Brief sexuality communication--a behavioural intervention to advance sexually transmitted infection/HIV prevention: a systematic review.

BACKGROUND: Throughout the last decade substantial research has been undertaken to develop evidence-based behaviour change interventions for sexual health promotion. Primary care could provide an opportunistic entry for brief sexual health communication. OBJECTIVES: We conducted a systematic review to explore opportunistic sexual and reproductive health services for sexual health communication delivered at primary health care level. SEARCH STRATEGY: We searched for studies on PubMed, ProQuest, CINAHL, Jstor, Scopus/Science Direct, Cochrane database of systematic reviews, EBSCO, CINAHL, PsychoInfo, and Web of Knowledge. Both published and unpublished articles were reviewed. SELECTION CRITERIA: All randomised controlled trials and controlled clinical trials were included. Participants of all ages, from adolescence onwards were included. Brief (10-60 minutes) interventions including some aspect of communication on sexual health issues were included. DATA COLLECTION AND ANALYSIS: Data were extracted by two reviewers independently using a standardised form. Interventions differed from each other, hence meta-analysis was not performed, and results are presented individually. MAIN RESULTS: A total of 247 articles were selected for full-text evaluation, 31 of which were included. Sexually transmitted infections (STIs)/HIV were less often reported in the intervention group compared with the control group. Condom use was higher in most studies in the intervention group. Numbers of sexual partners and unprotected sexual intercourse were lower in the intervention groups. CONCLUSIONS: There is evidence that brief counselling interventions have some effect in the reduction and prevention of STIs/HIV. Some questions could not be answered, such as the effect over time and in different settings and population groups.

WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update.

The production of guidelines for the management of drug-resistant tuberculosis (TB) fits the mandate of the World Health Organization (WHO) to support countries in the reinforcement of patient care. WHO commissioned external reviews to summarise evidence on priority questions regarding case-finding, treatment regimens for multidrug-resistant TB (MDR-TB), monitoring the response to MDR-TB treatment, and models of care. A multidisciplinary expert panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations. The recommendations support the wider use of rapid drug susceptibility testing for isoniazid and rifampicin or rifampicin alone using molecular techniques. Monitoring by sputum culture is important for early detection of failure during treatment. Regimens lasting ≥ 20 months and containing pyrazinamide, a fluoroquinolone, a second-line injectable drug, ethionamide (or prothionamide), and either cycloserine or p-aminosalicylic acid are recommended. The guidelines promote the early use of antiretroviral agents for TB patients with HIV on second-line drug regimens. Systems that primarily employ ambulatory models of care are recommended over others based mainly on hospitalisation. Scientific and medical associations should promote the recommendations among practitioners and public health decision makers involved in MDR-TB care. Controlled trials are needed to improve the quality of existing evidence, particularly on the optimal composition and duration of MDR-TB treatment regimens.

Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior).

BACKGROUND: Lateral and posterior position of the baby's head (the back of the baby's head facing to the mother's side or back) may be associated with more painful, prolonged or obstructed labour and difficult delivery. It is possible that certain positions adopted by the mother may influence the baby's position. OBJECTIVES: To assess the effects of adopting a hands and knees maternal posture in late pregnancy or during labour when the presenting part of the fetus is in a lateral or posterior position compared with no intervention. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (July 2007) and the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 2). SELECTION CRITERIA: Randomised trials of hands and knees maternal posture compared to other postures or controls. DATA COLLECTION AND ANALYSIS: Two review authors assessed trial eligibility and quality. MAIN RESULTS: Three trials (2794 women) were included. In one trial (100 women), four different postures (four groups of 20 women) were combined for the comparison with the control group of 20 women. Lateral or posterior position of the presenting part of the fetus was less likely to persist following 10 minutes in the hands and knees position compared to a sitting position (one trial, 100 women, relative risk (RR) 0.26, 95% confidence interval (CI) 0.18 to 0.38). In a second trial (2547 women), advice to assume the hands and knees posture for 10 minutes twice daily in the last weeks of pregnancy had no effect on the baby's position at delivery or any of the other pregnancy outcomes measured. The third trial studied the use of hands and knees position in labour and involved 147 labouring women at 37 or more weeks gestation. Occipito-posterior position of the baby was confirmed by ultrasound. Seventy women, who were randomised in the intervention group, assumed hands and knees positioning for a period of at least 30 minutes, compared to 77 women in the control group who did not assume hands and knees positioning in labour. The reduction in occipito-posterior or -transverse positions at delivery and operative deliveries were not statistically significant. There was a significant reduction in back pain. AUTHORS' CONCLUSIONS: Use of hands and knees position for 10 minutes twice daily to correct occipito-posterior position of the fetus in late pregnancy cannot be recommended as an intervention. This is not to suggest that women should not adopt this position if they find it comfortable. The use of position in labour was associated with reduced backache. Further trials are needed to assess the effects on other labour outcomes.

