How has COVID-19 affected the way we care for women
Medical Care
- Less face to face in all areas
- Less support/education/medical diagnosis
PRO: RANZCOG proactive in endorsing Telehealth/social media/other means
COVID-19 in Pregnancy
- recent endorsement by RANZCOG of use of Pfizer vaccine given maternal risk of COVID-19
- Labour when COVID-19 has proving taxing for health system to provide safely focusing both on staff members and patients
Community Fear
- General fear amongst community of presenting to hospital for care, more high risk pregnancies being cared for in low risk environments/no care at all (home brith)
PRO: RANZCOG/Health services have invested in providing education support and reassurance about in hospital saftey through social media/internet
What do you know about vaginal mesh and the surrounding controversy
Controversy
- Mesh has been used in multiple surgical specials as an improvement of native tissue grafts due to longevity and less repeat surgery
- Used effectively in urethral sling operations -> clinically this success was translated into a possible use in vaginal prolapse repair however this FAILED
Cx
- Mesh erosion/exposure in 8-15% of patients
- Occurrence of prolapse elsewhere
- Fistulae
- Pelvic pain that is difficult to treat
stress incontinence
- Lack of a central register of women who had mesh repair
Current RANZOG opinion
- Mesh should not be used for any vaginal; prolapse surgery
- If it is being considered -> use in a RCT + EXTENSIVE counselling
- Should only be performed by trained surgeons
Who to use mesh on
- Obsese.young
How How you manage a BMI 50 Primip Pregnancy
Pre-conception
- Optimise weight ? bariatric surgery
- If diabetic optimise sugar
- Folic acid 5mg (HIGH DOSE)
- General advice
Antenatally
- LISTEN TO THE WOMAN
- Early MDT input (Dietician/Exercise/High risk obs/Anaesthetics/Midwifery)
- Early OGTT
- Specific advice re GWG
- Consider Clean if other risk factors present
- Serial growth scans
- Offer IOL 39-40/40 given stillbirth risk depending on unit/senior clinicians
Intrapartum
- LISTEN TO THE WOMAN
- Adequate monitoring with FSE + Koala
- Midwifery assistance
- Alert anaesthetics
Postpartum
- Clexane required
- HTN/DM checks with GP
- Advice re loss of weight prior to next pregnancy =? ? Bartatric surgery
How had Obesity affected Obstetrics and Gynaecology
- Patient side
OBS
- High risk pregnancy, less options available to them ( Water births, IA, Physiological third stage) more intervention is often required in general
GYN
- Greater risks with anaesthesia/other medical comorbidities
- Recovery time is extended
-Less longevity of surgical repair - Doctor Side
- More technically difficult surgery
- Greater rates of Morbidity and mortality
- More repat surgery
- More difficult to train juniors given complex surgery
- Less likely to recommend surgical approach despite it might be gold standard due to obesity complexity
What do you know about birth trauma
STATS
- 2-6% of women meets the criteria for PTSD following childbirth
- 33% of women experience some trauma symptoms following childbirth
Things women perceive as bad
- Lack of choice
- Neglect by midwifery/obstrtric staff
- High level fo obstetric intervention
Consequences of Birth Trauma
- Poor relationship with baby
- Sexual dysfunction
- Anxiety and depression
- Seeking supportive and empathetic birth providers following poor experience -> AWAY FROM HOSPITAL
What can we do
- LISTEN to women
- PROMOTE SHARED DECISION MAKING
- BE EMPATHETIC
- Caseload midwifery
What role does RANZCOG play in Global Health
RANZOCG vision is to improve the health of women and their families in the geographical area
EDUCATION
- Aus Trainee -> Pacific
- Developing world trainee -> Aus
RESEARCH
- Supporting researching in developing countries with funding and support people
Pacific medical schools
ADVOCACY
- Promoting screening and population based health in developing nations
- Allows them to continue program on
Do you think midwifes alone should be able to manage pregnancies
I believe that appropriately selected, low risk women can have the majority of their care undertaken by a midwife, but I believe the best way we can care for women and their families during pregnancy in through a collaborative model.
Cons on midwifery only
- Midwives have a vast amount of experience on a lot of thing I don’t have
- Don’t have experience in difficult counselling/procedure explanation/consent/medical diseases of pregnancy/
Pros of Collaborative model
- Best use of everybody’s skillsets -> best people for the best job
- Obstetric risk lies on a continuum and our care should also
- RANZCOG have published guidelines on collaborative care + signed on t a memorandum of understanding between the college of midwifes in AUS
Certain chromosomal and genetic conditions put a huge economic burden on society. Subsequently, there has been increasing research into extended carrier screening to increase detection of particular conditions. Can you please comment on this and whether or not it should be universal?
