European Association of Perinatal Medicine (EAPM), European Board and College of Obstetricians and Gynaecologists (EBCOG), European Midwives Association (EMA). Joint position statement: Substandard and disrespectful care in labour - because words matter.

Substandard or disrespectful care during labour should be of serious concern for healthcare professionals, as it can affect one of the most important events in a woman's life. Substandard care refers to the use of interventions that are not considered best-practice, to the inadequate execution of interventions, to situations where best-practice interventions are withheld from patients, or there is lack of adequate informed consent. Disrespectful care refers to forms of verbal and non-verbal communication that affect patients' dignity, individuality, privacy, intimacy, or personal beliefs. There are many possible underlying causes for substandard and disrespectful care in labour, including difficulties in modifying behaviours, judgmental or paternalistic attitudes, personal interests and individualism, and a human tendency to make less arduous, less difficult, or less stressful clinical decisions. The term "obstetric violence" is used in some parts of the world to describe various forms of substandard and disrespectful care in labour, but suggests that it is mainly carried out by obstetricians and is a serious form of aggression, carried out with the intent to cause harm. We believe that this term should not be used, as it does not help to identify the underlying problem, its causes, or its correction. In addition, it is generally seen by obstetricians and other healthcare professionals as an unjust and offensive term, generating a defensive and less collaborative mindset. We reach out to all individuals and institutions sharing the common goal of improving women's experience during labour, to work together to address the underlying causes of substandard and disrespectful care, and to develop common strategies to deal with this problem, based on mutual comprehension, trust and respect.

EUROPEAN ASSOCIATION OF PERINATAL MEDICINE (EAPM) Position statement: Use of appropriate terminology for situations related to inadequate fetal oxygenation in labor.

In high-resource countries, adverse perinatal outcomes are currently rare in term, non-malformed fetuses, undergoing labor, but they remain a leading cause of medico-legal dispute. Precise terminology is important to describe situations related to inadequate fetal oxygenation in labor, to ensure appropriate communication between healthcare professionals and adequate transmission of information to parents. This position statement provides consensus definitions from European perinatologists and midwives regarding the most appropriate terminology to describe situations related to inadequate fetal oxygenation in labor: suspected fetal hypoxia, severe newborn acidemia, newborn metabolic acidosis, and hypoxic-ischemic encephalopathy. It also identifies terms that are imprecise or nonspecific to this situation, and should therefore be avoided by healthcare professionals: fetal well-being, fetal stress, fetal distress, non-reassuring fetal state, and birth asphyxia.

EUROPEAN ASSOCIATION OF PERINATAL MEDICINE (EAPM) EUROPEAN MIDWIVES ASSOCIATION (EMA) Joint position statement: Caesarean delivery rates at a country level should be in the 15-20 % range.

While cesarean deliveries performed for health indications can save lives, unnecessary cesareans cause unjustifiable health risks for the mother, newborn, and for future pregnancies. Previous recommendations for cesarean delivery rates at a country level in the 10-15% range are currently unrealistic, and the proposed concept that striving to achieve specific rates is not important has resulted in a confusing message reaching healthcare professionals and the public. It is important to have a clear understanding of when cesarean delivery rates are deviating from internationally acceptable ranges, to trigger the implementation of healthcare policies needed to correct this problem. Based on currently existing scientific evidence, we recommend that cesarean delivery rates at a country level should be in the 15-20% range. This advice is based on the demonstration of decreased maternal and neonatal mortalities when national cesarean delivery rates rise to circa 15%, but values exceeding 20% are not associated with further benefits. It is also based on real-world experiences from northern European countries, where cesarean delivery rates in the 15-20% range are associated with some of the best maternal and perinatal quality indicators in the world. With the increase in cesarean delivery rates projected for the coming years, experience in provision of intrapartum care may come under threat in many hospitals, and recovering from this situation is likely to be a major challenge. Professional and scientific societies, together with healthcare authorities and governments need to prioritize actions to reverse the upward trend in cesarean delivery rates observed in many countries, and to strive to achieve values as close as possible to the recommended range.

