in study (0.25% bupivacaine) and control (0.9% NaCl) groups. In both groups, intramuscular injection of diclofenac sodium 75 mg immediate after operation and IM tramadol 50 mg as required basis were given. Methods This study was hospital-based double blind randomized controlled study that was performed for a year from January 2015 to December 2015. Sixty patients who had undergone emergency caesarean section were randomly allocated to study and control groups. The patients in study group received 40 ml of 0.25% bupivacaine (n = 30) and 40 ml of 0.9% normal saline for control group. Diclofenac sodium (IM 75 mg) injection was given to both groups as postoperative analgesic. In postoperative period, IM tramadol 50 mg was used as a rescue analgesic agent in both groups when NRS score ≥4 or patient complained of pain. Each patient was assessed at 30 minutes, 2, 4, 6, 8, 12 and 24 hours postoperatively to investigate NRS pain scores (cm). The time to first request for postoperative analgesic, IM tramadol was noted to calculate the interval of analgesic requirement for both groups. Total tramadol consumption within the first 24 hours was also recorded. The potential complications of local anaesthetic such as seizure, coma, respiratory depression and hypotension were observed during TAP block. Results NRS pain scores at 30 minutes, 2, 4, 6, 8, 12 and 24 hours after surgery were assessed and compared to control group. They were significantly reduced in study group at all time points (P ≤ 0.0001) except at postoperative 30 minutes (P = 1). The mean duration of postoperative analgesia was significantly prolonged in study group (388.67 176.83 min) compared to control group (237.33 29.73 min) and P ≤ 0.0001. Mean total tramadol requirement in the first 24 hours was also significantly lower in study group (41.67 18.95 mg) in compare to control group (50.00 0 mg) and P = 0.02. There were no complications attributable to the surgical TAP block. Conclusion TAP block, as a part of multimodal analgesia, can cause reduced pain scores and reduction in analgesic requirement after caesarean section.

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culture in a patient without urinary symptoms, affects between 2 and 10% of pregnancies. If left untreated, 30% of women can develop acute pyelonephritis, as well as lead to significant maternal morbidity. Acute pyelonephritis can also result in spontaneous preterm birth and low birthweight. Despite its clinical importance, current UK advice on routine antenatal screening is inconsistent. The UK National Screening committee concluded that there was insufficient evidence for universal screening, however the National Institute of Clinical Excellence, the Scottish Intercollegiate Guidelines Network and the Royal College of Pathologists do recommend routine screening in early pregnancy. Imperial College Healthcare NHS Trust, London, UK does not currently have local guidelines on screening and treating asymptomatic bacteriuria. Methods Current management of urinary tract infections (UTI) in pregnancy was audited against standards published by the Royal College of Pathologists. Medical notes for 50 women at the end of their pregnancies were analysed by two obstetric trainees at St Mary’s Hospital, UK. Results A mid-stream urine (MSU) sample was cultured following the first antenatal visit in 8/50 (16%) women. There was positive bacterial growth in 3/8 samples (37%), with one patient being appropriately treated for Escherichia Coli; the remaining two samples were bacterial contaminants. A test of cure following antibiotic treatment with a repeat midstream urine culture was not performed. There is still routine use of nitrites and leucocytes in urine dipstick testing despite national advice in the absence of urinary symptoms to dipstick for glucose and protein only. In total for 50 pregnancies, 44 midstream urine cultures were performed, but only 2 patients (5%) had urinary symptoms. Contaminants were found in 11/44 (25%) of samples, with the most common contaminants being yeast, mixed bacterial growth and Enterococci. Due to the high rate of bacterial contaminants, a patient information poster to improve patient collection of a MSU sample was designed. This will be displayed in maternity clinical areas to improve successful clean collection of samples. Conclusion Screening for asymptomatic bacteriuria at the antenatal booking is now recommended at our Trust. We anticipate that the patient information poster for MSU collection will reduce contaminants, and this will be re-audited. A pregnancy specific management pathway covering MSU testing, treatment of UTI, differentiating pathogens and contaminants, and performing a test of cure is in publication. This will standardise care within our Hospital Trust.



OEP6208 Service review of coding of co-morbidities at delivery which impact on coding and tariff

Dann, P; Ansar, H; Nettletone, K; Khan, G; Singhal, T Obstetrics & Gynaecology, University Hospital Leicester NHS Trust, Leicester, UK

OEP6228 Is More Better? How does hospital infrastructure correlate with patient care: Women’s experiences and what matters most

Montagu, D1; Phillips, B1; Singhal, S2; Pratap Singh, V2; Kumar, A2; Kumar, V2; Kajal, 1,3 1

Global Health Sciences, University of California, San Francisco, USA; Research, Community Empowerment Lab, Lucknow, India; 3Maternal Health, National Health Mission, Lucknow, India 2

Introduction A service review undertaken in a tertiary obstetric

centre reviewed the coding of co-morbidities at delivery and the impact on tariff. The Department of Health recommends that health providers should review the existing recording of delivery practices to safeguard that practice is coded accurately, leading to correct payment for services provided. Maternity pathways were introduced, from which the commissioner makes a single payment per woman to the provider, reliant on coded information. A tariff review of Maternity cases at the University Hospitals Leicester (UHL) identified that in comparison to the national casemix, the percentage of women delivering at UHL classified as high risk had decreased since the year 2014–2015. Were deliveries being coded accurately or did the maternity population at UHL have lower risk deliveries? Objectives To determine whether there were any discrepancies in coding by clinicians and coders, affecting the tariff procurement and ultimately impacting the departmental financial income. From this, improvements can be made in the coding accuracy, clinicians educated about documentation and the detrimental financial implications and projections made for future years. Methods A team of clinicians reviewed 180 maternity case notes retrospectively (representing 20.4% of deliveries in a 1 week period in August 2016), checking the comorbidities of each case against the coding proforma. Results 45 women (25%) were delivered by caesarean section, 21 (11.6%) by instrumental and 104 (57.7%) by vaginal delivery. Of these 180 cases, 82 (45.5%) were identified as high risk. The deliveries coded as ‘low risk’’ or ‘deliveries without complications’ were re-reviewed, totalling 47 cases. 21 (44.7%) cases were coded correctly and 19 (40.4%) cases could have been changed to ‘deliveries with complications’. 7 (14.9%) cases could not be rereviewed due to missing data. Discussion The inaccurate coding of 19 cases (11.7%) demonstrated an underpayment of £863 per case, totalling £16,397. Extrapolating this cost difference to the 11000 deliveries per annum at UHL, shows the impact of this inaccurate coding and consequent underpayment is immense. Conclusion This review demonstrated a discrepancy between the coded and actual activity of the UHL Maternity department. The implications of this coding and consequent payment discrepancy therefore must be addressed, ensuring that the tariff paid is appropriate for the actual activity. In a climate of increasing demand for healthcare and financial difficulty within the NHS, clinicians and coders at UHL are working hard in collaboration to ensure accurate coding and therefore correct payment for the care provided.

Uttar Pradesh (UP), India’s most populous state, has the country’s worst statistics on maternal morbidity and mortality. The Quality-Plus (Q+) study seeks to understand what hospital factors lead to safer care and thus better experiences for women. The study focuses on high-volume (>200 deliveries/month) facilities in UP where 80% of all institutional births occur. This presentation will describe our analysis of differential patient experiences during facility deliveries, focusing on treatment, counseling, and respect given to women according to their wealth and caste, and how this treatment varies by facility type. Our study seeks to differentiate between treatment, good or bad, which is determined by client attributes, and treatment which is determined by facility management, size, staffing, and equipment quality. While both factors affect the patient’s experience, their interaction suggests how best to assure equitable quality for delivery care. Clinical quality was assessed using self-reported data from 727 health facilities across UP. Forty high-volume facilities of varying size, levels of infrastructure and staff, and location were selected for in-depth assessment. 2000 exit-interviews were conducted on delivery patients to measure person-centered care and assess other aspects of clinical and non-clinical quality. Patient and facility attributes – determined by structural assessments – are analyzed using regression analysis. Among the patients sampled thus far (n = 1000), over 80% are from rural areas and 51% report an annual family income of INR 50,000 or less (US$770). While respectful care is a significant issue in our sample, our results show little indication of caste bias: 75% (n = 165) of patients left alone by a healthcare worker are from historically vulnerable castes, and close to the 79% of our sample from these castes. Similarly, while 27% of all patients report feeling disrespected by providers, vulnerable and non-vulnerable castes report this experience at equivalent rates (P < 0.01). However, wealth matters: poorer women were more likely to report being left alone than wealthy women. Our findings will provide guidance to policy-makers considering critical choices between investments in higher-level centralized facilities or improvements in staffing and facilities in smaller locally responsive facilities. The trade-offs between these two options are particularly relevant for the poor and less educated women seeking care who typically begin labor in rural and periurban locales. As maternal morbidity and mortality rates are higher among lower SES populations, constructively addressing the health experiences of these women has the potential to positively impact future health-seeking behavior and outcomes in at-risk groups.


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OEP6229 Why hospitals fail: Understanding the drivers of quality of care in high volume maternity centers in Uttar Pradesh

OEP6321 Perception of the WHO surgical safety checklist by UK operating staff: Seven years after implementation, where do we stand?

Montagu, D1; Phillips, B1; Singhal, S2; Pratap Singh, V2; Kumar, A2; Kumar, V2; Kajal, 1,3

Duret, A1; Adams, S1; Winder, M1; Li, T1; Latimer, J2; Bolton, H2

1

1

Global Health Sciences, University of California, San Francisco, USA; Research, Community Empowerment Lab, Lucknow, India; 3Maternal Health, National Health Mission, Lucknow, India

School of Clinical Medicine, University of Cambridge, Cambridge, UK; 2Department of Gynaecological Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK

Introduction Uttar Pradesh, India’s most populous state, has

Objectives The WHO surgical safety checklist (SSC) was developed to tackle communication failure within operating teams and foster a safety culture, with the final aim of improving patient safety and perioperative morbidity and mortality. Despite randomised controlled trials demonstrating the reduction in perioperative adverse outcomes associated with SSC introduction, numerous studies identified resistance from UK operating room (OR) staff in the peri-implementation period. The goal of this study was to reassess the perception of the SSC seven years after its introduction. Methods We generated a nine-question survey which was circulated to OR staff in a tertiary centre in England. Results 175 responses were collected over nine days and highlighted several key themes. 85% agreed or strongly agreed that communication between team members had improved following the introduction of the SSC. 90% felt it had a positive impact on patient safety, especially amongst scrub and theatre nurses (78% reported strong positive change), describing the checklist as a method of standardising the required checks when teams, equipment and operations can be so variable. The survey highlighted discrepancy between the perceived role of the SSC in elective and emergency cases with a perceived need for an abbreviated version of the SSC for emergency cases, while advocates of the current SSC stressed how it helped in rapidly changing plans and unfamiliar teams. 75% of participants deemed ‘Team introductions by name and role’ and ‘Procedures, site and position confirmation’ to be the most important aspects of the SSC, while the least valuable part of the SSC was deemed to be the clinical coding checks (part of the modified SSC at study hospital), as selected by 44% of participants. The final identified themes were the need for senior surgeons and anaesthetists to be present during sign-in, and for the checklist to be carried out attentively, not as a tickbox exercise. Regularly updating the checklist and each specialty having a specifically tailored version of the SSC were suggested as means to achieve this. Conclusion Overall, this study highlighted a current positive attitude by OR staff towards the SSC, and some remaining challenges which offer room for improvement - the fact that Never Events are still occurring testifies to the need to further reinforce OR safety. This study was limited to a single centre, and the authors feel that valuable perspectives would be gained by repeating it in other UK hospitals to assess cross-centre variability.

2

amongst the country’s highest rate of maternal deaths. The Quality-Plus (Q+) study aims to determine the differential drivers of quality in high volume (>200 deliveries/month) facilities in UP, where 80% of all institutional births occur. This presentation will describe our analysis of the proximate determinants associated with better levels of both person-centered care (PCC) and clinical quality in high volume facilities in UP. It combines patient surveys and facility structural data with in-depth interviews of facility staff to understand what aspects of facility systems and patient characteristics most clearly determine quality. Methods Clinical quality was assessed using self-reported data from 750 health facilities across UP. High volume (n = 246) facilities were classified into 4 quartiles based on clinical quality scoring criteria. Forty geographically representative facilities from top and bottom quartiles were selected for in-depth assessment. Within these, 2000 exit interviews of delivery patients were conducted to measure PCC and proximate determinants of quality. In-depth interviews with providers and facility leadership are being conducted to triangulate the quantitative results with provider perspectives on quality of care. Results Early results from first 20 Q+ sites indicate a high variation in clinical and PCC quality measures between facilities. The validated PCC scale assesses knowledge, communication, dignity, and other core components of person-centered maternity care. Across all Q+ facilities, communication, treatment, and respect appears to be deficient. For example, among those respondents sampled thus far (n = 1000), 72% report that physical examinations are conducted without explanation. A quarter of all patients report feeling disrespected by their health provider and 34% cite few or no times that health providers tried to control their pain during and after delivery. We will triangulate provider in-depth interviews with these PCC data and clinical quality results to understand institutional and provider attributes, such as duration of leadership staff in a facility and facility staff team dynamics, to determine high and low levels of clinical care and PCC. Conclusion These findings will help policy-makers better understand key determinants of clinical safety and patient treatment in high-volume facilities and guide quality improvement initiatives to spearhead efforts to reduce maternal mortality in UP and beyond.

