Hospital factors associated with maternal and neonatal outcomes of deliveries to patients with a previous cesarean delivery: an ecological study.

BACKGROUND: Recommendations for deliveries of pregnant patients with a previous cesarean delivery and the type of hospitals deemed safe for these deliveries have evolved in recent years, although no studies have examined hospital factors and associated safety. We sought to evaluate maternal and neonatal outcomes among patients with a previous cesarean delivery by hospital tier and volume. METHODS: We carried out an ecological study of singleton live births delivered at term gestation to patients with a previous cesarean delivery in all Canadian hospitals (excluding Quebec), 2013-2019. We obtained data from the Discharge Abstract Database of the Canadian Institute for Health Information. The primary outcomes were severe maternal morbidity or mortality (SMMM), and serious neonatal morbidity or mortality (SNMM). We used regression modelling to examine hospital tier (tier 4 hospitals being those that provide the highest level of care) and volume; we also identified hospitals with high rates of SMMM and SNMM using within-tier comparisons and comparisons with the overall rate. RESULTS: We included 235 442 deliveries to patients with a previous cesarean delivery; SMMM and SNMM rates were 14.6 per 1000 deliveries and 4.6 per 1000 live births, respectively. Among patients with a parity of 1, SMMM rates were lower in tier 1 hospitals (adjusted incidence rate ratio [IRR] 0.68, 95% confidence interval [CI] 0.52-0.89) and higher in tier 4 hospitals (adjusted IRR 1.41, 95% CI 1.05-1.91) than in tier 2 hospitals; SNMM rates did not differ by hospital tier. Rates of SNMM increased with increasing hospital volume (adjusted IRR 1.02, 95% CI 1.00-1.04) and increasing rates of vaginal birth after cesarean delivery (adjusted IRR 1.02, 95% CI 1.01-1.04). Most hospitals had relatively low SMMM and SNMM rates, although a few hospitals in each tier and volume category had significantly higher rates than others. INTERPRETATION: Adverse maternal and neonatal outcomes among patients with a previous cesarean delivery showed no clear pattern of decreasing SMMM and SNMM with increasing tiers of service and hospital volume. All hospitals, irrespective of tier or size, should continually review their rates of adverse maternal and neonatal outcomes.

Preoperative diagnosis and management of inherited bleeding disorders in female adolescents and adults.

Although inherited bleeding disorders (IBDs) affect both females and males, this review of the preoperative diagnosis and management of IBDs focuses on genetic and gynecologic screening, diagnosis and management of affected and carrier females. A PubMed literature search was conducted, and the peer-reviewed literature on IBDs was evaluated and summarized. Best-practice considerations for screening, diagnosis and management of IBDs in female adolescents and adults, with GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) evidence level and ranking of recommendation strength, are presented. Health care providers need to increase their recognition of and support for female adolescents and adults with IBDs. Improved access to counselling, screening, testing and hemostatic management is also required. Patients should be educated and encouraged to report abnormal bleeding symptoms to their health care provider when they have a concern. It is hoped that this review of preoperative IBD diagnosis and management will enhance access to women-centred care to increase patients' understanding of IBDs and decrease their risk of IBD-related morbidity and mortality.

Guideline No. 427: Folic Acid and Multivitamin Supplementation for Prevention of Folic Acid-Sensitive Congenital Anomalies.

OBJECTIVE: To provide updated guidance on pre-conception folic acid and multivitamin supplementation for primary and secondary (recurrence) prevention of neural tube defects and other folate-sensitive congenital anomalies. TARGET POPULATION: Women aged 12-45 years who could become pregnant should be aware of the risk of serious birth defects without adequate pre-conception and first-trimester folic acid supplementation. OPTIONS: Optimizing folic acid supplementation is complex and depends on factors including dosage; type of supplement; bioavailability of folate from food, timing of initiating supplementation; and metabolic and genetic factors. For all women who could become pregnant, a low daily dosage of folic acid is recommended before conception and throughout pregnancy and breastfeeding. High-dosage folic acid supplementation is recommended only for women who can become pregnant and have had a previous pregnancy affected by a neural tube defect or other folate-sensitive congenital anomaly. Directed personalized approaches could be considered and adopted for women who can become pregnant and have complex risks (genetic, medical, or surgical risk factors), using new knowledge of co-factor metabolism and synergy, as well as red blood cell or serum folate testing. Such approaches would require changes to current provincial health care maternal serum folate screening/testing. OUTCOMES: New approaches to oral folic acid supplementation, including triage tools, need to be considered to optimize the benefits of decreasing risk of neural tube defects and folate-sensitive congenital anomalies. BENEFITS, HARMS, AND COSTS: Oral folic acid supplementation, or dietary folate intake combined with a multivitamin/micronutrient supplement, is associated with lower rates of neural tube defects, other folate-sensitive birth defects, and obstetrical complications. The costs are those attributable to daily vitamin supplementation and a healthy, folate-rich diet. EVIDENCE: A literature search was designed and carried in PubMed and the Cochrane Library databases from 1990 to 2021 using following MeSH terms and keywords (and variants): folic acid supplementation; folate food fortification; primary neural tube defect prevention; prevention of recurrence of neural tube defects; folate-sensitive birth defects; folate supplementation benefit; folate supplementation risk; folate pregnant woman physiology; pregnant woman RBC folate level; pregnant woman serum folate levels; folate and epilepsy; folate and obesity. This guideline was based upon expert guidelines or opinions, systematic reviews, randomized controlled clinical trials, and observational case-control studies and case series retrieved, published in English from 1990 to 2021. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: Maternity health care providers (physicians, midwives, nurses) and other providers of pregnancy-related wellness and health counselling. SUMMARY STATEMENTS: RECOMMENDATIONS.

