Wai Yoong - Academia.edu (original) (raw)

Papers by Wai Yoong

Journal of Obstetrics and Gynaecology, May 6, 2014

Th e rising rate of morbidly adherent placenta (MAP), attributed to the increase in caesarean sec... more Th e rising rate of morbidly adherent placenta (MAP), attributed to the increase in caesarean section (CS) deliveries (Wu et al. 2005), can lead to massive obstetric haemorrhage and its sequelae (blood transfusions, coagulopathy, sepsis and multi-organ failure), as well as complications such as peripartum hysterectomy. Indeed, there were two maternal deaths due to placenta accreta in a recent Confi dential Enquiry into Maternal Death (2006 – 2008) (Norman 2011) and MAP is implicated in at least 40% of all recent peripartum hysterectomies in the UK (Knight et al. 2008). Due to its vascular anastomoses, traditional surgical measures for postpartum haemorrhage such as compression sutures, uterine balloon tamponade and selective devascularisation are likely to be ineff ective and as such, the practising obstetrician now needs to develop a diff erent set of multidisciplinary specialist skills. First, a high index of suspicion is required in women with concomitant low lying placenta and previous CS (as they have a 500-fold increase in risk!): in these cases, magnetic resonance imaging (Palacios Jaraquemada and Bruno 2005) and ultrasound colour Dopplers (Warshak et al. 2006) can help correctly identify this condition. Optimisation of haemoglobin and preoperative multidisciplinary involvement of the haematologist, anaesthetist, urologist and interventional radiologist, together with planned delivery by an experienced obstetrician, is crucial. Th e inclusion of a gynaecological oncologist can also help reduce surgical morbidity and blood loss, particularly when there is parametrial invasion (Acton et al. 2014). Prophylactic pelvic balloon placement/infl ation and bilateral ureteric stenting can reduce early complications by a factor of 2.5 (18% vs 55%; p 0.02) (Eller et al. 2009). Th e baby is delivered by classical CS, avoiding any placental incision in order to reduce the likelihood of bleeding and this is planned for between 36 and 37 weeks to avoid labour and to enable scheduling of the multidisciplinary team. While it is generally accepted that the clinician should not try to separate the placenta (women who underwent attempted removal had greater morbidity; 67% vs 36%; p  0.04) (Eller et al. 2009), it is unclear if conservative treatment (intentional retention of placenta awaiting spontaneous autolysis) or radical surgery (elective hysterectomy with intact placenta) is best, as both options are associated with increased morbidity; the former for example, has an up to 30% risk of subsequent bleeding (Eller et al. 2009; Fitzpatrick et al. 2013). More recently, uterine conservation surgery utilising the principle of deliberate placental

Facts, views & vision in ObGyn, Mar 31, 2021

Journal of Obstetrics and Gynaecology, 2009

The stillbirth rate for singletons in the UK is approximately 5.3/1,000 births/year. Macrosomic b... more The stillbirth rate for singletons in the UK is approximately 5.3/1,000 births/year. Macrosomic babies are associated with obstructed labour and shoulder dystocia. Some 3.3% of stillborns weigh over 4 kg, when such problems are likely to be encountered. In developed countries, caesarean section is regarded as being more civilised than destructive operations for obstructed labour prior to full cervical dilatation in an interuterine death. However, when the cervix is fully dilated or severe shoulder dystocia is encountered, fetal destructive operations have half the maternal mortality rate of that associated with caesarean section, with fewer long-term sequelae. A significant obstacle in performing destructive operations in developed countries is the lack of skilled practitioners. It is difficult to acquire these skills in the UK, however simulated training can be provided with manikins. We feel mothers should be informed of the alternative of a destructive operation, potentially avoiding unnecessary caesarean section.

Journal of Obstetrics and Gynaecology, Jul 10, 2012

have described success with using this method to treat true interstitial ectopics (Moon et al. 20... more have described success with using this method to treat true interstitial ectopics (Moon et al. 2000), we proceeded to salpingotomy. Diathermy was used to open the superior border of the Fallopian tube at its most distended point. Hydro-dissection was used to separate the pregnancy tissue from the wall of the tube. Bleeding from the base of the tube was controlled with diathermy, and the superior border of the tube closed with interrupted Vicryl. The patient was discharged from hospital the following day and HCG levels rapidly fell below 2 mIU/ml.