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OEP6334 Care-seeking for maternal morbidity in Northern Nigeria: A qualitative study

OEP6348 How do women feel about having diabetes in pregnancy– an evaluation

Yargawa, J; Fottrell, E; Hill, Z Institute for Global Health, University College London, London, UK

Dixit, A; McKinnon, F; Webster, L; Martineau, M; Cotzias, C

Introduction Historically, maternal morbidity within community

Obstetrics & Gynaecology, Chelsea & Westminster Hospital NHS Trust, West Middlesex Hospital Site, London, UK

settings has been a neglected domain of safe motherhood relative to maternal mortality. Consequently, very little is known about how women and their families seek care for maternal ill-health, which significantly influences health outcomes. This study aimed to identify care-seeking behaviours for maternal morbidity in a region bearing a high burden of maternal health issues. Methods We conducted seven focus group discussions, 21 indepth interviews and 10 family interviews between December 2015 and June 2016 in Yola, North-east Nigeria. Married women who gave birth within the past two years were sampled purposively from the community to include a range of sociodemographic characteristics and morbidity status. All sessions were semi-structured and audio-recorded. The focus groups and in-depth interviews were transcribed. Data were analysed thematically at both explicit and latent levels and organised in NVivo 10. Results Women and their families managed maternal morbidities at home or through the formal health system. At home, they used regimens obtained from lay knowledge, traditional sources or pharmacies. For women who had home deliveries, delayed placental expulsion came out strongly as a morbidity that families would initially manage at home using a number of improvised strategies. Traditional medicine was used for therapeutic reasons and for morbidities perceived as having a spiritual cause, which were seen as undiagnosable and untreatable by doctors. Care was also sought in health facilities and, in a few cases, a health personnel was summoned home to provide care with interventions such as drips, injections and drugs. Factors that determined which care-seeking options were used included severity of the morbidity, familiarity with the morbidity and/or treatment, perceived cause of the morbidity, affordability and perceived efficacy of the option; perceptions of severity and familiarity were key drivers of seeking medical care. Educational level, age and gravidity/parity also influenced care-seeking. Approaches to care-seeking included usage of: one option exclusively, different options in a step-wise fashion, multiple options simultaneously. Conclusion Care-seeking for maternal morbidities is varied, with several patterns of care-seeking behaviours. As women and their families act promptly on morbidities deemed severe, changing perceptions of severity could therefore improve care-seeking and health outcomes. A step-wise usage of options implies that women may delay care-seeking and eventually reach health facilities too late. Certain home-based treatment strategies raise important safety concerns. Exploring maternal morbidity within community settings provides valuable insights that would have been missed in a facility-based study.

Objectives To understand antenatal women’s experiences of having a diagnosis of diabetes and how they feel lifestyle and monitoring recommendations affect them. Methods Pregnant women in a combined obstetric endocrine clinic with a diagnosis of diabetes (from May 2017) were asked to complete an anonymous questionnaire assessing their experiences of having diabetes in pregnancy managed in accordance with NICE guidelines Results The questionnaire was completed by 100 women; 85% (n = 85) had gestational and 15% (n = 15) pre-existing diabetes. Only 5% (n = 5) had not made changes to their diet following review in the clinic, with 62% (n = 62) making substantial changes to their diet. The cost of food shopping was the same or less for 66% (n = 66) and 73% (n = 73) reported that their family were eating more healthily. 52% (n = 52) of women were exercising more following the advice received. When asked about their experiences of capillary glucose testing during pregnancy, 44% (n = 44) reported they felt pressure to have perfect readings in their diary and 24% (n = 24) admitted to ‘made up’ entries. Reasons for making up readings included concern that the readings were too high and that readings had been missed. Overall, 35% (n = 35) of women reported that they thought about their diabetes often and were worried about it. Conclusion The impact of lifestyle changes, monitoring and treatment strategies for pregnant women that develop diabetes is substantial and affects the wider family. Evaluation of the experiences of women in individual units is imperative to ensure an optimal holistic approach to the care provided.

OEP6368 Recovery after gynaecological surgery

Ng, YS; Kang, JHL O&G, Kandang Kerbau Hospital, Singapore Aim To review the outcomes of patients after elective major

gynaecological surgery using current preoperative protocols in a tertiary hospital. With reference to enhanced recovery after surgery (ERAS) protocols, we seek to modify perioperative pathways to improve the outcomes as a prospective study. Methods All elective major gynaecological procedures for September 2017 in Kandang Kerbau Hospital(KKH), were reviewed for their preoperative ASA status, haemoglobin level, co-morbidities. Postoperative outcomes in terms of duration of hospital stay, complications during and after their hospital stay, and readmissions were looked into to help stratify potential areas


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for improvement. Procedures were categorised according to table code number as per ‘Table of Surgical Procedures’ by the Ministry of Health in Singapore. Results There were a total of 201 major gynaecological cases performed for September 2017. 42 cases were listed as gynaeoncological cases. 161 (80.1%) cases were given an ASA-1 status, 39 (19.4%) ASA-2 and 1 (0.5%) ASA-3. There were 16 diabetic patients in the study group and 34 with cardiovascular conditions. The mean age for all patients was 44.7 years old. Patients undergoing table 3 procedures have the youngest mean age of 39.6 years, followed by table 4 – 42.9, table 5 – 47.5 and table 6– 54.7 years old. Their respective BMIs were 22.8, 25.7, 24.8 and 27.36. Haemoglobin levels were highest, 12.9 g/dL, with table 6 patients and lowest with table 3 patients – 11.9 g/dL. Duration of hospital stay shows corresponding increase with table codes. Table 3 patients stay on the average of 1.2 days, table 4 – 3.4, table 5 – 5.6 and table 6 – 6.4 days. Postoperative complications during inpatient stay were notably the highest for table 5 cases, with 22.4% cases. 10% of table 6 patients had complications, followed by 5.9% cases for table 4 and 3.3% for table 3. Complications include postoperative ileus, anaemia needing transfusion and pyrexia needing escalation of antibiotics. Post-discharge, 5 (2.5%) patients were re-admitted with complications relating to their operation. Conclusion A variety of surgical specialties have implemented ERAS protocols catered to different type of procedures. The extra emphasis given to preoperative nutrition, avoidance of preoperative fasting, carbohydrate loading, together with postoperative management of nutrition and prevention of prolonged postoperative ileus have shown much promise. There may be much inertia, but with the introduction of a modified enhanced recovery pathway for gynaecological procedures in the near future, we hope to produce evidence of improved outcomes, not just in surgical competence, but also with perioperative management.

OEP6394 Audit on paired cord blood gas sampling at birth at an outer metropolitan general hospital

Blackett, S1; Pearce, A1; Basu, A123

Methods

A retrospective audit of all paired cord blood gas assays undertaken in one month (July 2017). Possible indications were identified from guidelines used in different states across Australia. Results

Total births – 151. Paired samples that should have been done as POCT in – 58 (38.41%). Paired cord samples attempted in – 38 (65.51%). Caesarean section – 17. Assisted vaginal birth – 11. Spontaneous vaginal birth – 10. Successful paired samples obtained in – 33 (86.84%). Paired samples attempted in Non-elective C. Section – 15. Assisted vaginal birth – 11. Meconium stained liquor – 4. Abnormal CTG – 15. Preterm – 7. Neonates requiring resuscitation – 14. Shoulder dystocia -1. More than 1 indication present in – 15. Though more samples were taken in operating theatre compared to birth suite this was not statistically significant (chi-square value 0.719; P = 0.3963; significant at 0.05]. The average blood loss in the transfused group of 76 women was 1523 ml with 26 women having a blood loss greater than 2 litres. The major haemorrhage protocol was activated in 7 cases. A total of 169 units of blood were transfused with majority receiving two units of blood (54/76; 71%) each. Whilst the day of transfusion ranged from day zero up to 4 days later, majority [41% (31/76)] received blood on the day of delivery. In women who received blood transfusion more than 24 h after the delivery i.e. when there was no active bleeding, in 60% cases [n = 18] pretransfusion haemoglobin level was >70 g/dl, where a potentially suitable alternative would have been oral or parenteral iron. Conclusion Despite the blood transfusion rate comparable to other maternity units, a significant proportion of women transfused blood could potentially be managed with oral or parenteral iron to further improve the efficiency of usage of blood.

OEP6531 Blood transfusion in obstetrics – essential or avoidable?

Gallagher, M; King, A

OEP6537 Quality improvement project: maternal lower urinary tract infection Obstetrics and Gynaecology, Royal Infirmary of Edinburgh, Edinburgh, UK

Wassermann, M; Gudipati, M Obstetrics and Gynecology, Sunderland Royal Hospital, Sunderland, UK Introduction Many blood transfusions in pregnancy can be

considered inappropriate and avoidable. Blood is an invaluable source to save life, but its availability is limited, therefore warrants efficient use. Women who are hemodynamically stable with haemoglobin >70 or 80 g/L can usually be managed with oral or parenteral iron. Blood transfusion in obstetric population has additional risk of sensitization to red cell antigens and consequently causing haemolytic disease of the fetus and newborn in subsequent pregnancies. The aim of the study was to estimate the incidence of peripartum blood transfusion, identify the contributing factors for postpartum haemorrhage (PPH) and assess the effective usage of blood products.

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Introduction This Quality Improvement Project (QIP) was

developed, to improve diagnosis and management of lower urinary tract infection in the maternal population in the Royal Infirmary of Edinburgh, Scotland. Lower urinary tract infection can be difficult to diagnose due to similarity of symptoms associated with normal pregnancy. Additionally standard testing of urine can be more cumbersome due to collection methods and interpretation of results. This project was undertaken to assess the appropriate diagnosis and management of lower urinary tract infections in the maternal population, with a view to improving accuracy. Methods QIP methodology, as per IHI (the Institution of Healthcare Improvement) and Healthcare Improvement Scotland were utilised. An aim statement was developed: To improve the accuracy of diagnosis and management of urine infection in pregnancy by



50% in the Obstetric Triage Unit, at the Royal Infirmary of Edinburgh, by August 2017. A ‘Process Map’ and ‘Driver Diagram’ were developed to further delineate the issue and provide focused areas for quality improvement. A ‘PDSA’ (Plan, Do, Study, Act) cycle was conducted. Results were presented locally and actions of improvement commenced. P – Plan One week retrospective data collection, to evaluate urine dip interpretation and management, from 14th to 20th November 2016. D – Do Data of the 256 maternal patients assessed in this time period to the Obstetric Triage department, was collected. Patient information anonymised and a data collection tool developed. S – Study Results were interpreted with the following conclusions: 1) Ensure clinically indicated urine testing occurs (27% did not have clinically indicated urine dip). 2) All urine positive for nitrates should be sent to microbiology (23% of urine positive for nitrates not sent to microbiology). 3) All patients with nitrates in the urine should receive antibiotics (38% of nitrate-positive urine untreated). 4) Improve documentation of antibiotic choice to aid further MSU/sensitivity tracking (25% not documented). A – Act Staff education Development of local guideline Patient information posters in antenatal areas for urine collection. Conclusion This project highlights the use of QIP methodology,

and has been successful in identifying the pitfalls in accurate diagnosis, investigation and management of lower urinary tract infection in maternal patients. Preliminary actions for improvement have been carried out. Further PDSA cycles are required as a measure of sustained improvement and change in practice.

analgesia with dose and time was recorded from BHT (Bead Head Ticket). The questionnaire detailed about the maximum pain perception during labor according to visual analogue scale. The patient satisfaction was categorized to three levels. Data was analyzed using Statistical Package for Social Scientist (SPSS (IBM, New York, USA)) software version 16.0. The results were presented in the form of tables, graphs and charts. Results 70 subjects were recruited to the study. 9 parturient were excluded because they underwent caesarean section due to obstetric indications. Out of 61, 7 patients received epidural analgesia. 31 parturient have received at least one dose of pethidine. There were 23 parturient who haven’t received any form of analgesia. The pain score of mothers who had epidural analgesia ranged from 6–8, while mothers who received pethidine ranged from 8– 10 and the group who did not received any form of analgesia ranged from 9–10 respectively. All the mothers who perceived a pain score of 8, 50% of mothers from the total study were generally satisfied. That included 53% from pethidine group and 47% from no analgesia group. The totally unsatisfied mothers consist of 42% from pethidine group and 58% from no analgesia group. Conclusion Mothers whose maximum pain score was 30. Average age was 48. Out of 14 day-case TLH patients. 1 patient (7%) reattended before 48 hours post-discharge in urinary retention and was catheterised. This patient then reattended after 120 hours due to failed TWOC.

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1 patient reattended after 48 hours. 4 patients reattended after 120 hours. No day-case TLH patients were readmitted as inpatients. Compared to inpatient TLH, reattendance rates were similar. Conclusion Day-case TLH was found to be practical and safe, as demonstrated by day-case TLH patients having similar reattendance rates compared to inpatient TLH. Compared to Perron-Burdick et al, day-case rates in SRH are low, whilst postoperative reattendance rates were similar. This could be because at SRH there is a lack of selection criteria to identify day-case TLH candidates. Research suggests that careful selection criteria alongside patient and staff education is key to successful day-case TLH. Patient expectations are not geared towards anticipating day-case surgery, and there is no dedicated day-case TLH patient information leaflet. For staff, whilst there is a day of surgery discharge checklist, this is not directly applicable to day-case TLH. This audit’s findings facilitate the need to develop a proforma with rigid selection criteria and a specific pathway for day of surgery discharge alongside a dedicated patient leaflet.

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OEP6607 Evaluation of Saving Babies Live Care Bundle (SPiRE) in UK maternity units

Lau, YZ12; Heazell, A2; Widdows, K2 1 Obstetrics and Gynaecology, The Royal Oldham Hospital NHS Trust, Manchester, UK; 2Obstetrics and Gynaecology, Saint Mary’s Hospital NHS Trust, Manchester, UK

Introduction The rate of stillbirths in the UK remains higher

than comparable countries, with an annual rate of reduction of only 1.4% per year in the last 20 years. The Saving Babies Lives Care Bundle was launched by NHS England in March 2016 with the aim of reducing stillbirths by 50% by 2030. The care bundle has four elements: reducing smoking in pregnancy, risk assessment and surveillance for fetal growth restriction, raising awareness of reduced fetal movement and effective fetal monitoring during labour. All of these are covered by clinical guidelines. Aim To appraise guidelines relating to the four key elements of the care bundle from 14 maternity units across the UK participating participating in the SPiRE study to analyse the effectiveness of the Saving Babies Lives Care Bundle. Methods Guidelines were assessed by one independent investigator using Appraisal of Guidelines for Research and Evaluation (AGREE) II Tool. Results 43 guidelines from 14 hospitals were appraised. The median overall score for each guideline was 4 (out of 7). There was large variation in the total scores from individual domains from 76–101 (out of 163). The greatest sources of variance were in the process for monitoring the impact of the guidelines and the procedure for updating the guidelines provided. The majority of guidelines needed some modifications. Conclusion Overall, the quality of the guidelines evaluated is variable and some modifications are required to reach a high

standard. In particular, guidelines should include procedures for updating guidelines and monitoring/ auditing criteria.

