a) F b) F c) T d) T e) T

Little good-quality evidence is available to suggest that all immediate risks are lower with any particular route of delivery, but when it comes to early postpartum haemorrhage (PPH), obstetric shock and the need for blood transfusions, there is now convincing evidence in favour of planned Caesarean section. Maternal mortality from planned Caesarean section is now believed to be much lower than from a vaginal birth at one in 78,000. Women who have had a previous Caesarean section are at an increased risk of unexplained stillbirths at or after 34 weeks of gestation, even after adjusting for smoking, maternal age, social deprivation and birth weight. This is probably due to abnormalities in uterine blood flow, abnormal placentation and subsequent abruption. A primary Caesarean section is associated with an increased risk of spontaneous miscarriage, reduced fetal growth and preterm birth in subsequent pregnancies.

a) F b) T c) F d) F e) F

See above for the explanations for a and b. Recent studies have confirmed that maternal satisfaction rates, both in the immediate postpartum period and again at 3 months, are at least comparable if not higher after planned Caesarean section. The only randomised-controlled trial that has addressed this issue of postpartum depression found no difference between women having planned vaginal births or Caesarean section.

a) F b) T c) F d) T e) T

In women aged 50–64 years, the prevalence of SUI was found to be high irrespective of the route of delivery (28.6% after Caesarean section and 30% after vaginal births). The only randomised-controlled trial that examined sexual function after childbirth did not find any difference in sexual function 6 months after a vaginal birth or a Caesarean section. Other studies have confirmed no difference in sexual function even at 12–18 months, irrespective of the route of delivery. The protective effect of Caesarean section on SUI decreases with age and is abolished with three consecutive Caesarean sections. Thus, women having three planned Caesarean sections are at a similar risk of developing SUI as those having three vaginal births. A vaginal birth carries only a small risk (less than 1%) of initiating persistent SUI, and, in most cases, symptoms resolve within 3 months. If SUI starting in pregnancy persists at 3 months postpartum, however, there is a 92% risk of long-lasting SUI. In contrast to SUI, when it comes to anal incontinence, Caesarean section is definitely protective. After vaginal births, as many as 35% of primiparous women and 44% of multiparous women have anal sphincter defects on endo-anal ultrasound, and 4% have fecal incontinence. Only 39% of anal incontinence resolves in 10 months.

a) F b) F c) F d) T e) F

The explanations for number 4 are combined with those for number 5.

a) F b) T c) F d) F e) F

First do no harm is often invoked as the meaning of beneficence. The primary meaning of this ethical principle is that the clinician should seek the greater balance of clinical goods over harms for patients. When approaching the limits of medicine to alter the course of a condition, disease, or injury, the clinician should prevent net clinical harm to the patient. Respect for autonomy requires the clinician to empower the pregnant woman to make informed decisions. Neither the concept of fetal rights nor the discourse of ‘right to life’ have any role to play in understanding the moral status of the fetus in the professional responsibility model of obstetric ethics. This is one the principal advantages of the model. Beneficence requires the clinician, on the basis of evidence-based clinical judgment, to offer, recommend, and carry out clinical management that, on balance, protects and promotes the health-related interests of pregnant and fetal patients. Fair treatment of patients is required by the ethical principle of justice, which is not the same as either respect for autonomy or beneficence.

a) F b) F c) F d) T e) F

Simply acceding to her request without recommending against an un-indicated surgical procedure is inconsistent with professional responsibility. The obstetrician may be personally uncomfortable with the woman’s request but personal comfort and discomfort are subordinate to well-reasoned professional responsibility. There is no need to consult with risk management because the obstetrician’s professional responsibility is clear. Professional responsibility requires the obstetrician not to act on a patient’s request without first carefully assessing it in terms of both beneficence-based and autonomy-based obligations to the pregnant woman and beneficence-based obligations to the fetal patient. These obligations require the obstetrician to recommend against Caesarean delivery and to engage the woman in a thorough-going, reflective informed consent process. The last response mistakenly assumes that no informed, reflective decision by a pregnant woman is ethically acceptable.

