Seroprevalence and placental transfer of SARS-CoV-2 antibodies in unvaccinated pregnant women.

PURPOSE: Pregnant women are at risk of severe SARS-CoV-2 infection, potentially leading to obstetric and neonatal complications. Placental transfer of antibodies directed to SARS-CoV-2 may be protective against neonatal COVID-19, but this remains to be studied. We aimed to determine the seroprevalence of SARS-CoV-2 antibodies in a population of unvaccinated pregnant women and to determine the placental transfer of these antibodies. METHODOLOGY: A total of 1197 unvaccinated women with mostly unknown pre-study SARS-CoV-2 infection status, were tested at delivery for SARS-CoV-2 spike protein IgG antibodies during the first year of the pandemic. Umbilical cord samples were collected and assessed for seropositivity if the mother was seropositive. Maternal characteristics, pregnancy and neonatal outcomes and data on SARS-CoV-2 infection were extracted from medical records. RESULTS: Specific IgG were detected in 258 women (21.6%). A significant placental transfer to the newborn was observed in 81.3% of cases. The earlier in the 2nd and 3rd trimesters that the mother had contracted the disease and the more symptomatic she was, the greater the likelihood of transplacental transfer of IgG to her newborn. CONCLUSION: Approximately one in five women had detectable anti-SARS-CoV-2 spike protein IgG antibodies at delivery during the first year of the pandemic, and these antibodies were significantly transferred to their fetuses. This research provides further evidence to better understand the dynamics of the placental transfer of SARS-CoV-2 IgG antibodies from mothers to their newborns, which is necessary to improve vaccination strategies.

Induction of labour at or near term for suspected fetal macrosomia.

BACKGROUND: Women with a suspected large-for-dates fetus or a fetus with suspected macrosomia (birthweight greater than 4000 g) are at risk of operative birth or caesarean section. The baby is also at increased risk of shoulder dystocia and trauma, in particular fractures and brachial plexus injury. Induction of labour may reduce these risks by decreasing the birthweight, but may also lead to longer labours and an increased risk of caesarean section. OBJECTIVES: To assess the effects of a policy of labour induction at or shortly before term (37 to 40 weeks) for suspected fetal macrosomia on the way of giving birth and maternal or perinatal morbidity. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016), contacted trial authors and searched reference lists of retrieved studies. SELECTION CRITERIA: Randomised trials of induction of labour for suspected fetal macrosomia. DATA COLLECTION AND ANALYSIS: Review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We contacted study authors for additional information. For key outcomes the quality of the evidence was assessed using the GRADE approach. MAIN RESULTS: We included four trials, involving 1190 women. It was not possible to blind women and staff to the intervention, but for other 'Risk of bias' domains these studies were assessed as being at low or unclear risk of bias. Compared to expectant management, there was no clear effect of induction of labour for suspected macrosomia on the risk of caesarean section (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.76 to 1.09; 1190 women; four trials, moderate-quality evidence) or instrumental delivery (RR 0.86, 95% CI 0.65 to 1.13; 1190 women; four trials, low-quality evidence). Shoulder dystocia (RR 0.60, 95% CI 0.37 to 0.98; 1190 women; four trials, moderate-quality evidence), and fracture (any) (RR 0.20, 95% CI 0.05 to 0.79; 1190 women; four studies, high-quality evidence) were reduced in the induction of labour group. There were no clear differences between groups for brachial plexus injury (two events were reported in the control group in one trial, low-quality evidence). There was no strong evidence of any difference between groups for measures of neonatal asphyxia; low five-minute infant Apgar scores (less than seven) or low arterial cord blood pH (RR 1.51, 95% CI 0.25 to 9.02; 858 infants; two trials, low-quality evidence; and, RR 1.01, 95% CI 0.46 to 2.22; 818 infants; one trial, moderate-quality evidence, respectively). Mean birthweight was lower in the induction group, but there was considerable heterogeneity between studies for this outcome (mean difference (MD) -178.03 g, 95% CI -315.26 to -40.81; 1190 infants; four studies; I2 = 89%).  For outcomes assessed using GRADE, we based our downgrading decisions on high risk of bias from lack of blinding and imprecision of effect estimates. AUTHORS' CONCLUSIONS: Induction of labour for suspected fetal macrosomia has not been shown to alter the risk of brachial plexus injury, but the power of the included studies to show a difference for such a rare event is limited. Also antenatal estimates of fetal weight are often inaccurate so many women may be worried unnecessarily, and many inductions may not be needed. Nevertheless, induction of labour for suspected fetal macrosomia results in a lower mean birthweight, and fewer birth fractures and shoulder dystocia. The observation of increased use of phototherapy in the largest trial, should also be kept in mind. Findings from trials included in the review suggest that to prevent one fracture it would be necessary to induce labour in 60 women. Since induction of labour does not appear to alter the rate of caesarean delivery or instrumental delivery, it is likely to be popular with many women. In settings where obstetricians can be reasonably confident about their scan assessment of fetal weight, the advantages and disadvantages of induction at or near term for fetuses suspected of being macrosomic should be discussed with parents. Although some parents and doctors may feel the evidence already justifies induction, others may justifiably disagree. Further trials of induction shortly before term for suspected fetal macrosomia are needed. Such trials should concentrate on refining the optimum gestation of induction, and improving the accuracy of the diagnosis of macrosomia.

Mechanical methods for induction of labour.