OEP6617 Our new statutory obligations under the amended Female Genital Mutilation Act 2003 (sections 70–75 of the serious crime act 2015): one year on

Howe, A Institute for Women’s Health, University College London, London, UK Introduction The UN estimates 200 million women and girls

worldwide are living with the effects of female genital mutilation (FGM), with 137,000 victims in England and Wales. Following the introduction of the amended FGM Act 2003 in October 2015, I reported that 1385 new cases were identified in England in the quarter before the new law and 1316 in the quarter following. In keeping with my aim, I have reviewed the data from the year following the new legislation, to determine its effect. Methods Using HSCIC and NHS digital data, combined with reports from UN, WHO and UNICEF I was able to analyse the 12 months following the legislation change. I also searched Ministry of Justice reports to study how many FGM protection orders (FGMPOs) and convictions have been made. Results Data revealed similar numbers of new cases of FGM reported in each 3-month period since October 2015 (1242, 1293 and 1204 respectively). However, there are large gaps in the data. Since July 2015, there have been 97 applications for FGMPOs and 79 orders. There have still been no FGM related convictions in the UK, despite 32 cases being reported to have happened in the UK between January and September 2016. Discussion The results are disappointing and we are yet to see substantial change. £4million has been spent and 22,000 FGM training sessions have been delivered but we are still failing to report properly and prosecute offenders. To achieve 2015’s Sustainable Development Goals, the UK must work to end FGM.

OEP6638 Improving consenting in obstetrics: A way to improve care in labour ward

Gopal, G; Ng, O-H; Lynch, P; Mudenha, R Obstetrics and Gynaecology, Ninewells hospital and Medical school, Dundee, UK Introduction Process of obtaining consent has attained the most

highlight in practice of obstetrics. Obstetric procedures do not come without risks. Providing ‘informed consent’ is crucial in consenting process, with respect to woman’s autonomy. We aimed to improve out consenting practice by standardising our consent forms by introducing pre-printed consent forms with risks typed


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on it as per RCOG Consent series for common procedures in obstetric labour ward. Methods We studied, then existing consent process for caesarean section, manual removal of placenta, perineal repair, instrumental delivery in Ninewells Hospital in East of Scotland from May 2017 to September 2017. Plan, Do, Study and ACT (PDSA cycle) quality improvement process was adopted. Plan: Prepared a list of various risks explained by all clinicians, by collecting and examining notes retrospectively. Prepared pictorial representation of written and quoted risks. Do: Introduced pre-printed consent forms with all quoted risks from RCOG Consent series for the above procedures. Study: Audited every week for compliance of forms use. Interpreted results of compliance on run charts. Act: Introduced changes after obtaining feedback in three cycles, also auditing compliance. Results PDSA cycle has been designed to improve and revise the pre-printed consent forms after comments from clinicians. Three cycles of change have been implemented. And the comments from clinicians has been on content, font - size and style of letters. Started from 58% coverage of risks quoted to nearly 90% of coverage of risks to all four procedures when pre-printed forms are used. Conclusion Quality improvement process is an ever-evolving practice. With above PDSA cycle we have seen a qualitative change towards standardising in consenting obstetric procedures in Ninewells Hospital in Scotland.

of reminder letter prior to hospital discharge, booking of clinic appointment for OGTT, a text message reminder prior to the scheduled appointment, and allowing flexibility of date if different from booked appointment. The uptake and results of OGTT 6– 12 weeks after delivery were re-evaluated. Results Before implementation of quality improvement measures, 60 out of 122 (49.2%) returned for postnatal OGTT within 3 months from delivery. Twelve (20.0%) was found to have impaired glucose tolerance (IGT) and three (5.0%) had diabetes mellitus. After implementing the measures, only 65 out of 136 (47.8%) had postnatal OGTT performed within 3 months from delivery. Among these women, nine (13.8%) had IGT and two (3.1%) had diabetes mellitus. Conclusion The uptake of postnatal OGTT is suboptimal and needs improvement. However, strategies involving reminder system generated from hospital were ineffective in improving OGTT uptake in our center. Reasons for poor uptake include childcare prioritization, lack of perceived importance of testing and disease consequences, the nature of the test which requires fasting and waiting of 120 minutes, lack of ownership between healthcare professionals, and the lack of an integrated healthcare system to support continuity of care following pregnancies. A better understanding of the determinants and barriers to postnatal screening and an integrated public health approach for the followup of these women are needed to improve the rate of postnatal diabetes screening.

OEP6711 Attendance for postnatal oral glucose tolerance test in women who had gestational diabetes and strategies to improve its uptake

OEP6724 Role of clinical governance in Maternal Death Review process: Strategies to response quality improvement management of maternal death from pre-eclampsia

Ching, SY; Chi, C; Yew, TW; Ho-Lim, SS; Zhang, HM Obstetrics and Gynaecology, National University Hospital, Singapore

Cahyanti, R; Wiyati, P; Hadijono, S Obstetrics & Gynecology, Faculty of Medicine, University of Diponegoro, Semarang, Indonesia

Introduction Asian women are at intrinsically higher risk of

developing gestational diabetes (GDM) and type 2 diabetes (T2DM), with 20% of pregnancies complicated by GDM in Singapore. GDM increases the risk for future T2DM by sevenfold. Therefore, postnatal follow-up of these women is essential to enable early behavioral and medical interventions, which have been shown to be effective in reducing the risk and complications of T2DM. Objective This study aims to review the uptake of postnatal oral glucose tolerance test (OGTT) and to evaluate potential strategies to improve compliance. Methods This is a quality improvement project for women with GDM delivered at the National University Hospital, Singapore. We examined the uptake and results of postnatal OGTT among women with GDM who delivered between 1st January 2015 and 31st March 2015. The quality improvement team then instituted measures that aimed to increase the uptake of postnatal OGTT for women with GDM who delivered between 1st April 2016 and 30th June 2016. They include emphasis of its significance during education sessions at diagnosis, pre-ordering of OGTT, issuance

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Objective To combat the gap of maternal death caused by preeclampsia as a preventable disease rather than a disease of theory by evolving quality improvement process based on Maternal Death Review (MDR) as a source implementation of evidence policy making in local context to perform clinical governance practices. Methods A case study from 2014 until 2016 in Semarang, Central Java, Indonesia with high number of Maternal Mortality Rate. The main intervention was based on developing capacity building in primary, secondary, tertiary prevention of pre-eclampsia in health service providers and facilities from MDR recommendation to enforce 4 steps practices to strengthen clinical governance of EmONC: developing pathway, coaching, implementation process and sustainability development. Evidence based intervention sited by on-site mentoring of management of clinical government practices, consisted of standard compliance regulation based on provider competencies, health facilities authority and referral system performance in the health facilities.



Results The performance of clinical governance practices had

been demonstrated on monitoring and evaluation process of maternal death review. The impact in reducing maternal death cases caused by pre-eclampsia from 51.5% (2014) to be 45.7% (2015) and 25% (2016). The intervention in 2014 focused on capacity building in preventing pre-eclampsia in primary care afforded increasing knowledge, skilled and attitude of health service provider in early detection and pre-referral stabilization (MgSO4 utilization) with result increasing the standard compliance in early management and timely referral of preeclampsia cases from 41.7% (2014), 77.1% (2015) and 85.4% (2016) correlated with reduction cases of pre-eclampsia death (P < 0.01). The main intervention of maternal death cases in 2015 was mainly by compliance in facility readiness and performance of emergency drill in developing team approach within result in association of increasing adequate management of pre-eclampsia in EmONC facilities 25.7% (2014), 57.1%(2015), and 85.7% (2016) with reducing percentage of pre-eclampsia death (P < 0.01). In 2016, mostly maternal death of pre-eclampsia after discharge from hospital, intervention by community monitoring until 42 days postpartum, pre-eclampsia cases significantly declined in case fatality rate, from eclampsia and pulmonary oedema (P < 0.01). Conclusion Integration intervention by involving clinical governance as a form monitoring and evaluation in maternal death review process works up standard compliance and quality improvement in primary, secondary and tertiary prevention of pre-eclampsia.

OEP6728 Unintentional administration of Ergometrine to a neonate

Witharane, B; Wickramarachchi, S Consultant JMO, Base Hospital, Puttalama Introduction Ergometrine, an alkaloid derived from ergot, (a

fungus) is a powerful uterotonic drug. It is given intramuscularly or intravenously, in emergency, for the prevention and treatment of PPH. Accidental administration of maternal Ergometrine (instead of neonatal Vitamin K) to a neonate took place in the labour room of a local hospital in Puttalam. This is a very rare incident and none have been reported in Sri Lanka. Ergometrine poisoning can be fatal as it causes seizures and respiratory depression. Our aim is to raise awareness regarding this preventable and treatable iatrogenic poisoning. Case A 24 year old gave birth to her second baby at the end of a 36 week long uneventful gestation by NVD. The baby’s Apgar score was 9 at 1 and 5 minutes after birth. A nursing officer unintentionally injected 1 vial of Ergometrine intramuscularly to the baby instead of the routinely administered 1 vial of Vitamin K. She realized her mistake and immediately alerted her superiors. The baby was quickly transferred to the nearest Base Hospital. Upon admission her SpO2 with oxygen via nasal prongs was 90% and her blood sugar level was 148 mg/dL. Her lungs were clear bilaterally upon auscultation. Two hours after admission she

developed seizures, irregular breathing with frequent apnoeic episodes and her SpO2 began to drop. She was intubated and connected to a ventilator. She was treated for Hypertensive Encephalopathy and Pulmonary Oedema until her death. The autopsy revealed focal reactive gliosis, diffuse and mildly constricted vessels in the brain. Both liver and kidney showed vascular congestion. The Government Analyst’s Department informed they are unable to test for Ergometrine. The cause of death was given as hypertensive encephalopathy following intramuscular administration of ergometrine considering the circumstantial evidence and suggestive microscopy. Conclusion Similar appearance of the vials of Ergometrine and Vitamin K may cause confusion. Redesigning them to make them more discernible will prevent this. The labour room must have designated nursing officers who have been specially trained for labour room work. If an error is made it must be identified and informed to the necessary superiors immediately.

OEP6790 ‘How can we convince people to change?’ Factors affecting uptake of a quality improvment bundle to reduce the incidence of obstetric anal sphincter injury: A qualitative exploration

Basu, M; Todiwala, A Obstetrics and Gynaecology, Medway NHS Foundation Trust, Kent, UK Objective Stop Traumatic OASIs Morbidity Project (STOMP) is a multidisciplinary quality improvement bundle, which aims to reduce the incidence of obstetric anal sphincter injuries (OASI). All midwifery and obstetric staff were asked to incorporate the practice principles of STOMP into their conduct of labour and delivery. The components of the STOMP bundle have been described elsewhere. Uptake of practice changes in quality improvement projects, and therefore success of these projects, is likely to be dependent on human and unit culture factors. The aim of this study was therefore to evaluate the perception of STOMP, and the practice points that it encompasses, amongst midwifery and obstetric staff. Methods This was a qualitative interview study conducted in the maternity unit of a large UK d hospital after STOMP had been in place for 30 months. The population consisted of midwifery and obstetric medical staff of all grades who were working on the unit at the time of the study. Each participant was taken through a semi-structured interview based on their opinions of and experience with STOMP, and the factors that affected their perceptions. Interviews were conducted by a member of the research team, who had not been involved in the design and implementation of STOMP. Interviews were recorded and then transcribed independently. A thematic analysis was undertaken using constant comparison derived from Grounded Theory. Results A total of 21 members of staff (61% midwifery staff, 39% obstetric medical staff) were interviewed before thematic saturation was reached. All staff who were interviewed expressed positive feelings about STOMP, but many were unsure of the


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viability of such a project working in other settings, as they felt that how such a project was implemented and championed and the culture of a unit were critical to success. The dominant themes that emerged on thematic analysis were: 1) Awareness of the long term effects of OASI as a driver for change, 2) Standardisation of delivery practices, 3) The importance of multidisciplinary champions, engagement and uptake, 4) The importance of unit culture and team working in effecting change, and 5) The challenges of long term sustainability. Conclusion The culture of a unit and the engagement of staff are likely to be important factors in determining the uptake of improvement bundles such as STOMP, which require staff to amend their practice. These factors should be considered in detail and factored into the design and implementation of quality improvement projects.

Discussion Our experience to date shows that this appraoch is well received by patients who appreciate the flexibility it offers in their busy lives. It has also delivered efficiencies in administrative time. We are monitoring the impact on uptake of LARC and anticipate data will further support this approach.

OEP6842 Progesterone only contraception implant procedures- audit and quality improvement

Lee, R; Logan, S; Wang, L Obstetrics & Gynaecology, National University Hospital, Singapore, Singapore Introduction The progesterone only implant (POI)/Implanon

OEP6835 User experience of sexual health hub: the new online counselling and booking tool for long acting reversible contraception appointments

Siddiqui, F; Horn, K Sexual Health Oldham, Virgin Care, Oldham, UK Introduction Timely access to contraceptive counselling and

increased use of LARCs (long acting reversible contraception) is recognised as the key to avoiding unintended pregnancy. In line with with national SRH strategy, we wanted to improve access to LARC by supporting women to make informed choices and reducing barriers to attending the service. Methods The national sexual health hub, launched in July 2016, includes access to contraception, sexual health and well being information, with positive promotion of LARCs, in one accessible site. A secure online triage and booking tool for clinic appointments includes pre-LARC counselling through online videos that enables women to attend for a single focussed LARC fitting appointment rather than the more traditional two visits. Results In the first 5 months we saw 151% increase visits to our LARC self-help content and use of pre-consultation videos; 14.5% of available bookable appointments made online; the majority out of hours 10% reduction in call volumes to services, saving 213 hours of admin time; 3 months post launch, we were seeing 45% more people visiting our national website than all local websites combined; 75% of people access the hub from a mobile device; improved patient experience and choice as evidenced through user survey: Very easy or easy to book an appointment online: 84%; Very easy or easy to find information and advice online: 92%; Very likely or likely to recommend to a friend: 96%; Visit the website again: 95%; Numerous positive free text comments e.g ‘Having the facility to book online appointment saves time and presssures, especially for a working individual it provided more flexibility’ ‘Quick and easy to use, much easier than ringing up or visiting to book an appointmnet especially for those out of town’.

