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Objectives: It is unclear if use of cesarean delivery in people with inflammatory bowel disease (IBD) is guideline-concordant. We compared the odds of cesarean delivery among primiparous individuals with IBD versus without, overall, and by disease characteristics, as well as time to subsequent delivery., Methods: Retrospective matched population-based cohort study between 1 April 1994 and 31 March 2020. Primiparous individuals aged 15-55 years with IBD were matched to those without IBD on age, year, hospital, and number of newborns delivered. Primary outcome was cesarean delivery versus vaginal delivery. Multivariable conditional logistic regression analyses were performed to estimate the odds of cesarean delivery among individuals with and without IBD as a binary exposure, and a categorical exposure based on IBD-related indications for cesarean delivery. Time to subsequent delivery was evaluated using a Cox proportional hazard model., Results: We matched 7472 individuals with IBD to 37 360 individuals without (99.02% match rate). Individuals with IBD were categorised as having perianal (PA) disease (IBD-PA, n = 764, 10.2%), prior ileal pouch-anal anastomosis (n = 212, 2.8%), or IBD-Other (n = 6496, 86.9%). Cesarean delivery rates were 35.4% in the IBD group versus 30.4% in their controls (adjusted odds ratio 1.27; 95% CI 1.20-1.34). IBD-ileal pouch-anal anastomosis had a cesarean delivery rate of 66.5%, compared to 49.9% in IBD-PA and 32.7% in IBD-Other. There was no significant difference in the rate of subsequent delivery in those with and without IBD (adjusted hazard ratio 1.03; 95% CI 1-1.07)., Conclusions: The higher risk of cesarean delivery in people with IBD reflects guideline-concordant use. Individuals with and without IBD were equally likely to have a subsequent delivery with similar timing., (Copyright © 2024 The Author. Published by Elsevier Inc. All rights reserved.)

Objective: Pregnancy is a risk factor for severe SARS-CoV-2 infection, which can result in adverse pregnancy outcomes, thus making understanding vaccine effectiveness (VE) in this population important. This study aimed to assess the VE of mRNA COVID-19 vaccines against symptomatic SARS-CoV-2 infection and COVID-19-related hospitalization in pregnant people., Methods: Population-based matched test-negative case-control study of pregnant people aged 18-49 years, of 12 or more weeks gestation in Ontario, Canada, symptomatic with possible SARS-CoV-2 infection, and having at least 1 positive (n = 1842) or negative (n = 8524) real-time polymerase chain reaction (RT-PCR) SARS-CoV-2 test between December 14, 2020, and December 31, 2021. The exposure was receipt of ≥1 dose of mRNA COVID-19 vaccine versus no vaccination. Exposure was further stratified by number and recency of doses. The primary outcome was a positive SARS-CoV-2 RT-PCR test. As a secondary outcome, VE for COVID-19-related hospitalization was assessed., Results: In the primary outcome analysis, there were 1821 positive cases, matched to 1821 negative controls. The mean (SD) maternal age was 31 (5) years. When compared to those unvaccinated, receipt of ≥1 dose was associated with an estimated VE of 39% (95% CI 29%-48%) for symptomatic infection, and 85% (95% CI 72%-92%) for COVID-19 hospitalization. VE estimates demonstrated waning with increased time since last vaccination., Conclusions: mRNA COVID-19 vaccines provide protection against symptomatic COVID-19 illness and are highly effective at preventing severe illness in pregnant people. The observed effect of vaccine waning highlights the importance of booster doses to provide optimal protection for pregnant people., (Copyright © 2023 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Background: Up to 40% of patients aged ≤55 years undergo concomitant bilateral salpingo-oophorectomy at the time of benign hysterectomy, with practice variation in bilateral salpingo-oophorectomy occurring along the lines of patient health and social factors. Disability is common in premenopausal women and is an important determinant of reproductive health more broadly; however, studies on bilateral salpingo-oophorectomy