Copper containing, framed intra-uterine devices for contraception.

BACKGROUND: Intrauterine devices (IUD) are safe and effective methods of long term reversible contraception. The design, and copper content as well as placement of the copper on IUDs could affect their effectiveness and side-effect profile. OBJECTIVES: We compared different copper IUDs for their effectiveness and side effects. SEARCH STRATEGY: Multiple electronic databases were searched with appropriate key words and names of the IUDs known to be in the market. We searched the reference lists of papers identified and contacted trialists when possible. There was no language restriction. SELECTION CRITERIA: Randomised controlled trials comparing different IUDs were considered. Trials needed to report on clinical outcomes. DATA COLLECTION AND ANALYSIS: Data on outcomes and trial characteristics were extracted in duplicate and independently by two reviewers. Meta-analysis results are expressed as rate difference (RD) using a fixed-effects model with 95% confidence interval (CI). In the presence of significant heterogeneity a random-effects model was applied. MAIN RESULTS: We included 35 trials, resulting in 18 comparisons of 10 different IUDs in approximately 48,000 women. TCu380A was more effective in preventing pregnancy than MLCu375 (RD 1.70%, 95% CI 0.07% to 2.95% after 4 years of use). TCu380A was also more effective than MLCu250, TCu220 and TCu200. There tended to be fewer pregnancies with TCu380S compared to TCu380A after the first year of use, a difference which was statistically significant in the fourth year (RD -1.62%, 95% CI -3.00% to -0.24%). This occurred despite more expulsions with TCu380S (RD 3.50%, 95% CI 0.36% to 6.63% at 4 years). MLCu375 was no more effective than TCu220 at 1 year of use, or MLCu250 and NovaT up to 3 years. Compared to TCu380A or TCu380S, none of the IUDs showed any benefits in terms of bleeding or pain, or any of the other reasons for early discontinuation. None of the trials that reported events at insertion found one IUD easier to insert than another or caused less pain at insertion. There is no evidence that uterine perforation rates vary by type of device. There are minimal randomised data on IUD use in nulliparous women. AUTHORS' CONCLUSIONS: TCu380A or TCu380S appear to be more effective than other IUDs. No IUD showed consistently lower removal rates for bleeding and pain in comparison to other IUDs. There is no evidence that any particular framed copper device is better suited to women who have not had children.

Copper containing, framed intra-uterine devices for contraception.

BACKGROUND: Intrauterine devices (IUD) are safe and effective methods of long term reversible contraception. Design and copper content of IUDs could affect their effectiveness and side-effect profile. OBJECTIVES: We compared different copper IUDs for their effectiveness and side effects. SEARCH STRATEGY: Multiple electronic databases were searched with appropriate key words and names of the IUDs known to be in the market. We searched the reference lists of papers identified and contacted trialists when possible. SELECTION CRITERIA: Randomised controlled trials comparing different IUDs were considered. Trials needed to report on clinical outcomes. DATA COLLECTION AND ANALYSIS: Data on outcomes and trial characteristics were extracted in duplicate and independently by two reviewers. Meta-analysis results are expressed as rate difference (RD) using a fixed-effects model with 95% confidence interval (CI). In the presence of significant heterogeneity a random-effects model was applied. MAIN RESULTS: We included 34 trials, resulting in 16 comparisons of different IUDs. TCu380A was more effective than MLCu375, MLCu250, TCu220 and TCu200. Changing the position of the copper on the arm of the IUD for TCu380S did not improve the efficacy of TCu380A. MLCu375 was no more effective than TCu220, at 1 year, MLCu250 to 3 years or NovaT to 3 years Compared to TCu380A, none of the IUDs showed any benefits in terms of bleeding or pain, or any of the other reasons for early discontinuation. AUTHORS' CONCLUSIONS: TCu380A is more effective compared to other IUDs. There is no data available comparing different IUDs in special subgroups, such as nulliparous women.

