Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.

Safe prevention of the primary cesarean delivery

Obstetric care consensus no. 1: safe prevention of the primary cesarean delivery.

Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis

The comparison of the immunological state of pregnancy to an immunosuppressed host-graft model continues to lead research and clinical practice to ill-defined approaches. This Review discusses recent evidence that supports the idea that immunological responses at the receptive maternal-fetal interface are not simply suppressed but are instead highly dynamic. We discuss the crucial role of trophoblast cells in shaping not only the way in which immune cells respond to the invading blastocyst but also how they collectively react to external stimuli. We also discuss the role of the microbiota in promoting a tolerogenic maternal immune system and highlight how subclinical viral infections can disrupt this status quo, leading to pregnancy complications.

The unique immunological and microbial aspects of pregnancy

Objective: the primary objective of these guidelines is to review the clinical aspects of Postpartum Haemorrhage (PPH) and provide guidelines to help clinicians prevent and manage excessive bleeding postpartum. Options: prevention, appropriate intervention, keys to minimizing its impact. Outcomes: establish practices to facilitate the identification of women who may be at particularly high risk of PPH and to allow prompt intervention should excessive bleeding occur Evidence: follows the Qualify of Evidence of The Canadian Task Force on the Periodic Health Examination. Values: developed by experts in the field of obstetrics. Benefits, harms and costs: the use of uterotonic drugs and other active management techniques have been evaluated based on their convenience, accuracy, availability and safety Recommendations: the 12 recommendations listed in the guidelines have been graded according to the level of evidence on which they are based Validation: Medline references were sought using the MeSH heading postpartum haemorrhage. The Cochrane Library was searched for relevant studies. The ALARM course Manual was consulted. Sponsors: developed and reviewed by the Clinical Practice Obstetrics Committee and approved by the Council of the SOGC. DEVELOPMENT

Prevention and Management of Postpartum Haemorrhage

Objective To design Canadian guidelines advising obstetric care providers of the maternal, fetal, and neonatal implications of aerobic and strength-conditioning exercises in pregnancy. Outcomes Knowledge of the impact of exercise on maternal, fetal, and neonatal morbidity, and of the maternal measures of fitness. Evidence MEDLINE search from 1966 to 2002 for English-language articles related to studies of maternal aerobic and strength conditioning in a previously sedentary population, maternal aerobic and strength conditioning in a previously active population, impact of aerobic and strength conditioning on early and late pregnancy outcomes, and impact of aerobic and strength conditioning on neonatal outcomes, as well as for review articles and meta-analyses related to exercise in pregnancy. Values The evidence collected was reviewed by the Society of Obstetricians and Gynaecologists of Canada (SOGC Clinical Practice Obstetrics Committee) with representation from the Canadian Society for Exercise Physiology, and quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on the Periodic Health Exam. Recommendations 1. All women without contraindications should be encouraged to participate in aerobic and strength-conditioning exercises as part of a healthy lifestyle during their pregnancy. (II-1,2B) 2. Reasonable goals of aerobic conditioning in pregnancy should be to maintain a good fitness level throughout pregnancy without trying to reach peak fitness or train for an athletic competition. (II-1,2C) 3. Women should choose activities that will minimize the risk of loss of balance and fetal trauma. (III-C) 4. Women should be advised that adverse pregnancy or neonatal outcomes are not increased for exercising women. (II-1,2B) 5. Initiation of pelvic floor exercises in the immediate postpartum period may reduce the risk of future urinary incontinence. (II-1C) 6. Women should be advised that moderate exercise during lactation does not affect the quantity or composition of breast milk or impact infant growth. (I-A) VALIDATION: This guideline has been approved by the SOGC Clinical Practice Obstetrics Committee, the Executive and Council of SOGC, and the Board of Directors of the Canadian Society for Exercise Physiology. Sponsors This guideline has been jointly sponsored by the Society of Obstetricians and Gynaecologists of Canada and the Canadian Society for Exercise Physiology.

Exercise in pregnancy and the postpartum period.

