DOI: 10.1111/1471-0528.
15635
www.bjog.org
ePosters
Labour and Delivery
EP.198
Breech delivery: should we encourage women to
consider it?
Lockley, S; Musa, R; Joyce, E; Buruiana, F;
Srinivasan, M
City Hospital, Birmingham, UK
Objectives Vaginal breech deliveries are high-risk events and as
such it is especially important to council these patients clearly on
modes of delivery and to ensure that RCOG standards are
complied with carefully. With recent history demonstrating a
general reduction in vaginal breech deliveries and increase in
caesarean section rates, it seemed prudent to assess our maternity
unit’s outcomes for different methods of delivering breech
presentation and how effectively we adhere to national guidance.
Method Data regarding breech presentations were retrospectively
collected between August 2017 and August 2018; these data were
collected from our Badgernet online system. Management and
outcome data were broadly collected for each delivery, and
compliance with RCOG guidelines regarding external cephalic
version (ECV), location of delivery, and use of syntocinon was
also assessed.
Results 55% of breech deliveries were unassisted vaginal
deliveries. Our findings suggest increased short-term fetal
morbidity with 4 cases (11%) going to the Neonatal Unit;
however, there were no long-term fetal issues. There were no
serious maternal complications following any of the vaginal
breech deliveries. Problems relating to high estimated blood loss
and other maternal complications were primarily an issue with
caesarean sections. Our unit was compliant with RCOG standards.
Conclusions Our results suggest that we should carry on with our
current safe practise. Patient counselling is paramount and we will
ensure that patients have access to updated information; part of
this effort will be ensuring that updated literature is available to
women who also do not speak English.
EP.199
Reducing full dilatation caesarean section: QIP
report
Lee, N; Furness, S; Pereira, S
Kingston Hospital, London, UK
Background Full dilatation caesarean section (FDCS) is associated
with increased morbidity and mortality, and rates are on the
increase. We observed a relatively high FDCS rate at our unit and
ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG
Abstracts
designed an intervention to increase the number of successful
instrumental deliveries and reduce FDCS rates.
Objectives Reduced FDCS and failed instrumental rates by
implementing an intervention called ‘Declare an Instrumental’.
Design Multidisciplinary meetings were held to explore reasons
for high FDCS and failed instrumental rates at our unit. An
intervention called ‘Declare an Instrumental’ was designed based
on feedback. By ‘declaring’ an instrumental delivery would be
conducted in a labour ward room, extra midwifery presence
would be provided and liaison between paediatric and anaesthetic
teams would occur. Retrospective and prospective data were
collected over 12-month period measuring FDCS and failed
instrumental rates before and after the implementation of the
project.
Methods All patients undergoing emergency caesarean section
and/or instrumental delivery between April 2017 and October
2018. Data were collected from electronic records and theatre
delivery books and inputted into Excel.
Results Feedback from trainees and staff was positive regarding
the project. FDCS and failed instrumental delivery rates fell
following implementation of the ‘Declare an instrumental’ project.
Conclusions Labour ward procedure and culture can affect
delivery mode and, in particular, lead to an increased FDCS and
failed instrumental rate. By identifying specific problems
associated with our unit’s practice regarding instrumental
deliveries in a labour ward room, we were able to reduce our
FDCS and failed instrumental rate.
EP.200
Labour ward leaders: working together for
safer care
Johnson, G; Lloyd, C
The Royal College of Midwives, London, UK
A survey of labour ward midwives and obstetricians identified a
lack of share learning and understanding of professional roles.
Midwives identified limited specific training for their leadership
roles, inadequate equipment, poor professional relationships, and
increasing maternity complexities impacting on outcomes for
women and babies. Obstetricians identified very similar challenges
and also aspects of isolation when seeking support from midwives.
The Kirkup report into Morecambe Bay identified poor
communication between professions and a lack of a shared vision
leading to poor outcomes. The NHS maternity safety agenda
identified the need to see a reduction in maternal and perinatal
morbidity and mortality. The Royal College of Midwives worked
in collaboration with The Royal College of Obstetricians and
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Gynaecologists, Atain and NHSE to design and deliver a one-day
multidisciplinary workshop for labour ward leaders. Obstetricians,
labour ward coordinators, and maternity safety leaders identified
teams of 7–8 to attend the workshop. Each team was asked to
identify a quality improvement (QI) initiative which the team
would work on after the workshop. The wider labour ward team
were to be included as part of the QI initiative. Four Pilot
programmes were run across England, with each workshop having
5–7 teams. A mix of teams enabled an opportunity to share ideas
and projects as well as networking. The pilot programmes
evaluated well and have since been rolled out across the UK and
Ireland.
The collaboration and shared learning bridge the gap between
midwives and doctors for the benefit of women and babies safety.
EP.201
An audit of external cephalic version procedures at
Kings College Hospital
Rehal, A; Datta, S
Kings College Hospital, London, UK
Objectives External cephalic version (ECV) is a method
commonly used to manipulate the fetus abdominally to a cephalic
presentation. The purpose of this audit was to evaluate all ECV
procedures over a one-year period in our unit, to analyse
subsequent pregnancy outcomes and compare these with previous
audits.
Design This was a retrospective audit, analysing all ECV
procedures performed in the year 2017.
Methods Data queries were used to extract all patients with a
non-cephalic fetus at the routine 36 weeks’ scan, and a second
query extracted all breech deliveries.
Results 250 fetuses were breech at the routine 36 weeks’ scan.
From these, 110 ECV procedures were attempted. 34.6% were
successful and 86% of these patients had a vaginal delivery. From
those procedures that failed, all patients delivered by caesarean
section. A greater success rate was seen in multiparous compared
with nulliparous patients (51% versus 26%). When compared
with the results from previous audits, there had been an overall
increase in ECV procedures; however, the success rate had fallen
compared to the previous year.
Conclusion The results show that antenatal detection of breech
presentation is extremely high in our unit and can be explained
by the routine 36 weeks’ scan. ECV remains one of the principal
methods to reduce the incidence of breech presentation, thereby
potentially avoiding caesarean section and its sequelae. Further
audit would need to be carried out looking at the factors
associated with failure in terms of case selection and operator
experience.
88 ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG
EP.202
Do obstetric factors influence the outcome of the
induction of labour process?
Venables, M1; Chen, T1; Lacey, L1,2; Quenby, S1,2
1
University of Warwick Medical School, Coventry, UK; 2UHCW,
Coventry, UK
Objectives An increasing number of women are undergoing
induction of labour at our University teaching hospital as part of
the initiatives to improve neonatal outcomes (36% women in
2017). We aimed to review the induction of labour process to
identify how it could be improved and to identify factors which
influence outcomes.
Design A retrospective cohort study of women who underwent
induction of labour from July to December 2017.
Methods Patients were identified from the induction diary. Data
were collected from maternal notes including patient
demographics, method and timing of the process, mode of
delivery, and delivery complications.
Results Data were collected from 369 nulliparous and 397 parous
women. The relative risk of caesarean section in nulliparous
women compared to parous women was 3.7 (95% CI 2.6–5.2).
When comparing the risk of caesarean section in patients who
were deemed to be favourable (BS ≥ 8) to those not favourable
(BS ≤ 7), the relative risk was not significant (RR 1.58, 95% CI
0.7–3.36). However, gestation over 40 weeks showed a statistically
significant increase in relative risk of caesarean section (RR 1.94,
95% CI 1.5–2.5).
Conclusions As expected, the caesarean section risks as higher in
nulliparous women when compared to parous women. Bishop score
was designed to predict the chance of successful vaginal delivery in
the subsequent 6 hours. From our cohort, it did not influence
outcome. This may be useful in our counselling of women about the
induction process. In keeping with the current literature, the risk of
caesarean section increased when patients are overdue.
EP.203
Do demographic factors influence mode of delivery
in patients undergoing induction of labour?
Chen, T1; Venables, M1; Lacey, L1,2; Quenby, S1,2
1
Warwick medical school, Coventry, UK; 2UHCW, Coventry, UK
Objectives An increasing number of patients are undergoing
induction of labour in the UK with the aim to improve neonatal
outcomes. At our university teaching hospital, 36% of patients
were induced in the last year. We aimed to review the processes
and outcomes of induction of labour at our trust.
Design A retrospective cohort study of all women who underwent
induction of labour at a university teaching hospital in a 6-month
period from July to December 2017 inclusive.
Method Patients were identified from the induction diary. Data
were collected from maternal notes including patient
demographics, mode of delivery, and complications at delivery.
Results Data were collected on 766 women (369 nulliparous, 397
parous). 65% had a normal vaginal delivery, 14% had an

instrumental delivery, and 21% had a caesarean section. The mean
age was 29.2 years (SD 5.8). The relative risk of caesarean section
was not increased by increased maternal age (defined ≥35 years)
(RR 1.02, 95% CI 0.72, 1.47). The mean BMI was 27.1 kg/m2 (SD
6.3). The relative risk of caesarean section was increased when
comparing obese women (BMI ≥ 30) with patients who are not
(BMI<30) (RR 1.38, 95% CI 1.03, 1.84).
Conclusions The delivery outcomes of induction of labour at our
university teaching hospital are similar to those reported in the
literature. In our population, as expected obesity increased the
risk of caesarean section; however, maternal age does not. We
could use these results to help to support the counselling of our
women about induction of labour.
EP.204
Managing the super morbidly obese pregnant
woman: outcomes of super morbidly obese
(BMI > 50) pregnant women in a UK District
General Hospital
Prince, SJ1,2; Law, H1
1
Colchester Hospital University Foundation Trust, Colchester, UK;
2
RCOG, London, UK
This audit aimed to look at the number of super morbidly obese
(BMI > 50) women delivering at a District General Hospital and
their delivery and neonatal outcomes.
A retrospective review was undertaken of maternity records of all
women booked with a BMI > 50 between October 2015 and
October 2016 (n = 24) that delivered at a UK District General
Hospital which averages 3800 deliveries a year and has a level 2
NICU.
Women with a BMI over 50 at booking accounted for 0.6% of all
deliveries. The average BMI was 53.6. Mode of delivery found a
46% caesarean section rate, 42% spontaneous vertex delivery rate,
and 13% forceps rate. Of these deliveries, primiparous women
had a 60% caesarean section and 20% instrumental rate. Where
women were attempting a VBAC 100% required a caesarean
section. As a group, 54% sustained a PPH > 500 ml and 21%
>1500 ml. NICU admissions were 20.8%. There was 1 maternal
and neonatal death in the BMI > 50 group during this period.
These figures when compared to similar larger data sets
internationally show that there is a significantly increased rate of
caesarean section in this population group: 49.1–60.6% (Marshall
et al, 2010; Crane et al, 2013). This has significant implications for
counselling with regard to mode of delivery and subsequent
maternal and neonatal outcomes particularly in primiparous and
previous caesarean section patient groups. Further work needs to
be done around optimising the care of women with a BMI > 50
and informing our delivery management and counselling
particularly in a post-Montgomery (2015) era.
ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG
ePosters
EP.205
The Golden Caesarean: a quality improvement
project to improve efficiency of elective caesarean
lists
Malin, G1; Banks, A2
1
Maternity Department, Nottingham University Hospitals NHS Trust,
Nottingham, UK; 2Anaesthetic Department, Nottingham University
Hospitals NHS Trust, Nottingham, UK
Background The CQC recommends dedicated operating lists for
elective caesarean births. Theatre time is expensive and must be
used efficiently. We sought to implement a strategy to optimise
list efficiency. In order to facilitate a prompt list start, the
following principles were employed:
 First woman on list identified (Golden Caesarean) – should not have
surgical or anaesthetic complexities.
 Inform woman and multidisciplinary team.
 Send for the woman at a prespecified time.
This idea was adapted from trauma lists which identify ‘Golden
Patients’.
Design Quality improvement project.
Objective To assess if the ‘Golden Caesarean’ strategy can
improve list efficiency.
Method ‘Golden Caesarean’ was implemented for Monday caesarean
lists from March 2018. Data on time of sending for the first woman,
and number of caesareans completed during the list time, were
compared with the Wednesday elective list of the same week.
Results 37 lists over a 20-week period. Twenty-eight staffed with
a separate obstetric consultant. Nine covered by the labour suite
obstetric consultant. Comparison of start times only included fully
staffed lists. Where a ‘Golden Caesarean’ was identified the mean
time of sending was 27 minutes earlier. When at least 3 caesareans
were listed, these were completed by the list finish time in 6/9
occasions on a Monday, and 0/4 occasions on a Wednesday. The
mean start time was 30 minutes earlier when the Monday list had
a separate obstetric consultant.
Conclusion The ‘Golden Caesarean’ strategy can improve list
efficiency. However, adequate staffing is vital to implement this
effectively.
EP.206
Pregnancy outcomes in women with a high BMI –
comparison of the ‘super-morbid’ obese, obese,
and the overweight over a 10-year period
Ganapathy, R; Shehata, H
Epsom and St. Helier University Hospitals NHS Trust, London, UK
Objective Impact of obesity on Pregnancy outcomes over a 10-
year period.
Design Data of 48,843 deliveries over a 10-year period. The time
period and volume will minimise errors in analysed outcomes.
Methods Data of all deliveries between January 2008 and
December 2017 extracted. Number of pregnancies in the period
was 49,512 after exclusions of miscarriage, TOP of pregnancy,
unrecorded BMI, analyses included 48,843 cases. Patients were
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grouped into their BMI category. Factors analysed were age,
ethnicity, parity, pregnancy complications including intrapartum,
and perinatal outcomes. We compared outcomes in the groups.
Results There were 58 women with a BMI >50, 727 with BMI of 40
to 49.9, 6980 with a BMI between 30 and 39.9, 13,176 women were
overweight, 26,436 had a normal BMI, and 1467 were underweight.
The subgroup of super-morbid obese (BMI of >50) and morbidly
obese have a 3X higher risk of having a caesarean and 40% need
medical induction, with a 4X times higher rate of PPH OF
>1000 ml. 18% had a birthweight >4 kg. Regression analysis shows
the BMI and ethnicity having a significant impact on outcomes.
Conclusions This significantly large data set from a multi-ethnic
population allows us to see the outcomes related to the
population we serve and informs decisions in care. Data on the
outcomes in morbidly obese women should be used to tailor
counselling and planning care in high-risk obstetric units.
EP.207
Obstetric trainees’ knowledge, views, and opinions
on physiological birth: a qualitative exploratory
study
Woodcock, R; Rocca-Ihenacho, L
City University London, London, UK
Objectives To explore obstetric trainees’ knowledge, views and
opinions on physiological birth. To understand aspects of
obstetric trainees’ decision-making surrounding physiological
birth. To explore obstetric trainees’ views on facilitating
physiological birth in the workplace.
Design Qualitative methodology, with a multicentre approach,
provided rich data regarding obstetric trainee’s knowledge, views,
and opinions. Ten participants, recruited through purposeful
sampling, had individual face-to-face semi-structured in-depth
interviews.
Method Thematic analysis and inductive coding were conducted
with aid of NVIVO qualitative data analysis (QDA) computer
software package.
Results Subjects ranged in age from 25 to 44 years. 90% of
participants were women; 70% were white British. In 10
interviews, individuals ranged from being a ‘Specialty Trainee’ 1
to ‘Specialty Trainee’ 7. Thematic analysis resulted in 5 main
themes: (1) lack of training and exposure to physiological birth,
(2) need for multidisciplinary training in physiological birth, (3)
high intervention rates in labour and birth, (4) impact of risk
culture and of fear of litigation, and (5) importance of support in
the workplace.
Conclusions This study highlighted that obstetric trainees had
little to no exposure, experience, and training of physiological
birth. Contrastingly, subjects expressed enthusiasm for
multidisciplinary training in physiological birth and working with
midwives in low-risk settings. Concerns regarding a rise in
intervention rates in labour and birth were present, and therefore,
obstetric trainees should be encouraged to gain experience on
physiological birth and senior obstetricians should continue to set
positive examples of promoting physiological birth.
90 ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG
EP.208
A ten-year study of the impact of working patterns
and the European working time directive on
Robson Group 1 caesarean section rates
Shanahan, I; Kane, D; Burke, N; Kent, E
Rotunda Hospital, Dublin, Ireland
Objectives Caesarean section (CS) rates are globally increasing in
spontaneous labouring nulliparous women, >37 weeks, cephalic
(Robson Group 1-RG1). Potentially, more CS occurs at night or
weekends, due to fatigue and increased workload. The
implementation of European Working Time Directive (EWTD) in
our hospital in 2012 means less hours but potentially fractures
continuity of care. This study aimed to determine the effect of
nocturnal hours, weekend call, and implementation of EWTD on
RG1 CS rates.
Method A database over a 10-year period in a large Irish tertiary
centre (2008–2017) was amalgamated from coding and clinical
sources, yielding 45,959 deliveries. RG1 CS rates were examined
by time of day (Day/night) and day of the week (weekday/
weekend). The rate of RG1 CS before and after EWTD
implementation was compared. Relative frequencies were
compared using chi-squared test in GraphPad; statistical
significance was defined as P-value<0.05.
Results There were 18,925 women in RG1. Overall RG1 CS rate
was 14.9% (n = 2835). Rates of RG1 CS were not statistically
different between those delivering on weekdays (15%, n = 2061)
and weekends (14.4%, n = 774, P = 0.22). During daytime hours,
the CS rate in this cohort was 15% (n = 7669) and was similar at
night time (14.9%, n = 1157, P = 0.72). Comparing the time
periods pre- and post-EWTD, there was a significant increase in
RG1 CS rates (13% versus 15.7%, P < 0.001).
Conclusion Working patterns do not appear to influence rates of
CS. The temporal increase in RG1 CS rate has continued despite
the implementation of improved working conditions with EWTD.
EP.209
Changing from FIGO to physiological CTG
interpretation: implementation of staff training
Knight, C; McMicking, J; Phipps, L; Napolitano, L;
Lloyd, J
Guy’s and St Thomas’ NHS Foundation Trust, London, UK
Objective To implement physiological CTG training for
obstetricians and midwives, and collect data to assess impact of
training.
Design Difficulties with CTG interpretation are highlighted in
national reports (RCOG Each Baby Counts; NHS Litigation
Authority) and local Trust RCAs. Units using Physiological CTG
Interpretation Guidelines have lower emergency CS and hypoxic-
ischaemic encephalopathy rates compared with units using
alternative guidelines.
Method In April 2018, we arranged an introductory half-day
multidisciplinary teaching session on CTG physiology. We then