Directive clinique no427 : Suppléments d'acide folique et multivitamines en prévention des anomalies congénitales sensibles à l'acide folique.

OBJECTIF: Offrir des recommandations à jour sur l'utilisation de multivitamines et de suppléments d'acide folique avant la conception pour la prévention primaire et secondaire (récidive) des anomalies du tube neural et des autres anomalies congénitales sensibles à l'acide folique. POPULATION CIBLE: Les femmes de 12 à 45 ans qui pourraient devenir enceintes doivent être informées des risques importants d'anomalies congénitales en l'absence d'une supplémentation adéquate en acide folique avant la conception et pendant le premier trimestre. OPTIONS: La supplémentation optimale en acide folique est complexe et repose sur divers facteurs tels que la dose, le type de suppléments, la biodisponibilité du folate dans l'alimentation, le moment du début de la supplémentation ainsi que sur les facteurs métaboliques et génétiques. Pour toutes les femmes qui peuvent devenir enceintes, une faible dose quotidienne d'acide folique est recommandée avant la conception et pendant la grossesse et l'allaitement. La supplémentation à forte dose d'acide folique est recommandée uniquement chez les femmes qui peuvent devenir enceintes et qui ont un antécédent de grossesse avec anomalie du tube neural ou toute autre anomalie congénitale sensible à l'acide folique. Il est possible d'envisager et d'adopter une approche personnalisée chez les femmes qui peuvent devenir enceintes et qui présentent des risques complexes (facteurs de risque génétiques, médicaux ou chirurgicaux) en se fondant sur les nouvelles connaissances en matière de métabolisme et synergie des cofacteurs et sur l'analyse du taux sérique et érythrocytaire d'acide folique. Ce genre d'approche exige une modification des protocoles provinciaux actuels de santé publique concernant le dépistage et l'analyse du taux sérique maternel d'acide folique. RéSULTATS: Les nouvelles stratégies de supplémentation en acide folique par voie orale, y compris dans les outils de triage, doivent être prises en compte pour diminuer de façon optimale le risque d'anomalies du tube neural et d'anomalies congénitales sensibles à l'acide folique. BéNéFICES, RISQUES ET COûTS: On observe une diminution du taux d'anomalies du tube neural, des autres anomalies congénitales sensibles à l'acide folique et des complications obstétricales chez les femmes qui prennent des suppléments oraux d'acide folique ou qui complémentent leur apport alimentaire en folate au moyen de multivitamines ou de suppléments de micronutriments. Les coûts relatifs sont liés à la prise quotidienne de suppléments vitaminiques et à l'adoption d'un régime alimentaire sain et riche en folate. DONNéES PROBANTES: Une recherche a été effectuée dans les bases de données PubMed et Cochrane Library pour trouver des articles publiés entre 1990 et 2021, en utilisant les termes MeSH et mots-clés (et leurs variantes) suivants : folate food fortification; primary neural tube defect prevention; prevention of recurrence of neural tube defects; folate-sensitive birth defects; folate supplementation benefit; folate supplementation risk; folate pregnant woman physiology; pregnant woman RBC folate level; pregnant woman serum folate levels; folate and epilepsy; folate and obesity. Cette directive clinique repose sur des lignes directrices et opinions de spécialistes, des revues systématiques, des essais cliniques randomisés et des études observationnelles de cas-témoin et de séries de cas qui ont été publiés en anglais entre 1990 et 2021. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Fournisseurs de soins de maternité (médecins, sages-femmes et infirmières) et autres fournisseurs d'accompagnement en santé et bien-être lié à la grossesse. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Canadian Enhanced Recovery After Surgery (ERAS) Cesarean Delivery Perioperative Management Survey.

Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement initiative that has spread across numerous surgical disciplines. The uptake of ERAS in cesarean delivery in Canada is presently unknown. This study surveyed the current practices of Society of Obstetricians and Gynaecologists of Canada (SOGC) members with regards to ERAS guidelines for preoperative, intraoperative, and postoperative cesarean delivery care. Survey responses highlight perioperative practice variations across Canada. Active implementation of ERAS cesarean delivery guidelines could potentially lessen variations in perioperative care, improve patient outcomes, and minimize health care costs.