A wider agreement is needed on basic intrapartum concepts.

Healthcare professionals working in labor wards worldwide regularly deal with the pressure of managing an emotionally charged and life-changing period for women, their families, and their friends. Furthermore, they frequently deal with long working hours, sleep deprivation, occasional scrutiny from the press, and legal dispute. The existing disagreements among leading scientific institutions on basic concepts of intrapartum care hinder the creation of a collective mental model in the labor ward, an aspect that is required for consistency in patient counseling and effective teamwork. Some of these disagreements are as follows: 1. When should laboring women be admitted to the hospital? 2. How long is the absence of labor progress acceptable before an intervention is proposed? 3. How long should women be allowed to push during the second stage of labor before an intervention is proposed? The international scientific community owes it to the vast number of healthcare professionals working in labor wards worldwide to agree on and provide clear definitions of these basic intrapartum concepts, thus making their work a little easier. International institutions, such as the International Federation of Gynecology and Obstetrics and the World Health Organization, have the highest authority to produce guidelines for the whole world, but the participation of leading national organizations, whose influence reaches well beyond the borders of their countries, is important for the wide dissemination of concepts.

European guidelines on perinatal care: corticosteroids for women at risk of preterm birth.

of recommendationsCorticosteroids should be administered to women at a gestational age between 24+0 and 33+6 weeks, when preterm birth is anticipated in the next seven days, as these have been consistently shown to reduce neonatal mortality and morbidity. (Strong-quality evidence; strong recommendation). In selected cases, extension of this period up to 34+6 weeks may be considered (Expert opinion). Optimal benefits are found in infants delivered within 7 days of corticosteroid administration. Even a single-dose administration should be given to women with imminent preterm birth, as this is likely to improve neurodevelopmental outcome (Moderate-quality evidence; conditional recommendation).Either betamethasone (12 mg administered intramuscularly twice, 24-hours apart) or dexamethasone (6 mg administered intramuscularly in four doses, 12-hours apart, or 12 mg administered intramuscularly twice, 24-hours apart), may be used (Moderate-quality evidence; Strong recommendation). Administration of two "all" doses is named a "course of corticosteroids".Administration between 22+0 and 23+6 weeks should be considered when preterm birth is anticipated in the next seven days and active newborn life-support is indicated, taking into account parental wishes. Clear survival benefit has been observed in these cases, but the impact on short-term neurological and respiratory function, as well as long-term neurodevelopmental outcome is still unclear (Low/moderate-quality evidence; Weak recommendation).Administration between 34 + 0 and 34 + 6 weeks should only be offered to a few selected cases (Expert opinion). Administration between 35+0 and 36+6 weeks should be restricted to prospective randomized trials. Current evidence suggests that although corticosteroids reduce the incidence of transient tachypnea of the newborn, they do not affect the incidence of respiratory distress syndrome, and they increase neonatal hypoglycemia. Long-term safety data are lacking (Moderate quality evidence; Conditional recommendation).Administration in pregnancies beyond 37+0 weeks is not indicated, even for scheduled cesarean delivery, as current evidence does not suggest benefit and the long-term effects remain unknown (Low-quality evidence; Conditional recommendation).Administration should be given in twin pregnancies, with the same indication and doses as for singletons. However, existing evidence suggests that it should be reserved for pregnancies at high-risk of delivering within a 7-day interval (Low-quality evidence; Conditional recommendation). Maternal diabetes mellitus is not a contraindication to the use of antenatal corticosteroids (Moderate quality evidence; Strong recommendation).A single repeat course of corticosteroids can be considered in pregnancies at less than 34+0 weeks gestation, if the previous course was completed more than seven days earlier, and there is a renewed risk of imminent delivery (Low-quality evidence; Conditional recommendation).

Quality of fetal heart rate monitoring with transabdominal fetal ECG during maternal movement in labor: A prospective study.