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(Merck Sharp & Dohme B.V., NJ, USA) NXT was approved for use in Singapore in January 2012 and comprises a single, nonbiodegradable, subdermal implant (SDI). It is a long acting reversible contraceptive, licensed for up to 3 years, which primarily inhibits ovulation. It has one of the lowest failure rate at < 1000 over 3 years. Training in insertion and removal comprises a biannual theoretical session, model arm practical and supervised live insertion/removal. The National University Hospital of Singapore Department of Obstetrics & Gynecology reviews morbidity/mortality statistics for gynecology procedures monthly. In contrast to intrauterine devices, procedures involving SDIs were neither reviewed nor had an addendum to formalise counselling. Medicolegal articles have highlighted harm associated with non-insertion, deep insertion and nerve injury and accompanying documentation deficits. Objectives To sprint audit case records for all outpatient progesterone only contraceptive implant insertions and removals and make recommendations to improve informed consent process, documentation and collection of morbidity statistics. Methods All outpatient procedures involving POI during April and May 2017 were identified by their charge code and electronic case records reviewed. Auditable outcomes included the following: appropriate medical and drug history, last menstrual period (LMP), side effects/risks, reason for removal (if applicable), consent, use of local anaesthetic, site of insertion/removal documented, palpable post procedure documented (insertion only) and complications (immediate and within 3 months). Results Insertions (n = 29) – medical and drug history, LMP, discussion of side effects and signed consent was documented in 55%, 90%, 86% and 93% respectively. Only 55% documented local anaesthetic use; 48%, site of insertion and 17%, SDI palpable post insertion. Immediate complications included bleeding and bruising (n = 2). Only 10/29 (34%) took up a 3 month review; four reported abnormal bleeding (n = 2) or post-insertion pain (n = 2). Removals (n = 23) – medical and drug history, indication for removal, discussion of side effects and signed consent was documented in 55%, 95%, 95%, 91%, respectively. 70% documented local anaesthetic use; 39%, site of removal and 69%, intact SDI. Immediate complications included severe bruising



(n = 1) from deep migration of implant and abnormal bleeding post removal (n = 1). Conclusion The audit highlighted deficiencies in documentation and recording of complications. An addendum was created to formalise the consent process and the procedures were added to the monthly risk management review. Open date review was advised, with women encouraged to return if concerns. The effect of the intervention will be re-audited.

OEP6864 Can simulated workshops significantly improve visual estimation of blood loss by labour room staff? An audit

Gankanda, W; Wijesinghe, D; Rathnayake, S; Atapattu, H; Amaradiwakara, P Obstetrics and Gyneacology, Teaching Hospital Mahamodara, Galle, Sri Lanka

improved significantly (P < 0.05) up to 40. There was no significant difference between nurses and midwifes in both pre and post test (P > 0.05). Conclusion Accurate visual estimation of blood loss is known to facilitate timely resuscitation, minimising the risk of disseminated intravascular coagulation and reducing the severity of haemorrhagic shock. The educational process with simulated workshops may assist labour room staff in everyday practice for more accurately estimate blood loss and recognize patient at risk of haemorrhagic complications.

OEP6874 A multi-centre study evaluating the impact of multi-professional obstetric emergencies training on staff safety attitudes and unit culture

Ghag, K1,2; Winter, C1,2; Bahl, R3; Lynch, M1,2; Lenguerrand, E1,4; Draycott, T1,2 1

Introduction Postpartum haemorrhage is a major cause of

morbidity and mortality in obstetric practice worldwide. In developing nations, where the vast majority of maternal deaths occur, the problem is exponentially greater. Underestimation of peripartum blood loss and delayed blood component therapy seem to be common factors in many cases of avoidable haemorrhage-related maternal mortality. Inaccurate blood loss assessment can result in significant adverse sequelae; overestimation can result in unnecessary transfusion, and perhaps more important, underestimation in delayed treatment. Objective Assess the basic knowledge about postpartum haemorrhage and assess the accuracy of visual estimation of blood loss and determine whether an educational programme with simulated workshops can improve the knowledge of PPH and accuracy of visual estimation of blood loss. Study setting Teaching hospital, Mahamodara, Galle, Sri Lanka. Study population Labour room staff including nurses and midwifes attached to teaching hospital, Mahamodara, Galle, Sri Lanka. Methods Expired whole blood was obtained from the blood bank, and five simulated scenarios with known measured blood loss were created using common surgical materials which was used as the explicit criteria for blood loss. Five single best answer questions prepared with regards to basic knowledge of postpartum haemorrhage. Answering the question paper and visually estimated blood loss scenarios were performed by labour room staff before and after a one hour lecture and practical session of visual estimation of blood loss. 10 marks allocated for correctly marked question and scenario. Result There were 32 participants of which 17 nurses and 15 midwifes. Their working experience in labour units range from 4 to 15 years (mean 7.4 years). All participants scored below 50 out of 100 marks before the workshop where mean score was 35. Average marks for 5 simulated scenarios was 20 out of 50 of with significant under-estimation of estimated blood loss in majority. After the simulated workshop mean score significantly (P < 0.05) increased up to 75 and average marks for 5 simulated scenarios

Research into Safety and Quality, Southmead Hospital, Bristol, UK; PROMPT Maternity Foundation, PROMPT Maternity Foundation, Bristol, UK; 3Obstetrics, St Michael’s Hospital, Bristol, UK; 4School of Clinical Sciences, University of Bristol, Bristol, UK 2

Introduction The importance of unit culture has been repeatedly

highlighted. Some multi-professional maternity training has been associated with improvements in teamworking, communication and safety. The Safety Attitudes Questionnaire (SAQ) is a validated psychometric tool that has been employed to evaluate maternity staff opinions at unit-level for six domains: Teamworking, Safety Climate, Job Satisfaction, Stress Recognition, Perception of Management, Working Conditions. This multicentre interrupted time-series study aimed to: 1. Investigate the effect of an obstetric emergencies training programme on staff safety attitudes in 7 maternity units in the Philippines. 2. Evaluate whether SAQ data can predict implementation at unit-level. Methods 7 maternity units in the Philippines participated in a feasibility study implementing local PRactical Obstetric MultiProfessional Training (PROMPT). Staff rated 53 SAQ statements using a 5-point Likert scale from ‘strongly disagree’ to ‘strongly agree’. Data were analysed using STATA software (StataCorp, Texas, USA). 1327 questionnaires (731 pre-training, 596 posttraining) were included in final analyses. Multiple linear regression analyses were performed, adjusting for age, gender, job role and years of experience. Results Analyses of the whole cohort demonstrated statistically significant improvements in 2 domains post-implementation: Stress Recognition (3.19, 95% CI:0.21, 6.16, P-value 0.036), Perception of Management (2.46, 95% CI:0.49, 4.44, P-value 0.014). Individual unit analyses demonstrated statistically significant improvements (P < 0.05) in 4 units: Unit A Teamworking, Job Satisfaction; Unit C Teamworking, Perception of Management; Unit D Teamworking, Safety Climate, Job Satisfaction; Unit F Stress Recognition, Working Conditions.


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Individual units’ baseline SAQ data did not correlate with the level of implementation of PROMPT training. Conclusion This is the first multi-centre evaluation of the impact of an obstetric emergencies training programme on staff safety attitudes and unit-level culture. It is feasible to collect unit-level SAQs across a diverse group of maternity units in a middleincome setting. This is the largest study of its type in the current literature. There was no correlation with markers of implementation for the training package, but there was a significant ceiling effect as all 7 units trained more than 90% of staff, which is much higher than similar studies in the UK and Australia. Local PROMPT training was associated with statistically significant improvements in attitudes across several domains and there were also interesting unit-level differences. It is likely that individual units have issues particular or peculiar to them that will be addressed by training. The use of SAQs is both feasible and useful; helping units to understand their own issues, as well as identify improvements post-training.

OEP6879 Interactive voice response technology in gynaecology – a pilot audit towards a quality improvement initiative

Nandy, T; Jackson, A Women’s Health, Royal Free London NHS Foundation Trust - Barnet & Chase Farm Hospitals, London, UK Objective To assess the feasibility of employing an automated

algorithmic tele-health service to reduce routine out-patient follow-up appointments, in suitable domains of gynaecology. Methods 2 assessors reviewed and audited consecutive gynaecology clinics in March 2015, and letters were reviewed to see if the current appointment or a subsequent appointment could have been replaced by automated follow-up using an interactive voice response (IVR) service. Inclusion criteria were used to identify patients (n = 259) who would be suitable for this purpose. Results Data analysis revealed that an overall pooled benefit would occur, with 24% of new patients appointments and 44% of follow-up patient appointments, saved. Of the respondents, 82.5% patients mentioned it would be helpful to be contacted every month to monitor their symptoms, and to help decide on the timing of their follow-up appointment. 65% of patients would find a secure automated phone questionnaire acceptable. Conclusion The pilot study suggests that an automated follow-up would be acceptable to the majority of our patients, and it would provide a more streamlined and better quality service tailored to individual patients needs. In addition, reduced face to face followup lends to a more cost effective service, with less inconvenience to patients and reduced time lost from work. Clinics might therefore be more accessible to the patient in need, and we would hope to maintain and potentially improve the quality of our service, by implementing such a technology.

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OEP7012 Retrospective data collection research and audit of services at a clinic for survivors of Female Genital Mutilation (FGM) in East London, England

Naga Subramanian, G; Patel, P; Barter, J TH-CASH, Barts Health NHS Trust, London, UK Introduction Violence against women is a pandemic of diversity

and FGM is a leading example of human rights violation on a global scale. For non-medical reasons, at least 200 million girls worldwide have been subjected to FGM. FGM is illegal in the UK. Migration of practising communities outside of their homeland necessitates the establishment of infrastructure in the host country to address the health needs of the affected girls and women. Our borough, Tower Hamlets in East London has a significant percentage of immigrants from Somalia, where the FGM prevalence has been 98%. Outpatient service for assessment and deinfibulation was set up in 1989 on an ad-hoc basis; it was increased to monthly 3-hour session assessing 4 clients. We identified the need for an audit of this service.This was the first audit. Aim Improve services and staff training/education by understanding:

Clients’ profile Issues around FGM Referral source Management Safeguarding Notable inconsistencies.

Standards: RCOG FGM guidelines. Methods Analysis of paper and electronic notes of clients from 01/01/2015 to 31/12/2016 (2 years). Results Clients booked–37. Attended–31. Age range–16 to 63. Ethnicity–74% Somalian. Country of birth–61% Somalia. Self-referral–27%. GP referral–24%. Psychological issues–45%. Urinary problems–23%. Dysmenorrhoea–39%. Dyspareunia–39%. Apareunia–16%. Sex not pleasurable–6%. Asymptomatic–23%. Type of FGM–48% Type 3. Age at FGM–61% 5 to 9 years. Deinfibulation offered. Accepted–36% (82% deinfibulated). Anaesthesia–78% local. STD screening–16%. Contraception discussion–13%. No planned follow-up–19%. FGM follow-up–54% DNA. FGM law explained–61%. HSIC enhanced dataset/purpose explained–55%.



Daughters under the age of 18–16%. Would the client allow their daughters undergo FGM–61% Not Documented (ND). Clients aware of their own genitalia being abnormal. Yes–49%. ND–36%. Advocate present–97% ND. Interpreter present–97% ND. Cases not electronically coded–84%. Conclusion & Recommendations

1 The extensive results give insight into the clients’ profile, needs and what care is offered. Collectively this has filled knowledge gaps and points to improvements needed particularly with safeguarding. 2 Need for holistic service to address the complex cases, including psychosexual, social and medical management. 3 Further education and training for healthcare professionals about issues around FGM and the mandatory reporting guidelines. 4 Continued advocacy campaigns among the immigrants from FGM practising communities. 5 Improve documentation by redesigning documentation template; plan to develop electronic records. 6 Repeat audit: 2018–2019.

OEP7061 Co-relation between the ACS and p Possum Calculator to improve patient understanding of the risk of postoperative morbidity and mortality

Arakkal, D1; Prabhu, P2; Evans, M2; Hoddnett, D2; Tailor, A1,3; Butler-Manuel, S1,3; Williams, P4; Madhuri, TK1,3 1

Department of Gynaecological Oncology, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK; 2Department of Anaesthetics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK; 3Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK; 4Department of Maths and Statistics, University of Surrey, Guildford, UK Introduction It is widely known that despite the informed

consent process, patient’s understanding of the potential postoperative complications is often poor. Several calculators are used to calculate the risk of postoperative morbidity and mortality offering varying risk assessments. One such calculator is the P-POSSUM risk scoring which is widely accepted in the United Kingdom for postoperative mortality and morbidity risk prediction. However published data suggest that it may overestimate risk which may cause undue patient anxiety. The ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Program) surgical risk calculator on the other hand is a validated web based tool based on 21 preoperative risk factors for the prediction of 8 postoperative outcomes. Aim A baseline audit to explore both these tools and the corelation between them and understand if they could be used to enhance patient understanding of risk in a subsequent prospective study. Performed by evaluating the P-POSSUM and ACS NSQIP

to assess its validity and relevance in gynaecological oncology patients. Methods Data collection undertaken through a dedicated gynaeoncology database at a tertiary referral cancer centre by both the anaesthetic and gynaeoncology team. Data collated on l67 patients undergoing laparotomy for suspected or diagnosed ovarian cancer over a period of 14 months (2015 November to 2016 December) in a retrospective manner. Any missing data were collected from the patient notes. Following data lock with the actual post-op event/complication that occured in this retrospective cohort, the risk calculators were used to calculate the risk scores for each patient. Mortality and morbidity predictions using the Portsmouth modification of the POSSUM and ACS algorithm were compared to the actual outcomes separately. Results n = 167. p POSSUM reports on mortality and morbidity only, the ACS NSQIP reports on individual complications as well. Surprisingly there was significant concordance between the actual complication that occurred and the predicted risk as shown. Conclusion This study suggests that further validation in a prospective model needs to be performed to evaluate if the risk scores may be used to inform patients preoperatively of their risk of complications and is currently being rolled out in a multicentre model.

OEP7091 Female Genital Mutilation: 5 year retrospective study of obstetric and neonatal outcomes at Sydney metropolitan hospital

Jellins, J1,2; Davis, G1,2 1

Women and Babies, Royal Prince Alfred Hospital, Syndney, Australia; Sydney Medical School, University of Sydney, Syndney, Australia

2

Introduction Female Genital Mutilation (FGM) involves any

procedure which removes part or all of the external genitalia or injury to the female genital organs for non-medical indications. FGM is internationally recognized as a human right violation to girls and women. Although the exact number of females affect globally is unknown, at least 200 million across 30 countries with around 1 in 3 girls aged 15 to 19 having been subjected to this procedure. FGM not only associated with obstetrics risks but also long term gynecological sequelae. FGM is illegal in Australia and New Zealand. Canterbury Hospital is a busy metropolitan hospital servicing a diverse and multicultural population in Western Sydney with approximately 1700 births a year. Women with FGM are triaged (where appropriate) to care through a Midwife Practitioner led service for both antenatal, intrapartum and postpartum care. Objectives To establish the prevalence of FGM in the women delivered at Canterbury Hospital over a five year period (January 2011 to December 2015 inclusive). The primary outcome was mode of delivery, with secondary outcomes assessing maternal and neonatal morbidity in these women. Documentation standards were audited against local policies and RANZCOG/ RCOG guidelines.