implemented weekly 60-minute CTG sessions led by a consultant/
ST6 + . We surveyed staff attending during a 6-week period to
assess understanding and obtain qualitative feedback.
Results 60% of staff responded including consultants, ST1-7, FY1-
2, midwifery practice leaders, and midwives. Presession confidence
was greater about FIGO (9% extremely, 49% confident, 34.5%
somewhat, 7.5% not) compared with physiological interpretation
(5.7%, 34.2%, 40.3%, 19.6%). Postsession confidence increased in
physiological (36% strongly, 62% agree, 2% disagree) with almost
all finding the session useful (39.5% extremely useful, 54.7% very
useful, 5.7% somewhat useful, 0% not useful). Qualitative
feedback enabled session modification: moving location to
increase attendance, increasing senior presence, standardised
introduction to physiological interpretation, discussing 1 case
only, clear distinction between FIGO and physiological
interpretation, case reflection including human factors.
Conclusion A structured CTG training approach, using both
familiar FIGO and new physiological guidelines, has improved
staff confidence in physiological interpretation. Qualitative
feedback enabled adjustments pertinent to our attendees’ learning
needs. We are continuing the weekly sessions and developing
additional half-day annual sessions for all staff including formal
knowledge testing.
EP.210
The PPH Butterfly study: an open label, phase II,
clinical trial of a novel medical device to manage
postpartum haemorrhage, with historical controls
Weeks, A1; Cunningham, C2; Cregan, L2;
Lambert, D1; Taylor, W3; Bedwell, C3;
Lavender, T3; Watt, P4; Fisher, T1;
Rosala-Hallas, A1; Lane, S1
1
University of Liverpool, Liverpool, UK; 2Liverpool Women’s Hospital,
Liverpool, UK; 3University of Manchester, Manchester, UK; 4Royal
Liverpool University Teaching Hospital, Liverpool, UK
Background Bimanual uterine compression is a very effective
treatment for atonic postpartum haemorrhage (PPH) and would
be an appropriate initial treatment to control blood loss.
However, it is painful, has overtones of gender-based violence,
and is very tiring to maintain. Its use is therefore limited to
extreme situations. The PPH Butterfly (PPHB) is designed to
replace the fist for bimanual compression, allowing firm
compression of the uterus. It also helps to diagnose the source of
the blood loss as, if the bleeding continues, then the likely cause is
vaginal lacerations.
Method The injection-moulded PPHB was designed in Liverpool.
The prototypes were tested first on mannequins and then on
healthy volunteers before a final design was produced. A
prospective cohort study was conducted in which the PPHB was
used on women with clinical PPH after vaginal birth. Verbal
consent was obtained before use. Clinical outcomes were
compared to that of a matched historical cohort.
Results Initial results show it to be acceptable to clinician and
participant and suggest that it may be effective at blood loss
ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG
ePosters
reduction and as an aid to diagnosis of the source of the blood
loss.
Conclusions The PPH Butterfly has shown good functionality in
mannequins, and Phase 1 human tests show it to be of an
appropriate size for immediate postpartum use. Phase 2 studies
now suggest that it is effective, safe, and acceptable to both
women and clinicians. The PPH Butterfly is a promising device
for the management of PPH.
EP.211
Antenatal education and mode of delivery: a
survey of primigravida patients
Tzafetas, M1,2; Iacovou, C1; Hill, R1; Hardy, M1;
Sajjad, N1; Girling, J1
1
West Middlesex University Hospital, London, UK; 2Imperial College
London, London, UK
Objectives To what extend are pregnant women educated about
the possible modes of delivery (MOD) during labour.
Design Prospective survey data collection from postnatal patients
at West Middlesex University Hospital, London.
Method All women included in the study were primigravida, with
singleton pregnancy, delivered at term and with knowledge of
English. A total of 11 participants over a period of one week were
included, a four-month period of survey collection will be
presented.
Results Only one (9%) of the participants had care provided by
an obstetrician during the antenatal period. More than half
(55%) attended antenatal classes, with the majority (71%) taking
place in a National Childbirth Trust (NCT) setting. Most
participants (91%) were aware of the possible MOD. This
information was provided by their midwifes (80%), antenatal
classes (60%), online (60%), and family members/friends (50%).
More than half (55%) specified in their birth plan they wished
for a natural spontaneous birth only and not consider a form of
assisted delivery.
Conclusions Our preliminary data highlight that although women
are aware of the different MOD that may be required, more than
half would not consider prior to labour an assisted delivery. One
out of four women however in the UK will require such a
method. Potentially unrealistic expectations and lack of antenatal
education of the pregnant individual, leading to delays in gaining
consent, could increase the risk of fetal/maternal compromise and
postnatal maternal mental health.
EP.212
Early secondary repair of an undiagnosed obstetric
anal sphincter injury (OASIS): a case report
Saadi, F; Thompson, A; McIlwaine, P
South West Acute Hospital, Enniskillen, UK
Primary repair of OASIS is usually performed in the immediate
postpartum period by a trained obstetrician following recognition.
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Secondary repair usually refers to surgical repair of the anal
sphincter in patients with faecal incontinence (includes missed
OASIS and previous primary repairs), often performed months or
years later by a specialist colorectal surgeon.
We report a case of a unrecognised anal sphincter injury after a
forceps delivery. The patient presented on day 3 with an infected
perineum and faecal incontinence. Conservative treatment was
commenced but on day 5, the patient was taken back to theatre
for exploration of perineal wound. This revealed a complete tear
of the external anal sphincter. Due to ongoing infection, the
wound was left open and the patient treated for a further
48 hours with antibiotics.
Third-degree tears are rarely detected at this stage; therefore,
limited data exist to guide optimal management in this particular
situation. The obstetrician liaised with the regional colorectal
surgeon specialising in secondary repairs. Decision made that the
obstetrician should attempt secondary repair despite unknown
success rate. A ‘covering’ stoma was felt to be unnecessary.
Re-approximation was difficult due to muscle retraction but a
standard overlapping technique was performed using 3.0 PDS and
standard protocol followed. Physiotherapy was initiated at an early
stage and the patient followed up regularly. Six-month review
patient was continent of both flatus and faeces with no urgency.
Multidisciplinary collaboration with regional expertise is
important in cases where clear guidance does not exist to ensure
optimal management.
EP.213
Real life vs reality TV
Ibrahim, E; Eogan, M; Alsudani, A
Rotunda hospital, Dublin, Ireland
The Rotunda is the oldest Maternity Hospital in Western Europe
founded in 1745. Since then, service provision has evolved from
overseeing 200 births annually to delivering more than 8000
babies each year.
In 2018 The Rotunda, its staff and patients agreed to participate
in a 6 episode fly on the wall documentary series. The aim of this
study was to assess how reflective the documentary was when
compared with demographics and labour outcomes as recorded in
the most recently published annual report (for the year 2017).
In total, the series followed 25 births (0.3% of the 8409 births
recorded). Thirteen (52%) resulted in normal birth, 2 (8%)
women required instrumental delivery, and 10 (40%) women had
caesarean section. This compares with an overall rate of CS birth
of 34% and a 16% instrumental delivery rate in the most recently
published annual report.
In the annual report, 15% of babies required a period of NICU
admission, similar to 16% of babies who featured on the
documentary.
Although there was a case of shoulder dystocia (4%) on the
documentary, no other obstetric morbidities, for example major
obstetric haemorrhage or OASIS, were recorded.
In conclusion, reality documentaries serve to highlight certain
aspects of maternity services; however, selection bias will always
92 ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG
mean that they only show a sample of the scenarios that present
every day and may not be an entirely accurate reflection of our
‘lived reality’!
EP.214
A service evaluation investigating surgical site
infection following the use of PICO dressings at
caesarean section
Baker, E1; Wright, G2; Jones, N1
1
University of Nottingham, Nottingham, UK; 2Nottingham University
Hospitals NHS Trust, Nottingham, UK
Background Caesarean section is an increasingly common method
of delivery, especially among women with an increased body mass
index (BMI). Surgical site infections (SSI) are an important public
health issue which is significantly increased in patients with a high
BMI. The increased incidence of both caesarean section and SSI
among women with an increased BMI indicates the need for
improved wound management and postoperative care in this
high-risk population. PICO dressings, a modified form of negative
pressure wound therapy, have been introduced for prevention of
SSI in this group.
Objective To investigate the rate of SSI in raised BMI patients
treated with PICO dressings following caesarean section.
Methods A retrospective, digital service evaluation of all PICO
dressing use following caesarean sections performed at
Nottingham University Hospital NHS Trust between October
2015 and October 2016.
Results A sample size of 123 patients identified as having had a
PICO dressing was analysed. The median age was 29 years and the
mean BMI at booking was 40.7 kg/m2. The SSI rate was 25.2%
(31/123). The BMI at booking of those with SSI was 2.6 kg/m2
higher than those without SSI (P = 0.024). There was a
significantly higher rate of infection following caesarean sections
performed by trainee-grade surgeons compared with consultants
(29.2% versus 9.7%, P = 0.032) but there were no differences in
gestational weight-gain, comorbidities, chorioamnionitis, category
of caesarean section, and wound closure technique.
Conclusions PICO dressings did not reduce the rate of SSI to the
extent that is presented in previous literature.
EP.215
Indications for and outcomes of induction of
labour in a large tertiary maternity unit
McCarthy, M1; McCarthy, C2; Conners, N3;
Meaney, S4; Russell, N1
1
Cork University Maternity Hospital, Cork, Ireland; 2University
Hospital Waterford, Waterford, Ireland; 3University College Cork,
Cork, Ireland; 4National Perinatal Epidemiology Centre, University
College Cork, Ireland, Cork, Ireland
Objectives We aimed to examine indications for induction of
labour (IOL) in a tertiary level maternity hospital, stratified by
mode of delivery.

Design and method We conducted a prospective chart review of
500 women undergoing IOL between 1 March and 15 May 2018.
Data were obtained from electronic patient records and analysed
using SPSS-23.
Results A total of 500 women were included in this study, 254
(51%) were primiparous and 246 (49%) were multiparous. IOL
was categorised in six ways: fetal/placental (n = 139, 27.8%),
maternal medical (n = 122, 24.4%), maternal characteristics
(n = 40, 8.0%), current obstetric (n = 34, 6.8%), postdates
(n = 136, 27.1%),and social/other (n = 29, 5.8%). Following IOL,
CS rates were 30.6% (n = 72%) in primiparous women and 8.3%
(n = 21) in multiparous women, compared to overall unit rates of
33.4% and 32.8%, respectively. Spontaneous vaginal delivery
(SVD) was achieved in 33.5% (n = 82) and 80.7% (n = 205) of
primiparous and multiparous women, respectively. CS rates in
these respective categories were 28.6% (n = 18) and 7.9% (n = 6)
for fetal/placental, 36.4% (n = 24) and 5.4% (n = 3) for maternal
medical, 25% (n = 5) and 5% (n = 1) for maternal characteristics,
and 29.4% (n = 5) and 11.8% (n = 2) for current obstetric
indications. All primiparous social inductions (n = 2) had a CS,
compared to 7.4% (n = 2) of their multiparous counterparts. Of
postdates IOLs, 27% (n = 21) of primiparous and 12% (n = 7) of
multiparous were delivered by CS.
Conclusions IOL has implications for hospital resources and can
affect a woman’s birth experiences. Through understanding the
frequency and indications of IOL, we can more effectively counsel
women about potential delivery outcomes.
EP.216
A multidisciplinary, multi-faceted systems approach
to redesigning care pathways in the Maternity
Assessment Unit
Chandiramani, M; Jakes, A; Lloyd, J; Pederiva, L;
Little, F; Cooper, C; Parker, P; Rajasingam, D
Guy’s and St Thomas NHS Foundation Trust, London, UK
Objectives The CQC identified the Maternity Assessment Unit
(MAU) in a central London tertiary hospital as having inadequate
capacity, poor patient and staff experience, and mandated
improvement. We undertook a multidisciplinary, integrated, trust-
wide care redesign programme (CRP) to transform care pathways
to improve unscheduled care by addressing waiting times,
situational awareness, safety and quality of care, and patient flow.
Design and methodology CRP consisted of case studies and
structured group sessions highlighting improvement methodology
(8 sessions/4 months) with protected coaching, team-time, and
web-based resources exploring organisational culture, operational
delivery, and unwarranted variation, encouraging experiential
learning and innovation. Core priorities included definition of
purpose, decreasing unwarranted clinical variation and
development of expected staff culture.
Results Development of a value proposition clarified the purpose
of MAU for staff and women, enabling staff to be SMART in their
actions and implement change. Consultation with key stakeholders
(staff, local GPs, and women) facilitated rebranding from
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Antenatal Day Unit to Maternity Assessment Unit, making it fit
for purpose. Unscheduled and scheduled pathways were
characterised and optimised. Changes were made to reduce waste,
enhancing processes that directly added value to women.
Implementation of a digital system identified triage and waiting
times, minimised duplication, and allowed for robust ongoing
quality improvement. Expectations around staff behaviour
encouraged accountability.
Conclusions Initial steps towards transformational change
required senior clinical leadership and support at the highest trust
level. Protected time for the multidisciplinary team, led by
frontline staff, to learn, reflect, and lead change together was
crucial and cannot be underestimated.
EP.217
Use of a fetal pillow in caesarean section at full
dilatation – a comparative study of maternal and
fetal outcomes
Sacre, H1; Sharp, A1,2
1
Liverpool Women’s Hospital, Liverpool, UK; 2University of Liverpool,
Liverpool, UK
Objectives Evidence from small cohorts examining use of a fetal
pillow during caesarean section at full cervical dilatation suggests
benefits in reduction of blood loss and surgical time. There is no
published study in a UK population. We therefore evaluated the
fetal pillow in a UK cohort.
Methods Retrospective audit of electronic patient records
identified all patients who underwent caesarean section at full
dilatation at Liverpool Women’s Hospital since the introduction
of the fetal pillow (September 2014–March 2018). We compared
maternal outcomes (estimated blood loss, blood transfusion,
number of nights inpatient stay) and neonatal outcomes (Apgar
score <7 at 5 minutes, umbilical arterial pH, NICU admission) of
caesarean section with or without the fetal pillow.
Results 410 second-stage caesarean sections were performed
during the period. The fetal pillow was used in 170 and not used
in 240. The only statistically significant maternal outcomes
associated with the fetal pillow were a lower number of nights in
hospital (3.5 versus 3.0 nights, P = 0.02) and a greater number of
women with blood loss >1000 ml where the fetal head was at/
below the ischial spines (32 versus 34, P = 0.0005). However, the
differences between these numbers are too small to be clinically
significant and no effect was observed on blood transfusion (8
versus 9, P = 0.63). There was no statistical difference in any
neonatal outcome.
Conclusion There appears to be no maternal or neonatal benefit
of using the fetal pillow during caesarean section at full dilatation
in our study.
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EP.218
Rethinking inductions of labour – a new induction
of labour MDT pathway at Sherwood Forest
Hospitals
Al-Samarrai, S; Goodwin, S
Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield,
UK
Introduction SFH were challenged by CQC, executive board to
question if women were being induced appropriately (IOL rate
>35%). Complaints received regarding patient experience
especially length of process and delays. Frustrations due to daily
‘firefighting’ to triage the most appropriate inductions. Concept
developed to review all IOL requests centrally as an MDT,
allowing prioritisation of most urgent and consensus opinion on
challenging cases with discussion around current evidence.
Methods IOL MDT set up twice weekly on labour suite to ensure
visibility and attendance from across the MDT. New IOL patient
leaflets Referral form developed for all antenatal areas. IOL slots
changed to morning – ensure inductions are part of ward round.
Auditing outcomes: delays during IOL/mode of birth/use of 2nd
Propess/‘failed IOL’. IOL-specific Friends & Family test; ‘did
you feel cared for’. Women contacted following MDT, offered
date and time, opportunity to raise questions about IOL, arrange
membrane sweeps and aromatherapy.
Results
Women: - ‘feeling more cared for’
- involved in decision-making
- recognises ‘change of mind’
Staff: - No longer feeling pressured to accept AND book
inductions
- Consensus opinion and evidence-based decisions.
- Less time spent booking & rearranging IOL’s.
Service: - IOL rates reduced (<25%)
- Improved flow
- significantly fewer delays in admission/changes of date
since implementation
- Increased number of women birthing baby prior to
24 hours following administration of Propess
- Focus on patient safety- appropriately timed inductions
and decreased delays for high-risk inductions
- involving women in the decision-making
Next - Midwife-led optimising induction clinic (aromatherapy/
steps: membrane sweeps)
- Outpatient induction
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EP.219
Quantitative fetal fibronectin (qfFN) undertaken
prior to insertion of rescue cerclage predicts
latency to delivery
Suff, N; Kuhrt, K; Tribe, R; Shennan, A;
Chandiramani, M
King’s College London, London, UK
Introduction & methods The aim of this study was to assess the
predictive value of cervicovaginal qfFN for sPTB in women with
bulging fetal membranes undergoing rescue cerclage. This was a
retrospective observational study from St Thomas’ Hospital, of
women with singleton pregnancy and bulging fetal membranes
presenting between 18 and 24 wks (n = 33) from 2015 to 2018.
qfFN concentrations were measured within 24 hours prior to
cerclage insertion.
Results The median gestational age was 20 + 0 wks (18 + 6-
21 + 2) at presentation and 29 + 3 wks (23 + 3-38 + 2) at
delivery, with median time from cerclage to delivery of 65.5 days
(17–126.5). qfFN at presentation correlated negatively with time
to delivery (Spearman’s rs = 0.52, P = 0.0016). There was a
significant difference in qfFN concentrations in women who
delivered preterm compared to those who did not, both within
28 days from testing (P = 0.0048) and <34 wks (P = 0.006). The
median time to delivery was 124 days (68–140) in women with
fFN 0–199 ng/ml, compared with 29 days (12–75) in women with
fFN > 200 ng/ml (P = 0.0014).
Conclusion qfFN has a role in predicting sPTB even in women
with bulging fetal membranes undergoing rescue cerclage. A
significant association between high fFN and underlying
inflammatory placental pathology has previously been shown and
this may explain the shorter time to delivery following cerclage in
women with fFN > 200 ng/mL. Given the serious risks associated
with rescue cerclage surgery, qfFN could be used to assist
individualised informed decision-making when inserting a cerclage
as well as in the counselling of these patients who remain at high
risk of delivering prematurely.
EP.220
#hellomyroleis– ‘A multidisciplinary quality
improvement project using role distinguished
colour coded lanyards to improve patient
experience and safety in Maternity’
Goodyear, G1; Wooldridge, R2; Crowe, S2
1
Newham University Hospital, Barts Health NHS Trust, London, UK;
2
Royal London Hospital, Barts Health NHS Trust, London, UK
Objectives The #hellomynameis initiative gained national
momentum and created a culture where patients can clearly identify
their caregivers by name. Maternity units pose a unique set of
challenges to identification: staff dressed in identical scrubs, quick
patient turnover, and multidisciplinary involvement in emergencies.
Design We implemented the coloured role lanyards used in
trauma to ensure patients could identify their caregivers. An

