I visited Porto, Portugal in March 2008 as part of the ENTOG exchange programme. This venture involved an insightful three day experience at St Joao hospital, the second biggest hospital in the country. Situated in the northern part of Portugal, rich in cultural heritage, Porto is also well known for its export of Port, a drink enjoyed worldwide. The experiences gained have left me with an invaluable knowledge of the differences in practice in Obstetrics and Gynaecology between Portugal and the United Kingdom. I also managed to get some sightseeing done and sample the local culinary delicacies!
The XVIII European Meeting and exchange programme this year was followed by the 20th EBCOG European congress in Lisbon which I also attended.
Visiting Hospital -St Joao Hospital
This hospital is a large University hospital and important tertiary referral unit serving the northern part of the Country. The department of Obstetrics and Gynaecology is a very active practical and academic centre and also a regional centre for assisted reproduction and Paediatric surgery. The unit consists of approximately 10 professors, 26 specialists, and numerous trainees at different levels of their postgraduate training in the speciality.
Obstetrics and Gynaecology is split over several floors with clinics on the ground floor, gynaecology on the first floor and the labour ward on the fourth floor. The hospital has approximately 2600 deliveries per year and the unit has Eight delivery rooms and two low risk rooms. In addition there are two rooms dedicated to emergency triage work. During my time at the hospital, I spent dedicated sessions in the Labour ward, Ultrasound department and Maternity assessment suite. I attempted to gain as much information in to the practices by shadowing residents and observation.
The emphasis of the programme was on obstetrics and my exposure to gynaecological theatre and clinic was limited. I shall therefore focus my attention on this area as well as postgraduate training structure in Portugal Unfortunately my command of the Portuguese language was limited. English was not widely spoken amongst doctors or patients and therefore it wasn't beneficial to sit in on antenatal clinics.
My initial impression was that service provision in Obstetrics was quite similar to that offered in the UK however on closer observation I did notice certain differences Initial striking differences were that all Doctors in the hospital were expected to wear a white coat. After expressing his alarm at me not even possessing one, the head of the department promptly issued me with one of his own! I soon realised the added benefits of the white coat as a status symbol both within the hospital and in the local shopping centre, where it was used to queue jump in most of the eating establishments! Trainees are referred to as residents within the hospital and are assigned according to a monthly rota depending on seniority.
Antenatal care
Maternity care in Porto is a largely protocol led service and this was evident from each resident carrying a copy of department guidelines around with them. Protocols are evidenced based and are broadly similar to UK obstetric units.
As in England midwives assume responsibility for the routine care of the low risk pregnant woman Antenatal care consists of a schedule of outpatient appointments mainly in the hospital. At each visit, the blood pressure and urine is checked as well as a routine obstetric assessment. Such assessments are recorded in maternity handheld records.
There is a greater emphasis on scanning in Portugal and almost all women undergo nuchal translucency scanning at around 11weeks gestation. There is also widespread use of 3D scanning in both the hospital and private sector. In addition all women have a routine third trimester ultrasound scan (around 30 weeks) presumably as a screening tool for growth restriction. All women also undergo routine Glucose tolerance testing at 24 weeks gestation to screen for gestational diabetes. Women have direct 24hr access to the labour suite with minor ailments of pregnancy.
Labour
Women who are undergoing normal labour are usually clerked in by a resident who decides whether she is low or high risk. Low risk labourers are generally cared for by midwives however deliveries may occasionally be carried out by residents. Partograms are designed in a similar manner and are plotted by midwives. Any concerns are reported to the residents on call immediately and there is a central alarm system for obstetric emergencies.
All women undergo continuous electronic fetal monitoring in labour and this is linked to a central monitoring system which is accessible from several areas in the labour suite. The fetal assessments are carried out using traditional CTG interpretation as well as the use of STAN and a locally developed technique called “Omniview” Sis porto. Opiates are used generously as pain relief in early labour. An epidural service is available and the local population had around an 80-90% uptake rate.
