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In the United States, there is a widespread belief that the overall cesarean birth rate is higher than necessary. Efforts are being directed toward decreasing the number of these procedures, in part by encouraging physicians to make changes in their management practices. Because breech presentations are associated with a high rate of cesarean birth, there is renewed interest in techniques such as external cephalic version (ECV) and vaginal breech delivery. The purpose of this document is to provide information about ECV by summarizing the relevant evidence presented in published studies and to make recommendations regarding its use in obstetric practice.

A new coronavirus (SARS-CoV-2) highlighted at the end of 2019 in China is spreading across all continents. Most often at the origin of a mild infectious syndrome, associating mild symptoms (fever, cough, myalgia, headache and possible digestive disorders) to different degrees, SARS-Covid-2 can cause serious pulmonary pathologies and sometimes death. Data on the consequences during pregnancy are limited. The first Chinese data published seem to show that the symptoms in pregnant women are the same as those of the general population. There are no cases of intrauterine maternal-fetal transmission, but cases of newborns infected early suggest that there could be vertical perpartum or neonatal transmission. Induced prematurity and cases of respiratory distress in newborns of infected mothers have been described. Pregnancy is known as a period at higher risk for the consequences of respiratory infections, as for influenza, so it seems important to screen for Covid-19 in the presence of symptoms and to monitor closely pregnant women. In this context of the SARS-Covid-2 epidemic, the societies of gynecology-obstetrics, infectious diseases and neonatalogy have proposed a French protocol for the management of possible and proven cases of SARS-Covid-2 in pregnant women. These proposals may evolve on a daily basis with the advancement of the epidemic and knowledge in pregnant women. Subsequently, an in-depth analysis of cases in pregnant women will be necessary in order to improve knowledge on the subject., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Introduction: Optimising the safety of obstetric patient care is a primary concern for many hospitals. Performance indicators measuring aspects of patient care processes can lead to improvements in health systems and the prevention of harm to the patient. We present our protocol for a scoping review to identify indicators for obstetric safety in low risk births. We aim to identify indicators addressing preventable hospital harms, to summarise the data and synthesise results., Methods and Analysis: We will use methods described by Arksey and O'Malley and further expanded by Levac et al . We will search electronic databases such as Medline, Embase, CINAHL and the Cochrane Library, and websites from professional bodies and other organisations, using an iterative search strategy.Two reviewers will independently screen titles and abstracts of search results to determine eligibility for inclusion. If eligibility is not clear, the reviewers will screen the full text version. If reviewers' decisions regarding eligibility differ, a third reviewer will review the record. Two reviewers will independently extract data from records that meet our inclusion criteria using a standardised data collection form. We will narratively describe quantitative data, such as the frequency with which indicators are identified, and conduct a thematic analysis of the qualitative data. We will compile a comprehensive list of patient safety indicators and organise them according to concepts that best suit the data such as the Donabedian model or the Hospital Harm Framework. We will discuss the implications for future research, clinical practice and policy-making. We will report the conduct of the review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews checklist., Ethics and Dissemination: The sources of information included in this scoping review will be available to the public. Therefore, ethics approval is not warranted. We will disseminate results in a peer-reviewed publication, conference/event presentation(s) and stakeholder communications., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

One of the most complex clinical problems in obstetrics and neonatology is caring for pregnant women at the threshold of viability. Births near viability boundaries are grave events that carry a high prevalence of neonatal death or an increased potential for severe lifelong complications and disabilities among those who survive. Compared with several decades ago, premature infants receiving neonatal care by today's standards have better outcomes than those born in other eras. However, preterm labor at periviability represents a more complex counseling and management challenge. Although preterm birth incidence between 20/7 and 25/7 weeks has remained unchanged, survival rates at earlier gestational ages have increased as perinatal and neonatal specialties have become more adept at caring for this at-risk population. Women face difficult choices about obstetric and neonatal interventions in light of uncertainties around survival and outcomes. This article reviews current neonatal statistics in reference to short- and long-term outcomes, key concepts in obstetric clinical management of an anticipated periviable birth, and counseling guidance to ensure shared-decision making.

Ensuring universal access to sexual and reproductive healthcare services is Target 3.7 of the United Nations Sustainable Development Goals (SDG). Refugee and migrant women and children are at particular risk of being forgotten in the global momentum to achieve this target. In this article we discuss the violations of sexual and reproductive health and rights (SRHR) of particular relevance to the refugee and migrant reality. We give context-specific examples of denial of health services to vulnerable groups; lack of dignity as a barrier to care; the vulnerability of adolescents; child marriage; weaponized rape; gender-based violence; and sexual trafficking. We discuss rights frameworks and models that are being used in response to these situations, as well as what remains to be done. Specifically, we call for obstetricians and gynecologists to act as individual providers and through their FIGO member societies to protect women's health and rights in these exposed settings., (© 2020 International Federation of Gynecology and Obstetrics.)

Problem: Midwifery-led continuity of care has well documented evidence of benefits for mothers and babies, however uptake of these models by Australian maternity services has been slow., Background: It is estimated that only 10% of women have access to midwifery-led continuity of care in Australia. The Quality Maternal Newborn Care (QMNC) Framework has been developed as a way to implement and upscale health systems that meet the needs of childbearing women and their infants. The Framework can be used to explore the qualities of existing maternity services., Aim: We aimed to use the QMNC Framework to explore the qualities of midwifery-led continuity of care in two distinct settings in Australia with recommendations for replication of the model in similar settings., Methods: Data were collected from services users and service providers via focus groups. Thematic analysis was used to develop initial findings that were then mapped back to the QMNC Framework., Findings: Good quality care was facilitated by Fostering connection, Providing flexibility for women and midwives and Having a sense of choice and control. Barriers to the provision of quality care were: Contested care and Needing more preparation for unexpected outcomes., Discussion: Midwifery-led continuity of carer models shift the power dynamic from a hierarchical one, to one of equality between women and midwives facilitating informed decision making. There are ongoing issues with collaboration between general practice, obstetrics and midwifery. Organisations have a responsibility to address the challenges of contested care and to prepare women for all possible outcomes to ensure women experience the best quality care as described in the framework., Conclusion: The QMNC Framework is a useful tool for exploring the facilitators and barriers to the widespread provision of midwifery-led continuity of care., (Crown Copyright © 2019. Published by Elsevier Ltd. All rights reserved.)