INTRODUCTION: Transabdominal electrocardiographic (TAfECG) acquisition of fetal heart rate (FHR) signals has recently been introduced into leading commercial cardiotocographic (CTG) monitors. Continuous wireless transmission of signals has raised the possibility of the technology being used during maternal mobilization in labor. This study aims to evaluate signal quality and accuracy of TAfECG acquisition of FHR signals during static and active maternal positions in labor when compared with Doppler signals and with the gold-standard method of fetal scalp electrode (FSE). MATERIAL AND METHODS: A total of 76 women with singleton term pregnancies in the active first stage of labor had simultaneously acquired FHR with TAfECG, Doppler, and FSE. Participants were asked to complete a supervised mobilization scheme, comprising five sequential 10-min periods of lying down, standing, sitting, walking, and rocking on the birthing ball. The three FHR signals were compared, defining signal loss as the percentage of signals under 20 bpm or exceeding 250 bpm and accuracy as the difference with FSE values. Computer analysis was used to quantify variability, accelerations, and decelerations. Static labor positions (lying down, standing, and sitting) were compared with active labor positions (walking and rocking on the birthing ball). RESULTS: Average signal loss was 5.3% with TAfECG (3.2% in static and 7.4% in active positions) and 15.5% with Doppler (8.3% in static and 30.7% in active positions). Average accuracy was 3.5 bpm with TAfECG (1.9 bpm in static and 5.04 bpm in active positions) and 13.9 bpm with Doppler (3.2 bpm in static and 24.7 bpm in active positions). Average variability was similar with TAfECG and FSE in static positions but significantly higher with TAfECG in active positions (23.6 vs. 13.5 bpm, p < 0.001). CONCLUSIONS: In static labor positions, TAfECG provides a low signal loss, similar to that obtained with FSE, and a good signal accuracy, so the technique can be considered reliable when the mother is lying down, standing, or sitting. During maternal movement, TAfECG causes an artificial increase in FHR variability, which can cause false reassurance regarding fetal oxygenation. Doppler signals are unreliable during maternal movements.

Provision of antenatal care in Europe-A scientific study commissioned by European Board and College of Obstetrics and Gynaecology (EBCOG).

Differences in the way health care delivery across countries may have important impacts on health outcomes and can result in inequalities. A questionnaire survey of members of national societies through EBCOG and EAPM was carried out in 2021. A total of 53 responses were received from 26 countries. Most countries reported that routine antenatal care is primarily delivered by medical staff, involving obstetric specialists or family doctors mostly in government-run facilities. Women from minority groups are able to access antenatal care easily in most countries. Less than 10% of women did not attend antenatal care throughout the pregnancy. Most booking for antenatal care takes place in the first trimester and the number of visits range from 6 to 10 depending on parity. Most countries provide routine ultrasound with 2-3 reported scans performed by specifically trained health care professionals. Facilities for prenatal screening/diagnosis of malformations in both low- and high-risk cases varied across Europe. While antenatal care is relatively standardized throughout Europe, important differences still exist in care delivery and accessibility to care. Antenatal preventive strategies appear to be variably available throughout Europe.

Use of external cephalic version in Portuguese public hospitals.

OBJECTIVE: To evaluate the use of external cephalic version (ECV) in Portuguese public hospitals with maternity services, as well as exploring the main motives for not offering the technique. METHODS: A cross-sectional observational study was conducted involving an online survey with 34 questions, accessed via an email addressed to all Heads of Department of Portuguese state-owned hospitals with maternity services. In centers where the technique was performed, information was requested on success rates, contraindications for the procedure, and practical aspects related to its use. In centers where ECV was not offered, the underlying reasons for this were queried. RESULTS: Answers were received from 41 out of the 43 state hospitals with maternity services (95.3%). Sixteen hospitals perform the technique (39%), with reported annual numbers ranging from 3 to 51, and success rates ranging from 25% to 85% (12 respondents). The main reasons for not offering the technique were lack of experience and lack of conditions to perform it safely. Most centers (87.8%) reported that they would welcome hands-on training in ECV. CONCLUSION: ECV is used in a minority of Portuguese state-owned hospitals. Efforts are needed to achieve a wider implementation of the technique, with a particular focus on simulation-based training.