Maternal perceptions of cesarean birth care: A qualitative study to inform ERAS guideline development.

BACKGROUND: Cesarean birth (CB) is the most common inpatient surgical procedure, and until recently, there were no internationally accepted, standardized clinical guidelines available. The Enhanced Recovery After Surgery (ERAS® ) program aims to improve outcomes through the development of international guidelines (IGs). As an ERAS IG for CB was being developed, this qualitative study was conducted to explore and consolidate women's experiences with CB. METHODS: Qualitative methods were used to assess the patient experience with current evidence-based CB protocols across operative phases. Twelve women who experienced CB at a single center in Canada were interviewed using an open-ended, semi-structured interview guide at six weeks postpartum. Two researchers coded the emerging themes separately and compared findings. RESULTS: Women described feeling informed, but felt they did not have a choice. Presurgery, women wanted more information about the risks of CB. Preoperatively, women expressed confusion with the procedures, but felt informed about local anesthesia and thermoregulation. Post-CB, women felt informed about pain and nausea control; however, urinary catheter removal was delayed when compared to the ERAS recommendations. Information about postpartum infant care was not well communicated, as many women were uninformed about delayed cord clamping and infant thermoregulation. CONCLUSIONS: This qualitative study provides opportunities to improve communication, the patient-practitioner relationship, and the overall satisfaction throughout the CB process. The findings support the implementation of patient decision aids and training with the shared decision model. The improved procedures recommended in the ERAS IG for CB have the potential to deliver significant improvements to patient care and patient satisfaction.

Guideline No. 416: Labour, Delivery, and Postpartum Care for People with Physical Disabilities.

OBJECTIVE: To describe evidence-based practice for managing the labour, delivery, and postpartum care of people with physical disabilities in Canada. TARGET POPULATION: This guideline addresses the needs of people with physical disabilities, with a focus on conditions that affect strength and mobility, as well as those that affect neurological or musculoskeletal function or structure. Although aspects of this guideline may apply to people with solely intellectual, developmental, or sensory disabilities (e.g., hearing and vision loss), the needs of this population are beyond the scope of this guideline. OUTCOMES: Safe and compassionate care for people with physical disabilities who are giving birth. BENEFITS, HARMS, AND COSTS: Implementation of this guideline will improve health care provider awareness of specific complications people with physical disabilities may experience during labour, delivery, and the postpartum period and therefore increase the likelihood of a safe birth. EVIDENCE: A literature review was conducted using MEDLINE (474), Embase (36), and the Cochrane Central Register of Controlled Trials (CENTRAL; 28) databases. The results have been filtered for English language, publication date of 2013 to present, observational studies, systematic reviews, meta-analyses, and guidelines and references in these publications were also reviewed. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: Maternal-fetal medicine specialists, obstetricians, family physicians, nurses, midwives, neurologists, physiatrists, and those who care for people with physical disabilities.

Evaluation of the Fetal Therapy Evidence in Lower Urinary Tract Obstruction: Would an ERAS Guideline Improve Outcomes?

BACKGROUND: Pregnancies that are prenatally identified to have fetal anomalies are complex and require expert multidisciplinary care. As many conditions can impact the fetus prenatally and require intervention, an enhanced recovery after surgery (ERAS) for lower urinary tract obstruction (LUTO) is being evaluated to determine the level of evidenced-based data available. PROBLEM: The percutaneous ultrasound-guided fetal surgery procedure for bladder neck obstruction is the focus for elements of preoperative counseling, intraoperative procedure/risk complications, and postoperative management. METHODS: A quality improvement review Squire 2.0 (2000-2020) was undertaken for the percutaneous LUTO fetal surgery shunting (lower urinary tract obstruction), process and procedure which require 2 process pathways, one to evaluate the fetal candidate and a second to treat. This structured review is focused on identifying the process elements to allow the determination of the number of evidenced-based elements that would allow for audit and measurement of the clinical element variance for comparative feedback to the individual surgical provider or surgery center. INTERVENTIONS: Titles and abstracts were screened to identify potentially relevant articles with priority given to meta-analyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series. RESULTS: A series of potential clinical elements for the diagnostic fetal evaluation and for the 3 protocol areas of surgical care for the procedures (pre-, intra-, and postoperative care) are identified using an ERAS-like process. CONCLUSIONS: The identified clinical elements have the potential for ERAS-LUTO fetal therapy guideline. Multidisciplinary collaboration (surgeon, anesthesia, nursing, imaging, and laboratory) is required for ERAS quality improvement in the pre-, intra-, and postoperative processes. Process elements in each of the operative areas can be audited, evaluated, compared, and modified/improved.

The Real Maternal Risks in a Pregnancy: A Structured Review to Enhance Maternal Understanding and Education.

