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The revised Dutch College of General Practitioners' practice guideline on 'Vaginal bleeding' provides recommendations for abnormal bleeding in women in the reproduction phase of life and for post-menopausal bleeding. This guideline is closely attuned to the guideline on 'Heavy menstrual bleeding' of the Dutch Society of Obstetrics and Gynaecology. Transvaginal sonography is not reliable for excluding endometrial carcinoma in women with abnormal vaginal bleeding treated with tamoxifen. The choice of medical treatment is determined in consultation with the patient. The following factors are assessed: severity and bother, long-term need for contraception, preference for cycle control, desire to have a child, pain during menstruation, comorbidity and use of medication. Treatment options are nonhormonal (NSAIDs, or tranexamic acid) or hormonal (a levonorgestrel-releasing intrauterine system, or combined oral contraceptive). In women of reproductive age, referral is indicated if medical treatment is not effective. Other indications are intracavitary abnormalities diagnosed by transvaginal sonography, tamoxifen use, persistent contact bleeding, and suspicion of coagulation disorders. Indications for referral for post-menopausal bleeding include: sonographic endometrial thickness > 4 mm, abnormal cervical cytology, tamoxifen use, irregular bleeding during use of hormone therapy for vasomotor symptoms and persistent or recurrent bleeding, regardless of endometrial thickness.

In the Dutch maternity care system women at low risk of complications in pregnancy and birth are distinguished from women at an increased risk. Primary care midwives are responsible for the care in the low-risk group, whereas obstetricians are responsible for care when the risk is increased. Most professionals and stakeholders agree that more continuity of care is warranted but there is no consensus on the ideal organization of care. A midwife-led continuity model of care has been shown to offer several health benefits compared with other models, such as 'shared care'. We argue that this model would be appropriate for the Netherlands. Midwives should provide care where possible and obstetricians where necessary in order to use the expertise of both professions most effectively. This requires an extension of the scope of practice for primary care midwives. This model requires good cooperation between midwives and obstetricians.

An audit is an instrument to improve quality of care. It primarily does this by revealing the extent to which medical professionals do not follow existing protocols for patient care. However, it should not replace robust research into new forms of care. Most audits are, in effect, no more than a series of cases of poor outcomes and cannot yield rigorous evidence. In an audit, Van Dillen et al. (2010) report 17 cases of postpartum hemorrhage (PPH) and eclampsia after home births and births started under midwifery care. They show that in 76% of these cases the care by the midwife and/or obstetrician did not follow existing Dutch practice guidelines or consensus. They make recommendations for changes in care, including the introduction of misoprostol in primary care and transfer to hospital if the placenta has not been delivered within half an hour. Although PPH and eclampsia are rare in Dutch primary obstetric care, midwives and obstetricians should make a better effort to adhere to practice guidelines aimed at delivering the best pregnancy and birth care. However, new forms of care should first be researched for effectiveness in lowering maternal morbidity, side effects and costs, before they can be implemented in practice.

Objective: To describe the audit of severe acute maternal morbidity in the Netherlands, indicating the audit procedure and possible points for improvement., Design: Descriptive audit investigation., Methods: Eight audit meetings were held concerning cases of severe acute maternal morbidity selected from a prospective, population-based, cohort investigation at all 98 obstetric departments in the Netherlands. Before the start of each meeting, details of the cases were sent to panel members for individual analysis. During the plenary meeting the findings were discussed, and more detailed information was available if required from the patient dossier. Substandard care was identified on the basis of the opinion of the majority of panel members., Results: Substandard care was identified in almost 80% of the SAMM cases discussed. Specific recommendations were formulated concerning the procedure of audit and also concerning local and national implementation of guidelines., Conclusion: Audit merits an important place both nationally and locally in Dutch obstetric practice. Quality improvement is generally possible without large changes to the system, specifically by optimising existing guidelines and putting them into practice.

