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I320 Intrapartum fetal monitoring – why people make mistakes and what we can do about it
Invited presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S1–S92
I317 How to get your paper published. Brought to you by BJOG and the International Journal of Gynecology and Obstetrics (IJGO)
I320 Intrapartum fetal monitoring – why people make mistakes and what we can do about it
P. Steer1 , T. Johnson2 , J. Moody3 , E. Jesper4 , C. Last5 , P. Wright6 , C. Hammond7 . 1 BJOG Editor in Chief, 2 IJGO Editor in Chief, 3 RCOG Head of Publications (Chair), 4 BJOG Managing Editor, 5 IJGO Managing Editor, 6 Wiley-Blackwell, 7 Elsevier
P. Steer
Come to our workshop to find out how to improve the chances of getting your paper published. The workshop will include advice on how to prepare your submission and structure your paper and also provide insights into what editors hate and what NOT to do. Find out what goes on behind the scenes in the Editorial Office and understand the initial checks that must be passed before your paper even reaches the Editor. Hear about the editorial and peer review processes, improve your understanding of publication ethics, good reporting guidelines and registering clinical trials. There will also be a chance to hear from the publishers – Wiley-Blackwell and Elsevier – about impact factors, the production process, author feedback and how widely your article will be distributed and accessed. I318 Error reduction through the use of technology P. Steer As Alexander Pope said almost 300 years ago, in his “essay on criticism”, “to err is human, to forgive divine”. In order to prevent mistakes, we must first accept that we all make them, and the correct response to an error is to examine our systems for delivering care, not automatically to blame the individual. When care delivery systems require the use of equipment, we need to make sure that the equipment is fit for purpose, and well maintained. Then we need to train staff effectively in its use. A key element in using equipment effectively is rehearsal of its use (“safety drills”) with appropriate testing at regular intervals. Warnings of safe limits can be built-in, with feedback ranging from visual and auditory warnings to automatic correction. Automatic archiving of data facilitates retrospective evaluation in the case of poor outcomes (“the black box”). The interaction of humans with machines requires much greater study, so that we can begin to understand why highly competent people can still make tragic errors. I319 Uterine compression sutures P. Steer The original concept of a uterine compression suture, devised up by Christopher B-Lynch, was published in 1997 in the British Journal of Obstetrics and Gynaecology. It was designed to be used after caesarean section; following vaginal births its use required the making of a lower segment transverse incision in the uterus. It was complicated because it was designed not to have sutures crossing the uterine cavity and producing tamponade. The concept of deliberate tampon by obliteration of the uterine cavity was introduced by Cho et al, and published in Obstetrics and Gynaecology in 2000. A simplified version of the B-Lynch suture which involved tamponade was published by Hayman et al in obstetrics and gynaecology in 2002. Follow-up does not suggest that tamponade with an absorbable suture produces long term complications such as synechiae. The main complication appears to be excessive compression of the uterus, producing ischaemic necrosis. This risk may be greater with simultaneous use of an intrauterine balloon.
