No. 155-Guidelines for Vaginal Birth After Previous Caesarean Birth.

OBJECTIVE: To provide evidence-based guidelines for the provision of a trial of labour (TOL) after Caesarean section. OUTCOME: Fetal and maternal morbidity and mortality associated with vaginal birth after Caesarean (VBAC) and repeat Caesarean section. EVIDENCE: MEDLINE database was searched for articles published from January 1, 1995, to February 28, 2004, using the key words "vaginal birth after Caesarean (Cesarean) section." The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam. RECOMMENDATIONS: VALIDATION: These guidelines were approved by the Clinical Practice Obstetrics and Executive Committees of the Society of Obstetricians and Gynaecologists of Canada.

No. 148-Guidelines for Operative Vaginal Birth.

OBJECTIVE: To provide guidelines for operative vaginal birth in the management of the second stage of labour. OPTIONS: Non-operative techniques, episiotomy, and Caesarean section are compared to operative vaginal birth. OUTCOME: Reduced fetal and maternal morbidity and mortality. EVIDENCE: MEDLINE and Cochrane databases were searched using the key words ''vacuum" and "birth" as well as "forceps" and "birth" for literature published in English from january 1970 to June 2004. The level of evidence and quality of rec-ommendations made are described using the Evaluation of Evidence from the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS: VALIDATION: The Clinical Practice Obstetrics Committee and Executive and Council of the Society of Obstetricians and Gynaecologists of Canada approved these guidelines.

Guidelines for vaginal birth after previous Caesarean birth.

OBJECTIVE: To provide evidence-based guidelines for the provision of a trial of labour (TOL) after Caesarean section. OUTCOME: Fetal and maternal morbidity and mortality associated with vaginal birth after Caesarean (VBAC) and repeat Caesarean section. EVIDENCE: MEDLINE database was searched for articles published from January 1, 1995, to February 28, 2004, using the key words "vaginal birth after Caesarean (Cesarean) section". The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam. RECOMMENDATIONS: 1. Provided there are no contraindications, a woman with 1 previous transverse low-segment Caesarean section should be offered a trial of labour (TOL) with appropriate discussion of perinatal risks and benefits. The process of informed consent with appropriate documentation should be an important part of the birth plan in a woman with a previous Caesarean section (II-2B). 2. The intention of a woman undergoing a TOL after Caesarean section should be clearly stated, and documentation of the previous uterine scar should be clearly marked on the prenatal record (II-2B). 3. For a safe labour after Caesarean section, a woman should deliver in a hospital where a timely Caesarean section is possible. The woman and her health care provider must be aware of the hospital resources and the availability of obstetric, anesthetic, pediatric, and operating-room staff (II-2A). 4. Each hospital should have a written policy in place regarding the notification and (or) consultation for the physicians responsible for a possible timely Caesarean section (III-B). 5. In the case of a TOL after Caesarean, an approximate time frame of 30 minutes should be considered adequate in the set-up of an urgent laparotomy (III-C). 6. Continuous electronic monitoring of women attempting a TOL after Caesarean section is recommended (II-2A). 7. Suspected uterine rupture requires urgent attention and expedited laparotomy to attempt to decrease maternal and perinatal morbidity and mortality (II-2A). 8. Oxytocin augmentation is not contraindicated in women undergoing a TOL after Caesarean section (11-2A). 9. Medical induction of labour with oxytocin may be associated with an increased risk of uterine rupture and should be used carefully after appropriate counselling (II-2B). 10. Medical induction of labour with prostaglandin E2 (dinoprostone) is associated with an increased risk of uterine rupture and should not be used except in rare circumstances and after appropriate counselling (II-2B). 11. Prostaglandin E1 (misoprostol) is associated with a high risk of uterine rupture and should not be used as part of a TOL after Caesarean section (II-2A). 12. A foley catheter may be safely used to ripen the cervix in a woman planning a TOL after Caesarean section (II-2A). 13. The available data suggest that a trial of labour in women with more than 1 previous Caesarean section is likely to be successful but is associated with a higher risk of uterine rupture (II-2B). 14. Multiple gestation is not a contraindication to TOL after Caesarean section (II-2B). 15. Diabetes mellitus is not a contraindication to TOL after Caesarean section (II-2B). 16. Suspected fetal macrosomia is not a contraindication to TOL after Caesarean section (II-2B). 17. Women delivering within 18 to 24 months of a Caesarean section should be counselled about an increased risk of uterine rupture in labour (II-2B). 18. Postdatism is not a contraindication to TOL after Caesarean section (II-2B). 19. Every effort should be made to obtain the previous Caesarean section operative report to determine the type of uterine incision used. In situations where the scar is unknown, information concerning the circumstances of the delivery is helpful in determining the likelihood of a low transverse incision. If the likelihood of a low transverse incision is high, a TOL after Caesarean section can be offered (II-2B). VALIDATION: These guidelines were approved by the Clinical Practice Obstetrics and Executive Committees of the Society of Obstetricians and Gynaecologists of Canada.

Guidelines for operative vaginal birth.