At the request of the State Secretary of the Dutch Ministry of Health, Welfare and Sport a national multidisciplinary workgroup developed an evidence-based practice guideline for the management of pregnant women with an imminent preterm delivery after a pregnancy of less than 26 weeks duration and for extremely preterm neonates. Active care measures are advised for neonates from a gestational age of 24 0/7 weeks onwards, unless there are serious arguments that justify a conservative management. In cases of imminent preterm delivery, intrauterine transport to a perinatological care centre is advised from a gestational age of 23 4/7 weeks onwards. In cases of imminent preterm delivery, glucocorticoids to enhance fetal lung maturity should be administered from a gestational age of 23 5/7 weeks onwards. From a gestational age of 24 0/7 weeks onwards a caesarean section may be considered if the fetal condition during spontaneous labour justifies this.

According to the Peristat II study, based on data from 2004, The Netherlands has almost the highest perinatal mortality rate in Europe. In 2006 perinatal mortality in The Netherlands was also higher than in the Flemish part of its neighbouring country Belgium (10.40 per thousand versus 7.76 per thousand). The difference in perinatal mortality between Flanders and The Netherlands cannot be explained by the risk factors analysed in the Peristat study, nor by the Dutch system of home deliveries. It is more likely that the attitude of Dutch professionals is too expectative, based on too much confidence in a non-intervention policy. Since the Peristat I publication many measures have been taken in The Netherlands in order to improve the quality of perinatal care. The most important are the start of the perinatal audit preparations, better prenatal screening and the introduction of preconception care.

Objective: Comparison of perinatal mortality in The Netherlands with that in other European countries (Peristat-II), and with data collected 5 years previously (Peristat-I)., Design: Descriptive study., Method: Indicators ofperinatal mortality which were developed for Peristat-I were used again in Peristat-II. Data on perinatal mortality in 2004 were delivered by 26 European countries. The Dutch data originated from national registers of midwives and gynaecologists and the National Neonatology Register., Results: In Peristat-I, from 22 weeks gestation, The Netherlands had the highest fetal mortality rate (7.4 per 1,000 total number of births). Furthermore, after Greece, The Netherlands had the highest early neonatal mortality rate (3.5 per 1,000 live births). In Peristat-II from 22 weeks gestation, after France, The Netherlands had the highest fetal mortality rate (7.0 per 1,000 total number of births). Of all western European countries, The Netherlands had the highest early neonatal mortality rate (3.0 per 1,000 live births). Over the past 5 years the perinatal mortality rate in The Netherlands has dropped from 10.9 to 10.0 per 1,000 total births but this drop has been faster in other countries., Conclusion: The Netherlands has a relatively high number of older mothers and multiple pregnancies, but this only partly explains the high Dutch perinatal mortality rate which still ranks unfavourably in the European tables. More research is necessary to gain insight into the prevalence of risk factors for perinatal mortality compared with other European countries. In addition, perinatal health and the quality ofperinatal healthcare deserve a more prominent position in Dutch research programmes.

--In 2007, the Dutch Society for Obstetrics and Gynaecology issued a revised version of the 1999 guideline on recurrent miscarriage. --The new guideline was developed according to the principles of evidence-based guideline development and includes levels of evidence. --The guideline contains recommendations for effective diagnosis and treatment and explicitly mentions certain diagnostic tests and treatments that should be avoided. --After a thorough investigation of a couples'-history, the type of diagnostic tests that should be offered to the couple can be determined. Patients with a low risk of having cytogenetic abnormalities or thrombophilia may be excluded from parental karyotyping and thrombophilia screening, respectively. --Women with confirmed antiphospholipid antibody syndrome should be offered anticoagulation treatment before and during subsequent pregnancies. --Effective therapy for unexplained recurrent miscarriage is lacking. However, the probability of a successful future pregnancy is high. This probability can be estimated based on the number of previous miscarriages and maternal age.