Physical exercise at term for enhancing the spontaneous onset of labor: a randomized clinical trial.

INTRODUCTION: Physical exercise at term is empirically used as a method of enhancing the spontaneous labor onset. The objective of this study was to evaluate the effect of controlled maternal physical exercise at term as a method of enhancing the spontaneous labor onset. MATERIALS AND METHODS: At 38 weeks low-risk pregnant women, with a singleton cephalic fetus and no previous cesarean deliveries were randomly allocated to one of two arms: the experimental group performed 30 min of walking 3 times a week at 4 km/h, and the control group maintained their usual work and household activities. The primary outcome measure was the rate of labor induction. A sample size of 60 per group was planned to detect a 10% difference in labor induction rate, at a significance level of 0.05 and a power of 0.80. RESULTS: The exercise group had a lower rate of labor induction (17.5 versus 33.3%, adjusted odds ratio [OR] = 0.28, 95% confidence interval [CI]; 0.14-0.87) and fewer operative vaginal deliveries (20.6 versus 38.1%, adjusted OR = 0.42, 95% CI; 0.17-0.92). No differences were found in gestational age at onset of spontaneous labor, duration of the active phase of labor, interval between induction and the active phase of labor, cesarean section rates, birth weight, and Apgar scores. No maternal or fetal heart rate abnormalities were recorded during the exercise sessions. CONCLUSIONS: For low-risk women at term walking for 30 min 3 times a week at 4 km/h from 38-week onwards is safe, enhances the spontaneous onset of labor and reduces operative vaginal delivery rates. KEY MESSAGE: Physical exercise at term is empirically used as a method of enhancing the spontaneous labor onset. In finding that for low-risk women walking for 30 min 3 times a week at 4 km/h from 38-week onwards enhances spontaneous labor onset of and reduces operative vaginal delivery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov. www.clinicaltrials.gov NCT02460185.

Sonographic knowledge of occiput position to decrease failed operative vaginal delivery: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: This study aimed to assess the efficacy of sonographic assessment of fetal occiput position before operative vaginal delivery to decrease the number of failed operative vaginal deliveries. DATA SOURCES: The search was conducted in MEDLINE, Embase, Web of Science, Scopus, ClinicalTrial.gov, Ovid, and Cochrane Library as electronic databases from the inception of each database to April 2021. No restrictions for language or geographic location were applied. STUDY ELIGIBILITY CRITERIA: Selection criteria included randomized controlled trails of pregnant women randomized to either sonographic or clinical digital diagnosis of fetal occiput position during the second stage of labor before operative vaginal delivery. METHODS: The primary outcome was failed operative vaginal delivery, defined as a failed fetal operative vaginal delivery (vacuum or forceps) extraction requiring a cesarean delivery or forceps after failed vacuum. The summary measures were reported as relative risks or as mean differences with 95% confidence intervals using the random effects model of DerSimonian and Laird. An I2 (Higgins I2) >0% was used to identify heterogeneity. RESULTS: A total of 4 randomized controlled trials including 1007 women with singleton, term, cephalic fetuses randomized to either the sonographic (n=484) or clinical digital (n=523) diagnosis of occiput position during the second stage of labor before operative vaginal delivery were included. Before operative vaginal delivery, fetal occiput position was diagnosed as anterior in 63.5% of the sonographic diagnosis group vs 69.5% in the clinical digital diagnosis group (P=.04). There was no significant difference in the rate of failed operative vaginal deliveries between the sonographic and clinical diagnosis of occiput position groups (9.9% vs 8.2%; relative risk, 1.14; 95% confidence interval, 0.77-1.68). Women randomized to sonographic diagnosis of occiput position had a significantly lower rate of occiput position discordance between the evaluation before operative vaginal delivery and the at birth evaluation when compared with those randomized to the clinical diagnosis group (2.3% vs 17.7%; relative risk, 0.16; 95% confidence interval, 0.04-0.74; P=.02). There were no significant differences in any of the other secondary obstetrical and perinatal outcomes assessed. CONCLUSION: Sonographic knowledge of occiput position before operative vaginal delivery does not seem to have an effect on the incidence of failed operative vaginal deliveries despite better sonographic accuracy in the occiput position diagnosis when compared with clinical assessment. Future studies should evaluate how a more accurate sonographic diagnosis of occiput position or other parameters can lead to a safer and more effective operative vaginal delivery technique.