OBJECTIVE: To provide guidelines for operative vaginal birth in the management of the second stage of labour. OPTIONS: Non-operative techniques, episiotomy, and Caesarean section are compared to operative vaginal birth. outcome: Reduced fetal and maternal morbidity and mortality. EVIDENCE: MEDLINE and Cochrane databases were searched using the key words 'vacuum' and 'birth' as well as 'forceps' and 'birth' for literature published in English from January 1970 to June 2004. The level of evidence and quality of recommendations made are described using the Evaluation of Evidence from the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS: 1. Non-operative interventions such as one-to-one support, partogram use, oxytocin use, and delayed pushing in women using epidurals will decrease need for operative birth. (I-A) 2. Manual rotation may be used alone or in conjunction with instrumental birth with little or no increased risk to the pregnant woman or to the fetus. (III-B) 3. Routine episiotomy is not necessary for an assisted vaginal birth. (II-1E) 4. When operative intervention in the second stage of labour is required, the options, risks, and benefits of vacuum, forceps, and Caesarean section must be considered. The choice of intervention needs to be individualized, as one is not clearly safer or more effective than the other. (II-B) 5. Failure of the chosen method, vacuum and/or forceps, to achieve delivery of the fetus in a reasonable time should be considered an indication for abandonment of the method. (III-C) 6. Adequate clinical experience and appropriate training of the operator are essential to the safe performance of operative deliveries. Hospital credentialing boards should grant privileges for performing these techniques only to an appropriately trained individual who demonstrates adequate skills. (III-C). VALIDATION: The Clinical Practice Obstetrics Committee and Executive and Council of the Society of Obstetricians and Gynaecologists of Canada approved these guidelines.

Guidelines for vaginal birth after previous Caesarean birth.

OBJECTIVE: To provide evidence-based guidelines for the provision of a trial of labour (TOL) after Caesarean section. OUTCOME: Fetal and maternal morbidity and mortality associated with vaginal birth after Caesarean (VBAC) and repeat Caesarean section. EVIDENCE: MEDLINE database was searched for articles published from January 1995 to February 2004, using the key words "vaginal birth after Caesarean (Cesarean) section." The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam. RECOMMENDATIONS: 1. Provided there are no contraindications, a woman with 1 previous transverse low-segment Caesarean section should be offered a trial of labour after Caesarean with appropriate discussion of maternal and perinatal risks and benefits. The process of informed consent with appropriate documentation should be an important part of the birth plan in a woman with a previous Caesarean section. (II-2B) 2. The intention of a woman undergoing a TOL after Caesarean should be clearly stated and documentation of the previous uterine scar should be clearly marked on the prenatal record. (II-2B) 3. For a safe labour after Caesarean section, the woman should deliver in a hospital where an immediate Caesarean section is available. The woman and her health-care provider must be aware of the hospital resources and the availability of obstetric, anaesthesia, pediatric, and operating-room staff. (II-2A) 4. Each hospital should have a written policy in place regarding the notification and/or consultation for the physicians responsible for a possible immediate Caesarean. (III B) 5. Continuous electronic fetal monitoring of women attempting a TOL after Caesarean is recommended. (II-2A) 6. Suspected uterine rupture requires urgent attention and expedited laparotomy in order to attempt to decrease maternal and perinatal morbidity and mortality. (II-2A) 7. Oxytocin augmentation is not contraindicated in women undergoing a TOL after Caesarean. (II-2A) 8. Medical induction of labour with oxytocin may be associated with an increased risk of uterine rupture and should be used carefully after appropriate counselling. (II-2B)9. Medical induction of labour with prostaglandin E2 (dinoprostone) is associated with an increased risk of uterine rupture and should not be used except in rare circumstances after appropriate counselling. (II-2B) 10. Prostaglandin E1 (misoprostol) is associated with a high risk of uterine rupture and should not be used as part of a TOL after Caesarean. (II-2A) 11. A foley catheter may be used safely to ripen the cervix in a woman planning a TOL after Caesarean. (II-2A) 12. The available data suggest that a trial of labour in women with more than one previous Caesarean section is likely to be successful but is associated with a higher risk of uterine rupture. (II-2B) 13. Multiple gestation is not a contraindication to a TOL after Caesarean. (II-2B) 14. Diabetes mellitus is not a contraindication to TOL after Caesarean. (II-2B) 15. Suspected fetal macrosomia is not a contraindication to a TOL after Caesarean. (II-2B) 16. Women delivering within 18 to 24 months of a Caesarean section should be counselled about an increased risk of uterine rupture in labour. (II-2B) 17. Postdatism is not a contraindication to a TOL after Caesarean. (II-2B) 18. Every effort should be made to obtain the previous Caesarean section operative report to determine the type of uterine incision used. In situations where the scar is unknown, information concerning the circumstances of the previous delivery is helpful in determining the likelihood of a low transverse incision. If the likelihood of a lower transverse incision is high, TOL after Caesarean can be offered. (II-2B) VALIDATION: These guidelines were approved by the Clinical Practice Obstetrics and Executive Committees of the Society of Obstetricians and Gynaecologists of Canada.

The management of nausea and vomiting of pregnancy.

OBJECTIVES: To review the evidence-based management of nausea and vomiting of pregnancy (NVP) and hyperemesis gravidarum. EVIDENCE: MEDLINE and Cochrane database searches were performed using the medical subject headings (MeSH) of treatment, nausea, vomiting, pregnancy, and hyperemesis gravidarum. The quality of evidence reported in these guidelines has been described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam. BENEFITS: NVP has a profound effect on women's health and quality of life during pregnancy, as well as a financial impact on the health care system, and its early recognition and management are recommended. (III-B) COST: Costs, including hospitalizations, additional office visits, and time lost from work, may be reduced if NVP is treated early.