a) F b) T c) F d) F e) F

The evidence about TOLAC after a previous classical incision supports a beneficence-based clinical judgment that TOLAC is unacceptably risky for the pregnant and fetal patients. Providing TOLAC is, therefore, inconsistent with the professional responsibility model of obstetric ethics. No obstetrician is ethically permitted to provide TOLAC to such patients, making referral to a colleague who does referral for substandard care, which is never permissible in professional medical ethics. Beneficence-based clinical judgment rules out TOLAC for such patients and rules in planned Caesarean delivery as the only ethically permissible form of intrapartum management. The obstetrician should, therefore, recommend against TOLAC and recommend planned Caesarean delivery. It is not necessary to consult Risk Management. Ethically impermissible forms of clinical management should never be provided. It is ethically impermissible to provide clinical management that is ruled out in beneficence-based clinical judgment.

a) F b) F c) T d) F e) F

Hysterectomy is the most common treatment for placenta accreta; however, this procedure requires advanced skills and resources. Total hysterectomy needs a wide pelvic-sub-peritoneal access and retrovesical dissection. If proximal vascular control is not guaranteed, the uncontrollable bleeding can end in sudden and devestating complications. Subtotal hysterectomy avoids the dissection of the invaded area, but it has a high risk of re-bleeding, because most parts of the invaded tissues and new vascularisation are placed below the uterine reflection. Although it is not a definitive solution, hysterotomy provides time to plan a complete solution later. If diagnosis is made during Caesarean section by Pfannenstiel incision, it is necessary to open the fascia by midline or to carry out a midline incision to access a non-invaded area. This approach has the lowest risk of bleeding and it is a better option if the resources and team are not available. Resection of the invaded area needs a skilled team and resources. Such emergency surgery is not an option if these conditions are not available. Although the initial appearance seems a local problem, the infraperitoneal involvement should never be underestimated. Compression sutures are only effective for some cases of atonic PPH and principally deal with upper segment bleeding – they are therefore unlikely to be effective with an accreta with a large collateral supply.

a) F b) F c) F d) T e) F

Because the internal iliac artery has multiple anastomoses from other pelvic vessels, ligature is not usually adequate for proximal vascular control. In addition, identification of the posterior trunk is hard but necessary to avoid ischaemic complications. In addition, if vessel dissection is not well performed, there is an additional risk of internal iliac vein damage. If this injury occurs, the solution is extremely difficult even for vascular surgeons, and obviously it provokes additional major haemorrhage. Endovascular occlusion has the possibility of causing embolisation contemporaneously. The transfer of a woman with active bleeding, however, can be extremely dangerous. On average, the time to transfer a woman and carry out a procedure, in ideal situations takes 40–60 mins. If the bleeding is equivalent to 10% of placental blood flow, in 1 h the blood loss can be about 3000 ml that can aggravate previous shock and coagulopathy. Uterine packing is the oldest but most efficient method for stopping bleeding in obstetrics. Compression of the lower uterus, with damage of the anterior wall and active bleeding, is practically impossible. The excessive pressure could even produce more damage and bleeding. Aortic internal compression is the ideal method of stopping bleeding quickly and safely. This method can be carried out with minimal training, with no risk of additional damage. Direct aortic compression over the promontory stops almost all blood flow to the pelvis immediately. Clearly, it is not a definitive solution, but provides time to replace volume (e.g. blood, products of blood, crystalloids) without active bleeding. Also, it provides time to call for skilled, well-trained or experienced surgeons. Apart from evident bleeding, proximal vascular control avoids coagulopathy by continuous blood loss. The collateral supply of the uterus is very large and uterine artery ligation alone will be ineffective.

a) T b) F c) F d) T e) F

Square sutures compress a specific area of lower segment regardless of how many pedicles that ‘participate’. Placement of square sutures is carried out over the lower uterus, far from important structures such as the ureter. The compression suture simultaneously compresses vessels that arise from the anterior and the posterior uterine walls, and also produces an artificial compression of the lower myometrium. The Hayman procedure occludes mainly the uterine body and its arterial branches. Because the lower uterine segment receives an additional blood supply from pelvic-subperitoneal vessels, this procedure is usually ineffective. It does not produce effective compression of the lower myometrium. This is also true of the B-Lynch suture. Embolisation of uterine arteries can produce haemostasis in these cases; however, an additional use of particles may well be necessary to occlude countercurrent, lower uterine pedicles. Uterine artery ligation alone is ineffective due to the large collateral pelvic blood supply.

