FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction.

Fetal growth restriction (FGR) is defined as the failure of the fetus to meet its growth potential due to a pathological factor, most commonly placental dysfunction. Worldwide, FGR is a leading cause of stillbirth, neonatal mortality, and short- and long-term morbidity. Ongoing advances in clinical care, especially in definitions, diagnosis, and management of FGR, require efforts to effectively translate these changes to the wide range of obstetric care providers. This article highlights agreements based on current research in the diagnosis and management of FGR, and the areas that need more research to provide further clarification of recommendations. The purpose of this article is to provide a comprehensive summary of available evidence along with practical recommendations concerning the care of pregnancies at risk of or complicated by FGR, with the overall goal to decrease the risk of stillbirth and neonatal mortality and morbidity associated with this condition. To achieve these goals, FIGO (the International Federation of Gynecology and Obstetrics) brought together international experts to review and summarize current knowledge of FGR. This summary is directed at multiple stakeholders, including healthcare providers, healthcare delivery organizations and providers, FIGO member societies, and professional organizations. Recognizing the variation in the resources and expertise available for the management of FGR in different countries or regions, this article attempts to take into consideration the unique aspects of antenatal care in low-resource settings (labelled "LRS" in the recommendations). This was achieved by collaboration with authors and FIGO member societies from low-resource settings such as India, Sub-Saharan Africa, the Middle East, and Latin America.

FIGO Statement: Restrictive use rather than routine use of episiotomy.

International standards for clinical staffing of delivery care in maternity units are currently lacking, with resulting gaps in provision leading to adverse outcomes and very poor experiences of care for women and families. While evidence­informed modelling approaches have been proposed based on population characteristics and estimated rates of complications, their application and outcomes in low­resource settings have not been reported. Here, FIGO's Safe Motherhood and Newborn Health Committee proposes indicative standards for labor wards as a starting point for policy and program development. These standards consider the volume of deliveries, the case mix, and the need to match clinical care requirements with an appropriate mix of professional skills among midwifery and obstetric staff. The role of Shift Leader in busy labor wards is emphasized. Application of the standards can help to assure women and their families of a safe but also positive birthing experience. FIGO calls for investment by partners to test these clinically­informed recommendations for delivery unit staffing at hospital and district level in low­ and middle­income country settings.

International survey of practices used in the diagnosis and management of placenta accreta spectrum disorders.

OBJECTIVE: To identify geographic differences in diagnostic and treatment practices during the perinatal management of placenta accreta spectrum (PAS) disorders. METHODS: An online survey was conducted from May 1 to August 1, 2017. The 18-item questionnaire was emailed to all members of the expert panel for the 2018 International Federation of Gynecology and Obstetrics consensus guidelines on PAS (n=34), as well as international experts who had contributed to the content of these guidelines (n=16). RESULTS: Questionnaires were returned by 36 of the 50 experts (72% response rate). Most respondents were from Europe (n=22; 61%) or Asia (n=9; 25%). Despite large disparity in the number of patients with PAS disorders managed surgically or conservatively (range from 0 to >1000) and the different techniques used by the respondents, the screening and diagnostic methods used were similar, with transvaginal imaging used by 31 (86%) experts, and both ultrasonography and magnetic resonance imaging used by 22 (61%). In all, 22 (61%) experts indicated a preference for radical surgery, with primary cesarean hysterectomy leaving the placenta in situ reported as the most frequent approach (n=20; 55%). CONCLUSION: Wide variation found in global PAS practices indicated a need for standardized data and an evidence-based approach to the diagnosis and management of PAS disorders.

Introduction: Why is intrapartum foetal monitoring necessary - Impact on outcomes and interventions.

Maintaining maternal oxygen supply is essential for foetal life, and labour constitutes an increased challenge to this. Good clinical judgement is required to evaluate the signs of reduced foetal oxygenation, to diagnose the underlying cause, to judge the reversibility of the condition and to determine the best timing for delivery. The main aim of intrapartum foetal monitoring is to identify foetuses that are being inadequately oxygenated, enabling appropriate action before the occurrence of injury. It is also to provide reassurance in cases of adequate foetal oxygenation, and thus to avoid unnecessary obstetric intervention. Poor foetal oxygenation is diagnosed by documenting metabolic acidosis in the umbilical cord immediately after birth or in the newborn circulation during the first minutes of life. However, most newborns recover quickly, and they do not develop relevant short- or long-term complications. Hypoxic-ischaemic encephalopathy is the short-term neurological dysfunction caused by inadequate intrapartum foetal oxygenation, and cerebral palsy of the spastic quadriplegic or dyskinetic types is the long-term neurological complication most commonly associated with it. Although there is insufficient evidence from randomised controlled trials to demonstrate that any form of intrapartum foetal monitoring reduces the incidence of adverse outcomes, reports from the clinical setting have documented a decrease in metabolic acidosis, hypoxic-ischaemic encephalopathy and intrapartum death over the last decades. It may be difficult to demonstrate the benefit of diagnostic techniques in complex environments such as the labour ward, but a reduction in the incidence of adverse clinical outcomes constitutes important evidence that intrapartum foetal monitoring makes a difference.