Journal of Obstetrics and Gynaecology, 2009

Bjog: An International Journal Of Obstetrics And Gynaecology, May 1, 2008

Journal of Obstetrics and Gynaecology, 2012

Missed outpatient appointments result in the inefficient utilisation of resources and have second... more Missed outpatient appointments result in the inefficient utilisation of resources and have secondary effects on the health of the non-attenders, as well as on other patients who have to wait longer for their appointments. The first part of the study involved retrospective analysis of trends of non-attendance based on a computerised database of all gynaecology appointments over 12 months. The second comprised a prospective case-control study in which women who missed their gynaecology outpatient appointments (index cases) over 2 months were compared with patients who attended the same clinics matched for indication for referral (control cases). The overall non-attendance rate over 12 months was 16.1%, of whom 42% were recurrent non-attenders. Data from 105 defaulters were compared with 105 non-defaulters who attended the same clinics. Defaulters were significantly younger, single or separated and were more likely to be 'follow-ups' rather than new cases (all p < 0.05). Longer intervals between the appointment letter and actual appointment date was significantly related to non-attendance (p = 0.01) and there was a trend to a greater degree of smoking and alcohol ingestion in the defaulter group (p = 0.059). Comparison of other variables such as severity of symptoms, parity, source of referral and fluency of English did not reach statistical significance (p > 0.05). This prospective study has demonstrated certain profiles which are common to defaulters and which can be used to develop strategies to minimise non-attendance. Examples include reducing the time interval between sending the appointment letter and actual appointment date and selectively over-booking younger, single women who smoke.

Journal of Obstetrics and Gynaecology, 2011

Although the Confidential Enquiry into Maternal Deaths raised concerns that immigrant women have ... more Although the Confidential Enquiry into Maternal Deaths raised concerns that immigrant women have significantly poorer obstetric outcomes when compared to native women, there is little published data on the obstetric outcomes of Chinese immigrants living in the UK. This retrospective, case-control study compared maternal demographics and obstetric outcomes of Chinese with British Caucasian women matched for parity and age, who served as controls. Data from 125 index and 125 control cases were analysed. A total of 74% of the Chinese women had little or no understanding of English. The Chinese women were more likely to be non-smokers, have a lower BMI and be unemployed than their British counterparts (p<0.001). They booked later (21.01 vs 15.35 weeks, p<0.0001) and attended on average one less antenatal clinic than controls (p<0.001). Chinese women were also less likely to deliver by caesarean section (p<0.05), but more likely to have a perineal tear (p<0.005). Pre-defined risk, gestation at delivery, birth weight, duration of labour, estimated blood loss and mean 5 min Apgar scores were comparable in both groups (p>0.05). In conclusion, there are significant differences in access to healthcare and the method of delivery, but overall, the obstetric outcomes of both ethnic groups are highly similar. This may be due to the 'healthy immigrant effect' or the increased use of interpreters and linkworkers in obstetric healthcare.

Journal of Obstetrics and Gynaecology, 2008

Backache is a common cause of morbidity among doctors and 50% of the obstetricians and gynaecolog... more Backache is a common cause of morbidity among doctors and 50% of the obstetricians and gynaecologists suffering from this attribute it to work practice and posture. Occupational injuries remain poorly studied among obstetricians and gynaecologists and we have therefore tried to assess the extent and demographics of work-related injuries sustained during training by sending an eight-item questionnaire to 418 Registrar grade trainees in the London area. A low 23.2% response rate (97/418) was obtained, despite second questionnaires being sent to initial non-responders. Out of the 97 responders, 28 (28.7%) had suffered injuries at work at least once throughout their career. There was female preponderance in those reporting injuries, with a female to male ratio of 3:1. Of the 28 positive responders, 11 were UK graduates, 7 EU and the remaining 10 from Colombia, West Indies, India and Sudan. The mean age was 32.5 +/- 4.2 years, with 21 of the 28 (75%) being senior trainees (post-MRCOG). The injuries reported were: forearm (4); wrist (7); thumb (3); hands (1) shoulder and neck (9), ankle (1) and lower back (6). Of these, 18 sought medical help and received treatment for these injuries, which included long-term physiotherapy, although no-one required surgery. Eight were forced to take time off work, with a cumulative total of 80 days; one had to prolong her training by 3 months. Seven trainees sustained their injuries (e.g. ligamentous strain of wrist and scaphoid fracture) while performing caesarean sections, while forceps deliveries were the cause of six occupational injuries (e.g. ligamentous strain of sacroiliac joint). Work-related injuries can have adverse effects on training and workforce. Awareness of correct surgical techniques and adoption of ergonomic posture when performing procedures may help to minimise the risk of a work-related injury.