European guidelines on perinatal care- Peripartum care Episiotomy.

OF RECOMMENDATIONS1. Episiotomy should be performed by indication only, and not routinely (Moderate quality evidence +++-; Strong recommendation). Accepted indications for episiotomy are to shorten the second stage of labor when there is suspected fetal hypoxia (Low quality evidence ++-; Weak recommendation); to prevent obstetric anal sphincter injury in vaginal operative deliveries, or when obstetric sphincter injury occurred in previous deliveries (Moderate quality evidence +++-; Strong recommendation)2. Mediolateral or lateral episiotomy technique should be used (Moderate quality evidence +++-; Strong recommendation). Labor ward staff should be offered regular training in correct episiotomy techniques (Moderate quality evidence +++-; Strong recommendation).3. Pain relief needs to be considered before episiotomy is performed, and epidural analgesia may be insufficient. The perineal skin needs to be tested for pain before an episiotomy is performed, even when an epidural is in place. Local anesthetics or pudendal block need to be considered as isolated or additional pain relief methods (Low quality evidence ++-; Strong recommendation).4. After childbirth the perineum should be carefully inspected, and the anal sphincter palpated to identify possible injury (Moderate quality evidence +++-; Strong recommendation). Primary suturing immediately after childbirth should be offered and a continuous suturing technique should be used when repairing an uncomplicated episiotomy (High quality evidence ++++; Strong recommendation).

European Guidelines on Perinatal Care - Oxytocin for induction and augmentation of labor[Formula: see text].

OF RECOMMENDATIONS1. Oxytocin for induction or augmentation of labor should not be started when there is a previous scar on the body of the uterus (such as previous classical cesarean section, uterine perforation or myomectomy when uterine cavity is reached) or in any other condition where labor or vaginal delivery are contraindicated. (Moderate quality evidence +++-; Strong recommendation).2. Oxytocin should not be started before at least 1 h has elapsed since amniotomy, 6 h since the use of dinoprostone (30 min if vaginal insert) and 4 h since the use of misoprostol (Low quality evidence ++- -; Moderate recommendation).3. Cardiotocography (CTG) should be performed and a normal pattern without tachysystole should be documented for at least 30 min before oxytocin is used. Continuous CTG, with adequate monitoring of both fetal heart rate and uterine contractions, should be maintained for as long as oxytocin is used, and thereafter until delivery (Low ++- - to moderate +++- quality evidence; Strong recommendation).4. For labor induction, at least 1-h should be allowed after amniotomy before oxytocin infusion is started, to evaluate whether adequate uterine contractility has meanwhile ensued. For augmentation of labor, if the membranes are intact and there are conditions for a safe amniotomy, the latter should be considered before oxytocin is started (Very low quality evidence +- --; Weak recommendation).5. Oxytocin should be administered intravenously using the following regimen: 5 IU oxytocin diluted in 500 mL of 0.9% normal saline (NaCl) (each mL contains 10 mIU of oxytocin), in an infusion pump at increasing rates, as shown in Table 1, until a frequency of 3-4 contractions per 10 min is reached, a non-reassuring CTG pattern ensues, or maximum rates are reached (Low quality evidence ++ - -; Strong recommendation). If the frequency of contractions exceeds 5 in 10 min, the infusion rate should be reduced, even if a normal CTG pattern is present. With a non-reassuring CTG pattern, urgent clinical assessment by an obstetrician is indicated, and strong consideration should be given to reducing or stopping the oxytocin infusion. The minimal effective dose of oxytocin should always be used. (Low ++- - to Moderate +++- - quality evidence; Strong recommendation).[Table: see text]6. Use of oxytocin for induction and augmentation of labor should be regularly audited (Low quality evidence ++--; Strong recommendation).