additional aim was to improve in communication and efficiency
during emergencies.
Methods Evidence to support the project was gathered from
patient complaint data and observation of skills and drills
communication and teamwork. Role defining lanyards were
provided for all staff and qualitative data were collected via Likert
scales on live drill closed-loop communication, appropriate role
allocation, and procedural efficiency. Staff and patient surveys
were performed to evaluate experience.
Results Patient responses were universally positive with all stating
they could identity staff clearly in emergency and non-emergency
situations. Role identification helped staff particularly when teams
were unfamiliar. This was most notable with junior doctors and
student midwives; they felt safer and were less anxious about
being given inappropriate tasks in an emergency.
Conclusions A simple idea has demonstrated a range of benefits
which the authors feel will continue to improve patient and staff
experience in a busy, high-risk maternity unit.
EP.221
Comparison of the Cook cervical ripening balloon
and prostaglandin E2 gel for induction of labour in
women who have had a previous caesarean
section
Southward, J1; Sharp, A1,2; Weeks, A1,2;
Barton, A1
1 2016, annual local CTG training undertaken by all staff has focused
Liverpool Women’s Hospital, Liverpool, UK; 2University of Liverpool,
Liverpool, UK
Objectives To compare the efficacy and safety of the Cook
cervical ripening balloon (CRB) with prostaglandin E2 gel for
induction of labour in women who have had a previous caesarean
section.
Methods Using a retrospective cohort design, data were collected
on women induced with Prostin E2 gel between April and
November 2017 (n = 63), and women induced with a Cook CRB
between November 2017 and August 2018 (n = 61). Outcomes
measured included mean time in labour, use of ARM and
oxytocin, mode of delivery, and indicators of neonatal wellbeing –
APGARs at 5 minutes, umbilical artery pH, and admission to
neonatal intensive care.
Results Mean time in labour in the Cook CRB group was
significantly longer, 470 minutes compared to 340 minutes
(P = 0.027), although women were managed as an outpatient in
the majority of CRB cases. More women had an ARM in the
Cook CRB group, 85.25% compared to 76.19% with Prostin gel,
but more women required oxytocin, 63.93% compared to 49.21%.
Vaginal delivery rate was significantly lower in the Cook CRB
group, 44.26% compared to 66.67% (P = 0.012). There was no
significant difference between the groups for APGARs at
5 minutes (P = 0.146), arterial pH (P = 0.053), or NICU
admission (P = 0.269).
Conclusion Induction of labour with a Cook CRB is associated
with longer time spent in labour and a lower vaginal delivery rate
compared with Prostin gel. There is no significant difference in
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neonatal outcomes between the two groups. Further study is
needed to make meaningful statements about uterine rupture and
these induction methods.
EP.222
Improving intrapartum fetal monitoring
interpretation and reducing harm at Sherwood
Forest Hospitals NHS Foundation Trust
Al-Samarrai, S; Bosworth, K
Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-
Ashfield, UK
Objectives Launched in 2015, Each Baby Counts focuses on
highlighting potentially avoidable intrapartum events. Intrapartum
fetal monitoring plays a vital role, and training to recognise when
babies are not coping with labour is required, instead of simplistic
‘pattern recognition’. A cluster of CTG-related incidents in 2016
led to scrutiny of CTG training and development of a quality
improvement initiative at Sherwood Forest Hospitals (SFH) to
enhance the CTG training and situational awareness.
Design/method In early 2017, SFH used money from the
Maternity Safety Training Fund, to enable all midwifery and core
medical staff to access physiologically based CTG training. Clinical
leaders were also given the opportunity to attend advanced training
sessions to cement that understanding. This training supported
enhanced assessment and decision-making. Additionally, since
on human factors, allowing better understanding of why incidents
occur and ways their effects can be ameliorated.
Results Since July 2017, there have been no reportable cases to
Each Baby Counts at SFH and the overall HIE 1-3 rate in 2018
has dropped by 85% compared to 2016.
Key factors - MDT training
- Empowering staff to challenge decision-making
- Human factors core to training
Conclusion This QIP runs alongside the development of an East
Midlands intrapartum fetal monitoring guideline following
concerns regarding the NICE intrapartum care guideline. SFH have
been involved in developing this guideline alongside a competency-
based assessment tool using fetal physiology as their basis, aiming to
reduce variations in training and care delivered between Trusts.
EP.223
Evaluation of induction of labour and large for
gestational age pregnancies at Musgrove Park
Hospital
Capay, E; McKie, L; Tanner, R
Musgrove Park Hospital, Bristol, UK
Objectives Rates of induction of labour (IOL) are increasing. The
reasons are complex and multifactorial. In our trust, one
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increasingly common indication is babies who are antenatally
classified as large for gestational age (LGA). This was particularly
notable following the introduction of GROW charts. The BMI of
the UK wide antenatal population is increasing, just one
contributing factor to the increase in LGA pregnancies. We
wanted to evaluate the outcome in our trust of inducing for LGA.
This was done in an effort to evaluate local practice and aid in
forming local guidelines while waiting for the results of the ‘Big
Baby Trial’ due in 2021. It is hoped that these local data can also
be used in counselling women when discussing IOL for LGA.
Methods LGA was defined by an estimated fetal weight plotting
equal or above the 90th centile on a GROW customised growth
chart. Our main outcome measures were failure of
induction, mode of delivery, and complications such as shoulder
dystocia. An electronic audit tool was used to look retrospectively
at the last 2 years of deliveries at the trust.
Results Less than 50% of IOLs for LGA resulted in a normal
vaginal delivery. No IOLs of truly LGA babies were delivered via a
normal vaginal delivery after 39 weeks.
Conclusions Other variants such as parity and gestation at which
IOL was commenced continue to significantly impact mode of
delivery and IOL appeared to have little significant impact on
mode of delivery for normal birthweight centiles.
EP.224
Intrapartum and postpartum outcomes for teenage
pregnancy
Wilson-Theaker, W; Gibson, M; Dey, T
Department of Obstetrics and Gynaecology, East Lancashire Hospitals
NHS Trust, UK
It is well-established that a link exists between teenage births and
increased mortality and morbidity for both mother and child.
Through Introduction of the Government’s 10 year Teenage
Pregnancy Strategy in 2000, rates of teenage pregnancy have
shown a steady decline. However in recent years, areas including
Blackburn and Darwen have shown a plateau in rates.
Objective It is for this reason we chose to explore the outcomes,
both in the intrapartum and postpartum period, for teenage
mothers in a busy Obstetrics Unit in the North West.
Method We reviewed the intrapartum and postpartum outcomes
for teenage pregnancies delivering throughout 2018. This included
if labour spontaneous or induced, length of second stage, mode of
delivery, and postpartum outcomes.
Here, we present our findings which we hope will prompt
exploration, and development of new methods to optimise the
care provided for these mothers.
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EP.225
Getting the right information to the right people
at the right time: a quality improvement project to
improve obstetric daily handover in NHS Fife
Simpson, L; Boyd, J
NHS Fife, Kirkcaldy, UK
Objectives Clinical handovers are an essential part of patient care,
safety, and risk management. This is particularly pertinent in
obstetrics due to the rapid turnover of patients and changing
levels of risk. This project aimed to improve the structure of the
obstetric unit’s daily handover, thereby facilitating reliable
communication of critical information.
Design A questionnaire-based quality improvement project was
performed.
Method Multidisciplinary team members’ views on the existing
handover were obtained via an online questionnaire and informal
discussions. Following analysis, a new handover template was
implemented. Improvement was assessed via a follow-up
questionnaire and discussions with staff.
Results Forty staff members completed the initial questionnaire.
Respondents said too much information was given at handover
most of the time 23% (9) or sometimes 46% (18). Too little
detail about relevant information was given sometimes 55% (22),
half the time 13% (5) and most of the time 15% (6). The
majority of respondents reported lack of consistency in handover
as information provided depended on the people involved most of
the time 36% (14) or always 31% (12). Global ratings were
obtained for the effectiveness of handover at ensuring safe
continuity of care (68%) and the overall quality of handover
(65%). After implementation, staff feedback was positive reporting
improvement in consistency of structure and content.
Conclusions Improvement in daily handover in maternity units is
possible. Staff involvement in the process of improvement
facilitates change. Anticipated benefits to patient care include
improved safety from facilitating accurate handover of
information in a timely manner.
EP.226
Safer delivery of women with a previous section
Olaru, A; O’Doherty, K; Robson, M
National Maternity Hospital, Dublin, Ireland
Background Caesarean section (CS) rates have increased
worldwide. Obstetricians may find that counselling for mode of
delivery in a pregnancy following caesarean section can be quite
challenging and a review of the previous delivery records and
current pregnancy is recommended to identify contraindications
to vaginal birth after caesarean.
Methods We conducted a retrospective cohort study on women
with previous caesarean section, during 2013–2017. Our aim was
to look at the delivery outcomes of these patients.
Results During the 5-year period, 4292 women with one previous
CS at greater than or equal to 37 weeks gestation delivered. In this
group of women, 35.6% (n = 1530) went into spontaneous labour,