Introduction: Global estimates suggest 2.6 million stillbirths and 2.5 million neonatal deaths occur annually worldwide. The majority of these deaths occur in low resource settings where analysis of health metrics and outcomes measurements may be challenging. We examined the misclassification of documented intrapartum stillbirth and factors associated with misclassification., Material and Methods: A prospective observational study was performed in 12 public hospitals in Nepal. Data were extracted from the medical records of all births that occurred during the 6-month period of the study. For the study purpose, we classified birth outcome based on the presence of fetal heart sound (FHS) at admission and use of neonatal resuscitation. The health worker-documented intrapartum stillbirths were considered potentially misclassified when there were FHS present at admission and no resuscitation initiated after birth. The association between potentially misclassified intrapartum stillbirth and complications during labor, birthweight and gestational age was assessed using Pearson's chi-square test, bivariate and multivariate logistic regression., Results: A total of 39 562 mother-infant dyads were enrolled in the study, all of whom had FHS at admission. Among the 391 intrapartum stillbirths recorded during the study, 180 (46.0%) of them had FHS at admission with no resuscitation initiated after birth and were considered potentially misclassified intrapartum stillbirths. Among these potentially misclassified intrapartum stillbirths, 170 (43.5%) had FHS present 15 minutes before birth and 10 had no FHS 15 minutes before birth Among the potentially misclassified intrapartum stillbirths, 23.3% had complications during labor, 93.3% had birthweight less than 2500 g and 90.0% were born preterm. The risk of intrapartum misclassification was nearly four times higher among low birthweight babies (adjusted odds ratio [aOR] 3.5, 95% confidence interval [CI] 1.8 to 7.0, P < 0.001) and five times higher among preterm babies (aOR 5.3, 95% CI 3.0 to 9.3, P < 0.001)., Conclusions: We estimate that 46% of intrapartum stillbirths were potentially misclassified intrapartum stillbirths. Improving quality of both FHS monitoring and neonatal resuscitation as well as measurement of the care will reduce the risk of potentially misclassified intrapartum stillbirth and consequently intrapartum stillbirth., (© 2019 Nordic Federation of Societies of Obstetrics and Gynecology.)

Background: Recent increases in maternal mortality and severe maternal morbidity highlight the need to improve systems for safe maternity care. We sought to identify whether publicly available state perinatal guidelines incorporate levels of maternal care (LoMC) criteria. Materials and Methods: We searched websites for 50 U.S. states and Washington, D.C. for LoMC guidelines. The Health Resources and Services Administration's Title V Program directors confirmed/updated search results through January 2018. Data abstracted included: (1) definitions of levels; (2) provider types; (3) facility capabilities and services; and (4) programmatic responsibilities as promoted in the 2015 Society for Maternal/Fetal Medicine and American College of Obstetricians and Gynecologists consensus document on LoMC. Results: LoMC guidelines were identified for 17 states; 12 defined four levels and five defined three levels of care. In Level I, 14/17 states specified obstetric provider availability for every birth and five specified an available surgeon to perform emergency cesareans. Fourteen states specified the availability of blood bank and laboratory services at all times. In the highest level (III or IV), 16/17 state guidelines specified a maternal/fetal medicine specialist; all but two specified anesthesia providers or services. Ten states referenced availability of an onsite intensive care unit in their highest level. All 17 state guidelines specified maternal transport and referral systems. Conclusions: Only one-third of states have publicly available perinatal guidelines incorporating LoMC criteria. Definitions, criteria, and nomenclature varied. Lack of LoMC guidelines with standardized criteria limits monitoring and evaluation of regionalized systems of maternal care.

From 2015 to 2018, the Ethiopian Society of Obstetricians & Gynecologists (ESOG), the American College of Obstetricians and Gynecologists, the Ethiopian Federal Ministry of Health, and the Center for International Reproductive Health Training at the University of Michigan collaborated to define and execute the goals of ESOG to enhance education, research, publishing, and clinical care in Ethiopia. We outline the processes used to define and execute these goals, accomplishments toward achieving them, and key lessons learned.

Objective: To describe some characteristics of the 97 teaching hospitals participating in the Projeto de Aprimoramento e Inovação no Cuidado e Ensino em Obstetrícia e Neonatologia (Apice ON-Project for Improvement and Innovation in Care and Teaching in Obstetrics and Neonatology)., Methods: The semester prior to the beginning of the program was adopted as the baseline to evaluate the subsequent structural and processes changes of this project. Secondary data from the first half of 2017 were extracted from the National Registry of Health Establishments (NRHE), the Hospital Information System and the Sistema de Informações sobre Nascidos Vivos (SINASC-Live Birth Information System)., Results: Before the implementation of the project, only 66% of the hospitals had a Baby-friendly Hospital Initiative, only 3% offered special accommodations for high-risk pregnant women, mothers and their newborns, and 45.4% hospitals adopted the skin-to-skin contact; 97% hospitals had separate rooms for pre-labor and vaginal delivery (93%), not following the recommendations of the Ministry of Health; nine hospitals (9%) had no rooming-in; there were few obstetrics nurses (less than 1% of professionals enrolled in the NRHE), and in only six hospitals the proportion of births assisted by this professional was above 50% of vaginal deliveries, while in eight this percentage ranged between 15% and 50%; the average cesarean section rate was 42%, ranging between 37.6% (Southeast) and 49.1% (Northeast); ten hospitals did not charge for companions according to inpatient hospital authorization., Conclusion: The study strengthens the relevance of the Apice ON project as an inducer of change of the care model in teaching hospitals and, therefore, as a strategy for the implementation of the national public policy represented by the Stork Network.

Ultrasound scanning is a cornerstone of modern antenatal care, enabling the detection of fetal abnormalities such as congenital disease, chromosomal defects and growth-disorders as well as maternal diseases such as pre-eclampsia. As technology and techniques evolve, care paradigms and clinical guidance must be re-evaluated with current literature so as to provide expectant parents with the highest quality of care. We present here the current state of the literature, the conflict between guidance and research endeavours and present suggestions for future study., Competing Interests: Declaration of Competing Interest Nil conflicts to declare, (Crown Copyright © 2019. Published by Elsevier B.V. All rights reserved.)

