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Publication #mycaesarean: An innovative service improvement programme to enhance the birth experience for women undergoing elective caesarean(AIMS, 2021-09-01) Smith, Georgia; Harford, Charlotte; Arlidge, Maggie; Smith, Georgia; Harford, Charlotte; Alridge, Maggie; Medical and Dental; Nursing and Midwifery RegisteredNo abstract available Full text freely available: https://www.aims.org.uk/journal/item/positive-experience-caesareansPublication Day case pathway for patients with hyperemesis: a qualitative improvement project(Wiley, 2021-06-06) Fernandopulle, Navindi; Doraiswamy, Jothi; Fernandopulle, Narindi; Doraiswamy, Jothi; Medical and DentalImplementation of a novel day case pathway for patients with severe nausea and vomiting in pregnancy: a qualitative improvement project. Objective Severe nausea and vomiting affects 75% of pregnant women. Patients that do not respond to initial management are referred via their GP to A&E. The Gynaecology Emergency Clinic (GEC) open from 9am to 5 pm on weekdays is a novel, innovative approach to managing these patients as a day case. It was developed after a PDSA cycle identified the need for a specialist hyperemesis pathway due to an increased number of admissions not receiving appropriate care. The main objective is to assess if patients are being referred appropriately from GP and A&E to GEC and onto the ward in line with national guidelines. Design GEC has dedicated nursing staff and clinicians to provide patients with antiemetics, fluids and appropriate care. A ‘hyperemesis pack’ has the paperwork for prescribing and information leaflets for patients. If patients remain unwell or arrive out of hours, they are admitted to the ward. Method Obtain records of patients from March to August 2020 who presented with nausea and vomiting in pregnancy and analyse the care they received. Results 77 attendances were analysed. 60% of patients had attended previously. Patients that attended outside the opening hours of the clinic were 5 times more likely to be admitted. 40% patients self referred to A&E. 80% of all patients prescribed ondansetron received no counselling regarding the risk of developing cleft lip and palate. 40% patients with prolonged hyperemesis had not been prescribed thiamine. PUQE score was not recorded in 94% admissions. Ketones were not recorded in 1 in 5 patients. 6% patients it was not clear if the GP had prescribed antiemetics prior to their attendance to hospital. Conclusion Encouraging referrals directly to the GEC clinic for the hyperemesis pathway reduces pressures on A&E, and referring patients during GEC opening hours reduces the likelihood of patients needing to be admitted overnight. This could lead to shorter waiting times for patients and improve their quality of life. The GEC pathway will be promoted through social media awareness and informing local GPs of this service. Lectures and small group teaching will be delivered to highlight recent changes in guidelines.Publication Spontaneous fundal uterine rupture in a non-labouring 31-week twin pregnancy and unknown previous hysteroscopic adhesiolysis: A case report(Elsevier, 2021-02-27) Smith, Georgia; Walker, Sarah; Vandhana, Ravi; Swingler, Rebecca; Smith, Georgia; Walker, Sarah; Vandhana, Ravi; Swingler, Rebecca; Medical and DentalA 46-year-old woman presented at 31 weeks of gestation with a twin pregnancy (dichorionic, diamniotic) and with mild abdominal pain, not in labour, leading to complete spontaneous fundal uterine rupture. She underwent prompt surgical intervention and resuscitation with packed red cells, cell-salvage blood and fresh frozen plasma (FFP). Twin 1 survived and twin 2 died. Risk factors for fundal uterine rupture were multiple pregnancy and hysteroscopic adhesiolysis, which was unknown during antenatal care. The mother and twin 1 made excellent progress post-operatively. This case highlights the importance of swift intervention to minimise maternal and perinatal morbidity and mortality.Publication Less Is More: A Narrative Review of Deciding When Surgical Intervention Should Be Withheld(Springer, 2022-03-18) Stout, Annabel; Hamer, Jack; Sharples, Tahlia; Tahmasebi, Farshad; Sharples, Talia; Medical and DentalDecision-making in surgery is one of the great unspoken challenges, an important but markedly challenging skill that takes a lifetime to master. The choice not to operate generally proves a significantly harder conclusion than opting for intervention. Our paper explores the influences which affect a clinician's decision to operate or not. The challenging situation where patient and clinician disagree on proposed management is also explored. Implications on management are discussed, with constructive communication techniques offered, including the recent COVID-19 pandemic.Publication EP.0375 An audit of care in the multiple pregnancy journey(Wiley, 2022-06-10) Brehaut, Georgina; Burton, Claudia; Arlidge, Maggie; Brehaut, Georgina; Burton, Claudia; Arlidge, Maggie; Medical and DentalObjective: To provide the highest quality multiple pregnancy care with the aim of reducing complications and improving outcomes for mothers and babies. To ascertain the current level of care being provided to women and families with multiple pregnancies. To assess whether this is in line with current national guidance which was updated in 2019. Design: Retrospective audit. Method: This audit analysed multiple pregnancies and multiple births between1st May 2020 to 1st May 2021. The audit standards were predefined based upon the NICE guidance NG137 Twin and Triplet Pregnancies. There was an expected compliance defined at 100%. Cases were identified through the