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Objectifs Determiner les risques et les avantages de l'accouchement du siege par voie vaginale planifie par rapport a la cesarienne planifiee et recommander des criteres de selection, des parametres de prise en charge intrapartum et des techniques d'accouchement du siege par voie vaginale. Options Accouchement du siege par voie vaginale planifie ou cesarienne planifiee en cas de grossesse monofœtale a terme. Issues Mortalite perinatale, morbidite neonatale et infantile a court et a long terme, mortalite maternelle et morbidite maternelle a court et a long terme. DONNeES PROBANTES: Des recherches ont ete effectuees dans la base de donnees Medline jusqu'a avril 2018 pour trouver des essais randomises et des etudes de cohortes qui comparent les issues apres l'accouchement du siege par voie vaginale planifie et la cesarienne planifiee, ainsi que des etudes de cohortes qui comparent les techniques d'accouchement du siege par voie vaginale. Des articles supplementaires ont ete reperes dans les bibliographies. Validation L'evaluation par les pairs de la presente directive clinique a ete realisee par des cliniciens internationaux experts en accouchement du siege par voie vaginale; la directive a egalement ete comparee a la ligne directrice du Royal College of Obstetricians and Gynecologists, Green-top Guideline No 20b : Management of Breech Presentation. Le contenu et les recommandations ont ete rediges et acceptes par les auteurs principaux. Le conseil d'administration de la Societe des obstetriciens et gynecologues du Canada a approuve la version definitive aux fins de publication. La qualite des donnees probantes utilisees dans le present document a ete evaluee au moyen des criteres du cadre methodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Promoteurs Societe des obstetriciens et gynecologues du Canada. DeCLARATIONS SOMMAIRES: RECOMMANDATIONS: Criteres de selection du travailPrise en charge du travailTechnique d'accouchementSituation et consentement.

Objectives To discern the risks and benefits of planned vaginal breech birth versus planned Caesarean section and to recommend selection criteria, intrapartum management parameters, and delivery techniques for vaginal breech birth. Options Planned vaginal breech birth or planned Caesarean section for women with a singleton breech fetus at term. Outcomes Perinatal mortality, short- and long-term neonatal/infant morbidity, maternal mortality, and short- and long-term maternal morbidity. Evidence Medline was searched up to April, 2018 for randomized trials and cohort studies comparing outcomes after planned vaginal breech birth and planned Caesarean section and for cohort studies comparing vaginal breech birth techniques. Additional articles were identified through bibliography tracing. Validation This guideline was peer reviewed by international clinicians with expertise in vaginal breech birth and compared with the 2017 Royal College of Obstetricians and Gynaecologists Green Top Guideline 20b: Management of Breech Presentation. The content and recommendations were drafted and agreed upon by the principal authors. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework. Sponsors The Society of Obstetricians and Gynaecologists of Canada. SUMMARY STATEMENTS 1External cephalic version is recommended to reduce the likelihood of Caesarean section. If unsuccessful, options include planned vaginal breech birth or planned Caesarean section (high). 2In appropriately selected women in hospitals with obstetricians skilled in vaginal breech birth, perinatal mortality is between 0.8 and 1.7/1000 for planned vaginal breech birth and between 0 and 0.8/1000 for planned Caesarean section (moderate). 3In appropriately selected women, planned vaginal breech birth is associated with greater short- but not long-term neonatal neurological morbidity. Regardless of planned mode of birth, cerebral palsy occurs in approximately 1.5/1000 breech births, and any abnormal neurological development occurs in approximately 3/100 (moderate). 4During planned vaginal breech birth, a clinician experienced in vaginal breech birth should supervise the first stage of labour and be present for the active second stage of labour and delivery (IA). Staff required for rapid Caesarean section and skilled neonatal resuscitation should be in-hospital during the active second stage of labour (low). 5Vaginal breech birth requires a high degree of skill and support. To avoid the increased risk of out-of-hospital vaginal breech birth, women who choose planned vaginal breech birth should be accommodated in-hospital. To facilitate this, referral to more experienced centres, back-up on-call arrangements, and continuing medical training in vaginal breech birth skills should be promoted (very low). RECOMMENDATIONS Labour Selection Criteria 1For a woman with breech presentation near term, pre- or early-labour ultrasound should be performed to assess type of breech presentation, flexion of the fetal head, and fetal growth. If a woman presents in labour and ultrasound is unavailable and has not recently been performed, Caesarean section is recommended (strong; moderate). 2Contraindications to planned vaginal breech birth include: aCord presentation (strong; very low) bFetal growth restriction (strong; moderate) cFetal macrosomia (estimated fetal weight >4000 g) (weak; low) dFootling breech presentation (1 or both hip[s] extended) (strong; moderate) eClinically inadequate maternal pelvis (weak; very low) fFetal anomaly likely to interfere with vaginal delivery (strong; low) gHyperextended fetal head (weak; low) 3For planned vaginal breech birth at term, care should be taken to rule out growth restriction. Estimated fetal weight should be between 2800 and 4000 g (strong; moderate). 4The maternal pelvis should be clinically assessed to be adequate. Radiologic pelvimetry is not necessary for planned vaginal breech birth. Provided fetal growth is normal, good progress in labour is an indicator of adequate fetal-pelvic proportions (weak; low). Labour Management 5Upon admission in labour and immediately prior to planned Caesarean section, breech presentation should be (re)confirmed with ultrasound (strong; low). 6During planned vaginal breech birth, continuous electronic fetal monitoring is recommended in labour. When membranes rupture, immediate vaginal examination is recommended to rule out prolapsed cord (strong; moderate). 7Oxytocin augmentation is acceptable to correct weak uterine contractions. If progress in labour is poor despite adequate contractions, Caesarean section is recommended (strong; moderate). 8Although data are limited, induction of labour with breech presentation does not appear to be associated with poorer outcomes than spontaneous labour (weak; low). 9A passive second stage of up to 90 minutes before active pushing is acceptable to allow the breech to descend well into the pelvis. Once active pushing commences, delivery should be accomplished or imminent within 60 minutes; otherwise, Caesarean section is recommended (strong; moderate). 10Planned vaginal breech birth should only occur in hospitals with Caesarean section capability. During the first stage of labour, Caesarean section should be available within a time frame similar to cephalic birth. This may vary according to geographical and other factors (strong; low). 11During the active second stage of labour, anaesthesia, pediatric, and operating room personnel should be in-hospital, available for rapid Caesarean section if necessary (strong; low). Delivery Technique 12An obstetrician skilled in vaginal breech birth should be present during the active second stage and breech delivery (strong; low). 13Effective maternal and uterine power is essential to safe delivery. When vaginal delivery is imminent, oxytocin infusion may be helpful to ensure strong uterine contractions between delivery of the body and the head (weak; low). 14Fetal traction during vaginal breech birth should be avoided if possible. Any fetal manipulation should only be applied after spontaneous delivery to the level of the umbilicus (strong; moderate). 15For expulsive delay after the breech has "crowned," power from above is very likely safer than traction from below. Techniques to maximize power from above include effective maternal effort, hands and knees posture, the Bracht manoeuvre, and oxytocin augmentation (strong; low). 16Nuchal arms may be reduced by the Lovset or Bickenbach manoeuvres (strong; low). 17The fetal head may deliver spontaneously, with the assistance of suprapubic pressure, by Mauriceau-Smellie-Veit manoeuvre, or with the assistance of Piper forceps. It is recommended that an assistant be available to assist with any necessary procedures (strong; low). 18The obstetrical team should have rehearsed a plan of action for the rare trapped after-coming head or irreducible nuchal arms: symphysiotomy or Zavanelli manoeuvre can be life-saving (weak; very low). Setting and Consent 19In the absence of a contraindication to vaginal delivery, a woman with a breech fetus should be informed of the risks and benefits of planned Caesarean section and planned vaginal breech birth. A woman's choice of delivery mode should be respected and consent obtained (strong; very low). 20The consent discussion and chosen plan should be well documented and communicated to labour-room staff. A sample consent form can be found in the Appendix (strong; very low). 21Hospitals offering planned vaginal breech birth should have a written protocol for selection and intrapartum management. Experienced obstetricians willing to back up junior colleagues will maximize a hospital's ability to offer vaginal breech birth (strong; very low). 22Hospitals without obstetricians skilled in vaginal breech birth should readily refer women desiring vaginal breech birth to a centre that has colleagues with those skills (strong; very low). 23Caesarean section should be recommended to women with a contraindication to vaginal breech birth. Women who decline this recommendation should be provided the best possible in-hospital care (strong; low). 24Theoretical and simulated hands-on vaginal breech birth training should be a part of basic obstetrical curricula and post-graduate skills training programs such as ALARM, ALSO, and MOREOB (strong; very low).

