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In the Term Breech Trial, the risk of maternal morbidity in women who delivered after planning for a caesarean section (CS) was not significantly different from those who delivered after planning for a vaginal birth. We undertook secondary analyses to determine factors associated with maternal morbidity among 2078 women.By using multiple logistic regression analyses, we determined the effect of prelabour CS, CS during early labour, CS during active labour, vaginal birth, and other factors on maternal morbidity. For 1536 women delivered after labour, we determined the effect of variables associated with labour on maternal morbidity.The risk of maternal morbidity was lowest following vaginal birth (odds ratio [OR] 1.0) and highest following CS during active labour (OR 3.33; 95% confidence intervals [CI] 1.75-6.33, P0.001). For those delivered after labour, a short active phase of the second stage of labour (30 minutes) was associated with the lowest risk of maternal morbidity (OR 0.25; 95% CI 0.11-0.57, P0.001).For women with a singleton fetus in breech resentation at term, maternal morbidity is lowest following vaginal birth and highest following CS during active labour.

Objective The purpose of this study was to determine whether planned cesarean delivery for the singleton fetus in breech presentation at term reduces the risk of death or neurodevelopmental delay at 2 years of age. Study design In selected centers in the Term Breech Trial, children were screened for abnormalities at ≥2 years of age with the Ages and Stages Questionnaire, followed by a neurodevelopmental assessment if the Ages and Stages Questionnaire score was abnormal. Results A total of 923 of 1159 children (79.6%) from 85 centers were followed to 2 years of age. The risk of death or neurodevelopmental delay was no different for the planned cesarean than for the planned vaginal birth groups (14 children [3.1%] vs 13 children [2.8%]; relative risk, 1.09; 95% CI, 0.52- 2.30; P =.85; risk difference, +0.3%; 95% CI, −1.9%, +2.4%). Conclusion Planned cesarean delivery is not associated with a reduction in risk of death or neurodevelopmental delay in children at 2 years of age.

Objectives: (1) To elucidate the views of obstetricians with respect to the use of transvaginal ultrasound in general, and, specifically, for determining cervical length, and the conditions under which obstetricians would employ cervical cerclage based on a sonographically revealed shortened cervix; and (2) to determine the possibility of a randomized controlled trial on the use of cervical cerclage in this situation. Methods: A 7-item questionnaire in French and English was designed and pretested. Questionnaires were mailed to 1421 physicians identified in the Canadian Medical Directory as practising obstetricians/gynaecologists in Canada. Returned questionnaires were scanned into an Access database for simple descriptive analyses. Results: Responses were received from 766 physicians. Of these 766 respondents, 604 physicians indicated they continued to practise obstetrics and supplied information that was usable in the analysis. The majority of the 604 respondents (85.6%) reported that they would recommend transvaginal ultrasound only in pregnant women with I or more risk factors for preterm birth. Respondents were most likely to recommend a cerclage, and least unsure of their decision to do so, if the gestational age was less than 23 weeks, the cervical length was less than 1 cm, and additional risk factors for preterm birth were present. As gestational age and cervical length increased, respondents were less likely to recommend cerclage and more unsure of their decision to do so. The pattern of responses was similar for singleton and multiple pregnancies. The McDonald technique was favoured over the Shirodkar technique by 70.4% of the respondents who performed cervical cerclage procedures. Adjunctive antibiotics were used with cerclage by 52.5% and adjunctive tocolytics were employed by 37.4%. The majority (68.8%) of the respondents who performed cervical cerclage procedures stated that they would participate in a randomized controlled trial on the effectiveness of cerclage for a sonographically revealed short cervix. Conclusion: In the case of a short cervix determined by ultrasound, there is significant uncertainty surrounding the decision whether to place a cerclage and considerable variation in the clinical practice on its placement. In the absence of good evidence to guide clinical practice, a randomized controlled trial is being planned.