The doula is becoming a more prominent sight in the delivery room in Portugal. Partners generally are the primary birthing partners and usually have separate access to the delivery room for privacy however they are encouraged to wear white coats when in the delivery room!
Assessments are carried out regularly in labour. A vaginal examination is carried out every hour in the active phase of labour until delivery to ensure adequate progress. Paired examinations are carried out by residents and midwives. The second stage of labour is managed by placing many women routinely in the lithotomy positions. Fundal pressure is routinely employed in the second stage of labour to aid delivery. There also appeared to be a rather liberal use of episiotomy.
The concept of trial of instrumental delivery in theatre is a practice that has emerged in the UK over the past few years in cases of possible failed instrumental delivery. This is not carried out in Porto and I saw two instances of failed instrumental deliveries in a delivery room being taken as an emergency to theatre.
Caesarean sections are usually carried out under regional anaesthetic however interestingly the operating surgeons did not have the help of a scrub –nurse to pass instruments and helped themselves to surgical instruments on a sterile tray. All caesarean sections are carried out by Specialists on the labour suite. These are the equivalent of post CCT fellows who have completed the training programme however are resident on the labour suite 24hrs a day. The Caesarean section rate was approximately 22% and every caesarean section from the previous day was discussed at a multidsiplinary meeting held at 8.30am every morning.
Postgraduate Training in Obstetrics and Gynaecology
Portuguese medical students undergo a six year training programme as part of their undergraduate curriculum. Having graduated from medical school, they undertake two years of general training in basic medical and surgical specialties.
This is followed by a postgraduate entrance exam which determines entry to higher medical training. The scores obtained in this exam enable them to choose which specialty they may enter. Some specialties such as dermatology are fiercely competitive and require high scores. Obstetrics and Gynaecology is also a popular specialty amongst junior doctors and as such requires good grades to access training programme.
Postgraduate training in Obstetrics and Gynaecology is a six year structured programme. The first two years focuses on general obstetrics and years three and four on general gynaecology The fifth year includes three month rotations in Oncology, assisted reproduction, minimal access surgery and urogynaecology. In the final year of training, a trainee may choose to spend six months in another hospital and in this year may choose to undertake further training in a subspecialty of their choice. Training is assessed by yearly assessments by examination and also using a variety of assessment tools similar to those used in the UK. Residents are allocated an educational supervisor at the commencement of the training programme and can approach them at any stage for support.
Some of the main differences in training is that all trainees are skilled in both transvaginal and abdominal Ultrasound scanning from an early stage. Scanning is employed routinely in gynaecology clinics as well as emergency triage department by junior trainees to aid diagnosis and guide management.
Trainees are also not expected to operate independently until they are accredited as a specialist and are very closely supervised at all times. Trainees work on average 42 hrs a week however this does not include a “12hr on call” session per week covering emergency gynaecology and labour ward.
Whilst on call there are two residents and two specialists.
- Resident: Within the six year training program
- Specialist: Post CCT fellow.
Generally patients are seen by the residents and then reviewed by the specialists
There are 24 specialists working at St Jaou and they undertake resident on call system until the age of 50. After 50 they work 12hrs and then over 55 stop on calls. The trainees were not generally aware of the European Working Time Directive and appeared to be very satisfied in both their current working conditions and enthusiastic about their future careers.
ENTOG Meeting and EBCOG Conference Lisbon
On the Tuesday I made the journey to Lisbon to attend the ENTOG meeting which was scheduled as part of the 20 th European Congress of Obstetrics and Gynaecology. This was a very informative and useful experience where I had the opportunity to meet with several other trainees from various European countries. Presentations were also made about the varied experiences of the trainees who were placed in hospitals across Portugal.
The ENTOG exchange programme and meeting is an experience that I recommend highly to trainees who are interested in the cultural diversity and differing approaches to women's health in Europe
Srinivas Amirchetty