Déterminer les risques et les avantages de l'accouchement du siège par voie vaginale planifié par rapport à la césarienne planifiée et recommander des critères de sélection, des paramètres de prise en charge intrapartum et des techniques d'accouchement du siège par voie vaginale.Accouchement du siège par voie vaginale planifié ou césarienne planifiée en cas de grossesse monofœtale à terme.Mortalité périnatale, morbidité néonatale et infantile à court et à long terme, mortalité maternelle et morbidité maternelle à court et à long terme. DONNéES PROBANTES: Des recherches ont été effectuées dans la base de données Medline jusqu'à avril 2018 pour trouver des essais randomisés et des études de cohortes qui comparent les issues après l'accouchement du siège par voie vaginale planifié et la césarienne planifiée, ainsi que des études de cohortes qui comparent les techniques d'accouchement du siège par voie vaginale. Des articles supplémentaires ont été repérés dans les bibliographies.L'évaluation par les pairs de la présente directive clinique a été réalisée par des cliniciens internationaux experts en accouchement du siège par voie vaginale; la directive a également été comparée à la ligne directrice du Royal College of Obstetricians and Gynecologists, Green-top Guideline NSociété des obstétriciens et gynécologues du Canada. DéCLARATIONS SOMMAIRES: RECOMMANDATIONS: Critères de sélection du travailPrise en charge du travailTechnique d'accouchementSituation et consentement.

Resume Objectif Une femme enceinte sur 12 en vient a subir des traumatismes physiques et ceux-ci exercent des effets importants sur la mortalite et la morbidite maternelles, ainsi que sur l'issue de la grossesse. La mise en oeuvre d'une approche multidisciplinaire s'avere justifiee pour assurer l'optimisation des issues, et ce, tant pour la mere que pour son foetus. Le present document a pour but d'offrir, aux fournisseurs de soins obstetricaux, une approche systematique factuelle qu'ils pourront utiliser pour assurer la prise en charge des patientes enceintes ayant subi un traumatisme. Issues Issues sanitaires et economiques considerables, par comparaison avec les pratiques de rechange. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans Medline, CINAHL et The Cochrane Library entre octobre 2007 et septembre 2013 au moyen d'un vocabulaire controle (« pregnancy », « Cesarean section », « hypotension », « domestic violence », « shock ») et de mots cles (« trauma », « perimortem Cesarean », « Kleihauer-Betke », « supine hypotension », « electrical shock ») appropries. Les resultats ont ete restreints aux analyses systematiques, aux etudes observationnelles et aux essais comparatifs randomises / essais cliniques comparatifs publies en anglais entre janvier 1968 et septembre 2013. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en fevrier 2014. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats a ete evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau). Avantages, desavantages et couts Nous nous attendons a ce que la presente directive clinique facilite l'offre de soins optimaux et uniformes dans les cas de grossesse compliquee par un traumatisme.

Shoulder dystocia can lead to death or brain damage for the baby. Traction on the head can damage the brachial plexus. The diagnosis should be made when the mother cannot push the shoulders out with her own efforts with the next contraction after delivery of the head. There should be no traction on the head to diagnose shoulder dystocia. McRoberts' position is acceptable but it should not be accompanied by any traction on the head. If the posterior shoulder is in the sacral hollow then the best approach is to use posterior axillary traction to deliver the posterior shoulder and arm. If both shoulders are above the pelvic brim, the posterior arm should be brought down with Jacquemier's maneuver. If that fails, cephalic replacement or symphysiotomy is the next step. After shoulder dystocia is resolved, one should wait 1 minute or so to allow placental blood to return to the baby before cutting the umbilical cord.

The human (h) placental lactogenic hormone chorionic somatomammotropin (CS) is highly produced during pregnancy and acts as a metabolic adaptor in response to maternal insulin resistance. Maternal obesity can exacerbate this “resistance”, and a >75% decrease in CS RNA levels was observed in term placentas from obese vs. lean women. The genes coding for hCS ( hCS-A and hCS-B) and placental growth hormone ( hGH-V) as well as the hCS-L pseudogene and pituitary growth hormone (GH) gene ( hGH-N) are located at a single locus on chromosome 17. Three remote hypersensitive sites (HS III–V) located >28 kb upstream of hGH-N as well as local hCS gene promoter and enhancer regions are implicated in hCS gene expression. A placenta-specific chromosomal architecture, including interaction between HS III–V and hCS but not hGH gene promoters, was detected in placentas from lean women (BMI 2) by using the chromosome conformation capture assay. This architecture was disrupted by pre-pregnancy maternal obesity (BMI >35 kg/m2), resulting in a predominant interaction between HS III and the hGH-N promoter, which was also observed in nonplacental tissues. This was accompanied by a decrease in hCS levels, which was consistent with reduced RNA polymerase II and CCAAT/enhancer-binding protein-β association with individual hCS promoter and enhancer sequences, respectively. Thus, pre-pregnancy maternal obesity disrupts the placental hGH/CS gene locus chromosomal architecture. However, based on data from obese women who develop GDM, insulin treatment partially recapitulates the chromosomal architecture seen in lean women and positively affects hCS production, presumably facilitating prolactin receptor-related signaling by hCS.

