Topical Discussions Flashcards
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