Contraceptive counselling and social representations: a qualitative study.

BACKGROUND: Contraceptive use is a complex issue and several studies have been conducted in an effort to understand user behaviour. It is of interest to explore the representations of professionals who give advice on contraception, since their views could have an impact on contraceptive use. METHODS: Individual in-depth interviews of 65 healthcare professionals likely to provide contraceptive advice to patients at a Swiss maternity unit. RESULTS: 83% of healthcare professionals interviewed were favourable to contraception in general while being highly critical of its practical efficacy. The methods most often spontaneously cited were oral contraceptive pills, male condom, intrauterine devices and hormonal implants. Theoretically, all methods should be proposed during contraceptive counselling but in practice interviewees have different social representations of user groups and associate them with specific contraceptive methods. Personal experience appears to play a bigger role than scientific knowledge. CONCLUSIONS: The counsellor's social representations probably play an important role in determining user behaviour. These representations should be taken into consideration in the training of healthcare professionals in this field.

Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior).

BACKGROUND: Lateral and posterior position of the baby's head (the back of the baby's head facing to the side or the mother's back) may be associated with more painful, prolonged or obstructed labour and difficult delivery. It is possible that certain positions adopted by the mother may influence the baby's position. OBJECTIVES: The objective of this review is to assess the effects of adopting a hands and knees maternal posture in late pregnancy or during labour when the presenting part of the fetus is in a lateral or posterior position, compared with no intervention. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (November 2004) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2004). SELECTION CRITERIA: Randomised trials of hands and knees maternal posture compared to other postures or controls. DATA COLLECTION AND ANALYSIS: Both review authors assessed trial eligibility and quality. MAIN RESULTS: Two trials of hands and knees posture during pregnancy were included. In one trial involving 100 women, four different postures (four groups of 20 women) were combined for the comparison with the control group of 20 women. Lateral or posterior position of the presenting part of the fetus was less likely to persist following 10 minutes in the hands and knees position compared to a sitting position (one trial, 100 women, relative risk (RR) 0.25, 95% confidence interval (CI) 0.17 to 0.37). In a second trial including 2547 women, advice to assume the hands and knees posture for 10 minutes twice daily in the last weeks of pregnancy had no effect on the baby's position at delivery or any of the other pregnancy outcomes measured. No trials of hands and knees posture during labour were included. AUTHORS' CONCLUSIONS: Use of hands and knees position for 10 minutes twice daily to correct occipitoposterior position of the fetus in late pregnancy cannot be recommended as an intervention. This is not to suggest that women should not adopt this position if they find it comfortable. The use of this position during labour has not been addressed in this review. In view of the promising short-term effects of the technique and its simplicity, further trials are justified to determine whether encouraging the use of hands and knees posture during rather than before labour, has any effect on substantive outcomes.

Medical versus surgical methods for first trimester termination of pregnancy.

