BACKGROUND Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues' experiences and published evidence. METHODS In late 2020, BJS contacted colleagues across the global surgical community and asked them to describe how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had affected their practice. In addition to this, the Commission undertook a literature review on the impact of COVID-19 on surgery and perioperative care. A thematic analysis was performed to identify the issues most frequently encountered by the correspondents, as well as the solutions and ideas suggested to address them. RESULTS BJS received communications for this Commission from leading clinicians and academics across a variety of surgical specialties in every inhabited continent. The responses from all over the world provided insights into multiple facets of surgical practice from a governmental level to individual clinical practice and training. CONCLUSION The COVID-19 pandemic has uncovered a variety of problems in healthcare systems, including negative impacts on surgical practice. Global surgical multidisciplinary teams are working collaboratively to address research questions about the future of surgery in the post-COVID-19 era. The COVID-19 pandemic is severely damaging surgical training. The establishment of a multidisciplinary ethics committee should be encouraged at all surgical oncology centres. Innovative leadership and collaboration is vital in the post-COVID-19 era.Members of the BJS Commission Team are co-authors of this study and are listed under the heading Collaborators.

Objective: To demonstrate that studies on induction of labour should be analyzed by parity as there is a significant difference in the labour outcome among induced nulliparous and multiparous women Methods: Obstetric outcome, specifically caesarean section rates, among induced term nulliparous and multiparous women without a previous caesarean section were analyzed using the Robson 10 group classification 2 for the year 2016. Results: The caesarean rates among nulliparous women in spontaneous and induced labour, Robson groups 1 and 2A, were 7.8% (151/1925) and 32.6% (437/1339) respectively and among multiparous (excluding those women with a previous caesarean section), Robson group 3 and 4A were 1%(24/2389) and 4.4% (44/1005), respectively. Pre labour caesarean rates for nulliparous and multiparous women, Robson groups 2B and 4B 2 were 3.9% (133/3397) and 2.8% (100/3494), of the respective single cephalic cohort at term. Conclusion: The data strongly suggests that studies on induction of labour should be analyzed by parity and should probably be confined to nulliparous women.

This paper proposes a method for generating maps of Local Climate Zones (LCZs) within a GIS using administrative and 2.5D building databases. The LCZs are computed from morphological indicators and building typology, on vector reference spatial units that correspond to urban islets, i.e. blocks of buildings surrounded by nearby roads. The main originality is that, while mean building height criteria correspond exactly to the LCZ classification, a k-means statistical method is used to determine, for each city, the limits between compact and open (and sparsely built) LCZs for high-, mid-and low-rise LCZs, respectively. For example, in SO12 LCZ look-up tables and the WUDAPT-L0 mapping approach, "compact" LCZs correspond to a building density of over 40%. The resulting groups for Nantes, Toulouse and Paris for mid-height, treated with the proposed statistical method, are 36%, 37% and 33.8% respectively. The LCZ maps for these three cities are compared to the WUDAPT LCZ maps, the latter being obtained from satellite imagery at a resolution of 100 m. MApUCE LCZ maps show more spatial details, due to their finer resolution, and more variety in urban LCZs within each conurbation. This is very important for modeling micro-climatic effects on town peripheries.

INTRODUCTION: Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality in the US. Many obstetrical teams rely on clinical judgment when managing PPH, however critical care research has demonstrated that specific and uniform protocols result in better outcomes. This study analyzed the effect of implementation of a checklist-based management protocol for PPH. METHODS: A checklist was developed by a multidisciplinary team for the management of PPH that focused on timely diagnosis and systematic administration of uterotonics, invasive interventions, transfusions, and lab draws. A training video was used to introduce the protocol to nursing and physician staff. Following formal implementation, pre and post-protocol analyses were performed using nine matched months from 2015 and 2016. Outcome measures were surrogates for maternal morbidity. RESULTS: 147 subjects met criteria in the pre-protocol group and 150 met criteria in the post-protocol group. Within the analysis of the first three matched months, there was a significant decrease in surgical interventions for PPH (p value 0.039) and a decreased length of stay for PPH following cesarean sections (p value 0.039). In the 9 month analysis, there was a significant decrease in severe PPH as defined by an EBL of >2L (p value 0.035). CONCLUSION: The implementation of a checklist based management protocol for PPH has shown a promising trend in improving maternal outcomes and healthcare delivery for obstetric hemorrhage. Specifically, significant improvement in severe PPH rates was demonstrated. Further multi-center research is needed to demonstrate consistent beneficial effects of such protocols.