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Methods A retrospective audit of all women affected by FGM delivered at Canterbury Hospital 5 year period between 2011– 2015 resulted in 142 consecutive confinements. Local Area Ethics approved access electronic medical records and clinical notes. The data was initially extracted from electronic medical records with remainder of data confirmed with clinical notes. All patient notes were reviewed to audit documentation standards. Maternal demographic details including FGM according to WHO definitions were collected along obstetric and neonatal outcomes. A complete data set was available for 141 women. Results 142 consecutive confinements during 5-year period accounted for 143 babies delivered. The total number of confinements over the 5-year period study period was 8655. There were 142 cases of FGM identified at antenatal booking (1.6%). 85.9% of women with FGM were characterised according to WHO criteria during the antenatal booking visit, with 40.9% affected by FGM type 3. Countries of birth with the highest prevalence seen were born in Somalia (25.5%), Sudan (21.3%) and Sierra Leone (19.9%). The majority of women affected by FGM were multiparous 85.1% during the audit period. The normal vaginal birth rate was 68%, with a low operative vaginal delivery rate (2.8%), all vacuum deliveries. The caesarean section rate was 29.1% with 14.9% performed as emergency procedures. Only one woman over the 5-year period underwent antenatal deinfibulation (0.7%). Intrapartum deinfibulation (anterior episiotomy) was performed in 1.1% of cases with 12.1% of women having previously been deinfibulated in prior deliveries. Medio-lateral episiotomy was performed in 13.5% of women with FGM at delivery. Third degree tear rate totalled 4.3% and was not proportional to classification of FGM. Overall, 7.1% of women had a postpartum haemorrhage with 42% of these in the group with FGM type 3 (table 1). A total of 9.22% of babies born to mothers affected by FGM were admitted to Special Care Nursery (SCN). A third of babies born over the study period were female. Adherence to policies relating to minimum documentation standards was poor. Statements pertaining to the illegality of FGM in NSW were only documented in 37.6% of cases. A further 7.8% cases noted a general statement such as ‘Would never have girl circumcised’. In addition, only 5.7% of women had their perineum viewed antenatally and the extent of their FGM documented in diagram form. Conclusion FGM is a complex sociocultural issue with many obstetric and psychosocial implications. Despite FGM being a risk factor for poor obstetric outcomes, we note a low operative vaginal delivery and severe perineal trauma rate in our population of women. This may be explained by the proportion of multiparous women. A high admission rate to SCN may reflect other complex medical, obstetric or social issues. The poor documentation standards can be improved with a proposed antenatal proforma (appendix) addressing both obstetric, gynaecology and social issues. This would allow consistent assessment and documentation of antenatal and intrapartum care plan to improve outcomes for our women.

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OEP7124 Bundled interventions to reduce Surgical Site Infections in Obstetrics and Gynaecology: interim review of a quality improvement initiative

Shahul Hameed, MS; Agarwal, IM; Koh Cheng, T Minimally Invasive Surgery Unit, Kk Women’s And Childen’s Hospital, Singapore Introduction Surgical Site Infections (SSI) are associated with

increased morbidity and costs. While multi-factorial, inappropriate type, timing and duration of perioperative antimicrobials are contributory. Beginning in July through September 2016, an increase in SSI’s in Obstetrics & Gynaecology (OG) was noted. Our aims were to evaluate SSI cases for potential causes and clustering, measure perioperative antimicrobial appropriateness, and develop interventions to reduce SSI, and improve appropriate perioperative antimicrobial use. Methods Data from SSI cases were collected and described. Subsequently, employing Plan-Do-Study-Act (PDSA) methodology, results were discussed and used to develop interventions together with stakeholders, and structural changes were suggested or implemented. Repeated reviews and changes were performed, and measurable processes were tracked in addition to SSI trends. Results We confirmed an increase in SSI from baseline of 0.7% to 1.8%. There was no temporal or spatial clustering, but 33% were obese, 97% received perioperative antibiotics within 60 min of incision, 76% received appropriate type/ dose of antibiotics, 55% received chlorhexidine-alcohol as surgical skin antisepsis, while 75% of Lower-Segment-Caesarean-Section SSI cases occurred >14 days postoperatively, suggesting multiple possible causes. Working with multiple stakeholders, a bundle of 7 interventions were developed as best practices for implementation. We also rectified a ‘downtime’ form used by junior doctors who were prescribing perioperative antibiotics erroneously. By end March 2017, total SSI rates had decreased to 0.4% from 1.8%, which was even lower than 2 years prior (see Fig 1). All SSI patients received timely perioperative antibiotics, 86% received chlorhexidinealcohol as surgical skin antisepsis, though only 57% of SSI cases received appropriate type/ dose of perioperative antibiotics. Conclusion Continuous engagement of all key stakeholders are

critical in implementing change by ensuring buy-in at all times. Improvements in outcomes often require both process as well as structural improvements. For some outcomes, a bundle of measures may be more effective than any intervention on its own.



OEP7206 Women’s Diagnostic Unit Dashboard at Whittington Hospital: How an early pregnancy dashboard has helped to improve service

Morje, M1; Swer, M2; Vogt, K3; Lieberman, G3

OEP7310 Improving patient safety at maternity handover: Quality improvement project

Sin, A(W-T); Beebeejaun, Y; Judah, H; Hameed, A Obstetrics, Princess Royal University Hospital, Bromley, London, UK

1

Obstetrics and Gynaecology, St Thomas’ Hospital, London, UK; 2 Obstetrics and Gynaecology, St George’s Hospital, London, UK; 3 Obstetrics and Gynaecology, Whittington Hospital, London, UK Introduction The Women’s Diagnostic Unit (WDU) dashboard at

Whittington Hospital was developed in November 2016 to safeguard existing good clinical practice and identify areas of improvement to ensure patient safety, monitor performance targets, and improve training. Methods Data were collected from multiple electronic and written records. Named staff members were assigned to update different areas of the dashboard. A traffic light system was developed using auditable standards from guidelines and discussion with consultants to monitor trends and targets. The following domains were assessed: Guidelines and departmental leaflets – documents over three years old were identified. Audits – completed and pending. Staffing levels – availability of scanning, clinical and administrative staff. Miscarriages – numbers of manual vacuum aspiration (MVA) and surgical management of miscarriages under GA (SMMs) on the emergency and elective lists; waiting times, and complications. Pregnancy of unknown location (PUL) – number of cases and whether patients required more than three visits to achieve diagnosis. Ectopic pregnancies – number of cases, missed diagnoses at first scan and complications. Complaints and serious incidents. Results Since November, the dashboard has been presented at the

departmental meeting on a quarterly basis. It recognised the following good practices: Staffing levels remained 90–100%. Low complication rate for SMMs. No complaints or serious incidents occurred.

The following areas were highlighted for improvement: Four guidelines required updating – these were delegated for review. MVAs were coded incorrectly – this was corrected to ensure appropriate financial compensation. PUL rates and missed ectopic pregnancies at first scan were higher than anticipated – guidelines were revisited and training needs were identified and met. Waiting times for elective SMMs were highlighted in certain months – the need for further surgical lists was evaluated. Conclusion The WDU dashboard has identified areas requiring

improvement so that appropriate and timely actions can be taken to rectify issues. This has allowed for better patient safety and satisfaction.

Introduction Patient safety and care are key concepts within the

provision of high quality maternity service. An effective handover system is paramount in our maternity service, where there may be high patient turnover. At Princess Royal University Hospital (PRUH), four cases of adverse clinical adverse incidence (CAI) were identified to have occurred during the time of handover in 2016. A quality improvement project to improve handover quality was initiated in December 2016. Our objective was to improve the multi-disciplinary handover at PRUH maternity by reducing the number of CAI occurring during handover period and to improve staff satisfaction on overall quality of handover. Methods A staff satisfaction survey (Phase 1 SS) was conducted within maternity between December 2016 and January 2017. This reviewed seven domains of handover quality: accuracy and conciseness of data, attention to acute patient, handover location, duration of handover, structure of handover, teaching and team building. A scoring system from 0 to 10 was used to grade staff’s satisfaction on each domain. Phase 1 SS had a 63% response rate and results were analysed. The survey reported only 25% of participants were satisfied with the current handover system and only 34.1% of participant felt that patient safety was adequately addressed during handover time. Initial steps focused on improving the accuracy and conciseness of information transferred to the incoming team. A campaign ‘Keep TRACK’ was initiated in June 2017. Delegation of the incoming junior registrar to be in charge of all acutely ill patients who are identified on a colour-based triage system allowed prompt review of acutely ill patients during handover time. Handover room was expanded to accommodate all staff working on labour ward to improve staff satisfaction, learning and team building. Results Overall, there has been a satisfactory improvement in the handover system at PRUH since the project commenced. In our latest CAI report, there has been no further CAI occurring at the time of handover. We are due to embrace in phase 2 of our SS survey, which will commence in January 2018. Discussion Individuals and organisations have a shared responsibility to ensure that safe continuity of information and responsibility between shift changes takes place. Our quality improvement project around hand over has shown objective improvement in reduction in number of CAI. It will be interesting to survey the staff for subjective improvement in their satisfaction around handover.


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OEP7315 A study of methods used for induction of labour in England. Are we doing the NICE thing?

Tattersall, M1; Gerval, M2

OEP7408 The use of an electronic notes system in Obstetric Units to document operative notes – do they improve documentation and what are the pitfalls?

1

Aggarwal, D; Moth, P; Magee, S

Obstetrics and Gynaecology, Ormskirk and District General Hospital, Ormskirk, UK; 2Obstetrics and Gynaecology, Imperial College London, London, UK

Women’s Health, Maidstone and Tunbridge Wells Hospital, Tunbridge Wells, UK

Introduction In 2008, the National Institute for Health and

Introduction With rising rates of operative delivery and their

Clinical Excellence (NICE) published a Clinical Guideline regarding ‘Induction of Labour’ (IOL) in England. This guideline remains current (a decision was made in May 2014 that no updating was required). The key recommendation of the guideline regarding the methods of IOL to be used was that vaginal prostaglandin E2 (PGE2) should be used for in all women unless there were specific clinical reasons not to do so. This study aimed to determine whether anecdotal evidence suggesting that this recommendation was not being followed widely in England was correct. Methods All National Health Service (NHS) Trusts in England believed to provide obstetric services were contacted and asked to provide a copy of current protocols or guidelines relating to IOL. Where possible, information regarding whether all women received prostaglandin (in the absence of contrary clinical reasons) was combined with information obtained from NHS Maternity Statistics for England for the 2012–13 financial year. Data was analysed nationally, as well as regionally (grouped by Strategic Health Authority (SHA), existing prior to March 2013). Results Of 140 NHS Trusts contacted, 135 provided copies of protocols used for IOL. One Trust did not provide a protocol despite several requests, another Trust stated it did not have a written protocol or guideline and three Trusts contacted confirmed that they did not provide consultant obstetric services or IOL. Thus, protocols were able to be reviewed for 98.5% of Trusts providing an IOL service in England. Review of these protocols showed that only 44.6% of protocols stated all women should receive vaginal PGE2. All other protocols stated that women with a Bishop score of at least a specific value should not receive vaginal PGE2 (mean = 7.8, range 6–10). Combination with information from the NHS Maternity Statistics estimated that nationally, only 42.9% of women were induced using protocols which stated all women should receive vaginal PGE2. However, regional analysis showed that this figure exhibited great variation throughout England, ranging from 22.4% in the North East SHA to 63.0% in the East of England SHA. Conclusion The majority of English NHS Trusts do not use protocols for IOL which reflect NICE guidance and the majority of women undergoing IOL in England are not cared for according to protocols which follow the NICE guidance. There are large regional variations in practice across England.

increasing complexity, it is more important than ever to ensure these are well documented, for both long and short-term care. This study aimed to see if the implementation of a standardised operation note format for caesarean sections (CS) via an electronic noted system improved documentation rates. Where documentation did not meet standards, further analysis was performed to find causes. Methods Retrospective 2 cycle audit in a medium-sized Kentbased Maternity Unit with 6000 deliveries per year. Delivery notes for all babies delivered by CS in August 2010 (n = 92) were compared to those of January 2017 (n = 132). The 2010 round involved analysis of paper notes, whereas the 2017 data was collected through the E3 documentation system. Results 57 notes were analysed in 2010, representing a 38% loss rate, compared to 100% notes reviewed in 2017. 87% (115/132) of operation notes were fully completed on proforma in 2017 compared to 51% (29/57) in 2010, representing a significant improvement in documentation. The grade of operating surgeon (with locum doctors included) and the category of CS did not affect the completion rates on the computerised system. There were occasions identified where operation notes were commenced, but due to parts of the proforma being incomplete, the E3 system would not complete and print the operation note, losing valuable information. Recording of Umbilical Cord Gases for Category 1 and 2 CS improved over the study period from 73% (24/33) to 82.7% (48/58). Conclusion The computerised system improved the audit process making notes easier to access for quantitative data analysis. Completion of operation notes improved with the introduction of the E3 documentation system, but remains suboptimal. This may affect postoperative management and follow-up, particularly in complicated cases. A training issue has been identified as all fields must be filled to allow a completed operation note to be printed. The limitation of this system are the variable quality of additional information, if it is not already included in the proforma/tick box options.

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OEP7434 Noise level – a predictor of clinical performance

Jensen, KR1; Hvidman, L2; Kierkegaard, O1; Manser, T3; Uldbjerg, N2; Brogaard, L1 1

Department of Gynaecology and Obstetrics, Horsens Regional Hospital, Horsens, Denmark; 2Department of Obstetrics and Gynaecology, Aarhus University Hospital, Skejby, Denmark; 3 University Hospital Bonn, Institute for Patient Safety, Faculty of Medicine, Bonn, Germany Introduction Studies have shown that noise is associated with

annoyance, stress and impaired performance. Especially sudden, unpredictable noise can cause a startle response and thus disruption. In emergencies, such as postpartum haemorrhage, distractions and reduced vigilance can be crucial to patient safety. As postpartum haemorrhage is a frequent and potentially lethal complication we aimed to investigate whether this association between noise and performance also is seen among obstetric teams managing major postpartum haemorrhage. Methods We obtained 96 real-life video and audio recordings of obstetric teams managing major postpartum haemorrhage from two Danish hospitals (a university hospital and a regional hospital). The videos were analysed according to clinical performance and the average noise level. Sources of very high noise levels above 90 dB were also identified. Audio recordings were analysed using the Praat software. Clinical performance, defined as the team management of the haemorrhage according to the protocol, was assessed by two obstetric consultants. They independently assessed all video recordings with the clinical performance tool TeamOBS-PPH. Clinical performance resulted in a percentage of performance where 100% was the best possible performance, and all teams with a score above 85% were defined as high performance teams. Results Our study finds that high performance teams were less noisy compared to low performance teams. The difference was in average 1.9 dB (95%CI 0.69–3.20) (P = 0.003). This is a considerable difference as decibel is a logarithmic scale and 3 dB is a doubling of the sound level pressure. Typical causes of noise above 90 dB were mother or baby crying, instruments dropping, and cupboard slamming. Conclusion Our analysis shows that high performance obstetric teams are less noisy. In future studies we will investigate whether the noise above 90 dB has a particular disruptive impact on the clinical performance or whether a continuously increased noise level is what causes reduced performance.