Journal of Obstetrics and Gynaecology, 2009

Dear Sir, We read with interest Mahran and colleagues’ (2008) article on ‘Avoiding over diagnosis... more Dear Sir, We read with interest Mahran and colleagues’ (2008) article on ‘Avoiding over diagnosis of shoulder dystocia’. Shoulder dystocia (SD) is currently defined by the Royal College of Obstetricians and Gynaecologists (RCOG) as ‘a delivery that requires additional manoeuvres to release the shoulders after gentle traction has failed’ (RCOG 2005). We would disagree with Mahran that applying the RCOG diagnostic criteria may improve the diagnosis of SD as this definition is imprecise and is subject to accoucher bias. In fact, both O’Leary (1992) and Christoffersson (2003) described the dilemma of SD being diagnosed when ‘standard delivery procedures of gentle downward traction of the fetal head and moderate fundal pressure fail to accomplish delivery’ as clinicians may have different understanding of the terms ‘gentle’ and ‘moderate’. A more objective classification has been proposed by the American College of Obstetrics and Gynecology, which is based on the complexity of the manoeuvres required to overcome the dystocia (Olugbile and Mascarenhas 2000). We would like to share the findings of our recently published retrospective study (Melendez et al. 2008) in which we compared 22 babies who sustained brachial nerve paralysis or skeletal fractures following severe SD (requiring admission to Special Care Baby Unit) with a control group (n1⁄4 22, matched for parity and ethnicity), which comprised the next infant delivered who was also deemed to have SD but did not suffer significant birth injuries. Our data showed that neonatal brachial plexus and bony injuries were more likely to occur in mothers with a history of gestational diabetes, previous babies 44 kg, clinical macrosomia and instrumental delivery. The median birth weight and postnatal anthropometric measurements, such as head circumference and ponderal indices, were significantly higher in the index group compared with those in the controls. Higher ponderal indices in the study group suggest that asymmetric babies with a greater weight to length ratio were more likely to sustain brachial plexus and bony injuries, and our study appears to be the first to document this finding. Screening and indeed predicting SD in the antenatal period is difficult, and SD is likely to remain an unpredictable event with no reliable way of anticipating the severity of the outcome. Fetal abdominal circumference measurements of 435 cm can be used to identify more than 90% of macrosomic infants although this method has shown a low positive predictive value in detecting specific cases of SD (Jazayeri et al. 1999). The use of fetal computerised tomography (CT) and magnetic resonance imaging (MRI) to measure shoulder to head ratios as well as biacromial distances show promise in identifying potential cases of severe SD especially in mothers with identifiable risk factors (Kitzmiller et al. 1987; Kastler et al. 1993). Obviously, further research in larger controlled trials is still needed to determine their predictive value.

Journal of Obstetrics and Gynaecology, 2010

papilliferum (Omole et al. 2003; Docimo et al. 2008); cyst neoplasm including cellular angiofibro... more papilliferum (Omole et al. 2003; Docimo et al. 2008); cyst neoplasm including cellular angiofibroma, and leiomyosarcoma (Dewdney et al. 2005; Silva et al. 2005); and miscellaneous pathologies, such as abscess associated with a fistulous tract, metastatic Crohn’s disease, and sarcoid. Management of complex perianal abscesses and fistulous tracts requires incision and drainage of the abscess followed by the insertion of a Seton suture which migrates out of the body over a period of months, allowing the tract to close up gradually behind. These have been shown to produce very good results (Theerapol et al. 2002). In contrast, a Bartholin’s abscess is managed by the drainage and marsupialisation of the gland. Our case highlights the importance of making the correct diagnosis and performing the appropriate procedure within a multidisciplinary team. The complications associated with performing an inappropriate procedure may be long term.

Journal of Obstetrics & Gynaecology, 2013

There is concern that the maternal mortality in ethnic minority women is significantly greater th... more There is concern that the maternal mortality in ethnic minority women is significantly greater than that of Caucasian British women. The objective of this study was to compare the demographic and obstetric outcomes between these two groups. Data were collected retrospectively over a 2-year period from 148 index and 148 control cases. The study group had statistically similar maternal age, labour duration, blood loss and mode of delivery compared with Caucasian British women (p > 0.05). A total of 68% of Turkish women spoke little or no English; were more likely to be non-smokers and also more likely to be married to unemployed spouses (p = 0.0001). This is the first study comparing obstetric outcomes of immigrant Turkish women with their Caucasian British counterparts. There was no significant difference in maternal or fetal outcomes, which could be attributed to the 'healthy migrant' theory, coupled with increased vigilance in ethnic minority pregnancies.