Nowadays, the absence of suitable data that describes the urban landscape in climate relevant terms for climatic models is a significant impediment to progress, even if the physics that underpins these models is universal. To address this data gap the World Urban Database and Access Portal Tools (WUDAPT) project focuses on creating a global database on cities suited for urban climate studies. The first phase of WUDAPT has established a protocol using the Local Climate Zones classification system to partition the urban landscape of cities into neighbourhood types that can inform parameter selection in model applications. In this paper, we explore the potential of these data for use in the application of the Weather Research Forecasting (WRF) model, which incorporates Building Effect Parameterization and Building Energy Model (BEP-BEM) schemes. The test is conducted for Madrid (Spain) during winter and summer and the results of using LCZ derived data are compared with those using CORINE land-cover data. The results are indicative but show that the LCZ scheme improves model performance. The paper emphasizes the need for further work to extend the value of these models for decisions on urban planning. However, such work will need useful urban data to make progress.

Early pregnancy identification of those at risk of later metabolic dysfunction may allow for pregnancy interventions to reduce maternal and fetal risk. We sought to investigate if maternal blood pressure in early pregnancy can predict later insulin resistance or fetal adiposity in a group at risk of macrosomia. This is a secondary analysis of a cohort of pregnancies from the ROLO randomized control trial of low GI diet in pregnancy to prevent the recurrence of macrosomia. Maternal blood pressure, weight and height were recorded at first antenatal consultation and body mass index (BMI) and mean arterial pressure (MAP) calculated. Fasting insulin and glucose were measured in early pregnancy and at 28 weeks and the HOMA index calculated. Fetal ultrasound at 34 weeks assessed fetal biometry including anterior abdominal wall width, a marker of fetal adiposity. A multivariate regression model was built to assess the relationship between maternal blood pressure and both insulin resistance and fetal adiposity, corrected for maternal BMI and original study group assignment. A total of 378 women were included in this secondary analysis. Maternal MAP in early pregnancy was 81.63 ± 6.7mmHg with a range from 53.3 to 102.3mmHg. MAP was significantly related to maternal BMI (r=0.3, p<0.001). On multivariate analysis, no significant relationship between BP and early pregnancy insulin resistance was observed. Maternal diastolic BP in early pregnancy however was independently related to fetal adiposity at 34 weeks, (β=0.158, p=0.02) and maternal systolic BP was independently related to maternal HOMA index (insulin resistance) at 28 weeks (β=0.162, p=0.014). Maternal early pregnancy blood pressure in a normotensive cohort may predict both later maternal and fetal metabolic dysfunction, independent of maternal BMI.

Treatment of hyperglycaemia in pregnancy is associated with a reduced risk of macrosomia. The objective of this study was to assess changes in maternal glycaemic and insulin profiles among women with GDM managed on diet, and investigate the influence of metabolic changes on neonatal outcomes. This is an observational secondary analysis of 93 pregnant women recruited to a randomised trial of probiotics in pregnancy (Props) which was found to have no influence on maternal glycaemia, insulin or neonatal outcomes. All women were diagnosed with GDM and were diet controlled. After diagnosis, women received antenatal care under the diabetes multidisciplinary team, including healthy lifestyle and low glycaemic index dietary advice and self-monitoring of blood glucose using glucometers. Fasting blood samples were collected following GDM diagnosis and repeated after 4-6 weeks for analysis of glucose, insulin and C-peptide. Homeostasis model assessment index (HOMA-IR) was calculated to assess insulin resistance. Changes in each parameter were calculated by paired samples t-test. Where significant changes were detected, associations with neonatal outcomes were assessed by correlation and regression analysis. A significant reduction in maternal fasting glucose (p<0.001) and HOMA-IR (p=0.045) was observed, but there were no changes in serum insulin or c-peptide. Reduction in fasting glucose did not correlate with any neonatal outcomes. Reduction in HOMA-IR was inversely correlated with neonatal birthweight (r=-0.27, p=0.013) and macrosomia (r=-0.28, p=0.012). These associations remained in regression analysis, adjusting for infant sex and gestation at delivery. No associations were detected with birthweight centile, LGA, SGA, admission to NICU or cord glucose and C-peptide. Women with GDM managed on diet experienced reductions in fasting glucose and HOMA-IR. This improvement in insulin sensitivity may help moderate birthweight and reduce the risk of macrosomia.