Physical trauma affects 1 in 12 pregnant women and has a major impact on maternal mortality and morbidity and on pregnancy outcome. A multidisciplinary approach is warranted to optimize outcome for both the mother and her fetus. The aim of this document is to provide the obstetric care provider with an evidence-based systematic approach to the pregnant trauma patient.Significant health and economic outcomes considered in comparing alternative practices.Published literature was retrieved through searches of Medline, CINAHL, and The Cochrane Library from October 2007 to September 2013 using appropriate controlled vocabulary (e.g., pregnancy, Cesarean section, hypotension, domestic violence, shock) and key words (e.g., trauma, perimortem Cesarean, Kleihauer-Betke, supine hypotension, electrical shock). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English between January 1968 and September 2013. Searches were updated on a regular basis and incorporated in the guideline to February 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).This guideline is expected to facilitate optimal and uniform care for pregnancies complicated by trauma. Summary Statement Specific traumatic injuries At this time, there is insufficient evidence to support the practice of disabling air bags for pregnant women. (III) Recommendations Primary survey 1. Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by a definitive pregnancy test or ultrasound scan. (III-C) 2. A nasogastric tube should be inserted in a semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic gastric content. (III-C) 3. Oxygen supplementation should be given to maintain maternal oxygen saturation95% to ensure adequate fetal oxygenation. (II-1B) 4. If needed, a thoracostomy tube should be inserted in an injured pregnant woman 1 or 2 intercostal spaces higher than usual. (III-C) 5. Two large bore (14 to 16 gauge) intravenous lines should be placed in a seriously injured pregnant woman. (III-C) 6. Because of their adverse effect on uteroplacental perfusion, vasopressors in pregnant women should be used only for intractable hypotension that is unresponsive to fluid resuscitation. (II-3B) 7. After mid-pregnancy, the gravid uterus should be moved off the inferior vena cava to increase venous return and cardiac output in the acutely injured pregnant woman. This may be achieved by manual displacement of the uterus or left lateral tilt. Care should be taken to secure the spinal cord when using left lateral tilt. (II-1B) 8. To avoid rhesus D (Rh) alloimmunization in Rh-negative mothers, O-negative blood should be transfused when needed until cross-matched blood becomes available. (I-A) 9. The abdominal portion of military anti-shock trousers should not be inflated on a pregnant woman because this may reduce placental perfusion. (II-3B) Transfer to health care facility 10. Transfer or transport to a maternity facility (triage of a labour and delivery unit) is advocated when injuries are neither life- nor limb-threatening and the fetus is viable (≥ 23 weeks), and to the emergency room when the fetus is under 23 weeks' gestational age or considered to be non-viable. When the injury is major, the patient should be transferred or transported to the trauma unit or emergency room, regardless of gestational age. (III-B) 11. When the severity of injury is undetermined or when the gestational age is uncertain, the patient should be evaluated in the trauma unit or emergency room to rule out major injuries. (III-C) Evaluation of a pregnant trauma patient in the emergency room 12. In cases of major trauma, the assessment, stabilization, and care of the pregnant women is the first priority; then, if the fetus is viable (≥ 23 weeks), fetal heart rate auscultation and fetal monitoring can be initiated and an obstetrical consultation obtained as soon as feasible. (II-3B) 13. In pregnant women with a viable fetus (≥ 23 weeks) and suspected uterine contractions, placental abruption, or traumatic uterine rupture, urgent obstetrical consultation is recommended. (II-3B) 14. In cases of vaginal bleeding at or after 23 weeks, speculum or digital vaginal examination should be deferred until placenta previa is excluded by a prior or current ultrasound scan. (III-C) Adjunctive tests for maternal assessment 15. Radiographic studies indicated for maternal evaluation including abdominal computed tomography should not be deferred or delayed due to concerns regarding fetal exposure to radiation. (II-2B) 16. Use of gadolinium-based contrast agents can be considered when maternal benefit outweighs potential fetal risks. (III-C) 17. In addition to the routine blood tests, a pregnant trauma patient should have a coagulation panel including fibrinogen. (III-C) 18. Focused abdominal sonography for trauma should be considered for detection of intraperitoneal bleeding in pregnant trauma patients. (II-3B) 19. Abdominal computed tomography may be considered as an alternative to diagnostic peritoneal lavage or open lavage when intra-abdominal bleeding is suspected. (III-C) Fetal assessment 20. All pregnant trauma patients with a viable pregnancy (≥ 23 weeks) should undergo electronic fetal monitoring for at least 4 hours. (II-3B) 21. Pregnant trauma patients (≥ 23 weeks) with adverse factors including uterine tenderness, significant abdominal pain, vaginal bleeding, sustained contractions (1/10 min), rupture of the membranes, atypical or abnormal fetal heart rate pattern, high risk mechanism of injury, or serum fibrinogen200 mg/dL should be admitted for observation for 24 hours. (III-B) 22. Anti-D immunoglobulin should be given to all rhesus D-negative pregnant trauma patients. (III-B) 23. In Rh-negative pregnant trauma patients, quantification of maternal-fetal hemorrhage by tests such as Kleihauer-Betke should be done to determine the need for additional doses of anti-D immunoglobulin. (III-B) 24. An urgent obstetrical ultrasound scan should be undertaken when the gestational age is undetermined and need for delivery is anticipated. (III-C) 25. All pregnant trauma patients with a viable pregnancy who are admitted for fetal monitoring for greater than 4 hours should have an obstetrical ultrasound prior to discharge from hospital. (III-C) 26. Fetal well-being should be carefully documented in cases involving violence, especially for legal purposes. (III-C) Obstetrical complications of trauma 27. Management of suspected placental abruption should not be delayed pending confirmation by ultrasonography as ultrasound is not a sensitive tool for its diagnosis. (II-3D) Specific traumatic injuries 28. Tetanus vaccination is safe in pregnancy and should be given when indicated. (II-3B) 29. Every woman who sustains trauma should be questioned specifically about domestic or intimate partner violence. (II-3B) 30. During prenatal visits, the caregiver should emphasize the importance of wearing seatbelts properly at all times. (II-2B) Perimortem Caesarean section 31. A Caesarean section should be performed for viable pregnancies (≥ 23 weeks) no later than 4 minutes (when possible) following maternal cardiac arrest to aid with maternal resuscitation and fetal salvage. (III-B).

Objectives This guideline reviews the evidence relating to the effects of parvovirus B19 on the pregnant woman and fetus, and discusses the management of women who are exposed to, who are at risk of developing, or who develop parvovirus B19 infection in pregnancy. Outcomes The outcomes evaluated were maternal outcomes including erythema infectiosum, arthropathy, anemia, and myocarditis, and fetal outcomes including spontaneous abortion, congenital anomalies, hydrops fetalis, stillbirth, and long-term effects. Evidence Published literature was retrieved through searches of PubMed and The Cochrane Library on July 8, 2013, using appropriate controlled vocabulary (MeSH terms "parvovirus" and "pregnancy") and key words (parvovirus, infection, pregnancy, hydrops). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date restrictions but results were limited to English or French language materials. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, and national and international medical specialty. Values The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Recommendations 1.Investigation for parvovirus B19 infection is recommended as part of the standard workup for fetal hydrops or intrauterine fetal death. (II-2A) 2.Routine screening for parvovirus immunity in low-risk pregnancies is not recommended. (II-2E) 3.Pregnant women who are exposed to, or who develop symptoms of, parvovirus B19 infection should be assessed to determine whether they are susceptible to infection (non-immune) or have a current infection by determining their parvovirus B19 immunoglobulin G and immunoglobulin M status. (II-2A) 4.If parvovirus B19 immunoglobulin G is present and immunoglobulin M is negative, the woman is immune and should be reassured that she will not develop infection and that the virus will not adversely affect her pregnancy. (II-2A) 5.If both parvovirus B19 immunoglobulin G and immunoglobulin M are negative (and the incubation period has passed), the woman is not immune and has not developed the infection. She should be advised to minimize exposure at work and at home. Absence from work should be considered on a case-by-case basis. (II-2C) Further studies are recommended to address ways to lessen exposure including the risk of occupational exposure. (III-A) 6.If a recent parvovirus B19 infection has been diagnosed in the woman, referral to an obstetrician or a maternal–fetal medicine specialist should be considered. (III-B) The woman should be counselled regarding risks of fetal transmission, fetal loss, and hydrops and serial ultrasounds should be performed every 1 to 2weeks, up to 12weeks after infection, to detect the development of anemia (using Doppler measurement of the middle cerebral artery peak systolic velocity) and hydrops. (III-B) If hydrops or evidence of fetal anemia develops, referral should be made to a specialist capable of fetal blood sampling and intravascular transfusion. (II-2B)

Objective The purpose of this study was to evaluate pregnancy outcomes in a cohort of women with a placental edge between 11 and 20mm from the internal cervical os, and to determine the likelihood of a successful vaginal delivery when trial of labour is attempted in these women. Methods We carried out a prospective observational study of women with singleton pregnancies and a placental edge between 11 and 20mm from the internal cervical os (identified by transvaginal sonography) who underwent a trial of labour. Results Fourteen women with the above characteristics underwent a trial of labour during the study period. The mean interval (± SD) from ultrasound to delivery was 17.2±9.6 days. Thirteen women (92.9%) delivered vaginally with no complications, and only one woman (7.1%) required an emergency Caesarean section for intrapartum bleeding. The risks of antepartum and postpartum hemorrhage were 21.4% and 14.3%, respectively. Conclusion Having a placental edge more than 10mm from the internal os, measured by transvaginal sonography near term, justifies allowing a trial of labour and carries a low risk of subsequent obstetrical hemorrhage.