OEP7460 Improving management of shoulder dystocia following introduction of obstetric emergency Practical Obstetric Multiprofessional Training (PROMPT) at a single Emirati Hospital

Alsafi, W; Bronkhorst, D; Sadek, Z; Aydeed, N; Rageh, H; Asghar, F; Elredy, M; Arfan, A; Obielumani, F; Mahmoud, S Obstetrics and Gynaecology, Mafraq Hospital, Abu Dhabi, United Arab Emirates Objective To assess management of and neonatal injury associated with shoulder dystocia in the two years following introduction of the Practical Obstetric Multiprofessional Training (PROMPT) at a single maternity center in the United Arab Emirates (UAE) with 2500 births per annum. Methods Retrospective, observational study comparing management and neonatal outcome of births complicated by shoulder dystocia before (January 2013–April 2015) and after (Janauary 2016–December 2017) introducing shoulder dystocia training at Mafraq Hospital, UAE. We reviewed intrapartum and postpartum records of cephalic, term singleton births where difficulty with the shoulders delivery was documented during the study periods. Our training programme consisted of a monthly multiprofessional 1-day intrapartum emergencies training that included a 20-minute lecture followed by a 30-minute practical session on shoulder dystocia management. All clincians providing maternity completed their training once per year. Results During the pretraining and post-training periods, the numbers of eligible births were 3507 and 2667 respectively. The shoulder dystocia rate pretraining was 33 (0.9%) and posttraining 36 (1.3%). After introduction of training, clinical management improved: McRoberts position, pretraining 26/33 (78.8%) to 35/36 (97%) posttraining; suprapubic pressure 15/32 (46.9%) to 25/36 (69.4%); internal rotational maneuver 7/32 (21.8%) to 3/36 (8.3%); delivery of posterior arm 4/32 (12.5%) to 7/36 (19.4%); no recognized maneuvers performed 7/32 (21.8%) to 1/36 (2.7%). In pretraing, out of 32 shoulder dystocias, there were 11 neonatal injuries (34.4%). These were 10 cases of reduced limb movements and one case of Erb’s palsy. In post-training, out of 36 incidences of shoulder dystocias, there were 9 neonatal injuries (25%). These include 6 cases of reduced limb movemnts, two fractures and one Erb’s palsy. Conclusion The introduction of shoulder dystocia training for all maternity staff was associated with improved management and of births complicated by shoulder dystocia. To our knowledge, these first UAE outcomes are consistent with other international results and support recommendations that annual training in a ‘PROMPT’ like program be mandatory for all clinicians involved in providing maternity care.


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OEP5867 Why is it so hard to ‘catch’ a baby? – The typical encounter of Australian medical students in birth suite

Cheng, H1; De Costa, C1; Woods, C2 1

Discipline of Obstetric and Gynaecology, James Cook University, Cairns, Australia; 2University of New England, Senior Research Fellow, Armadale, Australia Introduction Australian medical students are placed with a

midwife to assist and learn the process of normal labour. Competition with midwifery students, combined with increasing numbers of medical students has led to declining standards of such clinical exposure. This study aims to identify the views and challenges faced by Australian medical students in acquiring vaginal delivery experience in birth suite. Methods The study involved conducting a multiple choice consisting of ten questions. The survey was distributed electronically to James Cook University final year medical students who had completed the obstetric rotation. The survey aimed to explore medical students’ views on compulsory vaginal delivery and in-labour vaginal examination (VE) and to identify the difficulties they faced in achieving these requirements. Also, the survey was set out to determine students’ perceived readiness to deal with obstetric emergency as a junior doctor. The survey was conducted between 1 May and 1 September 2017. Results This survey achieved a 54% (96/179) response rate. Among these, 53 (55%) achieved the required numbers of handson births. When asked about difficulties achieving required numbers of births, 15 (16%) had no difficulty, 32 (33%) reported few births occurring during their shifts, 47 (49%) reported competition with midwifery students, and two reported maternal refusal to have a student present. Fifty-six (58%) students were able to perform a VE in labour; 40 (42%) were not. The students identified the main reasons for the latter were: the attending midwife did not think it was appropriate, and the opportunity did not arise, gender/cultural issues and no willing mothers. Majority (92%) of students believe that having hands-on experience of birth should be a compulsory part of medical training and 75 (78%) believed that learning VE during labour is important. Only one third of students felt prepared to manage an unexpected vaginal birth presenting during their initial postgraduate year. Conclusion Urgent communication between medical and midwifery education providers is required for cooperative student timetabling in order to address the increasing competition between students assisting in vaginal deliveries. New teaching method is required to guarantee medical graduate basic obstetric competency.

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OEP5997 Obstetric sepsis simulation through the eyes of junior doctors

Lekoudis, E; Davis, B Obstetrics and Gynaecology, North Devon District Hospital, Barnstaple, UK Introduction Sepsis remains a significant cause of maternal

mortality in the UK. Rapid assessment and treatment of sepsis are, therefore, central to reducing maternal morbidity. As the vast majority of obstetric emergency care is registrar or consultant led, junior medical staff may not gain sufficient experience of managing obstetric emergencies, such as sepsis. Necessary experience could be facilitated through simulation, a training tool employed in obstetrics since the 18th-century, as it provides a safe environment in which management of complex scenarios can be practiced and reviewed to improve patient outcomes. Methods A simulation programme, developed at North Devon District Hospital maternity unit, sought participation from obstetric, midwifery, anaesthetic and paediatric teams. A scenario based on the assessment and management of severe puerperal sepsis was delivered using a high-fidelity simulation mannequin. To improve environmental fidelity, the simulation took place on the labour ward. In this scenario, a Postpartum mother presented with a history of rigors, offensive vaginal discharge and subsequent severe sepsis. Rapid diagnosis and administration of the ‘sepsis 6’ bundle was required before seeking ITU support, as despite treatment, the patient continued to deteriorate. For the purpose of this simulation, obstetric SHOs were required to lead the emergency management as the registrar and consultant were busy in theatre. The case was observed by a consultant obstetrician, a consultant anaesthetist, a clinical fellow in simulation and a simulation technician who subsequently debriefed the participants using the Pendleton’s Rules for feedback provision. Discussion/results One key finding from participant feedback was that this simulation afforded them an alternative pathway to gain experience of managing an obstetric emergency, subsequently providing them with the essential skills and confidence required to progress in their careers. Feedback from facilitators and participants also identified gaps in the knowledge of junior doctors with regard to differences in managing sepsis in obstetric patients as opposed to the general medical patient. For example, the inclusion of vaginal swabs in the septic screen, the choice of antibiotics and the presence of an emergency ‘sepsis box’ located on labour ward. Conclusion High fidelity simulation is a useful learning tool for the junior members of an obstetric team to acquire essential experience, leadership and clinical skills for managing obstetric emergencies in a safe environment.



OEP6035 ‘Becoming a Consultant‘ – career transition experiences of newly qualified O&G specialists

OG Transitions plans to use these findings to develop a structured peer-support programme for new consultants in the UK. These principles could be adapted to any international setting.

O’Dwyer, S1,2; Adams, T1,2 1

Obstetrics and Gynaecology, Imperial College Healthcare NHS Trust, London, UK; 2Obstetrics and Gynaecology, Southport and Ormskirk Hospital NHS Trust, Liverpool, UK Introduction Specialty training in Obstetrics and Gynaecology

(O&G) worldwide can take anything from four to seven years (and upwards) to complete following a doctor’s primary medical qualification. The completion of specialist training and shift in role from trainee/resident/junior doctor to consultant/attending/ specialist doctor is one of the least studied and yet most challenging periods in a doctors’ career. We conducted an international survey of O&G specialists who had completed specialist training in the past five years, aiming to describe the experiences and challenges faced during this career transition. Methods Our web-based survey was distributed via email distribution lists of a peer support network for newly qualified O&G specialists (OG Transitions) and by the Royal College of Obstetricians and Gynaecologists international members list. We chose a mixed methods design, using quantitative questionnaire data and qualitative methods to analyse free-text responses. Results We received responses from 69 doctors working in 18 different countries (with representation from Europe, North America, Africa, Asia and Australasia). In spite of variations in healthcare systems internationally, qualitative analysis revealed the following themes: 1. Need for recognition as equal to established consultant colleagues. 2. Need for support structures. 3. Leadership and change management roles can be rewarding but also daunting. 4. Desire for work-life balance, autonomy and career control. 5. Wider systems and budgets impacting on workplace satisfaction. Conclusion O&G is a specialty that requires a substantial out-ofhours commitment, even at a senior level. Particularly with local and national financial pressures, the clinical challenges can be stressful and substantial. These are compounded with the sudden increase in responsibility when a junior doctor makes the career transition into becoming a specialist/consultant, and many new consultants are given change management and educational/ supervision responsibilities. Many consultants have minimal access to this important aspect of leadership during their specialist training period. Following adverse outcome, consultants have to cope with being the clinician ultimately responsible for overall care (and deal with their own second victim issues), but they also have to support the women and families, support their teams, and provide constructive negative feedback. Unfortunately, hierarchy and discrimination issues remain barriers to providing new consultants access to effective support structures. Conversely, peer support, departmental support and mentorship (informal and formal) are positive and protective factors.

OEP6036 Medical student and midwife interactions in the labour ward: A New Zealand experience

Ormandy, J1; Webster, C2; Yu, T-C2 1

Obstetrics & Gynaecology, Canterbury District Health Board, Christchurch, New Zealand; 2Centre for Medical and Health Sciences Education, University of Auckland, Auckland, New Zealand Introduction New Zealand (NZ) medical students are expected to

be involved in intrapartum care and normal vaginal births during their undergraduate training. The NZ model of maternity care is unique with midwives practising independently and autonomously. The support of midwives is required for medical students to gain practical experience on the labour ward. While international literature has identified misunderstandings between midwives and medical students regarding their respective roles, there have been no previous studies assessing medical student and midwife interactions within the unique NZ environment. Objectives To assess and compare medical student and midwife perceptions toward the role of medical students on the labour ward and the appropriateness of students performing various skills and tasks. To identify incentives and barriers to medical student involvement on the labour ward. Methods A postal questionnaire collecting quantitative and qualitative data regarding medical student involvement on the labour ward was sent to medical students and midwives from two NZ teaching hospitals. To identify underlying skill domains, an exploratory factor analysis (EFA) was performed using data describing participant perceptions towards 19 clinical skills that medical students could potentially perform on the labour ward. Qualitative data underwent thematic analysis. Results There were 125 study participants with response rates of 92/264 (35%) for midwives and 33/91 (36%) for medical students. Both groups felt that it was important for medical students to gain clinical experience on the labour ward. The EFA demonstrated that participant perceptions toward medical student involvement in the labour ward fell into three skill domains: 1. observational, 2. non-intimate procedural and 3. intimate procedural. In all three domains midwives perceived a lesser role for the medical students than the students themselves and these differences were statistically significant in the two procedural domains (P < 0.01). Incentives to medical student involvement included satisfaction from teaching, belief in the need for a welltrained medical workforce, student enthusiasm and a student sense of belonging. Barriers to student involvement included time pressures, uncertainty regarding the role of medical students, competition with students of other disciplines, male gender, disinterested students and perceived obstetrician – midwife conflict.


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Conclusion Midwives and medical students had divergent views

on the appropriate role of medical students in the labour ward with midwives perceiving a lesser role for the students than the students themselves. Many midwives were unaware of the potential skills of medical students. Addressing these discrepancies could enhance medical student experiences in the labour ward.

OEP6051 A sustainable model to improve maternal health and promote early obstetric care in resource poor regions

Foo, S1; Tagore, S2; Mathur, M1; Juay, SN3; Loh, A4; Wilson, C5; Tan, KH2; Jacobsen, A6; Kwek, K2 1 Department of General Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, Singapore; 2Department of Maternal and Fetal medicine, KK Women’s and Children’s Hospital, Singapore; 3KK Women’s and Children’s Hospital, Department of Nursing, Singapore; 4 Yong Loo Lin School of Medicine, National University of Singapore, Singapore; 5Water and Health Foundation, Water and Health Foundation, Singapore; 6Department of Paediatric Surgery, KK Women’s and Children’s Hospital, Singapore

Objective Maternal mortality is a leading global public health challenge. We describe here a sustainable training programme which builds local capacity in emergency obstetric care in Cambodia. Design A feasibility study by KK Women’s and Children’s Hospital, Singapore was conducted to understand the infrastructure, manpower and state of healthcare resources in the local communities at Cambodia, as well as the training needs. Then, a training model was developed and implemented in the region, with support of the local health authorities and a partner non-governmental organization. Subsequently, the training model was assessed for effectiveness. Setting Cambodia is an agricultural country located in Southeast Asia which had her health infrastructure decimated during a conflict period. Population or Sample A total of 192 Cambodian healthcare providers were trained by the local Cambodian trainers, supported initially by the Singapore team, from 2013 to 2015. Patients under the care of these trained healthcare providers were evaluated for obstetric outcomes. Methods Frequency of main obstetric outcomes was collected annually from 2012 to 2016. Chi-square test was performed on main obstetric outcomes. Main Outcome Measures Frequency of deliveries, postpartum haemorrhage (PPH), pre-eclampsia (PE), haemorrhage by miscarriage, difficult delivery, caesarean sections, deliveries by using Forceps and maternal deaths annually from 2012 (just prior to the inception of the programme) to 2016. Results There is a significant decreasing trend for PPH, PE, haemorrhage by miscarriage, and increasing trend for other difficult deliveries and caesarean sections. Conclusion This sustainable model has potential for positive impact on obstetric education and maternal outcomes such as PPH, PE and haemorrhage by miscarriage. This programme may

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be adopted in other resource-poor countries, particularly in Southeast Asia.