Extended carrier screening is emerging technology that offers couples information that was previously never available. Bioethical it poses significant questions to our community about their acceptance of risk and around the equity of such technology.
Screening
- Can take many forms: Detailed family history/simple investigations such as an FBE for thalassaemia or involved
- From an ethical perspective it is essential that the couple are informed about what screening means for themselves/their family/their future pregnancies
- Can be couple screening toughener or initial partner screening -> other partner
Carrier screening should be universal if there is equitable distribution amongst the community. ethical issues arise regarding testing individuals who do not have financial access to IVF ( Similar to a screening test where there is no reasonable hope of cure)
RANZCOG are moving towards a model of generalist and subspecialist training. Do you believe that subspecialists should have a basic skillset in all aspects of O&G or just have expertise in their subspecialty
Pro basic skillset
- Currently required of advanced trainees
- Truely means that all specialists are obstetricians and gynaecologists
- Able to work in regional areas and provide essential services where required
Con’s basic skillset
- Prevents real focused honing into a specialty and development of best level fo skillset
- extreme focus is what multiple surgical specialties do in order to provide best care and may be the most efficient model of health care an a system level
Patient has an abnormal CTG requiring immediate caesarean. A surgical procedure of the same urgency status is in progress and will take another 90 min. What will you do?
- Escalate Care
- Call consultant and make them aware of situation
- Call theatre and made them aware of situation -> options of calling in a second theatre - Improve the clinical scenario
- Intra-uterine resuscitation (Stop synt/Fluid/terbutaline/consider instrument vaginal delivery/epis) - Improve clinical situation of other patient
- Give temporising measures to other patient
- assist the OT team to finish with other case faster
** DOCUMENT/DEBRIEF/FOLLOW UP**
Who has indicated that we should aim for a C/S rate of 15%.
- What issues does this raise
- How would you address this at your hospital
Caesarean section rate is a frequently discussed metric. recently in Australia our C/S rate has been climbing to currently approx 35%.
Why is it higher
- BMI/GDM/Older pt
- C/S for maternal request
- C/S is a safe operation in Australia
How can I address the C/S rate at my hopsital
- Improve protocol surrounding intra-uterine resuscitation
Encourage VBAC’s in Bendigo we have an excellent VBAC
Improve antenatal education amongst couples
- Reduce non essential C/S
One of your colleagues come to you describing having suffered bullying at the hand of senior manager. How would you support them
RANZCOG take a zero tolerance policy with regards to workplace bullying
- Immediate care of friend
- Personal support
- referral to RANZCOG support services
- GP/psychology/ - Support colleague to escalate appropriate up RANZCOG chain -> senior registrar/
There is a significant rise in the number of people being diagnosed with the flu and it is recommended that all women receive the flu vaccine in pregnancy. Why is this important? Can you comment on whether this is a direct or indirect cause of maternal death?
- Influenza causes increased mortality and morbidity in pregnant women. Pregnant patient are at much risk risk of hospitalisation and ICU admission when affected with influenza. RANZCOG has clear guidelines on the importance of offering women vaccination whilst pregnant
- A death from influenza infection would constitute a indirect maternal death, as there was no direct obstetric complication that lead to death but rather a physiological process worsened by pregnancy
Indigenous patients have higher perinatal mortality rates. Why do you think this is and what can we do to close the gap between indigenous and non-indigenous health outcomes?
First Nations people suffered worse outcomes in all areas of medicine and O&G is not different
Why
- Greater incidence of medical cormorbidities (GDM, DM, Heart/lung disease)
- Poorer health literacy
- Over-represented in rural remote areas
- Over-represented in socially challenging circumstances (Homeless, Victim of DV)
What can we do
- UNDERSTAND + BE EMPATHETIC + BE FLEXIBLE WITH CARE
- Indigenous health services providers
- Provider health care on country
- Health resources in language
Bullying and harassment. What can the college can do to minimize it. What can you do as a trainee?
Problem in multiple specialties, however RANCOG deal with problem well
What can COLLEGE do
- Promote zero tolerance policy
- Education to consultants about bias/workplace relationships/education
What can I do
- Educate myself on bullying behavior
- Support colleagues experiencing bullying behaviour
- Report Bullying to RANZCOG training committee
How does the media influence the practice of obstetrics and gynecology?
