Training and expertise in undertaking assisted vaginal delivery (AVD): a mixed methods systematic review of practitioners views and experiences

Abstract: Background: During childbirth, complications may arise which necessitate an expedited delivery of the fetus. One option is instrumental assistance (forceps or a vacuum-cup), which, if used with skill and sensitivity, can improve maternal/neonatal outcomes. This review aimed to understand the core competencies and expertise required for skilled use in AVD in conjunction with reviewing potential barriers and facilitators to gaining competency and expertise, from the point of view of maternity care practitioners, funders and policy makers. Methods: A mixed methods systematic review was undertaken in five databases. Inclusion criteria were primary studies reporting views, opinions, perspectives and experiences of the target group in relation to the expertise, training, behaviours and competencies required for optimal AVD, barriers and facilitators to achieving practitioner competencies, and to the implementation of appropriate training. Quality appraisal was carried out on included studies. A mixed-methods convergent synthesis was carried out, and the findings were subjected to GRADE-CERQual assessment of confidence. Results: 31 papers, reporting on 27 studies and published 1985–2020 were included. Studies included qualitative designs (3), mixed methods (3), and quantitative surveys (21). The majority (23) were from high-income countries, two from upper-middle income countries, one from a lower-income country: one survey included 111 low-middle countries. Confidence in the 10 statements of findings was mostly low, with one exception (moderate confidence). The review found that AVD competency comprises of inter-related skill sets including non-technical skills (e.g. behaviours), general clinical skills; and specific technical skills associated with particular instrument use. We found that practitioners needed and welcomed additional specific training, where a combination of teaching methods were used, to gain skills and confidence in this field. Clinical mentorship, and observing others confidently using the full range of instruments, was also required, and valued, to develop competency and expertise in AVD. However, concerns regarding poor outcomes and litigation were also raised. Conclusion: Access to specific AVD training, using a combination of teaching methods. Complements, but does not replace, close clinical mentorship from experts who are positive about AVD, and opportunities to practice emerging AVD skills with supportive supervision. Further research is required to ascertain effective modalities for wider training, education, and supportive supervision for optimal AVD use

Derivation of predicted no-effect concentrations for lindane, 3,4-dichloroaniline, atrazine, and copper

Environmental risk assessment is a key feature of regulations controlling the placing of new, and the maintenance of existing, chemicals products in the market place. For example, European Commission Directive 93/67/EC on Risk Assessment for New Notified Substances and Commission Regulation (EC) No. 1488/94 on Risk Assessment for Existing Substances requires that risk assessments be carried out for new and existing substances in the European Community. The process of environmental risk assessment seeks to determine the balance of probability of species and communities being damaged by chemical releases. The process relies upon a valid estimation of a predicted environmental concentration (PEC) in relevant environmental compartments and a predicted no effect concentration (PNEC) below which the organisms present in that compartment are unlikely to be significantly affected. If the PEC exceeds the PNEC there is a potential for damaging effects to occur. This article focuses on the determination of PNECs for risk assessment. Methods for determining a PNEC described in OECD Monograph 26 (1989, Report of the OECD Workshop on Ecological Effect Assessment, Paris, France, have been applied to data derived for the four chemicals lindane, 3,4-dichloroaniline, atrazine, and copper in a series of collaborative research projects funded by the European Commission

Development of methods for evaluating toxicity to freshwater ecosystems

This article presents a summary of a collaborative research program involving five European research groups, that was partly funded by the European Commission under its Environmental Research Program. The objective of the program was to develop aquatic toxicity tests that could be used to obtain data for inclusion at Level 2 of the Risk Evaluation Scheme for the Notification of Substances as required by the 7th Amendment to EC Directive 79/831/EEC. Currently only a very limited number of test methods have been described that can be used for this purpose and these are based on an even smaller number of test species. Tests based upon algae (Chlamydomonas reinhardi, Scenedesmus subspicatus, and Euglena gracilis), protozoa (Tetrahymena pyriformis), rotifera (Brachionus calyciflorus), crustacea (Gammarus pulex), and diptera (Chironomus riparius) were developed. The tests encompassed a range of end points and were evaluated against four reference chemicals: lindane, 3, 4-dichloroaniline (DCA), atrazine, and copper. The capacity of the tests to identify concentrations that are chronically toxic in the field was addressed by comparing the effects threshold concentrations determined in the laboratory tests with those determined for similar and/or related species and end points in stream and pond mesocosm studies. The lowest no-observed-effect concentrations (NOEC), EC(x), or LC(x) values obtained for lindane, atrazine, and copper were comparable with the lowest values obtained in the mesocosms. The lowest chronic NOEC determined for DCA using the laboratory tests was approximately 200 times higher than the lowest NOEC in the mesocosms

