Editor’s Choice

The European Working Time Directive (EWTD) of the Council of Europe (93/104/EC) is designed to protect the health and safety of workers in the European Union. It lays down minimum requirements relating to working hours, rest periods, annual leave and night working (http://www.en.wikipedia.org/wiki/Working_Time_Directive). Enacted in 1993, but in many countries phased in over more than a decade, it has had major effects on training in surgery. The working week is restricted to an average of 48 hours, with many subsidiary requirements such as: a minimum daily consecutive rest period of 11 hours, a minimum rest period of 24 hours in each 7-day period (or 48 hours in 14 days) and a maximum of 8 hours work in any 24 hours for ‘night workers in stressful jobs’. Much surgical training has traditionally taken place while dealing with emergencies at night. Guidelines now suggest that much of this work can more safely be deferred to daytime hours, with a consequent reduction in training opportunities for surgeons on night duty who are then not allowed to work during the day. This has led the Royal College of Surgeons of England (RCSE) to campaign against the restriction of surgical working hours. An October 2009 press release from the RCSE said that ‘since the implementation of the directive in August patients have been switched between up to four doctors in 24 hours—whereas previously junior doctors working an 80-hour week could guarantee continuity of treatment.’ John Black, President of the RCSE, told the UK newspaper The Times that ‘Multiple handovers are inherently unsafe. Every handover is an accident waiting to happen.’ A 2009 report from the RCSE reported that 90% of trainee doctors were exceeding their timetabled hours on a weekly basis, 85% reported coming in on their days off to perform operations, 68% felt that their training and skills had deteriorated as a result of shift-working patterns introduced to meet the working-time regulations, and 71% felt the reduction in overall hours had not led to any improvement in their work–life balance (http://www.rcseng.ac.uk/news/, accessed 4 November 2009). Impairment of the quality of surgical training secondary to reduced working time has also been reported from the USA, even though the reduction has only been to 80 hours (Jackson and Tarpley, BMJ 2009;339:1062–4). How do these issues play out in gynaecology? In this issue, we publish four papers that relate to training in gynaecological oncology surgery. On page 1, James Nevin and colleagues from the The PanBirmingham Gynaecological Cancer Centre (UK) comment on the growing perception that the development and maintenance of radical hysterectomy skills is becoming more difficult. Part of the problem is that the incidence of malignant disease is falling and alternatives to surgery have increasingly been introduced, but a major component is that trainees are entering training programmes with less surgical experience of open procedures. This makes it difficult for them to move on to learn the laparoscopic techniques that are increasingly being used. While the original Royal College of Obstetricians and Gynaecologists training syllabus required that trainees complete at least 20 radical cervical resections over 2 years, current caseloads in Birmingham provide a maximum of 14, and over half of these cases are performed laparoscopically. Moreover, once acquired, competency will be difficult to maintain. How are things outside the UK? In the commentary, colleagues from the USA, Canada and Belgium report similar challenges, and suggest some solutions. On page 26, Naik and colleagues from Gateshead (UK) report that 11.5% of women being operated on for gynaecological cancer needed bowel surgery. Of these 262 operations, only 21 were performed by a training fellow, although they did assist at an additional 204 cases. They highlight the need for trainees to attend supplementary modules in gastrointestinal surgery to gain relevant experience. They recommend the introduction of formal postfellowship training programmes to continue the development of appropriate skills, as insufficient experience is currently available within existing fellowship programmes. We invited the eminent gynaecological cancer specialist Scott Eisenkop from Los Angeles (USA) to comment on this paper, and in his mini-commentary he highlights the additional competition for training time from the need for trainees to carry out research (often in the laboratory), and to develop experience with the use of robotics. He emphasises the need for every surgeon to keep detailed records of procedures performed. In the future this will be necessary for revalidation in the UK, while in many parts of the world publishing details of one’s experience and success rates is already routine and expected by prospective patients. The importance of gynaecological oncologists being familiar with the management of bowel obstruction is highlighted in the paper by Rauh-Hain and colleagues from Boston (USA), on page 32. They report on 48 women with bowel obstruction resulting from ovarian cancer, and compare their progress with that of 192 controls, and found it to be associated with an impaired progression-free survival. In BJOG we have published a number of papers highlighting the ethical issues associated with various forms of gynaecological surgery, ranging from reconstruction of the hymen (restoring virginity) to female genital mutilation. In this month’s issue we highlight another growing area of concern, cosmetic labial surgery. On page 20, Lih-Mei Liao and her colleagues report that increasing numbers of healthy women are seeking surgery to ‘improve the appearance of their vulva’. Vaginal rejuvenation, designer vaginoplasty and G spot amplification are now among the procedures being actively marketed. Author Sarah Creighton has commented that ‘advertisements promote labial surgery as easy answers to women’s insecurities about their genital appearances—insecurities that are fuelled by the very advertisements that prescribe a homogenised prepubescent genital appearance standard for all women.’ She points out that surgery may damage nerve supply and when objectively assessed, is associated with impaired sensitivity and sexual function. Arguably, gynaecologists have a responsibility to promote healthier messages about the normal variation in female genitalia. In addition, surely women cannot give proper informed consent without information from good-quality research on the long-term effects of such surgery on women’s sexual function and wellbeing. Vaginal birth after previous caesarean (VBAC), commonly called ‘trial of scar’ in the UK, has always been more common in Europe than in the USA, probably because of the influence in the USA of Craigin’s dictum ‘once a caesarean always a caesarean’ (Cragin EB. NY Med J 1916;104:1–3). However, in the 1990s in the USA, there was a surge of enthusiasm for VBAC, which has since fallen away again following the publication of many anxiety-provoking accounts of intrapartum uterine rupture. Nonetheless, between 15% and 30% of women with one previous caesarean will opt for a VBAC. But surely two previous sections must mandate a repeat performance? This question is addressed on page 5 in a systematic review by Tahseen and Griffiths. Their pooled data analysis of 5666 cases shows a successful vaginal delivery rate of 71.1% following two previous caesareans. Unfortunately, this was attended by a scar rupture incidence of 1.36%, with a hysterectomy rate of 0.55%. Risks were lowest in women reporting a previous vaginal delivery. Repeat elective caesarean section did not however produce significantly lower rates of hysterectomy, blood transfusion or febrile morbidity overall, because the higher rates in women requiring an emergency caesarean were balanced by lower rates in those achieving a successful vaginal birth. They conclude that VBAC after two previous caesareans remains a reasonable option for women who are prepared to accept the associated risks. In the last year or so we have published a number of articles highlighting the major contribution of the use of too much syntocinon (causing uterine hyperstimulation in labour and consequent fetal asphyxia) to indefensible medicolegal cases, resulting in large financial settlements. This month we publish a paper illustrating the dangers of too high a dose of syntocinon even after the baby is born. On page 76, Jonsson and colleagues from Uppsala report a randomised controlled trial of intravenous boluses of 5 or 10 IU of oxytocin given to 123 women after delivery of the baby at caesarean section as prophylaxis against uterine atony and postpartum haemorrhage. Effects on the cardiovascular system were assessed by monitoring the electrocardiogram and recording symptoms such as chest pain and shortness of breath. More than one in five (21.6%) women given 10 IU had ST depression on the electrocardiogram, compared with fewer than one in 12 (7.7%) given 5 IU. Eleven percent of women given 10 IU complained of chest pain or shortness of breath, compared with 3.3% in the group given 5 IU. There was a fall in mean arterial pressure of 17 mmHg in the 10 IU group, compared with 9 mmHg in the 5 IU group. There were no differences in the blood loss or change in haemoglobin values between the two groups, although at the request of the obstetrician, seven women in the 5 IU group were given an additional oxytocin infusion and two were given intramuscular carboprost. The issues raised by this paper are further discussed in the letter from Muhammad Ajmal on page 118, who reminds us that oxytocin causes selective vasodilatation and vasoconstriction in a variety of blood vessels. Vasodilatation occurs primarily in the subcutaneous vessels, with vasoconstriction occurring primarily in the splanchnic bed and coronary arteries. The vasodilatation leads to a drop in blood pressure, which combined with the vasoconstriction in the coronary arteries is the probable cause of the electrocardiogram changes seen in the Jonsson et al. paper. He lists other papers reporting drops in mean arterial pressure of as much as 27 mmHg following bolus injection of syntocinon, and goes on to point out that the uterotonic efficacy of 2 IU of oxytocin is similar to that of 5 IU, while the haemodynamic effects are even less. It seems that this is another example of a situation where an effective treatment has in clinical practice been gradually altered on the basis that ‘more is better’ without recognition of the increasing incidence of adverse side effects. Maria Jonsson responds on page 119 by pointing out that giving a bolus over at least 5 minutes has been shown to reduce the cardiovascular side effects without compromising therapeutic benefits, and suggests that the alternative of giving a lower-dose oxytocin infusion on a continuing basis may be preferable, both in terms of avoiding side effects and reducing blood loss. Our theme issue for 2010 has been compiled by editors Adam Balen and Pierre Martin-Hirsch, and guest editor Sarah Creighton. Although serious pathology in adolescence is rare, functional problems are common and distress levels are often high. Problems such as menstrual pain occur in over 90% of female adolescents, and one in four miss schooling as a result. Although disorders of sexual development are rare, they deserve specialised care by experts if major emotional trauma is to be avoided (as illustrated recently by the unfortunate case of Caster Semenya, the South African 800 m runner who won the gold medal at the recent Athletics World Championships). Other important topics covered include preservation of fertility after treatment for cancer, the management of ovarian cysts in children, the diagnosis of polycystic ovarian syndrome in juveniles, and the vaccination of schoolgirls against human papillomavirus. The papers have been specially selected to contain important updates from experts on these difficult and controversial topics. They deserve close attention. Our theme issue will be on infections in pregnancy, under the aegis of editors Julia Hussein and Austin Ugwumadu, and guest editor Steven Witkin. Their call for papers is now on our website (http://www.bjog.org), with a submission deadline of 31 May 2010. Theme issues increase downloads and citations of papers by 50% or more, so if you want to give your paper global prominence, start preparing it for submission now!

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