BACKGROUND: Induced abortions are very commonly practiced interventions worldwide. A variety of medical abortion methods have been introduced during the last decade in addition to existing surgical methods. In this review we systematically searched for and combined all evidence from randomised controlled trials comparing surgical with medical abortion. OBJECTIVES: To evaluate medical methods in comparison to surgical methods for first-trimester abortion with respect to efficacy, side effects and acceptability. SEARCH STRATEGY: The Cochrane Controlled Trials Register, MEDLINE (with the Cochrane 3-stage search strategy)(1966-2000) and Popline (1970-2000) were systematically searched. There were no language preferences in searching. Reference lists of retrieved papers were searched. Experts in WHO/HRP were contacted. SELECTION CRITERIA: Randomised trials of any surgical abortion method compared with any medical abortion method in the first trimester. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data extraction was made independently by two reviewers. MAIN RESULTS: Six studies mostly with small sample sizes, comparing 4 different interventions (prostaglandins alone, mifepristone alone, and mifepristone/misoprostol and methotrexate/misoprostol versus vacuum aspiration) were included. Results are sometimes based on one trial only. Prostaglandins vs vacuum aspiration: the rate of abortions not completed with the intended method was statistically significant higher in the prostaglandin group (2.7, 95% CI 1.1 to 6.8) compared to surgery. There are no data on the most commonly medical (mifepristone/misoprostol) and surgical abortion available to be included in the review. Duration of bleeding was longer in the medical abortion groups compared to vacuum aspiration. There was only one major complication (uterine perforation) in one trial in the surgical group. There was no difference between the groups for ongoing pregnancies at the time of follow-up or pelvic infections. No data on acceptability, side effects or women's satisfaction with the procedure were available for inclusion in the review. AUTHORS' CONCLUSIONS: The results are derived from relatively small trials. Prostaglandins used alone seems to be less effective and more painful compared to surgical first-trimester abortion. However, there is inadequate evidence to comment on the acceptability and side effects of medical compared to surgical first-trimester abortions. There is a need for trials to address the efficacy of currently used methods and women's preferences more reliably.

Cephalic version by postural management for breech presentation.

BACKGROUND: It is possible that maternal posture may influence fetal position. Many postural techniques have been used to promote cephalic version. OBJECTIVES: The objective of this review was to assess the effects of postural management of breech presentation on measures of pregnancy outcome. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth trials register and Controlled Trials Register were searched. Date of last search: March 2000. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing postural management with pelvic elevation for breech presentation, with a control group. DATA COLLECTION AND ANALYSIS: Eligibility and trial quality were assessed by one or both reviewers. MAIN RESULTS: Five studies involving a total of 392 women were included. No effect of postural management on the rate non-cephalic births was detected, either for the subgroup in which no external cephalic version was attempted, or for the group overall (relative risk 0.95, 95% confidence interval 0.81 to 1.11). No differences were detected for caesarean sections or Apgar scores below seven at one minute. REVIEWER'S CONCLUSIONS: There is no evidence to support the use of postural management for breech presentation. The numbers of women studied to date remain relatively small.

Tocolytics for suspected intrapartum fetal distress.

BACKGROUND: Prophylactic tocolysis with betamimetics and other agents has become widespread as a treatment for fetal distress. Uterine relaxation may improve placental blood flow and therefore fetal oxygenation. However there may also be adverse maternal cardiovascular effects. OBJECTIVES: The objective of this review was to assess the effects of tocolytic therapy for suspected fetal distress on fetal, maternal and perinatal outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register. Date of last search: February 1999. SELECTION CRITERIA: Randomised trials comparing tocolytic therapy with no treatment or treatment with another tocolytic agent for suspected fetal distress. DATA COLLECTION AND ANALYSIS: Two reviewers assessed trial quality and extracted data. MAIN RESULTS: Three studies were included. Compared with no treatment, there were fewer failed improvements in fetal heart rate abnormalities with tocolytic therapy (relative risk 0.26, 95% 0.13 to 0.53). Betamimetic therapy compared with magnesium sulphate showed a non-significant trend towards reduced uterine activity (relative risk 0.07, 95% confidence interval 0.00 to 1.10). REVIEWER'S CONCLUSIONS: Betamimetic therapy appears to be able to reduce the number of fetal heart rate abnormalities and perhaps reduce uterine activity. However there is not enough evidence based on clinically important outcomes to evaluate the use of betamimetics for suspected fetal distress.

Tocolysis for preventing fetal distress in second stage of labour.