BACKGROUND: Mechanical methods were the first methods developed to ripen the cervix and induce labour. During recent decades they have been substituted by pharmacological methods. Potential advantages of mechanical methods, compared with pharmacological methods may include reduction in side effects that could improve neonatal outcomes. This is an update of a review first published in 2001, last updated in 2012. OBJECTIVES: To determine the effectiveness and safety of mechanical methods for third trimester (> 24 weeks' gestation) induction of labour in comparison with prostaglandin E2 (PGE2) (vaginal and intracervical), low-dose misoprostol (oral and vaginal), amniotomy or oxytocin. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies (9 January 2018). We updated the search in March 2019 and added the search results to the awaiting classification section of the review. SELECTION CRITERIA: Clinical trials comparing mechanical methods used for third trimester cervical ripening or labour induction with pharmacological methods. Mechanical methods include: (1) the introduction of a catheter through the cervix into the extra-amniotic space with balloon insufflation; (2) introduction of laminaria tents, or their synthetic equivalent (Dilapan), into the cervical canal; (3) use of a catheter to inject fluid into the extra-amniotic space (EASI). This review includes the following comparisons: (1) specific mechanical methods (balloon catheter, laminaria tents or EASI) compared with prostaglandins (different types, different routes) or with oxytocin; (2) single balloon compared to a double balloon; (3) addition of prostaglandins or oxytocin to mechanical methods compared with prostaglandins or oxytocin alone. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors independently extracted data and assessed the quality of the evidence using the GRADE approach. MAIN RESULTS: This review includes a total of 112 trials, with 104 studies contributing data (22,055 women; 21 comparisons). Risk of bias of trials varied. Overall, the evidence was graded from very-low to moderate quality. All evidence was downgraded for lack of blinding and, for many comparisons, the effect estimates were too imprecise to make a valid judgement.   Balloon versus vaginal PGE2: there may be little or no difference in vaginal deliveries not achieved within 24 hours (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.82 to 1.26; 7 studies; 1685 women; low-quality evidence) and there probably is little or no difference in caesarean sections (RR 1.00, 95% CI 0.92 to 1.09; 28 studies; 6619 women; moderate-quality evidence) between induction of labour with a balloon catheter and vaginal PGE2. A balloon catheter probably reduces the risk of uterine hyperstimulation with fetal heart rate (FHR) changes (RR 0.35, 95% CI 0.18 to 0.67; 6 studies; 1966 women; moderate-quality evidence), serious neonatal morbidity or perinatal death (RR 0.48, 95% CI 0.25 to 0.93; 8 studies; 2757 women; moderate-quality evidence) and may slightly reduce the risk of aneonatal intensive care unit (NICU) admission (RR 0.82, 95% CI 0.65 to 1.04; 3647 women; 12 studies; low-quality evidence). It is uncertain whether there is a difference in serious maternal morbidity or death (RR 0.20, 95% CI 0.01 to 4.12; 4 studies; 1481 women) or five-minute Apgar score < 7 (RR 0.74, 95% CI 0.49 to 1.14; 4271 women; 14 studies) because the quality of the evidence was found to be very low and low, respectively. Balloon versus low-dose vaginal misoprostol: it is uncertain whether there is a difference in vaginal deliveries not achieved within 24 hours between induction of labour with a balloon catheter and vaginal misoprostol (RR 1.09, 95% CI 0.85 to 1.39; 340 women; 2 studies; low-quality evidence). A balloon catheter probably reduces the risk of uterine hyperstimulation with FHR changes (RR 0.39, 95% CI 0.18 to 0.85; 1322 women; 8 studies; moderate-quality evidence) but may increase the risk of a caesarean section (RR 1.28, 95% CI 1.02 to 1.60; 1756 women; 12 studies; low-quality evidence). It is uncertain whether there is a difference in serious neonatal morbidity or perinatal death (RR 0.58, 95% CI 0.12 to 2.66; 381 women; 3 studies), serious maternal morbidity or death (no events; 4 studies, 464 women), both very low-quality evidence, and five-minute Apgar score < 7 (RR 1.00, 95% CI 0.50 to 1.97; 941 women; 7 studies) and NICU admissions (RR 1.00, 95% CI 0.61 to 1.63; 1302 women; 9 studies) both low-quality evidence. Balloon versus low-dose oral misoprostol: a balloon catheter probably increases the risk of a vaginal delivery not achieved within 24 hours (RR 1.28, 95% CI 1.13 to 1.46; 782 women, 2 studies, and probably slightly increases the risk of a caesarean section (RR 1.17, 95% CI 1.04 to 1.32; 3178 women; 7 studies; both moderate-quality evidence) when compared to oral misoprostol. It is uncertain whether there is a difference in uterine hyperstimulation with FHR changes (RR 0.81, 95% CI 0.48 to 1.38; 2033 women; 2 studies), serious neonatal morbidity or perinatal death (RR 1.11, 95% CI 0.60 to 2.06; 2627 women; 3 studies), both low-quality evidence, serious maternal morbidity or death (RR 0.50, 95% CI 0.05 to 5.52; 2627 women; 3 studies), very low-quality evidence, five-minute Apgar scores < 7 (RR 0.71, 95% CI 0.38 to 1.32; 2693 women; 4 studies) and NICU admissions (RR 0.82, 95% CI 0.58 to 1.17; 2873 women; 5 studies) both low-quality evidence. AUTHORS' CONCLUSIONS: Low- to moderate-quality evidence shows mechanical induction with a balloon is probably as effective as induction of labour with vaginal PGE2. However, a balloon seems to have a more favourable safety profile. More research on this comparison does not seem warranted. Moderate-quality evidence shows a balloon catheter may be slightly less effective as oral misoprostol, but it remains unclear if there is a difference in safety outcomes for the neonate. When compared to low-dose vaginal misoprostol, low-quality evidence shows a balloon may be less effective, but probably has a better safety profile. Future research could be focused more on safety aspects for the neonate and maternal satisfaction.

Influence of organizational factors on the offer and success rate of a trial of labor after cesarean section in Belgium: an ecological study.

BACKGROUND: Trial of Labor After Cesarean is an important strategy for reducing the overall rate of cesarean delivery. Offering the option of vaginal delivery to a woman with a history of cesarean section requires the ability to manage a potential uterine rupture quickly and effectively. This requires infrastructure and organization of the maternity unit so that the decision-to-delivery interval is as short as possible when uterine rupture is suspected. We hypothesize that the organizational characteristics of maternity units in Belgium have an impact on their proposal and success rates of trial of labour after cesarean section. METHODS: We collected data on the organizational characteristics of Belgian maternity units using an online questionnaire. Data on the frequency of cesarean section, trial of labor and vaginal birth after cesarean section were obtained from regional perinatal registries. We analyzed the determinants of the proposal and success of trial of labor after cesarean section and report the associations as mean proportions. RESULTS: Of the 101 maternity units contacted, 97 responded to the questionnaire and data from 95 was included in the analysis. Continuous on-site presence of a gynecologist and an anesthetist was associated with a higher proportion of trial of labor after cesarean section, compared to units where staff was on-call from home (51% versus 46%, p = 0.04). There is a non-significant trend towards more trial of labor after cesarean section in units with an operating room in or near the delivery unit and a shorter transfer time, in larger units (> 1500 deliveries/year) and in units with a neonatal intensive care unit. The proposal of trial of labor after cesarean section and its success was negatively correlated to the number of cesarean section in the maternity unit (Spearman' rho = 0.50 and 0.42, p value < 0.001). CONCLUSIONS: Organizational differences in maternity units appear to affect the proposal of trial of labor after cesarean section. Addressing these organizational factors may not be sufficient to change practice, given that general tendency to perform a cesarean section in the maternity unit is the main contributor to the percentage of trial of labor after cesarean.

Late miscarriage and stillbirth in asymptomatic and symptomatic hospitalised pregnant women in Belgium during the first and second waves of COVID-19: a prospective nationwide population-based study.