9.3% (n = 398) had their labour induced, and 55% (n = 2364) had
a prelabour CS. Of those who had a prelabour CS, 52.8%
(n = 1249) had no medical or obstetric indication compared to
47.1% (n = 1115) performed for maternal or obstetric reason
(P = 0.025) mostly at 39 weeks. The CS rate in spontaneous onset
of labour group was 21.5% (n = 330/1530) compared to 44.2%
(n = 176/398) in the induced labour group and only 4.1% women
required oxytocin acceleration during labour.
Conclusions More than half of the prelabour CS are performed
for no medical or obstetric indication. In view of the low
operative delivery rates in spontaneous labour in women with one
previous caesarean, obstetricians should encourage women
between 39 and 41 weeks to wait to go into spontaneous labour
and aim for a short labour with no use of oxytocin.
EP.227
Supporting maternal choice and theatre birth
experience: a prospective audit of skin-to-skin
contact during caesarean
Tiong, B; Baig, H; Malin, G; Banks, A
Nottingham University Hospitals NHS Trust, Nottingham, UK
Background Early skin-to-skin (STS) contact has been shown to
improve bonding and successful establishment of breastfeeding.
Local guidance is to offer the opportunity for STS contact to all
women. Facilitating this during caesarean birth is part of a local
project to improve maternal experience of theatre and supports
the Unicef Baby Friendly Initiative.
Objective To assess our rate of STS contact in theatre, during
caesarean birth.
Design Prospective audit between 8/10/18 and 5/11/18, at the
City Hospital Campus of Nottingham University Hospitals NHS
trust.
Method Staff were asked to complete a data collection form for
every caesarean birth for one month. Electronic patient health
records for all caesareans performed during this time period were
reviewed, and further information obtained.
Results Seventy-eight caesarean births took place. Forty-two audit
forms were completed, and information for a further 11 women
was acquired electronically. Twenty-five women performed STS,
and 13 birth partners.
Conclusions STS was offered in 90% of caesarean births where
there were no contraindications. Raising awareness, or introducing
a caesarean birth plan, may increase rates further.
Urgency of Type of anaesthetic Skin to skin
caesarean Regional General N (%)
Category 1 4 1 0
Category 2 18 0 6 (33)
Category 3 4 1 2 (29)
Category 4 25 0 20 (80)
Total 51 2 28 (53)
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EP.228
Sitting on a goldmine. A guide to using routinely
collected NHS data to answer research questions –
the POOL study example
Sanders, J; Cannings-John, R; Barlow, C;
Lugg-Widger, F; Milton, R; Robling, M
Cardiff University, Cardiff, UK
Objective To share the processes required to use routinely
collected maternity and neonatal data for research purposes using
the POOL study example.
Design A case study of using of routine maternity and neonatal
data for research purposes, to include adaptation of locally
collected electronic data, data extraction, transfer, matching, and
required permissions.
Method POOL is an NIHR funded cohort study designed to
establish whether waterbirth, compared to leaving a pool prior to
birth, is as safe for mothers and their infants. The study will use
individual-level data relating to 600,000 women, covering the
period January 2015–November 2020, entered into local maternity
information systems at 30 NHS Trusts as part of their clinical
episode. The National Neonatal Research Database (NNRD) holds
individual-level data on all infants admitted to neonatal units in
England, Scotland, and Wales from 2014. To obtain data on any
infant who required admission to a neonatal unit following their
mother’s pool use in labour, the identifiers of all infants born to
women who used a pool at participating sites will be matched to
any records held by the NNRD. Matched pseudonymised maternal
and neonatal data will then be transferred to the study team for
analysis.
Results The POOL study provides a successful example of
obtaining NHS permissions, and approval from the Health
Research Authority’s Confidentiality Advisory Group (CAG) to
use identifiable health data without explicit participant consent.
The potential for using locally held maternity information for
research purposes will be explored.
Reason STS did not take place
Maternal reason Neonatal reason Declined Not offered
2 1 2 0
3 4 2 3
1 1 1 0
2 0 2 1
8 6 7 4
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EP.229
Virtual reality as a distraction therapy in obstetrics
and gynaecology
Harper, AM1; Sivanathan, A2; Jordan, A3;
Harper, ST2; Worth, A4; Lim, T2; Denison, FC5
1
Edinburgh Medical School, The University of Edinburgh, Edinburgh,
UK; 2Institute of Mechanical, Process and Energy Engineering, Heriot
Watt University, Edinburgh, UK; 3Edinburgh Tommy’s Centre for
Maternal and Fetal Health, The University of Edinburgh, Edinburgh,
UK; 4Edinburgh Clinical Research Facility, The University of
Edinburgh, Edinburgh, UK; 5MRC Centre for Reproductive Health,
The University of Edinburgh, Edinburgh, UK
Background Virtual reality (VR) is emerging as an effective
distraction therapy for patients undergoing painful/distressing
healthcare procedures.
Objective To explore women’s and obstetric and gynaecology
(O&G) healthcare professionals’ views on the acceptability,
feasibility, and preferences for VR distraction therapy within O&G.
Methods Women with current/previous O&G service contact and
O&G professionals completed questionnaires. Topics included
were as follows: (1) VR use in clinical settings (e.g. for labour,
hysteroscopy), (2) hardware (i.e. types of head equipment), and
(3) software (i.e. content, audio) options. A consultation meeting
was held with women, O&G professionals, and VR technologists
to enable real-world insight into the technology.
Results A total f 247 questionnaires were completed (90 obstetric
and 157 gynaecology). Women were positive about the potential
use of VR within both O&G clinical settings. Although O&G
professionals were broadly supportive, obstetric professionals were
more enthusiastic than gynaecology professionals. Visually,
stereoscopic glasses were the most popular head equipment;
however, women and obstetric professionals preferred headsets for
viewing images. All preferred natural content and accompanying
audio. Views on complete immersion were largely negative with
lower immersion levels preferred for distraction in obstetrics.
Conclusions Women are interested in the potential of VR
distraction therapy within O&G with obstetric professionals being
more supportive than gynaecology professionals. Reported
hardware (self-contained head equipment permitting
communication) and software (natural content with
accompanying audio) preferences that incorporate different
immersion levels are currently limited by VR technologies. Future
studies should allow participants to experience VR technologies,
inform design specifications, and ultimately pilot the technology.
EP.230
Second trimester 12-day delayed twin delivery
interval with a positive neonatal outcome: a case
report and overview of current practice
Moran, O1; Heazell, A2; Rahman, S2
1
St Mary’s Hospital, Manchester, UK; 2St Mary’s Hospital,
Manchester, UK
A 32-year-old multiparous woman with dichorionic diamniotic
pregnancy delivered twin 1 by spontaneous vaginal delivery at
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26 + 0 weeks gestation. The umbilical cord was ligated and the
placenta was left in situ. She was given prophylactic oral
antibiotics and underwent strict monitoring both as an inpatient
and outpatient. The second twin was delivered 12 days later by
emergency caesarean section for suspected chorioamnionitis. This
was confirmed by placental histology. Both twins were born in
good condition and progressed well. Twin 1 suffered more
complications than twin 2 that were generally associated with
prematurity, including lung disease, necrotising enterocolitis, and
anaemia.
Management of this woman was consistent with numerous
published case reports worldwide on prolonging inter-twin
delivery interval. Review of these reports shows all cases ligated
the umbilical cord of twin 1. Some cases demonstrated use for
vaginal antiseptics, cervical cerclage, and tocolysis. The majority of
cases documented monitoring by blood counts, vaginal swabs, and
ultrasound. Overall, there was a positive neonatal outcome for
twin 2.
Twelve-day delivery interval is one of the longest reported cases in
the United Kingdom. Our case demonstrates support for twin
delivery interval in extremely premature twin deliveries to
improve neonatal outcome for twin 2, but emphasises the
requirement for adequate monitoring for chorioamnionitis and
maternal sepsis to allow for timely intervention.
EP.231
How can the management of major obstetric
haemorrhage be improved? A single-centre five-
year audit in a high-risk obstetric unit in London
Netto, M1; Chandrakumar, D2;
Raychoudhury, A3; Parisaei, M4
1
Royal Free Hospital, London, UK; 2Whittington Hospital, London,
UK; 3Queen Mary, University of London, London, UK; 4Homerton
University Hospital, London, UK
Objectives Postpartum haemorrhage is the leading cause of
maternal mortality in low-income countries and remains a leading
direct cause of maternal mortality in UK. Timely and appropriate
management can prevent morbidity and mortality. This single-
centre five-year audit, based at Homerton University Hospital,
compares current practice to local guidelines for major obstetric
haemorrhage (MOH).
Method In this retrospective audit, all cases of MOH were
identified from April 2013 to April 2018. Yearly data collection
was obtained from K2 Athena and electronic patient records
regarding antenatal, intrapartum, and postpartum care. Analysis in
this audit focussed largely on management in the intrapartum
period.
Results Since 2013, the number of MOH cases increased from 46
to 168 between 2013/14 and 2017/18. The definition of MOH
changed to ≥1500 ml from ≥2000 ml, which contributed to this
increase. Cell salvage use has not improved since 2013, being used
in only 23% elective and 19% emergency caesareans in 2017/18.
Both yearly mean and maximum blood loss have decreased. Mean
blood loss in 2017/18 was 1993 ml, compared with 2875 ml in

2013/14. Maximum blood loss in 2017/18 was 6500 ml, compared
with 7500 ml in 2013/14. The use of tranexamic acid increased to
74% in 2017/18.
Conclusion The change in definition of MOH to ≥1500 ml may
have positively contributed to our data, resulting in earlier
recognition and prompt medical/surgical intervention.
Departmental education and the wider use of tranexamic acid
have also contributed to these results. The use of cell salvage
should be increased for cases that carry high risk for MOH.
EP.232
Risk factors for postpartum haemorrhage of
1500 ml or above in England and Wales: a cohort
study of 492,974 women
Jardine, J1,2; Walker, K1; van der Meulen, J1;
Maternity, N; Perinatal Audit Project Team2;
Pasupathy, D3
1
London School of Hygiene and Tropical Medicine, London, UK;
2
Royal College of Obstetricians and Gynaecologists, London, UK;
3
King’s College London, London, UK
Objectives Postpartum haemorrhage (PPH) is a leading cause of
maternal morbidity and mortality. The aim of this study was to
understand risk factors for PPH of 1500 ml or more.
Design Retrospective cohort study.
Methods Data from maternity information systems were linked to
admission data from Hospital and Patient Episode Statistics for
registerable births in England and Wales in 2015–16. Trusts/
boards were excluded if blood loss was recorded for <80% of
births. Records were excluded if missing mode of delivery or
blood loss. Multivariate logistic regression models were
constructed stratified by elective caesarean section (ELCS) and
trial of labour (TOL).
Results A total of 492,974 women were included; 54,087 (10.97%)
delivered by ELCS. PPH rate was 2.80% among women with
ELCS, and 2.76% in women with TOL (P = 0.59). In women with
TOL, rate of PPH was 1.56% in unassisted vaginal, 4.93% in
instrumental, 3.26% in breech vaginal, and 5.74% in emergency
caesarean delivery. Among women with TOL, rate of PPH was
higher in women of black ethnic origin (AdjOR 1.42 (95% CI
(1.31, 1.53)); in multiple birth (AdjOR 4.51 (4.10, 4.96)) and
stillbirth (AdjOR 3.01 (2.48, 3.65)). PPH rate rose with maternal
BMI (BMI 30–35 1.19 (1.12, 1.27); AdjOR BMI ≥ 50 AdjOR 1.96
(1.44, 2.67)); at extremes of gestational age (at 24–27 + 0, AdjOR
2.05 (2.15, 4.33); at 42–43 + 6, AdjOR 1.48 (1.35, 1.62)) and
higher birthweights (4500–4999 g AdjOR 4.20 (3.79, 4.66)). Risk
of PPH was not increased with previous caesarean (AdjOR 1.11
(0.92, 1.36)).
Conclusions We report contemporaneous risk factors for PPH,
which can inform discussion on management and place of birth.
ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG
ePosters
EP.233
Caesarean delivery of dichorionic diamniotic twins
in separate horns of complete bicornuate uterus
through one incision
Le Grys, H; Watkins, K; Holmes, R; Clarke, J
Royal Cornwall Hospital, Truro, UK
Pregnancy in women with M€ ullerian duct anomalies is often
associated with poor outcomes including miscarriage, premature
labour, preterm rupture of membranes, and malpresentation.
Twin pregnancy in separate horns of a bicornuate uterus is
extremely rare. Much of the literature is based only on case
reports, most of which describe delivery by bilateral low transverse
caesarean section.
We present a 31-year-old with a history of one previous vaginal
delivery with a spontaneous conception of dichorionic diamniotic
twins. At her anomaly scan, it was found she had a complete
bicornuate uterus with only one cervix and a twin located in each
cavity. Antenatal scanning was challenging, but a shared distal
cavity seemed to appear as the lower segment formed. The
pregnancy progressed uneventfully until she presented in preterm
labour with intact membranes at 34 weeks gestation. The
presenting twin was breech so a caesarean section was performed.
At caesarean, the anatomy was assessed and a decision made for
lower transverse incision on the right horn. After delivery of the
cephalic twin from the right cavity, assess to the left horn was
explored. The baby’s leg was visible and the breech accessible and
the baby was delivered successfully through the same incision by
breech extraction. Her recovery was uncomplicated.
EP.234
One-year audit of targeted routine antenatal anti-D
prophylaxis in Portiuncula University Hospital
Donohoe, O; Mulvany, L; O’Connor, E;
de Tavernier, M-C
Portiuncula University Hospital, Ballinasloe, Ireland
PUH was the first hospital in Ireland to introduce targeted
routine antenatal anti-D prophylaxis (tRAADP) in 2017.
Quantitative PCR identifies cell-free fetal DNA (cffDNA) in
maternal blood after 11 + 2/40, establishing fetal rhesus status.
RhD-negative patients carrying RhD-positive fetuses receive
targeted routine anti-D prophylaxis at 28 weeks, at birth, and
after PSEs.
The objective was to avoid unnecessary administration of anti-D
to pregnant patients carrying RhD-negative fetuses. We also want
to measure efficacy and cost of tRAADP.
Records of RhD-negative mothers from June 2017 to June 2018
were analysed. cffDNA results were correlated with postnatal cord
bloods. The cost of tRAADP in its first year was compared to the
estimated cost of RAADP for the same patient sample.
Among 273 RhD-negative mothers, there were 168 (61.5%) RhD-
positive fetuses, and 105 (38.5%) RhD-negative fetuses. The test
had 100% sensitivity and specificity. The cost of the tRAADP
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programme was €42,443. The estimated cost of RAADP for the are improved. Working towards reducing diurnal variation in
same patient sample was €53,886, showing the possible saving of decision-to-delivery intervals could result in better perinatal
€11,453 last year. outcomes.
We avoided giving anti-D unnecessarily to 38.5% RhD-negative
patients carrying a RhD-negative fetus. This is consistent with the
predicted 40% of RhD mothers to whom routine anti-D
administration is unbeneficial. This is clinically and ethically EP.236
significant as we avoided administration of a human blood Massive obstetric haemorrhage in term and
product to these patients, and eliminated the burden of preterm gestations
preventing HDN. Test accuracy and cost saving were important Finnegan, C; Hehir, M; Tully, E; Flood, K;
findings. We hope these findings will be considered at a national Breathnach, F; Malone, F
level.
RCSI, Dublin, Ireland

Massive obstetric haemorrhage (MOH) is a leading cause of

EP.235 maternal morbidity. We sought to examine causes, characteristics,
and outcomes of MOH in term and preterm gestations.
Diurnal variation in decision-to-delivery intervals
This was a retrospective cohort study of cases of MOH over a
and correlation with adverse outcomes at
ten-year period from 2006 to 2015 in a large tertiary referral
emergency caesarean section in urban Uganda: institution. MOH was defined as blood loss of >2500 ml,
a prospective cohort study transfusing >5 units red cell concentrate (RCC) or coagulopathy.
Hughes, N1; Nakimuli, A2; Patient, C3; Variables and outcomes in term (≥37 weeks) were compared with
Moffett, A1; Aiken, C1 those in preterm gestations (<37 weeks).
1
University of Cambridge, Cambridge, UK; 2Makere University, There were 85,139 deliveries over the period and mean rate of
Kampala, Uganda; 3Addenbrooke’s Hospital, Cambridge, UK preterm delivery was 6.8%, which did not change (range 6.3–
7.4%; P = 0.85). A total of 143 cases of MOH occurred: a rate of
Objectives Preventing perinatal morbidity and mortality is often 0.16%. 68% (98/143) occurred in term gestations with 32% (45/
critically time-dependent. However in many low-resource 143) in preterm. MOH in preterm gestations occurred at mean
maternity settings, demand outstrips the capacity for prompt gestation 31.2  4.9 weeks. The rate of MOH was higher among
intervention. There are no context-specific guidelines for preterm than term 0.77% (45/5816) versus 0.12% (98/79,323);
attainable decision-to-delivery intervals in low-resource settings. P < 0.0001. Preterm mothers who had MOH were likely to have
We aimed to describe diurnal variation in decision-to-delivery caesarean delivery (82% [37/45] versus 50% [49/98]; P = 0.002).
intervals and risk of adverse perinatal outcomes at emergency Preterm MOH patients had longer stay than term (9.4  10
caesarean section deliveries in urban Uganda. versus 5.8  3.7; P = 0.002). There was no difference in use of
Design Prospective cohort study of all emergency caesarean intrauterine balloon (18% [8/45] versus 29% [29/98]; P = 0.15).
sections performed in a single tertiary referral hospital in Uganda Regardless of gestation patients received similar units RCC
during June 2017. (5.7  5.4 units versus 6.7  4.9 units; P = 0.3).
Methods A total of 344 deliveries were included. The risk of MOH is higher in preterm pregnancies; these women
Adjusted additive dynamic regression models and Cox are more likely to have caesarean delivery and longer hospital stay.
proportional hazards models were used for analysis. Senior advice should be sought when additional blood loss is
Results On average, 13.7 emergency caesarean deliveries were noted during delivery due to increased risk of MOH.
performed per day. The median decision-to-delivery interval was
5.5 hours. The average decision-to-delivery interval varied
diurnally, decisions made at midnight took 2 hours longer to
enact than those at midday (P < 0.05). The risk of perinatal death
increased by >50% between the highest-risk time of decision-
making (22:00–02:00) and the lowest-risk time (08:00–12:00).
There was no diurnal variation in the risk of stillbirth or
composite maternal morbidity. Fetal distress (OR 1.63, CI: 1.23–
2.15; P < 0.001), previous caesarean section (OR 1.66, CI: 1.24–
2.21; P < 0.01), malpresentation (OR 1.78, CI: 1.17–2.69;
P < 0.01), antepartum haemorrhage (OR 1.56, CI: 1.00–2.43,
P < 0.05), and impending uterine rupture (OR 1.85, CI: 1.24–
2.78; P < 0.05) were all associated with shorter decision-to-
delivery intervals.
Conclusion Average decision-to-delivery intervals in this busy
sub-Saharan African setting are strikingly long. During periods
when decision-to-delivery intervals are shorter, perinatal outcomes