This review sought to use high-level published data sources for system knowledge translation, collaborative enhanced maternal education and understanding, and prospective maternal quality and safety care planning. The goal was to answer the following question: What are the short- and long-term maternal risks ("near misses," adverse events, severe morbidity and mortality) associated with pregnancy and childbirth? A structured analysis of the literature (systematic review, meta-analysis, observational case-control cohort), focusing on publications between 2016 and April 2019, was undertaken using the following key word search strategy: maternal, morbidity, mortality, co-morbidities (BMI, fertility, hypertension, cardiac, chronic renal disease, diabetes, mental health, stroke), preconception, antepartum, intrapartum, postpartum, "near miss," and adverse events. Only large cohort database sources with control comparison studies were accepted for inclusion because maternal mortality events are rare. Systematic review and meta-analysis were not undertaken because of the wide clinical scope and the goal of creating an education algorithm tool. For this educational tool, the results were presented in a counselling format that included a control group of common maternal morbidity from a regional maternity cohort (2017) of 54 000 births and published risk estimates for pre-conception, pregnancy-associated comorbidity, pregnancy-onset conditions, long-term maternal health associations, and maternal mortality scenarios. Because issues related to maternal comorbidities are increasing in prevalence, personalized pre-conception education on maternal pregnancy risk estimates needs to be encouraged and available to promote greater understanding. This maternal morbidity and mortality evaluation tool allows for patient-provider review and recognition of the possible leading factors associated with an increased risk of maternal morbidity: pre-conception risks (maternal age >45 years; pre-existing cardiac or hypertensive conditions) and pregnancy-obstetrical risks (gestational hypertension, preeclampsia, eclampsia; caesarean delivery, whether preterm or term; operative vaginal delivery; maternal sepsis; placenta accreta spectrum; and antepartum or postpartum hemorrhage).

Guideline No. 409: Intrauterine Fetal Diagnostic Testing in Women with Chronic Viral Infections.

OBJECTIVE: This revised guideline provides updated information for the care of women with chronic viral infections who require intrauterine fetal diagnostic testing. TARGET POPULATION: Women with chronic viral infections who are pregnant or planning a pregnancy. OPTIONS: Non-invasive screening tests for diagnosis: maternal serum placental analytes with or without nuchal translucency, sonography, maternal serum cell-free placental DNA; and intrauterine fetal diagnostic testing: amniocentesis, chorionic villus sampling, cordocentesis. OUTCOMES: The recommendations in this guideline have the potential to decrease or eliminate morbidity and mortality in women with chronic viral infections and their infants, which is associated with significant health and economic outcomes. EVIDENCE: Published literature was retrieved through searches of PubMed, guidelines of national societies (Society of Obstetricians and Gynaecologists of Canada, American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, other international societies), and the Cochrane Library using appropriate controlled vocabulary (amniocentesis, chorionic villus sampling, cordocentesis, procedure pregnancy loss risk, viral vertical transmission, fetal and neonatal infection) and keywords (maternal infection or exposure, hepatitis B, hepatitis C, human immunodeficiency virus). Results were restricted to systematic reviews, randomized controlled trials or controlled clinical trials (if available), and observational case-control studies or case series from 2012 to 2019 published in English or French. Studies from 1966 to 2002 were previously reviewed in the SOGC guideline No. 123: Amniocentesis and Women with Hepatitis B, Hepatitis C, or Human Immunodeficiency Virus, and those from 2002 to 2012 were previously reviewed in the SOGC guideline No. 309: Prenatal Invasive Procedures in Women With Hepatitis B, Hepatitis C, and/or Human Immunodeficiency Virus Infections. Updated literature searches were completed regularly through August 2019 and were incorporated into this guideline. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: The intended users are maternity care providers and women with chronic viral infections. This guideline provides information to educate and counsel these women, and to offer them reproductive options. RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Directive clinique no 409 : Tests diagnostiques fœtaux intra-utérins en cas d'infection virale chronique maternelle.