Objectives To determine the appropriateness of guidelines recommending routine Cesarean section (CS) for the delivery of macrosomic fetuses weighing ?4500 grams. Methods This was a cross-sectional study of trends and outcomes of macrosomic deliveries at a single, tertiary hospital over a 35 yearperiod (1980 to 2015). A previous review of macrosomic deliveries suggested safety of vaginal delivery in this population locally. Outcomes from that ‘Early Group’ (1980-1989) were then compared to a ‘Late Group’ (2006-2015). Delivery records and hospital charts for all newborns weighing ?4500 grams at birth were reviewed to determine the prevalence of macrosomia as well as mode of delivery and other maternal covariates in order to compare outcomes between groups. Results The rate of macrosomia has been stable over the past 35years (2.3% Early Group vs 2.7% Late Group, p=0.4). Most macrosomic fetuses were successfully delivered vaginally, although the rate of emergency intrapartum CS has increased (18% Early Group vs 27% Late Group, p Conclusions While some professional guidelines have recommended that all macrosomic fetuses be delivered by routine CS, this has not been our local practice and to date, no macrosomic baby at our centre has died or been permanently injured as a result of intrapartum complications of vaginal delivery. However, the emergency CS rate in this population has increased from 18 to 27% and warrants further study.

Objective We reviewed cases of group B Streptococcus (GBS) sepsis in term infants at our institution to identify areas for potential prevention. Methods We identified cases by searching our institution's microbiology databases for all positive GBS blood and cerebrospinal fluid cultures taken from infants between 2008 and 2013. Patients were included if the timing of the positive culture met the criteria for early-onset GBS disease (age 7 days or under). Charts that met inclusion criteria were abstracted for details related to antepartum screening, intrapartum care, and postpartum outcome. Results There are an average of 10 000 deliveries per year in our institution. During the five-year period (2008–2013), we identified 13 cases representing early-onset GBS disease in term infants. Of the 13 cases, nine mothers screened negative for GBS, two screened positive, and two were screened unknown. Four cases qualified for intrapartum prophylaxis; of these, two did not receive appropriate prophylaxis, one because of parental refusal and one for unspecified reasons after the membranes had been ruptured for > 18 hours. All 13 infants had confirmed GBS bacteremia, and four had concurrent GBS meningitis. One infant died and one infant had neurologic sequelae. Conclusion Early-onset GBS disease in term infants continues to occur at our institution, and consequences for the infant can be severe. The majority of cases identified were screened and managed in accordance with current guidelines. Most cases were GBS negative when screened in the antepartum period, raising the question of whether a more sensitive test or a test closer to delivery could prevent further cases of early-onset GBS disease.

To advocate for the use of a common classification system for Caesarean section across Canada.A variety of clinical parameters for classification were considered.Consideration of a common system for classifying Caesarean section.Studies published in English from 1976 to December 2011 were retrieved through searches of Medline and PubMed, using appropriate controlled vocabulary and key words (Caesarean section, vaginal birth after Caesarean, classification). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified through searching the web sites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and the web sites of national and international medical specialty societies.The studies reviewed were classified according to criteria described by the Canadian Task Force on Preventive Health Care, and the recommendation for practice ranked according to this classification (Table 1).The Society of Obstetricians and Gynaecologists of Canada. Recommendation Modified Robson criteria should be used to enable comparison of Caesarean section rates and indications. (III-B).

Enteroviruses are a common cause of neonatal infection. In particular, Coxsackie B viruses are often associated with severe, fatal disease. The antenatal diagnosis of Coxsackie B viral infections is uncommon. We present a unique case of Coxsackie B4 virus ventriculitis and myocarditis causing fetal hydrops at 22 weeks gestation. Transmission was inferred by viral isolation from the amniotic fluid and by placental pathology. We also describe two additional cases of fatal neonatal Coxsackie B4 infection complicated by myocarditis and encephalitis with cerebral necrosis in a 4-day-old female and by myocarditis, spinal leptomeningitis, and hepatitis in a 4-day-old male. Transplacental acquisition of infection carries a poor prognosis. We propose that Coxsackie B virus should be considered in the investigation of nonimmune hydrops, particularly in the presence of cardiac dysfunction.

Resume Objectif Analyser la litterature portant sur l'utilisation de l'echographie diagnostique dans la prise en charge des grossesses gemellaires. Formuler des recommandations quant a la meilleure facon d'utiliser l'echographie dans les cas de grossesse gemellaire. Issues Baisse des taux de mortalite et de morbidite perinatales, ainsi que des taux de morbidite neonatale a court et a long terme, dans les cas de grossesse gemellaire. Optimisation du recours a l'echographie dans les cas de grossesse gemellaire. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans PubMed et The Cochrane Library, en 2008 et en 2009, au moyen d'un vocabulaire controle (p. ex. « twin », « ultrasound », « cervix », « prematurity ») et de mots cles (p. ex. « acardiac », « twin », « reversed arterial perfusion », « twin-to-twin transfusion syndrome », « amniotic fluid ») adequats. Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Aucune restriction n'a ete imposee en matiere de date. Les etudes ont ete restreintes a celles qui disposaient d'un resume ou d'un texte en francais ou en anglais. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en septembre 2009. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs Les donnees recueillies ont ete analysees par le comite d'imagerie diagnostique de la Societe des obstetriciens et gynecologues du Canada, avec l'apport des membres du comite de medecine fœto-maternelle et du comite de genetique de la SOGC. Les recommandations ont ete formulees conformement aux lignes directrices elaborees par le Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). Avantages, desavantages et couts La facilitation et l'optimisation du recours a l'echographie dans les cas de grossesse gemellaire constituent les avantages auxquels l'on s'attend de la presente directive clinique.

Objectives To review (1) the use of ultrasonographic-derived cervical length measurement in predicting preterm birth and (2) interventions associated with a short cervical length. Outcomes Reduction in rates of prematurity and/or better identification of those at risk, as well as possible prevention of unnecessary interventions. Evidence Published literature was retrieved through searches of PubMed and The Cochrane Library up to December 2009, using appropriate controlled vocabulary and key words (preterm labour, ultrasound, cervix, incompetent cervix, transvaginal, transperineal, cervical length, fibronectin). Results were restricted to general and systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The evidence and this guideline were reviewed by the Diagnostic Imaging Committee and the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada, and the recommendations were made according to the guidelines developed by The Canadian Task Force on Preventive Health Care (Table 1). Benefits, harms, and costs Preterm birth is a leading cause of perinatal morbidity and mortality. Use of the ultrasonographic technique reviewed in this guideline may help identify women at risk of preterm birth and, in some circumstances, lead to interventions that may reduce the rate of preterm birth. Sponsors The Society of Obstetricians and Gynaecologists of Canada.

Resume Objectifs Analyser (1) l'utilisation de la mesure echographique de la longueur cervicale pour predire l'accouchement preterme et (2) les interventions associees a une courte longueur cervicale Issues Reduction des taux de prematurite et/ou meilleure identification des personnes exposees a des risques, ainsi que la prevention possible des interventions inutiles Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans PubMed et The Cochrane Library, jusqu'en decembre 2009, au moyen d'un vocabulaire controle et de mots cles adequats (« preterm labour », « ultrasound », « cervix », « incompetent cervix », « transvaginal », « transperineal », « cervical length », « fibronectin »). Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Aucune restriction n'a ete imposee en matiere de date ou de langue. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales Valeurs Les resultats et la presente directive clinique ont ete analyses par le comite d'imagerie diagnostique et le comite de medecine fœto-maternelle de la Societe des obstetriciens et gynecologues du Canada, et les recommandations ont ete formulees en fonction des lignes directrices elaborees par le Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1) Avantages, desavantages et couts L'accouchement preterme est l'une des principales causes de morbidite et de mortalite perinatales Le recours a la technique echographique analysee dans le cadre de la presente directive clinique pourrait contribuer a l'identification des femmes exposees a des risques d'accouchement preterme et, dans certains cas, mener a des interventions qui pourraient reduire le taux d'accouchement preterme Commanditaire La Societe des obstetriciens et gynecologues du Canada