BACKGROUND: Stillbirth has been recognized as a possible complication of a SARS-CoV-2 infection during pregnancy, probably due to destructive placental lesions (SARS-CoV-2 placentitis). The aim of this work is to analyse stillbirth and late miscarriage cases in unvaccinated pregnant women infected with SARS-CoV-2 during the first two waves (wild-type period) in Belgium. METHODS: Stillbirths and late miscarriages in our prospective observational nationwide registry of SARS-CoV-2 infected pregnant women (n = 982) were classified by three authors using a modified WHO-UMC classification system for standardized case causality assessment. RESULTS: Our cohort included 982 hospitalised pregnant women infected with SARS-CoV-2, with 23 fetal demises (10 late miscarriages from 12 to 22 weeks of gestational age and 13 stillbirths). The stillbirth rate was 9.5‰ for singleton pregnancies and 83.3‰ for multiple pregnancies, which seems higher than for the background population (respectively 5.6‰ and 13.8‰). The agreement between assessors about the causal relationship with SARS-Cov-2 infection was fair (global weighted kappa value of 0.66). Among these demises, 17.4% (4/23) were "certainly" attributable to SARS-CoV-2 infection, 13.0% (3/23) "probably" and 30.4% (7/23) "possibly". Better agreement in the rating was noticed when pathological examination of the placenta and identification of the virus were available, underlining the importance of a thorough investigation in case of intra-uterine fetal demise. CONCLUSIONS: SARS-CoV-2 causality assessment of late miscarriage and stillbirth cases in our Belgian nationwide case series has shown that half of the fetal losses could be attributable to SARS-CoV-2. We must consider in future epidemic emergencies to rigorously investigate cases of intra-uterine fetal demise and to store placental tissue and other material for future analyses.

Impact of the first wave of the COVID-19 pandemic on birth rates in Europe: a time series analysis in 24 countries.

STUDY QUESTION: Did the first wave of the COVID-19 pandemic have an impact on monthly birth rates in Europe? SUMMARY ANSWER: Using datasets on live births per month in Europe, collected from the Human Fertility Database, we found a -14.1% decline in live births in January 2021 (i.e. 9-10 months after the epidemic peaks and first lockdowns), compared to the average number of live births in January 2018 and 2019. WHAT IS KNOWN ALREADY: Previous pandemics in the 20th and 21st centuries have been associated with a decline in birth rates 9 months after their peak, and a rebound in births over time. Lockdowns were necessary to control the first wave of the COVID-19 pandemic and may have had an impact on subsequent birth rates. STUDY DESIGN, SIZE, DURATION: Monthly time series data on live births from January 2018 to March 2021 were extracted to provide a time-series analysis of birthrates during and after the first wave of the COVID-19 pandemic in 24 European countries. PARTICIPANTS/MATERIALS, SETTING, METHODS: We conducted a random-effect generalized least squares regression to assess the seasonality of births from January 2018 to March 2021, and to identify potential differences in monthly live births after the first wave of the COVID-19 pandemic, considering the seasonality of births. To quantify these potential differences, we estimated the variation rate between the monthly live births observed during 2020 and 2021 and the mean of the 2018-2019 monthly live births in Europe. Factors potentially associated with a variation in monthly birth rates were assessed using univariable and multivariable generalized linear regressions. MAIN RESULTS AND THE ROLE OF CHANCE: When considering the seasonality of births, January 2021 was the only month with a significant difference in live births. A drop of -14.1% was observed compared to the average number of live births in January 2018 and 2019. At the national level, this drop was observed 9-10 months after the epidemic peaks in 13 countries. The duration of lockdowns was the variable that had the stronger association with this decrease, whereas higher incomes per capita could be a factor limiting this decline. A rebound in births compared to the previous years occurred in March 2021 in 13 countries. LIMITATIONS, REASONS FOR CAUTION: Our data are based on national data, limiting the power in the multivariable models used and the identification of other potential factors contributing to a decrease or an increase in birth rates. In addition, we collected only live births up to April 2021, which precludes the identification of a difference in births seasonality in 2021. WIDER IMPLICATIONS OF THE FINDINGS: As with previous pandemics, the COVID-19 outbreak was associated with a decline in births 9 months after its first wave. This trend may be associated with the duration of the lockdowns. Although there was a rebound in births in the following months, it does not seem to compensate for this decline. STUDY FUNDING/COMPETING INTEREST(S): The authors receive no external funding and have no conflict of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

The distribution of pelvic organ support defects in women undergoing pelvic organ prolapse surgery and compartment specific risk factors.

INTRODUCTION AND HYPOTHESIS: The objective of our study was to describe the distribution of pelvic organ prolapse (POP) in a population of women undergoing POP reconstructive surgery and to identify compartment-specific risk factors. METHODS: We conducted a retrospective observational study in a cohort of 326 women who underwent POP repair and had a standardized preoperative POP assessment using the Baden-Walker classification. The distribution of POP grade was described for each vaginal compartment. The association between the involvement of each specific compartment and predictors was evaluated with a logistic regression model. RESULTS: The frequency of significant POP (grade ≥ 2) was 79% in the anterior compartment, 49% in the middle/apical compartment and 31% in the posterior compartment. Combined significant anterior and apical defects were present in 25% of women. Increasing age was a significant risk factor for apical defect (between 60 and 70 years OR = 2.4, 95% CI 1.2-4.6; > 70 years OR = 3.4, 95% CI 1.7-6.6). Previous hysterectomy (OR = 2.2, 95% CI 1.0-4.6) was a significant risk factor for posterior defect. CONCLUSIONS: In a population undergoing POP surgery, anterior compartment involvement is the most common and serious defect and can often be associated with an apical defect, especially in older women. In case of previous hysterectomy, the posterior compartment may be weakened. These findings may help surgeons to select the appropriate POP reconstructive surgery, which often should address both anterior and apical defects.

A cross-sectional study on pelvic floor symptoms in women living with Female Genital Mutilation/Cutting.