Objective: Identification of determinants affecting the outcome of external cephalic version (ECV) in breech presentation, and investigation of the impact of ECV--performed according to a standardized protocol in an outpatient clinic--on the mode of delivery., Design: Retrospective analysis., Method: In 2003 a standardized protocol of ECV was developed in the outpatient clinic for obstetrics of the Catharina Hospital in Eindhoven, the Netherlands; it was tested in 'version office visits'. Obstetric characteristics of all pregnant women who underwent attempts of ECV in the clinic from January 2004 until June 2006 during these sessions, and the subsequent births, were analysed. 85% of all ECVs were performed by the same hospital midwife and gynaecologist, in accordance with the protocol., Results: ECV was successful in 96 of 209 pregnant women (46%). In 1 pregnant woman an emergency caesarean section was performed after ECV because of partial abruptio placentae. Nulliparity, incomplete breech presentation and low birth weight of the baby were associated with a lower success rate of ECV in this study. In the group with a successful ECV the percentage of caesarean deliveries was substantially lower (9 versus 83%; odds ratio: 0.21; 95% CI: 0.09-0.51)., Conclusion: A regular team consisting of a hospital midwife and a gynaecologist working according to a standardized protocol for ECV in a case of breech presentation proved successful: the number of term breech presentations substantially diminished and therefore the percentage of caesarean sections was lower in the group in which ECV had been successful. This could have considerable impact on health care in the Netherlands in terms of reduced maternal morbidity and cost savings.

3 pregnant women, aged 27, 33 and 31 years respectively, were carriers of haemophilia A. The first patient had a caesarean section without prior measurement or substitution of factor VIII. She gave birth to a healthy boy, but developed severe diffuse abdominal bleeding after a few hours. The second patient had a normal level of factor VIII, and lived 100 km away from the nearest haemophilia treatment centre. Ultrasound investigation revealed a female foetus. She gave birth in the local hospital. The third patient was pregnant with a male foetus, but refused further prenatal investigation. Contrary to medical advice she gave birth at home. For carriers of haemophilia, there are several options for prenatal diagnosis and managing labour and delivery. Early referral is advised and the need for adequate counselling is explained. It is important to have an experienced haemophilia treatment centre nearby, where haematologists, gynaecologists, geneticists and paediatricians cooperate in caring for pregnant carriers of haemophilia.

Objective: Evaluation of policy and treatment of deliveries at the limits of viability in the Netherlands and resulting survival figures., Design: Cohort study., Method: Within the framework of the European 'Models of organising access to intensive care for very preterm births in Europe' (MOSAIC) study, data was collected on all 512 births in 2003 (terminations excluded) following 22-31 weeks gestation in the catchment areas of the perinatal centres in Nijmegen and Utrecht, the Netherlands., Results: Gynaecologists and neonatologists practised a reserved policy for the active treatment of pregnancies under 25 weeks (5/77; 6%); all infants died. At 25 weeks, an active obstetric policy was used in one quarter of pregnancies, but none of the infants survived. Even at 26 weeks pregnancy, the obstetric policy was reserved and the mortality relatively high (9/31; 29%). From the neonatal deaths, 86 out of 92 (93%) were preceded by a decision either not to start or to discontinue treatment., Conclusion: Dutch obstetricians and neonatologists practised a reserved policy at the limits of neonatal viability. There is more need for active antenatal transfer to perinatal centres for those at the lower limit of neonatal viability to enable well-balanced decisions to take place. The parents' wishes should always be taken into account.

The guideline for referral to perinatology centres in cases of imminent preterm birth at 24-26 weeks gestation, is poorly adhered to by Dutch gynaecologists. Unfortunately, the guideline can be interpreted in various ways and the reasons for non-adherence remain unclear. In addition, no measures were taken to implement the guideline when it was published. This means that the usefulness of the finding that the guideline is poorly adhered to is limited.

In the field of obstetrics, important clinical questions have been addressed by multicentre randomised trials, but only a limited number of such trials have been carried out in the Netherlands. Implementation of the results is hampered because the organisation of Dutch obstetric practice differs from that abroad. In view of this, all ten Dutch perinatal centres and more than 30 non-academic hospitals initiated 6 randomised trials with the aim of improving their quality and power, as well as the subsequent implementation of the trial results. Clinical questions that were addressed included: (a) whether or not labour should be induced in women with foetal growth retardation at term; (b) whether or not labour should be induced in women with preeclampsia or pregnancy-induced hypertension at term; (c) whether or not labour should be induced in women with ruptured membranes at term; (d) which form of foetal surveillance is most effective in women with a high-risk pregnancy at or near term; (e) which form of foetal surveillance is most effective in women with growth retardation at 26 to 32 weeks; and (f) whether premature delivery during a multiple pregnancy can be effectively prevented by prophylactic administration of progesterone.

