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The Future of OB/GYN – A Global Perspective

Imperial College London. The Joseph Price Oration. The Future of OB/GYN – A Global Perspective. Philip J Steer Emeritus Professor of Obstetrics Academic Department of Obstetrics and Gynaecology Chelsea and Westminster Hospital. 15 th September 2017. Joseph Price.

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The Future of OB/GYN – A Global Perspective

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  1. Imperial College London The Joseph Price Oration The Future of OB/GYN – A Global Perspective Philip J Steer Emeritus Professor of Obstetrics Academic Department of Obstetrics and Gynaecology Chelsea and Westminster Hospital • 15th September 2017

  2. Joseph Price • Born Rockingham County Virginia 1853 • MD University of Pennsylvania 1877 • Married Louise Troth, seven children • Obstetrical and Gynecological Department Philadelphia Dispensary • Abdominal surgery for ‘pelvic suppuration’ developed in the slums of Philadelphia “in the midst of filth and squalor”

  3. Joseph Price • Embraced the Listerian principles of aseptic surgery • 1891 founded 241 North Eighteenth Street Philadelphia • President, American Association of Obstetricians and Gynecologists 1895 • Died 1911 from retroperitoneal infection 2o to septicaemia

  4. Joseph Price • Never accepted Pasteur’s germ theory • Invited by Professor Penrose to lecture at the University – “These were not successful as far as the class was concerned” • “He had not the habit of mind for the writing of a scientific or technical paper” • (Howard A Kelly 1858-1943)

  5. Joseph Price presented the first paper at the first meeting of the American Association of Obstetricians and Gynecologists in 1881 – “Drainage in Abdominal Surgery”

  6. James Kennedy (1869-1957) • Assisted Joseph Price for 11 years • Worked at Price Memorial Hospital • 10 minute vaginal hysterectomy using Kennedy clamps • Established the Joseph Price oration in 1927 • Hospital razed 1950 to make way for a freeway – money donated to the AAOG • Aged 65 married Jean, aged 25

  7. Global issues I will address • Gender balance in OB/GYN professionals • The legal challenge • Delivery by C-section and the microbiome • Ensuring appropriate care

  8. Birth 1947

  9. Birth 2017

  10. Guy’s Hospital Medical School, University of London, 1965

  11. UK Royal College Presidents2017: • Royal College of Surgeons • Royal College of Physicians • Royal College of Obstetricians and Gynaecologists • Royal College of Paediatrics and Child Health • Royal College of Pathologists • Royal College of Radiologists • Royal College of General Practitioners • Dean, Royal College of Psychiatrists • Chair of the Academy of Medical Royal Colleges • Chair elect of the Academy of Medical Royal Colleges • Chair, British Medical Association Board of Science • Editor in Chief, BMJ

  12. Federal Almazov North-West Medical Research Centre, Russian Federation, May 2017 ‘Advances’ Congress, Trivandrum, Kerala, August 2017

  13. The future of Global OB/GYN staffing is female • Is it still important for men to be involved in reproductive health care?

  14. Crown indemnity Introduced for all NHS work

  15. Total Expenditure of the NHS Litigation Authority up to and including 2016-17 £1.707 B Million Pounds Sterling The data above have been extracted from the annual reports of the NHS litigation Authority, the website containing these reports is: http://resolution.nhs.uk/annual-report-and-accounts-201617/

  16. Annual value of NHSLA obstetrics payouts per year ≈ £2.3M per day, £1,220 per birth £853M £M Year

  17. Cost of a single cerebral palsy case January 2015 £10,135,511 March 2016 £17,000,000 April 2017 £25,300,000

  18. Changes to the Ogden formula March 2017 • Interest rate used to calculate payouts changed from +2.5% to - 0.75% • East Lancashire Hospitals NHS Trust payout for 10 year old girl with cerebral palsy increased from £3.77M in January 2017 to £9.29M in March 2017 • 2.5 fold increase

  19. Litigation globally • South Africa ↑ • Malaysia ↑ • India ↑ • USA ↑ • Bumper sticker seen in California: • Support the legal profession – • send your daughter to Medical School

  20. So what is the problem?

  21. The Daily TelegraphWednesday 16th August 2017 • Record rise in newborn babies with brain injury • NHS faces £2bn claims for blunders