OEP6102 Assessing knowledge, attitudes, skills and values: A holistic and objective approach to assessment of residents

Li, XY1; Huang, LB2; Ang, YF2; Lim, WSW2; Mathur, M1 1 Obstetrics and Gynecology, KK Women’s and Children’s Hospital, Singhealth Obstetrics and Gynecology, Singapore; 2OBGYN ACP, Singhealth, Singapore

Introduction The Singhealth O&G Residency took its first batch

in 2011 and our pioneer batch of eight residents has just graduated from the six year residency programme in 2017, leaving a current active strength of 59 residents, of which 35 are in junior residency and 24 in senior residency. The program aims to nurture not just competent obstetricians and gynaecologists, but to groom leaders in this field clinically, in research and education. Traditionally, resident evaluation is focused on knowledge and skills, with little emphasis on attitudes, values, research output and teaching. Our team redesigned this to make assessment inclusive and holistic. Methods Our team devised an objective assessment method based on the original criteria. Two new categories, Scholarly Activities and Citizenship Points were added to enhance existing assessment system. Each component is awarded a weighted maximum score which adds towards the final score. Scholarly activities included contributions in research both in progress and published or presented, as well as teaching, mentoring and involvement with quality improvement projects. Citizenship scores were introduced with the intention of commending residents who contribute enthusiastically towards promoting the culture and values of the program and are prompt in their administrative duties. Residents were to pro-actively update the program executives of their involvements and contributions. Residents and faculty were consulted with regards to the appropriateness and suitability of the new criteria and recommendations used to fine tune the process before implementation. After adopting the new assessment system, data reflecting residents’ research and citizenship output was collected and analysed, whilst previously there were no clear records on residents’ involvement. Conclusion Prior to implementation in 2015, there were no official records documenting residents’ research activities and participation in residency activities. As a program, we were not able to track our progress and maturation as an academic centre and commend our residents on their research output and citizenship activities. Since starting this new evaluation, we have noted a stark increase in reporting of teaching and citizenship activities by residents, and are also able to keep clear documentation of residents’ research output. We hope that



residents will be motivated by this assessment system to develop as well rounded obstetricians and gynaecologists.

obstetric emergencies, and on how simulation might be used to contribute to training in leadership and teamwork skills.

OEP6156 Leadership under the lens: Teamwork and leadership styles in simulated obstetric emergencies

OEP6179 Implementation and validation of a retroperitoneal dissection curriculum

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Calvert, K ; Carpini, J ; Carter, S ; Epee-Bekima, M1; Leung, Y1

Yousuf, A1; Frecker, H23; Satkunaratnam, A24; Shore, E24

Obstetrics and Gynaecology, King Edward Memorial Hospital, Perth, Australia; 2Business School, University of Western Australia, Perth, Australia

1 Obstetrics and Gynecology, Sidra Medicine, Doha, Qatar; 2Obstetrics and Gynecology, University of Toronto, Toronto, Canada; 3Obstetrics and Gynecology, Michael Garron Hospital, Toronto, Canada; 4 Obstetrics and Gynecology, St. Michael, Toronto, Canada

Introduction It is now well established that poor teamwork leads

Introduction Competency-based education requires educators to

to poor outcomes in medical emergencies. Failed communication leads to direct and measurable deficiencies in arrest protocols, leading directly to patient harm. In obstetrics poor communication has been shown to lead to a delay in correct treatment administration, directly measured as a delay in time to administer MgSo4 in the setting of a simulated eclamptic seizure. Although the importance of effective teamwork is clear, ‘teamwork’ is not well defined in medicine and there is a lack of consensus on what constitutes effective teamwork, including leadership styles. This is particularly true in the interdisciplinary team setting of obstetric emergencies. As part of an audience analysis of a SimWars exercise, we investigated whether two different leadership models used in simulated obstetric emergencies impacted observer evaluation of the performance of the multidisciplinary participant teams. Methods The validated TEAM tool was used to assess teamwork performance in two simulations performed as part of a SimWars exercise at the Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) 2016 Annual Scientific Meeting. The SimWars event ran as a live, on-stage simulation exercise with audience and expert panel observation facilitated with the use of microphones and cameras. The panel consisted of seven national and international experts in the fields of obstetric simulation and teamwork. The panel analysed the teamwork and leadership behaviours demonstrated both contemporaneously, using the TEAM tool, and post-hoc using semi-structured interviews. Results One scenario ran with an observational leadership style with a flattened hierarchy, and a second ran with a directive leadership style, as judged by the panel of simulation experts. 158 audience response questionnaires were analyzed. A paired samples t-test comparing the mean team performance scores between the observational and directive teams showed a mean score of 3.03 for the team with the observational leadership style (SD 0.59) compared to the directive leadership mean score of 3.55 (SD 0.44, P < 0.001, 99%CI 0.64 - 0.4). Conclusion Although the literature suggests that successful teamwork relies on open communication and flattened hierarchy, our study suggests that the preferred model in obstetrics is a directive leadership style. Further work is required on the ideal attributes of a successful team leader in the specific arena of

use simulation training for the purposes of education and assessment of resident trainees. Research demonstrates that improvement in surgical skills acquired in a simulated environment is transferrable to the operative environment. The surgical ability to open the retroperitoneal space and identify the ureter is a fundamental skill for gynecologists. Integrating simulation models into a formal and comprehensive curriculum for teaching ureterolysis could translate to increased surgical competency. Objectives Our goal was to design, implement and validate a comprehensive curriculum for laparoscopic retroperitoneal dissection (LRD) to identify the ureter. Study Design A comprehensive curriculum, encompassing didactic and technical skills components and using a previously developed pelvic model, was designed to teach laparoscopic ureterolysis. Novice surgeons (PGY 3–5) were recruited. Participants completed pre- and post- curriculum multiple-choice questionnaires (MCQ) to evaluate a didactic component. Pre- and post- performance on the model was video-recorded. As part of the technical component, participants received constructive feedback from expert surgeons on how to perform LRD using the simulation model. Participants were then video-recorded performing LRD in the operating room within 3 months of the curriculum. All videos were blindly assessed by an expert using the objective structured assessment of technical skills (OSATS) tool. At the conclusion of the study, participants completed a course evaluation. Results Thirty novice gynaecologic surgeons were recruited. High baseline knowledge of ureteric anatomy and injury (MCQ score median and interquartile (IQR)) still significantly increased from 7 (5–7.25) pre-curriculum to 8 (7–9) post-curriculum (P < 0.001). The median (IQR) technical OSATS score increased significantly from 24.5 (23–28.25) pre-curriculum to 30 (29.75– 32) post-curriculum (P < 0.001). Video recordings were completed for 23 participants performing LRD in the operating room. Intraoperative OSATS scores (median of 29 (27–32)) correlated with post-curriculum OSATS scores on the model (r = 0.53, P = 0.01). The ureter was identified intraoperatively by 91% (n = 21/23) of participants. The majority of residents (81%, n = 21/26) were more comfortable completing a supervised retroperitoneal dissection as a result of participating in the

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curriculum. Residents felt that this model would be useful to enhance skills acquisition prior to performing the skill in the operating room (65%, n = 17/26). Conclusion A comprehensive retroperitoneal dissection curriculum showed improvement in cognitive knowledge and technical skills, which also translated to competent performance in the operating room. In addition to the objective measures, residents felt that their skills acquisition was improved following course completion.

OEP6275 Hybrid simulation training to develop medical students’ competency in intrauterine contraceptive device insertion

There was significant increase in pre- and post-simulation mean scores for all three clinical skills; history-taking (5.1 pretest, 8.8 post-test, P ≤ 0.0005), counselling skills (40.11 pre-test, 57.85 post-test, P ≤ 0.0005), procedural skills (15.16 pre-test, 49.09 post-test, P ≤ 0.0005), when compared using a two-sided Wilcoxon signed rank sum test. A statistically significant increase (60 pretest, 115.6 posttest, P ≤ 0.0005) was also noted in total marks achieved. Overall assessment of activity was rated from very good to excellent by 83.5% of participants. Three themes were generated from the open ended questions of evaluation forms. These were; strengths of activity, limitations and way-forward. Conclusion Hybrid simulation training significantly improved short term competency of IUCD insertion in medical students. The students highly appreciated this method of teaching.

Amerjee, A; Akhtar, M; Ahmed, I; Irfan, S Obstetrics and Gynecology, Aga Khan University Hospital, Karachi, Pakistan Introduction Simulation-based training (SBT) is increasingly

being used in medical sciences to improve confidence and competency in performing different procedures. It provides opportunity to learn and practice new skills without putting actual patients at risk. Hybrid simulation combines patient interaction (using simulated patient) with bench model (tasktrainer) that allows procedural-skill practice. This provides realism to learners that is lacking in pelvic models alone. Hybrid simulation training (HST) was introduced to provide students opportunity to learn and practice Intrauterine Contraceptive Device (IUCD) insertion skill, on pelvic model along with relevant history-taking/counseling skills on simulated patient (SP). Methods Study setting: Centre of Innovation in Medical Education (CIME) at the Aga Khan University Hospital (AKUH) between October 2016 to September 2017. Research Design: Quasi-Experimental Mixed Method Study Sampling Technique: Purposive sampling Study population: Consenting third year medical students Sample size: 90 students Data collection tools: 1 Standardized pretest and posttest marking sheet. 2 Standardized End-of -Activity Evaluation Survey (Likert scale along with open-ended responses). Data collection procedure Students had an interactive session on contraception and were provided with reading material and video clip on IUCD insertion before the HST. They were pretested and marked on history taking, counseling and procedural skills using the SP and manikin simultaneously. They were then taught and allowed to practice the insertion of IUCD on a manikin. This was followed by posttest. The activity concluded with a debriefing session that consolidated the learning. This was followed by evaluation of the HST by the students. Results Out of 90 total students 74 were present for the workshop. Amongst these, 73 completed the pre- and post-test and evaluation survey, of which all contained matching unique identifiers and were eligible for analysis.

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OEP6609 Faking It? Laparoscopic box pelvic simulator design

Henry, R; Ferguson, G Obstetrics and Gynaecololgy, Daisy Hill Hospital, Newry, UK Introduction Modern medical training with its limitations along

with patient pressure for treatment by experienced clinicians have contributed to a reduction in procedural training opportunities available to junior doctors. It has been clearly demonstrated that laparoscopic skills and performance improve progressively with practice. Simulators can be incorporated into the training of laparoscopic surgeons with both virtual reality simulators and box trainers in widespread use. Box trainers provide visual and haptic feedback when performing laparoscopic tasks and have the advantage of being cheaper as well as accessible outside the workplace. One of the issues with box training in gynaecology is no availability of an anatomical model of the female pelvis. We designed an anatomical pelvis for use within the box trainers facilitating anatomical and procedural learning. Design Specifications included the need for: 1 Anatomical representation of the female pelvis demonstrating key anatomical relationships within gynaecological procedures. 2 Adaptable to fit inside existing box trainers. 3 To be able to simulate a wide range of gynaecological procedures.

The box was designed through a series of drawings, a prototype was then developed and adjustments made following a pilot, before production of the final model. Box creation A wooden frame with a mount to fix the pelvic model was designed to allow for insertion into existing box trainers and also to provide structural support. A model pelvis was mounted on the frame including uterus, tubes, ovaries, ligaments, bladder and ureters. They were designed with insertable ovarian cyst and ectopic pregnancies to demonstrate pathology. The models were made out of readily available household items at a cost of under £10 per model for materials. Findings These boxes were used at the inaugural Gynaecology Laparoscopic Operating Skills (GLOS) course with positive feedback. Through description, video and still images we will



show these boxes being used to simulate laparoscopic ovarian cystectomy, salpingectomy, salpingotomy, total laparoscopic hysterectomy and vault closure. They have the flexibility to be used for more advanced procedures including ureteric suturing and cystotomy repair as well as provide anatomical training in the form of a practical model making session with opportunities to simulate open procedures. Conclusion This multi-functional pelvic model represents relevant anatomy and gives opportunity to develop multiple technical and procedural skills. Practical, high quality and cost effective training can be accomplished with the use of these models. Integration of these into the curriculum will enhance training in laparoscopic procedures for trainees at a budget friendly price.

should be decided by examiners, relate to exam difficulty and clinical performance, yield satisfactory number of fail/pass without affecting standards; combination and modified-Angoff were most fair, but maximized workload. Difficulties in applications were explored, and training needs highlighted. Conclusion Different methods yield different results. Most examiners support use of combination methods of absolute and relative standards. Choice of standard should be based on evidence and relate to assessment goals. Staff training should support implementation.

OEP6630 Setting standards in objective structured clinical examinations (OSCEs): Relative, absolute or a combination?

Yu, M1; Wilson, E2; Janssens, S1,2

Mahmoud Hussein, S1; Gerais, S2; Dymock, D3; Fowler, E3 1

OBGYN, Mafraq Hospital, United Arab Emirates, Abu Dhabi; OBGYN, University of Khartoum, khartoum, Sudan; 3TLHP, University of Bristol, Bristol, UK 2

Introduction This study was conducted in Sudan, on the final

Objective Structured Clinical Examination (OSCE), for undergraduate medical students, Faculty of Medicine, University of Khartoum, 2012–13 and 2015–16. Here faculty traditionally used relative standards for setting pass-scores. Criterion referencing was newly introduced. This changed numbers of passing students, increased workload, and created strong debates between examiners who support absolute standards and those who advocate relative. This study investigated substantive and discursive effects of the standard change. Objectives The research had two parts; the first was quantitative; to determine pass-scores of the OSCE, and compare the generated failure rates and fail/pass students, using Relative, Absolute, and Combination standard setting methods. The second was qualitative; to assess examiners views on the use of these methods in determining pass-scores, failure rates, fail/pass students, workload and educational benefits. Methods A 3-days OSCE was administered to 323 students. Five standard setting methods; Norm-referencing, Holistic, modifiedAngoff, Borderline, and Hofstee combinations, were applied from the 2012–13 exam. Views of 47 examiners were collected using a structured questionnaire in 2015–16. Chi-Square and MannWhitney tests were applied for comparing Quantitative data, and Content analysis for qualitative data. Results Pass-scores were lowest with Norm-referencing, Holistic, and modified-Angoff, highest with Borderline, in between for Hoftsee. Generated fail/pass students and failure rates followed similar patterns, with significant differences. Examiners thought more students passed with Norm-referencing, followed by Borderline, and least with modified-Angoff; that pass scores

OEP6832 A simulation based training program to improve delivery of the impacted fetal head at caesarean section 1

Obstetrics and Gynaecology, Mater Mother’s Hospital, Australia; School of Medicine, UQ School of Medicine, Brisbane, Australia

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Introduction Deep impaction of the fetal head at caesarean

section (CS) can have disastrous maternal and fetal consequences, especially when faced by inexperienced clinicians. ‘Desperate Debra (Adam, Rouilly Ltd, Kent, UK) is a high fidelity, validated simulator for fully dilated caesarean sections. An education package incorporating the Desperate Debra simulator was developed to improve trainee knowledge and skill in fetal head disempaction in CS at fully dilated. Methods A training package including an educational video and simulator practice was developed following consultant obstetrician opinion and a literature review. Obstetric trainees at the Mater Mother’s Hospital, Brisbane, were assessed for knowledge, skills and confidence prior to training, and followed up at 2 – 4 weeks with a repeat assessment. Results Twelve trainees have completed the initial education package, and eleven successfully delivered the fetal head. Median time to delivery was 22.01 seconds. The mean pre-package test score was 11.79 (SD 2.74). A statistically significant association between years practicing and pre-package test score (R = 0.6183, P = 0.02) was seen, but not between pre-package confidence (P = 0.98) or time to first delivery (P = 0.44) was seen. Trainees generally reported that the package improved their skills (83.33%), knowledge (83.33%) and confidence (75%). 83% of the trainees felt the video was useful for their training, and all trainees found the simulator useful for their training. Discussion The educational package has been well received thus far. Further follow-up is required to assess the objective benefits of the package in improving trainee skill, knowledge and confidence.