Sir, As a specialist trainee in Obstetrics and Gynaecology in Ireland, I wish to add some supportive information to reinforce the suggestion that the minimum time spent training in gynaecology be one year. An important issue for all trainees in Obstetrics and Gynaecology in this country, and indeed globally, is the struggle to acquire a good standard of surgical competency in gynaecology. The total number of years spent on the higher specialist training programme equates to approximately 5 years. Rotations between hospitals/regions on the specialist register are typically changed over on a yearly basis, with a few exceptions. This means that theoretically if a trainee is employed in the one institution for a period of 12 months that the system would allow for the trainee to remain operating with the same trainer for that time period. As the scheme encompasses both obstetrics and gynaecology training, at least one year with a designated gynaecology theatre list should not infringe upon obstetrics experience. I am including an anecdotal synopsis of my own exposure to gynaecology in theatre and cases performed while working as a Specialist Registrar in the National Maternity Hospital. While working here I also had a full time clinical involvement in obstetrics, including antenatal clinics and covering labour ward sessions. Favouring the argument for at least one year of operating in one centre, with one trainer for higher specialist trainees, is my experience as a 3rd year higher specialist trainee in obstetrics and gynaecology. Over a consecutive 12 month period at the National Maternity Hospital, 2013-2014, only 50% of theatre sessions were attended by me due to annual leave (consultant and my own) EWTD, having time off pre and post call (which was avoided if at all possible)and also where there was no unscheduled leave of absence. Attending one operating list a week the cases included 7 abdominal major cases, 8 vaginal hysterectomies and 14 vaginal repairs. This is a very basic and probably inadequate number of major procedures for a specialist trainee. In our view (myself and my trainer) the minimum amount of time for attachment to a unit should be one year, not forgetting that the trainer needs to establish a rapport with the trainee. N Maher, M Foley Department of Obstetrics & Gynaecology, National Maternity Hospital, Holles St, Dublin 2 Email: niamhisa@gmail.com Gynaecology Training for Higher Specialist Trainees in Obstetrics and Gynaecology, a Personal View 1

Objective: To determine the incidence and clinical presentations of preterm birth (PTB) <34 weeks gestation at the National Maternity Hospital (NMH), Dublin, Ireland and the University of Colorado Hospital (UCH), Denver, Colorado, between January 2007 to June 2008. Study Design: Retrospective cohort study using data from perinatal databases. Pregnancies complicated by anomalies, multiple gestations, and fetal demise were excluded. PTB was categorized as resulting from preterm labor (PTL), premature rupture of the membranes (PROM), and medically indicated preterm birth (MIPTB). Data were analyzed using univariate analyses, χ2, and Fisher exact test. Results: There were 12 739 births at NMH and 4 029 at UCH with a total of 407 PTBs <34 weeks at NMH (1.7%) and UCH (4.8%), respectively (P<.0001). Spontaneous preterm labor, PPROM, and MIPTB occurred 4, 2, and 3 times more frequently at UCH versus NMH. Chorioamnionitis was 3-fold higher at UCH (13.2% vs. 3.2% at NMH, p=0.001). Conclusion: Although the rate of PTB <34 weeks was significantly higher at UCH, the distribution of indications was remarkably similar. The incidence of chorioamnionitis was significantly higher at UCH. Further investigation of the similarities and differences between these populations is imperative in the effort to understand PTB and reduce its incidence worldwide.