Introduction: To determine a minimum threshold of medical staffing needs (obstetricians-gynecologists, anesthesiologists-resuscitation specialists, nurse-anesthetists, pediatricians, and midwives) to ensure the safety and quality of care for unscheduled obstetrics-gynecology activity., Materials and Methods: Face to face meetings of French healthcare professionals involved in perinatal care in different types of practices (academic hospital, community hospital or private practice) who belong to French perinatal societies: French National College of Gynecologists-Obstetricians (CNGOF), the French Society of Anesthesia and Resuscitation Specialists (SFAR), the French Society of Neonatology (SFN), the French Society of Perinatal Medicine (SFMP), the National College of French Midwives (CNSF), and the French Federation of Perinatal Care Networks (FFRSP)., Results: Different minimum thresholds for each category of care provider were proposed according to the number of births/year in the facility. These minimum thresholds can be modulated upwards as a function of the level of care (Level 1, 2 or 3 for perinatal centers), existence of an emergency department, and responsibilities as a referral center for maternal-fetal and/or surgical care. For example, an obstetrics-gynecology department handling 3000-4500 births per year without serving as a referral center must have an obstetrician-gynecologist, an anesthesiologist-resuscitation specialist, a nurse-anesthetist, and a pediatrician onsite specifically to provide care for unscheduled obstetrics-gynecology needs and a second obstetrician-gynecologist available within a time compatible with security requirements 24/7; the number of midwives always present (24/7) onsite and dedicated to unscheduled care is 5.1 for 3000 births and 7.2 for 4500 births. A maternity unit's occupancy rate must not exceed 85 %., Conclusion: The minimum thresholds proposed here are intended to improve the safety and quality of care of women who require unscheduled care in obstetrics-gynecology or during the perinatal period., Competing Interests: Declaration of Competing Interest Loïc Sentilhes and Dan Benhamou are consultants for Ferring Pharmaceuticals. The other authors report no conflicts of interest in relation to this article., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: As Medicaid has increasingly financed managed care plans since the 1990s, it is important to understand the corresponding impacts on the well-being of disadvantaged mothers and infants. This study examines how a Medicaid managed care (MMC) program in Pennsylvania (PA) impacts disadvantaged women's obstetrical care utilization and access as well as their birth outcomes. Materials and Methods: This study uses a dataset of PA disadvantaged women who had multiple singleton births in 1994-2004. As to the empirical approach, we apply a linear multiple regression model to implement a pre-post design with control groups. The model also controls for unmeasured maternal birth-invariant characteristics, which affect take-up of Medicaid coverage and managed care plans. Results: The sample for the main analysis consists of 78,346 sibling births. We find the program roll-out reduces usage of some high-tech obstetrical services and limits access to high-quality hospital services, thereby contributing to cost savings. However, implementation of the program is also associated with deterioration in birth outcomes, worse prenatal care, and an elevated risk of inappropriate gestational weight gain. Conclusions: Cost containment through transition to MMC can be fulfilled at the price of maternal health care utilization and infant welfare. Therefore, caution is needed in design and delivery of managed care to low-income women.

To examine the communication between obstetric providers and their socioeconomically disadvantaged, African American patients who are overweight and obese during pregnancy, and whether this communication relates to outcomes. Pregnant patients and their obstetric providers were surveyed between October 2012 and March 2016 at Washington University School of Medicine in St. Louis, MO. Percent agreement between patients' and obstetric providers' survey responses was analyzed and measured (κ coefficient). Descriptive and multilevel logistic regression analyses aimed at identifying the relation of perceived communication between providers and patients to gestational weight gain, diet, and exercise during pregnancy. A total of 99 pregnant women and 18 obstetric providers participated in the study. Significant lack of agreement was observed between patients and obstetric providers regarding communication about weight gain recommendations, risk factors associated with excessive weight gain, what constitutes adequate exercise per week, exercise recommendations, dietary recommendations, and risk factors associated with a poor diet. Our findings suggest patients were not receiving intended messages from their obstetric providers. Thus, more effective patient-obstetric provider communication is needed regarding gestational weight gain, exercise and dietary recommendations among overweight/obese, socioeconomically disadvantaged, African American women.

This article aimed to identify the scientific evidence about the educational strategies used to promote prenatal health. This is a systematic meta-synthesis. Analysis of published studies revealed the emergence of two central thematic categories: methodological strategies for the educational activities and; educational tools to promote prenatal health. The most used strategy was health education with pregnant women or couples, using conversation circles and focus groups as methods to target the public. The strategies and educational tools used to promote maternal health in prenatal care seek to anchor the expanded concept of health and to contribute to the construction of varied models of health education.

Importance: The tort liability system is intended to serve 3 functions: compensate patients who sustain injury from negligence, provide corrective justice, and deter negligence. Deterrence, in theory, occurs because clinicians know that they may experience adverse consequences if they negligently injure patients., Objective: To review empirical findings regarding the association between malpractice liability risk (ie, the extent to which clinicians face the threat of being sued and having to pay damages) and health care quality and safety., Data Sources and Study Selection: Systematic search of multiple databases for studies published between January 1, 1990, and November 25, 2019, examining the relationship between malpractice liability risk measures and health outcomes or structural and process indicators of health care quality., Data Extraction and Synthesis: Information on the exposure and outcome measures, results, and acknowledged limitations was extracted by 2 reviewers. Meta-analytic pooling was not possible due to variations in study designs; therefore, studies were summarized descriptively and assessed qualitatively., Main Outcomes and Measures: Associations between malpractice risk measures and health care quality and safety outcomes. Exposure measures included physicians' malpractice insurance premiums, state tort reforms, frequency of paid claims, average claim payment, physicians' claims history, total malpractice payments, jury awards, the presence of an immunity from malpractice liability, the Centers for Medicare & Medicaid Services' Medicare malpractice geographic practice cost index, and composite measures combining these measures. Outcome measures included patient mortality; hospital readmissions, avoidable admissions, and prolonged length of stay; receipt of cancer screening; Agency for Healthcare Research and Quality patient safety indicators and other measures of adverse events; measures of hospital and nursing home quality; and patient satisfaction., Results: Thirty-seven studies were included; 28 examined hospital care only and 16 focused on obstetrical care. Among obstetrical care studies, 9 found no significant association between liability risk and outcomes (such as Apgar score and birth injuries) and 7 found limited evidence for an association. Among 20 studies of patient mortality in nonobstetrical care settings, 15 found no evidence of an association with liability risk and 5 found limited evidence. Among 7 studies that examined hospital readmissions and avoidable initial hospitalizations, none found evidence of an association between liability risk and outcomes. Among 12 studies of other measures (eg, patient safety indicators, process-of-care quality measures, patient satisfaction), 7 found no association between liability risk and these outcomes and 5 identified significant associations in some analyses., Conclusions and Relevance: In this systematic review, most studies found no association between measures of malpractice liability risk and health care quality and outcomes. Although gaps in the evidence remain, the available findings suggested that greater tort liability, at least in its current form, was not associated with improved quality of care.

