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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.

Objective: To design Canadian guidelines advising obstetric care providers of the maternal, fetal, and neonatal implications of aerobic and strength-conditioning exercises in pregnancy., Outcomes: Knowledge of the impact of exercise on maternal, fetal, and neonatal morbidity, and of the maternal measures of fitness., Evidence: MEDLINE search from 1966 to 2002 for English-language articles related to studies of maternal aerobic and strength conditioning in a previously sedentary population, maternal aerobic and strength conditioning in a previously active population, impact of aerobic and strength conditioning on early and late pregnancy outcomes, and impact of aerobic and strength conditioning on neonatal outcomes, as well as for review articles and meta-analyses related to exercise in pregnancy., Values: The evidence collected was reviewed by the Society of Obstetricians and Gynaecologists of Canada (SOGC Clinical Practice Obstetrics Committee) with representation from the Canadian Society for Exercise Physiology, and quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on the Periodic Health Exam., Recommendations: 1. All women without contraindications should be encouraged to participate in aerobic and strength-conditioning exercises as part of a healthy lifestyle during their pregnancy. (II-1,2B) 2. Reasonable goals of aerobic conditioning in pregnancy should be to maintain a good fitness level throughout pregnancy without trying to reach peak fitness or train for an athletic competition. (II-1,2C) 3. Women should choose activities that will minimize the risk of loss of balance and fetal trauma. (III-C) 4. Women should be advised that adverse pregnancy or neonatal outcomes are not increased for exercising women. (II-1,2B) 5. Initiation of pelvic floor exercises in the immediate postpartum period may reduce the risk of future urinary incontinence. (II-1C) 6. Women should be advised that moderate exercise during lactation does not affect the quantity or composition of breast milk or impact infant growth. (I-A) VALIDATION: This guideline has been approved by the SOGC Clinical Practice Obstetrics Committee, the Executive and Council of SOGC, and the Board of Directors of the Canadian Society for Exercise Physiology., Sponsors: This guideline has been jointly sponsored by the Society of Obstetricians and Gynaecologists of Canada and the Canadian Society for Exercise Physiology.

Immediately following a scream of fear, a sixty-year old woman complained of severe bilateral headache which relapsed several times over the following month during exercise. There was no history of sympathomimetic drug intake. The work-up was normal save for minimal subarachnoid bleeding and the angiogram showed a disseminated "sausage-string" appearance over all cerebral arterial territories, without aneurysm. The unusual triggering event in this case and the subsequent recurrence of headache in relation to exercise lead us to discuss possible links between the clinical entity of "Isolated benign cerebral angiopathy" and exertional headache.