OBJECTIVE: Probiotics are live microorganisms that may confer health benefits on the host. Recent trials of probiotic use among healthy pregnant women demonstrate potential for improved glycemic control. The aim of this study was to investigate the effects of a probiotic capsule intervention on maternal metabolic parameters and pregnancy outcome among women with gestational diabetes.STUDY DESIGN: This double-blind placebo-controlled randomized trial recruited pregnant women with a new diagnosis of gestational diabetes or impaired glucose tolerance following a 3-hour 100-g glucose tolerance test. Women were randomized to a daily probiotic (Lactobacillus salivarius UCC118) or placebo capsule from diagnosis until delivery. Fasting blood samples were collected at baseline and 46 weeks after capsule commencement for analysis of glucose, insulin, c-peptide, and lipids. The primary outcome was difference in fasting glucose postintervention, first analyzed on an intention-to-treat basis and followed by per-protocol analysis that excluded women commenced on pharmacological therapy (insulin or metformin). Secondary outcomes were changes in insulin, c-peptide, homeostasis model assessment and lipids, requirement for pharmacological therapy, and neonatal anthropometry.RESULTS: Of 149 women recruited and randomized, there were no differences between the probiotic and placebo groups in postintervention fasting glucose (4.65 +/- 0.49 vs 4.65 +/- 0.53 mmol/L; P = 373), requirement for pharmacological therapy (17% vs 14%; P = .643), or birthweight (3.57 +/- 0.64 vs 3.60 +/- 0.57 kg; P = .845). Among 100 women managed with diet and exercise alone, fasting plasma glucose decreased significantly within both the probiotic (4.76 +/- 0.45 to 4.57 +/- 0.42 mmol/L; P < .001) and placebo (4.85 +/- 0.58 to 4.58 +/- 0.45 mmol/L; P <. 001) groups, but the levels between groups did not differ (P = .316). The late gestation-related rise in total and low-density lipoprotein (LDL) cholesterol was attenuated in the probiotic vs the placebo group (+0.27 +/- 0.48 vs +0.50 +/- 0.52 mmol/L total cholesterol, P = .031; +0.08 +/- 0.51 vs +0.31 +/- 0.45 mmol/L LDL cholesterol, P = .011). No differences were noted between groups in other metabolic parameters or pregnancy outcome.CONCLUSION: A probiotic capsule intervention among women with abnormal glucose tolerance had no impact on glycemic control. The observed attenuation of the normal pregnancy-induced rise in total and LDL cholesterol following probiotic treatment requires further investigation, particularly in this obstetric group at risk of future metabolic syndrome.