  22. Is even higher elective Cesarean Section rates the answer?

  23. Maternal mortality • Antibiotics • Safe blood transfusion • Anaesthesia • Improved surgery

  24. Caesarean section and perinatal mortality rates in England & Wales

  25. Countries with CS rates >30% • China • Brazil • USA • Mexico • Iran • Argentina Gibbons L, et al, M, Althabe F. Am J Obstet Gynecol. 2012;206(4):331.e1-19. Italy Australia Chile Paraguay Cuba Korea

  26. Lancet. 2009 29;374(9691):675-6.Elective caesarean sections--risks to the infant.Steer PJ, Modi N.

  27. Problems of ELSCS for the baby, compared with vaginal birth • 20% increase in Diabetes1 • 20% increase in Asthma2 • ↑ Allergy3 • ↑ Obesity4 • Abnormal stress responses5 Cardwell CR, Stene LC, Joner G, et al. Diabetologia2008; 51: 726−35. ThavagnanamSet al ClinExp Allergy 2008; 38: 629−33. Koplin J, et al. Pediatr Allergy Immunol2008;19: 682−27. UtzRL. http://www.cppa.utah.edu/publications/health/PP_Prenatal_Care_Childhood_Obesity.pdf Miller NM, et al. BJOG 2005; 112: 921−26.

  28. Acquiring the correct gut flora • Baby has correct antibodies for maternal gut flora • Baby acquires mother’s gut flora as its mouth sweeps across the perineum

  29. Acquiring the correct gut flora • Baby born by CS can acquire mismatched gut flora • ? Leads to long term immune imbalance

  30. Publications on:Microbiome and pregnancy

  31. http://mamaseeds.com/blog/antibiotics/how-seed-your-baby-healthy-microbiome-last-lifetime/http://mamaseeds.com/blog/antibiotics/how-seed-your-baby-healthy-microbiome-last-lifetime/

  32. Nat Med. 2016 Mar;22(3):250-3 We conducted a pilot study in which infants delivered by C-section were exposed to maternal vaginal fluids at birth. ….our results demonstrate that vaginal microbes can be partially restored at birth in C-section–delivered babies. The long-term health consequences of restoring the microbiota of C-section–delivered infants remain unclear Newborns may develop severe infections from exposure to vaginal commensals and pathogens, which the mother may carry asymptomatically. • These include group B streptococcus • (the most common cause of neonatal sepsis), • herpes simplex virus, Chlamydia trachomatis, • And Neisseria gonorrhoeae

  33. The Global Problem • Knowledge about pregnancy has increased by >1,000% over the last 80 years • Many national guidelines for good practice now exist and clinicians are expected to know about them and practice accordingly • Unfortunately clinician’s brains have not increased in size by 1000% • We are being swamped with data

  34. Women’s expectations • Traditionally, people went to doctors who told them what they should do to stay healthy or be healed • Nowadays, people expect to be active participants in their care and make choices • Individuals are bewildered by the choices available and need reliable information • Doctors have insufficient time/knowledge to give full information and explain the options

  35. Data collection • The volume of pregnancy data is much too large for paper, and paper based data cannot be readily analysed • Data collection started in the 1970s using the PDP 11 and punched cards!

  36. But soon moved to PCs Midwife entering data St Mary’s Hospital 1982

  37. And was rolled out to 17 maternity units across the North West Thames Region in 1988

  38. COMPUTERISATION LED TO FEWER ERRORS • 75% reduction in major errors in birth notification Maresh et al (1983) Br J ObstetGynaecol90: 227-231 • Computer provides more and better information than unstructured history taking in antenatal clinics Lilford et al (1992) BMJ 305: 1181-1184

  39. Involving the mother and GP • A major DoH and BT project in the mid 1990s showed that this was feasible Steer PJ, Brockman A. A randomised controlled trial of computer data processing in the antenatal clinic. Br J ObstetGynaecol 1998; 105:1219.

  40. THE OPTICAL MEMORY CARD SYSTEM AS A DISTRIBUTED COMPUTING NETWORK

  41. But the project failed due to the limitations of the technology and its high cost

  42. Guidelines (protocols) • Started to be produced in the 1990s • NICE guideline on antenatal care now has 428 pages • Additional guidelines on diabetes in pregnancy, induction of labour, caesarean section etc. etc. • RCOG now has more than 60 green-top guidelines and 15 good practice guides

  43. BT project linked guidelines to pregnancy data

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