Emergencies in Obstetrics and Gynaecology

Gynaecological Emergencies in the Tropics: Recent Advances in Management

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Overall, the retest phase resulted in a significantly lower median number of questions asked compared with the test phase [ Perfect agreement between the expected and the observed triage decisions was found in Overestimation of the emergency level was observed in 63 ratings 9. Underestimation of the emergency level was slightly more frequent and was observed in 78 Levels 1 and 4 were more often allocated correctly than levels 2 and 3, the latter being more prone to assessment errors Table 2.

In univariate analysis, no factor was significantly associated with the correct allocation of the emergency level during the triage process or overtriage Table 3. Undertriage occurred less frequently for gynaecology than obstetric vignettes OR 0. The multivariate model showed that having the certificate in obstetrics and gynaecology emergencies was an independent factor for the avoidance of undertriage OR 0.

We were able to confirm the reliability of the SETS in an obstetrics and gynaecology setting and to explore the performance of nurses and midwives in the triage process. Moreover, we observed an excellent agreement between the reference standard and evaluators in Compared with other available triage instruments in obstetrics and gynaecology, the SETS has the advantage of being an integrated scale based on an extensively tested system in a general emergency department. There are several limitations to our study.

However, we used a standardised approach to implement the triage simulator in an obstetrics and gynaecology unit. There may be a selection bias due to exclusion of the sickest, sequential evaluation and, finally, the impossibility of performing test—retest processes.

Although users considered the simulator's narrative content to be close to reality, it lacked visual features, a detail previously proven to be beneficial, 18 and a revised version is currently under development.

Edited by S Arulkumaran

Ideally, the evaluation of a triage scale should incorporate the assessment of clinical outcome depending on triage level assignment and to address the potential adverse outcomes that would have resulted from the misassignment. Vignette 4 described a term pregnancy driving the evaluator towards orientation to the labour suite when easily available.

Finally, vignette 24 illustrated a case of sexual assault, which represents a delicate situation from medical, psychological and juridical points of view. The potential impact of an underestimation would be that severe cases might be unsafely diverted to lower acuity with potentially significant negative impact on the clinical outcome.

In our study, four vignettes were frequently rated with a lower level than expected 6, 18, 21, We considered this underestimation as a worrying finding. Associated hypotension should have prompted classifying the vignette at a higher level, although hyperemesis is usually considered a nonsevere disease.

Vignette 21 was a case of a common genital infection. The high pain score should have generated the allocation to level 3 instead of 4. Finally, vignette 25 illustrated the situation of an elderly woman presenting with pelvic organ prolapse. A level 3 management for the patient's comfort would be preferable over redirection towards an outpatient setting level 4. The right balance between overestimation and underestimation remains a subject of debate.

Obstetrics

Many authors consider underestimation more problematic and frequently argue that patient safety is of greater value than economic efficiency. Hospital administrators usually favour instruments that minimise the inappropriate use of resources. We observed also an important variability in the number of questions asked by participants. This is possibly a reflection of the difficulties encountered by triage professionals to obtain relevant information to stratify patients and deliver the most efficient care.

A similar variability has been described also in previous studies using a simulator or written vignettes. None declared. Completed disclosure of interests form available to view online as supporting Information. NVR managed the data, including quality control. AGA provided statistical advice on study design. NVR takes responsibility for the paper as a whole. The study was submitted to and approved in by the local Ethics Committee of the Geneva University Hospitals no. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors.

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Design Thirty clinical vignettes presenting the most frequent indications for obstetrics and gynaecology emergency consultations were evaluated twice using a computerised simulator. Setting The study was performed at the emergency unit of obstetrics and gynaecology at the Geneva University Hospitals. Sample The vignettes were submitted to nurses and midwives. Main outcome measures Triage acuity.

Results We obtained a total of evaluations. Tweetable abstract The Swiss Emergency Triage Scale is a valid and reliable tool for obstetrics and gynaecology emergency triage. Introduction Triage is the preliminary clinical assessment process that sorts patients before full diagnosis and treatment and has become crucial in times of overcrowded emergency units and resource constraints. Statistical analysis Because we were constrained by the number of participants and the number of clinical vignettes, we estimated that the expected variance for an expected ICC between 0.