rates among women with disabilities are lacking., Objective: This study aimed to examine whether the use of concomitant bilateral salpingo-oophorectomy at the time of benign hysterectomy differs by preexisting disability status in adult females aged ≤55 years., Study Design: This population-based cross-sectional study used data from the 2016-2019 US National Inpatient Sample. Females undergoing inpatient hysterectomy for a benign gynecologic indication (n=74,315) were classified as having physical (6.1%), sensory (0.1%), intellectual or developmental (0.2%), or multiple (0.2%) disabilities and compared with those without a disability. Logistic regression was used to estimate risk ratios for differences in bilateral salpingo-oophorectomy rates by disability status, adjusted for patient and clinical factors. Models were stratified by potentially avoidable or potentially appropriate bilateral salpingo-oophorectomy based on the presence of clinical indications for ovarian removal and by age group., Results: Bilateral salpingo-oophorectomy at the time of benign hysterectomy occurred in 26.0% of females without a disability, with rates clearly elevated in those with a physical (33.2%; adjusted risk ratio, 1.10; 95% confidence interval, 1.05-1.14) or intellectual or developmental (31.1%; adjusted risk ratio, 1.32; 95% confidence interval, 1.02-1.64) disability, possibly elevated in those with multiple disabilities (38.2%; adjusted risk ratio, 1.20; 95% confidence interval, 0.94-1.45), and similar in those with a sensory disability (31.2%; adjusted risk ratio, 0.98; 95% confidence interval, 0.83-1.13). The results were similar but with lower statistical precision for potentially avoidable and potentially appropriate bilateral salpingo-oophorectomy, which occurred in 9.1% and 17.0% of females without a disability, respectively. The largest differences in bilateral salpingo-oophorectomy rates among women with any disability were observed in the perimenopausal 45- to 49-year age group., Conclusion: Females with disabilities experienced elevated concomitant bilateral salpingo-oophorectomy rates at the time of benign hysterectomy, particularly those with an intellectual or developmental disability and those of perimenopausal age, although some estimates were imprecise. Equity-focused physician training in surgical counseling and research into the epidemiology and experiences of gynecologic conditions among females with a disability may be beneficial., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Significant changes to the delivery of obstetrical care that occurred with the onset of the COVID-19 pandemic may be associated with higher risks of adverse maternal outcomes. We evaluated preeclampsia/HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome and composite severe maternal morbidity (SMM) among pregnant people who gave birth during the COVID-19 pandemic and compared these data with those of people who gave birth before the pandemic in Ontario, Canada., Methods: This was a population-based, retrospective cohort study using linked administrative data sets from ICES. Data on pregnant people at ≥20 weeks gestation who gave birth between March 15, 2020, and September 30, 2021, were compared with those of pregnant people who gave birth within the same date range for the years 2015-2019. We used multivariable logistic regression to assess the effect of the pandemic period on the odds of preeclampsia/HELLP syndrome and composite SMM, adjusting for maternal baseline characteristics and comorbidities., Results: There were no differences between the study periods in the adjusted odds ratios (aORs) for preeclampsia/HELLP syndrome among primiparous (aOR 1.00; 95% CI 0.91-1.11) and multiparous (aOR 0.94; 95% CI 0.81-1.09) patients and no differences for composite SMM (primiparous, aOR 1.00; 95% CI 0.95-1.05; multiparous, aOR 1.01; 95% CI 0.95-1.08)., Conclusion: Adverse maternal outcomes were not higher among pregnant people who gave birth during the first 18 months of the COVID-19 pandemic in Ontario, Canada, when compared with those who gave birth before the pandemic., (Copyright © 2022 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the impact of