A study on the quality of primary obstetric care in uncomplicated pregnancies carried out by means of a checklist revealed substandard factors in perinatal care in 71 out of 72 pregnancies. However there are many objections to the quality-control procedure. Some items on the original checklist had to be abandoned due to lack of evidence. In other items definitions and circumstances had not been properly considered and in some cases the patient's own wishes were responsible for a change in policy. The quality of the care delivered cannot be judged only by counting items on a checklist, but requires careful consideration of the situation and of the circumstances that led to the choices in perinatal care.

Objective: Analysis of the effects of population-based determinants (maternal age, parity, multiple pregnancy and ethnicity) and of professional and organisational factors (conservative management in case of early preterm birth, the policy on prenatal screening and the Dutch obstetric-care system in general) on perinatal mortality., Design: Population-based prospective cohort study., Method: In a regional cohort (Zaanstreek) of 8031 pregnancies in the period 1990-1994 data were prospectively collected in an electronic database by deliverers of primary and secondary care. Analysis focussed on the effect on perinatal mortality of maternal age, parity, multiple pregnancy, ethnicity and professional and organisational factors (the policy in case of early preterm birth, the policy on prenatal screening and the Dutch obstetric-care system in general). Perinatal mortality was defined as mortality from a gestational age of 22 weeks until 28 days post partum., Results: The perinatal mortality in the Zaanstreek was 12.6/1000. Increasing the gestational age to 28 weeks decreased the perinatal mortality by 29%. The perinatal mortality in this cohort was significantly affected by parity, multiple pregnancy and maternal age (relative risk: 2.8), but not by ethnicity if corrected for the previous factors. Conservative management in case of early preterm birth and a restrictive screening policy for lethal birth defects were associated with an increase in perinatal mortality. In 31 of 92 singleton pregnancies followed by perinatal mortality, a relationship to substandard care was established. In 7 cases this relationship was probable and in 1 case the midwife was responsible., Conclusion: Given the magnitude of their effects, both independently and via interaction, stratification for maternal age, parity, multiple pregnancy and ethnicity must precede any interpretation and comparison of perinatal mortality rates. Although clinical policy played a modest role, a negative role of the organisation of obstetric care was unlikely in this cohort. A definitive judgement as to the quality of perinatal care would require extension of the evaluation to at least the entire first year of life in connection with the morbidity. The most favourable effects can be expected from stimulatory measures directed at lowering the age at first pregnancy.

The Dutch College of General Practitioners' (NHG) guideline on hormonal contraception does not follow the WHO criteria for the use of oral contraceptives in contrast to the guideline of the Dutch Society of Obstetrics and Gynaecology. Contrary to the WHO criteria, the NHG guideline considers a blood-pressure measurement before starting with an oral contraceptive to be unnecessary. It also considers no form of migraine to be a contraindication for oral contraceptives. The NHG guideline further disclaims the (slightly) increased risk of developing breast cancer in women using oral contraceptives. It advises initiation of oral-contraceptive use two weeks postpartum in non-breastfeeding women and six weeks postpartum in breastfeeding women, instead of the three weeks and six months, respectively, indicated in the WHO guideline. Lastly, the NHG guideline is too optimistic as to the reliability of oral-contraceptive use, as no distinction is made between efficacy and effectiveness. Such discrepancies between two Dutch guidelines can be detrimental to women's health care. The WHO criteria for contraceptive use may be a valuable tool to overcome differences of opinion so as to achieve a badly needed full consensus.