BACKGROUND: Prophylactic tocolysis with betamimetics and other agents has become widespread as a treatment for fetal distress. Uterine relaxation may improve placental blood flow and therefore fetal oxygenation. However there may also be adverse maternal cardiovascular effects. OBJECTIVES: The objective of this review was to assess the effects of prophylactic betamimetic therapy during the second stage of labour on perinatal outcome. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register were searched. Date of last search: February 1999. SELECTION CRITERIA: Randomised trials comparing prophylactic intravenous betamimetic therapy during the second stage of labour with placebo or no treatment in uncomplicated pregnancies. DATA COLLECTION AND ANALYSIS: The reviewers assessed trial quality and extracted data. MAIN RESULTS: One study involving 100 women was included. Compared to placebo, prophylactic betamimetic therapy was associated with an increase in forceps deliveries (relative risk 1.83, 95% confidence interval 1.02 to 3. 29). There were no clear effects on postpartum haemorrhage, neonatal irritability, feeding slowness, umbilical arterial pH values or Apgar scores at 2 minutes. REVIEWER'S CONCLUSIONS: There is no evidence to support the prophylactic use of betamimetics during the second stage of labour.

Cephalic version by postural management for breech presentation.

BACKGROUND: It is possible that maternal posture may influence fetal position. Many postural techniques have been used to promote cephalic version. OBJECTIVES: The objective of this review was to assess the effects of postural management of breech presentation on measures of pregnancy outcome. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth trials register and Controlled Trials Register were searched. Date of last search: February 1999. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing postural management with pelvic elevation for breech presentation, with a control group. DATA COLLECTION AND ANALYSIS: Eligibility and trial quality were assessed by both reviewers. MAIN RESULTS: Three studies involving a total of 192 women were included. Postural management was associated with a non-significant trend towards fewer non-cephalic births (relative risk 0.90, 95% confidence interval 0. 73 to 1.12). No differences were detected for caesarean sections or Apgar scores below seven at one minute. REVIEWER'S CONCLUSIONS: There is not enough evidence to evaluate the use of postural management for breech presentation.

Expedited versus conservative approaches for vaginal delivery in breech presentation.

BACKGROUND: In a vaginal breech birth there may be benefit from rapid delivery of the baby to prevent progressive acidosis. However, this needs to be weighed against the potential trauma of a quick delivery. OBJECTIVES: The objective of this review was to assess the effects of expedited vaginal delivery (breech delivery from umbilicus to delivery of the head within one contraction) on perinatal outcomes. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth trials register and the Cochrane Controlled Trials Register were searched. Date of last search: February 1999. SELECTION CRITERIA: Randomised trials of expedited vaginal breech delivery compared with delivery not routinely expedited in women undergoing vaginal breech delivery. DATA COLLECTION AND ANALYSIS: Eligibility and trial quality were assessed by one reviewer. MAIN RESULTS: No studies were included. REVIEWER'S CONCLUSIONS: There is not enough evidence to evaluate the effects of expedited vaginal breech delivery.

External cephalic version for breech presentation at term.

BACKGROUND: Management of breech presentation is controversial, both in regard to manipulation of the position of the fetus and the method of delivery. External cephalic version may reduce the number of breech presentations and caesarean sections, but there also have been reports of increased perinatal mortality with the procedure. OBJECTIVES: The objective of this review was to assess the effects of external cephalic version at term on measures of pregnancy outcome. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth trials register was searched. Date of last search: October 1997. SELECTION CRITERIA: Randomised trials of external cephalic version at term (with or without tocolysis) compared with no attempt at external cephalic version in women with breech presentation. DATA COLLECTION AND ANALYSIS: Eligibility and trial quality were assessed by GJH and checked by RK. MAIN RESULTS: Six studies were included. External cephalic version at term was associated with a significant reduction in non-cephalic births (relative risk 0.42, 95% confidence interval 0.35 to 0.50) and caesarean section (relative risk 0.52, 95% confidence interval 0.39 to 0.71). There was no significant effect on perinatal mortality (relative risk 0.44, 95% confidence interval 0.07 to 2.92). REVIEWER'S CONCLUSIONS: Attempting cephalic version at term appears to reduce the chance of non-cephalic births and caesarean section. There is not enough evidence to assess any risks of external cephalic version at term.

Abdominal decompression in normal pregnancy.