class III obesity (body mass index >40 kg/m 2 ) on wait times for endometrial cancer surgery in Ontario, as well as other factors that influence wait time., Methods: We performed a population-based cross-sectional study evaluating diagnosis-to-surgery time for women with endometrioid adenocarcinoma of the endometrium, during the period of 2006 to 2015, using linked administrative databases. Wait time differences between women with and without class III obesity were evaluated using a Wilcoxon rank-sum test. A multivariable generalized linear model under a generalized estimating equations approach was used to evaluate patient factors (i.e., obesity, age, comorbidities, marginalization, recent immigration, diagnosis year, geographic location), tumour characteristics (i.e., grade, stage), provider type (i.e., surgeon specialty), and institutional characteristics (i.e., rurality, hysterectomy volume, availability of minimally invasive surgery) that influence wait times., Results: In total, 9797 women met the criteria for inclusion; 2171 (22%) had class III obesity. The overall median wait time was 55 days (interquartile range [IQR] 37-77 d) and the median wait time was significantly longer for women with class III obesity (62 [IQR 43-88] vs. 53 [IQR 36-74] d, standardized mean difference, 0.30). Age <40 or >70 years, comorbidities, lower-grade disease, surgery at an urban teaching hospital, and surgery at a high-volume hospital with greater availability of minimally invasive surgery were associated with longer wait times. After adjusting for these variables, women with class III obesity waited 12% longer., Conclusion: Class III obesity, comorbidities, and older age are associated with a longer diagnosis-to-surgery time. As the prevalence of obesity and endometrial cancer rise, processes are needed to promote equitable, timely access to care., (Copyright © 2020 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Objective: Myomectomy is offered for treatment of symptomatic uterine fibroids in women who desire to maintain fertility. An open approach, sometimes necessitated by the size or number of fibroids, is associated with a high rate of perioperative blood transfusion. Our goal was to obtain expert consensus on interventions aimed at reducing blood loss and subsequent transfusion in open myomectomy for inclusion in an intraoperative care pathway., Methods: A two-round modified Delphi approach was used to generate consensus on a pathway of interventions to reduce blood loss in open myomectomy. A multidisciplinary expert panel consisting of anaesthesiologists, hematologists, and gynaecologic surgeons rated interventions for inclusion in or exclusion from the pathway (Canadian Task Force Classification III)., Results: Twenty-three expert panel members participated in the Delphi. Consensus was achieved in both the Delphi's first (Cronbach α = 0.92) and second (Cronbach α = 0.94) rounds. Of 11 proposed interventions, five (dilute vasopressin, tranexamic acid, pericervical tourniquet, cell saver, and restrictive transfusion practice) reached consensus for inclusion in the pathway., Conclusion: A modified Delphi consensus approach was used to inform the development of an intraoperative pathway to reduce blood loss and subsequent transfusion in women undergoing open myomectomy. Future studies will investigate the effect of this intraoperative blood conservation pathway on reducing intraoperative blood loss and blood transfusion rates among women undergoing open myomectomy., (Copyright © 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Objective Data: Robotic assistance may facilitate completion of minimally invasive hysterectomy, which is the standard of care for the treatment of early-stage endometrial cancer, in patients for whom conventional laparoscopy is challenging. The aim of this systematic review was to assess conversion to laparotomy and perioperative complications after laparoscopic and robotic hysterectomy in patients with endometrial cancer and obesity (body mass index, ≥30 kg/m 2 )., Study: We systematically searched MEDLINE, EMBASE, and Evidence-Based Medicine Reviews (January 1, 2000, to July 18, 2018) for studies of patients with