• Team Objective Structured Bedside Assessment (TOSBA) as formative assessment in undergraduate Obstetrics and Gynaecology: a cohort study.

      Deane, Richard P; Joyce, Pauline; Murphy, Deirdre J (BioMed Central, 2015-10-09)
      Team Objective Structured Bedside Assessment (TOSBA) is a learning approach in which a team of medical students undertake a set of structured clinical tasks with real patients in order to reach a diagnosis and formulate a management plan and receive immediate feedback on their performance from a facilitator. TOSBA was introduced as formative assessment to an 8-week undergraduate teaching programme in Obstetrics and Gynaecology (O&G) in 2013/14. Each student completed 5 TOSBA sessions during the rotation. The aim of the study was to evaluate TOSBA as a teaching method to provide formative assessment for medical students during their clinical rotation. The research questions were: Does TOSBA improve clinical, communication and/or reasoning skills? Does TOSBA provide quality feedback?
    • The thickness and volume of LLETZ specimens can predict the relative risk of pregnancy-related morbidity.

      Khalid, S; Dimitriou, E; Conroy, R; Paraskevaidis, E; Kyrgiou, M; Harrity, C; Arbyn, M; Prendiville, W; RCSI Department of Gynaecology, Coombe Women & Infants University Hospital, Dublin, Ireland. (2012-05)
      The aim of this study was to determine if the individual physical characteristics of the extirpated transformation zone after large loop excision of the transformation zone (LLETZ) might predict the relative risk of adverse obstetric outcome, specifically preterm labour (PTL).
    • Thromboprophylaxis for women undergoing caesarean section.

      Kennedy, C; O'Dwyer, V; O'Kelly, S; Farah, N; Kennelly, M; Turner, M J; UCD Centre for Human Reproduction, Coombe Women and Infant's University Hospital, Cork St, Dublin 8. (2012-02)
      Thromboprophylaxis for women undergoing caesarean section (CS) was introduced in the hospital in 1995. This study audited the use of tinzaparin prophylaxis in a nested cohort of women who screened negative for diabetes mellitus at 28 weeks gestation. All the women had their weight measured and BMI calculated at the first antenatal visit. Of the 284 women, 68 (24%) had a CS and all received tinzaparin. Of the 68, however, 94% received a dose lower than recommended. Compliance with prophylaxis was complete but compliance with the recommended dosage was suboptimal, which may result in venous thromboembolism after CS despite thromboprophylaxis.
    • Timing of screening for gestational diabetes mellitus in women with moderate and severe obesity.

      O'Dwyer, Vicky; Farah, Nadine; Hogan, Jennifer; O'Connor, Norah; Kennelly, Mairead M; Turner, Michael J; University College Dublin Centre for Human Reproduction, Coombe Women and Infants University Hospital, Ireland. vicky.odwyer@ucd.ie (2012-04)
      We evaluated screening with a diagnostic oral glucose tolerance test earlier than 20 weeks gestation in women with moderate to severe obesity.
    • To screen or not to screen for subclinical hypothyroidism in pregnancy?

      Freyne, A; Byrne, B (Irish Medical Journal, 2013-06)
      Not unlike screening for gestational diabetes, controversy prevails over the value of screening for thyroid disease in pregnancy. Fortunately, overt hypothyroidism is rare in pregnancy (0.3-0.5%) because it is associated with infertility and increased rates of first trimester miscarriage. Studies suggest that obstetric complications such as hypertension, placental abruption, preterm delivery, perinatal morbidity and mortality are increased in women with hypothyroidism in pregnancy1 and there is evidence that the offspring of untreated mothers have neuropsychological and cognitive impairment. Subclinical hypothyroidism (Elevated TSH and normal Free T4) is estimated to be present in 2 â 2.5% of pregnant women. It is not as clearly associated with adverse obstetric and neonatal outcome but there is some evidence that maternal subclinical hypothyroidism is associated with impaired psychomotor development in the offspring 2.
    • The treatment of CIN: what are the risks?