a) F b) F c) T d) F e) F

On the basis of published studies, it appears that puerperal hysterectomy in the presence of shock and coagulopathy can be dangerous, because the procedure involves the additional blood loss about 2000–3000 ml. This volume can aggravate the pre-existing shock and lead to life-threatening multiple organ failure later on. Uterine arterial embolisation is difficult in the presence of shock by vasoconstriction. Coagulopathy is not a strict contraindication, because the arterial puncture site can be sealed by specific products. However, the time to transfer a woman with shock and active bleeding can cause further haemostatic and haemodynamic deterioration. Uterine wrapping with Eschmarch’s bandage to stop the uterine bleeding immediately works in cases of coagulopathy. This is a standard method used in trauma surgery, and it is available in almost all surgical units. After placing two uterine wraps, the uterine size is reduced by one-half, through intensive tissue compression, Additionally, the procedure transfers uterine blood to the intravascular space through uterine veins. Uterine elastic wrapping provides time to replace volume and to restore clotting. It can be left in place for hours without risk of uterine damage. When clinical conditions are stable, the bandage is removed and compression sutures can be placed to achieve definitive haemostasis. The key is adequate uterine compression and simple pelvic packing is unlikely to achieve this. The intrauterine balloon is an excellent method of stopping uterine bleeding. Its efficacy, however, is diminished by shock and coagulopathy. This is likely because, during this condition, the uterus remains flaccid, and this decreases the balloon pressure and efficacy. Balloon tamponade achieves haemostasis by blocking the vessel openings or pressure on vessels and allows time for the blood to clot in the vessels of the placental bed. Hence, balloon tamponade is effective before coagulopathy develops.

a) F b) T c) T d) F e) F

Although the accuracy of the statistics may be questioned, evidence is consistent that fears of malpractice account for only a small part of the increase in the primary Caesarean section rate. It seems that financial incentives, time-management considerations, impatience with abnormal labours, and uncertainty with abnormal fetal heart rate patterns are likely to be more relevant especially during labour. As reflected in the thought experiment by Hankins, elective primary Caesarean section has significant benefits for reducing fetal and newborn harm from trauma, hypoxia, and stillbirth. That analysis is predicated on the first delivery. It is unlikely that those benefits extend to subsequent deliveries born after a prior Caesarean section. Evidence does not show an improvement in maternal outcomes by Caesarean section. The only potential issue is that of perineal preservation and long term pelvic floor protection is still an issue of much debate. The rising Caesarean section rate cuts across all ethnic groups, maternal demographics and gestational ages.

a) F b) F c) F d) T e) T

The risk of rupture was unchanged over the several decades preceding and since 1995. Evidence does not show a significant change in adverse fetal outcome, notwithstanding their risk of complications, especially if the uterus ruptured. Clearly, adverse outcome for the fetus was a prime mover of the decision to pursue a lawsuit. Because the rise in the VBAC rate was associated with a significant broadening of the indications for VBAC, a spate of successful lawsuits took place alleging (appropriately) lack of informed consent. This led to the modification of recommendations, to more inimical informed consent forms, and a decrease in the willingness of hospitals, clinicians and patients to participate. An informed consent form that emphasises adverse outcomes and grants immunity to the clinician for conduct related to the VBAC did not rest well with many women who refused to sign the document irrespective of their desire to pursue VBAC.

a) F b) T c) F d) T e) F

The test of the adequacy or appropriateness of the informed consent is determined by the woman, not the clinician. Informed consent is a dynamic process, not a signed piece of paper. It should be obtained with reasonably full disclosure and without coercion. As circumstances change, the informed consent needs to be revisited. A woman has the right to be informed of any significant change in the prognosis of an illness or the course of labour. When such a change occurs, the informed consent must be updated and the patient may renew or withdraw her consent. If a woman has withdrawn her consent for the VBAC attempt, the informed consent must be renegotiated and, if the woman continues to desire a Caesarean section, then this should be offered.

a) F b) F c) F d) T e) F

Average blood loss at Caesarean section when measured accurately is 930 ml.