Placenta Accreta Overlying a Caesarean Section Scar: A 10-Year Experience in a Tertiary-Care Centre in Portugal.

INTRODUCTION: Placenta accreta spectrum disorders are among the leading causes of maternal morbidity and mortality and their prevalence is likely to increase in the future. The risk of placenta accreta spectrum disorders is highest in cases of placenta previa overlying a previous cesarean section scar. Few studies have evaluated placenta accreta spectrum disorders in Portugal. The aim of this study was to review the cases of placenta accreta spectrum overlying a cesarean section scar managed in a Portuguese tertiary center over the last decade. MATERIAL AND METHODS: Retrospective, cross-sectional study, with data collected from hospital databases. Only cases with histopathological confirmation of placenta accreta spectrum were included. RESULTS: During the study period, 15 cases of placenta accreta spectrum overlying a cesarean section scar were diagnosed (prevalence 0.6/1000). All cases were diagnosed antenatally. A transverse cesarean section was present in all cases; 13 were managed by a scheduled multidisciplinary approach, while two required emergent management. Total or subtotal hysterectomy was performed in 12 cases. There were no cases of maternal or neonatal death. Histopathological evaluation confirmed nine cases of placenta accreta, three cases of placenta increta and three cases of placenta percreta. DISCUSSION: Early antenatal diagnosis is important for a programmed multidisciplinary management of these cases, which may reduce potential morbidity and mortality and ensure better obstetric outcomes. CONCLUSION: This case series of placenta accreta spectrum overlying a cesarean section scar reports the reality of a tertiary-care perinatal center in Portugal, in which no maternal or neonatal mortality due to placenta accreta spectrum was registered over the last decade; this may be attributed to prenatal diagnosis and a coordinated multidisciplinary team approach.

Introdução: O acretismo placentário está entre as principais causas de morbilidade e mortalidade materna, sendo provável que a sua prevalência venha a aumentar. O risco é máximo em casos de placenta prévia sobre cicatriz de cesariana. Existem poucos estudos sobre esta realidade em Portugal. O objetivo deste estudo foi rever os casos de acretismo placentário sobre cicatriz de cesariana prévia, ocorridos ao longo da última década num centro terciário português. Material e Métodos: Estudo retrospetivo, transversal, com dados recolhidos de bases de dados hospitalares; foram incluídos apenas casos com confirmação histopatológica de acretismo placentário. Resultados: Foram diagnosticados 15 casos durante o período do estudo (prevalência 0,6 / 1000). Todos os casos foram diagnosticados durante a gravidez. Em todos os casos foi realizada cesariana; 13 foram agendadas com base numa abordagem multidisciplinar, e duas foram emergentes. Em 12 casos foi realizada histerectomia total ou subtotal. Não se registaram casos de mortalidade materna ou neonatal. O estudo histopatológico confirmou nove casos de placenta acreta, três de placenta increta e três de placenta percreta. Discussão: O diagnóstico pré-natal precoce é fundamental para um planeamento multidisciplinar que permita reduzir a potencial morbilidade e mortalidade e garantir melhores desfechos obstétricos. Conclusão: Esta série de casos de acretismo placentário sobre cicatriz de cesariana relata a realidade de um centro de assistência perinatal terciário em Portugal, no qual não se registou mortalidade materna ou neonatal ao longo da última década; esta situação é atribuível ao diagnóstico pré-natal eficiente e à abordagem coordenada por uma equipa multidisciplinar.

EBCOG position statement on COVID-19 vaccination for pregnant and breastfeeding women.

Covid 19 pandemic has led to significant mortality and long term morbidity globally. Pregnant women are at increased risk of severe illness from COVID 19 infection. There is an urgent need for all health authorities and Governments to offer vaccination to all pregnant women especially those with high risk pregnancy.

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.

Equity in coronavirus disease 2019 vaccine development and deployment.