      Prendiville, W; Royal College of Surgeons in Ireland, Department of Gynaecology, Coombe and, Tallagh Hospital, Dublin, Ireland. walter.prendiville@gmail.com (2012-02-01)
      The treatment of CIN: what are the risks?The treatment of squamous cervical intraepithelial neoplasia is to remove or destroy the transformation zone (TZ). It is likely that no method of treatment is superior to another if it is performed properly and the limited available evidence supports this view. The significant advantages of excision (simplicity, cost, outpatient procedure, histological examination of the entire TZ) mean that treatment thresholds may have lowered over the last decade. Long-term pregnancy-related morbidity associated with excision has been reported recently. The evidence would suggest that this increase equates to a genuine increase in serious adverse outcome for cone biopsy but not large loop excision of the transformation zone (LLETZ). The available data also point to an increase in both incomplete excision and premature labour associated with the excision of large endocervical TZs. The clinical implications arising from this are firstly that women with large type 2 and 3 TZs need appropriate counselling before treatment and that the threshold for treating young women with mild abnormalities needs review.
    • Ultrasound assessment of placental function: the effectiveness of placental biometry in a low-risk population as a predictor of a small for gestational age neonate.

      McGinty, Patricia; Farah, Nadine; Dwyer, Vicky O; Hogan, Jennifer; Reilly, Amanda; Turner, Michael J; Stuart, Bernard; Kennelly, Máireád M; Ultrasound and Fetal Medicine Centre, Coombe Women & Infants University Hospital, Dublin, Ireland. (2012-07)
      The aims of the study were to establish reference ranges for placental length and thickness in a low-risk obstetric population and to assess the likelihood of a small for gestational age (SGA) neonate on the basis of placental length at 18-24 weeks' gestation.
    • Undergraduate medical education in substance use in Ireland: a review of the literature and discussion paper.

      O'Brien, S; Cullen, W; UCD General Practice, UCD School of Medicine and Medical Science, Coombe Healthcare Centre, Dolphins Barn, Dublin 8, Ireland. sarahob17@gmail.com (2011-12)
      Medical complications of substance use are a considerable cause of morbidity and the role of the physician in the care of such problems has consistently been demonstrated. Appropriate knowledge and skills are necessary to carry out this role.
    • Understanding Women's Differing Experiences of Distress after Colposcopy: A Qualitative Interview Study.

      O'Connor, Mairead; Waller, Jo; Gallagher, Pamela; Martin, Cara M; O'Leary, John J; D'Arcy, Tom; Prendiville, Walter; Flannelly, Grainne; Sharp, Linda (Elsevier, 2015)
      Women who have an abnormal cervical cytology test may be referred for a colposcopy. Accumulating evidence suggests some women may experience distress after colposcopy. This exploratory study examined women's differing experiences of post-colposcopy distress with the aim of identifying factors that are predictive of, or protective against, distress.
    • An unusual reproductive consequence of needle excision of the transformation zone.

      Ramphul, M; Dimitriou, E; Byrne, B; Coombe Women and Infants University Hospital, Dublin, Ireland. ramphulm@tcd.ie (2012-02-01)
    • The use of digital media by women using the maternity services in a developed country.

      O'Higgins, A; Murphy, O C; Egan, A; Mullaney, L; Sheehan, S; Turner, M J (Irish Medical Journal, 2014-11)
      The provision of high quality healthcare information about pregnancy is important to women and to healthcare professionals and it is 1 driven, in part, by a desire to improve clinical outcomes,. The objective of this study was to examine the use of digital media by women' to access pregnancy information. A questionnaire was distributed to women attending a large maternity hospital. Of the 522 respondents, the mean age was 31.8 years, 45% (235/522) were nulliparous, 62% (324/522) lived in the capital city and 29% (150/522) attended the hospital as private patients. Overall 95% (498/522) used the internet for pregnancy information, 76% (399/522) had a smartphone and 59% (235/399) of smartphone owners had used a pregnancy smartapp. The nature of internet usage for pregnancy information included discussion forums (70%), social networks (67%), video media (48%), e-books (15%), blogs (13%), microblogs (9%) and podcasts (4%). Even women who were socially disadvantaged reported high levels of digital media usage. In contemporary maternity care women use digital media extensively for pregnancy information. All maternity services should have a digital media strategy.
    • The use of quality control performance charts to analyze cesarean delivery rates nationally.