BACKGROUND: Female Genital Mutilation/Cutting (FGM/C) concerns over 200 million women and girls worldwide and is associated with obstetric trauma and long-term urogynaecological and psychosexual complications that are often under-investigated and undertreated. The aim of this study was to assess the pelvic floor distress and the impact of pelvic floor and psychosexual symptoms among migrant women with different types of FGM/C. METHODS: This cross-sectional study was conducted between April 2016 and January 2019 at the Division of Gynaecology of the Geneva University Hospitals. The participants were interviewed on socio-demographic and background information, underwent a systematic gynaecological examination to assess the presence and type of FGM/C and eventual Pelvic Organ Prolapse (POP), and completed six validated questionnaires on pelvic floor and psychosexual symptoms (PFDI-20 and PFIQ7 on pelvic floor distress and impact, FISI and WCS on faecal incontinence and constipation, PISQ-IR and FGSIS on sexual function and genital self-image). The participants' scores were compared with scores of uncut women available from the literature. The association between selected variables and higher scores for distress and impact of pelvic floor symptoms was assessed using univariate and multivariable linear regression models. RESULTS: 124 women with a mean age of 31.5 (± 7.5), mostly with a normal BMI, and with no significant POP were included. PFDI-20 and PFIQ-7 mean (± SD) scores were of 49.5 (± 52.0) and 40.7 (± 53.6) respectively. In comparison with the available literature, the participants' scores were lower than those of uncut women with pelvic floor dysfunction but higher than those of uncut women without such disorders. Past violent events other than FGM/C and forced or arranged marriage, age at FGM/C of more than 10, a period of staying in Switzerland of less than 6 months, and nulliparity were significantly associated with higher scores for distress and impact of pelvic floor symptoms, independently of known risk factors such as age, weight, ongoing pregnancy and history of episiotomy. CONCLUSIONS: Women with various types of FGM/C, without POP, can suffer from pelvic floor symptoms responsible for distress and impact on their daily life. TRIAL REGISTRATION: The study protocol was approved by the Swiss Ethics Committee on research involving humans (protocol n°15-224).

Membrane sweeping for induction of labour.

BACKGROUND: Induction of labour involves stimulating uterine contractions artificially to promote the onset of labour. There are several pharmacological, surgical and mechanical methods used to induce labour. Membrane sweeping is a mechanical technique whereby a clinician inserts one or two fingers into the cervix and using a continuous circular sweeping motion detaches the inferior pole of the membranes from the lower uterine segment. This produces hormones that encourage effacement and dilatation potentially promoting labour. This review is an update to a review first published in 2005. OBJECTIVES: To assess the effects and safety of membrane sweeping for induction of labour in women at or near term (≥ 36 weeks' gestation). SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register (25 February 2019), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (25 February 2019), and reference lists of retrieved studies. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing membrane sweeping used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed on a predefined list of labour induction methods. Cluster-randomised trials were eligible, but none were identified. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion, risk of bias and extracted data. Data were checked for accuracy. Disagreements were resolved by discussion, or by including a third review author. The certainty of the evidence was assessed using the GRADE approach. MAIN RESULTS: We included 44 studies (20 new to this update), reporting data for 6940 women and their infants. We used random-effects throughout. Overall, the risk of bias was assessed as low or unclear risk in most domains across studies. Evidence certainty, assessed using GRADE, was found to be generally low, mainly due to study design, inconsistency and imprecision. Six studies (n = 1284) compared membrane sweeping with more than one intervention and were thus included in more than one comparison. No trials reported on the outcomes uterine hyperstimulation with/without fetal heart rate (FHR) change, uterine rupture or neonatal encephalopathy. Forty studies (6548 participants) compared membrane sweeping with no treatment/sham Women randomised to membrane sweeping may be more likely to experience: · spontaneous onset of labour (average risk ratio (aRR) 1.21, 95% confidence interval (CI) 1.08 to 1.34, 17 studies, 3170 participants, low-certainty evidence). but less likely to experience: · induction (aRR 0.73, 95% CI 0.56 to 0.94, 16 studies, 3224 participants, low-certainty evidence); There may be little to no difference between groups for: · caesareans (aRR 0.94, 95% CI 0.85 to 1.04, 32 studies, 5499 participants, moderate-certainty evidence); · spontaneous vaginal birth (aRR 1.03, 95% CI 0.99 to 1.07, 26 studies, 4538 participants, moderate-certainty evidence); · maternal death or serious morbidity (aRR 0.83, 95% CI 0.57 to 1.20, 17 studies, 2749 participants, low-certainty evidence); · neonatal perinatal death or serious morbidity (aRR 0.83, 95% CI 0.59 to 1.17, 18 studies, 3696 participants, low-certainty evidence). Four studies reported data for 480 women comparing membrane sweeping with vaginal/intracervical prostaglandins There may be little to no difference between groups for the outcomes: · spontaneous onset of labour (aRR, 1.24, 95% CI 0.98 to 1.57, 3 studies, 339 participants, low-certainty evidence); · induction (aRR 0.90, 95% CI 0.56 to 1.45, 2 studies, 157 participants, low-certainty evidence); · caesarean (aRR 0.69, 95% CI 0.44 to 1.09, 3 studies, 339 participants, low-certainty evidence); · spontaneous vaginal birth (aRR 1.12, 95% CI 0.95 to 1.32, 2 studies, 252 participants, low-certainty evidence); · maternal death or serious morbidity (aRR 0.93, 95% CI 0.27 to 3.21, 1 study, 87 participants, low-certainty evidence); · neonatal perinatal death or serious morbidity (aRR 0.40, 95% CI 0.12 to 1.33, 2 studies, 269 participants, low-certainty evidence). One study, reported data for 104 women, comparing membrane sweeping with intravenous oxytocin +/- amniotomy There may be little to no difference between groups for: · spontaneous onset of labour (aRR 1.32, 95% CI 88 to 1.96, 1 study, 69 participants, low-certainty evidence); · induction (aRR 0.51, 95% CI 0.05 to 5.42, 1 study, 69 participants, low-certainty evidence); · caesarean (aRR 0.69, 95% CI 0.12 to 3.85, 1 study, 69 participants, low-certainty evidence); · maternal death or serious morbidity was reported on, but there were no events. Two studies providing data for 160 women compared membrane sweeping with vaginal/oral misoprostol There may be little to no difference between groups for: · caesareans (RR 0.82, 95% CI 0.31 to 2.17, 1 study, 96 participants, low-certainty evidence). One study providing data for 355 women which compared once weekly membrane sweep with twice-weekly membrane sweep and a sham procedure There may be little to no difference between groups for: · induction (RR 1.19, 95% CI 0.76 to 1.85, 1 study, 234 participants, low-certainty); · caesareans (RR 0.93, 95% CI 0.60 to 1.46, 1 study, 234 participants, low-certainty evidence); · spontaneous vaginal birth (RR 1.00, 95% CI 0.86 to 1.17, 1 study, 234 participants, moderate-certainty evidence); · maternal death or serious maternal morbidity (RR 0.78, 95% CI 0.30 to 2.02, 1 study, 234 participants, low-certainty evidence); · neonatal death or serious neonatal perinatal morbidity (RR 2.00, 95% CI 0.18 to 21.76, 1 study, 234 participants, low-certainty evidence); We found no studies that compared membrane sweeping with amniotomy only or mechanical methods. Three studies, providing data for 675 women, reported that women indicated favourably on their experience of membrane sweeping with one study reporting that 88% (n = 312) of women questioned in the postnatal period would choose membrane sweeping in the next pregnancy. Two studies reporting data for 290 women reported that membrane sweeping is more cost-effective than using prostaglandins, although more research should be undertaken in this area. AUTHORS' CONCLUSIONS: Membrane sweeping may be effective in achieving a spontaneous onset of labour, but the evidence for this was of low certainty. When compared to expectant management, it potentially reduces the incidence of formal induction of labour. Questions remain as to whether there is an optimal number of membrane sweeps and timings and gestation of these to facilitate induction of labour.