The impact of migration on women's mental health in the postpartum period / O impacto da migração na saúde mental das mulheres no pós-parto

ABSTRACT OBJECTIVE To assess the influence of I mmigration on the psychological health of women after childbirth. METHODS In this cross-sectional study, immigrant and Portuguese-native women delivering in the four public hospitals of the metropolitan area of Porto, Portugal, were contacted by telephone between February and December 2012 during the first postpartum month to schedule a home visit and fill in a questionnaire. Most immigrant (76.1%) and Portuguese mothers (80.0%) agreed to participate and with the visits, thus a total of 89 immigrants and 188 Portuguese women were included in the study. The questionnaire included the application of four validated scales: Mental Health Inventory-5, Edinburgh Postpartum Depression Scale, Perceived Stress Scale, and Scale of Satisfaction with Social Support. Statistical analysis included t-test and Chi-square or Fisher's test, and logistic regression models. RESULTS Immigrants had an increased risk of postpartum depression (OR = 6.444, 95%CI 1.858-22.344), and of low satisfaction with social support (OR = 6.118, 95%CI 1.991-18.798). We did not perceive any associations between migrant state, perceived stress, and impoverished mental health. CONCLUSIONS Immigrant mothers have increased vulnerabilities in the postpartum period, resulting in an increased risk of postpartum depression and lesser satisfaction with the received social support.

RESUMO OBJETIVO Avaliar a influência da imigração na saúde psicológica da mulher após o parto. MÉTODOS Neste estudo transversal, mulheres imigrantes e portuguesas com partos nos quatro hospitais públicos da região metropolitana de Porto, Portugal, foram contatadas por telefone entre fevereiro e dezembro de 2012, durante o primeiro mês pós-parto, para agendar uma visita domiciliar e preencher um questionário. A maioria das mães imigrantes (76,1%) e das mães portuguesas (80,0%) aceitou participar e aceder a visitas domiciliares, totalizando 89 imigrantes e 188 mulheres portuguesas incluídas no estudo. O questionário incluiu a aplicação de quatro escalas validadas: Inventário de Saúde Mental-5, Escala de Depressão Pós-parto de Edimburgo, Escala de Stress Percebido e Escala de Satisfação com o Suporte Social. As análises estatísticas incluíram os testes t-student, Qui-quadrado ou teste de Fisher e o cálculo de modelos de regressão logística. RESULTADOS As imigrantes tiveram risco aumentado de depressão pós-parto (OR 6,444; IC95% 1,858-22,344) e de baixa satisfação com o suporte social (OR = 6,118; IC95% 1,991-18,798). Não houve associação entre migração, stress percebido e saúde mental empobrecida. CONCLUSÕES Mães imigrantes apresentam vulnerabilidades aumentadas no período pós-parto, aumentando o risco de depressão pós-parto e havendo menor satisfação com o apoio social recebido.

Obesity and the challenges of caesarean delivery: prevention and management of wound complications.

Caesarean section in obese patients is associated with an increased risk of surgical wound complications, including haematoma, seroma, abscess and dehiscence. This review focusses on the available strategies to decrease wound complications in this population, and on the clinical management of these situations. Appropriate dose of prophylactic antibiotics, closure of the subcutaneous tissue, and avoidance of subcutaneous drains reduce the incidence of wound complications associated with caesarean section in obese patients. For treatment of superficial wound infection associated with dehiscence, there are data from general surgery patients to suggest that the use of vacuum-assisted devices leads to faster healing and that surgical reclosure is preferable to healing by secondary intention, when there are no signs of ongoing infection. There is a need for stronger evidence regarding the prevention and management of wound complications for caesarean section in obese women.

Assessing maternal healthcare inequities among migrants: a qualitative study / Avaliando desigualdades de saude materna em migrantes: um estudo qualitativo / Evaluacion de las inequidades en salud materna entre los inmigrantes: un estudio cualitativo

Considering pregnancy and motherhood as periods of increased vulnerability in migrant women, to characterize the healthcare provided to this collective, we sought to identify and understand patterns of satisfaction and demand of maternal and child healthcare, assessing women’s perceptions about its quality. The study followed a qualitative methodology (semi-structured interviews) for collecting and analysing data (content analysis) and was conducted in Porto, the second largest city of Portugal. Participants were 25 recent immigrant mothers from Eastern European countries, Brazil, Portuguese-speaking African countries and six native Portuguese recent mothers (for comparison), contacted through social associations and institutions. Data suggests that healthcare depends not only on accessibility but especially on social opportunities. Equitable public health action must provide individuals and groups the equal opportunity to meet their needs, which may not be achieved by providing the same standard if care to all.