      Turner, Michael J; University College Dublin Centre for Human Reproduction, Coombe Women and Infants, University Hospital, Dublin, Ireland. michael.turner@ucd.ie (2012-02-01)
      OBJECTIVE: To examine the use of quality control performance charts to analyze cesarean rates nationally. METHODS: Information on cesarean rates was obtained for all 19 Irish maternity hospitals receiving state funding in 2009. All women who underwent cesarean delivery of a live or stillborn infant weighing 500 g or more between January 1 and December 31 were included. Deliveries were classified as elective or emergency. Individual hospitals were not identified in the analysis. RESULTS: The mean rates per hospital of elective and emergency cesarean were 12.9+/-2.6% (n=9337) and 13.8+/-3.0% (n=9989), respectively-giving an overall mean rate of 26.7+/-4.2% (n=19326) per hospital. Cesarean rates were normally distributed. Using a quality control performance chart with a cutoff 2 standard deviations from the mean, 1 hospital was above the normal range for both total and elective cesareans, indicating that its pre-labor obstetric practices warrant clinical review. Another hospital had a mean emergency cesarean rate above the normal range, indicating that its labor ward practices warrant review. CONCLUSION: Quality control performance charts can be used to analyze cesarean rates nationally and, thus, to identify hospitals at which obstetric practices should be reviewed.
    • Vaginal breech delivery at term: the doctors' dilemma.

      Turner, M J; Maguire, P J (Irish Medical Journal, 2015-03)
      "When an operation is once performed, nobody can ever prove that it was unnecessary". The Craze for Operations from The Doctorâ s Dilemma: Preface on Doctors by George Bernard Shaw, 1909*. Breech presentation complicates 3-4% of deliveries at term and it is associated with an increased risk of perinatal mortality and morbidity 1,2 . The increased fetal risks may be due to the hypoxia or trauma associated with a vaginal delivery, but this can be minimised if cases suitable for vaginal delivery are carefully selected and labour is supervised by experienced clinical staff 2,3 . The increased fetal risk may also be due to other causes, such as congenital malformations, which are independent of the mode of delivery. Before 2000, the elective caesarean section (CS) rate for breech presentation had been rising as obstetricians attempted to avoid the fetal risks associated with vaginal delivery.
    • Vaginal prostaglandin gel to induce labour in women with one previous caesarean section.

      Agnew, G; Turner, M J; UCD School of Medicine and Medical Science, Coombe Women and Infants University, Hospital, Dublin, Ireland. gerryagnew@gmail.com (2012-02-01)
      This retrospective study reviewed the mode of delivery when vaginal prostaglandins were used to induce labour in women with a single previous lower segment caesarean section. Over a 4-year period, PGE 2 gel was used cautiously in low doses in 54 women. Induction with PGE 2 gel was associated with an overall vaginal birth after caesarean section (VBAC) rate of 74%, which compared favourably with the 74% VBAC rate in women who went into spontaneous labour (n = 1969). There were no adverse outcomes recorded after the prostaglandin inductions but the number reported are too small to draw any conclusions about the risks, such as uterine rupture. We report our results because they may be helpful in assessing the chances of a successful VBAC in the uncommon clinical circumstances where prostaglandin induction is being considered.
    • What is the value of ultrasound soft tissue measurements in the prediction of abnormal fetal growth?