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OEP7253 An assesment of student satisfaction with real clinical setting of intrauterine device (IUD) and implant insertion skills

Sangun, DIE; Prawitasari, S; Rahman, MN; Emilia, O Obstetrics and Gynecology, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia Introduction Real clinical teaching environment is now widely

used in medical education, with its value increasingly being recognized. We develop an elective program for medical students to provide family planning services in real clients. However, it is not yet established whether students differ in their satisfaction upon this setting. Summary of work We develop an questionnaire to evaluate students’ satisfaction. Fifty-seven fourth year medical students participated and were assigned to insert intrauterine device (IUD) and implants to eligible clients in Sleman District, supervised by gynecologist consultants. Paired T-test was performed using Statistical Package for the Social Sciences (SPSS (IBM, New York, USA)) version 21. Summary of results Students were highly satisfied for most of the items asked (mean score 8.19 in 0 to 10 scale). Significant differences when comparing means of pre- and post-questionnaire scores were identified in the following items; self-confidence, lecture being helpful for their preparedness, ability to insert adequately, and adequate time for insertion. Discussion Most students responded positively for each item asked. Their high perception of satisfaction may be due to several factors i.e. adequate preparation (lecture, tutorial, skills training), cooperative clients and supportive supervisors. However, some students expressed their dissatisfaction about the examination room setting and availability of instruments. Conclusion Students feel satisfied about their overall clinical performance. The adoption of real setting clinical services where students encounter real clients for the first time can positively enhance capacity for student learning. This study supports students’ experiential learning and construction of theories into practice. Take home messages An ideal environment to learn is, to let our students meet real clients; no other way works better!

OEP7256 Risk management with simulation training: A match made in heaven!

Lekoudis, E; West, K

OEP7265 Introduction of a dedicated ultrasound teaching clinic in gynaecology

El Shamy, T; Vogiatzi, M Obstetrics and Gynaecology, Royal Derby Hospital, Derby, UK Introduction In 2013 the RCOG introduced the latest training

Obstetrics and Gynaecology, North Devon District Hospital, Barnstaple, UK Introduction Obstetric emergencies are infrequent, high-stake

events, making obstetrics a major challenge for patient safety. Unfortunately, serious incidents do occur, many of which are the result of a ‘Swiss cheese model’ pattern. These incidents however do offer opportunities from which to learn and to improve

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patient safety. How best to implement this learning continues to be explored. There is increasing emphasis on simulation training with one study finding a persistent 37% improvement in perinatal morbidity following the implementation of a simulation program. In our maternity department we have taken this one step further by providing tailored simulations to recent serious incidents in the department. Here we discuss how this is achieved and the potential results of this method of learning. Methods A scenario is developed based on a case that has either been a serious incident or could have been. The simulation is run with the participation of the involved teams; these may include the obstetric, midwifery, anaesthetic and paediatric teams. It is delivered using a high-fidelity simulation mannequin in the area where the incident took place, normally on labour ward. A trained simulation team observe the simulation and provide debrief and feedback. Discussion This simulation training provides an opportunity to identity potential gaps that can be learned from in a way that, we feel, case discussion alone does not provide. We have found that it helps identify gaps in knowledge and issues with equipment, as well as the acquisition of non-practical skills, such as situational awareness, leadership, team working and communication skills. These skills provide the backbone to patient safety. Furthermore obstetric emergencies involve a broad multidisciplinary team. Simulation helps create a shared understanding between these different healthcare professionals, reducing the risk of harm and creating a better working environment. Basing the scenarios on incidents that occur within the department provides an opportunity for those involved to get support and advice with regards to the incident. It is imperative that we steer away from a culture of blame and instead put the emphasis on studying problems within the system that may have contributed. It should also be highlighted that these are distressing and at times traumatic events and sensitivity around re-enacting such situations is essential. Conclusion Overall, we feel that this method of learning from serious incidents has huge benefits. Improving knowledge, leadership and team working skills and ultimately reducing the risk of further serious incidents and perinatal morbidity.

matrix for specialist trainees on an Obs & Gynae training programme. This set waypoints for training objectives to be achieved e.g. basic ultrasound curriculum completion by the end of ST3. There are also 3 intermediate ultrasound modules that align with ATSMs and subspecialty pathways: Intermediate ultrasound of normal fetal anomaly.



Intermediate ultrasound in gynaecology. Intermediate ultrasound of early pregnancy complications. The theoretical component of the curricula is delivered through RCOG-approved courses. Nonetheless, the RCOG acknowledges that ‘there is no standard model for the provision of practical ultrasound training’ and practical teaching is often delivered ‘altruistically’ by other departments, mainly sonographers. However, such altruism is idiosyncratic to individual trusts. It has been long acknowledged that trainees have difficulty accessing training in this area. Aim The aim was to facilitate ultrasound training to ST doctors in obs & gynae. Methods A dedicated gynaecology ultrasound teaching clinic was introduced in October 2016, running once a fortnight, supervised by a Teaching Fellow (TE) and a consultant (MV). We had a single scan room set up for both early pregnancy and gynaecology scans. A trainee would be allocated 30 minutes per scan under direct supervision. Six scans were done for each clinic. The business case was cost neutral. Results From October 2016 to August 2017 75 early pregnancy scans and 25 gynaecology scans were undertaken by seven trainees rotating through. Two trainees completed the basic module. Another trainee completed the intermediate gynae module. The remaining commenced intermediate modules in Derby and had achieved 50–60% of their module before rotating elsewhere. Three senior doctors (one gynaecology consultant and two SAS doctors) attended to refresh their scanning skills in basic ultrasound scanning. Feedback from patients and trainees was excellent. Conclusion The introduction of the ultrasound teaching clinic has been successful and has been embedded in our unit. We plan to continue and expand to deliver RCOG scan matrix requirements possibly to other units.

OEP7298 Frequency of stressors in obstetrics and gynaecology postgraduate trainees in a teaching hospital of Lahore, Pakistan

Munir, SI Obstetrics & Gynaecology, Fatima Jinnah Medical College, Lahore, Pakistan Introduction It is a well-known fact that obstetrics and

gynaecology post graduate training is a stressful period. A trainee is expected to work efficiently and effectively with excessive workload of patients and in uncomfortable working environment. There is stress of learning operative skills, studying the extensive syllabus and passing the postgraduate examination. To balance personal life with such demanding training is not easy and causes many mental, physical and professional stresses. Stressors are personal and environmental factors which cause stress. Due to this stress the uptake of obstetrics and gynaecology specialty and retention in the specialty is declining globally. Although it is stated, in international literature, that obstetrics and gynaecology residency has the very high prevalence of stress than

any other specialty there is minimal information available about local situation. This study is designed to find out specific stress factors related to this specialty and frequency of various stress factors in a large teaching hospital in Lahore, Pakistan. Methods It is a cross sectional observational study. A Postgraduate Stressor Questionnaire (PSQ) is used to take responses of obstetrics and gynaecology postgraduate trainees in a teaching hospital of Lahore regarding various stress factors in the training and their frequencies. This tool studies frequency of various stressors under seven headings: Academic related stressors, Performance pressure related stress, Work Family related stressors, Bureaucratic constraints related stressors, Poor relationship with superior related stressors, Poor relationship with colleagues related stressors, Poor job prospects related stressors. IBM SPSS Statistics for windows, version 20 software (IBM Corp., Armonk, NY, USA) was used for analysis. Mean and standard deviations were calculated for each component of every stressor. Frequencies were calculated for all twenty eight stressors. Results The results of this study showed that performance pressure related stressors are the most common 58%, among which work overload is the commonest 87%. The second most common cause of stress is academic 52% among which lengthy syllabus was 67%. Work Family related stressors were the third most common 40% and rest of the stressors were 20% or less. Two specific stressors related with obstetrics and gynae specialty were fear of poor fetomaternal outcome 68% and work overload 38%. Conclusion Stress is high among postgraduate obstetrics and gynaecology trainees and its the need of hour to make polices and develop a support system for helping those trainees who face problems in this training period.

OEP7327 Who’s leading maternity teams? A pilot study in simulation

Janssens, S1,2,3; Simon, R4; Marshall, S2 1 Mothers, Babies and Womens’ Health Services, Mater Health, Brisbane, Australia; 2Faculty of Medicine and Nursing, Monash University, Melbourne, Australia; 3Obstetrics and Gynaecology, University of Queensland, Brisbane, Australia; 4Centre for Medical Simulation, Harvard Medical School, Boston, United States

Introduction Leadership is vital to effective teamwork in health

care action teams including maternity teams. Despite a recent focus on leadership training in health care teams, lack of effective team leadership continues to be reported. One reason for the continued failure of team leadership may be that effective leadership is too complex a task to be effectively performed by a single leader. Shared leadership is associated with improved team performance in organisational and other team contexts. Sharing leadership may be advantageous in maternity teams due to high task complexity and task interdependence and the highly diverse and specialised skills of team members. There is currently a lack of understanding of who is leading maternity teams and if leadership is shared.


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Aims To develop and pilot a coding system to explore leadership

sharing in maternity teams. Methods A prospective non-blinded study of video recordings of simulated maternity emergencies was performed at the Mater Education, Brisbane, Australia. Prior to participation in the scenarios, all multidisciplinary teams were orientated to the simulation environment and participated in a 45 minute interactive training session on Crisis Resource Management principles which included the importance of a designated a singular hands off leader. A coding system was developed following literature review and review by five subject matter experts. Leadership utterances were coded into four categories: clinical, coordinating, communicating and supportive. Twelve teams managing cases of postpartum haemorrhage were reviewed and coded. Results Obstetric doctors had the highest overall number of leadership utterances, being the dominant leader (L1) (by number of utterances) in 8 of the 12 cases. In three cases a midwife and in one an anaesthetist was the most dominant leader. The dominant leader contributed 53% of leadership utterances, and combined, the three most dominant leaders spoke more than 90% of leadership utterances. Most leadership utterances were of a clinical nature, accounting for 60%, with co-ordination and communication accounting for 24.0% and 13.9% respectively. There was little supportive leadership identified (1.8%). Conclusion A significant amount of leadership is shared in maternity teams despite the recommendation for a singular leader to be designated. The coding systems was feasible to use. Further validation of the coding system may lead to its development as a useful tool for studying leadership sharing in maternity teams. Future research should assess how shared leadership is related to teamwork and clinical performance in maternity teams.

Category P: E-Poster Presentations: Urogynaecology (including Maternal Birth Trauma) PEP5671 Causes and management of urogenital fistulas at a tertiary referral center in Saudi Arabia

Osman, S; Albadr, A; Dawood, A; Malabarey, O; AlMosaieed, B Urogynecology, King Fahad Medical City, Women Specialized Hospital, Riyadh, Saudi Arabia Purpose To review the etiology and management of urogenital

fistulas at a tertiary care referral center. Methods All cases of urogenital fistula referred to King Fahad

Medical City, Riyadh, Saudi Arabia, from January 2005 until July 2016 were retrospectively identified from electronic records and analyzed. The data collected included the patient’s age and parity, etiology and type of fistula, radiological findings, management and outcome. Results Among 32 cases of urogenital fistula recorded, there were 17 (53.1%) cases of vesicovaginal fistula, six (18.8%) vesicouterine

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fistula, four (12.5%) vesicocervical fistula, two (6.3%) ureterovaginal fistula and three (9.4%) multiple fistulas (vesicovaginal; -uterine; -cervical). The mean parity was 5.9 (0–15). Obstetric surgery was the most common etiology in 22 fistulas (68.8%). Twenty of these (90.9%) were complications of caesarean delivery, of which 16 (80%) were repeated caesarean delivery. A total of 40 surgical procedures were performed to repair the fistula, 20 (50%) via an abdominal approach, 11 (27.5%) via a vaginal approach, seven (17.5) via a robotic approach and two (5%) using cystoscopic fulguration. Primary surgical repair was successful in 23 patients (74%), second repair in five (16.1%) and the third repair in one (3.1%). One fistula was cured after bladder catheterization and two patients are awaiting the third repair. Conclusion Unlike the etiology of urogenital fistulas in other countries, most cases referred to our unit followed repeated caesarean delivery, none was caused by obstructed labor and only a few occurred after hysterectomy. The majority of patients were cured after primary surgical repair.

PEP5759 Consultation techniques for doctors in urogynaecology clinics: counselling patients for mid-urethral tape insertion

Bachkangi, P; Salman, M Obstetrics and Gynaecology, Lincoln County Hospital, Lincoln, UK Introduction Consultation techniques are important for the

provision of safe medical patient care. Clear communication and preoperative counselling are fundamental cornerstones for every clinical consultation that involves surgical management. In our urogynaecology outpatient clinics (UGOC) we manage patients with urinary stress incontinence (USI), a condition affecting 4–35% of women. If conservative management fails, surgery is indicated if the patient wishes. The type of surgery is decided by a multidisciplinary team (MDT) and the verdict is then discussed with the patients in UGOC. Doctors need to explain the suggested management by the MDT, counsel the patients about the surgical intervention, and offer the relevant leaflets about the procedure to enable them make an informed decision. The leaflet we use in our clinic is produced by the British Society of Urogynaecologists (BSUG). Aim To establish if the recommended consultation techniques are being followed in UGOC: a) Arrange MDT referral for patients requiring surgical management. b) Provision of BSUG information leaflets and consenting. c) Appropriate consenting. d) Enquiring about patient satisfaction and quality of life pre and postoperatively. Methods Data were obtained from a retrospective audit conducted in our Trust UGOCs, examining all patients who underwent continence procedures from 2013 to 2015. The standards used were from: a) ‘Urinary incontinence in women: management’ guideline (NICE CG 171 and CG 40)