endometrial cancer and obesity (body mass index, ≥30 kg/m 2 ) who underwent primary hysterectomy., Study Appraisal and Synthesis Methods: We determined the pooled proportions of conversion, organ/vessel injury, venous thromboembolism, and blood transfusion. We assessed risk of bias with the Institute of Health Economics Quality Appraisal Checklist for single-arm studies, and Newcastle-Ottawa Quality Scale for double-arm studies., Results: We identified 51 observational studies that reported on 10,800 patients with endometrial cancer and obesity (study-level body mass index, 31.0-56.3 kg/m 2 ). The pooled proportions of conversion from laparoscopic and robotic hysterectomy were 6.5% (95% confidence interval, 4.3-9.9) and 5.5% (95% confidence interval, 3.3-9.1), respectively, among patients with a body mass index of ≥30 kg/m 2 , and 7.0% (95% confidence interval, 3.2-14.5) and 3.8% (95% confidence interval, 1.4-9.9) among patients with body mass index of ≥40 kg/m 2 . Inadequate exposure because of adhesions/visceral adiposity was the most common reason for conversion for both laparoscopic (32%) and robotic hysterectomy (61%); however, intolerance of the Trendelenburg position caused 31% of laparoscopic conversions and 6% of robotic hysterectomy conversions. The pooled proportions of organ/vessel injury (laparoscopic, 3.5% [95% confidence interval, 2.2-5.5]; robotic hysterectomy, 1.2% [95% confidence interval, 0.4-3.4]), venous thromboembolism (laparoscopic, 0.5% [95% confidence interval, 0.2-1.2]; robotic hysterectomy, 0.5% [95% confidence interval, 0.1-2.0]), and blood transfusion (laparoscopic, 2.8% [95% confidence interval, 1.5-5.1]; robotic hysterectomy, 2.1% [95% confidence interval, 1.6-3.8]) were low and not appreciably different between arms., Conclusion: Robotic and laparoscopic hysterectomy have similar rates perioperative complications in patients with endometrial cancer and obesity, but robotic hysterectomy may reduce conversions because of positional intolerance in patients with morbid obesity. Existing literature is limited by selection and confounding bias, and randomized trials are needed to inform practice standards in this population., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Worldwide, the rate of operative vaginal deliveries has decreased, and as a result trainees are lacking exposure and training. The aim of this study was to determine whether a video-based masterclass can improve trainees' confidence, comfort, and knowledge in performing second stage labour assessments and selecting appropriate patients and instruments for operative vaginal deliveries., Methods: Current University of Toronto obstetrics and gynaecology residents were invited to participate. The intervention included two videos on second stage assessment: (1) selecting the appropriate patient and (2) selecting the appropriate instrument for an operative vaginal delivery. Trainees' comfort and confidence were assessed pre- and post-intervention. A focus group was conducted that assessed trainees' knowledge acquisition. Descriptive thematic analysis was performed, and common themes were extracted., Results: On average, residents have performed more vacuum deliveries than forceps deliveries as primary operators (26.4 vs. 7.9). Following the video intervention, there was a statistically significant improvement (P ≤ 0.05) in trainees' comfort in the following areas: (1) understanding the maternal pelvis, (2) choosing instruments, (3) choosing forceps, (4) deciding the location of delivery, (5) identifying favourable clinical factors, and (6) identifying poor prognostic clinical factors. There was no difference in trainees' self-confidence. Major themes from focus group data included new knowledge gained on second stage assessment techniques, new approaches to existing knowledge, and the multiple challenges and barriers that exist to learning., Conclusion: Video-based education on second stage labour assessment and operative vaginal delivery improves trainees' comfort and serves as a valuable complementary tool to clinical learning., (Copyright © 2018 Society of Obstetricians and Gynaecologists of Canada. Published by Elsevier Inc. All rights reserved.)