BACKGROUND: Abdominal decompression was developed as a means of pain relief during labour. It has also been used for complications of pregnancy, and in healthy pregnant women in an attempt to improve fetal wellbeing and intellectual development. OBJECTIVES: The objective of this review was to assess the effects of prophylactic abdominal decompression on admission for pre-eclampsia, fetal growth, perinatal morbidity and mortality and childhood development. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register were searched. Date of last search: February 1999. SELECTION CRITERIA: Randomised trials comparing abdominal decompression with dummy decompression or no treatment in healthy pregnant women. DATA COLLECTION AND ANALYSIS: Eligibility and trial quality were assessed by one reviewer. MAIN RESULTS: Three studies were included. There was no difference between the abdominal decompression groups and the control groups for low birth weight (relative risk 0.69, 95% confidence interval 0.27 to 1.77) and perinatal mortality (relative risk 2.47, 95% confidence interval 0.77 to 7.92). There were no differences in admission for pre-eclampsia, Apgar score and childhood development. REVIEWER'S CONCLUSIONS: There is no evidence to support the use of abdominal decompression in normal pregnancies. Future research should be directed towards the use of abdominal decompression during labour, and during complicated pregnancies.

Hands/knees posture in late pregnancy or labour for fetal malposition (lateral or posterior).

BACKGROUND: Lateral and posterior position of the fetal presenting parts may be associated with more painful, prolonged or obstructed labour and difficult delivery. It is possible that maternal posture may influence fetal position. OBJECTIVES: The objective of this review is to assess the effects of adopting a hands and knees maternal posture in late pregnancy when the presenting part of the fetus is in a lateral or posterior position. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register. Date of last search: February 1999. SELECTION CRITERIA: Randomised trials of hands and knees maternal posture compared to other postures. DATA COLLECTION AND ANALYSIS: Both reviewers assessed trial eligibility and quality. MAIN RESULTS: One trial involving 100 women was included. Four different postures (four groups of 20 women) were combined for the comparison with the control group of 20 women. Lateral or posterior position of the presenting part of the fetus was less likely to persist following 10 minutes in the hands and knees position compared to a sitting position (relative risk 0.25, 95% confidence interval 0.17 to 0.37). REVIEWER'S CONCLUSIONS: Hands and knees maternal posture for lateral or posterior fetal presentation appears to result in short term effects ion fetal position. No other perinatal or maternal outcomes were reported. There is not enough evidence to evaluate the effectiveness of a hands and knees maternal posture when the fetal presenting part is lateral or posterior, on clinically important outcomes.

Piracetam for fetal distress in labour.

BACKGROUND: Piracetam is thought to promote the metabolism of brain cells when they are hypoxic. It has been used to prevent adverse effects of fetal distress. OBJECTIVES: The objective of this review was to assess the effects of piracetam for suspected fetal distress in labour on method of delivery and perinatal morbidity. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register were searched. Date of last search: February 1999. SELECTION CRITERIA: Randomised trials of piracetam compared with placebo or no treatment for suspected fetal distress in labour. DATA COLLECTION AND ANALYSIS: Both reviewers assessed eligibility and trial quality. MAIN RESULTS: One study of 96 women was included. Piracetam compared with placebo was associated with a trend to reduced need for caesarean section (relative risk 0.57, 95% confidence interval 0.32 to 1.03). There were no statistically significant differences in relative risk between the piracetam and placebo group for neonatal morbidity (measured by neonatal respiratory distress) or Apgar score. REVIEWER'S CONCLUSIONS: There is not enough evidence to evaluate the use of piracetam for fetal distress in labour.

Operative versus conservative management for 'fetal distress' in labour.

BACKGROUND: Suspected fetal distress usually results in expedited delivery of a baby (often operatively). The potential harm to a mother and baby from operative delivery may not always be justified especially when fetal distress may be misdiagnosed. Even with a correct diagnosis it is not clear whether an operative or conservative approach is better. OBJECTIVES: The objective of this review was to assess the effects of operative management for fetal distress on maternal and perinatal morbidity. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register were searched. Date of last search: October 1997. SELECTION CRITERIA: Randomised trials of operative (caesarean section or expedited vaginal delivery) versus conservative management of suspected fetal distress. DATA COLLECTION AND ANALYSIS: Trial quality assessment and data extraction were done by both reviewers. MAIN RESULTS: One study of 350 women was included. This trial was carried out in 1959. There was no difference in perinatal mortality (relative risk 1.18, 95% confidence interval 0.56 to 2.48). REVIEWER'S CONCLUSIONS: There have been no contemporary trials of operative versus conservative management of suspected fetal distress. In settings without modern obstetric facilities, a policy of operative delivery in the event of meconium-stained liquor or fetal heart rate changes has not been shown to reduce perinatal mortality.