OBJECTIF: La présente directive clinique révisée met à jour les renseignements sur la prestation de soins aux femmes atteintes d'une infection virale chronique devant se soumettre à un test diagnostique fœtal intra-utérin. POPULATION CIBLE: Femmes atteintes d'une infection virale chronique qui sont enceintes ou prévoient le devenir. OPTIONS: Tests de dépistage non invasifs à des fins diagnostiques : marqueurs placentaires sériques maternels avec ou sans mesure de la clarté nucale, échographie, ADN fœtal libre circulant dans le sang maternel; et tests diagnostiques fœtaux intra-utérins : amniocentèse, biopsie choriale (choriocentèse), cordocentèse. ISSUES: Les recommandations de la présente directive clinique pourraient réduire ou éliminer la morbi-mortalité chez les femmes atteintes d'une infection virale chronique et leurs nourrissons, ce qui est associé à d'importantes conséquences sur les plans de la santé et de l'économie. DONNéES PROBANTES: La littérature publiée a été recueillie au moyen de recherches dans les bases de données PubMed et Cochrane Library ainsi que dans les directives cliniques de sociétés médicales nationales et internationales (Société des obstétriciens et gynécologues du Canada, American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine et d'autres sociétés internationales) en utilisant un vocabulaire (amniocentesis, chorionic villus sampling, cordocentesis, procedure pregnancy loss risk, viral vertical transmission, fetal and neonatal infection) et des mots clés (maternal infection or exposure, hepatitis B, hepatitis C, human immunodeficiency virus) contrôlés et appropriés. Les résultats retenus se limitent aux revues systématiques, aux essais cliniques randomisés ou aux essais cliniques comparatifs (si disponibles) et aux études cas-témoins observationnelles ou études de série de cas publiées entre 2012 et 2019 en anglais ou en français. Les études publiées entre 1966 et 2002 ont déjà été examinées dans la directive clinique de la SOGC no 123, L'amniocentèse chez les femmes infectées par l'hépatite B, l'hépatite C ou le virus de l'immunodéficience humaine; les études publiées entre 2002 et 2012 ont quant à elles été examinées dans la directive clinique de la SOGC no 309, Interventions effractives prénatales chez les femmes qui présentent des infections par le virus de l'hépatite B, le virus de l'hépatite C et/ou le virus de l'immunodéficience humaine. De nouvelles recherches ont été effectuées dans la littérature jusqu'en août 2019, puis ont été intégrées à la présente directive clinique. MéTHODES DE VALIDATION: L'auteur a évalué la qualité des données probantes et la solidité des recommandations au moyen du cadre méthodologique GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Consulter l'annexe A en ligne (le tableau A1 pour les définitions et le tableau A2 pour les interprétations des recommandations fortes et faibles). PUBLIC VISé: Les utilisateurs prévus sont des fournisseurs de soins de maternité et les femmes atteintes d'une infection virale chronique. Cette directive fournit des renseignements pour renseigner et conseiller ces femmes et leur offrir des options de procréation. RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Acute Perinatal Infection and the Evidenced-Based Risk of Intrauterine Diagnostic Testing: A Structured Review.

BACKGROUND: The prevalence of perinatal infection from maternal exposure is increasing. The prevalence of acute maternal infections identifies cytomegalovirus, parvovirus B19, toxoplasmosis, and varicella as the most common organisms and in the order of frequency. Maternal informed consent and understanding is required before intrauterine testing for fetal infectious and possible genetic risk assessment. METHODS: This structured review of the reproductive published literature focuses on the risks of amniocentesis and cordocentesis diagnostic procedure-related fetal loss rates and fetal vertical transmission (VT) rates from published infected pregnant cohorts. RESULTS: The total postprocedure fetal loss rate for diagnostic amniocentesis procedures, in limited infectious cohorts, is 1.5% and does not appear to be increased compared to "noninfected" amniocentesis cohorts using an estimated background spontaneous fetal loss rate (no procedure) of 0.65%. The "pooled" unintended fetal loss rate is from small infected population cohorts, but can be used for counseling purposes. Postcordocentesis fetal loss risk, in an infected cohort, is not possible to estimate due to limited data. The "biological spontaneous fetal loss rate" risk with a perinatal infection (positive or negative fetal anomalies) and no diagnostic procedure before 20 weeks of gestation is reviewed. The risk of VT in acute infection cohorts as a result of the intra-amniotic diagnostic procedure is not found to be increased. CONCLUSION: The unintended "fetal loss" rate after amniocentesis for perinatal infected cohorts is similar to that of noninfected cohorts, but the estimate is based on limited infected cohorts. There was no procedure-based risk of fetal VT in the infected cohorts, but identification of postprocedure maternal bleeding into the amniotic cavity increases the potential risk. Maternal knowledge translation and an informed consent process with risk-benefit maternal/fetal risk counseling are required prior to any diagnostic amniocentesis procedure.

Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society recommendations (part 3).

BACKGROUND: This Enhanced Recovery After Surgery Guideline for postoperative care in cesarean delivery will provide best practice, evidenced-based recommendations for postoperative care with primarily a maternal focus. OBJECTIVE: The pathway process for scheduled and unscheduled cesarean delivery for this Enhanced Recovery After Surgery cesarean delivery guideline will consider time from completion of cesarean delivery until maternal hospital discharge. STUDY DESIGN: The literature search (1966-2017) used Embase and PubMed to search medical subject headings that included "Cesarean Section," "Cesarean Delivery," "Cesarean Section Delivery," and all postoperative Enhanced Recovery After Surgery items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses evaluated the quality of evidence, and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system as used and described in previous Enhanced Recovery After Surgery Guidelines. RESULTS: The Enhanced Recovery After Surgery cesarean delivery guideline/pathway has created a pathway for postoperative care. Specifics include sham feeding, nausea and vomiting prevention, postoperative analgesia, nutritional care, glucose control, thromboembolism prophylaxis, early mobilization, urinary drainage, and discharge counseling. A number of elements of postoperative care of women who undergo cesarean delivery are recommended, based on the evidence. CONCLUSION: As the Enhanced Recovery After Surgery cesarean delivery pathway (elements/processes) are studied, implemented, audited, evaluated, and optimized by the maternity care teams, there will be an opportunity for focused and optimized areas of care and recommendations to be further enhanced.