ObjectiveTo assess the effect of a low glycemic index (GI) diet in pregnancy on maternal and fetal insulin resistance, leptin, and markers of inflammation.Study DesignA secondary analysis of the ROLO study, a randomized control trial of low GI diet in pregnancy to prevent macrosomia. Women were recruited at first consultation. At this visit and at 28 weeks fasting serum was analysed for insulin, leptin, TNF- α and IL-6. Maternal insulin resistance was calculated using the HOMA index. At delivery cord blood concentrations of leptin, TNF- α and IL-6 were recorded. Fetal insulin resistance was assessed with cord blood C-peptide estimation.ResultsThis analysis included 621 women recruited to the ROLO study. There was no difference between the two groups in fasting insulin or HOMA at 28 weeks. Similarly, no difference was noted in cord C-peptide between those who did and did not receive low GI advice in pregnancy. Women in the intervention arm of the study did have a lower overall rise in insulin concentrations from early pregnancy to 28 weeks gestation, p=0.04. 20% of women in the intervention arm were in the highest quartile for insulin change (28 week insulin minus insulin at booking) compared to 29% of controls (p=0.02). There was no difference between the two groups in leptin concentrations in early pregnancy, at 28 weeks or in cord blood at delivery. There was no difference between those who did or did not receive low GI advice with respect to either TNF- α or IL-6 in early pregnancy, at 28 weeks or in cord blood.ConclusionTabled 1 Open table in a new tab ObjectiveTo assess the effect of a low glycemic index (GI) diet in pregnancy on maternal and fetal insulin resistance, leptin, and markers of inflammation. To assess the effect of a low glycemic index (GI) diet in pregnancy on maternal and fetal insulin resistance, leptin, and markers of inflammation. Study DesignA secondary analysis of the ROLO study, a randomized control trial of low GI diet in pregnancy to prevent macrosomia. Women were recruited at first consultation. At this visit and at 28 weeks fasting serum was analysed for insulin, leptin, TNF- α and IL-6. Maternal insulin resistance was calculated using the HOMA index. At delivery cord blood concentrations of leptin, TNF- α and IL-6 were recorded. Fetal insulin resistance was assessed with cord blood C-peptide estimation. A secondary analysis of the ROLO study, a randomized control trial of low GI diet in pregnancy to prevent macrosomia. Women were recruited at first consultation. At this visit and at 28 weeks fasting serum was analysed for insulin, leptin, TNF- α and IL-6. Maternal insulin resistance was calculated using the HOMA index. At delivery cord blood concentrations of leptin, TNF- α and IL-6 were recorded. Fetal insulin resistance was assessed with cord blood C-peptide estimation. ResultsThis analysis included 621 women recruited to the ROLO study. There was no difference between the two groups in fasting insulin or HOMA at 28 weeks. Similarly, no difference was noted in cord C-peptide between those who did and did not receive low GI advice in pregnancy. Women in the intervention arm of the study did have a lower overall rise in insulin concentrations from early pregnancy to 28 weeks gestation, p=0.04. 20% of women in the intervention arm were in the highest quartile for insulin change (28 week insulin minus insulin at booking) compared to 29% of controls (p=0.02). There was no difference between the two groups in leptin concentrations in early pregnancy, at 28 weeks or in cord blood at delivery. There was no difference between those who did or did not receive low GI advice with respect to either TNF- α or IL-6 in early pregnancy, at 28 weeks or in cord blood. This analysis included 621 women recruited to the ROLO study. There was no difference between the two groups in fasting insulin or HOMA at 28 weeks. Similarly, no difference was noted in cord C-peptide between those who did and did not receive low GI advice in pregnancy. Women in the intervention arm of the study did have a lower overall rise in insulin concentrations from early pregnancy to 28 weeks gestation, p=0.04. 20% of women in the intervention arm were in the highest quartile for insulin change (28 week insulin minus insulin at booking) compared to 29% of controls (p=0.02). There was no difference between the two groups in leptin concentrations in early pregnancy, at 28 weeks or in cord blood at delivery. There was no difference between those who did or did not receive low GI advice with respect to either TNF- α or IL-6 in early pregnancy, at 28 weeks or in cord blood. ConclusionTabled 1 Open table in a new tab

The aim of this study was to assess the prevalence of severe maternal morbidity (SMM) as based on the Robson Ten Groups Classification system (TGCS). The National Maternity Hospital is a tertiary level unit with 9,000+ maternities per annum. SMM is prospectively reported and analysed based on either organ system (hepatic, cerebral, cardiac), complication (anaesthetic, hysterectomy, uterine rupture, anaesthetic) or on admission to an intensive care or coronary care unit. Cases from January 2007 to December 2011 were reviewed and assigned to the relevant TGCS group and reported as numbers/ per 1000 maternities. Between January 2007 and December 2011 there were 45,688 maternities, of which 156 met the criteria for major maternal morbidity, giving an overall rate of 3.1/1000 maternities, similar to our previous publication. Cases delivering in the first or second trimester (n=13) were excluded from this current analysis. The remaining 143 cases were classified as shown in Table 1. The highest prevalence of SMM was within Group 10 (preterm deliveries). Of the 51 maternities within this group, the majority of women were delivered as a result of the morbidity; the most common indication (n=26) being severe pre-eclampsia, eclampsia or HELLP syndrome. Maternities with multiple pregnancies or previous caesarean deliveries had higher prevalence of SMM compared to singleton, unscarred pregnancies. SMM prevalence within those undergoing induced labour was higher than those presenting in spontaneous labour, with no difference between the nulliparous and multiparous induced groups. The lowest rate of morbidity was found in women presenting in spontaneous labour. The TGCS system, already in use for comparison between units regarding caesarean delivery rates, can also be used to compare incidence of severe maternal morbidity. Most concerning is the SMM within multiparous women undergoing induction of labour, a group previously considered "low risk".Tabled 1Severe maternal morbidity as analysed by the Robson Ten GroupsCS: Caesarean Section. Open table in a new tab