The recommendations present the current knowledge and procedures, which can be modified and changed in some cases, after careful analysis of a given clinical situation, which in the future may become the basis for their modification and updating.

Importance: Induction of labor (IOL) is a common obstetric intervention that stimulates the onset of labor using artificial methods., Objective: The aim of this study was to summarize and compare recommendations from 4 national or international medical societies on the IOL., Evidence Acquisition: A descriptive review was conducted of major published guidelines on IOL: the American College of Obstetricians and Gynecologists' "Induction of Labor" and "Management of Late-Term and Postterm Pregnancies," the guidelines of the Society of Obstetricians and Gynaecologists of Canada (SOGC) on "Induction of Labour," those of the National Institute for Health and Care Excellence (NICE) on "Inducing Labour," and the World Health Organization's (WHO's) "Recommendations for Induction of Labour" and "WHO Recommendations: Induction of Labour at or Beyond Term." These guidelines were compared in terms of their recommendations on clinical indications and methods., Results: Many similar indications and contraindications to IOL are identified between American College of Obstetricians and Gynecologists and SOGC, whereas NICE and WHO do not mention any contraindications. The timing of IOL in postterm pregnancies also differs among the guidelines. Regarding the methods of induction, all the medical societies recommend the use of membrane sweeping, mechanical methods, prostaglandins, and oxytocin, whereas NICE argues against the use of misoprostol for IOL. The American College of Obstetricians and Gynecologists and SOGC consider amniotomy a method of IOL, whereas NICE and WHO do not recommend it. All the guidelines also make similar recommendations regarding the management of uterine tachysystole in cases of IOL., Conclusions: The World Health Organization seems to be the most evidence-based guideline with recommendations based mainly on Cochrane reviews. The variation in the clinical indications and methods of IOL highlights the need to adopt an international consensus, which may help to optimize the quality of obstetric care and further promote evidence-based medicine.

Thirteen years after the last supplement on obstetric fistula, the authors challenge the progress achieved. Citing the ongoing need for a standardized classification system, uniform surgical training and certification, evaluation, follow-up, and research, we emphasize the need for improved communication and coordination between government and nongovernment entities invested in ending obstetric fistula. Struck by the call by the United Nations to end obstetric fistula by 2030, we stress the need for increased and targeted funding of programs that are of the highest quality and impact., (© 2020 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Polish Society of Gynecologists and Obstetricians recommendations on supplementation during pregnancy.

Periostin (POSTN) is a multifunctional glycoprotein that belongs to the group of extracellular matrix (ECM) proteins. Due to the molecular structure, cellular interactions, tissue locations as well functions of POSTN, we realize that its pivotal role is organization and regulation of ECM microenvironment. In available databases there is a lack of data summarizing current knowledge about POSTN expression in the field of gynecology and obstetrics. We conducted a search in PubMed of the National Library of Medicine and Google Scholar. Databases were extensively searched for all original and review articles/book chapters published in English until December 2019 and related to periostin expression. All relevant articles were reviewed and presented as appropriate. In the field of POSTN expression there is only one paper evaluating its involvement in cervical cancer cell metabolism and only two studies analyzing its myometrial commitment: maintenance during pregnancy and induction of parturition in physiology as well control of fibroids biology in pathology. Much more attention has been devoted to the expression of described protein in the endometriosis, and above all in ovarian cancer. Finally, a few studies carried out among pregnant women were presented. In this review study we presented current knowledge about periostin expression in the field of gynecology and obstetrics. Many achieved results are interesting and further studies are needed to verify some hypotheses. Structure, signaling pathways as well many functions of periostin are well-described. However, as it was clearly shown there is a lot of unknown issues which are waiting to be explored.

This article addresses coding and liability related to obstetric and gynecologic ultrasound examinations. The coding section includes an overview of general concepts, highlighting the differences between coding in hospital-owned facilities and provider-owned clinics. It also addresses the importance of correct International Classification of Diseases, 10th edition, coding, emphasizing the use of the most specific applicable codes. This section discusses proper coding and applicable parameters for early pregnancy and gynecologic ultrasound examination. The liability section addresses common errors leading to litigation in obstetric and gynecologic ultrasound practice. Examples are given demonstrating how such errors lead to liability actions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Maternal mortality and severe maternal morbidity, particularly among women of color, have increased in the United States. The leading medical causes of maternal mortality include cardiovascular disease, infection, and common obstetric complications such as hemorrhage and vary by timing relative to the end of pregnancy. Although specific modifications in the clinical management of some of these conditions have been instituted, more can be done to improve the system of care for high-risk women at facility and population levels. The goal of levels of maternal care is to reduce maternal morbidity and mortality, including existing disparities, by encouraging the growth and maturation of systems for the provision of risk-appropriate care specific to maternal health needs. To standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care, this classification system establishes levels of maternal care that pertain to basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). The determination of the appropriate level of care to be provided by a given facility should be guided by regional and state health care entities, national accreditation and professional organization guidelines, identified regional perinatal health care service needs, and regional resources. State and regional authorities should work together with the multiple institutions within a region, and with the input from their obstetric care providers, to determine the appropriate coordinated system of care and to implement policies that promote and support a regionalized system of care. These relationships enhance the ability of women to give birth safely in their communities while providing support for circumstances when higher level resources are needed. This document is a revision of the original 2015 Levels of Maternal Care Obstetric Care Consensus, which has been revised primarily to clarify terminology and to include more recent data based on published literature and feedback from levels of maternal care implementation., (Copyright © 2019 American College of Obstetricians and Gynecologists. Published by Elsevier Inc. All rights reserved.)