Objective: Our aim was to characterize the management and outcome of women admitted to a tertiary high-risk obstetrics unit with a short cervix (≤25 mm), measured on transvaginal ultrasound (TVS), and to determine the latency period from diagnosis to delivery., Methods: A retrospective chart review of women admitted to the High Risk Obstetrics Unit at Sunnybrook Health Sciences Centre between 2005-2011 with an ultrasound-identified short cervix was done., Results: A total of 110 women admitted for a short cervix between 2005-2011 (N = 56 singletons; N = 54 twin gestations) met the inclusion criteria. The mean latency to delivery was 62.6 days; mean GA at delivery was 33.9 weeks. Following 7 and 14 days of admission, 5.5% and 11.8% of women had delivered, respectively. Preterm birth occurred in 70% of all women. Cervical length was a significant factor in predicting latency among singletons, whereas the length of stay in hospital for activity restriction was not., Conclusions: Although many women with a short cervix delivered preterm, only a small proportion delivered within 2 weeks of admission. Although it is not clear whether inpatient management improves the pregnancy outcome, these findings have implications for both patient care and health resources., (Copyright © 2017 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Objective: Achieving clinical competence in managing safe vaginal breech delivery (VBD) is challenging in contemporary obstetrics. Novel educational strategies are required, as exposure of obstetric trainees to VBD remains limited. The aim of this study was to identify the verbal and non-verbal skills required to manage VBD through filmed demonstration by experts., Methods: Labour and delivery nursing staff at three large university-affiliated hospitals identified clinicians whom they considered skilled in VBD. Obstetricians consistently identified were invited to participate in the study. Participants were filmed performing a VBD on a birth simulator while discussing their assessment, technique, and providing clinical pearls based on their experience. Two study members reviewed all videos and documented verbal and non-verbal components of the assessment, grouped them into common themes, and produced an integrated summary. This was circulated to all participants and reviewed by senior obstetricians from outside Canada., Results: Seventeen clinicians were identified; 12 (70%) consented to participation. Themes identified were meticulous assessment and pre-pregnancy counselling; roles of the multidisciplinary team; need for careful and appropriate communication with parents; specific techniques of the delivery; and postpartum care and documentation. A clinical task list was generated based on this analysis., Conclusion: Derived from clinicians with extensive experience, we have developed a comprehensive task list outlining the important features involved in safe VBD. Common themes in the experts' teaching for safe VBD included rigorous antepartum selection and counselling, appreciation for when to convert to Caesarean section, and a "hands off" delivery technique.

Objective: Increased rates of delivery by Caesarean section have resulted in a reduction in rates of instrumental deliveries. This has led to a new educational challenge for teaching and development of skills. In teaching trainees, there are subconscious tasks that the supervising staff may not review because they are automatic. This study aimed to create a new tool to meet this challenge: to identify the core steps required to perform a non-rotational forceps delivery safely and successfully., Methods: Labour and delivery nursing staff of three large teaching hospitals were asked to identify clinicians they considered to be particularly skilled in non-rotational forceps deliveries. Obstetricians who were identified consistently in this way were invited to participate in the study. After providing written consent, participants were then filmed performing a non-rotational forceps delivery on a model. Two clinicians reviewed all videos and documented verbal and non-verbal components of the assessment. Thematic analysis combined findings into an integrated summary. The initial summary was then circulated to all participants for their approval., Results: Seventeen clinicians were identified and consented. Themes identified included the need for careful assessment of suitability for operative delivery, the role of the multidisciplinary team, the need for careful and appropriate communication with the parents, the technique of delivery itself, and postpartum care and documentation., Conclusion: In the core steps identified, the clinicians balanced respect for the "elegant technique" of non-rotational forceps deliveries with careful assessment and knowing when to stop if safety criteria were not met.

Objective: Fetal malposition is a common indication for Caesarean section in the second stage of labour. Rotational (Kielland) forceps are a valuable tool in select situations for successful vaginal delivery; however, learning opportunities are scarce. Our aim was to identify the verbal and non-verbal components of performing a safe Kielland forceps delivery through filmed demonstrations by expert practitioners on models to develop a task list for training purposes., Methods: Labour and delivery nurses at three university-affiliated hospitals identified clinicians whom they considered skilled in Kielland forceps deliveries. These physicians gave consent and were filmed performing Kielland forceps deliveries on a model, describing their assessment and technique and sharing clinical pearls based on their experience. Two clinicians reviewed the videos independently and recorded verbal and non-verbal components of the assessment; thematic analysis was performed and a core task list was developed. The algorithm was circulated to participants to ensure consensus., Results: Eleven clinicians were identified; eight participated. Common themes were prevention of persistent malposition where possible, a thorough assessment to determine suitability for forceps delivery, roles of the multidisciplinary team, description of the Kielland forceps and technical aspects related to their use, the importance of communication with the parents and the team (including consent, debriefing, and documentation), and "red flags" that indicate the need to stop when safety criteria cannot be met., Conclusion: Development of a cognitive task list, derived from years of experience with Kielland forceps deliveries by expert clinicians, provides an inclusive algorithm that may facilitate standardized resident training to enhance education in rotational forceps deliveries.