Resume Objectif Fournir une directive clinique quant a l'administration prenatale de sulfate de magnesium (MgSO4) a des fins de neuroprotection foetale pour ce qui est du nouveau-ne issu d'un accouchement preterme. Options L'administration prenatale de MgSO4 devrait etre envisagee a des fins de neuroprotection foetale en presence d'un accouchement preterme imminent (defini comme une forte probabilite d'accouchement en raison d'un travail actif en presence d'une dilatation cervicale ≥ 4 cm, avec ou sans rupture pretravail des membranes preterme, et/ou un accouchement preterme planifie en raison d'indications foetales ou maternelles) chez une patiente en etant a ≤ 31+6 semaines. Il n'existe aucun autre agent neuroprotecteur foetal connu. Issues Les criteres d'evaluation sont l'incidence de l'infirmite motrice cerebrale (IMC) et le deces neonatal. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans PubMed ou Medline, CINAHL et The Cochrane Library, en mai 2010, au moyen d'un vocabulaire controle et de mots cles adequats (« magnesium sulphate », « cerebral palsy », « preterm birth »). Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles pertinentes. Aucune restriction n'a ete imposee en matiere de date ou de langue. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en aout 2010. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats a ete evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). Avantages, desavantages et couts L'administration prenatale de sulfate de magnesium a des fins de neuroprotection foetale attenue le risque de « deces ou d'IMC » (RR, 0,85; IC a 95 %, 0,74 – 0,98; 4 essais, 4 446 nouveau-nes), de « deces ou d'IMC allant de moderee a grave » (RR, 0,85; IC a 95 %, 0,73 – 0,99; 3 essais, 4 250 nouveau-nes), de « toute forme d'IMC » (RR, 0,71; IC a 95 %, 0,55 – 0,91; 4 essais, 4 446 nouveaunes), d'« IMC allant de moderee a grave » (RR, 0,60; IC a 95 %, 0,43 – 0,84; 3 essais, 4 250 nouveau-nes) et de « dysfonction substantielle de la motricite globale » (incapacite de marcher sans aide) (RR, 0,60; IC a 95 %, 0,43 – 0,83; 3 essais, 4 287 nouveau-nes) a l'âge de deux ans. Les resultats etaient concordants d'un essai et d'une meta-analyse a l'autre. Nous n'anticipons aucune hausse significative des couts de sante, puisque les femmes admissibles au traitement prenatal au MgSO4 seront considerees comme etant sur le point de connaitre un accouchement preterme. Validation La directive clinique nationale australienne a ete publiee en mars 2010 par le Antenatal Magnesium Sulphate for Neuroprotection Guideline Development Panel. L'administration prenatale de MgSO4 a ete recommandee a des fins de neuroprotection foetale en fonction de la meme posologie que celle qui est recommandee dans la presente directive clinique. Cependant, l'administration de MgSO4 n'a ete recommandee qu'a Commanditaire Instituts de recherche en sante du Canada (IRSC).

Objective To provide guidelines for the use of antenatal magnesium sulphate (MgSO 4 ) for fetal neuroprotection of the preterm infant. Options Antenatal MgSO4 administration should be considered for fetal neuroprotection when women present at ≤ 31+6 weeks with imminent preterm birth, defined as a high likelihood of birth because of active labour with cervical dilatation ≥ 4 cm, with or without preterm pre-labour rupture of membranes, and/or planned preterm birth for fetal or maternal indications. There are no other known fetal neuroprotective agents. Outcomes The outcomes measured are the incidence of cerebral palsy (CP) and neonatal death. Evidence Published literature was retrieved through searches of PubMed or Medline, CINAHL, and the Cochrane Library in May 2010, using appropriate controlled vocabulary and key words (magnesium sulphate, cerebral palsy, preterm birth). Results were restricted to systematic reviews, randomized controlled trials, and relevant observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to August 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Benefits, harms, and costs: Antenatal magnesium sulphate for fetal neuroprotection reduces the risk of "death or CP" (RR 0.85; 95% CI 0.74 to 0.98; 4 trials, 4446 infants), "death or moderatesevere CP" (RR 0.85; 95% CI 0.73 to 0.99; 3 trials, 4250 infants), "any CP" (RR 0.71; 95% CI 0.55 to 0.91; 4, trials, 4446 infants), "moderate-to-severe CP" (RR 0.60; 95% CI 0.43 to 0.84; 3 trials, 4250 infants), and "substantial gross motor dysfunction" (inability to walk without assistance) (RR 0.60; 95% CI 0.43 to 0.83; 3 trials, 4287 women) at 2 years of age. Results were consistent between trials and across the meta-analyses. There is no anticipated significant increase in health care-related costs, because women eligible to receive antenatal MgSO4 will be judged to have imminent preterm birth. Validation Australian National Clinical Practice Guidelines were published in March 2010 by the Antenatal Magnesium Sulphate for Neuroprotection Guideline Development Panel. Antenatal MgSO 4 was recommended for fetal neuroprotection in the same dosage as recommended in these guidelines. However, MgSO 4 was recommended only at 4 for fetal neuroprotection. It stated that, "the available evidence suggests that magnesium sulphate given before anticipated early preterm birth reduces the risk of cerebral palsy in surviving infants." No official opinion was given on a gestational age cut-off, but it was recommended that physicians develop specific guidelines around the issues of inclusion criteria, dosage, concurrent tocolysis, and monitoring in accordance with one of the larger trials. Sponsors Canadian Institutes of Health Research (CIHR).

Resume Objectif Accroitre la sensibilisation a la consommation problematique de substances psychoactives pendant la grossesse et les connaissances a ce sujet, et formuler des recommandations factuelles pour la prise en charge de ce difficile probleme clinique a l'intention de tous les fournisseurs de soins de sante Options La presente directive clinique analyse l'utilisation d'outils de depistage, l'approche generale envers les soins et les recommandations pour la prise en charge clinique de la consommation problematique de substances psychoactives pendant la grossesse Issues Recommandations factuelles pour le depistage et la prise en charge de la consommation problematique de substances psychoactives pendant la grossesse et la lactation Resultats Des recherches ont ete menees dans Medline, PubMed, CINAHL et The Cochrane Library en vue d'en tirer les articles publies depuis 1950 au moyen des mots cles suivants : « substance-related disorders », « mass screening », « pregnancy complications », « pregnancy », « prenatal care », « cocaine », « cannabis », « methadone », « opioid », « tobacco », « nicotine », « solvents », « hallucinogens » et « amphetamines ».Les resultats ont ete restreints aux analyses systematiques et aux essais comparatifs randomises / essais cliniques comparatifs.Des recherches subsequentes visant les etudes observationnelles ont egalement ete menees en raison de la rarete des ECR dans ce domaine d'etude.Les articles ont ete restreints aux etudes menees chez l'homme publiees en anglais.Des articles additionnels ont ete identifies manuellement par l'analyse des listes de references des articles selectionnes.Les recherches ont ete mises a jour de facon reguliere et leurs resultats ont ete incorpores a la directive clinique jusqu'en decembre 2009.La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats a ete evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs.Les recommandations visant la pratique ont ete classees conformement a la methode decrite dans ce rapport (Tableau 1). Avantages, desavantages et couts La presente directive clinique a pour but d'accroitre les connaissances et le degre d'aisance des fournisseurs de soins de sante aux femmes enceintes qui presentent des troubles lies a la consommation de substances psychoactives L'amelioration de l'acces aux soins de sante et a une aide pour l'obtention d'un traitement adequat de l'assuetude mene a une baisse des couts de sante et des taux maternels et neonatals de morbidite et de mortalite. Recommendations 1. Toutes les femmes enceintes et les femmes en âge de procreer devraient periodiquement faire l'objet d'un depistage de la consommation d'alcool, de tabac, de medicaments d'ordonnance et de drogues illicites. (III-A) 2. Lorsque le depistage de la consommation de substances psychoactives s'avere cliniquement indique, le depistage de drogue dans l'urine constitue la methode a privilegier. (II-2A) Le consentement eclaire de la patiente devrait etre obtenu avant que la tenue d'un depistage toxicologique maternel ne soit demandee. (III-B) 3. Les politiques et les obligations juridiques liees au depistage toxicologique chez les nouveau-nes peuvent varier d'un territoire de competence a l'autre, et les fournisseurs de soins devraient se familiariser avec les reglements en vigueur dans leur region. (III-A) 4. Les fournisseurs de soins de sante devraient utiliser une approche flexible envers les soins a offrir aux femmes qui connaissent des problemes de consommation de substances psychoactives. De plus, ils devraient favoriser l'utilisation de toutes les ressources communautaires disponibles. (II-2B) 5. Les femmes devraient se voir offrir des conseils au sujet des risques qu'occasionne la consommation de drogues pendant les periodes periconceptionnelle, antepartum et postpartum. (III-B) 6. Le counseling visant l'abandon du tabagisme devrait etre considere comme etant l'intervention de premiere intention pour ce qui est des femmes enceintes qui fument. (I-A) Le recours a la therapie de remplacement de la nicotine et/ou a la pharmacotherapie peut etre envisage lorsque le counseling echoue. (I-A) 7. Le traitement de substitution a la methadone devrait constituer la norme de diligence pour ce qui est des femmes qui presentent une dependance aux opioides pendant la grossesse. (II-IA) L'utilisation d'autres preparations opioides a liberation prolongee peut etre envisagee lorsque la methadone n'est pas disponible. (II-2B) 8. La desintoxication visant les opioides ne devrait etre mise en oeuvre qu'aupres de certaines femmes, et ce, en raison du risque eleve de rechute. (II-2B) 9. Les femmes qui presentent une dependance aux opiaces devraient etre avisees que les nouveau-nes exposes a l'heroine, aux opioides d'ordonnance, a la methadone ou a la buprenorphine pendant la grossesse font l'objet d'une etroite surveillance visant a deceler les symptomes du sevrage neonatal (syndrome d'abstinence neonatale). (II-2B) Les hopitaux offrant des soins obstetricaux devraient elaborer un protocole pour l'evaluation et la prise en charge des nouveau-nes exposes aux opiaces pendant la grossesse. (III-B) 10. La planification prenatale de l'analgesie intrapartum et postpartum peut etre offerte a toutes les femmes, en consultation avec les fournisseurs de soins appropries. (III-B) 11. Les risques et les avantages de l'allaitement devraient etre ponderes de facon personnalisee, puisque le traitement de substitution a la methadone ne constitue pas une contre-indication a l'allaitement. (II-3B)