Is female genital mutilation associated with eclampsia? Evidence from a nationally representative survey data.

BACKGROUND: Studies have shown the impact of female genital mutilation (FGM), especially infibulation (WHO type III), on reproductive health, and adverse obstetric outcomes like postpartum haemorrhage and obstructed labour. However, whether an association exists with maternal hypertensive complication is not known. The present study sought to investigate the role of the different types of FGM on the occurrence of eclampsia. METHODS: The study used data from the 2006 Demographic and health survey of Mali. The proportion of eclampsia in women with each type of FGM and the unadjusted and adjusted odds ratios (OR) were calculated, using women without FGM as reference group. Unadjusted and adjusted OR were also calculated for women who underwent infibulation compared to the rest of the population under study (women without FGM and women with FGM type I, II, and IV). RESULTS: In the 3997 women included, the prevalence of infibulation was 10.2% (n = 407) while 331 women did not report FGM (8.3%). The proportion of women reporting signs and symptoms suggestive of eclampsia was 5.9% (n = 234). Compared with the absence of female genital mutilation and adjusted for covariates, infibulation was associated with eclampsia (aOR 2.5; 95% CI:1.4-4.6), while the association was not significant in women with other categories of FGM. A similar aOR was found when comparing women with infibulation with the pooled sample of women without FGM and women with the other forms of FGM. CONCLUSION: The present study suggests a possible association between infibulation and eclampsia. Future studies could investigate this association in other settings. If these findings are confirmed, the possible biological mechanisms and preventive strategies should be investigated.

Mechanical methods for induction of labour.

BACKGROUND: Mechanical methods were the first methods developed to ripen the cervix and induce labour. During recent decades they have been substituted by pharmacological methods. Potential advantages of mechanical methods, compared with pharmacological methods may include reduction in side effects that could improve neonatal outcomes. This is an update of a review first published in 2001, last updated in 2012. OBJECTIVES: To determine the effectiveness and safety of mechanical methods for third trimester (> 24 weeks' gestation) induction of labour in comparison with prostaglandin E2 (PGE2) (vaginal and intracervical), low-dose misoprostol (oral and vaginal), amniotomy or oxytocin. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies (9 January 2018). We updated the search in March 2019 and added the search results to the awaiting classification section of the review. SELECTION CRITERIA: Clinical trials comparing mechanical methods used for third trimester cervical ripening or labour induction with pharmacological methods.Mechanical methods include: (1) the introduction of a catheter through the cervix into the extra-amniotic space with balloon insufflation; (2) introduction of laminaria tents, or their synthetic equivalent (Dilapan), into the cervical canal; (3) use of a catheter to inject fluid into the extra-amniotic space (EASI).This review includes the following comparisons: (1) specific mechanical methods (balloon catheter, laminaria tents or EASI) compared with prostaglandins (different types, different routes) or with oxytocin; (2) single balloon compared to a double balloon; (3) addition of prostaglandins or oxytocin to mechanical methods compared with prostaglandins or oxytocin alone. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors independently extracted data and assessed the quality of the evidence using the GRADE approach. MAIN RESULTS: This review update includes a total of 113 trials (22,373 women) contributing data to 21 comparisons. Risk of bias of trials varied. Overall, the evidence was graded from very-low to moderate quality. All evidence was downgraded for lack of blinding and, for many comparisons, the effect estimates were too imprecise to make a valid judgement.Balloon versus vaginal PGE2: there may be little or no difference in vaginal deliveries not achieved within 24 hours (average risk ratio (RR) 1.01, 95% confidence interval (CI) 0.82 to 1.26; 7 studies; 1685 women; I² = 79%; low-quality evidence) and there probably is little or no difference in caesarean sections (RR 1.00, 95% CI 0.92 to 1.09; 28 studies; 6619 women; moderate-quality evidence) between induction of labour with a balloon catheter and vaginal PGE2. A balloon catheter probably reduces the risk of uterine hyperstimulation with fetal heart rate (FHR) changes (RR 0.35, 95% CI 0.18 to 0.67; 6 studies; 1966 women; moderate-quality evidence), serious neonatal morbidity or perinatal death (RR 0.48, 95% CI 0.25 to 0.93; 8 studies; 2757 women; moderate-quality evidence) and may slightly reduce the risk of aneonatal intensive care unit (NICU) admission (RR 0.82, 95% CI 0.65 to 1.04; 3647 women; 12 studies; low-quality evidence). It is uncertain whether there is a difference in serious maternal morbidity or death (RR 0.20, 95% CI 0.01 to 4.12; 4 studies; 1481 women) or five-minute Apgar score < 7 (RR 0.74, 95% CI 0.49 to 1.14; 4271 women; 14 studies) because the quality of the evidence was found to be very low and low, respectively.Balloon versus low-dose vaginal misoprostol: it is uncertain whether there is a difference in vaginal deliveries not achieved within 24 hours between induction of labour with a balloon catheter and vaginal misoprostol (RR 1.09, 95% CI 0.85 to 1.39; 340 women; 2 studies; low-quality evidence). A balloon catheter probably reduces the risk of uterine hyperstimulation with FHR changes (RR 0.39, 95% CI 0.18 to 0.85; 1322 women; 8 studies; moderate-quality evidence) but may increase the risk of a caesarean section (average RR 1.28, 95% CI 1.02 to 1.60; 1756 women; 12 studies; I² = 45%; low-quality evidence). It is uncertain whether there is a difference in serious neonatal morbidity or perinatal death (RR 0.58, 95% CI 0.12 to 2.66; 381 women; 3 studies), serious maternal morbidity or death (no events; 4 studies, 464 women), both very low-quality evidence, and five-minute Apgar score < 7 (RR 1.00, 95% CI 0.50 to 1.97; 941 women; 7 studies) and NICU admissions (RR 1.00, 95% CI 0.61 to 1.63; 1302 women; 9 studies) both low-quality evidence.Balloon versus low-dose oral misoprostol: a balloon catheter probably increases the risk of a vaginal delivery not achieved within 24 hours (RR 1.28, 95% CI 1.13 to 1.46; 782 women, 2 studies, and probably slightly increases the risk of a caesarean section (RR 1.17, 95% CI 1.04 to 1.32; 3178 women; 7 studies; both moderate-quality evidence) when compared to oral misoprostol. It is uncertain whether there is a difference in uterine hyperstimulation with FHR changes (RR 0.81, 95% CI 0.48 to 1.38; 2033 women; 2 studies), serious neonatal morbidity or perinatal death (RR 1.11, 95% CI 0.60 to 2.06; 2627 women; 3 studies), both low-quality evidence, serious maternal morbidity or death (RR 0.50, 95% CI 0.05 to 5.52; 2627 women; 3 studies), very low-quality evidence, five-minute Apgar scores < 7 (RR 0.71, 95% CI 0.38 to 1.32; 2693 women; 4 studies) and NICU admissions (RR 0.82, 95% CI 0.58 to 1.17; 2873 women; 5 studies) both low-quality evidence. AUTHORS' CONCLUSIONS: Low- to moderate-quality evidence shows mechanical induction with a balloon is probably as effective as induction of labour with vaginal PGE2. However, a balloon seems to have a more favourable safety profile. More research on this comparison does not seem warranted.Moderate-quality evidence shows a balloon catheter may be slightly less effective as oral misoprostol, but it remains unclear if there is a difference in safety outcomes for the neonate. When compared to low-dose vaginal misoprostol, low-quality evidence shows a balloon may be less effective, but probably has a better safety profile.Future research could be focused more on safety aspects for the neonate and maternal satisfaction.