a) F b) T c) F d) T e) F

Oxytocin injected by intravenous bolus at Caesarean section can cause hypotension. The optimal dose of intravenous oxytocin to give by bolus at Caesarean section, which causes uterine contraction with minimal side-effects of hypotension, is 2.5–5 iu. Misoprostol is inferior to oxytocin for PPH prophylaxis.

a) F b) T c) T d) F e) T

After failed medical treatment for uterine atony at Caesarean section, conservative surgical measures, such as uterine compression sutures, are recommended before proceeding to Caesarean hysterectomy. In cases of placenta praevia and accreta, or extensive uterine rupture, Caesarean hysterectomy may be carried out immediately as the first-line treatment after delivery of the baby. Sub-total hysterectomy is an adequate procedure to arrest the haemorrhage in most cases of PPH at Caesarean section, although, with major placenta praevia or uterine rupture extending down to the cervix, it would be insufficient. Most studies suggest the rate of occurrence of urological injuries at Caesarean section to be around 8%. The rate of re-laparotomy for ongoing bleeding after Caesarean hysterectomy is 8–18%.

a) T b) T c) T d) T e) T

All the conditions mentioned can cause PPH at Caesarean section. It is important that the surgeon systematically determines the cause of the excessive bleeding so that the correct modality of treatment to stop the bleeding can be used or better surgical assistance sought.

a) F b) T c) F d) T e) T

Uterine compression sutures, balloon tamponade and ergometrine are unhelpful when the excessive bleeding at Caesarean section is caused by extension of the angles of the uterine incision laterally into the broad ligament. The bleeding in this situation is traumatic, involving vessels of the uterine artery. The best way to arrest this form of bleeding is by uterine artery ligation. Haemostatic sutures can also be used and will reduce bleeding in most cases, but could cause a haematoma in the broad ligament.

a) T b) F c) T d) T e) F

The Term Breech Trial (2000) was a large multicentre, randomised-controlled trial of planned Caesarean section compared with planned vaginal breech delivery. Perinatal mortality, neonatal mortality and serious neonatal morbidity were lower for the planned Caesarean delivery group (17 out of 1039) than for the planned vaginal delivery group (52 out of 1039) (RR 0.33, 95% CI 0.19 to 0.56). A 2-year follow up of children from the Term Breech Trial study was published in 2004. It reported no difference between the two groups in morbidity, mortality and neurodevelopmental outcome. In The Term Breech Trial, no difference was found in perinatal mortality between a planned Caesarean section and a trial of vaginal breech delivery in countries with a low perinatal mortality rate, but a striking difference was found in serious short-term neonatal morbidity (0.4% v 5.1%). In 2006, the Royal College of Obstetricians and Gynaecologists and the American College of Obstetrics and Gynecology replaced their restrictive 2001 breech guidelines with new versions supportive of selected vaginal breech birth. No good evidence is available about the safety or otherwise of vaginal birth of preterm breech. A number of retrospective studies have shown that vaginal breech delivery of preterm and low birth weight newborns, particularly in nulliparous women, was associated with significantly increased neonatal mortality compared with Caesarean delivery.

a) T b) F c) F d) T e) T

Substantial epidemiologic data show an increased risk of stillbirth in twins more than 37–38 weeks gestation compared with that of singletons. Most authorities now consider that the optimum time of delivery for uncomplicated twins is between 37 and 39 weeks. Large epidemiological studies have also suggested that the second twin is at especially high risk of adverse perinatal outcome, including death. Although pooled retrospective data favour Caesarean delivery for twins where the first twin is non-vertex, the evidence is not strong. No prospective, randomised study has been published. No good evidence supports Caesarean delivery when the first twin is vertex and second twin is non-vertex. It is expected that some real evidence-based guidance will be provided by the results of the ongoing Twin Birth Study, a large international RCT of 2400 twin pregnancies randomly assigned to deliver vaginally or by Caesarean. In a vertex/vertex twin delivery, the second twin may not remain vertex presenting in 20% cases after the vaginal delivery of the first twin. This contributes to the increased perinatal mortality and morbidity risk of the second twin.