Objective To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers Options This guideline reviews the use of screening tools, general approach to care, and recommendations for clinical management of problematic substance use in pregnancy. Outcomes Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation. Evidence Medline, PubMed, CINAHL, and The Cochrane Library were searched for articles published from 1950 using the following key words: substance-related disorders, mass screening, pregnancy complications, pregnancy, prenatal care, cocaine, cannabis, methadone, opioid, tobacco, nicotine, solvents, hallucinogens, and amphetamines. Results were initially restricted to systematic reviews and randomized control trials/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English Additional articles were located by hand searching through article reference lists. Searches were updated on a regular basis and incorporated in the guideline up to December 2009. Grey (unpublished) literature was also identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care Recommendations for practice were ranked according to the method described in that report (Table 1) Benefits, harms, and costs This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders Improved access to health care and assistance with appropriate addiction care leads to reduced health care costs and decreased maternal and neonatal morbidity and mortality. Recommendations 1. All pregnant women and women of childbearing age should be screened periodically for alcohol, tobacco, and prescription and illicit drug use. (III-A) 2. When testing for substance use is clinically indicated, urine drug screening is the preferred method. (II-2A) Informed consent should be obtained from the woman before maternal drug toxicology testing is ordered. (III-B) 3. Policies and legal requirements with respect to drug testing of newborns may vary by jurisdiction, and caregivers should be familiar with the regulations in their region. (III-A) 4. Health care providers should employ a flexible approach to the care of women who have substance use problems, and they should encourage the use of all available community resources. (II-2B) 5. Women should be counselled about the risks of periconception, antepartum, and postpartum drug use. (III-B) 6. Smoking cessation counselling should be considered as a first-line intervention for pregnant smokers. (I-A) Nicotine replacement therapy and/or pharmacotherapy can be considered if counselling is not successful. (I-A) 7. Methadone maintenance treatment should be standard of care for opioid-dependent women during pregnancy. (II-IA) Other slow-release opioid preparations may be considered if methadone is not available. (II-2B) 8. Opioid detoxification should be reserved for selected women because of the high risk of relapse to opioids. (II-2B) 9. Opiate-dependent women should be informed that neonates exposed to heroin, prescription opioids, methadone, or buprenorphine during pregnancy are monitored closely for symptoms and signs of neonatal withdrawal (neonatal abstinence syndrome). (II-2B) Hospitals providing obstetric care should develop a protocol for assessment and management of neonates exposed to opiates during pregnancy. (III-B) 10. Antenatal planning for intrapartum and postpartum analgesia may be offered for all women in consultation with appropriate health care providers. (III-B) 11. The risks and benefits of breastfeeding should be weighed on an individual basis because methadone maintenance therapy is not a contraindication to breastfeeding. (II-3B)

Background Urgent delivery of the fetus is often considered as the treatment of choice for mothers in their second or third trimester with hepatitis unique to pregnancy (HUP). Objective To determine whether standard liver function tests (serum bilirubin and international normalized ratio levels) help to identify mothers and their newborns who might benefit from early delivery. Methods A total of 149 patients with HUP were retrospectively classified as those with normal (stable-HUP, n=118) or abnormal (progressive-HUP, n=31) liver function tests. Clinical outcomes consisted of maternal lengths of hospital stay after delivery and neonatal appearance, pulse, grimace, activity, respiration score ratings at 0 and 5 min. Results Patients with stable-HUP had similar lengths of hospital stay after delivery whether delivered early (4.8±3.4 days) or at term (4.8±3.6 days). Appearance, pulse, grimace, activity, respiration score ratings at birth were similar in neonates from patients with stable-HUP delivered prematurely (5.8±2.7) and at term (7.8±1.7, P=0.48) but significantly higher at 5 min in those delivered at term (7.5±2.0 vs. 8.9±0.3, P=0.003). Too few patients with progressive-HUP were delivered at term (N=4) to allow similar comparisons in this cohort. Conclusion The results of this study indicate that mothers with HUP and normal liver function tests (bilirubin and international normalized ratio) can be safely followed to term without jeopardizing the health of either mother or neonates. Additional studies are required to determine whether abnormal liver function tests represent an indication for immediate delivery of the fetus in mothers with HUP.

Cervical insufficiency is a precursor of preterm birth. Treatment with emergency cervical cerclage is contraindicated in the presence of intra-amniotic infection. Detecting infection with Gram stain and culture of amniotic fluid lacks sensitivity. Proteomic profiling of amniotic fluid in cervical insufficiency may help identify pregnancies best suited for emergency cerclage.Thirty-two pregnant women underwent amniocentesis for routine genetic testing (n = 22) or after diagnosis of cervical insufficiency (n = 10). The proteomic profiles of the amniotic fluid samples were compared in a cross-sectional fashion, including sub-analyses of women with cervical insufficiency and latency periods of1 week and1 week post-diagnosis.Mean gestational age at diagnosis of cervical insufficiency was 21.4 weeks (95% CI 20.6-22.1). Proteomic analysis yielded 40 (7.2%, P 0.05) differentially expressed proteins between women with delivery1 week (n = 6) vs.1 week (n = 4). Women who delivered1 week had activated inflammatory response (z = 2.3, P = 6.71E-09), chemotaxis of immune cells (z = 2.9, P = 2.01E-08), and inhibited bacterial growth (z = -2.2, P = 5.82E-05). A multivariate model of eight biomarkers positively associated with cases of1 week latency and distinguished cases from controls (97.8%, cross-validation accuracy 92.7%, P = 0.0009).In this pilot study, significant differences in the amniotic fluid proteomic profiles in cases of cervical insufficiency compared to genetic amniocentesis were observed. Proteomic signatures were predictive of achieving latency1 week after diagnosis of cervical insufficiency. These preliminary findings suggest that proteomic analysis may be of value in predicting outcome following cervical insufficiency and warrants further validation in larger studies.