Clinical interventions that influence vaginal birth after cesarean delivery rates: Systematic Review & Meta-Analysis.

BACKGROUND: To systematically review the literature on clinical interventions that influence vaginal birth after cesarean (VBAC) rates. METHODS: We searched Ovid Medline, Ovid Embase, Wiley Cochrane Library, CINAHL via EBSCOhost; and Ovid PsycINFO. Additional studies were identified by searching for clinical trial records, conference proceedings and dissertations. Limits were applied for language (English and French) and year of publication (1985 to present). Two reviewers independently screened comparative studies (randomized or non-randomized controlled trials, and observational designs) according to a priori eligibility criteria: women with prior cesarean sections; any clinical intervention or exposure intended to increase the VBAC rate; any comparator; and, outcomes reporting VBAC, uterine rupture and uterine dehiscence rates. One reviewer extracted data and a second reviewer verified for accuracy. Meta-analysis was conducted using Mantel-Haenszel (random effects model) relative risks (VBAC rate) and risk differences (uterine rupture and dehiscence). Two reviewers independently conducted methodological quality assessments using the Mixed Methods Appraisal Tool (MMAT). RESULTS: Twenty-nine studies (six trials and 23 cohorts) examined different clinical interventions affecting rates of vaginal deliveries among women with a prior cesarean delivery (CD). Methodological quality was good overall for the trials; however, concerns among the cohort studies regarding selection bias, comparability of groups and outcome measurement resulted in higher risk of bias. Interventions for labor induction, with or without cervical ripening, included pharmacologic (oxytocin, prostaglandins, misoprostol, mifepristone, epidural analgesia), non-pharmacologic (membrane sweep, amniotomy, balloon devices), and combined (pharmacologic and non-pharmacologic). Single studies with small sample sizes and event rates contributed to most comparisons, with no clear differences between groups on rates of VBAC, uterine rupture and uterine dehiscence. CONCLUSIONS: This systematic review evaluated clinical interventions directed at increasing the rate of vaginal delivery among women with a prior CD and found low to very low certainty in the body of evidence for cervical ripening and/or labor induction techniques. There is insufficient high-quality evidence to inform optimal clinical interventions among women attempting a trial of labor after a prior CD.

Choosing Pre-conception Planning for Women/Families: Counselling and Informed Consent (Part 2) - Pre-conception Reproductive Planning, Lifestyle, Immunization, and Psychosocial Issues.

OBJECTIVE: To inform reproductive and other health care providers about pre-conception evaluation, including considerations for reproductive planning, lifestyle modification, immunization status and attitudes, and psychosocial issues. OPTIONS: This counselling information can be used for patient education and planning and possible pre-conception and/or prenatal testing. OUTCOMES: This information may allow for improved risk assessment when pre-conception counselling for individual patients and their families is used. CONSIDERATIONS FOR PRE-CONCEPTION CARE (PART 2) REGARDING PRE-CONCEPTION REPRODUCTIVE PLANNING, LIFESTYLE, IMMUNIZATIONS, AND PSYCHOSOCIAL ISSUES: CONSIDERATION FOR CARE STATEMENTS: For this review article, the Consideration for Care Statements use the Grading of Recommendations, Assessment, Development and Evaluations strength and quality principles because they are comparable for the clinician and the patient/public user. For example, "Strong" for clinicians is defined as "the recommendation would apply to most individuals. Formal discussion aids are not likely to be needed to help individuals make decisions consistent with their values and preferences." For patients/the public, "Strong" is defined as, "we believe most people in this situation would want the recommended course of actions and only a small number would not." Quality of evidence (High, Moderate, Low) is based on the confidence that the true effect lies close to that of the estimate of the effect. In addition, the Canadian Task Force on Preventive Health Care key to evidence statements and grading of recommendations are included. EVIDENCE: PubMed, Medline, and the Cochrane Database were searched until May 2017, using appropriate key words (i.e., preconception, reproductive planning, lifestyle modification, immunization risks and benefits, psychosocial pregnancy factors/issues). Grey (unpublished) literature was identified through searching websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, and national and international medical specialty societies. BENEFITS, HARMS, AND COSTS: The benefits for the patient and her family from receiving this pre-conception counseling would include an increased understanding of the relevant issues for both pre-conception and in early pregnancy as well as better pregnancy outcomes. Harm includes potential increased anxiety or psychological stress associated with the possibility of identifying maternal pregnancy risks.

A Review of Enhanced Recovery After Surgery Principles Used for Scheduled Caesarean Delivery.