OBJECTIVE To provide guidelines for operative vaginal birth in the management of the second stage of labour. OPTIONS Non-operative techniques, episiotomy, and Caesarean section are compared to operative vaginal birth. outcome: Reduced fetal and maternal morbidity and mortality. EVIDENCE MEDLINE and Cochrane databases were searched using the key words 'vacuum' and 'birth' as well as 'forceps' and 'birth' for literature published in English from January 1970 to June 2004. The level of evidence and quality of recommendations made are described using the Evaluation of Evidence from the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS 1. Non-operative interventions such as one-to-one support, partogram use, oxytocin use, and delayed pushing in women using epidurals will decrease need for operative birth. (I-A) 2. Manual rotation may be used alone or in conjunction with instrumental birth with little or no increased risk to the pregnant woman or to the fetus. (III-B) 3. Routine episiotomy is not necessary for an assisted vaginal birth. (II-1E) 4. When operative intervention in the second stage of labour is required, the options, risks, and benefits of vacuum, forceps, and Caesarean section must be considered. The choice of intervention needs to be individualized, as one is not clearly safer or more effective than the other. (II-B) 5. Failure of the chosen method, vacuum and/or forceps, to achieve delivery of the fetus in a reasonable time should be considered an indication for abandonment of the method. (III-C) 6. Adequate clinical experience and appropriate training of the operator are essential to the safe performance of operative deliveries. Hospital credentialing boards should grant privileges for performing these techniques only to an appropriately trained individual who demonstrates adequate skills. (III-C). VALIDATION The Clinical Practice Obstetrics Committee and Executive and Council of the Society of Obstetricians and Gynaecologists of Canada approved these guidelines.

Guidelines for operative vaginal birth.

Objective To establish national standards of care for the screening and recording of alcohol use and counselling on alcohol use of women of child-bearing age and pregnant women based on the most up-to-date evidence. Evidence Published literature was retrieved through searches of PubMed, CINAHL, and the Cochrane Library in May 2009 using appropriate controlled vocabulary (e.g., pregnancy complications, alcohol drinking, prenatal care) and key words (e.g., pregnancy, alcohol consumption, risk reduction). Results were restricted to literature published in the last five years with the following research designs: systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no language restrictions. Searches were updated on a regular basis and incorporated in the guideline to May 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment (HTA) and HTA-related agencies, national and international medical specialty societies, clinical practice guideline collections, and clinical trial registries. Each simple-article was screened for relevance and the full text acquired if determined to be relevant. The evidence obtained was reviewed and evaluated by the members of the Expert Workgroup established by the Society of Obstetricians and Gynaecologists of Canada. The quality of evidence was evaluated and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. Values The quality of evidence was rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table 1). Sponsor The Public Health Agency of Canada and the Society of Obstetricians and Gynaecologists of Canada. Endorsement These consensus guidelines have been endorsed by the Association of Obstetricians and Gynecologists of Quebec; the Canadian Association of Midwives; the Canadian Association of Perinatal, Women's Health and Neonatal Nurses (CAPWHN); the College of Family Physicians of Canada; the Federation of Medical Women of Canada; the Society of Rural Physicians of Canada; and Motherisk. Summary Statements 1.There is evidence that alcohol consumption in pregnancy can cause fetal harm. (II-2) There is insufficient evidence regarding fetal safety or harm at low levels of alcohol consumption in pregnancy. (III) 2.There is insufficient evidence to define any threshold for low-level drinking in pregnancy. (III) 3.Abstinence is the prudent choice for a woman who is or might become pregnant. (III) 4.Intensive culture-, gender-, and family-appropriate interventions need to be available and accessible for women with problematic drinking and/or alcohol dependence. (II-2) Recommendations 1.Universal screening for alcohol consumption should be done periodically for all pregnant women and women of child-bearing age. Ideally, at-risk drinking could be identified before pregnancy, allowing for change. (II-2B) 2.Health care providers should create a safe environment for women to report alcohol consumption. (III-A) 3.The public should be informed that alcohol screening and support for women at risk is part of routine women's health care. (III-A) 4.Health care providers should be aware of the risk factors associated with alcohol use in women of reproductive age. (III-B) 5.Brief interventions are effective and should be provided by health care providers for women with at-risk drinking. (II-2B) 6.If a woman continues to use alcohol during pregnancy, harm reduction/treatment strategies should be encouraged. (II-2B) 7.Pregnant women should be given priority access to withdrawal management and treatment. (III-A) 8.Health care providers should advise women that low-level consumption of alcohol in early pregnancy is not an indication for termination of pregnancy. (II-2A)

https://westernhealth.nl.ca/uploads/Addictions%20Prevention%20and%20Mental%20Health%20Promotion/Clinical%20Guidelines.pdf

Alcohol use and pregnancy consensus clinical guidelines.

Objective: To provide evidence-based guidelines for the provision of a trial of labour (TOL) after Caesarean section.

http://www.csh.org.tw/dr.tcj/Educartion/Guideline/OB%20guideline/VABC%204%20Guideline.pdf

Marie-Jocelyne Martel

Papers

Prevention and Management of Postpartum Haemorrhage

Exercise in pregnancy and the postpartum period.

Guidelines for operative vaginal birth.

Alcohol use and pregnancy consensus clinical guidelines.

Guidelines for vaginal birth after previous Caesarean birth.