Background: Clinical learning environments influence the learning and performance of learners by creating learning opportunities and experiences. The maternity ward offers a major educational opportunity for midwifery students, obstetrics and gynecology residents and medical interns to acquire and improve crucial skills., Objectives: This study seeks to determine the way in which the clinical learning environment of the maternity ward creates learning opportunities and enables the accumulation of experiences for the noted learners., Methods: This qualitative study was conducted using inductive content analysis at the Maternity Ward of Shahid Beheshti Hospital, affiliated with University of Medical Sciences. Midwifery students, medical interns and obstetrics and gynecology residents spend a certain period of time in this ward as a mandatory part of their obstetrics and gynecology training. Data were collected through semi-structured individual interviews and observations and were then analyzed in MAXQDA concurrently with data collection., Results: Three main categories emerged from the analysis of the data collected from the interviews and observations: disorganized learning opportunities, heavy emotional load and learners' abandonment in the care-provider and learner role., Conclusion: The maternity ward lacked the necessary organization to generate an environment conducive to learning and independent practice for the three groups of learners. The learners' training and acquired skills were thus affected by the clinical learning environment., (Copyright © 2019. Published by Elsevier Ltd.)

This study was performed to investigate whether the Japanese guidelines for gestational weight gain (GWG) can be used to determine the risks of multiple pregnancy outcomes and estimate optimal GWG in 101,336 women with singleton pregnancies in 2013. Multivariable logistic regression analyses indicated that the risks associated with low birth weight, small for gestational age, and preterm birth increased significantly with weight gain below the Japanese guidelines, and the risks of macrosomia and large for gestational age increased with weight gain above the guidelines regardless of Asian-specific pre-pregnancy body mass index (BMI). The GWG cutoff points estimated from the adjusted area under the receiver operating characteristics curve >0.6 corresponded to 10-13.8 kg in underweight women with pre-pregnancy BMI < 18.5 kg/m 2 ; 10-13.7 kg in normal weight women with pre-pregnancy BMI 18.5-22.9 kg/m 2 ; 8.5-11.4 kg in overweight women with pre-pregnancy BMI 23-24.9 kg/m 2 , 5-13.3 kg in obese women with pre-pregnancy BMI 25-29.9 kg/m 2 ; and 4.7 kg in obese women with pre-pregnancy BMI ≥ 30 kg/m 2 . The optimal GWG ranges proposed by the present study are slightly higher than those recommended by the current Japanese guidelines.

Objective: To validate the NHSLA maternity claims taxonomy at the level of a single maternity service and assess its ability to direct quality improvement., Design: Qualitative descriptive study., Setting: Medico-legal claims between 1 January 2000 and 31 December 2016 from a maternity service in metropolitan Melbourne, Australia., Population: All obstetric claims and incident notifications occurring within the date range were included for analysis., Methods: De-identified claims and notifications data were derived from the files of the insurer of Victorian public health services. Data included claim date, incident date and summary, and claim cost. All reported issues were coded using the NHSLA taxonomy and the lead issue identified., Main Outcome Measures: Rate of claims and notifications, relative frequency of issues, a revised taxonomy., Results: A combined total of 265 claims and incidents were reported during the 6 years. Of these 59 were excluded, leaving 198 medico-legal events for analysis (1.66 events/1000 births). The costs for all claims was $46.7 million. The most common claim issues were related to management of labour (n = 63, $17.7 million), cardiotocographic interpretation (n = 43, $24.4 million), and stillbirth (n = 35, $656,750). The original NHSLA classification was not sufficiently detailed to inform care improvement programmes. A revised taxonomy and coding flowchart is presented., Conclusions: Systematic analysis of obstetric medico-legal claims data can potentially be used to inform quality and safety improvement., Tweetable Abstract: New taxonomy to target health improvement from maternity claims based on NHSLA Ten Years of Maternity Claims., (© 2019 Royal College of Obstetricians and Gynaecologists.)

Background: Lack of trained personnel is a major obstacle to providing the full package of emergency obstetric and newborn care (EmONC) services in Ethiopia and other low-income countries. The aim of this study was to evaluate whether a blended learning approach to in-service EmONC training could be as effective as a conventional learning approach while reducing costs., Methods: A quasi-experimental study design assigned providers in need of EmONC training to blended learning (12 days of offsite training followed by daily SMS and weekly phone calls) or conventional learning (18 days of offsite training followed by a facility visit to mentor participants). A self-administered questionnaire measured provider knowledge before training and three months afterwards. Provider skills were assessed three months post-training with an Objective Structured Clinical Examination (OSCE). Independent sample t-test and multiple linear regression analysis were used to assess differences in mean percentage knowledge and skills scores between learning groups. The direct costs and cost-effectiveness of each learning approach were calculated., Result: Knowledge scores were similar for the blended and conventional learning groups before training (58.5% vs 61.5%, p = 0.358) and three months post-training (74.7% vs 75.5% = 0.720), with no significant difference in gains made. Post-training skills scores were significantly higher for conventional than blended learning (85.8% vs 75.3%, p < 0.001). After controlling for other factors in the multiple linear regression analysis, providers with a university degree had significantly higher skills scores than those with a diploma (p < 0.001). Training costs were lower for blended learning than conventional learning (1032 USD vs 1648 USD per trainee)., Conclusion: Blended learning approach using SMS and phone calls was as effective as conventional one to increase providers' knowledge with substantially lower costs. Further study is warranted to examine the effect of blended learning on providers' skills., (Copyright © 2019. Published by Elsevier Ltd.)

Objective: To compare midwife and obstetrician labor practices and birth outcomes in women with low-risk pregnancies delivered in the hospital., Methods: We conducted a retrospective cohort study of singleton births of 37 0/7-42 6/7 weeks of gestation at 11 hospitals between January 1, 2014, and December 31, 2018. Exclusions included intrapartum transfer from home-birth center, antepartum stillbirth, previous cesarean delivery, practitioner other than midwife or obstetrician, prelabor cesarean, prepregnancy maternal disease, and pregnancy complications or risk factors. Interventions (induction, artificial rupture of membranes, epidural, oxytocin, and episiotomy), mode of delivery, maternal outcomes (third- or fourth-degree laceration, postpartum hemorrhage, blood transfusion, and severe maternal morbidity), and newborn outcomes (shoulder dystocia, 5-minute Apgar score less than 7, resuscitation at delivery, birth trauma, and neonatal intensive care unit admission) were examined by practitioner type. We used modified Poisson regression models adjusted for individual confounders to assess risk ratios, stratified by parity, for health care provider type and perinatal outcomes., Results: The study cohort comprised 23,100 births (3,816 midwife and 19,284 obstetrician). Compared with obstetricians, midwifery patients had significantly lower intervention rates, an approximately 30% lower risk of cesarean delivery in nulliparous patients (adjusted relative risk [aRR] 0.68; 95th% CI 0.57-0.82), and an approximately 40% lower risk of cesarean in multiparous patients (aRR 0.57; 95th% CI 0.36-0.89). Operative vaginal birth was also less common in nulliparous patients (aRR 0.73; 95th% CI 0.57-0.93) and multiparous patients (aRR 0.30; 95th% CI 0.14-0.63). Shoulder dystocia was more common in multiparous patients receiving midwifery care (aRR 1.42; 95th% CI 1.04-1.92)., Conclusions: In low-risk pregnancies, midwifery care in labor was associated with decreased intervention, decreased cesarean and operative vaginal births, and, in multiparous women, an increased risk for shoulder dystocia. Greater integration of midwifery care into maternity services in the United States may reduce intervention in labor and potentially even cesarean delivery, in low-risk pregnancies. Larger research studies are needed to evaluate uncommon but important maternal and newborn outcomes.