Journal of Obstetrics and Gynaecology, 2009

Healthcare professionals working in the field of obstetrics and gynaecology may encounter patient... more Healthcare professionals working in the field of obstetrics and gynaecology may encounter patients from a variety of cultural backgrounds, particularly in our inner cities. These women may have similar cultural beliefs and values about aspects of care they experience compared with native women, but they may also have differing beliefs and may present with preconceptions about the care they expect to receive. In our experience, traditional medical training has limited core teaching on the existence of such cultural variations, and professionals often only experience them through working in the clinical setting. This review was, therefore, undertaken with the aim of increasing awareness of such variations, in order to promote more holistic management, and ultimately to enhance patient care.

Archives of Gynecology and Obstetrics

Postgraduate Medical Journal

We explore how engagement with checklists and adoption of a strict ‘checking’ discipline help avo... more We explore how engagement with checklists and adoption of a strict ‘checking’ discipline help avoid unintentional individual, team and systemic errors. Paradoxically, this is equally important when performing repetitive mundane tasks as well as during times of high-stress workload. In this article, we aim to discuss the different types of checklists and explain how deviations from a ‘checking’ discipline can lead to never events such as wrong side or site surgery. Well-designed checklists function as mental notes and prompts in clinical situations where the combination of fatigue and stress can contribute to a decline in cognitive performance. Furthermore, the need for proactive discussion by all members of the team during the implementation of the surgical checklist also reinforces the concept of teamwork and contributes towards effective communication. Patient safety is often a product of good communication, teamwork and anticipation: a ‘checking’ mentality remains the lynchpin wh...

Postgraduate Medical Journal

Purpose COVID-19 vaccine uptake among pregnant women has been low, particularly in younger and et... more Purpose COVID-19 vaccine uptake among pregnant women has been low, particularly in younger and ethnic minority mothers. We performed a ‘snapshot’ survey to explore vaccine uptake and factors which influence this, as well as underlying beliefs regarding COVID-19 vaccination among pregnant women in a North London hospital. Study design Pregnant women were invited to complete an anonymised survey, where data were collected on demographics, personal and household vaccination status, and beliefs about the vaccine. Free-text comments were analysed thematically. Results Two hundred and two women completed the survey, of whom 56.9% (n=115) were unvaccinated and 43.1% (n=87) had received at least one dose of COVID-19 vaccine, with 35.6% (n=72) having received two doses. Factors associated with acceptance of vaccination included: (a) age over 25 years (57.6% vaccinated vs 17.2% under 25 years); (b) Asian ethnicity (69.4% vaccinated vs 41.2% white ethnicity, 27.5% black/Caribbean/African/black...

BMJ Case Reports, 2021

Brachial plexus injury is a rare but potentially serious complication of laparoscopic surgery. Lo... more Brachial plexus injury is a rare but potentially serious complication of laparoscopic surgery. Loss of motor and/or sensory innervation can have a significant impact on the patient’s quality of life following otherwise successful surgery. A 38-year-old underwent elective laparoscopic management of severe endometriosis during which she was placed in steep head-down tilt Lloyd-Davies position for a prolonged period. On awakening from anaesthesia, the patient had no sensation or movement of her dominant right arm. A total plexus brachialis injury was suspected. As advised by a neurologist, an MRI brachial plexus, nerve conduction study and electromyography were requested. She was managed conservatively and made a gradual recovery with a degree of residual musculocutaneous nerve neuropathy. The incidence of brachial plexus injury following laparoscopy is unknown but the brachial plexus is particularly susceptible to injury as a result of patient positioning and prolonged operative time....

Journal of patient safety, 2017

with great interest. We agree that distractions and interruptions can affect theater performance ... more with great interest. We agree that distractions and interruptions can affect theater performance and would like to share findings of a study we conducted to objectively quantify the frequency and impact of these 2 factors during elective gynecology lists. Attention refers to the focus an operator has over the sensory stimuli he or she chooses to process—during a surgical procedure, selective attention is employed by the surgeon to concentrate on the primary task of operating, at the exclusion of others. A distraction, therefore, is defined as an event that could divert the attention of the primary surgeon (or members of the surgical team) from set taskswhile an interruption constituted a break in task activity. Distractions could be visual (e.g., view of monitor being blocked), auditory (phones and bleeps), equipment failures, and irrelevant communications and can force an operator to switch attention from a primary task to process the new stimuli. In our study, the mean number of interruptions per case was 26 episodes, whereas the mean number of level II/III distractionswas 17 episodes per case (level I: minimal level of distraction and operating team not affected; level II: >1 member of the surgical team was visibly distracted from their task; level III: more than 1 member of the team, including the operating consultant, is affected and visibly distracted from task). Interestingly, 90% of interruptions occur in the first 30 minutes of the procedure and 80.9% affected more than 1 member of operating team, leading to a break in task activity (level II/III). Although no complications,