S79
Intrapartum fetal monitoring relies predominantly on assessing changes in the fetal heart rate, and unfortunately interpreting fetal heart rate patterns is difficult. Although a consensus has been reached about the criteria on which judgement should be based, the fact that errors continued to be made indicates that there remain fundamental problems. These include inadequate training, lack of skills testing, poor supervision, an emphasis on solo practice (“oneto-one care”), desensitisation to slowly developing abnormalities, and risk taking amongst caregivers. Procedures designed to improve the sensitivity and specificity of intrapartum monitoring have proved either too cumbersome and time-consuming (fetal blood sampling and pH estimation), ineffective (fetal pulse oximetry), or even more complex (ECG waveform analysis). A possible solution is the development of computerised cardiotocogram interpretation expert systems, which have not only been shown to be as reliable as the most expert clinicians, but can also take into account additional information such as the presence of meconium staining of the amniotic fluid and the progress of labour. Such systems do not get tired, do not take vacations, and can work effectively 24/7. A prospective randomised controlled trial of one such system has recently been funded in the United Kingdom and the study will examine the outcome of its use in 23,000 labours, compared with 23,000 controls. The effectiveness of the alerts produced will clearly be critical, because it is no use recommending the correct action if the birth attendant ignores the recommendation. Techniques may need to be developed to encourage compliance. I321 Educational programme on pelvic floor medicine and reconstructive surgery M. Stenchever. Seattle, WA, USA Committee 1 of the FIGO Task Force on Pelvic Floor Dysfunction was given the assignment to develop an Educational Programs on Pelvic Floor Medicine and Reconstructive Surgery for residents and fellows. We will report on the curricula agreed to by the committee which was composed of urogynecologists from several institutions around the world. The committee took into consideration different resources that would be available in different countries, and the consensus that was arrived at was designed to offer minimal standards for training residents and fellows in this area of our discipline. I322 Understanding the immunological potential of HPV vaccines P.L. Stern. Immunology Group, Paterson Institute for Cancer Research, University of Manchester, Manchester, UK The lifecycle of the human papillomavirus (HPV) takes place entirely within the target epithelium and includes several immune evasion strategies to avoid alerting the host immune response.[1] Indeed, only about half of women exposed to oncogenic HPV infection make antibodies to the viral capsid proteins [2,3] and the titres induced are generally low and may not always be sufficient to prevent a subsequent infection.[2] Protection induced by prophylactic viral vaccines is largely, if not entirely, mediated by neutralizing antibodies that prevent virus infection,[4,5] and a key challenge for HPV vaccine development is to induce high levels of these antibodies. The choice of adjuvant can have a significant impact on vaccine immunogenicity,[6] including neutralizing antibody titers achieved following vaccination.[7] HPV-16/18 AS04-adjuvanted vaccine (Cervarix® , GlaxoSmithKline), contains proprietary Adjuvant System 04 (AS04), which combines aluminium hydroxide
I317 How to get your paper published. Brought to you by BJOG and the International Journal of Gynecology and Obstetrics (IJGO)
I320 Intrapartum fetal monitoring – why people make mistakes and what we can do about it
P. Steer1 , T. Johnson2 , J. Moody3 , E. Jesper4 , C. Last5 , P. Wright6 , C. Hammond7 . 1 BJOG Editor in Chief, 2 IJGO Editor in Chief, 3 RCOG Head of Publications (Chair), 4 BJOG Managing Editor, 5 IJGO Managing Editor, 6 Wiley-Blackwell, 7 Elsevier
P. Steer
Come to our workshop to find out how to improve the chances of getting your paper published. The workshop will include advice on how to prepare your submission and structure your paper and also provide insights into what editors hate and what NOT to do. Find out what goes on behind the scenes in the Editorial Office and understand the initial checks that must be passed before your paper even reaches the Editor. Hear about the editorial and peer review processes, improve your understanding of publication ethics, good reporting guidelines and registering clinical trials. There will also be a chance to hear from the publishers – Wiley-Blackwell and Elsevier – about impact factors, the production process, author feedback and how widely your article will be distributed and accessed. I318 Error reduction through the use of technology P. Steer As Alexander Pope said almost 300 years ago, in his “essay on criticism”, “to err is human, to forgive divine”. In order to prevent mistakes, we must first accept that we all make them, and the correct response to an error is to examine our systems for delivering care, not automatically to blame the individual. When care delivery systems require the use of equipment, we need to make sure that the equipment is fit for purpose, and well maintained. Then we need to train staff effectively in its use. A key element in using equipment effectively is rehearsal of its use (“safety drills”) with appropriate testing at regular intervals. Warnings of safe limits can be built-in, with feedback ranging from visual and auditory warnings to automatic correction. Automatic archiving of data facilitates retrospective evaluation in the case of poor outcomes (“the black box”). The interaction of humans with machines requires much greater study, so that we can begin to understand why highly competent people can still make tragic errors. I319 Uterine compression sutures P. Steer The original concept of a uterine compression suture, devised up by Christopher B-Lynch, was published in 1997 in the British Journal of Obstetrics and Gynaecology. It was designed to be used after caesarean section; following vaginal births its use required the making of a lower segment transverse incision in the uterus. It was complicated because it was designed not to have sutures crossing the uterine cavity and producing tamponade. The concept of deliberate tampon by obliteration of the uterine cavity was introduced by Cho et al, and published in Obstetrics and Gynaecology in 2000. A simplified version of the B-Lynch suture which involved tamponade was published by Hayman et al in obstetrics and gynaecology in 2002. Follow-up does not suggest that tamponade with an absorbable suture produces long term complications such as synechiae. The main complication appears to be excessive compression of the uterus, producing ischaemic necrosis. This risk may be greater with simultaneous use of an intrauterine balloon.