informatics team. Antenatal, intrapartum and postnatal notes were analysed. Both written notes and computer systems including Trakcare and Viewpoint were used. Data extracted was collated within excel and included information about maternal, fetal and neonatal factors. These were then assessed against the audit standards prior to being analysed by clinicians to draw conclusions and recommendations. Results: Certain areas of antenatal and postnatal care showed 100% compliance with the audit standards. These included; documentation of chorionicity/amnionicity at first scan, referral to fetal medicine if <10th centile, continuous foetal heart rate monitoring in labour and active management of third stage of labour. All MCDA pregnancies were counselled on risk of twin-to-twin transfusion syndrome. However the following areas did not meet the standard; only 23.30% had evidence of aspirin prescription from 12 weeks, 16.67% had full blood count between 20–24 weeks and 63.33% at 28 weeks. 66.67% met recommendations for fetal growth assessment by ultrasound.70% were counselled on risk of preeclampsia, 66.67% were counselled on risk of pre-term birth, 36.67% were counselled regarding corticosteroids, 90% discussed mode of delivery options, 70% were counselled on growth concerns, 16.67% were counselled on risk of post-partum haemorrhage, 86.67% had discussed epidural and 93.33% of deliveries occurred at recommended gestation, or earlier if risk of maternal/fetal compromise. Conclusions: These results are encouraging for intrapartum and postnatal care but show areas for significant improvement. In particular, aspirin for reduction of hypertensive disease, appropriate scan surveillance, optimisation of haemoglobin levels, and the antenatal risk discussions and options with regard to mode of birth need improvement and documentation. It is important to understand the limitations when auditing clinical discussions retrospectively. Following a period of staff education and implementation of an updated care pathway we will reaudit to ensure the best possible care is provided.Publication PD01 First UK report of pregnancy and childbirth in X-linked erythropoietic protoporphyria(Oxford University Press, 2023-06-26) Schulenburg-Brand, Danja; Powell, James; Srivastava, Pushplata; Swingler, Rebecca; Peek, Russell; Swingler, Rebecca; Peek, Russell; Medical and DentalX-linked erythropoietic protoporphyria (XLEPP), an exceptionally rare form of cutaneous porphyria, is characterized by significant acute painful photosensitivity and a risk of both reduced bone mineral density and protoporphyric hepatopathy that may progress to liver failure. Diagnosis requires demonstration of significantly elevated red cell total porphyrins consisting of both zinc and free protoporphyrin analysed on venous whole blood. As the condition is X-linked, any offspring of an affected woman has a 50% chance of inheriting the disease-causing ALAS2 gain-of-function mutation. There are no reported cases of pregnancy in XLEPP in the literature, and no published experience of managing newborn infants that may have inherited XLEPP who develop neonatal jaundice, which requires treatment with phototherapy. Here we describe the clinical course of a 29-year-old woman with XLEPP (part of a four-generation XLEPP family) and idiopathic thrombocytopenia during pregnancy—the first documented case in the UK, to our knowledge. A multiprofessional team considered the potential risks posed by XLEPP and idiopathic thrombocytopenia for the pregnancy, birth and newborn. Haematological and biochemical indices were monitored throughout the pregnancy. The mother experienced increased photosensitivity and worsening idiopathic thrombocytopenia during the pregnancy, the majority of which occurred over summer. Idiopathic thrombocytopenia did not respond to treatment with steroids and immunoglobulin, necessitating a general anaesthetic for the planned caesarean section. A male infant was born in good condition at term. Maternal blood loss was only just above average. The baby remained well in the immediate postnatal period. Although the baby did not require treatment for jaundice, management planned in advance included minimizing factors predisposing to jaundice, including optimal timing of cord clamping and early feed support, the urgent analysis of cord blood erythrocyte porphyrins within 24 h, using a light-emitting diode phototherapy device with narrow spectrum emission between 450 and 470 nm and minimal emission at 400 nm, monitoring the baby closely for signs of distress and skin changes, and considering adjustment of the phototherapy thresholds or using alternative treatments should jaundice occur. Cord blood erythrocyte total porphyrin results suggested the baby had inherited XLEPP and would be photosensitive. This was later confirmed by mutation analysis.Publication Exploring midwives’ perceptions and experiences of home birth(MIDIRS (Midwives Info. & Resource Service), 2025-06) Hughes, Susan; Hughes, Susan; Nursing and Midwifery RegisteredIn the context of the low national home birth rate, a local home birth service was developed. Since its implementation, there has been no formal review of factors that may influence the home birth service’s effectiveness. Midwives’ perceptions and experience of home birth, which can have an impact on the home birth rate, has been largely unexplored. This service evaluation used a qualitative approach, which highlights that midwives believe issues such as: exposure to home birth, midwifery philosophy, essential home birth training and investment from management would increase midwives’ feelings of confidence in home birth, potentially increasing local home birth rates.