The development of toxicity tests for freshwater pollutants and their validation in stream and pond mesocosms

The number and variety of freshwater species and bioassay procedures currently recommended in European Directives for assessing the risk posed by pollutants to freshwater ecosystems is rather limited. The aim of the three consecutive European Commission-sponsored programmes described here was to modify or develop new laboratory methods that could be used for evaluating toxicity to freshwater species and which would be suitable for incorporation into the current "notification scheme" for new substances. An essential phase of each project was a validation process in which results of laboratory tests were compared with values obtained in the field using structural and functional responses of communities. The laboratory tests were developed by Fraunhofer-Institut für Umweltchemie und Ökotoxikologie (FhG) Potsdam-Rehbrücke with algae, protozoa and a variety of in vitro cellular/subcellular preparations; by the State University of Ghent with water column invertebrates, and by Cardiff University with benthic invertebrates. The laboratory tests included in vitro procedures, conventional whole organism single species tests, simple multi-species systems and microcosms. The field validation was carried out by Shell Research Sittingbourne employing artificial streams and by FhG Schmallenberg and GSF-Forschungszentrum für Umwelt und Gesundheit, Munich with artificial ponds and included single species responses but also structural and functional community responses. The same reference chemicals: lindane, copper, 3,4-dichloroaniline and atrazine were used by all laboratories. A comparison of the most sensitive toxicity response determined for each reference chemical using the laboratory toxicity tests, with that determined by the field simulation procedures revealed that for the reference chemicals lindane, copper and atrazine, adverse effects were not detected either for single organisms or for structural and functional characteristics of the community or ecosystem, at concentrations below those identified in the laboratory toxicity tests. In the case of dichloroaniline, however, effects on the population dynamics of one species in the pond mesocosm were recorded at a concentration ×16 below that reported in the laboratory. We conclude that appropriately designed, relatively simple and inexpensive laboratory toxicity tests with a selection of test species are generally adequate, with small application factors, for predicting the environmental risk of polluting chemicals to freshwater ecosystems

Sublethal and sex-specific cypermethrin effects in toxicity testing with the midge *Chironomus riparius* Meigen

Goedkoop W, Spann N, Åkerblom N. Sublethal and sex-specific cypermethrin effects in toxicity testing with the midge *Chironomus riparius* Meigen. Ecotoxicology. 2010;19(7):1201-1208.We quantified sublethal and sex-specific cypermethrin effects in experiments (29 days) with the midge Chironomus riparius at different levels of sediment organic matter content (0, 5, and 20%). We found highly significant effects of cypermethrin concentrations and sediment type on emergence, mean development rate, and adult size. For example, emergence/survival rates were 70–100% below 0.8 μg/l and unaffected by organic matter content. At 3.2 μg/l, however, no larvae survived in sediment without organic matter, but survival successively increased to 26 ± 11% in sediment with 20% organic matter. Mean development rates were always higher for males than for females, and significant differences between sexes occurred consistently in controls and in treatments with our lowest concentration of 0.05 μg/l. Sex-specific differences in mean development rate decreased across the cypermethrin gradient, suggesting that male development was affected more than that of females at similar concentrations. We also found an increase in adult size across the concentration gradient in sediments lacking organic matter and suggest an increased feeding activity due to sublethal toxic stress as a probable causal mechanism. We speculate that the observed sex-specific effects on development rates and adult size can have strong repercussions on emergence timing and fecundity, respectively