Results We obtained a total of ratings Evaluation of the triage process We observed a wide variability in the median IQR number of questions asked per vignette, ranging from 8. Figure 1 Open in figure viewer PowerPoint. Variability in the number of questions asked per vignette A , and in the number of questions asked per participant B. Triage performance evaluation in the test phase Perfect agreement between the expected and the observed triage decisions was found in Discussion Main findings We were able to confirm the reliability of the SETS in an obstetrics and gynaecology setting and to explore the performance of nurses and midwives in the triage process.

Strengths and limitations Compared with other available triage instruments in obstetrics and gynaecology, the SETS has the advantage of being an integrated scale based on an extensively tested system in a general emergency department. Disclosure of interests None declared. Details of ethics approval The study was submitted to and approved in by the local Ethics Committee of the Geneva University Hospitals no. Funding The study was supported by funds from the Geneva University Hospitals for quality projects.

Thirty scenarios included in the triage simulator. J Emerg Nursing ; 25 : — Crossref PubMed Google Scholar. Google Scholar. PubMed Google Scholar. The end of the 19th century did mark a significant accomplishment in the profession with the advancements in asepsis and anaesthesia , which paved the way for the mainstream introduction and later success of the Caesarean Section.

Before the s mortality rates in lying-hospitals would reach unacceptably high levels and became an area of public concern. Much of these maternal deaths were due to puerperal fever , then known as childbed fever. In the s Dr. Ignaz Semmelweis noticed that women giving birth at home had a much lower incidence of childbed fever than those giving birth by physicians in lying-hospitals.

Despite the publication of this information, doctors still would not wash. It was not until the 20th century when advancements in aseptic technique and the understanding of disease would play a significant role in the decrease of maternal mortality rates among many populations. The development of obstetrics as a practice for accredited doctors happened at the turn of the 18th century and thus was very differently developed in Europe and in the Americas due to the independence of many countries in the Americas from European powers.

Gynaecology and Obstetrics gained attention in the American medical field at the end of the nineteenth century through the development of such procedures as the ovariotomy. These procedures then were shared with European surgeons who replicated the surgeries. This was a period when antiseptic, aseptic or anaesthetic measures were just being introduced to surgical and observational procedures and without these procedures surgeries were dangerous and often fatal.

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Following are two surgeons noted for their contributions to these fields include Ephraim McDowell and James Marion Sims. Ephraim McDowell developed a surgical practice in and performed the first ovariotomy in on a year-old widow who then lived on for thirty-one more years. He had attempted to share this with John Bell whom he had practiced under who had retired to Italy. Bell was said to have died without seeing the document but it was published by an associate in Extractions of Diseased Ovaria in By the mid-century the surgery was both successfully and unsuccessfully being performed.

Pennsylvanian surgeons the Attlee brothers made this procedure very routine for a total of surgeries—John Attlee performed 64 successfully of 78 while his brother William reported — between the years of and Marion Sims was the surgeon responsible for being the first treating a vesicovaginal fistula [16] —a condition linked to many caused mainly by prolonged pressing of the feotus against the pelvis or other causes such as rape, hysterectomy, or other operations— and also having been doctor to many European royals and the 20th President of the United States James A.

Garfield after he had been shot. Sims does have a controversial medical past.

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Under the beliefs at the time about pain and the prejudice towards African people, he had practiced his surgical skills and developed skills on slaves. One of the women he operated on was named Anarcha Westcott , the woman he first treated for a fistula. Women and men inhabited very different roles in natal care up to the 18th century. The role of a physician was exclusively held by men who went to university, an overly male institution, who would theorize anatomy and the process of reproduction based on theological teaching and philosophy.

Many beliefs about the female body and menstruation in the 17th and 18th centuries were inaccurate; clearly resulting from the lack of literature about the practice. During the birth of a child, men were rarely present. Women from the neighbourhood or family would join in on the process of birth and assist in many different ways.

The one position where men would help with the birth of a child would be in the sitting position, usually when performed on the side of a bed to support the mother. Men were introduced into the field of obstetrics in the nineteenth century and resulted in a change of the focus of this profession. Gynaecology directly resulted as a new and separate field of study from obstetrics and focused on the curing of illness and indispositions of female sexual organs. This had some relevance to some conditions as menopause, uterine and cervical problems, and childbirth could leave the mother in need of extensive surgery to repair tissue.

But, there was also a large blame of the uterus for completely unrelated conditions. This led to many social consequences of the nineteenth century. From Wikipedia, the free encyclopedia.

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