Objective To review the evidence and provide recommendations for the counselling and management of obese parturients. Outcomes Outcomes evaluated include the impact of maternal obesity on the provision of antenatal and intrapartum care, maternal morbidity and mortality, and perinatal morbidity and mortality. Evidence Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetrical anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to April 2009. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The evidence obtained was reviewed and evaluated by the Maternal Fetal Medicine and Clinical Practice Obstetric Committees of the SOGC under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. Benefits, Harms, and Costs Implementation of the recommendations in this guideline should increase recognition of the issues clinicians need to be aware of when managing obese women in pregnancy, improve communication and consultation amongst the obstetrical care team, and encourage federal and provincial agencies to educate Canadians about the values of entering pregnancy with as healthy a weight as possible.

Resume Objectifs Analyser les principes du diagnostic prenatal de l'infection congenitale a cytomegalovirus (CMV) et decrire les issues des grossesses affectees. Issues Prise en charge efficace de l'infection fœtale a la suite d'une infection a CMV maternelle primaire et secondaire pendant la grossesse. Parmi les symptomes neonataux, on trouve le retard de croissance intra-uterin (RCIU), la microcephalie, l'hepatosplenomegalie, les petechies, l'ictere, la chorioretinite, la thrombocytopenie et l'anemie; parmi les sequelles a long terme, on trouve la surdite de perception, la deficience mentale, le retard du developpement psychomoteur et la deficience visuelle. La presente directive clinique offre un cadre pour le diagnostic et la prise en charge des infections a CMV soupconnees. Resultats Des recherches ont ete menees dans Medline en vue d'en tirer les articles publies en anglais, entre 1966 et 2009, au moyen d'un vocabulaire controle (infection congenitale a CMV) et de mots cles (retard de croissance intra-uterin, microcephalie) appropries. Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Les recherches ont ete regulierement mises a jour et leurs resultats ont ete incorpores a la directive clinique. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Recommandations La qualite des resultats signales dans le present document a ete evaluee au moyen des criteres d'evaluation des resultats decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). 1.Le diagnostic de l'infection a cytomegalovirus (CMV) maternelle primaire pendant la grossesse devrait etre fonde sur l'apparition de novo d'IgG propre au virus dans le serum d'une femme enceinte qui etait auparavant seronegative ou sur la detection d'anticorps IgM specifiques associes a de l'IgG de faible avidite. (II-2A) 2.En presence d'une infection maternelle primaire, les parents devraient etre avises du risque (de 30 % a 40 %) de transmission intra-uterine et d'infection fœtale, et du risque (de 20 % a 25 %) de voir apparaitre des sequelles postnatales lorsque le fœtus est infecte. (II-2A) 3.Le diagnostic prenatal de l'infection a CMV fœtale devrait etre fonde sur l'amniocentese, laquelle devrait etre menee au moins sept semaines a la suite du moment presume de l'infection maternelle et apres la 21 e semaine de gestation. Cet intervalle est important puisqu'il faut de cinq a sept semaines a la suite de l'infection fœtale et de la replication subsequente du virus dans le rein pour qu'une quantite detectable de virus soit secretee dans le liquide amniotique. (II-2A) 4.Le diagnostic de l'infection secondaire devrait etre fonde sur une hausse considerable du titre des anticorps IgM avec ou sans la presence d'anticorps IgM specifiques et en presence d'IgG de forte avidite. Dans les cas etablis d'infection secondaire, le recours a l'amniocentese peut etre envisage, mais le rapport risque–avantage est different en raison du faible taux de transmission. (III-C) 5.A la suite d'un diagnostic d'infection a CMV fœtale, des examens echographiques en serie devraient etre menes toutes les deux a quatre semaines afin de demeurer a l'affut des anomalies echographiques qui pourraient contribuer a la determination du pronostic fœtal; cependant, il est important d'etre conscient que l'absence de constatations echographiques ne garantit pas l'obtention d'une issue normale. (II-2B) 6.La determination quantitative de l'ADN de CMV dans le liquide amniotique peut contribuer a la prediction de l'issue fœtale. (II-3B) 7.Le depistage serologique systematique du CMV chez les femmes enceintes n'est actuellement pas recommande. (III-B) 8.Le depistage serologique du CMV peut etre envisage chez les femmes qui en viennent a presenter des symptomes grippaux pendant la grossesse ou a la suite de la detection de signes echographiques semblant indiquer une infection a CMV. (III-B) 9.Les femmes seronegatives œuvrant dans le domaine de la sante et des soins aux enfants peuvent se voir offrir un suivi serologique pendant la grossesse. Un suivi peut egalement etre envisage dans le cas des femmes enceintes seronegatives qui comptent un enfant en bas âge frequentant une garderie. (III-B)

Resume Objectif Analyser les donnees et formuler des recommandations en ce qui concerne le counseling et la prise en charge des parturientes obeses. Issues Parmi les issues evaluees, on trouve les effets de l’obesite maternelle sur l’offre de soins prenatals et intrapartum, ainsi que sur la morbidite et la mortalite maternelles et perinatales. Resultats Des recherches ont ete menees aupres de Statistique Canada, de Medline et de The Cochrane Library en vue d’en tirer la litterature portant sur les effets de l’obesite pendant la grossesse sur les soins prenatals et intrapartum, la morbidite et la mortalite maternelles, l’anesthesie obstetricale, et la morbidite et la mortalite perinatales. Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Aucune restriction en fonction de la date ou de la langue n’a ete mise en œuvre. Les recherches ont ete regulierement mises a jour et leurs resultats ont ete incorpores a la directive clinique jusqu’en avril 2009. La litterature grise (non publiee) a ete identifiee par l’intermediaire de recherches menees dans les sites Web d’organismes s’interessant a l’evaluation des technologies dans le domaine de la sante et d’organismes connexes, dans des collections de directives cliniques, dans des registres d’essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs Les resultats cumules ont ete analyses et evalues par le comite de medecine fœto-maternelle et le comite de pratique clinique-obstetrique de la SOGC, sous la gouverne des auteurs principaux, et les recommandations ont ete formulees conformement aux lignes directrices elaborees par le Groupe d’etude canadien sur les soins de sante preventifs. Avantages, desavantages et couts :La mise en œuvre des recommandations formulees dans la presente directive clinique devraient sensibiliser davantage les cliniciens aux aspects qui doivent etre pris en consideration dans le cadre de la prise en charge des femmes obeses pendant la grossesse, ameliorer la communication et la consultation au sein de l’equipe de soins obstetricaux, et inciter les organismes federaux et provinciaux a sensibiliser les Canadiennes aux bienfaits du maintien d’un poids aussi sante que possible avant la grossesse. Recommandations 1. Les examens de sante periodiques et les autres consultations de nature gynecologique se deroulant avant la grossesse constituent des occasions ideales d’aborder le sujet de la perte de poids avant la conception. Les femmes devraient etre incitees a presenter, avant la grossesse, un IMC 2 et, idealement, 2 . (III-B) 2. L’IMC devrait etre calcule en fonction de la taille et du poids pregrossesses. Les femmes qui presentent un IMC pregrossesse > 30 kg/m 2 sont considerees comme etant obeses. Ce renseignement peut s’averer utile dans le cadre du counseling visant les risques pour la grossesse qui sont associes a l’obesite. (II-2B) 3. Les femmes enceintes obeses devraient se voir offrir des services de counseling au sujet du gain ponderal, de la nutrition et des choix alimentaires. (II-2B) 4. Les femmes obeses devraient etre avisees qu’elles sont exposees a des risques de complications medicales telles que les maladies cardiaques, les maladies pulmonaires, l’hypertension gestationnelle, le diabete gestationnel et l’apnee obstructive du sommeil. La pratique reguliere d’exercices pendant la grossesse peut contribuer a attenuer certains de ces risques. (II-2B) 5. Les femmes obeses devraient etre avisees que leur fœtus est expose a un risque accru d’anomalies congenitales; un depistage approprie devrait etre mis en œuvre. (II-2B) 6. Les fournisseurs de soins obstetricaux devraient tenir compte de l’IMC au moment de prendre des dispositions en vue de la tenue d’une evaluation anatomique fœtale au cours du deuxieme trimestre. Une evaluation anatomique menee a 20–22 semaines pourrait s’averer mieux indiquee pour ce qui est des patientes enceintes obeses. (II-2B) 7. Les femmes enceintes obeses courent un risque accru de subir une cesarienne; de plus, leur taux de reussite en ce qui concerne l’accouchement vaginal a la suite d’une cesarienne connait une baisse. (II-2B) 8. Le tenue d’une consultation prenatale aupres d’un anesthesiste devrait etre envisagee, afin de passer en revue les options en matiere d’analgesie et de s’assurer de la mise en place d’un plan de prise en charge lorsque l’option de l’anesthesie regionale est retenue. (III-B) 9. Le risque de thromboembolie veineuse de chaque femme obese devrait etre evalue. Dans certaines situations cliniques, le fait d’envisager une thromboprophylaxie devrait etre personnalise. (III-B)