100 ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG

EP.237
Measured blood loss (MBL) as an integral part of
postpartum haemorrhage (PPH) management:
quality improvement on a national scale through
OBSCymru, the obstetric bleeding strategy
for Wales
Scarr, C1,2; Sengupta, N3,2; John, M2; Stevens, J4;
James, K1,5; Kelly, K6,2; Collins, P1,2; Collis, R1,2;
Bell, S1,2; Macgillivray, E5; Greaves, K2;
Kitchen, T1,2
1 and the vault closed.
Cardiff & Vale University Health Board, Cardiff, UK; 2OBS Cymru,
Wales, UK; 3Betsi Cadwaladr University Health Board, Rhyl, UK;
4
Aneurin Bevan University Health Board, Newport, UK; 5OBS Cymru,
Cardiff, UK; 6Betsi Cadwaladr University Health Board, Wrexham, UK
Objectives OBSCymru is a national quality improvement project
aiming to reduce morbidity from PPH. MBL after all deliveries is
key to early escalation of treatment.
Design As a single intervention, MBL is ineffective in reducing
PPH, so the OBSCymru approach includes 4 pillars: risk
assessment; early recognition of PPH by MBL; multidisciplinary
involvement at the bedside at 1000 ml PPH, and patient-specific
blood product management, guided by point-of-care testing.
Methods MBL has been taught to the obstetric MDT in a
standardised video and workshop in mandatory training days and
on an ad-hoc basis. It has also been integrated into the
undergraduate midwifery curriculum. The OBSCymru approach
to PPH management is followed in all Consultant Led Units
(CLUs) across Wales. The MBL training programme commenced
following an initial MBL audit and has been repeated at six
monthly intervals, coordinated by local champion midwives.
Results At baseline, MBL was performed in 72% of elective
caesarean sections (CS), 87% emergency CS, 53% instrumental
deliveries, and 37% of spontaneous vaginal deliveries (SVD). At
six months, MBL was performed in 93% of elective CS, 99%
emergency CS, 90% instrumental deliveries, and 76% SVDs. This
change was maintained at one year. For all deliveries in Wales,
MBL has increased from 50.8% to 88.5% following training. For
PPH’s ≥1000 ml, MBL is performed in 95% nationally.
Conclusion MBL after all deliveries across Wales has increased
and this change maintained at one year. Staff have enthusiastically
embraced this cornerstone of OBSCymru to improve quality of
PPH management.
EP.238
Caesarean hysterectomy: a novel approach to
technique and training
Ferguson, E; Allam, M
NHS Lanarkshire, Wishaw, UK
Objectives Postpartum haemorrhage (PPH) is a major cause of
maternal death and timely hysterectomy can save life.
Obstetricians seldom have opportunities to practice surgical
techniques for PPH or receive quality training during the acute
ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG
ePosters
situation. We present a simple technique for performing caesarean
hysterectomy that we simulated on a bovine model to facilitate
training.
Design A bovine bladder, uterus, cervix, vagina, and broad
ligaments were used to simulate all stages of caesarean
hysterectomy. Conventional hysterectomy was performed with
division/securing of the round ligaments and uterine artery
pedicles. Extensive bladder dissection was avoided and vaginal
length preserved by inserting fingers through the cervix from
above into the fornices and using diathermy to open the vagina
close to the cervix. The uterus and cervix could thus be excised
Method The wet-laboratory model was tested in a training
session with 6 obstetricians working in pairs with facilitator
assistant. Tissue handling is similar to in-vivo and immediate
feedback/instruction was provided by the facilitator. Hand-eye
coordination, placement of clamps and sutures and
communication with fellow registrar/assistant could be practised
in a safe environment.
Results Registrar/consultant participants completed pre- and post-
training questionnaires using a Likert scale to rate confidence in
this rarely/never performed procedure. Although obstetricians
would be unlikely to perform this unaided, training significantly
increased participants’ confidence with proceeding with life-saving
surgery.
Conclusions This model allows enhancement of technical skills
using cheap and available specimens. High-quality training in a
highly stressful procedure was delivered with benefit.
EP.239
The clinical decision-making required for the
management of a longitudinal vaginal septum
diagnosed in labour: a case study
Maxey, V; Prior, E
West Suffolk Hospital, Bury St Edmunds, UK
Background A vaginal septum may be transverse or longitudinal.
A longitudinal vaginal septum occurs during embryogenesis with
failure of complete fusion of the Mullerian ducts. We present a
case of a partial longitudinal vaginal septum that presented for the
first time in early labour and the clinical decision-making this
involved.
Case study A primiparous woman booked for low-risk antenatal
care. She was admitted at 40 + 12 gestation for postdates
induction of labour. She herself had an uneventful antenatal
period and past medical and surgical history. After insertion of a
Dinoprostone pessary, she presented in early labour whereby on
vaginal examination, a tissue division could be felt by the
midwife. Consultant opinion was sort. On examination, a 5-mm-
thick vertical septum could be felt between the anterior and
posterior vaginal walls and involved tissue from the level of the
hymen to 5 mm inferior to the cervix. The unpredictability of its
effect on labour was discussed with the patient who at this time
was 3 cm dilated, with the cervix effacing inline with the septum.
Potential risks were discussed including obstructed labour,
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haemorrhage, and damage to surrounding organs. The patient
opted to undergo caesarean section whereby a left unicornuate
uterus was identified.
Conclusion Postnatally, an MRI pelvis and imaging of the
maternal urinary tract were arranged to detect associated
abnormalities. The evidence surrounding management of a
longitudinal vaginal septum in labour is scarce and one must
consider the risks of surgical division in labour where
preprocedural imaging has not been undertaken.
EP.240
Extremely obese pregnant patients – how do they
deliver? An audit of the extremely obese
population in a large district general hospital
O’Heney, J; MacSwan, R; Hashi, A; Howard, R
Barking, Havering & Redbridge University Hospitals NHS Trust,
Romford, Essex, UK
In 2007, UKOSS initiated a study of extreme obesity. We have
noticed an increasing prevalence of extremely obese patients
within our local population and audited this to compare with
UKOSS data. We identified women who booked with a BMI of 50
or above in 2016/2017. We identified 43 pregnancies in 41
women.
Eight of these women subsequently miscarried, 2 transferred care,
1 had medical termination for severe abnormalities, and 32
pregnancies delivered at our hospital. These deliveries give us an
extremely obese birth rate of 19.3 cases per 10,000 deliveries,
comparing to the UKOSS study national rate of 8.7 cases per
10,000 deliveries.
Eight of 32 were primiparous, of whom 6 delivered vaginally
(75%). Eighteen of 32 (56%) deliveries were by caesarean section
(CS) compared to our hospitals normal rate of 30%. 50% of CS
were as an emergency. All women with a previous CS delivered by
CS – one of which was a failed VBAC. Four of 12 women with
previous vaginal delivery(ies) delivered by CS. Reasons for
emergency CS included pathological CTG (2/9), failure to
progress (2/9), malpresentation (2/9), APH (2/9), and previous CS
in early labour (1/9). Two of 32 delivered prematurely. Fifteen
(47%) patients had a PPH. One patient had a 3rd-degree tear and
one other had a shoulder dystocia.
This audit shows that we have over twice the number of extremely
obese women delivering compared to the UKOSS study. This is
likely to be a combination of the national rate of obesity increasing
together with the deprived population that our hospital serves.
EP.241
An audit of clinical handover on the labour ward
McMahon, G; Kalisse, T; Imcha, M
University Maternity Hospital Limerick, Limerick, Ireland
Objectives To audit issues discussed and attendance of relevant
disciplines at handover.
102 ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG
Design Adequate clinical handover is an essential part of good
clinical practice, medical management, and patient safety. Recently
in our hospital, we have set up a multidisciplinary handover
occurring on the labour ward daily from Monday to Friday.
Methods A designated proforma of issues to be discussed and an
attendance sign-in attendance sheet is passed around at each
clinical handover from Monday to Friday. These records were
stored and used for data collection for this audit for one-month
period.
Results There was a total of 23 weekdays in July 2018 included in
the audit. Issues discussed included: women in labour (100%),
women in special observation unit (87%), theatre (91.3%),
neonatal unit (95.7%), antenatal wards (91.3%), postnatal wards
(78.3%), IMEWS triggers (82.6%), current reported clinical
incidents (82.6%), hygiene/decontamination (78.3%), bed status
(87.0%), inter-hospital transfer (87%), relevant staffing Risks
(78.3%), equipment issues (52.2%), risks identified (73.9%).
Attendance was as follows: 95.7% for Obstetrics Consultant,
95.7% for Obstetrics Registrar, 56.5% for Obstetrics SHO, 100%
for the Clinical Midwife Manager on the Labour Ward, 82.6% for
Clinical Midwife Manager in the operating theatre, 95.7% for the
Clinical Midwife Manager in the antenatal ward, 95.7% for the
Clinical Midwife Manager in the postnatal wards, 87% for
Neonatal Unit staff, 87% for the paediatric team, and 39.1% for
the anaesthetic team.
Conclusion Overall, attendance at each handover meeting is quite
good but there is room for improvement.
EP.242
Induction of labour (IOL): are we giving women
what they want?
Rothnie, K; Gray, L; Kausar, S
Mid Essex Hospital Trust, Chelmsford, UK
Objectives In 2017, one in every five deliveries in the UK was
induced. With induction of labour (IOL) rates increasing, it is
vital to remember the impact this can have on the birth
experience of women. IOL can place more strain on labour wards
than spontaneous labour, potentially resulting in patients
experiencing delays. The aim is to assess patient satisfaction with
the current IOL practices at Mid Essex Hospital Trust (MEHT).
Design A qualitative study of women having IOL from September
to October 2018 at MEHT. Questionnaires used 24–28 hours
postnatally to collect information on patients’ personal
experiences of IOL.
Results Twenty- five questionnaires were distributed with a total
of 18 responses collected. 83% (n = 15) felt they understood the
induction process. 72% (n = 13) felt they had enough information
regarding the induction process. 67% (n = 12) felt involved in the
initial decision-making. Overall, 72% (n = 13) were satisfied with
their experience, and 66% (n = 12) would recommend IOL to
others. Comments included the need to increase staffing levels on
labour ward to prevent long waits, to provide suitable
accommodation for partners on postnatal ward, to provide more
information regarding IOL in antenatal clinic at the time of IOL

decision, and that some midwives were not ‘supportive/
informative’ enough.
Conclusions Overall, a satisfactory outcome came from patient’s
experiences of IOL at MEHT. To improve further, actions include
review of the IOL information booklet provided in antenatal
clinic, direction of patients towards informative websites to self-
educate, and implementation of early warnings and frequent
updates for patients regarding delays.
EP.243
A retrospective audit of the maternal and neonatal
outcomes and factors associated with caesarean
section for all women transferred to theatre in the
second stage of labour at Stoke Mandeville
Hospital in 2016
D’Arcy, R; Robertson, K; Himabindu, A
Buckinghamshire Hospitals NHS Trust, Aylesbury, UK
Objectives To compare maternal and neonatal outcomes for all
women transferred to theatre in the second stage of labour based
on mode of delivery, and explore factors associated with caesarean
section (CS).
Study design Retrospective audit.
Methods All eligible women were identified using electronic
hospital records and information was collected about
demographic characteristics and delivery outcomes. Odds ratios
were calculated to explore differences in outcomes for women
with operative vaginal delivery (OVD) and CS, and women who
had different types of rotational OVD. Factors associated with risk
of CS were investigated, and logistic regression was used to adjust
for demographic confounders.
Results A total of 413 women were transferred to theatre and
80.4% (95%CI 76.6–84.2%) had OVD and 19.6% (95%CI 15.8–
23.4%) had CS. Women who had CS had increased odds of major
haemorrhage (aOR 9.8 95% CI 3.6–37.0) compared to women
who had OVD. No differences were observed for other maternal
or neonatal outcomes. Fetal malposition was associated with
increased odds of CS (aOR 4.37 95% CI 2.15–8.19). No other
factors associated with CS were identified. Rotational forceps
delivery was associated with increased odds of fetal acidaemia
(aOR 2.63 95% CI 1.01–6.84) compared to manual or vacuum
rotation; however, there was not an increased odds of low Apgar
score or NICU admission.
Conclusions Second-stage CS confers significant risk to the
mother of major haemorrhage and was strongly associated with
malposition. Obstetric training in safe rotational OVD must be
promoted to prevent second-stage CS and its associated
morbidity.
ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG
ePosters
EP.244
Impact of a novel induction of labour pathway
Patel, M1; Tower, C2; Sheils, F2
1
University of Manchester, Manchester, UK; 2Manchester University
Hospital NHS Foundation Trust, Manchester, UK
Objectives Induction of labour (IOL) is an increasingly common
obstetric intervention aiming to reduce poor maternal and fetal
outcomes. Previous audits had highlighted delays in the process at
St Mary’s Hospital. A novel pathway of a dedicated elective
workload area on the delivery unit was introduced including
additional midwives and a separate coordinator, allowing IOL to
be managed as an elective pathway. The IOL pathway was audited
against locally set standards, and those derived from National
Institute of Health (NICE) guideline 70.
Design Standards were based on ‘ideal’ perceived patient flow
through the pathway and guidelines.
Method A prospective audit was conducted of 100 women who
were admitted for induction. Data collection occurred from a
combination of paper and electronic records.
Results The most common indication for IOL was small
gestational age (16%) with 15% for large for gestational age.
Prostaglandin administration within 2 hours of admission
occurred in 47% improved from the previous audit of 32%.
49% of women were transferred to delivery unit within 4 hours
once ready for ARM, median:4:14 hours (interquartile range,
IQR 01:08–10:39). Moreover, 78% of women were transferred to
DU within 24 hours of admission, median:19:36 hours (IQR
13:42–28:11). 93% had oxytocin commenced with one hour of
ARM and median admission to delivery time was 26 hours
56 minutes.
Conclusion The new pathway improved patient flow and there
has been anecdotal positive staff feedback. However, delays in the
process persist, especially with prostaglandin administration and
DU transfer. A possible reason being the increasing number of
inductions.
EP.245
Using telemetry during labour and birth: women’s
and midwives’ experiences
Watson, K1,2; Mills, T1; Lavender, T1
1
The University of Manchester, Manchester, UK; 2Manchester
University NHS Foundation Trust, Manchester, UK
Objectives Wireless fetal heart rate monitoring during labour
(telemetry) is increasingly being used in UK maternity units but
there is no contemporary evidence surrounding its effects or
impact. This qualitative study aimed to understand in-depth the
experiences of women and midwives using telemetry to
continuously monitor the fetal heart in active labour.
Design Grounded theory (GT) methodology was chosen which
ensured inductive analysis and emergence of data-driven theory.
Method Following research governance approvals, in-depth, face-
to-face interviews were conducted with 11 women and 14
midwives from two NHS Trusts in Northwest England. Data were
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transcribed verbatim and analysed concurrently with collection,
according to GT principles.
Results Major emergent crossover themes for both women and
midwives include ‘choice, control and dignity’ – telemetry gave
women the choice to be more mobile during labour which led to
greater control of labour experiences and increased dignity
especially around personal hygiene; ‘a sense of normality’ – both
women and midwives voiced that telemetry enabled them to
incorporate aspects of normal labour and birth practices such as
choice of positions and use of a birth pool; ‘culture and
environment’ – both had an influence on uptake and
prioritisation of telemetry use on labour wards and impacted on
both midwives and women’s experiences of its use.
Conclusions Ongoing analysis presents evidence for positive
impact of the use telemetry, for both women and midwives, where
continuous fetal heart rate monitoring is required. Further
research on effect of telemetry on clinical outcomes, control, and
satisfaction is ongoing.
Results and conclusion The total number of women included was
18,536. The table shows a clear trend emerging with significantly
higher rates of CS in older mothers with higher BMIs (P < 0.05).
Primigravid women aged 20–24 with a BMI of <18.5 had a CS
rate of only 10%, while older women 35–39 and 40–44 with a
BMI of 35–39.5 had a CS rate of 59% & 73%, respectively. This
study is an initial phase of a large multicentre study to develop a
counselling tool for our population to more accurately predict a
women’s risk of CS in her first pregnancy based on age and BMI.
EP.247
Postdate pregnancy in nulliparous women:
induction of labour at 42 weeks is inefficient – it is
time for management change
Matiluko, A1; Galimberti, A2
1
University Hospitals’ Leicester, Leicester, UK; 2Sheffield Teaching
Hospitals, Sheffield, UK

Retrospective survey of all pregnancies between 1/8/2016 and 31/

EP.246
Determine the patient’s risk of caesarean section in
a primigravid population based on age and BMI
Ganeriwal, S1; Ryan, G2; Purandare, N2;
Geary, M3
1 Results A total of 536 nulliparous women had spontaneous
RCSI, Dublin, Ireland; 2Galway University Hospital, Galway, Ireland;
3
Rotunda Hospital, Dublin, Ireland
Objective The aim of this study is to develop a counselling tool
to determine caesarean section (CS) risk in a first pregnancy
stratified by age & BMI.
Design and method This was a retrospective review of CS
performed on primigravid women in Galway University Hospital
& The Rotunda Hospital from 2014 to 2017. The percentage of
women who had a CS was calculated for each group by age &
BMI. BMI was divided as per WHO classification. Age was
divided into 8 groups: 1. <20, 2. 20–24, 3. 25–29, 4. 30–34, 5. 35–
39, 6. 40–44, 7. 45–49, and 8. ≥50. A table was created plotting
age against BMI. Statistical analysis was performed using
regression analysis with SPSS.
12/2016 in a large teaching hospital in the United Kingdom was
performed to identify factors which affect outcome. Record of all
babies delivered beyond 24 weeks of pregnancy was included.
Documentation and analysis were on Microsoft excel. Results are
presented as percentages and 95% confidence interval.
labour. 74%, 25%, and 1% occurred at ≤40, 41 and 42 weeks,
respectively, 813 Multiparous women achieved spontaneous
labour. 81%, 18%, and 1% occurred at ≤40, 41, and 42 weeks,
respectively. Of 344 nulliparous women, 59%, 28%, and 13% were
induced at ≤40, 41, and 42 weeks, respectively. Of 307
multiparous women, 72%, 16%, and 12% were induced at ≤40,
41, and 42 weeks, respectively.
Conclusion We suggest induction of labour 40–41 weeks of
pregnancy in nulliparous women. Our results suggest higher rates
of vaginal delivery compared with induction of labour at
42 weeks. 1% of nulliparous women spontaneously laboured at
42 weeks.