a) F b) T c) T d) F e) T

Groups 1, 2 and 5 contribute consistently to two-thirds of all Caesarean section rates. This illustrates an important principle in the study of Caesarean section rates that groups 1 and 2 are the biggest contributors of primary Caesarean sections, and group 5 is the biggest contributor of repeat Caesarean sections and the biggest single group contributor. Any strategy to reduce Caesarean section will need to be based primarily on groups 1 and 2, but also on group 5. Each group, however, will need other outcomes to be assessed in conjunction with the Caesarean section rates to decide appropriate management. Group 9 is a small group consistently 0.3–0.6% in size. Because of its nature, the Caesarean section rate is always 100%, and this group will therefore validate data quality. Although reducing Caesarean section rates in breech and twin pregnancies is much discussed, they rarely contribute more than 5% in absolute terms of the total Caesarean section rate. Group 3 is a large group, but because it normally contains low-risk women, the Caesarean section rate is rarely above 3%. If it is, then data collection is more likely to be a problem rather than a high Caesarean section rate.

a) F b) T c) F d) F e) T

The purpose of the MDQAP is not to reduce the Caesarean section but to decide the most appropriate Caesarean section rate taking into account all the other outcomes. The purpose of the MDQAP is to produce quality care but this cannot be done unless a standardised clinical report is produced. It is not simple to implement and requires leadership, commitment and discipline. Its success depends on many things, obstetricians only being one of these. Audit must be continuous and not intermittent so that variations in outcomes can be spotted quickly. By having these classified into different groups of women, any changes will be noticed more quickly and allow for more specific changes in management if required.

a) T b) T c) T d) F e) F

Practically, this monitoring and classification has been done and is illustrated in the National Maternity Hospital Clinical Report. The indications will vary according to nulliparous and multiparous women (with and without a scar), and again has been illustrated in the National Maternity Hospital Clinical Report. The distribution of the indications for Caesarean section in labour between fetal and dystocia, and particularly the subclassification of dystocia, will reflect the incidence, timing, dose and regimen of oxytocin in the individual delivery unit. This will particularly be true in group 1. In labour, the most common indication for Caesarean section is not fetal distress. Maternal request is not a well-defined indication. A practical and pragmatic definition is required if this subject is going be able to be studied.

a) F b) F c) F d) F e) F

The 10-Group Classification was first popularised by its use for analysing Caesarean sections. It was initially designed, however, to look at all events and outcomes in labour and delivery. Sometimes, sub-group analysis is useful and occasionally certain groups, for example (1and 2), and (3 and 4), when combined give additional information. It does include all women and that is one of the benefits of the 10-Group analysis as it is totally inclusive but individual groups are mutually exclusive. No individual woman can be classified into more than one group. Indications once defined and standardised should be used within each group as their incidence, implications and management will vary. Maternal request could, therefore, occur theoretically in each group. A nulliparous woman with a single cephalic pregnancy at greater than or equal to 37 weeks requesting a Caesarean section and planned to have one, but goes into spontaneous labour and proceeds with a Caesarean section will be recorded as maternal request. In the labour classification, it is recorded under dystocia no oxytocin by convention. The 10-Group Classification does not need a computer system, and one of the principles behind the classification was that it should be universal and possible to record with just a pencil and paper hence the gestation being only preterm or term. The 10-Group Classification was designed so that it could be used prospectively allowing changes to be made in certain groups of women if indicated.

a) F b) T c) T d) F e) F

No randomised-controlled trials have been conducted in this area, as it is extremely difficult, if not impossible, to conduct for this aim. The pH drops by 0.011 per min. The longer the duration, the lower the pH. Some studies have shown that this time scale is achievable in well-equipped and adequately trained units. The latest ACOG’s guideline emphasise the capability of an obstetric unit to accomplish delivery in 30 mins, instead of a ‘requirement’ for all emergency cases.

a) F b) T c) F d) F e) T

For category 1 and 2, RCOG recommends carrying out a Caesarean section as quickly as possible after making the decision, particularly for category 1, and to carry out category 2 Caesarean section in most situations within 75 mins of making the decision. The conditions described in b are life-threatening situations. Iatrogenic hyperstimulation can be managed by stopping the oxytocin infusion with or without acute tocolytic treatment. The hypertonic uterus often resolves in a tolerable period of time. Amnioinfusion has only been shown to be useful in cord compression owing to oligohydramnios. It is postulated that the relief of pain may lead to an imbalance in the type of maternal circulating catecholamines. Increased myometrial tone and increased uterine vascular resistance may be caused by the decrease of epinephrine levels in the continuing presence of high norepinephrine levels associated with the sudden onset of pain relief.