Both cesarean surgery and induction of labor have become common procedures performed in all labor wards in an attempt to reduce adverse obstetrical and neonatal outcomes. Thus, recent evidence, led by the ARRIVE Trial, demonstrated that elective induction at 39 weeks reduced the rates of cesarean deliveries and of hypertensive disorders of pregnancy. However, some concerns must be addressed, as the benefits of universal policies have to be outweighed with the current circumstances of implementation, the economic impact, the number of procedures needed to effectively reduce complications, and, above all, women's perception towards this approach. Therefore, it would be interesting to explore individualization strategies, instead of general recommendations, to offer personalized care., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Competing Interests: Competing interestsThe BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: none. Further details of The BMJ policy on financial interests are here: https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests

Background: Preterm infants are a group at high risk of having experienced placental insufficiency. It is unclear which growth charts perform best in identifying infants at increased risk of stillbirth and other adverse perinatal outcomes. We compared 2 birthweight charts (population centiles and INTERGROWTH-21st birthweight centiles) and 3 fetal growth charts (INTERGROWTH-21st fetal growth charts, World Health Organization fetal growth charts, and Gestation Related Optimal Weight [GROW] customised growth charts) to identify which chart performed best in identifying infants at increased risk of adverse perinatal outcome in a preterm population., Methods and Findings: We conducted a retrospective cohort study of all preterm infants born at 24.0 to 36.9 weeks gestation in Victoria, Australia, from 2005 to 2015 (28,968 records available for analysis). All above growth charts were applied to the population. Proportions classified as <5th centile and <10th centile by each chart were compared, as were proportions of stillborn infants considered small for gestational age (SGA, <10th centile) by each chart. We then compared the relative performance of non-overlapping SGA cohorts by each chart to our low-risk reference population (infants born appropriate size for gestational age [>10th and <90th centile] by all intrauterine charts [AGAall]) for the following perinatal outcomes: stillbirth, perinatal mortality (stillbirth or neonatal death), Apgar <4 or <7 at 5 minutes, neonatal intensive care unit admissions, suspicion of poor fetal growth leading to expedited delivery, and cesarean section. All intrauterine charts classified a greater proportion of infants as <5th or <10th centile than birthweight charts. The magnitude of the difference between birthweight and fetal charts was greater at more preterm gestations. Of the fetal charts, GROW customised charts classified the greatest number of infants as SGA (22.3%) and the greatest number of stillborn infants as SGA (57%). INTERGROWTH classified almost no additional infants as SGA that were not already considered SGA on GROW or WHO charts; however, those infants classified as SGA by INTERGROWTH had the greatest risk of both stillbirth and total perinatal mortality. GROW customised charts classified a larger proportion of infants as SGA, and these infants were still at increased risk of mortality and adverse perinatal outcomes compared to the AGAall population. Consistent with similar studies in this field, our study was limited in comparing growth charts by the degree of overlap, with many infants classified as SGA by multiple charts. We attempted to overcome this by examining and comparing sub-populations classified as SGA by only 1 growth chart., Conclusions: In this study, fetal charts classified greater proportions of preterm and stillborn infants as SGA, which more accurately reflected true fetal growth restriction. Of the intrauterine charts, INTERGROWTH classified the smallest number of preterm infants as SGA, although it identified a particularly high-risk cohort, and GROW customised charts classified the greatest number at increased risk of perinatal mortality., Competing Interests: The authors have declared that no competing interests exist.

Background: Patients treated in health care facilities that provide services in the fields of obstetrics, gynecology, and neonatology are especially vulnerable. Large multidisciplinary teams of physicians, multiple invasive and noninvasive diagnostic and therapeutic procedures, and the use of advanced technologies increase the probability of adverse events. The evaluation of knowledge about patient safety culture among nurses and midwives working in such units and the identification of critical areas at a health care institution would reduce the number of adverse events and improve patient safety. The aim of the study was to evaluate the opinion of nurses and midwives working in clinical departments that provide services in the fields of obstetrics, gynecology, and neonatology about patient safety culture and to explore potential predictors for the overall perception of safety. Methods: We used the Hospital Survey on Patient Safety Culture (HSOPSC) to evaluate nurses' and midwives' opinion about patient safety issues. The overall response rate in the survey was 100% ( n  = 233). Results: The analysis of the dimensions of safety on the unit level showed that the respondents' most positive evaluations were in the Organizational Learning - Continuous Improvement (73.2%) and Feedback and Communication about Error (66.8%) dimensions, and the most negative evaluations in the Non-punitive Response to Error (33.5%) and Staffing (44.6%) dimensions. On the hospital level, the evaluation of the safety dimensions ranged between 41.4 and 56.8%. The percentage of positive responses in the outcome dimensions Frequency of Events Reported was 82.4%. We found a significant association between the outcome dimension Frequency of Events Reported and the Hospital Management Support for Patient Safety and Feedback and Communication about Error Dimensions. Conclusions: On the hospital level, the critical domains in health care facilities that provide services in the fields of obstetrics, gynecology, and neonatology were Teamwork Across Hospital Units, and on the unit level - Communication Openness, Teamwork Within Units, Non-punitive Response to Error, and Staffing. The remaining domains were seen as having a potential for improvement.