European Journal of Obstetrics & Gynecology and Reproductive Biology

The Obstetrician & Gynaecologist, 2018

Journal of Obstetrics and Gynaecology, May 6, 2014

Th e rising rate of morbidly adherent placenta (MAP), attributed to the increase in caesarean sec... more Th e rising rate of morbidly adherent placenta (MAP), attributed to the increase in caesarean section (CS) deliveries (Wu et al. 2005), can lead to massive obstetric haemorrhage and its sequelae (blood transfusions, coagulopathy, sepsis and multi-organ failure), as well as complications such as peripartum hysterectomy. Indeed, there were two maternal deaths due to placenta accreta in a recent Confi dential Enquiry into Maternal Death (2006 – 2008) (Norman 2011) and MAP is implicated in at least 40% of all recent peripartum hysterectomies in the UK (Knight et al. 2008). Due to its vascular anastomoses, traditional surgical measures for postpartum haemorrhage such as compression sutures, uterine balloon tamponade and selective devascularisation are likely to be ineff ective and as such, the practising obstetrician now needs to develop a diff erent set of multidisciplinary specialist skills. First, a high index of suspicion is required in women with concomitant low lying placenta and previous CS (as they have a 500-fold increase in risk!): in these cases, magnetic resonance imaging (Palacios Jaraquemada and Bruno 2005) and ultrasound colour Dopplers (Warshak et al. 2006) can help correctly identify this condition. Optimisation of haemoglobin and preoperative multidisciplinary involvement of the haematologist, anaesthetist, urologist and interventional radiologist, together with planned delivery by an experienced obstetrician, is crucial. Th e inclusion of a gynaecological oncologist can also help reduce surgical morbidity and blood loss, particularly when there is parametrial invasion (Acton et al. 2014). Prophylactic pelvic balloon placement/infl ation and bilateral ureteric stenting can reduce early complications by a factor of 2.5 (18% vs 55%; p 0.02) (Eller et al. 2009). Th e baby is delivered by classical CS, avoiding any placental incision in order to reduce the likelihood of bleeding and this is planned for between 36 and 37 weeks to avoid labour and to enable scheduling of the multidisciplinary team. While it is generally accepted that the clinician should not try to separate the placenta (women who underwent attempted removal had greater morbidity; 67% vs 36%; p  0.04) (Eller et al. 2009), it is unclear if conservative treatment (intentional retention of placenta awaiting spontaneous autolysis) or radical surgery (elective hysterectomy with intact placenta) is best, as both options are associated with increased morbidity; the former for example, has an up to 30% risk of subsequent bleeding (Eller et al. 2009; Fitzpatrick et al. 2013). More recently, uterine conservation surgery utilising the principle of deliberate placental

Facts, views & vision in ObGyn, Mar 31, 2021

Journal of Obstetrics and Gynaecology, 2009

The stillbirth rate for singletons in the UK is approximately 5.3/1,000 births/year. Macrosomic b... more The stillbirth rate for singletons in the UK is approximately 5.3/1,000 births/year. Macrosomic babies are associated with obstructed labour and shoulder dystocia. Some 3.3% of stillborns weigh over 4 kg, when such problems are likely to be encountered. In developed countries, caesarean section is regarded as being more civilised than destructive operations for obstructed labour prior to full cervical dilatation in an interuterine death. However, when the cervix is fully dilated or severe shoulder dystocia is encountered, fetal destructive operations have half the maternal mortality rate of that associated with caesarean section, with fewer long-term sequelae. A significant obstacle in performing destructive operations in developed countries is the lack of skilled practitioners. It is difficult to acquire these skills in the UK, however simulated training can be provided with manikins. We feel mothers should be informed of the alternative of a destructive operation, potentially avoiding unnecessary caesarean section.

Journal of Obstetrics and Gynaecology, Jul 10, 2012

have described success with using this method to treat true interstitial ectopics (Moon et al. 20... more have described success with using this method to treat true interstitial ectopics (Moon et al. 2000), we proceeded to salpingotomy. Diathermy was used to open the superior border of the Fallopian tube at its most distended point. Hydro-dissection was used to separate the pregnancy tissue from the wall of the tube. Bleeding from the base of the tube was controlled with diathermy, and the superior border of the tube closed with interrupted Vicryl. The patient was discharged from hospital the following day and HCG levels rapidly fell below 2 mIU/ml.