[Tranexamic acid for the management of postpartum haemorrhage : current knowledge]. / Acide tranexamique dans la prise en charge de l'hémorragie du postpartum : connaissances actuelles.

Postpartum haemorrhage (PPH) is the leading cause of maternal death. Primary causes are mostly of obstetrical origin. PPH can be worsened by secondary coagulopathy. This is due to dilution or consumption of coagulation factors and fibrinolysis activation. The use of tranexamic acid, an antifibrinolytic agent, in the management of PPH has been proposed and practiced for several years, following evidence of its efficacy and safety in other settings, including traumatology. The benefit of administration of TXA during PPH has recently been proved by the WOMAN study. This review recalls the physiopathological mechanisms involved in the genesis and aggravation of PPH. It presents the current state of knowledge on the prophylactic and therapeutic efficacy of tranexamic acid in PPH and summarizes the current recommendations in obstetrics.

L'hémorragie du postpartum (HPP) représente la principale cause de mortalité maternelle. Les causes primaires sont d'origine obstétricale dans la majorité des cas. Cependant l'HPP peut être aggravée par une coagulopathie secondaire. Celle-ci est due à la dilution ou la consommation des facteurs de la coagulation ainsi qu'à l'activation de la fibrinolyse. L'utilisation d'acide tranexamique (ATX), un antifibrinolytique, dans la prise en charge de l'HPP est proposée et pratiquée depuis plusieurs années, suite aux preuves de son efficacité et de sa sécurité dans d'autres contextes, notamment en traumatologie. L'utilisation lors de l'HPP a récemment été évaluée notamment par l'étude WOMAN et le bénéfice de l'administration a été prouvé. Cet article rappelle les mécanismes physiopathologiques en jeu dans la genèse et l'aggravation de l'HPP. Il présente l'état des connaissances actuelles sur l'efficacité prophylactique et thérapeutique de l'ATX en cas d'HPP et fait la synthèse des recommandations actuelles en obstétrique.

[Pre-gestational diabetes : an increasingly common entity]. / Diabète prégestationnel : une entité de plus en plus fréquente.

Pre-gestational diabetes, which is defined by the presence of diabetes prior to pregnancy, is an ever-increasing entity. Its management includes an optimization of the glycemic control before the beginning of pregnancy, but also a constant adaptation of the treatment during pregnancy. Good monitoring and adequate glycemic control throughout pregnancy are of course necessary to minimize complications for both the fetus and the mother.

Le diabète prégestationnel, qui se définit par la présence d'un diabète antérieur à une grossesse, est une entité en constante augmentation. Sa prise en charge comprend d'une part une optimisation du contrôle glycémique avant le début de la grossesse, mais également une constante adaptation du traitement antidiabétique durant la grossesse. Une bonne surveillance et un bon contrôle glycémique durant toute la grossesse sont bien évidemment nécessaires afin de limiter au mieux les complications tant pour le fœtus que pour la mère.

Self-sampling to improve cervical cancer screening coverage in Switzerland: a randomised controlled trial.

BACKGROUND: The aim of this study is to evaluate whether self-sampling can increase screening attendance of women who do not attend regular screening in Switzerland. METHODS: Participants were proactively recruited in Geneva between September 2011 and November 2015. Women (25-69 years) who had not undergone CC screening in the last 3 years were considered eligible. Through a 1 : 1 ratio randomisation, enrolled participants were invited to either undergo liquid-based cytology, which was performed by a health-care provider (control group, CG) or to take a self-sample for HPV-testing, which was mailed to their home (intervention group, IG). RESULTS: A total of 331 and 336 women were randomised in the CG and in the IG, respectively. Overall, 7.3% (95% CI: 4.9-10.6) women in the CG and 5.7% (95% CI: 3.6-8.7) women in the IG did not undergo the initial screening (P=0.400). There were 1.95% (95% CI: 0.8-4.3) women in the CG and 5.05% (95% CI: 3.1-8.1) women in the IG with a positive screen who did not attend triage and colposcopy (P=0.036). CONCLUSIONS: The participation in CC screening in women offered self-sampling was not higher than among those offered specimen collection by a clinician. Compliance with further follow-up for women with a positive HPV test on the self-sample requires further attention.

Single versus double-layer uterine closure at cesarean: impact on lower uterine segment thickness at next pregnancy.

BACKGROUND: Uterine rupture is a potential life-threatening complication during a trial of labor after cesarean delivery. Single-layer closure of the uterus at cesarean delivery has been associated with an increased risk of uterine rupture compared with double-layer closure. Lower uterine segment thickness measurement by ultrasound has been used to evaluate the quality of the uterine scar after cesarean delivery and is associated with the risk of uterine rupture. OBJECTIVE: To estimate the impact of previous uterine closure on lower uterine segment thickness. STUDY DESIGN: Women with a previous single low-transverse cesarean delivery were recruited at 34-38 weeks' gestation. Transabdominal and transvaginal ultrasound evaluation of the lower uterine segment thickness was performed by a sonographer blinded to clinical data. Previous operative reports were reviewed to obtain the type of previous uterine closure. Third-trimester lower uterine segment thickness at the next pregnancy was compared according to the number of layers sutured and according to the type of thread for uterine closure, using weighted mean differences and multivariate logistic regression analyses. RESULTS: Of 1613 women recruited, with operative reports available, 495 (31%) had a single-layer and 1118 (69%) had a double-layer closure. The mean third-trimester lower uterine segment thickness was 3.3 ± 1.3 mm and the proportion with lower uterine segment thickness <2.0 mm was 10.5%. Double-layer closure of the uterus was associated with a thicker lower uterine segment than single-layer closure (weighted mean difference: 0.11 mm; 95% confidence interval [CI], 0.02 to 0.21 mm). In multivariate logistic regression analyses, a double-layer closure also was associated with a reduced risk of lower uterine segment thickness <2.0 mm (odd ratio [OR], 0.68; 95% CI, 0.51 to 0.90). Compared with synthetic thread, the use of catgut for uterine closure had no significant impact on third-trimester lower uterine segment thickness (WMD: -0.10 mm; 95% CI, -0.22 to 0.02 mm) or on the risk of lower uterine segment thickness <2.0 mm (OR, 0.95; 95% CI, 0.67 to 1.33). Finally, double-layer closure was associated with a reduced risk of uterine scar defect (RR, 0.32; 95% CI, 0.17 to 0.61) at birth. CONCLUSION: Compared with single-layer closure, a double-layer closure of the uterus at previous cesarean delivery is associated with a thicker third-trimester lower uterine segment and a reduced risk of lower uterine segment thickness <2.0 mm in the next pregnancy. The type of thread for uterine closure has no significant impact on lower uterine segment thickness.