In the Dutch College of General Practitioners' (NHG) practice guideline on the menopause (which also covers hormone therapy), menopausal transition is considered as a physiological life process with inconveniences which can generally be settled by providing information, while leaving hormonal treatment for women who experience serious restrictions in their daily life as a consequence of vasomotor flushes or urogenital atrophy. In those cases, the guideline says, hormonal treatment should not be given for longer than three to six months, after which it should be stopped until a relapse arises. However, it usually takes at least six months of oestrogen replacement therapy to restore urogenital atrophy as well as for the woman to recover from its discomforts such as dyspareunia. Dosages of oestrogens in different hormonal therapies should be 50% or 25% of those advocated in the guideline, as the lowest effective dosage of oestrogen is sufficient. More generally, a woman affected by menopausal inconveniences is not a patient. She deserves to decide for herself whether or not she is willing to use hormone replacement therapy, and if so, she should be allowed to decide on the duration of hormone treatment. The physician should provide adequate information and benevolent supervision.

Bimanual examination is frequently done for the evaluation of internal female genitals in gynaecologic and obstetric patients. Reliability of bimanual examination is influenced by several factors such as the woman's age and physique, but also by the experience of the examiner. Additional transvaginal sonographic assessment increases both the sensitivity and specificity of the diagnostic procedure, especially where the ovaries are concerned. However, transvaginal sonography is not an alternative to bimanual examination. In obstetrics, bimanual examination is an essential diagnostic procedure at parturition. Bimanual examination is unpleasant for most patients and not without risks. This underscores the importance of adequate skills in performing the technique, and the importance of accurate consideration of the necessity of the procedure.

Objective: To inventory the functioning and the results of obstetrics in the West-Frisian islands in 1995 and 1996., Design: Retrospective., Method: With enquiry forms information was gathered from the six GP practices in the West Frisian islands concerning the course and results of every pregnancy with a delivery between 1 January 1995 and 31 December 1996. Of emergency transfers during labour and in the postpartum period the time span between moment of applying for a transport and arrival at the hospital ashore was noted. Results were compared with those for the total province of Friesland and the national Dutch results., Results: Of the 253 women 23 (9%) had a primary indication for hospital delivery under care of a gynaecologist. During pregnancy 52 patients (21%) were directed for hospital delivery. 23 (9%) of the 178 patients awaiting the home delivery were referred during labour and 155 women (61%) delivered at home. After delivery 3 patients were admitted. The median time span in emergency transfers was 77.5 min (range: 60-105) with transport by boat and 65 min (55-120) with transport by heli. The island people delivered at home in 61% compared with 37% in Friesland in 1996 and 31% in the Netherlands in 1993, had a hospital delivery under care of a gynaecologist in 39% compared with 56% in Friesland and 58% in the Netherlands in 1996, had a caesarean section in 6% compared with 10% in Friesland and the Netherlands in 1996. There were two foetal mortalities and one neonatal mortality., Conclusion: In comparison with the national data the island obstetrics is characterized by a higher home delivery rate, less specialist involvement and a lower caesarean section rate.

Objective: To determine if the birth prevalence data on congenital malformations in the national perinatal registries, the Landelijke Verloskunde Registratie (LVR) (National Obstetrical Registry) and the Landelijke Neonatologie Registratie (LNR) (National Neonatological Registry), can be combined into one nationwide database, and if so to determine the validity of this database., Design: Descriptive., Setting: TNO Prevention and Health, Leiden, the Netherlands., Methods: Investigation of the registered number of congenital malformations in the LVR/LNR, the amount of overlapping and the possibility of combining the LVR and LNR into one nationwide database. The validity of this database was evaluated by comparing the total number of registered children with the total number expected in the Netherlands. Furthermore the total number of children registered in the nationwide database was compared with children registered by the European registration of congenital anomalies and twins (EUROCAT) in the Northern Netherlands., Results: The LVR and LNR were mostly complementary with respect to the registration of congenital anomalies and could be combined to one nationwide database. For sixteen important diagnoses this nationwide database contained approximately 87% of the total number expected in the Netherlands. Comparing this database with the data of EUROCAT in the Northern Netherlands showed that one-third of these congenital malformations (n = 229 in 217 children) were registered in both systems, while 99 (43%) were only registered by EUROCAT and 50 (22%) only by the nationwide database., Conclusion: It was possible to create a nationwide database, which can supplement the regional EUROCAT data with nationwide data on sixteen important diagnoses of congenital malformations.