The coronavirus disease 2019 pandemic exposed weaknesses in multiple domains and widened gender-based inequalities across the world. It also stimulated extraordinary scientific achievement by bringing vaccines to the public in less than a year. In this article, we discuss the implications of current vaccination guidance for pregnant and lactating women, if their exclusion from the first wave of vaccine trials was justified, and if a change in the current vaccine development pathway is necessary. Pregnant and lactating women were not included in the initial severe acute respiratory syndrome coronavirus 2 vaccine trials. Therefore, perhaps unsurprisingly, the first vaccine regulatory approvals have been accompanied by inconsistent advice from public health, governmental, and professional authorities around the world. Denying vaccination to women who, although pregnant or breastfeeding, are fully capable of autonomous decision making is a throwback to a paternalistic era. Conversely, lack of evidence generated in a timely manner, upon which to make an informed decision, shifts responsibility from research sponsors and regulators and places the burden of decision making upon the woman and her healthcare advisor. The World Health Organization, the Task Force on Research Specific to Pregnant Women and Lactating Women, and others have highlighted the long-standing disadvantage experienced by women in relation to the development of vaccines and medicines. It is uncertain whether there was sufficient justification for excluding pregnant and lactating women from the initial severe acute respiratory syndrome coronavirus 2 vaccine trials. In future, we recommend that regulators mandate plans that describe the development pathway for new vaccines and medicines that address the needs of women who are pregnant or lactating. These should incorporate, at the outset, a careful consideration of the balance of the risks of exclusion from or inclusion in initial studies, patient and public perspectives, details of "developmental and reproductive toxicity" studies, and approaches to collect data systematically from participants who are unknowingly pregnant at the time of exposure. This requires careful consideration of any previous knowledge about the mode of action of the vaccine and the likelihood of toxicity or teratogenicity. We also support the view that the default position should be a "presumption of inclusion," with exclusion of women who are pregnant or lactating only if justified on specific, not generic, grounds. Finally, we recommend closer coordination across countries with the aim of issuing consistent public health advice.

Maternal morbidity and mortality due to placenta accreta spectrum disorders.

Placenta accreta spectrum (PAS) disorders are an increasing health problem in many parts of the world. They are an important risk factor for adverse maternal outcomes related to delivery, with a reported 18-fold increase in maternal morbidity. Profuse haemorrhage after attempting to remove the placenta is the most frequent complication and can lead to major maternal morbidity and ultimately to maternal death. Morbidity can also arise from the multiple procedures required to treat PAS disorders. Intensive care unit admission, mechanical ventilation, infection, and prolonged hospitalization are common in these patients. Long-term complications related to infertility and psychological disturbances can also occur and may have a strong and long-lasting impact on women's health. Antenatal diagnosis allows for appropriate scheduling of delivery and referral to a specialized centre and has been shown to reduce maternal morbidity and mortality.

External cephalic version: Predictors of success and influence on caesarean rates.

OBJECTIVE: To evaluate the success rate of external cephalic version, predictive factors for success of this maneuver and to examine how it affects mode of delivery, pregnancy and neonatal outcome rates. STUDY DESIGN: Retrospective cross-sectional study performed in a tertiary care university hospital between January 2002 and June 2018. A total of 324 ECVs were performed in 321 pregnancies. Maternal and ultrasound data, procedure-related factors, birth characteristics and neonatal data were collected. Absolute and relative frequencies were used for descriptive analysis and the chi-square test for comparative analysis. Odds ratios with 95 % confidence intervals were calculated. RESULTS: The overall success rate of the procedure was 33,3%. Multiparity, transverse lie, unengaged breech presentation, low body mass index, soft uterus and palpable fetal head were independent risk factors for success. No statistically significant association was found with other variables. Routine use of ECV allowed a reduction in cesarean delivery rates for breech presentation, with no increase in maternal or neonatal morbidity. Operative delivery rates after successful ECV were similar to those of the general population. DISCUSSION AND CONCLUSION: Despite a relatively low overall success rate, routine use of ECV can result in reduced cesarean delivery rates with similar perinatal outcomes. Conveyed information on the success rate of ECV can be adapted to individual patient characteristics.