Journal of Obstetrics and Gynaecology, 2009

Bjog: An International Journal Of Obstetrics And Gynaecology, May 1, 2008

Journal of Obstetrics and Gynaecology, 2012

Missed outpatient appointments result in the inefficient utilisation of resources and have second... more Missed outpatient appointments result in the inefficient utilisation of resources and have secondary effects on the health of the non-attenders, as well as on other patients who have to wait longer for their appointments. The first part of the study involved retrospective analysis of trends of non-attendance based on a computerised database of all gynaecology appointments over 12 months. The second comprised a prospective case-control study in which women who missed their gynaecology outpatient appointments (index cases) over 2 months were compared with patients who attended the same clinics matched for indication for referral (control cases). The overall non-attendance rate over 12 months was 16.1%, of whom 42% were recurrent non-attenders. Data from 105 defaulters were compared with 105 non-defaulters who attended the same clinics. Defaulters were significantly younger, single or separated and were more likely to be 'follow-ups' rather than new cases (all p < 0.05). Longer intervals between the appointment letter and actual appointment date was significantly related to non-attendance (p = 0.01) and there was a trend to a greater degree of smoking and alcohol ingestion in the defaulter group (p = 0.059). Comparison of other variables such as severity of symptoms, parity, source of referral and fluency of English did not reach statistical significance (p > 0.05). This prospective study has demonstrated certain profiles which are common to defaulters and which can be used to develop strategies to minimise non-attendance. Examples include reducing the time interval between sending the appointment letter and actual appointment date and selectively over-booking younger, single women who smoke.

Journal of Obstetrics and Gynaecology, 2011

Although the Confidential Enquiry into Maternal Deaths raised concerns that immigrant women have ... more Although the Confidential Enquiry into Maternal Deaths raised concerns that immigrant women have significantly poorer obstetric outcomes when compared to native women, there is little published data on the obstetric outcomes of Chinese immigrants living in the UK. This retrospective, case-control study compared maternal demographics and obstetric outcomes of Chinese with British Caucasian women matched for parity and age, who served as controls. Data from 125 index and 125 control cases were analysed. A total of 74% of the Chinese women had little or no understanding of English. The Chinese women were more likely to be non-smokers, have a lower BMI and be unemployed than their British counterparts (p<0.001). They booked later (21.01 vs 15.35 weeks, p<0.0001) and attended on average one less antenatal clinic than controls (p<0.001). Chinese women were also less likely to deliver by caesarean section (p<0.05), but more likely to have a perineal tear (p<0.005). Pre-defined risk, gestation at delivery, birth weight, duration of labour, estimated blood loss and mean 5 min Apgar scores were comparable in both groups (p>0.05). In conclusion, there are significant differences in access to healthcare and the method of delivery, but overall, the obstetric outcomes of both ethnic groups are highly similar. This may be due to the 'healthy immigrant effect' or the increased use of interpreters and linkworkers in obstetric healthcare.

Journal of Obstetrics and Gynaecology, 2008

Backache is a common cause of morbidity among doctors and 50% of the obstetricians and gynaecolog... more Backache is a common cause of morbidity among doctors and 50% of the obstetricians and gynaecologists suffering from this attribute it to work practice and posture. Occupational injuries remain poorly studied among obstetricians and gynaecologists and we have therefore tried to assess the extent and demographics of work-related injuries sustained during training by sending an eight-item questionnaire to 418 Registrar grade trainees in the London area. A low 23.2% response rate (97/418) was obtained, despite second questionnaires being sent to initial non-responders. Out of the 97 responders, 28 (28.7%) had suffered injuries at work at least once throughout their career. There was female preponderance in those reporting injuries, with a female to male ratio of 3:1. Of the 28 positive responders, 11 were UK graduates, 7 EU and the remaining 10 from Colombia, West Indies, India and Sudan. The mean age was 32.5 +/- 4.2 years, with 21 of the 28 (75%) being senior trainees (post-MRCOG). The injuries reported were: forearm (4); wrist (7); thumb (3); hands (1) shoulder and neck (9), ankle (1) and lower back (6). Of these, 18 sought medical help and received treatment for these injuries, which included long-term physiotherapy, although no-one required surgery. Eight were forced to take time off work, with a cumulative total of 80 days; one had to prolong her training by 3 months. Seven trainees sustained their injuries (e.g. ligamentous strain of wrist and scaphoid fracture) while performing caesarean sections, while forceps deliveries were the cause of six occupational injuries (e.g. ligamentous strain of sacroiliac joint). Work-related injuries can have adverse effects on training and workforce. Awareness of correct surgical techniques and adoption of ergonomic posture when performing procedures may help to minimise the risk of a work-related injury.