S79
Intrapartum fetal monitoring relies predominantly on assessing changes in the fetal heart rate, and unfortunately interpreting fetal heart rate patterns is difficult. Although a consensus has been reached about the criteria on which judgement should be based, the fact that errors continued to be made indicates that there remain fundamental problems. These include inadequate training, lack of skills testing, poor supervision, an emphasis on solo practice (“oneto-one care”), desensitisation to slowly developing abnormalities, and risk taking amongst caregivers. Procedures designed to improve the sensitivity and specificity of intrapartum monitoring have proved either too cumbersome and time-consuming (fetal blood sampling and pH estimation), ineffective (fetal pulse oximetry), or even more complex (ECG waveform analysis). A possible solution is the development of computerised cardiotocogram interpretation expert systems, which have not only been shown to be as reliable as the most expert clinicians, but can also take into account additional information such as the presence of meconium staining of the amniotic fluid and the progress of labour. Such systems do not get tired, do not take vacations, and can work effectively 24/7. A prospective randomised controlled trial of one such system has recently been funded in the United Kingdom and the study will examine the outcome of its use in 23,000 labours, compared with 23,000 controls. The effectiveness of the alerts produced will clearly be critical, because it is no use recommending the correct action if the birth attendant ignores the recommendation. Techniques may need to be developed to encourage compliance. I321 Educational programme on pelvic floor medicine and reconstructive surgery M. Stenchever. Seattle, WA, USA Committee 1 of the FIGO Task Force on Pelvic Floor Dysfunction was given the assignment to develop an Educational Programs on Pelvic Floor Medicine and Reconstructive Surgery for residents and fellows. We will report on the curricula agreed to by the committee which was composed of urogynecologists from several institutions around the world. The committee took into consideration different resources that would be available in different countries, and the consensus that was arrived at was designed to offer minimal standards for training residents and fellows in this area of our discipline. I322 Understanding the immunological potential of HPV vaccines P.L. Stern. Immunology Group, Paterson Institute for Cancer Research, University of Manchester, Manchester, UK The lifecycle of the human papillomavirus (HPV) takes place entirely within the target epithelium and includes several immune evasion strategies to avoid alerting the host immune response.[1] Indeed, only about half of women exposed to oncogenic HPV infection make antibodies to the viral capsid proteins [2,3] and the titres induced are generally low and may not always be sufficient to prevent a subsequent infection.[2] Protection induced by prophylactic viral vaccines is largely, if not entirely, mediated by neutralizing antibodies that prevent virus infection,[4,5] and a key challenge for HPV vaccine development is to induce high levels of these antibodies. The choice of adjuvant can have a significant impact on vaccine immunogenicity,[6] including neutralizing antibody titers achieved following vaccination.[7] HPV-16/18 AS04-adjuvanted vaccine (Cervarix® , GlaxoSmithKline), contains proprietary Adjuvant System 04 (AS04), which combines aluminium hydroxide