In about 3% to 4% of all pregnancies at term, the fetal presentation will be noncephalic. External cephalic version (ECV) at term has been shown to decrease the rate of noncephalic presentation at birth and to decrease the rate of cesarean section associated with breech presentation. However, success rates for ECV are low. We did a randomized trial to compare a policy of beginning ECV early, at between 34 and 36 weeks' gestation, and beginning ECV at 37 to 38 weeks' gestation.At 25 centers in seven countries, 233 women with a singleton breech fetus were randomly assigned to having an ECV procedure done early (at between 34 weeks 0 days and 36 weeks 0 days), or delayed (at between 37 weeks 0 days and 38 weeks 0 days). An experienced practitioner undertook the ECV procedure, and repeat ECV procedures were allowed. Tocolytics and use of epidural analgesia were included as part of the protocol. The primary outcome was the rate of noncephalic presentation at birth. An intention-to-treat analysis was used.Data were received for 232 women, with 116 women in each of the early and delayed ECV groups. Of these, 86.2% in the early ECV group and 67.2% in the delayed ECV group had at least one ECV performed. The rate of noncephalic presentation at birth in the early ECV group was 66 of 116 (56.9%) and 77 of 116 (66.4%) in the delayed ECV group (relative risk [RR] [95% CI] 0.86 [0.70-1.05], P =.09). The rate of serious fetal complications and the rate of preterm birth at37 weeks were not significantly increased in the early ECV group compared with the delayed ECV group (6.9% vs 7.8%, RR [95% CI] 0.89 [0.36-2.22], P =.69 and 8.6% vs 6.1%, RR [95% CI] 1.42 [0.56-3.59], P =.31, respectively). The rate of cesarean section in the early ECV group was 75 of 116 (64.7%) and 83 of 116 (71.6%) in the delayed ECV group (RR [95% CI] 0.90 [0.76-1.08], P =.32). Neonatal outcomes were comparable in the two groups. The rate of reversion to noncephalic was low in both groups. The majority of women in both groups indicated that they would consider having an ECV in another pregnancy.Early ECV performed at 34 to 36 weeks compared with 37 to 38 weeks may reduce the risk of noncephalic presentation at delivery. A large pragmatic trial of early ECV is now required to assess this approach further in terms of cesarean section rates and neonatal outcomes before changes in clinical practice.

Objective To determine whether ‘less tight’ (versus ‘tight’) control of nonsevere hypertension results in a difference in diastolic blood pressure (dBP) between groups. Design Randomised controlled trial (ISRCTN#57277508). Setting Seventeen obstetric centres in Canada, Australia, New Zealand, and UK. Population Inclusion: pregnant women, dBP 90–109 mmHg, pre-existing/gestational hypertension; live fetus(es); and 20–33+6 weeks. Exclusion: systolic blood pressure ≥ 170 mmHg and proteinuria, contraindication, or major fetal anomaly. Methods Randomisation to less tight (target dBP, 100 mmHg) or tight (target dBP, 85 mmHg) blood pressure control. Main outcome measures Primary: mean dBP at 28, 32 and 36 weeks. Secondary: clinician compliance and women’s satisfaction. Other: serious perinatal and maternal complications. Results A total of 132 women were randomised to less tight (n= 66; seven had no study visit) or tight control (n= 66; one was lost to follow up; seven had no study visit). Mean dBP was significantly lower with tight control: −3.5 mmHg, 95% credible interval (−6.4, −0.6). Clinician compliance was 79% in both groups. Women were satisfied with their care. With less tight (versus tight) control, the rates of other treatments and outcomes were the following: post-randomisation antenatal antihypertensive medication use: 46 (69.7%) versus 58 (89.2%), severe hypertension: 38 (57.6%) versus 26 (40.0%), proteinuria: 16 (24.2%) versus 20 (30.8%), serious maternal complications: 3 (4.6%) versus 2 (3.1%), preterm birth: 24 (36.4%) versus 26 (40.0%), birthweight: 2675 ± 858 versus 2501 ± 855 g, neonatal intensive care unit (NICU) admission: 15 (22.7%) versus 22 (34.4%), and serious perinatal complications: 9 (13.6%) versus 14 (21.5%). Conclusion The CHIPS pilot trial confirms the feasibility and importance of a large definitive trial to determine the effects of less tight control on serious perinatal and maternal complications.