There is an increasing body of evidence to support the success of Enhanced Recovery After Surgery (ERAS) for a wide range of surgical procedures. There has been little formalized application, however, of ERAS principles in obstetrical surgery. The aim of this review was to examine the evidence base of perioperative care for patients undergoing Caesarean delivery (CD) and to determine the feasibility of developing an ERAS Society guideline for this obstetrical care plan. The literature on enhanced recovery programs was reviewed, including fast-track surgery and perioperative care components in the preoperative, intraoperative, and postoperative phases of CD. These studies included randomized controlled trials (RCTs), prospective cohort studies, non-RCT studies, meta-analyses, systematic reviews, reviews, and case studies. This is not a systematic review because each ERAS topic area would require a new question. Certain ERAS elements have the potential to benefit patients undergoing CD. These elements include patient education, preoperative optimization, prophylaxis against thromboembolism, antimicrobial prophylaxis, postoperative nausea and vomiting prevention, hypothermia prevention, perioperative fluid management, postoperative analgesia, ileus prevention, breastfeeding promotion, and early mobilization. ERAS has the potential to be successfully implemented in CD on the basis of the evidence obtained from this review. Knowledge transfer and implementation will require multidisciplinary coordination in the preoperative, intraoperative, and postoperative phases and the development of a formalized ERAS guideline.

Effectiveness and Accuracy of Tests for Preterm Delivery in Symptomatic Women: A Systematic Review.

This study systematically reviewed evidence on the effectiveness and accuracy of predictive tests for preterm delivery among symptomatic women. The study included English-language systematic reviews (SRs) on any predictive test for preterm delivery among symptomatic women and primary studies for placental alpha-microglobulin-1. PubMed, Wiley Cochrane Library, the Centre for Reviews and Dissemination Database, the National Guidelines Clearinghouse, and the TRIP database were searched for SRs, PubMed and PubMed Central via the Wiley Cochrane Library were searched for primary studies. One reviewer performed study selection, with input from a second reviewer when needed. One reviewer appraised study quality and extracted: study characteristics (i.e., country, funding source, study design [primary studies] or synthesis method [SRs], study appraisal method [SRs]), population characteristics, index test(s) and cut-off points used, comparator(s) or reference standard(s), and outcomes. A second reviewed a random 10% sample. The authors synthesized the findings narratively. Of 451 unique records, the review included 22 (17 SRs, five primary studies). For effectiveness, there was evidence for use of transvaginal sonographic cervical length assessment (15-25 mm cut point) in reducing incidence of preterm delivery at <37 weeks (relative risk 0.64; 95% CI 0.44-0.94, one SR of three trials; n = 287) but lack of support for cervicovaginal fetal fibronectin. In terms of accuracy, one high-quality study within a best-evidence SR showed that cervical length measurement was useful to predict delivery within 48 hours (LR+ 6.43, 95% CI 5.17-8.00; LR- 0.03, 95% CI 0.00-0.42; n = 510) and 7 days (LR+ 8.61, 95% CI 6.65-11.14; LR- 0.03, 95% CI 0.00-0.18; n = 510). Accuracy of placental alpha-microglobulin-1 testing was not supported for most end points. In conclusion, some evidence supports the effectiveness of cervical length as a predictor of preterm delivery in symptomatic women. Evidence for most tests is limited in quality and quantity.

The Impact of Prenatal Diagnosis of Selected Central Nervous System Anomalies for Prenatal Counselling Based on Significant Pregnancy Morbidity and Neonatal Outcomes.

BACKGROUND & OBJECTIVES: Prenatal screening and diagnostic imaging advances have led to an increased detection of CNS anomalies, including ventriculomegaly/congenital hydrocephalus (HCP), Dandy-Walker malformation (DWM), and myelomeningocele (MMC). Data on pregnancy outcomes and the impact of prenatal diagnosis on neonatal outcomes is limited. Our study aimed to provide data on obstetric and neonatal outcomes following prenatal diagnosis of one of three CNS anomalies. METHODS: A retrospective search of two databases in Alberta, Canada and NICU chart review of cases between 2001 and 2011was completed. Primary outcomes for each group were pregnancy outcome (live birth, stillbirth, and termination) and detection rate. Secondary outcomes were live and total birth prevalence, mode of delivery, GA at delivery, and length of NICU stay for inborn versus outborn patients. RESULTS: Prenatal detection rates were 91.6% (HCP), 83.4% (DWM), and 92.9 % (MMC). Termination rates were 30.2% (DWM), 34.2% (HCP), and 48.5% (MMC). Median GA (weeks, range) at diagnosis were 22 (17-38), 20 (12-37), and 20.5 (18-34) for HCP, DWM, and MMC, respectively. Rate of Caesarean section for fetal indication was 50.0%, 44.4%, and 42.9% for HCP, DWM, and MMC, respectively. Median NICU length of stay was longer for outborn patients than inborn patients and were as follows: (range) 33.0 (21-38) versus 8.5 (1-49) d (HCP), and 29 (29-57) versus 14 (2-75) d (DWM). CONCLUSION: This study provides termination rates, obstetric interventions, and NICU length of stay for prenatally-identified CNS anomalies. Collectively, this study assists prenatal counselling women with a fetus affected by a described CNS anomaly.