Exercise for pregnant women with pre-existing diabetes for improving maternal and fetal outcomes.

BACKGROUND: Pregnancies with pre-existing diabetes are high risk, with increased risk of poorer fetal, neonatal, and maternal outcomes. Identifying interventions to improving health outcomes for women with diabetes and their infants is a priority, as rates of diabetes continue to increase.Exercise has been shown to have benefits for non-pregnant individuals with pre-existing type 2 diabetes, such as improving glycaemic control, and reducing visceral adipose tissue and plasma triglycerides. For pregnant women with pre-existing diabetes, the effects of exercise interventions on the mother and her baby are unknown.An earlier Cochrane review on 'Exercise for pregnant women with diabetes' considered both pre-existing diabetes and gestational diabetes. That Cochrane review has now been split into two new reviews (following new protocols) - one on gestational diabetes and one on pre-existing diabetes (this review). OBJECTIVES: To evaluate the effects of exercise interventions for improving maternal and fetal outcomes in women with pre-existing diabetes. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) on 27 June 2017, and reference lists of retrieved studies. SELECTION CRITERIA: We had planned to include published or unpublished randomised controlled trials (RCT) or cluster-randomised trials, in full text or abstract format that compared any type of exercise programme, added to standard care, targeted at women with known pre-gestational diabetes (type 1 or type 2 diabetes), at any stage of pregnancy, compared with 1) standard care alone or 2) standard care plus another exercise intervention. Quasi-randomised and cross-over trials were excluded. Conference abstracts were handled in the same way as full-text publications.Women with gestational diabetes mellitus were excluded, as they were covered in a separate Cochrane review. DATA COLLECTION AND ANALYSIS: We had planned that two review authors would independently assess all the potential studies we identified as a result of the search strategy. For eligible studies, two review authors would have independently extracted the data using an agreed form. We had planned to resolve discrepancies through discussion, or by consulting a third person. We also had planned to assess the evidence using the GRADE approach. MAIN RESULTS: We did not identify any randomised controlled trials. AUTHORS' CONCLUSIONS: There was no evidence from RCTs that evaluated the effects of exercise interventions for improving maternal and fetal outcomes in women with pre-existing diabetes.Good quality, large randomised controlled trials are urgently needed to identify exercise interventions that are safe, and improve health outcomes for women with pre-existing diabetes and their babies. Future studies in this area could utilise the standardised outcomes in this review, in order to improve consistency between trials in this area, and aid future meta-analysis.

Exercise for pregnant women with gestational diabetes for improving maternal and fetal outcomes.

BACKGROUND: Gestational diabetes mellitus (GDM) is associated with both short- and long-term complications for the mother and her baby. Exercise interventions may be useful in helping with glycaemic control and improve maternal and infant outcomes.The original review on Exercise for diabetic pregnant women has been split into two new review titles reflecting the role of exercise for pregnant women with gestational diabetes and for pregnant women with pre-existing diabetes. Exercise for pregnant women with gestational diabetes for improving maternal and fetal outcomes (this review) Exercise for pregnant women with pre-existing diabetes for improving maternal and fetal outcomes OBJECTIVES: To evaluate the effects of exercise interventions for improving maternal and fetal outcomes in women with GDM. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (27 August 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (18th August 2016), and reference lists of retrieved studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing an exercise intervention with standard care or another intervention in pregnant women diagnosed with gestational diabetes. Quasi-randomised and cross-over studies, and studies including women with pre-existing type 1 or type 2 diabetes were not eligible for inclusion. DATA COLLECTION AND ANALYSIS: All selection of studies, assessment of trial quality and data extraction was conducted independently by two review authors. Data were checked for accuracy. MAIN RESULTS: We included 11 randomised trials, involving 638 women. The overall risk of bias was judged to be unclear due to lack of methodological detail in the included studies.For the mother, there was no clear evidence of a difference between women in the exercise group and those in the control group for the risk of pre-eclampsia as the measure of hypertensive disorders of pregnancy (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.01 to 7.09; two RCTs, 48 women; low-quality evidence), birth by caesarean section (RR 0.86, 95% CI 0.63 to 1.16; five RCTs, 316 women; I2 = 0%; moderate-quality evidence), the risk of induction of labour (RR 1.38, 95% CI 0.71 to 2.68; one RCT, 40 women; low-quality evidence) or maternal body mass index at follow-up (postnatal weight retention or return to pre-pregnancy weight) (mean difference (MD) 0.11 kg/m2, 95% CI -1.04 to 1.26; three RCTs, 254 women; I2 = 0%; high-quality evidence). Development of type 2 diabetes, perineal trauma/tearing and postnatal depression were not reported as outcomes in the included studies.For the infant/child/adult, a single small (n = 19) trial reported no perinatal mortality (stillbirth and neonatal mortality) events in either the exercise intervention or control group (low-quality evidence). There was no clear evidence of a difference between groups for a mortality and morbidity composite (variously defined by trials, e.g. perinatal or infant death, shoulder dystocia, bone fracture or nerve palsy) (RR 0.56, 95% CI 0.12 to 2.61; two RCTs, 169 infants; I2 = 0%; moderate-quality evidence) or neonatal hypoglycaemia (RR 2.00, 95% CI 0.20 to 20.04; one RCT, 34 infants; low-quality evidence). None of the included trials pre-specified large-for-gestational age, adiposity (neonatal/infant, childhood or adulthood), diabetes (childhood or adulthood) or neurosensory disability (neonatal/infant) as trial outcomes.Other maternal outcomes of interest: exercise interventions were associated with both reduced fasting blood glucose concentrations (average standardised mean difference (SMD) -0.59, 95% CI -1.07 to -0.11; four RCTs, 363 women; I2 = 73%; T2 = 0.19) and a reduced postprandial blood glucose concentration compared with control interventions (average SMD -0.85, 95% CI -1.15 to -0.55; three RCTs, 344 women; I2 = 34%; T2 = 0.03). AUTHORS' CONCLUSIONS: Short- and long-term outcomes of interest for this review were poorly reported. Current evidence is confounded by the large variety of exercise interventions. There was insufficient high-quality evidence to be able to determine any differences between exercise and control groups for our outcomes of interest. For the woman, both fasting and postprandial blood glucose concentrations were reduced compared with the control groups. There are currently insufficient data for us to determine if there are also benefits for the infant. The quality of the evidence in this review ranged from high to low quality and the main reason for downgrading was for risk of bias and imprecision (wide CIs, low event rates and small sample size). Development of type 2 diabetes, perineal trauma/tearing, postnatal depression, large-for-gestational age, adiposity (neonate/infant, childhood or adulthood), diabetes (childhood or adulthood) or neurosensory disability (neonate/infant) were not reported as outcomes in the included studies.Further research is required comparing different types of exercise interventions with control groups or with another exercise intervention that reports on both the short- and long-term outcomes (for both the mother and infant/child) as listed in this review.