We wished to determine prescribing practices of obstetricians in Canada regarding tocolytics, antenatal corticosteroids, and progesterone for women at increased risk of preterm labour and birth, and to determine whether these practices changed between 1997-98 and 2004.Two cross-sectional surveys of Canadian obstetricians were conducted. The initial survey was in 1997-98 (N = 1313); the follow-up survey was in 2004 (N = 1508).Response rates were 46.4% in 1997-98 and 43.3% in 2004. Most respondents reported that they prescribed tocolytics to women with signs and symptoms of preterm labour (97.4% in 1997-98; 92.2% in 2004; P0.001) but use had decreased. In 1997-98, 20.0% of respondents used tocolytics for48 hours during one course of treatment, whereas in 2004, only 9.6% did this (P = 0.06). The tocolytic prescribed most frequently was magnesium sulphate in 1997-98 (40.6% of respondents), whereas in 2004, it was indomethacin (47.5% of respondents). The use of repeat courses of antenatal corticosteroids decreased from 72.9% in 1997-98 to 18.7% in 2004 (P0.001). In 2004, only a few respondents (7.0%) prescribed progesterone for women at increased risk of preterm birth.Most Canadian obstetricians continue to use tocolytics for women in preterm labour, although use has decreased over time, and the most frequently prescribed tocolytic has changed from magnesium sulphate to indomethacin. The use of repeat courses of antenatal corticosteroids decreased substantially during this time, and in 2004, progesterone was not in frequent use.

Objective This study was undertaken to compare maternal outcomes at 2 years postpartum after planned cesarean section and planned vaginal birth for the singleton fetus in breech presentation at term. Study design In selected centers in the Term Breech Trial, mothers completed a structured questionnaire at 2 or more years postpartum to determine their health in the previous 3 to 6 months. Results A total of 917 of 1159 (79.1%) mothers from 85 centers completed a follow-up questionnaire at 2 years postpartum. There were no differences between groups in breast feeding, relationship with child or partner, pain, subsequent pregnancy, incontinence, depression, urinary, menstrual or sexual problems, fatigue, or distressing memories of the birth experience. Planned cesarean section was associated with a higher risk of constipation ( P =.02). Conclusion Maternal outcomes at 2 years postpartum are similar after planned cesarean section and planned vaginal birth for the singleton breech fetus at term.

(1) To determine if women faculty members in departments of Obstetrics and Gynaecology were less likely than men to achieve promotion; and (2) to assess gender differences in attitudes towards promotion.Department chairs at the 16 medical schools in Canada were approached to participate in this study. A questionnaire was mailed to the obstetricians/gynaecologists in faculties of medicine at the 15 Canadian medical schools that agreed to participate. Likelihood of promotion for women and men was compared using survival analysis, controlling for other factors. Survival (event) time was the time in years between completion of residency and achieving promotion.The response rate was 72% (376/522). Overall, 37% of respondents were women, and 63% were men. The women respondents were younger than the men, with a mean age of 43.4 +/- 7.9 years compared to 52.8 +/- 8.9 years. Of those in an academic stream, 39% of women (29/75) and 62% of men (90/145) had attained senior academic ranks. Completing residency more recently was associated with a higher likelihood of promotion to Assistant Professor (hazard ratio [HR], 1.05; P0.001). The likelihood of promotion to Professor was lower for women than for men (HR, 0.40; P = 0.05). Having a mentor was associated with a higher likelihood of promotion to Professor (HR, 2.33; P = 0.002). Women were more likely to perceive barriers to promotion, such as family care responsibilities (P0.001).Independent of the respondent's gender, recent completion of residency and having a mentor were the most significant factors increasing the likelihood of promotion in Canadian medical school departments of Obstetrics and Gynaecology. As women were found to be less likely than men to achieve promotion to Professor, mentoring and strategies that focus on facilitating promotion for women should be encouraged to ensure there are academic leaders in obstetrics and gynaecology in the future.