a) T b) F c) T d) T e) T

Fetal weight greater than 4000 g, short inter-delivery interval (less than 18 months or greater than 24 months), induction of labour and the use of high doses of oxytocin have been shown to increase the risk of uterine rupture during a trial of labour after Caesarean delivery in at least two studies. Several studies have shown that previous vaginal delivery decreases the risk. It is important to realise, however, that the ability of clinical variables to predict uterine rupture is poor. Attempts to create clinically useful multivariate logistic regression models, including clinical variables to estimate the individual risk of uterine rupture in each woman, have failed. Even though such models have been created, diagnostic information was too poor for them to be clinically useful. In view of this, it seems attractive to use ultrasound assessment of the lower uterine segment at 35–40 gestational weeks to try to improve estimation of the risk of uterine rupture during trial of labour in women with a Caesarean hysterotomy scar. One study used multivariate logistic regression analysis to show that a sonographically thin lower uterine segment (full thickness less than 2.3 mm), single layer closure of the hysterotomy and short inter-delivery interval (less than 18 months) significantly and independently predicted uterine rupture or dehiscence. The model, however, was created using a small number of participants, and the design of the study was not appropriate, so the results may be biased. The idea of combining clinical information with ultrasound information, however, seems attractive and should be explored in future studies.

a) F b) T c) T d) F e) F

The successful completion of stipulated OSATS is just one of a number of criteria required for progress at the waypoints of the specialty training programme. Other criteria include a pass in the relevant MRCOG examination (Part 1 for ST2 exit and Part 2 for ST5 exit). The three purposes identified for OSATS in the Matrix of Educational Progression are the demonstration of evidence of training in practical skills; confirmation of competence; and confirmation of continued competence. In the case of Caesarean section, it is the second of these purposes that is relevant to progression through the waypoints of the training programme. The tool only assesses technical competence within a procedure, rather than the decision to undertake that procedure. This is an important distinction, particularly in the case of Caesarean section, where it is often harder to decide to undertake a category 1 section rather than to carry out the procedure itself. The RCOG is planning currently to pilot the Non-Technical Skills for Surgeons (NOTSS) tool in order to capture non-technical skills on the labour ward, such as decision-making and communication. One of the three roles for the OSATS tool is to demonstrate ‘continued’ competence in a given procedure, once a trainee has been identified as ready for independent practice. Such an assessment should take place annually, with a procedure complexity appropriate for the year of training. The Matrix of Educational Progression requires different OSATS to be successfully completed for different technical competencies at different stages of the specialty training programme. For example, the OSATS confirming competence in lower-segment Caesarean section (at the appropriate level of complexity) is a requirement for ST2 exit, ST5 exit and ST7 exit. The OSATS confirming competency for assisted vaginal delivery, however, is only a requirement for ST2 exit, whereas the OSATS for rotational vaginal delivery and trial in theatre is only a requirement for ST7 exit.

a) F b) T c) F d) F e) T

Before attempting an OSATS in an entire procedure, trainees are first required to have demonstrated competence at the individual component parts (i.e. incising the visceral peritoneum and safely dissecting the bladder off the lower segment) in isolation. Of these, however, only opening and closing the abdomen has a specific OSATS, which is a requirement for ST1 exit. The three levels of complexity for the Caesarean-section procedure are identified in the Matrix of Educational Progression as follows: uncomplicated, intermediate and complex. The specific criteria, however, for each categorisation is not currently documented comprehensively, ensuring that there is an element of subjectivity in this judgment when it is recorded in any given encounter. The OSATS form used for Caesarean section is the same at all levels of procedure complexity. As such, the technical checklist is designed to cover straightforward and more complicated procedures. The trainee vignettes suggest that the OSATS tool seems to be better-suited to assessing performance in more straightforward cases than in more complicated cases. This seems to be due to a combination of the generic form design and insufficient assessor training.