Considerando a gravidez e a maternidade como períodos de maior vulnerabilidade em mulheres migrantes, a fim de caracterizar os cuidados de saúde prestados, procurou-se identificar e compreender padrões de satisfação e procura de cuidados de saúde materna e infantil, avaliando as suas percepções sobre a qualidade deles. O estudo seguiu uma metodologia qualitativa (entrevistas semiestruturadas) para a coleta e análise de dados (análise de conteúdo) e foi realizado no Porto, a segunda maior cidade de Portugal. As participantes foram 25 mães recém-imigradas do Leste Europeu, Brasil, e países africanos de língua portuguesa e seis Portuguesas (para comparação), contatadas pelas associações e instituições sociais. Os dados sugerem que a saúde depende não só da acessibilidade, mas especialmente das oportunidades sociais. Ações equitativas de saúde pública devem proporcionar aos indivíduos e grupos oportunidades iguais para satisfazer as suas necessidades, que podem não ser alcançadas fornecendo o mesmo tratamento padrão para todos.

Considerando el embarazo y maternidad como los períodos de mayor vulnerabilidad para las mujeres inmigrantes, y con el fin de caracterizar la asistencia sanitaria, se buscó identificar y comprender patrones de satisfacción y demanda de salud materno-infantil, así como la evaluación de las percepciones sobre la calidad de los mismos. El estudio siguió una metodología cualitativa (entrevistas semi-estructuradas) para la recogida y análisis de datos (análisis de contenido) y se llevó a cabo en Porto, la segunda ciudad más grande de Portugal. Las participantes fueron 25 madres, inmigrantes recientes de países de la Europa del Este, Brasil, países africanos de habla portuguesa y seis nativas portuguesas (para su comparación), contactadas a través de asociaciones e instituciones sociales. Los datos sugieren que la asistencia sanitaria no sólo depende de la accesibilidad, sino especialmente de las oportunidades sociales. Las acciones equitativas de salud pública deben proporcionar igualdad de oportunidades a las personas y grupos para satisfacer sus necesidades, que no se pueden lograr al ofrecer una misma atención estándar a todos.

Skin adhesive versus subcuticular suture for perineal skin repair after episiotomy--a randomized controlled trial.

OBJECTIVE: Surgical repair of perineal lesions after delivery is frequently associated with pain and discomfort, interfering with the normal activities of the puerperium. The aim of this study was to compare perineal skin repair after episiotomy with adhesive glue versus a subcuticular suture, regarding the incidence of pain and wound complications. STUDY DESIGN: Randomized clinical trial. SETTING: Tertiary care university hospital. MATERIAL AND METHODS: One hundred women having mediolateral episiotomy at vaginal delivery were enrolled. They were randomized to receive skin adhesive (n = 53) or subcuticular suture (n = 47) for closure of perineal skin. The main outcome measure was self-evaluated pain in the 30 days following delivery. Secondary outcome measures were technical difficulties reported with the procedure, duration of surgical repair, wound complications observed at 42-68 hours post-partum and re-initiation of sexual activity by 30 days post-partum. RESULTS: No significant differences were observed between the two groups in incidence of technical difficulties and failed procedures, pain during the procedure, wound complications at hospital discharge, self-evaluated measures of pain at 7 and 30 days or re-initiation of sexual activity by 30 days post-partum. The skin adhesive group had a significantly shorter mean duration of the procedure (four minutes less). CONCLUSION: Perineal skin closure using adhesive glue is faster than subcuticular suture, and associated with a similar incidence of complications and pain in the first 30 days.

The modified Misgav-Ladach versus the Pfannenstiel-Kerr technique for cesarean section: a randomized trial.

BACKGROUND: Modifications to the classic cesarean section technique described by Pfannenstiel and Kerr have been proposed in the last few years. The objective of this trial was to compare intraoperative and short-term postoperative outcomes between the Pfannenstiel-Kerr and the modified Misgav-Ladach (MML) techniques for cesarean section. METHODS: This prospective randomized trial involved 162 patients undergoing transverse lower uterine segment cesarean section. Patients were allocated to one of the two arms: 88 to the MML technique and 74 to the Pfannenstiel-Kerr technique. Main outcome measures were defined as the duration of surgery, analgesic requirements, and bowel restitution by the second postoperative day. Additional outcomes evaluated were febrile morbidity, postoperative antibiotic use, postpartum endometritis, and wound complications. Student's t, Mann-Whitney, and Chi-square tests were used for statistical analysis of the results, and a p < 0.05 was considered as the probability level reflecting significant differences. RESULTS: No differences between groups were noted in the incidence of analgesic requirements, bowel restitution by the second postoperative day, febrile morbidity, antibiotic requirements, endometritis, or wound complications. The MML technique took on average 12 min less to complete (p = 0.001). CONCLUSION: The MML technique is faster to perform and similar in terms of febrile morbidity, time to bowel restitution, or need for postoperative medications. It is likely to be more cost-effective.