Objective: Placenta accreta, morbid adherence to the uterus to the myometrium, is commonest in association with placenta previa in women previously delivered by caesarean section (CS). It has become proportionally a greater cause of major maternal morbidity and mortality as the frequency of other serious obstetric complications has declined. The aim of this study was to examine the incidence of placenta accreta in the context of a rising caesarean delivery rate.Study design: Retrospective review of the incidence of placenta accreta in parous women during the 36 years 1975-2010. Cases were identified from hospital records and then correlated with pathological reports. The incidence of placenta accreta was analysed in the context of women previously delivered by CS.Results: During the 36-year period in our unit, 157,162 multiparous women delivered, of whom 15,151 (9.6%) had a previous CS scar. The institutional incidence of CS rose from 4.1% in 1975 to 20.7% in 2010. Twenty-five parous women, all with a previous CS, had placenta accreta requiring hysterectomy. The overall incidence of placenta accreta was 1.65 per 1000 parous women with a previous CS, but was low (1.06/1000) until 2002. From 2003 to 2010 the incidence rose to 2.37/1000 previous CS deliveries (OR 2.2; 95% CI 1.05-5.1).Conclusion: The frequency of placenta accreta correlated steadily with the CS rate until 2000. Since then, the incidence has nearly doubled in women with previous CS scars, suggesting an additional causative influence on risk. (C) 2013 Published by Elsevier Ireland Ltd.

Background Evidence is accumulating that leptin can be regarded as a biomarker of fetal adiposity. We sought to clarify the relationship between maternal and fetal leptin, insulin resistance and both maternal and fetal adiposity in a healthy, euglycemic population. Methods This is a prospective study of 574 mother and infant pairs. Women were recruited at first antenatal consultation. At this visit maternal weight, height and arm circumference (a marker of maternal adiposity) were recorded. Maternal leptin, glucose and insulin were measured in early pregnancy and again at 28 weeks and the HOMA index calculated. At 34 weeks, ultrasound assessed fetal anthropometry including anterior abdominal wall width (AAW), a marker of fetal adiposity. At delivery birthweight and cord blood c-peptide and leptin were recorded. Results There was a correlation between maternal and fetal leptin concentrations and both maternal BMI ((r=0.52 in early pregnancy, r=0.42 at 28 weeks, r=0.16 in cord blood, p<0.001 for all) and maternal adiposity (r=0.46 in early pregnancy, r=0.34 at 28 weeks and r=0.215 in cord blood, p<0.05 for all). Those with higher HOMA indices at each timepoint had higher leptin concentrations. Fetal, not maternal, leptin was significantly related to AAW at 34 weeks (r=0.14, p=0.013). Conclusion Our findings confirm the significant influence of leptin on fetal growth. Leptin was associated not only with the deposition of fat in utero but also with maternal and fetal insulin resistance. These findings suggest that leptin is a biomarker for fetal adiposity, and may have a role in the fetal programming of childhood obesity.