Purpose: We report on a successful quality improvement project designed to increase access to perinatal mental health services through universal screening for postpartum depression (PPD) and facilitating referrals for evaluation and treatment, at a multi-site, integrated system of pediatric and obstetric practices in Houston, Texas., Description: Obstetric practices administered screenings twice during pregnancy and at 6 weeks postpartum. Pediatric practices screened women at the 2 week and 2, 4, and 6-month well-baby visit. Women with a score of 10 or higher on the Edinburgh Postnatal Depression Scale (EPDS) or women that reported thoughts of self-harm were offered a referral to a mental health provider. Data on screening and referrals were collected from the electronic medical record., Results: A total of 102,906 screens for PPD were completed between May 2014 and July 2018. Of those, 6487 (6.3%) screened positive. The total number of women referred to treatment were 3893 (3.8%). Of referred women 2172 (55.8%) completed an appointment with a mental health provider within 60 days of referral. Rates of completed appointments varied by the level of integration of the mental health provider and referring physician: women referred by pediatrics in a Level 1 coordinated system completed 20.0% of referrals; obstetrics Level 4 co-located system, 76.6%; and obstetrics Level 5 integrated model, 82.7%., Conclusion: This project demonstrated that with planning, systems review and trained staff, PPD screening can be integrated into obstetric and pediatric practices and high screening and referral rates can be achieved.

Objective: To measure future and current resident perspectives on obstetrics and gynecology residency training structure and possible future models., Methods: Medical students invited for obstetrics and gynecology residency interviews and residents (postgraduate year [PGY]-1-4) at the University of Colorado, the University of Washington, the University of California San Francisco, Loyola University, Saint Joseph's Hospital, and Texas A&M in 2017-2018 received a voluntary, electronic survey regarding possible models for restructuring residency training. Student and resident responses were compared using χ test for categorical and two-sample t-test for continuous items., Results: Applicants (63%, 280/444) and residents (66%, 101/153) had similar response rates (overall response rate 64%). Applicants (24%) and residents (29%) reported having concerns about the current structure of residency training. The ideal residency duration was reported as 4 years by 72% of applicants and 85% of residents. Lack of gynecologic surgical volume was the most frequently reported concern among applicants (75%) and residents (72%). Fourth-year tracking (focusing on training aligned with postgraduation career path) was preferred by 90% of applicants and 77% of residents (P=.002) and 92% among respondents planning fellowship. Most applicants (68%) and residents (75%) preferred not starting fellowship training after the 3rd year of residency., Discussion: The majority of learners surveyed support a 4-year training structure but likewise support individualizing training in PGY-4. It is imperative that obstetrics and gynecology leadership consider this and other feedback from learners when considering modifications to the current training paradigm.

Protocols and checklists have been shown to reduce patient harm through improved standardization and communication. Implementation of protocols and guidelines often is delayed because of lack of health care provider awareness or difficult clinical algorithms in medical institutions. However, the use of checklists and protocols clearly has been demonstrated to improve outcomes and their use is strongly encouraged. Checklists and protocols should be incorporated into systems as a way to help practitioners provide the best evidence-based care to their patients.

The Japan Society of Obstetrics and Gynecology Reproductive Endocrinology Committee summarizes the activities of each subcommittee below from April 2017 to March 2019. Current important issues regarding reproductive medicine were examined and discussed from social, political, ethical and scientific viewpoints. A nation-wide survey targeted at OB/GYN facilities revealed the usual procedure in diagnosis and management of fertility-desiring POI patients and fertility outcomes of the patients. How to introduce and adapt FIGO AUB systems to obstetric and gynecologic practices in Japan was examined and discussed., (© 2019 Japan Society of Obstetrics and Gynecology.)

Residency programs across the United States are searching for ways to improve surgical skills and operative experiences in obstetrics and gynecology residencies. We developed an obstetrics and gynecology residency program that offers a flexible curriculum, referred to as tracking, to address these needs. Curriculum content was developed using a modified Delphi method, using input from experts in medical education and obstetrics and gynecology. Outcome data were collected on trainees who graduated between 2016 and 2019, including postgraduate fellowship placement and our residents' achievement of surgical minimum requirements based on procedure logs. Trainees from this program have consistently exceeded minimal surgical requirements in all areas, regardless of tracking preference. Since the beginning of the program in 2012, more than 60% of graduates have matriculated into fellowships. Flexible curricula, such as tracking, offer one approach to a changing climate of medicine. The ability to offer flexible, focused, and individualized training is an approach with great potential to produce graduates who excel in all areas of obstetrics and gynecology while sharpening skills specific to their areas of interest.

Objective: To assess the completeness of obstetric referral letters/notes at the district level of healthcare., Design: An implementation research within three districts in Greater Accra region using mixed methods. During baseline and intervention phases, referral processes for all obstetric referrals from lower level facilities seen at the district hospitals were documented including indications for referrals, availability and completeness of referral notes/forms. An assessment of before and after intervention availability and completeness of referral forms was carried out. Focus group discussions, non-participant observations and in-depth interviews with health workers and pregnant women were conducted for qualitative data., Setting: Three (3) districts in the Greater Accra region of Ghana., Participants: Pregnant women referred from lower levels of care to and seen at the district hospital, health workers within the three districts and pregnant women attending antenatal clinic in the district and their family members or spouses., Intervention: An enhanced interfacility referral communication system consisting of training, provision of communication tools for facilities, formation of hospital referral teams and strengthening feedback mechanisms., Outcome: Completeness of obstetric referral letters/notes., Results: Proportion of obstetric referrals with referral notes improved from 27.2% to 44.3% from the baseline to intervention period. Mean completeness (95% CI) of all forms was 71.3% (64.1% to 78.5%) for the study period, improving from 70.7% (60.4% to 80.9%) to 71.9% (61.1% to 82.7%) from baseline to intervention periods. Health workers reported they do not always provide referral notes and that most referral notes are not completely filled due to various reasons., Conclusions: Most obstetric referrals did not have referral notes. The few notes provided were not completely filled. Interventions such as training of health workers, regular review of referral processes and use of electronic records can help improve both the provision of and completeness of the referral notes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background: Maternal mental health is an international public health concern. Many women experience mental ill-health during and after pregnancy, but assessment is not part of routine maternity care in many low- and middle-income countries. Healthcare providers are in a position to identify and support women who experience mental health disorders during and after pregnancy. We sought to investigate the knowledge, attitudes and perceptions of routine screening for maternal mental health during and after pregnancy among healthcare providers providing routine maternity care in Accra, Ghana. Enabling factors, barriers and potential management options to routinely screen maternal mental health during and after pregnancy were explored., Methods: Semi-structured key informant interviews (n = 20) and one focus group discussion (n = 4) were conducted with healthcare providers working in one public hospital in Accra, Ghana. Transcribed interviews were coded by topic and then grouped into categories. Thematic framework analysis was undertaken to identify emerging themes., Results: Most healthcare providers are aware of the importance of maternal mental health and would be keen to help women who experience mental ill-health during and after pregnancy, if resources were available to do so. An enabling factor was the suggestion of introducing a culturally appropriate mental health screening tool. However, compromised mental health was often considered a 'spiritual issue' and not routinely screened for by healthcare providers, nor requested by women. Barriers to the provision of quality maternal mental health care included lack of trained staff and lack of time., Conclusions: Healthcare providers are aware of the problem of the lack of maternal mental health provision during and after pregnancy and are open to developing protocols to improve care. Currently, screening for maternal mental ill-health is not part of routine maternity care. The establishment of such a service requires the reprioritisation of workloads, further training, and a change in the attitudes and practices of healthcare providers. Education to change the attitudes of healthcare providers, women and the wider community towards mental health is needed. The development and implementation of culturally appropriate guidelines would be beneficial and result in better quality of maternity care.

