Lily Lee

Guidelines for the Management of Pregnancy at 41+0 to 42+0 Weeks

OBJECTIVE To provide evidence-based guidelines for the management of pregnancy at 41+0 to 42+0 weeks. OUTCOMES Reduction of perinatal mortality associated with Caesarean section at 41+0 to 42+0 weeks of pregnancy. EVIDENCE The Medline database, the Cochrane Library, and the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynecologists, were searched for English language articles published between 1966 and March 2007, using the following key words: prolonged pregnancy, post-term pregnancy, and postdates pregnancy. The quality of evidence was evaluated and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. Recommendations 1. First trimester ultrasound should be offered, ideally between 11 and 14 weeks, to all women, as it is a more accurate assessment of gestational age than last menstrual period with fewer pregnancies prolonged past 41+0 weeks. (I-A) 2. If there is a difference of greater than 5 days between gestational age dated using the last menstrual period and first trimester ultrasound, the estimated date of delivery should be adjusted as per the first trimester ultrasound. (I-A) 3. If there is a difference of greater than 10 days between gestational age dated using the last menstrual period and second trimester ultrasound, the estimated date of delivery should be adjusted as per the second trimester ultrasound. (I-A) 4. When there has been both a first and second trimester ultrasound, gestational age should be determined by the earliest ultrasound. (I-A) 5. Women should be offered the option of membrane sweeping commencing at 38 to 41 weeks, following a discussion of risks and benefits. (I-A) 6. Women should be offered induction at 41+0 to 42+0 weeks, as the present evidence reveals a decrease in perinatal mortality without increased risk of Caesarean section. (I-A) 7. Antenatal testing used in the monitoring of the 41- to 42-week pregnancy should include at least a non-stress test and an assessment of amniotic fluid volume. (I-A) 8. Each obstetrical department should establish guidelines dependent on local resources for scheduling of labour induction. (I-A).

Epidemiological investigation of a temporal increase in atonic postpartum haemorrhage: a population‐based retrospective cohort study

Increases in atonic postpartum haemorrhage (PPH) have been reported from several countries in recent years. We attempted to determine the potential cause of the increase in atonic and severe atonic PPH.

Contribution of prepregnancy body mass index and gestational weight gain to caesarean birth in Canada

BackgroundOverweight and obese women are known to be at increased risk of caesarean birth. This study estimates the contribution of prepregnancy body mass index (BMI) and gestational weight gain (GWG) to caesarean births in Canada.MethodsWe analyzed data from women in the Canadian Maternity Experiences Survey who had a singleton term live birth in 2005-2006. Adjusted odds ratios for caesarean birth across BMI and GWG groups were derived, separately for nulliparous women and parous women with and without a prior caesarean. Population attributable fractions of caesarean births associated with above normal BMI and excess GWG were calculated.ResultsThe overall caesarean birth rate was 25.7%. Among nulliparous and parous women without a previous caesarean birth, rates in obese women were 45.1% and 9.7% respectively, and rates in women who gained above their recommended GWG were 33.5% and 8.0% respectively. Caesarean birth was more strongly associated with BMI than with GWG. However, due to the high prevalence of excess GWG (48.8%), the proportion of caesareans associated with above normal BMI and excess GWG was similar [10.1% (95% CI: 9.9-10.2) and 10.9% (95% CI: 10.7-11.1) respectively]. Overall, one in five (20.2%, 95% CI: 20.0-20.4) caesarean births was associated with above normal BMI or excess GWG.ConclusionsOverweight and obese BMI and above recommended GWG are significantly associated with caesarean birth in singleton term pregnancies in Canada. Strategies to reduce caesarean births must include measures to prevent overweight and obese BMI prior to conception and promote recommended weight gain throughout pregnancy.

Rationale and recommendations for improving definitions, registration requirements and procedures related to fetal death and stillbirth

definitions, registration requirements and procedures related to fetal death and stillbirth KS Joseph, M Basso, C Davies, L Lee, D Ellwood, DB Fell, D Fowler, B Kinniburgh, MS Kramer, K Lim, P Selke, D Shaw, A Sneddon, A Sprague, K Williams a University of British Columbia, Vancouver, BC, Canada b Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, BC, Canada c Perinatal Services BC, Vancouver, BC, Canada d Gold Coast University Hospital and Griffith University, Southport, Gold Coast, Qld, Australia e BORN Ontario, Ottawa, ON, Canada f National Abortion Federation, Victoria, BC, Canada g McGill University, Montreal, QU, Canada Correspondence: KS Joseph, Room C403, Department of Obstetrics and Gynaecology, Children’s and Women Hospital and Health Centre of British Columbia, 4500 Oak Street, Vancouver, British Columbia V6H 3N1, Canada. Email ksjoseph@cfri.ca

Re-conceptualising stillbirth and revisiting birth surveillance.

The increased focus on stillbirth related issues in recent years has brought several previously neglected issues ‘out of the shadows’ [1] and highlighted the need for greater preventive efforts and better care for bereaved mothers and families. Some issues (such as the option of cesarean delivery for fetal death at late gestation [2], viewing the fetus following pregnancy termination for a fetal anomaly [3,4] and acknowledgement of paternal grief and anxiety [5]) reflect a substantial shift from previous traditions in clinical practice. At a conceptual level as well, there are challenges that may lead to a break with tradition. These include definitional aspects related to fetal death and stillbirth, and considerations related to the surveillance of pregnancy outcomes. Is fetal death or (still)birth following fetal demise the central event of medical concern? Should fetal deaths due to iatrogenic pregnancy termination be excluded from the definition of fetal death? What viability criteria should be used to distinguish between early pregnancy loss and fetal death at later gestation? Should surveillance of pregnancy outcomes be restricted to viable fetuses or should surveillance be more comprehensive? Do fetal deaths resulting from iatrogenic pregnancy termination constitute private events to be recorded in medical charts or do they require registration and publicly accessible documentation? In this commentary, we briefly review such concerns [6,7], with the hope of initiating an international discussion and consensus. This article is protected by copyright. All rights reserved.

The INTERGROWTH-21st gestational weight gain standard and interpregnancy weight increase: A population-based study of successive pregnancies.

To link the INTERGROWTH‐21st gestational weight gain standard with the risks of excess maternal postpartum weight retention, approximated by womens weight change between successive pregnancies.