Journal of Obstetrics and Gynaecology, 2009

Dear Sir, We read with interest Mahran and colleagues’ (2008) article on ‘Avoiding over diagnosis... more Dear Sir, We read with interest Mahran and colleagues’ (2008) article on ‘Avoiding over diagnosis of shoulder dystocia’. Shoulder dystocia (SD) is currently defined by the Royal College of Obstetricians and Gynaecologists (RCOG) as ‘a delivery that requires additional manoeuvres to release the shoulders after gentle traction has failed’ (RCOG 2005). We would disagree with Mahran that applying the RCOG diagnostic criteria may improve the diagnosis of SD as this definition is imprecise and is subject to accoucher bias. In fact, both O’Leary (1992) and Christoffersson (2003) described the dilemma of SD being diagnosed when ‘standard delivery procedures of gentle downward traction of the fetal head and moderate fundal pressure fail to accomplish delivery’ as clinicians may have different understanding of the terms ‘gentle’ and ‘moderate’. A more objective classification has been proposed by the American College of Obstetrics and Gynecology, which is based on the complexity of the manoeuvres required to overcome the dystocia (Olugbile and Mascarenhas 2000). We would like to share the findings of our recently published retrospective study (Melendez et al. 2008) in which we compared 22 babies who sustained brachial nerve paralysis or skeletal fractures following severe SD (requiring admission to Special Care Baby Unit) with a control group (n1⁄4 22, matched for parity and ethnicity), which comprised the next infant delivered who was also deemed to have SD but did not suffer significant birth injuries. Our data showed that neonatal brachial plexus and bony injuries were more likely to occur in mothers with a history of gestational diabetes, previous babies 44 kg, clinical macrosomia and instrumental delivery. The median birth weight and postnatal anthropometric measurements, such as head circumference and ponderal indices, were significantly higher in the index group compared with those in the controls. Higher ponderal indices in the study group suggest that asymmetric babies with a greater weight to length ratio were more likely to sustain brachial plexus and bony injuries, and our study appears to be the first to document this finding. Screening and indeed predicting SD in the antenatal period is difficult, and SD is likely to remain an unpredictable event with no reliable way of anticipating the severity of the outcome. Fetal abdominal circumference measurements of 435 cm can be used to identify more than 90% of macrosomic infants although this method has shown a low positive predictive value in detecting specific cases of SD (Jazayeri et al. 1999). The use of fetal computerised tomography (CT) and magnetic resonance imaging (MRI) to measure shoulder to head ratios as well as biacromial distances show promise in identifying potential cases of severe SD especially in mothers with identifiable risk factors (Kitzmiller et al. 1987; Kastler et al. 1993). Obviously, further research in larger controlled trials is still needed to determine their predictive value.

Journal of Obstetrics and Gynaecology, 2010

papilliferum (Omole et al. 2003; Docimo et al. 2008); cyst neoplasm including cellular angiofibro... more papilliferum (Omole et al. 2003; Docimo et al. 2008); cyst neoplasm including cellular angiofibroma, and leiomyosarcoma (Dewdney et al. 2005; Silva et al. 2005); and miscellaneous pathologies, such as abscess associated with a fistulous tract, metastatic Crohn’s disease, and sarcoid. Management of complex perianal abscesses and fistulous tracts requires incision and drainage of the abscess followed by the insertion of a Seton suture which migrates out of the body over a period of months, allowing the tract to close up gradually behind. These have been shown to produce very good results (Theerapol et al. 2002). In contrast, a Bartholin’s abscess is managed by the drainage and marsupialisation of the gland. Our case highlights the importance of making the correct diagnosis and performing the appropriate procedure within a multidisciplinary team. The complications associated with performing an inappropriate procedure may be long term.

Journal of Obstetrics & Gynaecology, 2013

There is concern that the maternal mortality in ethnic minority women is significantly greater th... more There is concern that the maternal mortality in ethnic minority women is significantly greater than that of Caucasian British women. The objective of this study was to compare the demographic and obstetric outcomes between these two groups. Data were collected retrospectively over a 2-year period from 148 index and 148 control cases. The study group had statistically similar maternal age, labour duration, blood loss and mode of delivery compared with Caucasian British women (p > 0.05). A total of 68% of Turkish women spoke little or no English; were more likely to be non-smokers and also more likely to be married to unemployed spouses (p = 0.0001). This is the first study comparing obstetric outcomes of immigrant Turkish women with their Caucasian British counterparts. There was no significant difference in maternal or fetal outcomes, which could be attributed to the 'healthy migrant' theory, coupled with increased vigilance in ethnic minority pregnancies.

Journal of Obstetrics and Gynaecology, 2009

Healthcare professionals working in the field of obstetrics and gynaecology may encounter patient... more Healthcare professionals working in the field of obstetrics and gynaecology may encounter patients from a variety of cultural backgrounds, particularly in our inner cities. These women may have similar cultural beliefs and values about aspects of care they experience compared with native women, but they may also have differing beliefs and may present with preconceptions about the care they expect to receive. In our experience, traditional medical training has limited core teaching on the existence of such cultural variations, and professionals often only experience them through working in the clinical setting. This review was, therefore, undertaken with the aim of increasing awareness of such variations, in order to promote more holistic management, and ultimately to enhance patient care.