Nulliparous % vaginal delivery Nulliparous % Multiparous % vaginal delivery Multiparous %

including instrumental (95% CI) caesarean section including instrumental (95% CI) caesarean section
(95% CI) (95% CI)

Spontaneous labour
≤40 weeks 85% (82–88) 15% (12–18) 90% (88–92) 10 (7–12)
41 weeks 80% (74–86) 20% (14–20) 89% (88–94) 11 (6–16)
42 weeks 88% (65–110) 12% ( 10–35) 90% (71–108) 10% ( 8–29)
Induced labour
≤40 weeks 65% (58–71) 35% (28–42) 89% (85–95) 11% (6–15)
41 weeks 62% (52–72) 38% (28–48) 78% (66–89) 22% (10–33)
42 weeks 43% (29–57) 57% (42–71) 86% (75–97) 14% (2–25)

104 ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG

EP.248
Personal hygiene care practices on the delivery unit
of St Mary’s hospital
Robinson, S1; Kelly, T2
1
University of Manchester, Manchester, UK; 2Manchester University
NHS Foundation Trust, Manchester, UK
This paper aims to assess if the delivery unit at Saint Mary’s
hospital is following current guidelines surrounding personal
hygiene such as washing and oral hygiene. Good personal hygiene
has proven to decrease infections of surgical wounds; this is
important as nationally 27.8% of deliveries are done by a
caesarean section. Good oral hygiene has been shown to decrease
incidents of pneumonia and reduce anaesthetic complications.
Current guidelines state patients awaiting surgery should have a
wash at least the day before surgery; patient’s oral hygiene should
be assessed and toothbrushing prescribed when admitted to
hospital.
To assess if the delivery unit followed these guidelines ward
rounds were observed to find when patients last washed and
cleaned their teeth, if any members of staff assessed this and if
toothbrushing was prescribed. Morning and afternoon ward
rounds were observed over a 2-week period, and 53 patients were
included in this study.
Only 34% of patients had been assessed, 72% of patients had
washed in the past day, and 62% of patients cleaned their teeth in
the past day but only 7% had toothbrushing prescribed.
The conclusion of this paper is that the delivery unit does not
currently meet guidelines on personal care for many possible
reasons including lack of staff confidence and barriers for the
patient to mobilise.
EP.249
The influence of obstetric experience on
management of twin pregnancies: a local based
survey
Al-Obaidly, S1,2; Al-Ibrahim, A1; Bayo, A1
1
Obstetrics and Gynecology Department, Women’s Wellness and
Research Center, Hamad Medical Corporation, Doha, Qatar; 2Weill
Cornell Medicine-Qatar, Doha, Qatar
Objectives To review the antepartum and intrapartum
obstetricians’ practice in the management of uncomplicated
MCDA and DCDA twin pregnancies.
Design Online questionnaires and email surveys.
Method 116 e-invitations were sent to eligible obstetricians who
were practicing at any of our 4 major maternity units in Qatar.
The survey included 31 questions about antepartum counselling of
mode of delivery, VBAC, IOL, and intrapartum management of
uncomplicated twin pregnancies.
Results The participants who anonymously completed the survey
were 71 obstetricians. Sixty-one (85%) of obstetricians were with
>10 years clinical experience. Twenty (28%) would not counsel
for vaginal birth in uncomplicated MCDA twins. Four (6%)
would not counsel for vaginal birth in nulliparous women
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regardless of chorionicity. Forty-one (58%) obstetricians would
not counsel for vaginal birth in nulliparous women with
uncomplicated MCDA twins. Forty-three (60.5%) obstetricians
would not counsel for TOLAC/VBAC and 31 (43%) would not
induce twins. In regard to second twin delivery, 11 (15%) opt to
expedite the delivery of second twin. Fifty-eight (82%) opt on
waiting. Twenty-seven of the waiting group opt to wait for
30 minutes and the remaining 33 obstetricians had chosen
variable duration provided a normal CTG.
Conclusions There is variation in the clinical management of twin
pregnancy. Despite the established clinical evidence of the
comparable perinatal safety of twins vaginal birth with caesarean
section, there is still tendency among obstetricians towards
advocating delivery by caesarean section in uncomplicated twin
pregnancy.
EP.250
Induction of labour (IOL): are we inducing women
appropriately as per hospital guidelines?
Rothnie, K; Kausar, S
Mid Essex Hospital Trust, Chelmsford, UK
Objectives An induced labour has an impact on the birth
experience of women. Although a relatively common procedure, it
may be less efficient and more painful than a spontaneous labour.
This large impact on the health of women and their babies
requires induction of labour (IOL) to be clearly clinically justified.
The aim is to assess current IOL practices at Mid Essex Hospital
Trust (MEHT), and measure outcomes against local hospital
guidelines.
Design Retrospective data collection of women having IOL from
April to June 2018 at MEHT. Local hospital guidelines used to
assess if IOL offered with correct indications and at the correct
gestation.
Results Thirty patients identified as having IOL. IOL was offered
for a multitude of conditions (gestational diabetes, pre-eclampsia,
pregnancy-induced hypertension), small/large for gestational age
babies, PROM, and fetal concerns. 83% (n = 25) were offered IOL
at the correct gestation. 53% (n = 16) had normal vaginal
delivery, 20% (n = 6) instrumental delivery, and 27% (n = 8)
emergency caesarean section. 83% (n = 25) experienced
complications, the most common being hyperstimulation at 78%
(n = 7). 20% (n = 5) experienced blood loss >1 l.
Conclusions 83% (n = 25) of patients were appropriately offered
IOL. However, when compared to the national average there are
associated higher emergency caesarean section (27% versus 16%)
and instrumental delivery (20% versus 12%) rates. This may result
in a potential for higher rates of complications. Appropriate
communication and standardised risk assessment and
accountability are required for all IOL decisions to reduce
unnecessary inductions.
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EP.251
Investigation into the true relative financial costs
of Planned Caesarean Section (PCS) versus Planned
Vaginal Birth (PVB) taking into account litigation
and compensation for harm
West, J1; Taylor, M2
1
None retired, Exeter, UK; 2Royal Devon & Exeter NHS Foundation
Trust, Exeter, UK
Objectives To determine the true relative costs of Planned
Vaginal Birth (PVB) versus Planned Caesarean Section (PCS)
accounting for litigation and compensation for harm (LCFH).
Background The 2011 Clinical Guideline CG132 of the National
Institute for Health and Care Excellence concludes that even
excluding litigation and compensation for harm (LCFH)
Caesarean Section for Maternal Request (CSMR) may be cost-
effective compared with PVB when ‘downstream’ costs are
included. Nevertheless, negative attitudes to CSMR and its cost
remain common.
Design & method Retrospective analysis of published data of
NHS Reference Costs, relative risks of complications of childbirth
according to planned mode of delivery, and NHS Resolution
accounts.
Results The ‘per birth’ ratio of the cost of LCFH is calculated to
be greater than 9:1 for PVB versus PCS. The NHS Resolution
overall provision for financial liability for LCFH rose in 2017/8 by
£13,723 million. Based on 48% being due to obstetrics and a birth
rate of 646,794 (the number of births in England in 2017), the
anticipated liability for LCFH may now have reached £1018 for
PCS and £9166 for PVB. This difference in cost is approximately
3X higher than the base birth cost of planned CS.
Conclusion There is no justification to discourage CSMR on
financial grounds. If LCFH is a proxy for clinical risk, the
possibility of clinical error is a major factor that should be
included in counselling and consent procedures for expectant
mothers.
EP.252
Labour and delivery outcomes in induction of
labour (IOL) for small for gestational age (SGA)
pregnancies
Cox, P; O’Dwyer, S
Queen Charlotte’s and Chelsea Hospital, London, UK
Objectives To assess method of induction, labour, delivery, and
neonatal outcomes in women with SGA fetuses requiring IOL
over a six-month period in a London teaching hospital.
Design Retrospective cohort study.
Method Twenty-four patients were collected over the study
period using the induction of labour (IOL) admissions book. Data
were collected from electronic patient records and analysed with
Microsoft Excel.
Results Twenty-four women were induced at an average gestation
37 + 2 days. Sixteen received propess, 6 prostin, 1 balloon, and 1
106 ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG
rupture of membranes with oxytocin. There was an 83% vaginal
delivery rate with no neonates having pH <7.1 and one having an
Apgar <10 at 10 minutes. 13% women required intrapartum
antibiotics. There were no cases of neonatal unit admission. In
women with no previous vaginal delivery (13), there was a 69%
vaginal delivery rate with no neonatal complications. Total
duration of induction was reduced when the woman presented
directly to labour ward as opposed to waiting on the antenatal
ward.
Conclusions There was an overall high vaginal delivery rate with
low maternal and neonatal complications. Our unit protocol states
that IOL for these high-risk pregnancies should be started on the
labour ward for enhanced fetal monitoring. Pathway design
ensuring women have a bed on labour ward ready when they
present for IOL was associated with timely commencement of
induction. Choice of induction agent depends on cervical
assessment.
EP.253
Labour and delivery outcomes in women with a
previous caesarean requiring induction of labour
Cox, P; O’Dwyer, S
Queen Charlotte’s and Chelsea Hospital, London, UK
Objectives To assess method of induction, labour, delivery, and
neonatal outcomes in women with a previous caesarean section
requiring induction of labour over a six-month period in a
London teaching hospital.
Design A retrospective cohort study assessing elective induction
of labour in women with a previous caesarean section.
Method Thirty-five patients were collected over the study period
using the induction of labour (IOL) admissions book. Data were
collected from electronic patient records and analysed with
Microsoft Excel.
Results The 35 women were induced at an average gestation
39 + 3 days. Sixteen underwent balloon induction and 19 had
rupture of membranes with oxytocin augmentation. There was a
69% vaginal delivery rate with one neonate having pH <7.1 and
Apgar <10 at 10 minutes. 17% women required intrapartum
antibiotics. There were no cases of scar dehiscence of neonatal
unit admission. In women with no previous vaginal delivery (21),
there was a 62% vaginal delivery rate. Those having a balloon
induction had a 31% vaginal delivery rate.
Conclusions There was an overall high vaginal delivery rate with
low maternal and neonatal complications. Balloon induction is
associated with lower vaginal delivery rates most likely due to the
cervix being more unfavourable at the start of IOL. Improvement
work in currently in progress trialling outpatient IOL with balloon
catheters in this group to enhance the woman’s experience and
reduce inpatient stay.