Piracetam for fetal distress in labour.

BACKGROUND: Piracetam is thought to promote the metabolism of brain cells when they are hypoxic. It has been used to prevent adverse effects of fetal distress. OBJECTIVES: The objective of this review was to assess the effects of piracetam for suspected fetal distress in labour on method of delivery and perinatal morbidity. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register (The Cochrane Library Issue 3, 2001) were searched. Date of last search: September 2001. SELECTION CRITERIA: Randomised trials of piracetam compared with placebo or no treatment for suspected fetal distress in labour. DATA COLLECTION AND ANALYSIS: Both reviewers assessed eligibility and trial quality. MAIN RESULTS: One study of 96 women was included. Piracetam compared with placebo was associated with a trend to reduced need for caesarean section (relative risk 0.57, 95% confidence interval 0.32 to 1.03). There were no statistically significant differences in relative risk between the piracetam and placebo group for neonatal morbidity (measured by neonatal respiratory distress) or Apgar score. REVIEWER'S CONCLUSIONS: There is not enough evidence to evaluate the use of piracetam for fetal distress in labour.

Techniques for the interruption of tubal patency for female sterilisation.

BACKGROUND: Female sterilization is the most popular contraceptive method worldwide. Several techniques are described in the literature, however only few of them are commonly used and properly evaluated. OBJECTIVES: To compare the different tubal occlusion techniques in terms of major and minor morbidity, failure rates (pregnancies), technical failures and difficulties and women's and surgeons' views. SEARCH STRATEGY: The Cochrane Controlled Trials Register has been searched. A search of the reference lists of identified trials was performed. An additional MEDLINE search was done using an Internet search service Pub Med. SELECTION CRITERIA: All randomized controlled trials comparing different techniques for tubal sterilization, regardless of the way of entry in the abdominal cavity or the method of anesthesia. DATA COLLECTION AND ANALYSIS: Trials under consideration were evaluated for methodological quality and appropriateness for inclusion. Nine relevant studies were included and the results were stratified in five groups: tubal ring versus clip, modified Pomeroy versus electrocoagulation, tubal ring versus electrocoagulation, modified Pomeroy versus Filshie clip and Hulka versus Filshie clip. Results are reported as odds ratio for dichotomous outcomes and weighted mean differences for continuous outcomes. MAIN RESULTS: Tubal ring versus clip: Minor morbidity was higher in the ring group (Peto OR 2.15; 95% CI 1.22, 3.78). Technical difficulties were found less frequent in the clip group ( Peto OR 3.87; 95% CI 1.90, 7.89). There was no difference in failure rates between the two groups (Peto OR 0.70; 95% CI 0.28, 1.76). Pomeroy versus electrocoagulation: Women undergoing modified Pomeroy technique had higher major morbidity than with electrocoagulation technique (Peto OR 2.87; 95% CI 1.13, 7.25). Postoperative pain was more frequent in the Pomeroy group (Peto OR 3.85; 95% CI 2.91, 5.10). Tubal ring versus electrocoagulation: Post operative pain was more frequently reported in the tubal ring group. No pregnancies were reported. Pomeroy versus Filshie clip: In the trial comparing the two interventions only one pregnancy was reported in the Pomeroy group after follow-up for 24 months. No differences were found when comparing Hulka versus Filshie clip in the only study that compared these two devices (Toplis 1988). REVIEWER'S CONCLUSIONS: Electrocoagulation was associated with less morbidity when compared with tubal ring and other methods. However the risk of burns to the small bowel might be a serious criticism of the approach. The small sample size and the relative short period of follow-up in these studies limited the power to show clinical or statistical differences for rare outcomes such as failure rates. Aspects such as training, costs and maintenance of the equipment may be important factors in deciding which method to choose.