Archives of Gynecology and Obstetrics

Postgraduate Medical Journal

We explore how engagement with checklists and adoption of a strict ‘checking’ discipline help avo... more We explore how engagement with checklists and adoption of a strict ‘checking’ discipline help avoid unintentional individual, team and systemic errors. Paradoxically, this is equally important when performing repetitive mundane tasks as well as during times of high-stress workload. In this article, we aim to discuss the different types of checklists and explain how deviations from a ‘checking’ discipline can lead to never events such as wrong side or site surgery. Well-designed checklists function as mental notes and prompts in clinical situations where the combination of fatigue and stress can contribute to a decline in cognitive performance. Furthermore, the need for proactive discussion by all members of the team during the implementation of the surgical checklist also reinforces the concept of teamwork and contributes towards effective communication. Patient safety is often a product of good communication, teamwork and anticipation: a ‘checking’ mentality remains the lynchpin wh...

Postgraduate Medical Journal

Purpose COVID-19 vaccine uptake among pregnant women has been low, particularly in younger and et... more Purpose COVID-19 vaccine uptake among pregnant women has been low, particularly in younger and ethnic minority mothers. We performed a ‘snapshot’ survey to explore vaccine uptake and factors which influence this, as well as underlying beliefs regarding COVID-19 vaccination among pregnant women in a North London hospital. Study design Pregnant women were invited to complete an anonymised survey, where data were collected on demographics, personal and household vaccination status, and beliefs about the vaccine. Free-text comments were analysed thematically. Results Two hundred and two women completed the survey, of whom 56.9% (n=115) were unvaccinated and 43.1% (n=87) had received at least one dose of COVID-19 vaccine, with 35.6% (n=72) having received two doses. Factors associated with acceptance of vaccination included: (a) age over 25 years (57.6% vaccinated vs 17.2% under 25 years); (b) Asian ethnicity (69.4% vaccinated vs 41.2% white ethnicity, 27.5% black/Caribbean/African/black...

BMJ Case Reports, 2021

Brachial plexus injury is a rare but potentially serious complication of laparoscopic surgery. Lo... more Brachial plexus injury is a rare but potentially serious complication of laparoscopic surgery. Loss of motor and/or sensory innervation can have a significant impact on the patient’s quality of life following otherwise successful surgery. A 38-year-old underwent elective laparoscopic management of severe endometriosis during which she was placed in steep head-down tilt Lloyd-Davies position for a prolonged period. On awakening from anaesthesia, the patient had no sensation or movement of her dominant right arm. A total plexus brachialis injury was suspected. As advised by a neurologist, an MRI brachial plexus, nerve conduction study and electromyography were requested. She was managed conservatively and made a gradual recovery with a degree of residual musculocutaneous nerve neuropathy. The incidence of brachial plexus injury following laparoscopy is unknown but the brachial plexus is particularly susceptible to injury as a result of patient positioning and prolonged operative time....

Journal of patient safety, 2017

with great interest. We agree that distractions and interruptions can affect theater performance ... more with great interest. We agree that distractions and interruptions can affect theater performance and would like to share findings of a study we conducted to objectively quantify the frequency and impact of these 2 factors during elective gynecology lists. Attention refers to the focus an operator has over the sensory stimuli he or she chooses to process—during a surgical procedure, selective attention is employed by the surgeon to concentrate on the primary task of operating, at the exclusion of others. A distraction, therefore, is defined as an event that could divert the attention of the primary surgeon (or members of the surgical team) from set taskswhile an interruption constituted a break in task activity. Distractions could be visual (e.g., view of monitor being blocked), auditory (phones and bleeps), equipment failures, and irrelevant communications and can force an operator to switch attention from a primary task to process the new stimuli. In our study, the mean number of interruptions per case was 26 episodes, whereas the mean number of level II/III distractionswas 17 episodes per case (level I: minimal level of distraction and operating team not affected; level II: >1 member of the surgical team was visibly distracted from their task; level III: more than 1 member of the team, including the operating consultant, is affected and visibly distracted from task). Interestingly, 90% of interruptions occur in the first 30 minutes of the procedure and 80.9% affected more than 1 member of operating team, leading to a break in task activity (level II/III). Although no complications,

European Journal of Obstetrics & Gynecology and Reproductive Biology

The Obstetrician & Gynaecologist, 2018