Guideline No. 401: sonographic cervical length in Singleton Pregnancies: techniques and clinical applications

To assess the association between sonography-derived cervical length measurement and preterm birth. To describe the various techniques to measure cervical length using sonography. To review the natural history of the short cervix. To review the clinical uses, predictive ability, and utility of sonography-measured short cervix. Reduction in rates of prematurity and/or better identification of those at risk, as well as possible prevention of unnecessary interventions. Intended Users Clinicians involved in the obstetrical management or cervical imaging of patients at increased risk of a short cervix. Women at increased risk of a short cervix or at risk of preterm birth. Literature published up to June 2019 was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary and key words (preterm labour, ultrasound, cervix, cervical insufficiency, transvaginal, transperineal, cervical length, fibronectin). Results were restricted to general and systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. There were no date or language restrictions. Grey (unpublished) literature was identified through searching the websites of health technology assessment agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. The evidence and this guideline were reviewed by the Diagnostic Imaging Committee of the Society of Obstetricians and Gynaecologists of Canada, and the recommendations were made and graded according to the rankings of the Canadian Task Force on Preventive Health Care ( Online Appendix Table A1). Preterm birth is a leading cause of perinatal morbidity and mortality. Use of the sonographic technique reviewed in this guideline may help identify women at risk of preterm birth and, in some circumstances, lead to interventions that may reduce the rate of preterm birth.

Randomized comparison of oral misoprostol and oxytocin for labor induction in term prelabor membrane rupture.

OBJECTIVES: To compare labor induction intervals between oral misoprostol and intravenous oxytocin in women who present at term with premature rupture of membranes. METHODS: One hundred eight women were randomly assigned to misoprostol 50 microg orally every 4 hours as needed or intravenous oxytocin. The primary outcome measure was time from induction to vaginal delivery. Sample size was calculated using a two-tailed alpha of 0.05 and power of 80%. RESULTS: Baseline demographic data, including maternal age, gestation, parity, Bishop score, birth weight, and group B streptococcal status, were similar. The mean time +/-standard deviation to vaginal birth with oral misoprostol was 720+/-382 minutes compared with 501+/-389 minutes with oxytocin (P = .007). The durations of the first, second, and third stages of labor were similar. There were no differences in maternal secondary outcomes, including cesarean birth (eight and seven, respectively), infection, maternal satisfaction with labor, epidural use, perineal trauma, manual placental removal, or gastrointestinal side effects. Neonatal outcomes including cord pH, Apgar scores, infection, and admission to neonatal intensive care unit were not different. CONCLUSION: Although labor induction with oral misoprostol was effective, oxytocin resulted in a shorter induction-to-delivery interval. Active labor intervals and other maternal and neonatal outcomes were similar.

Quality improvement efforts in oncology: are we ready to begin?

Large variations in the quality of cancer care are a matter of concern in the United States. Despite spending over 15% of our GNP on health care, more than any other country in the world, some cancer patients face significant risks of dying from their treatment precisely because of their choice of physician. The Institute of Medicine has reported that variations in the quality of cancer are large, and that low-experienced providers are more likely to provide a lower quality of medical care. Increased pressures to contain costs have led to concern that the quality and outcomes of cancer care may only worsen. One reaction to this situation is a greater reliance on "report cards." In an effort to address both quality and cost issues, providers are looking outside the health care sector for guidance for more acceptable alternatives to report cards, which are often viewed as punitive. The approach that they most often have selected recently is termed continuous quality improvement (CQI) or total quality management (TQM). In this article, we describe the potential benefits and drawbacks of CQI efforts in oncology, review experiences with four different CQI cancer programs, and make recommendations about future CQI efforts.