EP.254
Shared learning for clinical trials of an
investigational medicinal product (CTIMPs) –
lessons from the high or low dose syntocinon
(HOLDS) trial
Kenyon, S1; Brocklehurst, P1; Ewer, A1;
Hewston, R2; Hinshaw, K3; Johnston, T4;
Middleton, L1; Sanders, J5; Waugh, J6
1
University of Birmingham, Birmingham, UK; 2None, Worcester, UK;
3
Sunderland Royal Hospital, Sunderland, UK; 4Birmingham Women’s
and Children’s NHS Foundation Trust, Birmingham, UK; 5Cardiff
University, Cardiff, UK; 6University of Auckland, Auckland,
New Zealand
Objectives To share learning from unanticipated challenges
encountered by HOLDS regarding the packaging and storage of
IMP (Syntocinon).
Design Retrospective report of challenges encountered within a
multicentre CTIMP which compares standard dose with a high
dose regimen of syntocinon for women delayed in the first stage
of labour.
Methods This NIHR HTA multicentre, randomised, double-blind
controlled trial of 1500 women from 30 sites began recruiting in
June 2017. The IMP was packaged within regulatory approvals
and stored in Delivery Suite fridges with routine monitoring
processes used to ensure necessary storage temperature
compliance.
Results Routine monitoring processes uncovered 233 temperature
deviations outside the recommended range of 2–8°C across 84%
(16/19) of active sites, leading to suspension of recruitment in
October 2017. Extensive revisions to the guidelines for IMP
monitoring and storage were introduced, which included use of
buffered thermometers. Deviations were reduced to 38 across 29%
of sites (7/24). Following a four-month approval process,
recruitment restarted in June 2018. In August 2018, it was
identified that the IMP had been packaged by an MHRA provider
at temperatures outside 2–8°C, meaning it could not be used. The
trial was suspended again and there are now insufficient funds to
continue without an extension. Recruitment targets were met
when the trial was open.
Conclusion Researchers should carefully consider using routine
processes to ensure compliance with regulations surrounding
packaging, distribution, and storage of investigational medicinal
products. These findings could have implications for drugs stored
in Delivery Suite fridges used in clinical practice.
EP.255
Is there a role for virtual reality and immersive
technology for pain relief of women in labour?
Yorke, S; Thangaratinum, S
QMUL, London, UK
Background Currently low-risk mothers who deliver in
midwifery-led birthing units do not have access to epidural for
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ePosters
pain relief. Immersive virtual reality (VR) technology is a non-
pharmacological, non-invasive method with the potential to
minimise pain, anxiety, and stress in these settings. VR devices
provide immersive, realistic, three-dimensional experiences that
‘transport’ users to novel environments, by providing
multisensory information and allowing patients to ‘escape’ to
pleasant locations and realities.
Objective To assess the feasibility of VR and immersive
technology for low-risk women in labour; and the willingness of
patients and healthcare professionals to use this technology.
Methods A systematic review of the current literature on VR use
in labour was undertaken by searching major electronic databases
(1990- present). We undertook two surveys (for women and
healthcare professionals) to assess willingness and acceptability of
VR and Immersive Technologies in low-risk labour and to
investigate if there is a role for such technologies in this setting.
The surveys were aimed to capture women’s attitudes towards
using VR headsets on pain, stress, anxiety, and use of epidural.
Results Through the systematic review, we identified one RCT
pilot study in the USA demonstrating that use of VR in labour
reduced sensory pain 1.5 (95% CI, 0.8 to 2.2) and anxiety
1.5 (95% CI, 0.8 to 2.3). The majority of participants said
they would be very interested in a new VR development
specifically for labour (Frey et al., 2018). Results of the survey will
be provided if the abstract is accepted.
EP.256
Quantitative Fibronectin to help Decision-making in
women with Symptoms of preterm labour (QUIDS):
acceptability for clinicians and women, a
qualitative assessment
White, H1; O’Brien, E2; Stock, S3; Lavender, T1
1
The University of Manchester, Manchester, UK; 2The University of
Liverpool, Liverpool, UK; 3University of Edinburgh, Edinburgh, UK
Diagnosis of preterm labour in women who present with
symptoms is complex. Inaccurate diagnosis may lead to over- or
under-treatment. The Quantitative Fibronectin to help Decision-
making in women with Symptoms of preterm labour (QUIDS)
study aimed to develop and externally validate a decision-support
tool based on a validated prognostic model using quantitative
fetal Fibronectin (fFN) concentration in combination with clinical
risk factors, with over 3000 women. This qualitative part of the
study aimed to assess the acceptability of fFN testing and a
decision-support tool for women and clinicians.
A qualitative, interpretive approach was taken using semi-
structured interviews, conducted over the telephone. Eligibility
criteria included women between 22 and 34 weeks gestation,
presenting with symptoms of preterm labour, and clinicians
experienced in using fFN. Telephone interviews of 30 women and
31 clinicians from 13 Trusts were audio recorded with consent
and transcribed verbatim.
Semi-structured interviews enabled participants to talk freely
about their experiences, while focusing on the a priori aim. A
hypothetical clinical scenario gave clinicians experience of using
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results from the prognostic model. Women’s interview data will EP.258
be analysed with results from State Trait Anxiety Inventory A pragmatic evaluation of barriers and facilitators
questionnaires completed pre- and post-fFN testing, to to the implementation of an obstetric innovation
understand the rationale for questionnaire answers. (Episcissors) across maternity units in the North
Framework analysis is underway to derive themes from the data,
East and North Cumbria
and full results will be ready to present at the conference. Study
findings will provide useful information about the acceptability of
Farnworth, A1; Ayuk, P2; Robson, S1
1
a decision-support tool, considerations for implementation into Newcastle University, Newcastle upon Tyne, UK; 2Newcastle upn
practice, and women and clinicians’ experience of diagnostic Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
testing in preterm labour.
Objectives Episcissors are an obstetric innovation designed to
reduce rates of obstetric anal sphincter injury. Implementation has
been encouraged via the NHS Innovation Accelerator Scheme. In
EP.257 the North East and North Cumbria (NENC), the Academic
Myotonia congenita in pregnancy: implications for Health Science Network (AHSN) also provided NHS Trusts with
labour and delivery initial financial support to purchase Episcissors. The impact of
Short, D; Sewnauth, K; Keay, A; McCartney, J implementation on clinical outcomes was evaluated using
routinely collected data. The objective of this evaluation was to
Forth Valley Royal Hospital, Falkirk, UK
explore the barriers and facilitators to implementation of
Episcissors across the NENC region.
Background Myotonia congenita is a genetic disorder affecting
Methods One midwifery and one medical contact were identified
skeletal muscle, causing prolonged bouts of sustained muscle
at eight NHS Trusts in the NENC region. In implementing Trusts
contractions. It is caused by a mutation in the CLCN1 gene which
(n = 5), a telephone interview was conducted with interviewees at
codes for a chloride membrane channel. Incidence is 1:100,000,
the start of implementation and repeated 4–6 months later.
and inheritance can be either AR or AD.
Interviews were also conducted with non-implementing Trusts
Case A 25-year-old primiparous patient who was diagnosed with
(n = 3). Notes taken during the interviews were categorised in
myotonia congenita at 37 weeks gestation presented to the
accordance with two theory driven frameworks (Consolidated
antenatal clinic at 38 weeks gestation with worsening symptoms,
Framework for Implementation Research and Taxonomy of
chiefly, increasing leg stiffness and leg locking. A plan for
Implementation Outcomes).
induction of labour was made prompting urgent planning for the
Results A number of bureaucratic, cultural, and practical barriers
management of her labour. Consideration was needed for the
to successful implementation and evaluation of outcomes were
management of pain, positioning in labour, and choice of drugs,
identified. Fiscal assistance and support from clinical leaders were
for any interventions. Positioning was a potential difficulty given
significant facilitators. Examples of barriers were complex
the leg stiffness and the propensity to locking, particularly if an
organisational procurement processes, issues around storage/
emergency situation arose. To address this, consideration was
sterilisation of Episcissors, and concerns about the strength of the
given to ELCS which was declined by the patient. The obstetric
evidence base about Episcissors. With regard to the latter,
anaesthetist compiled a clear plan for drug therapy should it be
clinicians were reassured by the collection of local data about
required, including the avoidance of intramuscular injections,
implementation by the AHSN.
inhalation anaesthetic agents, and depolarising muscle relaxants.
Conclusions This theory informed evaluation offers a useful
Pain may cause myotonic crisis in patients with this condition so
insight into factors that significantly support or hinder successful
early epidural was recommended and accepted. Her labour was
region-wide implementation and evaluation of innovation in NHS
subsequently uneventful with delivery by SVD. Given the concerns
services.
regarding drug choices, genetic testing of cord blood was
recommended to better inform the child’s care.
Conclusions Many interventions seen as standard intrapartum
management could have negative consequences for patients with
myotonia congenita. Careful planning and a clear MDT approach
are necessary to avoid harm.

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EP.259
The clinical and cost-effectiveness of testing for
group B streptococcus: a cluster randomised trial
with economic and acceptability evaluations (GBS3)
Walker, K1; Gray, J2; Petrou, S3; Ayers, S4;
Ogollah, R1; Mitchell, E1; Dorling, J5;
Thornton, J1; Plumb, J6; Downe, S7; Taylor, V8;
Grace, N9; Parry, D10; Cooper, T11; Daniels, J1
1
University of Nottingham, Nottingham, UK; 2Birmingham Children’s
Hospital, Birmingham, UK; 3The University of Warwick, Warwick,
UK; 4University of London, London, UK; 5Dalhousie University, Nova
Scotia, Canada; 6Group B Streptococcus Support, London, UK;
7
University of Central Lancashire, Preston, UK; 8NHS England,
Derbyshire, UK; 9Independent Consultant, Nottingham, UK;
10
National Childbirth Trust, London, UK; 11Warrington and Halton
Hospitals NHS Foundation Trust, Warrington, UK
Objectives Does routine testing of women for group B
streptococcus (GBS) colonisation either in late pregnancy or
labour to guide the offer of intrapartum antibiotic prophylaxis
reduce the occurrence of early onset neonatal sepsis, compared to
the current risk factor based strategy?.
Design We will conduct a multicentre prospective two-arm
parallel cluster randomised controlled trial, with internal pilot and
feasibility evaluation and parallel economic modelling.
Methods The study will be conducted in up to 80 maternity units
in England, Scotland, and Wales. The population will include all
women who plan a vaginal birth (including a trial of labour), at
any gestational age ≥24 weeks.
The primary comparison will be a ‘risk factor based strategy’
(usual practice) to a ‘routine testing strategy’. Sub-randomisation
of the ‘routine testing strategy’: intrapartum testing at ≥37 weeks
of vaginal-rectal swab with the GBS GeneXpert rapid test, or
antenatal testing at 35–37 weeks with enrichment culture. The
primary outcome is all-cause early neonatal sepsis. Secondary
outcomes include process outcomes (e.g. testing coverage, result
available in time); economic outcomes (cost per case of early
neonatal sepsis avoided); and qualitative outcomes (barriers and
facilitators to implementation; fidelity to guidelines by clinicians;
acceptability of tests, of universal IAP approach for preterm
labours, and of antenatal screening; impact on birth location
choice; parental information requirements). A total of 320,000
women will be included in the study over 2 years from 80 units.
This will enable detection of a 40% reduction in the primary
outcome with 90% power.
Results Recruitment commences in February 2020.
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ePosters
EP.260
A study to determine the feasibility of a
randomised trial of different techniques for
Managing an Impacted fetal heaD At emergency
caesarean Section (MIDAS)
Walker, K1; Jones, N1; Mitchell, E1; Tempest, N2;
Plachcinski, R3; Dorling, J4; Pallotti, P1;
Ogollah, R1; Bradshaw, L1; Ayers, S5; Knight, M6;
Pillai, A7; Thornton, J1
1
University of Nottingham, Nottingham, UK; 2Liverpool Women’s
Hospital, Liverpool, UK; 3National Childbirth Trust, London, UK;
4
Dalhousie University, Nova Scotia, Canada; 5University of London,
London, UK; 6University of Oxford, Oxford, UK; 7Nottingham
University Hospitals NHS Trust, Nottingham, UK
Objectives To determine the feasibility of a randomised trial of
different techniques for managing an impacted fetal head during
emergency caesarean section.
Design This study includes five interconnecting work packages:
1 To conduct four national surveys of parents, obstetricians, mid-
wives, and obstetric anaesthetists. To conduct a focus group of
women who have experienced second-stage CS to determine the
acceptability of a randomised trial in this area.
2 To conduct a UKOSS surveillance study to determine the incidence
and consequences of impacted fetal head in the UK.
3 Based on the findings of 1-2, a Delphi survey will be conducted fol-
lowed by a consensus meeting of experts and important stakehold-
ers to decide which techniques should be tested in an RCT.
4 On the basis of 1-3, a randomised trial of different techniques for
managing an impacted fetal head during emergency sections will be
designed.
5 To conduct a national survey followed by three focus groups: of
obstetricians/senior trainee obstetricians; women who have experi-
enced a second-stage CS and primiparous women to determine the
acceptability and feasibility of the planned RCT..
Conclusions The results of this study will be the driving force
behind any future randomised trial in this area. It will increase
our understanding of the prevalence of an impacted fetal head at
caesarean section and the frequency of complications for the
mother and baby arising from it. It will increase awareness of the
problem among healthcare professionals and parents. It will
highlight training deficiencies in this area.
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EP.261 recorded, but upright seemed to be associated with greater SVD

Childbirth experience questionnaire 2: validating its (aOR 29.7, 95% CI 17.9–49.0, P < 0.0001). Data suggest a 35%
use in the United Kingdom increase in SVD for every 1 cm/hr-increase in rate of cervical
change (95% CI 20–51%, P < 0.0001) and every 1 hour-increase in
Walker, K; Thornton, J
second stage was associated with a 65% reduction in SVD (95% CI
University of Nottingham, Nottingham, UK 60–70%, P < 0.0001). Data also showed most NW attended the
hospital early (median 3 cm dilated (IQR 1–5 cm)).
Objectives To test whether the Childbirth Experience
Conclusion This study suggests epidural is associated with mode
Questionnaire 2 (CEQ-2) is a valid tool to measure childbirth
of delivery and clarity antenatally regarding analgesia options and
experience in UK mothers.
position in the second stage could ensure women are able to
Design A prospective postnatal postal/online questionnaire study
make informed choices. Upright position may favour SVD in
and face-to-face completion of the CEQ-2 in a small subset of
women without an epidural but a RCT is needed to provide a
mothers over 12 months. A total of 475 women who have
definitive answer.
laboured and given birth to their first baby at 37–41 completed
weeks at Nottingham University Hospitals NHS Trust were
identified in the postnatal period by their obstetrician or midwife
on the postnatal ward. Written consent was obtained. EP.263
Methods Women were sent two questionnaires in the post when Systematic review of the interventions to reduce
they were one-month postnatal: the CEQ-2 and Part C of the the incidence of wound infection and dehiscence
Care Quality Commission Maternity Survey (2010). Women were following childbirth-related perineal trauma
also sent the CEQ-2 when they were 6 weeks postnatal by post.
Jones, K1; Webb, S1,2; Manresa, M3; Hodgetts
We asked a small subgroup of women of all ages on the postnatal
ward (25) to complete the CEQ-2 and asked them some questions Morton, V1,2; Morris, K1,2
1
face to face about the questionnaire. Birmingham Women’s and Children’s NHS Foundation Trust,
Results A total of 511 eligible women were identified and of those Birmingham, UK; 2Institute of Applied Health Research, College of
511 women agreed to join the study between 10 October 2017 Medical and Dental Sciences, University of Birmingham., Birmingham,
and 4 October 2018 and were sent postnatal questionnaires. UK; 3Hospital General de Granollers, Barcelona, Spain
Completed questionnaires were returned by 260 women (51%
Objectives Childbirth-related perineal trauma (CRPT) occurs in
response rate). We are awaiting the final 6-week questionnaires
approximately 70–80% of vaginal births. Despite the known
for 3 women and then the results will be analysed. The full results
morbidities associated with perineal wound infection and
will be available for analysis in December 2018.
dehiscence, the use of interventions to reduce the incidence of
healing complications is unexplored. This review is designed to
evaluate these interventions and their effectiveness for reducing
EP.262 the incidence of wound infection and dehiscence following CRPT.
Factors associated with mode of delivery in Design A comprehensive and systematic review of the literature.
nulliparous women who begin labour Method Medline, Embase, and Cinahl databases were searched
from inception to September 2018 using MeSH, textwords, and
Fox, C1; Hardy, P2; Macarthur, C2
1
appropriate word variants to ensure capturing all relevant non-
Birmingham Women’s and Children’s NHS Foundation Trust, randomised and randomised studies. No restrictions were placed
Birmingham, UK; 2University of Birmingham, Birmingham, UK
on mode of delivery, degree of trauma, parity or type of
intervention to reduce the risk of limiting the search to all
Objectives CS rates are rising despite WHO recommendation that
possibly relevant articles.
a rate >10–15% does not confer additional benefits. There’s
Results Twenty-seven studies were included (19 randomised and
evidence that more nulliparous women (NW) with epidural
8 non-randomised). A range of different interventions were
achieve SVD if they adopt lateral position. Evidence is lacking for
identified with the majority having little positive effect on
the 70% who deliver without epidural. This study investigated
reducing the incidence of infection or dehiscence. Quality
baseline and dynamic factors, specifically cervical findings and
assessment of the studies exposed inadequacies in several
maternal position, on mode of delivery for NW.
methodological areas. There was great heterogeneity among the
Design Cross-sectional study of NW delivering at two UK centres
studies, particularly regarding perineal wound infection definition
1 September 2016–30 September 2017.
and confirmation, making meta-analysis of the data impossible.
Methods Data were anonymised and extracted from electronic
Conclusions This review demonstrates that despite the known
systems. Baseline characteristics and labour variables were compared
high occurrence of CRPT and the associated long-term morbidity
by centre. The relationship between labour variables, epidural and
from infection in the immediate postnatal period, there a few
SVD were explored using multivariable logistic regression.
validated, effective interventions to reduce the risk of infection. It
Results Data were reported on 3983 women. Women with an
highlights an urgent need for randomised controlled trials to
epidural were older and had a higher BMI (P < 0.0001)). Induction
evaluate potential interventions designed to reduce the incidence
and SVD were higher in the DGH (44.8% versus 30.0%, P < 0.0001;
of perineal wound infection and dehiscence.
48.3% versus 44.1%, P = 0.002). Maternal position was poorly