A Randomized Controlled Trial of the Safety and Immunogenicity of Tetanus, Diphtheria, and Acellular Pertussis Vaccine Immunization During Pregnancy and Subsequent Infant Immune Response.

Background: Immunization of pregnant women with tetanus-diphtheria-acellular pertussis vaccine (Tdap) provides protection against pertussis to the newborn infant. Methods: In a randomized, controlled, observer-blind, multicenter clinical trial, we measured the safety and immunogenicity of Tdap during pregnancy and the effect on the infant's immune response to primary vaccination at 2, 4, and 6 months and booster vaccination at 12 months of age. A total of 273 women received either Tdap or tetanus-diphtheria (Td) vaccine in the third trimester and provided information for the safety analysis and samples for the immunogenicity analyses; 261 infants provided serum for the immunogenicity analyses. Results: Rates of adverse events were similar in both groups. Infants of Tdap recipients had cord blood levels that were 21% higher than maternal levels for pertussis toxoid (PT), 13% higher for filamentous hemagglutinin (FHA), 4% higher for pertactin (PRN), and 7% higher for fimbriae (FIM). These infants had significantly higher PT antibody levels at birth and at 2 months and significantly higher FHA, PRN, and FIM antibodies at birth and 2 and 4 months, but significantly lower PT and FHA antibody levels at 6 and 7 months and significantly lower PRN and FIM antibody levels at 7 months than infants whose mothers received Td. Differences persisted prebooster at 12 months for all antigens and postbooster 1 month later for PT, FHA, and FIM. Conclusions: This study demonstrated that Tdap during pregnancy results in higher levels of antibodies early in infancy but lower levels after the primary vaccine series. Clinical Trials Registration: NCT00553228.

Guidelines for Antenatal and Preoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society Recommendations (Part 1).

This Enhanced Recovery After Surgery (ERAS) Guideline for perioperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for preoperative, intraoperative, and postoperative phases with, primarily, a maternal focus. The focused pathway process for scheduled and unscheduled cesarean delivery for this ERAS Cesarean Delivery Guideline will consider from the time from decision to operate (starting with the 30-60 minutes before skin incision) to hospital discharge. The literature search (1966-2017) used Embase and PubMed to search medical subject headings that included "Cesarean Section," "Cesarean Section," "Cesarean Section Delivery" and all pre- and intraoperative ERAS items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses that evaluated the quality of evidence and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system, as used and described in previous ERAS Guidelines. The ERAS Cesarean Delivery Guideline/Pathway has created a maternal focused pathway (for scheduled and unscheduled surgery starting from 30-60 minutes before skin incision to maternal discharge) with ERAS cesarean delivery consensus recommendations preoperative elements (anesthetic medications, fasting, carbohydrate supplementation, prophylactic antibiotics/skin preparation, ), intraoperative elements (anesthetic management, maternal hypothermia prevention, surgical technique, hysterotomy creation and closure, management of peritoneum, subcutaneous space, and skin closure), perioperative fluid management, and postoperative elements (chewing gum, management of nausea and vomiting, analgesia, timing of food intake, glucose management, antithrombotic prophylaxis, timing of ambulation, urinary management, and timing of maternal and neonate discharge). Limited topics for optimized care and for antenatal education and counselling and the immediate neonatal needs at delivery are discussed. Strong recommendations for element use were given for preoperative (antenatal education and counselling, use of antacids and histamine, H2 receptor antagonists, 2-hour fasting and small meal within 6 hours surgery, antimicrobial prophylaxis and skin preparation/chlorhexidine-alcohol), intraoperative (regional anesthesia, prevention of maternal hypothermia [forced warm air, warmed intravenous fluids, room temperature]), perioperative (fluid management for euvolemia and neonatal immediate care needs that include delayed cord clamping), and postoperative (fluid management to prevent nausea and vomiting, antiemetic use, analgesia with nonsteroidal antiinflammatory drugs/paracetamol, regular diet within 2 hours, tight capillary glucose control, pneumatic compression stocking for venous thromboembolism prophylaxis, immediate removal of urinary catheter). Recommendations against the element use were made for preoperative (maternal sedation, bowel preparation), intraoperative (neonatal oral suctioning or increased inspired oxygen), and postoperative (heparin should not be used routinely venous thromboembolism prophylaxis). Because these ERAS cesarean delivery pathway recommendations (elements/processes) are studied, implemented, audited, evaluated, and optimized by the maternity care teams, this will create an opportunity for the focused and optimized areas of care research with further enhanced care and recommendation.