Background: Uganda, a low resource country, implemented the skilled attendance at birth strategy, to meet a key target of the 5th Millenium Development Goal (MDG), 75% reduction in maternal mortality ratio. Maternal mortality rates remained high, despite the improvement in facility delivery rates. In this paper, we analyse the strategies implemented and bottlenecks experienced as Uganda's skilled birth attendance policy was rolled out. These experiences provide important lessons for decision makers as they implement policies to further improve maternity care., Methods: This is a case study of the implementation process, involving a document review and in-depth interviews among key informants selected from the Ministry of Health, Professional Organisations, Ugandan Parliament, the Health Service Commission, the private not-for-profit sector, non-government organisations, and District Health Officers. The Walt and Gilson health policy triangle guided data collection and analysis., Results: The skilled birth attendance policy was an important priority on Uganda's maternal health agenda and received strong political commitment, and support from development partners and national stakeholders. Considerable effort was devoted to implementation of this policy through strategies to increase the availability of skilled health workers for instance through expanded midwifery training, and creation of the comprehensive nurse midwife cadre. In addition, access to emergency obstetric care improved to some extent as the physical infrastructure expanded, and distribution of medicines and supplies improved. However, health worker recruitment was slow in part due to the restrictive staff norms that were remnants of previous policies. Despite considerable resources allocated to creating the comprehensive nurse midwife cadre, this resulted in nurses that lacked midwifery skills, while the training of specialised midwives reduced. The rate of expansion of the physical infrastructure outpaced the available human resources, equipment, blood infrastructure, and several health facilities were not fully functional., Conclusion: Uganda's skilled birth attendance policy aimed to increase access to obstetric care, but recruitment of human resources, and infrastructural capacity to provide good quality care remain a challenge. This study highlights the complex issues and unexpected consequences of policy implementation. Further evaluation of this policy is needed as decision-makers develop strategies to improve access to skilled care at birth.

Workshops are an important part of the IFPA annual meeting as they allow for discussion of specialized topics. At IFPA meeting 2018 there were nine themed workshops, five of which are summarised in this report. These workshops discussed new perspectives and knowledge in the following areas of research: 1) preeclampsia; 2) abnormally invasive placenta; 3) placental infection; 4) gestational trophoblastic disease; 4) drug delivery to treat placental dysfunction., (Copyright © 2019. Published by Elsevier Ltd.)

Failure to rescue refers to the inability to prevent death from health care complications. The fact that more than half of severe maternal morbidity and maternal deaths are classified as preventable, and black women have 2 to 3 times the risk for adjusted severe morbidity and maternal mortality suggest there is a problem with failure to rescue in US maternity care. This article reviews national efforts to improve rescue capacity in maternity care and data on communication breakdowns and disrespect in maternity care, and outlines individual and organizational actions that can be taken to improve communication and rescue processes.

Introduction: The objective of these clinical practice guidelines was to analyse all of the interventions during pregnancy and childbirth that might prevent obstetric anal sphincter injuries (OASIS) and postnatal pelvic floor symptoms., Material and Methods: These guidelines were developed in accordance with the methods prescribed by the French Health Authority (HAS)., Results: A prenatal clinical examination of the perineum is recommended for women with a history of Crohn's disease, OASIS, genital mutilation, or perianal lesions (professional consensus). Just after delivery, a perineal examination is recommended to check for OASIS (Grade B); if there is doubt about the diagnosis, a second opinion should be requested (Grade C). In case of OASIS, the injuries (including their severity) and the technique for their repair should be described in detail (Grade C). Perineal massage during pregnancy must be encouraged among women who want it (Grade B). No intervention conducted before the start of the active phase of the second stage of labour has been shown to be effective in reducing the risk of perineal injury. The crowning of the baby's head should be manually controlled and the posterior perineum manually supported to reduce the risk of OASIS (Grade C). The performance of an episiotomy during normal deliveries is not recommended to reduce the risk of OASIS (Grade A). In instrumental deliveries, episiotomy may be indicated to avoid OASIS (Grade C). When an episiotomy is performed, a mediolateral incision is recommended (Grade B). The indication for episiotomy should be explained to the woman, and she should consent before its performance. Advising women to have a caesarean delivery for primary prevention of postnatal urinary or anal incontinence is not recommended (Grade B). During pregnancy and again in the labour room, obstetrics professionals should focus on the woman's expectations and inform her about the modes of delivery., (Copyright © 2019 CNGOF. Published by Elsevier Masson SAS.. All rights reserved.)

This article will review the basic principles of risk management, the role of the risk manager, and the importance of risk management in the patient safety movement as it pertains to obstetrics and gynecology. Several tools that are used by risk managers including risk assessments and root cause analyses will be used to illustrate positive patient safety measures that can be initiated to decrease adverse outcomes and reduced risk to an organization. The dramatic reduction in adverse outcomes and claims after the introduction of patient safety initiatives in a major obstetrical service will be reviewed.

Patient safety remains a concern for practice in traditional office settings as well as emerging forms of telehealth. Effective leadership is required to establish a culture of safety in office practice, with all staff undergoing appropriate credentialing and privileging. Key areas of focus for office safety are documentation and follow-up of patient encounters, medication safety, and surgical safety. Medication safety standards include prescribed medications, office administered injections and samples given to patients. Similar rules of patient safety apply to both hospital-based and office-based surgical procedures. Telehealth will present new challenges for maintaining patient safety, for which more study is needed.