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EP.264
Systematic review of the incidence of wound
infection and dehiscence following childbirth-
related perineal trauma
Jones, K1; Webb, S1,2; Manresa, M3; Hodgetts
Morton, V1,2; Morris, K1,2
1
Birmingham Women’s and Children’s NHS Foundation Trust.,
Birmingham, UK; 2Institute of Applied Health Research, College of
Medical and Dental Sciences, University of Birmingham, UK,
Birmingham, UK; 3Hospital General de Granollers, Barcelona, Spain
Objectives Childbirth-related perineal trauma, either
spontaneously or episiotomy, occurs in approximately 70–80% of
vaginal births. Infection in the postnatal period is associated with
wound dehiscence, granulation tissue formation, dyspareunia, and
pelvic floor dysfunction, often leading to long-term physical and
psychological problems. This review is designed to determine the
incidence of childbirth-related perineal wound infection and
dehiscence.
Design A comprehensive and systematic review of the literature.
Method Medline, Embase, and Cinahl databases were searched
from inception to September 2018 using MeSH, textwords, and
appropriate word variants to ensure capturing all relevant studies.
No restrictions were placed on mode of delivery, degree of
trauma, or parity to reduce the risk of limiting the search to all
possibly relevant articles.
Results Twenty-two studies were included (10 cohort, 2 case
control, and 10 reporting incidence or prevalence). Reported
incidence of childbirth-related perineal wound infection ranged
from 0.1% to 23.6% and wound dehiscence from 0.21% to 24.6%.
Quality assessment of the included studies exposed inadequacies
in several methodological areas. There was great heterogeneity
among the studies, particularly regarding perineal wound infection
definition and confirmation, making effective synthesis of the data
almost impossible.
Conclusions This review demonstrates that despite the known
high occurrence of perineal trauma during childbirth and
associated long-term morbidity from infection in the immediate
postnatal period, the true incidence remains largely unknown.
There is an urgent need for a validated, feasible, and standardised
diagnostic tool to aid in the early identification of perineal wound
infection in both primary and secondary healthcare settings.
EP.265
‘Consent for operative vaginal births’ a patient
survey
Barnes, S; El-Gohari, A; Matthews, M; Bear, C;
Jong, B
Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells, UK
Since the Montgomery ruling, there is an increasing awareness by all
clinical staff of the importance of consent in the clinical setting. The
intrapartum environment provides unique challenges to obtaining
consent but we have little feedback of how well this is performed. In
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ePosters
2013, the human rights charity Birthrights reported that 24% of
women who had an instrumental birth did not feel that they
consented to the procedure, a worryingly large number.
We therefore surveyed all families who had an operative vaginal
birth over a three-week period at Tunbridge Wells Hospital. In
total, 35 families responded.
Our results showed that 77% of women had informed consented
to an operative vaginal birth as they reported explanation of risks,
alternative modes of delivery and additional procedures. We most
commonly do not discuss alternative modes of delivery (20%) or
risks of an operative delivery (17%).
Reassuringly over 90% of women felt respected and looked after
in labour and 100% of women said they felt safe and that all
healthcare professionals introduced themselves. But 51% of our
women had further or unanswered questions.
In conclusion, we found that most women have an informed
consent discussion over an instrumental delivery but, similarly to
the Birthrights report, 23% have incomplete consent taken. We
are therefore motivated to improve our consent taking process for
operative vaginal deliveries and provide more information and
debriefing to families afterwards. This is part of an ongoing
project aimed at improving the care of women who have an
operative vaginal birth.
EP.266
Using the Robson classification to audit caesarean
sections
McMahon, G; Daly, N; Imcha, M
University Maternity Hospital Limerick, Limerick, Ireland
Objectives To classify caesarean sections using the 10-Group
Robson Classification and to identify indications for caesarean
sections.
Methods All patients undergoing caesarean sections in a one-
month period were identified by using the theatre register, and
data were collected from patient’s notes.
Results A total of 335 women delivered during the study period.
Of the 335, 105 patients who had a LSCS (31.5%) were included
in the audit. Of 105, 34 (32.4%) were nulliparous, 101 (96.2%)
were singleton pregnancies, 42 (40%) did not have a previous
section, and 87 (82.9%) did not have a vaginal delivery prior to
section. Of the 41 women with one previous section, 30 had an
elective repeat section and 11 had a caesarean section during
labour. Of the 25 Category 2 sections, 22 were women with no
previous section. There were 65 (61.9%) Category Four Sections.
Of 105, 73 (68.9%) patients were not in labour, 14 (13.2%) had
spontaneous onset, and 18 (17%) had induction of labour. There
were 5 (4.8%) patients in Group 1, 20 (23.8%) in Group 2, 2
(1.9%) in Group 3, 4 (3.8%) in Group 4, 57 (54.3%) in Group 5,
1 (1%) in Group 6, 1 (1%) in Group 7, 4 (3.8%) in Group 8, 3
(2.9%) in Group 9, and 8 (7.6%) in Group 10.
Conclusion Using the Robson Classification System allows for a
standardised comparison of caesarean section rates and to identify
trends in caesarean section rates.
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EP.267
What did they tell you about the CTG? A
satisfaction survey done to identify women’s
opinions on CTG monitoring and staff
communication in labour
McMahon, G; Rogers, A; Woulfe, Z; Liew, NC;
Smyth, M; Burke, G; Imcha, M
University Maternity Hospital Limerick, Limerick, Ireland
Objectives To identify women’s satisfaction with communication
about the CTG during their time in labour.
Methods An anonymous survey was completed by women
undergoing labour and delivery. A second survey included patient
demographics and was completed by staff.
Results Forty-eight women were included. Mean maternal age at
delivery was 29.5 years. Of 48, 60% had a spontaneous vaginal
delivery, 23.3% had an instrumental delivery, and 16.7% had a
caesarean section. All women said the staff explained the CTG to
them and they were satisfied with this communication. In 83.3%
of cases (n = 40), another member of staff offered a second
opinion on the CTG and 100% were satisfied with the
communication from this person. All women felt confident that
the staff knew what they were doing and also felt included in any
decision that was made as a result of the CTG. Of the 48 women,
30.2% said they wanted to know something about the CTG but
did not ask at the time (n = 15). When asked about how they felt
about having CTG monitoring done during labour, 75% felt very
reassured (n = 36) and 25% felt reassured (n = 12), no one said it
made them anxious or worried. When asked about their overall
experience of communication from staff, 83.3% said excellent
(n = 40) and 16.7% said good (n = 8). Of 48, 79.1% of women
rated their birthing experience as excellent (n = 38) and 20.9%
said good (n = 10).
Conclusion Overall, women rate the quality of staff’s
communication about the CTG during labour and delivery highly.
EP.268
Efficacy of vaginally placed cervical cerclage among
women who have undergone a previous full
dilatation caesarean section
Hickland, M1; Story, L1; Cauldwell, M2;
Watson, H1; Carter, J1; Shennan, A1
1
King’s College London, London, UK; 2St Thomas’ Hospital,
London, UK
Objectives To assess the efficacy of transvaginal cervical cerclage
(TVC) among women with a previous full dilatation caesarean
section (FDCS) followed by a late miscarriage or spontaneous
preterm birth (sPTB).
Design A retrospective data analysis was performed using the
Preterm Clinical Network database. FDCS is associated with a six-
fold increased risk of sPTB and a three-fold increased risk of
recurrent sPTB compared with vaginal birth. Data are limited
regarding efficacy of TVC in this group of women.
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Methods Women attending the Preterm Surveillance clinic at St
Thomas’ Hospital who had a FDCS followed by a sPTB or late
miscarriage, followed by a third pregnancy, were identified.
Controls were women attending the clinic with a risk factor for
sPTB with any previous delivery mode. Treatment modalities were
noted: no intervention, TVC, or transabdominal cerclage (TAC).
The primary outcome was delivery <30 weeks. A Fisher’s exact
test was used to compare groups.
Results Fifty-four pregnancy events were included in the study
group, 19 received TVC. There were 942 controls, 154 received
TVC. 52.6% of cases with a TVC delivered <30 weeks gestation
compared with 3% in the control group (P < 0.0001). No
significant differences between the control and study groups for
women receiving TAC were observed.
Conclusions TVC is a less effective treatment modality among
women who have had an FDCS followed by a sPTB or late
miscarriage compared with other high-risk groups of women.
Further work is required to confirm these findings and whether a
TAC may be a more suitable intervention.
EP.269
Successful delayed-interval delivery in the presence
of clinical chorioamnionitis in the leading twin: a
report of two cases
Sukumaran, S1; Kanagalingam, D2
1
University of Birmingham, Birmingham, UK; 2Singapore General
Hospital, Singapore, Singapore
We present two cases of diamniotic, dichorionic twin pregnancies,
in which after the loss of the first fetus in the setting of clinical
chorioamnionitis, both pregnancies were successfully managed by
delayed-interval delivery (DID) and resulted in survival of the
second twin without disability.
Patient A presented at 20 weeks gestation (GW) with preterm
prelabour rupture of membranes (PPROM) and a dilated cervix.
The patient was managed conservatively with close monitoring for
signs of chorioamnionitis. Cord prolapse occurred at 24 weeks
and twin one was delivered stillborn. Cervical dilatation
subsequently resolved. At 27 weeks, PPROM occurred followed by
maternal fever and abdominal pain. She underwent an emergency
caesarean section in view of possible chorioamnionitis. Placental
histology subsequently identified severe funisitis and
chorioamnionitis in the earlier delivery.
Patient B presented with bulging fetal membranes at 22 weeks.
She developed chorioamnionitis and spontaneous miscarriage of
twin one occurred. Clinical and laboratory evidence of
chorioamnionitis resolved after antibiotic treatment and cervical
dilatation returned to normal. At 25 weeks, PPROM occurred
followed by symptoms and signs of chorioamnionitis. Labour
ensued, but an emergency caesarean section was performed for
cord presentation. Histology of the placenta confirmed
chorioamnionitis.
DID can be successful in the setting of clinical chorioamnionitis
of the leading twin, with key prognostic predictors being
resolution of both cervical dilatation and signs of infection on

delivery of the first twin. We postulate that if clinical
chorioamnionitis is localised to the amniotic sac of the leading
fetus (DCDA twins), DID may have a good prognosis.
EP.270
The use of tranexamic acid in postpartum
haemorrhage
Duncan, A; Hutchison, L; Bennett, R; Dick, J
Royal Alexandra Hospital, NHS Greater Glasgow and Clyde,
Paisley, UK
Objectives This is a clinical improvement study on the use of
tranexamic acid during the management of PPH at the Royal
Alexandra Hospital. Local obstetric guidelines implemented this
year recommend tranexamic acid is considered in women with a
PPH ≥ 1500 ml. This study aimed to identify local practice and
areas for improvement, with a view to increasing the recommended
use of this medication in the management of major PPH.
Design and method Thirty sequential cases of PPH ≥ 1500 ml
were identified, using the labour ward delivery book to identify
cases. The electronic maternity notes were used to identify
whether tranexamic acid was administered. At present, we are
introducing targeted clinical improvement measures to increase
awareness and education about guidance on tranexamic acid.
Following these, we plan to collect data on a further 30 patients
with a PPH ≥ 1500 ml in order to assess the effect of these
interventions.
Results The initial round of data collection showed tranexamic
acid was given in a third of cases of PPH ≥ 1500 ml. Further
results are awaited pending the second round of data collection.
Conclusions Our initial data collection suggests there is scope to
increase local awareness about the use of tranexamic acid in PPH.
The WOMAN study has shown it to be safe and effective in
reducing maternal mortality associated with PPH. Therefore, we
hope to see an increase in the use of tranexamic acid during PPH
following clinical improvement measures. We suggest that this
topic continues to be audited locally to monitor ongoing practice.
EP.271
Debunking debriefing: developing a directed
discussion postdelivery
McCarthy, C; Russell, N
Cork University Maternity Hospital, Cork, Ireland
Debriefing of women by obstetricians is recommended following
adverse events and can reduce psychological morbidity and
anxiety in future pregnancies. It was aimed to evaluate and
improve rates of obstetric debriefing following operative deliveries.
Consecutive delivery records were collated for all publicly booked
operative vaginal deliveries and caesarean section (CS; n = 292)
over a six-week period. Chart review assessed documentation and
content of postnatal debriefing. An intervention consisting of two
20-minute staff education sessions was conducted, and relevant
ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG
ePosters
literature was provided to staff. Seven weeks following this, a
further review was conducted (n = 318).
The initial debriefing rate was 24.6% (n = 72), with
improvements in rates of debriefing ascending proportional to
level of training. Future mode of delivery was discussed in 6.9%
of women following primary CS. Following the intervention,
debriefing improved to 59.1% (n = 190; P < 0.0001). This
improvement was most marked in the first three weeks following
training (71.5%; n = 103). There was a statistically significant
(P < 0.0001) improvement in documentation by all categories of
Non-Consultant Hospital Doctors, with SHO’s, Junior Registrars
and Senior Registrars improving by 1060%, 173%, and 118%,
respectively. Future mode of delivery discussion rates also
improved to 22.7% (P < 0.0001).
Using a simple, cost-neutral intervention, debriefing rates
improved by 144% overall. This study demonstrates that small
changes in practice can potentially change women’s perception of
childbirth and positively affect future pregnancies. Continual
improvements need to be made to ensure the maximum number
of women are debriefed appropriately and given the opportunity
to discuss current and future care needs and requirements.
EP.272
Risk perception on the labour ward
McCarthy, C1; Rochford, M1; McNamara, K1;
Meaney, S2; O’Donoghue, K3
1
Cork University Maternity Hospital, Cork, Ireland; 2National
Perinatal Epidemiology Centre, Cork, Ireland; 3INFANT, Cork, Ireland
The concept of risk in medicine has become more pervasive over
the last number of years. We aimed to assess opinions/behaviours
of risk on the labour ward (LW) by conducting a questionnaire-
based study of staff.
Over 64% (73/114) of staff completed the questionnaire, divided
between doctors (31; 42.5%) and midwives (42; 57.5%). Over half
of respondents (41; 56.2%) experienced daily, with 23.2%
(n = 17) believing risk is too prevalent. The most common words
associated with risk were ‘danger’ (51; 69.8%), ‘harm’ (47; 64.3%),
and ‘hazard’ (46; 63.0%). Risk-associated negative emotions
included apprehension (50; 68.4%) and worry (44; 60.2%) with
fewer respondents associating risk with excitement (22; 30.1%)
and interest (22; 30.1%).
Doctors were more likely than midwives to describe their
behaviour as ‘calm’ in a risky situation (28; 90.3% versus 29;
69.0%, P < 0.05). Those with more years’ experience were more
likely to rely on risk assessment or a ‘gut feeling’ than clinical
guidelines or advice from others when evaluating clinical
situations regardless of occupation. Experiencing adverse events
caused respondents to re-examine their care (64; 87.7%), with a
fear of negative outcomes and difficulty sleeping noted by half of
respondents (36; 50.6%). It was felt that more staff support
services following an adverse event were required (70, 95.8%).
This study gives insight into the opinion of staff on risk, with
negative terminology being more prevalent. These experiences
affect staff professionally and personally. Risk-reduction strategies
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and increased staff support could help reduce the frequency of
risk events and improve staff experience.
EP.273
Calling for Category 1 caesarean section under
general anaesthetic – think again! Presenting a
lesser known non-obstetric complication of
emergency caesarean section
Halder, N1; Mukhopadhyay, L2
1
Glangwili General Hospital, Carmarthen, UK; 2Singleton Hospital,
Swansea, UK
Introduction Accidental extravasation of drugs from intravenous
drip into subcutaneous or perivascular space is not uncommon
ranging from 10% to 30% of all intravenous therapy. Most of the
time the consequences are minor; however, sometimes it may
cause serious complications like inflammation and necrosis.
Case P1 with previous vaginal delivery attended obstetric triage at
35 + 3 weeks gestation in labour with breech presentation. She
was 6 cm dilated at admission and declined vaginal breech
delivery hence was planned for Category 1 CS under general
anaesthetic (GA). At induction, the patient was awake after
administration of anaesthetic agent – thiopentone sodium. The
cannula was found to be tissued. A new one was sited and patient
was put to sleep with repeat dose of thiopentone. The operation
went well and the baby was delivered in good condition. On the
recommendation of plastic surgery team, the area was washed out
with normal saline and hyaluronidase at the earliest opportunity
and elevated. The area was closely monitored and there were no
signs of tissue ischaemia or necrosis; therefore, patient was
discharged home on Day 3.
Discussion Extravasation injuries depend on the nature of drugs
like vesicants, which cause tissue necrosis; irritants, which cause
inflammation; and those with no tissue damaging properties.
Thiopentone sodium is known to have vesicant property.
Conclusion The time difference in achieving adequate anaesthesia
in spinal versus general anaesthetic is 7–8 minutes only that has
114 ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG
not shown to affect the clinical outcome. Obstetricians need to be
mindful of this when requesting general anaesthetic.
EP.274
Pilot study to define traction force on the fetus
applied during non-rotational forceps delivery
Gamblin, H1; Munteanu, A1; Crudace, M2;
Hinshaw, K1,2; Joyce, T2
1
City of Sunderland Hospitals, Sunderland, UK; 2Newcastle University,
Newcastle, UK
Objective The UK operative vaginal delivery rate is 12%, with
50% being forceps’ deliveries. There is little contemporary
research on traction forces during a forceps’ delivery. In 1989,
Dennen suggested the maximal force should not exceed 200
Newtons for primigravidae. This study aims to provide up to date
research on safe traction forces, which could have great clinical
applications.
Design A small prospective cohort investigation into traction
force, using the clinicians in one unit.
Method A traction force rig was designed with a fetal mannequin
attached. Traction force was measured with forceps applied to the
fetal head. Pajot’s manoeuvre was used. Eleven obstetric consultants
and trainees at Sunderland Royal Hospital (of varying experience)
were asked to apply traction, firstly with the ‘normal force’ they
would use during a delivery, and secondly with the ‘maximum
force’ they would exert. Basic demographics were recorded.
Results We will present our results outlining the ‘normal’ and’
maximal’ forces applied and will confirm how they relate to data
presented by Dennen. We have further analysed data comparing
male versus female obstetricians, and the effects of height and
weight and ‘operator experience’ on the traction force. Results
from statistical analysis will be presented.
Conclusion The average traction forces found were consistent
with Dennen’s early data, supporting the accepted maximal
traction force of approximately 200N. This pilot study has
produced some interesting data that could be expanded to look at
clinical association of force with fetal and maternal morbidity.