      Farah, N; Stuart, B; Donnelly, V; Rafferty, G; Turner, M; UCD School of Medicine and Medical Science, Coombe Women and Infants University, Hospital, Dublin 8, Ireland. nadine.farah@ucd.ie (2012-02-01)
      Abnormal fetal growth increases the complications of pregnancy not only for the baby but also for the mother. Growth abnormalities also have lifelong consequences. These babies are at increased risk of insulin resistance, diabetes and hypertension later in life. It is important to identify these babies antenatally to optimise their clinical care. Although used extensively antenatally to monitor fetal growth, ultrasound has its limitations. Despite the use of more than 50 different formulae to estimate fetal weight, their performance has been poor at the extremes of fetal weight. Over the past 20 years there has been emerging interest in studying fetal soft tissue measurements to improve detection of growth abnormalities. This review paper outlines the value of soft tissue measurements in identifying fetal growth abnormalities, in estimating fetal weight and in managing diabetes mellitus in pregnancy.
    • What models of maternity care do pregnant women in Ireland want?

      Byrne, C; Kennedy, C; O'Dwyer, V; Farah, N; Kennelly, M; Turner, M J; UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, , Cork St, Dublin 8 (2012-02-01)
      The introduction of new models of care in the Irish maternity services has been recommended by both advocacy groups and strategic reports. Yet there is a dearth of information about what models of care pregnant women want. We surveyed women in early pregnancy who were attending a large Dublin maternity hospital. Demographic and clinical details were recorded from the hospital chart. Of the 501 women, 351 (70%) (352 (70.3%) of women wanted shared antenatal care between their family doctor and either a hospital doctor or midwife. 228 (45.5%) preferred to have their baby delivered in a doctor-led unit, while 215 (42.9%) preferred a midwifery-led unit. Of those 215 (42.9%), 118 (55%) met criteria for suitability. There was minimal demand (1.6%) for home births. Choice was influenced by whether the woman was attending for private care or not. Safety is the most important factor for women when choosing the type of maternity care they want. Pregnant women want a wide range of choices when it comes to models of maternity care. Their choice is strongly influenced by safety considerations, and will be determined in part by risk assessment.
    • What models of maternity care do pregnant women in Ireland want?

      Byrne, C; Kennedy, Cormac; O'Dwyer, V (Irish Medical Journal, 2011-06)
    • WITHDRAWN: Active versus expectant management in the third stage of labour.

      Prendiville, Walter J P; Elbourne, Diana; McDonald, Susan J; Department of Obstetrics and Gynaecology, Coombe Lying-In Hospital, Dolphin's, Barn, Dublin 8, Ireland. (2012-02-01)
      BACKGROUND: Expectant management of the third stage of labour involves allowing the placenta to deliver spontaneously or aiding by gravity or nipple stimulation. Active management involves administration of a prophylactic oxytocic before delivery of the placenta, and usually early cord clamping and cutting, and controlled cord traction of the umbilical cord. OBJECTIVES: The objective of this review was to assess the effects of active versus expectant management on blood loss, post partum haemorrhage and other maternal and perinatal complications of the third stage of labour. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Randomised trials comparing active and expectant management of the third stage of labour in women who were expecting a vaginal delivery. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by the reviewers. MAIN RESULTS: Five studies were included. Four of the trials were of good quality. Compared to expectant management, active management (in the setting of a maternity hospital) was associated with the following reduced risks: maternal blood loss (weighted mean difference -79.33 millilitres, 95% confidence interval -94.29 to -64.37); post partum haemorrhage of more than 500 millilitres (relative risk 0.38, 95% confidence interval 0.32 to 0.46); prolonged third stage of labour (weighted mean difference -9.77 minutes, 95% confidence interval -10.00 to -9.53). Active management was associated with an increased risk of maternal nausea (relative risk 1.83, 95% confidence interval 1.51 to 2.23), vomiting and raised blood pressure (probably due to the use of ergometrine). No advantages or disadvantages were apparent for the baby. AUTHORS' CONCLUSIONS: Routine 'active management' is superior to 'expectant management' in terms of blood loss, post partum haemorrhage and other serious complications of the third stage of labour. Active management is, however, associated with an increased risk of unpleasant side effects (eg nausea and vomiting), and hypertension, where ergometrine is used. Active management should be the routine management of choice for women expecting to deliver a baby by vaginal delivery in a maternity hospital. The implications are less clear for other settings including domiciliary practice (in developing and industrialised countries).