[Out-of-hospital delivery : present state and perspectives]. / Accouchement extrahospitalier : état des lieux et perspectives.

Out-of-hospital delivery is rare in Switzerland and it accounted for 2,5 % of all the births in 2015. In Switzerland, out-of-hospital childbirth is not subject to any official regulations. It takes place mainly in midwifery units (1,6 %) and at home (0,9 %), by independent midwifes. One in six women needs to be transferred to a hospital because of complications. Perinatal mortality is higher in out-of-hospital childbirth and the hospital is the safest place to give birth. The level of intervention may be lower, maybe because the women choosing to give birth in alternative settings are at lower risk.

L'accouchement extrahospitalier est un phénomène rare en Suisse et concernait 2,5 % des naissances en 2015. En Suisse, il n'est pas soumis à une réglementation officielle. Il a lieu majoritairement en maison de naissance (1,6 %) puis à domicile (0,9 %), par une sage-femme indépendante. Parmi ces parturientes, une femme sur six doit être référée à une équipe hospitalière en raison de complications durant le travail. La mortalité périnatale est plus élevée lors d'un accouchement extrahospitalier, ce qui place l'hôpital comme le lieu le plus sûr pour accoucher. En contrepartie, le niveau d'intervention pourrait être plus bas quand l'accouchement est planifié hors de l'hôpital, mais ceci pourrait être dû au fait que ces femmes sont à bas risque.

Induction of labour versus expectant management for large-for-date fetuses: a randomised controlled trial.

BACKGROUND: Macrosomic fetuses are at increased risk of shoulder dystocia. We aimed to compare induction of labour with expectant management for large-for-date fetuses for prevention of shoulder dystocia and other neonatal and maternal morbidity associated with macrosomia. METHODS: We did this pragmatic, randomised controlled trial between Oct 1, 2002, and Jan 1, 2009, in 19 tertiary-care centres in France, Switzerland, and Belgium. Women with singleton fetuses whose estimated weight exceeded the 95th percentile, were randomly assigned (1:1), via computer-generated permuted-block randomisation (block size of four to eight) to receive induction of labour within 3 days between 37(+0) weeks and 38(+6) weeks of gestation, or expectant management. Randomisation was stratified by centre. Participants and caregivers were not masked to group assignment. Our primary outcome was a composite of clinically significant shoulder dystocia, fracture of the clavicle, brachial plexus injury, intracranial haemorrhage, or death. We did analyses by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00190320. FINDINGS: We randomly assigned 409 women to the induction group and 413 women to the expectant management group, of whom 407 women and 411 women, respectively, were included in the final analysis. Mean birthweight was 3831 g (SD 324) in the induction group and 4118 g (392) in the expectant group. Induction of labour significantly reduced the risk of shoulder dystocia or associated morbidity (n=8) compared with expectant management (n=25; relative risk [RR] 0·32, 95% CI 0·15-0·71; p=0·004). We recorded no brachial plexus injuries, intracranial haemorrhages, or perinatal deaths. The likelihood of spontaneous vaginal delivery was higher in women in the induction group than in those in the expectant management group (RR 1·14, 95% CI 1·01-1·29). Caesarean delivery and neonatal morbidity did not differ significantly between the groups. INTERPRETATION: Induction of labour for suspected large-for-date fetuses is associated with a reduced risk of shoulder dystocia and associated morbidity compared with expectant management. Induction of labour does not increase the risk of caesarean delivery and improves the likelihood of spontaneous vaginal delivery. These benefits should be balanced with the effects of early-term induction of labour. FUNDING: Assistance Publique-Hôpitaux de Paris and the University of Geneva.

Lower uterine segment thickness to prevent uterine rupture and adverse perinatal outcomes: a multicenter prospective study.

BACKGROUND: Choice of delivery route after previous cesarean delivery can be difficult because both trial of labor after cesarean delivery and elective repeat cesarean delivery are associated with risks. The major risk that is associated with trial of labor after cesarean delivery is uterine rupture that requires emergency laparotomy. OBJECTIVE: This study aimed to estimate the occurrence of uterine rupture during trial of labor after cesarean delivery when lower uterine segment thickness measurement is included in the decision-making process about the route of delivery. STUDY DESIGN: In 4 tertiary-care centers, we prospectively recruited women between 34 and 38 weeks of gestation who were contemplating a vaginal birth after a previous single low-transverse cesarean delivery. Lower uterine segment thickness was measured by ultrasound imaging and integrated in the decision of delivery route. According to lower uterine segment thickness, women were classified in 3 risk categories for uterine rupture: high risk (<2.0 mm), intermediate risk (2.0-2.4 mm), and low risk (≥2.5 mm). Our primary outcome was symptomatic uterine rupture, which was defined as requiring urgent laparotomy. We calculated that 942 women who were undergoing a trial of labor after cesarean delivery should be included to be able to show a risk of uterine rupture <0.8%. RESULTS: We recruited 1856 women, of whom 1849 (99%) had a complete follow-up data. Lower uterine segment thickness was <2.0 mm in 194 women (11%), 2.0-2.4 mm in 217 women (12%), and ≥2.5 mm in 1438 women (78%). Rate of trial of labor was 9%, 42%, and 61% in the 3 categories, respectively (P<.0001). Of 984 trials of labor, there were no symptomatic uterine ruptures, which is a rate that was lower than the 0.8% expected rate (P=.0001). CONCLUSION: The inclusion of lower uterine segment thickness measurement in the decision of the route of delivery allows a low risk of uterine rupture during trial of labor after cesarean delivery.