BACKGROUND:Pre-pregnancy care improves pregnancy outcomes in type 1 diabetes mellitus (T1DM). Continuous subcutaneous insulin infusion (CSII) therapy and multiple daily injection (MDI) therapy can both be used to achieve glycaemic targets, but few data are available to compare their efficacy in pre-pregnancy care.AIM:To compare MDI and CSII in pre-pregnancy care in T1DM.METHODS:Retrospective database review of women with T1DM attending the Dublin Diabetes in Pregnancy Centre.RESULTS:464 women with T1DM (40 treated with CSII) were included. Women attending for pre-pregnancy care had lower HbA1c levels at booking to antenatal services [52 ± 10 mmol/mol (6.9 ± 0.9 %) vs. 62 ± 16 mmol/mol (7.8 ± 1.5 %), p < 0.001], and booked at an earlier gestation (6 ± 2 vs. 8 ± 6 weeks, p < 0.001). In those who attended for pre-pregnancy care, the CSII group had lower HbA1c levels at booking than those using MDI [48 ± 8 mmol/mol (6.5 ± 0.7 %) vs. 53 ± 10 mmol/mol (7.0 ± 0.9 %), p = 0.03]. Gestational age at delivery and birth weight did not differ between groups. Caesarean section rates were associated with CSII use (p < 0.001), duration of diabetes (p = 0.002), and parity (p = 0.006). Nulliparous women using CSII with a longer history of diabetes were more likely to deliver by Caesarean section. There was no perinatal mortality.CONCLUSIONS:Pre-pregnancy care delivered by a specialist multi-disciplinary team effectively reduces HbA1c levels peri-conception. CSII use results in lower HbA1c levels in pre-pregnancy care in selected individuals and should be considered in women with T1DM planning pregnancy.

Introduction In 2011 “life style intervention” was introduced in addition to a low glycaemic diet and insulin (when required), for management of patients diagnosed with gestational diabetes (GDM) at the National Maternity Hospital. Methods A prospective study of the potential benefit of lifestyle intervention versus standard management in the treatment of gestational diabetes mellitus. Lifestyle management included group education on diet and exercise and a personal glucometer for home blood sugar monitoring, reinforced at least weekly contact with the diabetic team. Data on demographics, insulin use and macrosomia was collected. Results In the period 2008–2010, 412 cases with GDM received standard management and from 2011 onwards, data was available on 353 cases of GDM following the introduction of life style intervention. Patient demographics were similar in both groups and there was no significant difference in mean age, BMI, gestational weight gain and ethnicity between the two groups. In the pre-intervention cohort, 40.7% (168/412) were treated with insulin, compared with 22% (78/353) post intervention (p < 0.001).The incidence of macrosomia (birth weight >90% centile for gestational age) was 20% prior to 2011 (84/412) and 13.8% (49/353) following intervention (p < 0.04) (Table 1). Conclusion The results show that the intervention has almost halved the need for insulin treatment in patients with GDM without any compromise in fetal outcome. The results strongly suggest that a randomised trail of life style intervention should be conducted.

A fathers presence during labour is now commonplace in modern obstetric practise. We sought to evaluate fathers’ experiences of pregnancy, labour and delivery. A survey was distributed to fathers in the postnatal period, and comprised of 17 questions. The questions were quantitative and multiple-choice in nature. No qualitative data was sought. A total of 1000 completed questionnaires were submitted for analysis. The mean age of fathers in the study was 33.8 years. Approximately 70% of the population were married, while 27.3% were in long term relationships. A significant percentage of the fathers were employed (88.1%) in paid work. Less than 8% were unemployed. First time fathers constituted the largest group (53.7%). Planned pregnancies constituted 77.9% with 2.5% as a result of fertility treatment. Seventy percent of fathers were ‘overjoyed’, 18.4% were ‘pleased’ and 11.3% responded either neutrally or negatively to the news of the pregnancy. Fathers were found to be likely to be present at ultrasound scans (89.1%) but less likely to be involved in antenatal education classes (48%). Almost all fathers were present at the delivery (97.2%). Nearly half of the fathers (49.6%) planned to attend the delivery because they really wanted to witness the birth, 43% attended to support their partner. At every stage of the pregnancy fathers perceived midwifery staff to have communicated better when compared to medical staff. Our quantitative survey found that in general fathers involvement with the pregnancy process and their attendance at the birth to be a positive experience. Communication processes can be improved to better support the father in his role during this time.