Moreso now than ever, the media plays a significant role in influencing patient perspectives of O&G
Media corporations have a direct line to women and their families across australia, and their coverage, massively influences peoples expectation and perspective of normal. Recent examples include films about birth trauma, stories OASIS and even about cosmetic gynaecology
Our role as O&G’s is to provide best evidence based care and balance the often one sided media opinion. Most effective way do to this is likely through working with media to provide a balances opinion int he media
What indices are the most useful in monitoring performance in obstetrics practice?
Key indices
- Overall perinatal mortality/morbidity
- Induction rate
- OASIS rate
- PPH Rate
- MATERNAL SATISFACTION
Important that health services audit regularly to catch performance change and implement change to improve performance
What are the elements of a screening test
We offer multiple screening tests in O&G. CST/FTCS/NIPT
Elements of effective screen as defined by the WHO
- Problem being screen for need to be prevalent in population being screening
- Must be able to detect disease in early/latent phase
- Disease needs to have appropriate treatment already and have evidence that patient outcomes are improved with earlier treatment
- Both screening and treatment procedures need to be acceptable to population
- Screening needs to unbiased, and a continued process
- cost of screening needs to be economically balanced with cost of treatment at a later disease phase
Compared to 15 years ago, we are seeing significantly higher rates of gestational diabetes. Why do you think this is the case? What are the risk factors, and what can we do about it?
Why ( Risk factors)
- Increasing incidence of lifestyle disease within our community Obesity/Smoking/Medical comorbidities
- Multicultrual population of Australia means there are ethnic group that are more prone (African/south east asian)
What can we do
- Encourage healthy lifestyle for all of our patients
Discuss pre-conception medical optimisation gestational
- Diagnose GDM appropriate and manage complications
What are some shortcomings in the O&G/ Any training program and how would you overcome this?
- Lack of surgical exposure
- Due to: Increasing pt complexity, improved medical therapy, increasing patient sub specialisation
- BETTER: Simulation, train the trainers, ? longer training program - Geographically always in same place
- Acknowlegde rural term and sub-speciality rotations, however don’t see how different people from different states do thing???
Recently Medicare has increased rebates for mental health appointments among maternity patients. Please discuss why you think mental health in pregnancy is important and what you can do to combat this issue.
Mental health care is essential during a woman’s and her families pregnancy
Why
- Antenatal: Women with mental illness less likely to attend appointments, less likely to enact medical therapy, les slickly to take on information about pregnancy and childbirth
- Intrapartum: Women with poor mental health are less likely to be able to deal with the rigours of childbirth and are more likely to suffer birth related trauma from
- Postpartum: Mental health is essential in the post part, depression/anxiety get in the way of attachment and these women are more likely to suffered PND and other post parts spectrum
What can I do
- Ask often and be empathetic
- Refer patient,/provide a health service which supports mental health triage
- be flexible with care phone appts/support people
What are your priorities for the delivery of health care to women
Womens health care has come a long way in the last 50 yrs however there are still significant steps to make
Key priorities
- Equitable distribution of health care
- Focus of women in regional/rural areas alongside first nations womens as those populations current have poorer health outcomes that other populations
- Consider First Nations/regiional models of health care - Focus on women centred care and shared decision maing
- Master of bioethics -> promote autonomy
- Create a healthcare system that promotes womens autonomy - Multidisciplinary approach
- Use the best skill sets available to manage patients appropriately
Tell about a recently published paper you have read and how it has changed your practice
- Constantly working to improve my exposure to EBM, currently received emails from the Mercy perinatal journal club on the run
- Study which looks at correlation between hypertensive disorders of pregnancy and CVD risk in later life
- NSW data, shows that women who suffer from HDP are twice as likely to suffer with CVD ( ischaemic heart disease, stroke for hypertensive disorder requiring hospitalisation or death
Obstetrics Units are being shut down. Why is this happening what effects is it having and how can we prevent this
I have a personal lived experience with this happening recently with the Castlemaine obstetric service being shut down and re-opened within the space of a year
Why are they being shut down
- Poor patient outcomes
- Unable to reliably provide appropriate levels fo patient care due to staffing
Effects
- Significant effect of women in the community
How can we prevent this
- Clinical governance and risk management input
- Strong input from the community
- Input from overarching organisation such as safer care Victoria + Local hospitals to support skill development ( GPO’s come to our hospital for skill development)