Objectives To describe the etiology of vasa previa and the risk factors and associated condition, to identify the various clinical presentations of vasa previa, to describe the ultrasound tools used in its diagnosis, and to describe the management of vasa previa. Outcomes Reduction of perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short-term and long-term maternal morbidity and mortality. Evidence Published literature on randomized trials prospective cohort studies, and selected retrospective cohort studies was retrieved through searches of PubMed or Medline, CINAHL, and the Cochrane Library, using appropriate controlled vocabulary (e.g., selected epidemiological studies comparing delivery by Caesarean section with vaginal delivery studies comparing outcomes when vasa previa is diagnosed antenatally vs. intrapartum) and key words (e.g. vasa previa). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated into the guideline to October 1, 2008. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and from national and international medical specialty societies. Values The evidence collected was reviewed by the Diagnostic Imaging Committee and the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on Preventive Health Care. Benefits, Harms, and Costs The benefit expected from this guideline is facilitation of optimal and uniform care for pregnancies complicated by vasa previa. Sponsors The Society of Obstetricians and Gynaecologists of Canada.

Objective To review the evidence and provide recommendations on the use of antibiotics in preterm premature rupture of the membranes (PPROM). Outcomes Outcomes evaluated include the effect of antibiotic treatment on maternal infection, chorioamnionitis, and neonatal morbidity and mortality. Evidence Published literature was retrieved through searches of Medline, EMBASE, CINAHL, and The Cochrane Library, using appropriate controlled vocabulary and key words (PPROM, infection, and antibiotics). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and new material incorporated in the guideline to July 2008. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. Benefits, Harms, and Costs Guideline implementation should assist the practitioner in developing an approach to the use of antibiotics in women with PPROM. Patients will benefit from appropriate management of this condition. Validation This guideline has been reviewed and approved by the Infectious Diseases Committee and the Maternal Fetal Medicine Committee of the SOGC, and approved by the Executive and Council of the SOGC. Sponsor The Society of Obstetricians and Gynaecologists of Canada. Recommendations 1.Following PPROM at 32 weeks' gestation, antibiotics should be administered to women who are not in labour in order to prolong pregnancy and to decrease maternal and neonatal morbidity (I-A). 2.The use of antibiotics should be gestational-age dependent. The evidence for benefit is greater at earlier gestational ages ( 3.For women with PPROM at >32 weeks' gestation, administration of antibiotics to prolong pregnancy is recommended if fetal lung maturity cannot be proven and/or delivery is not planned (I-A). 4.Antibiotic regimens may consist of an initial parenteral phase followed by an oral phase, or may consist of only an oral phase (I-A). 5.Antibiotics of choice are penicillins or macrolide antibiotics (erythromycin) in parenteral and/or oral forms. (I-A) In patients allergic to penicillin, macrolide antibiotics should be used alone (III-B). 6.The following two regimens may be used (the two regimens were used in the largest PPROM randomized controlled trials that showed a decrease in both maternal and neonatal morbidity): (1) ampicillin2g IV every 6 hours and erythromycin 250 mg IV every 6 hours for 48 hours followed by amoxicillin 250 mg orally every 8 hours and erythromycin 333 mg orally every 8 hours for 5 days (I-A); (2) erythromycin 250 mg orally every 6 hours for 10 days (I-A). 7.Amoxicillin/clavulanic acid should not be used because of an increased risk of necrotizing enterocolitis in neonates exposed to this antibiotic. Amoxicillin without clavulanic acid is safe (I-A). 8.Women presenting with PPROM should be screened for urinary tract infections, sexually transmitted infections, and group B streptococcus carriage, and treated with appropriate antibiotics if positive (II-2B).

Resume Objectif Analyser les resultats et formuler des recommandations quant a l'utilisation d'antibiotiques en presence d'une rupture prematuree des membranes preterme (RPMP). Issues Parmi les issues evaluees, on trouvait l'effet de l'antibiotherapie sur l'infection maternelle, la chorioamnionite et la morbidite et la mortalite neonatales. Resultats La litterature publiee a ete identifiee par l'intermediaire de recherches menees dans PubMed ou Medline, CINAHL et la Cochrane Library, au moyen d'un vocabulaire controle approprie et de mots cles ( PPROM , infection et antibiotics ). Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Aucune restriction quant a la date ou a la langue n'a ete mise en œuvre. Les recherches ont ete regulierement mises a jour et les donnees publiees jusqu'en juillet 2008 ont ete integrees a la directive clinique. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs Les resultats obtenus ont ete evalues par le comite sur les maladies infectieuses de la Societe des obstetriciens et gynecologues du Canada (SOGC), sous la direction des auteurs principaux; les recommandations ont ete formulees en fonction des lignes directrices elaborees par le Groupe d'etude canadien sur les soins de sante preventifs. Avantages, desavantages et couts La mise en œuvre de la presente directive clinique devrait aider les praticiens a elaborer une approche quant au recours a l'antibiotherapie chez les femmes qui presentent une RPMP. Les patientes tireront avantage d'une prise en charge adequate de cette pathologie. Validation La presente directive clinique a ete analysee et approuvee par le comite sur les maladies infectieuses et le comite de medecine fœto-maternelle, et approuvee par le comite executif et le Conseil de la Societe des obstetriciens et gynecologues du Canada. Commanditaire La Societe des obstetriciens et gynecologues du Canada. Recommendations 1.A la suite d'une RPMP a ≤ 32 semaines de gestation, des antibiotiques devraient etre administres aux femmes qui ne sont pas en travail afin de prolonger la grossesse et d'attenuer la morbidite maternelle et neonatale. (I-A) 2.Le recours aux antibiotiques devrait etre fonction de l'âge gestationnel. Les resultats en soutenant les avantages sont plus concluants en ce qui concerne les âges gestationnels moins avances ( 3.En ce qui concerne les femmes qui connaissent une RPMP a > 32 semaines de gestation, l'administration d'antibiotiques visant la prolongation de la grossesse est recommandee lorsque la maturite pulmonaire fœtale ne peut etre prouvee et/ou lorsque l'accouchement n'est pas planifie. (I-A) 4.Les schemas posologiques d'antibiotiques peuvent comprendre une phase parenterale initiale suivie d'une phase orale ou n'etre constitues que d'une phase orale. (I-A) 5.Les antibiotiques a privilegier sont les penicillines ou les antibiotiques macrolides (erythromycine) sous forme parenterale et/ou orale. (I-A) Chez les patientes allergiques a la penicilline, les antibiotiques macrolides devraient etre utilises seuls. (III-B) 6.Les deux schemas posologiques suivants peuvent etre utilises (ils ont tous deux ete utilises par les plus importants essais comparatifs randomises s'etant penches sur la RPMP qui ont indique une baisse de la morbidite maternelle et neonatale) : (1) ampicilline, a raison de 2 g IV toutes les 6 heures, et erythromycine, a raison de 250 mg IV toutes les 6 heures, pendant 48 heures, le tout etant suivi d'amoxicilline, a raison de 250 mg par voie orale toutes les 8 heures, et d'erythromycine, a raison de 333 mg par voie orale toutes les 8 heures, pendant 5 jours (I-A); (2) erythromycine, a raison de 250 mg par voie orale toutes les 6 heures, pendant 10 jours (I-A) 7.L'amoxicilline/acide clavulanique ne devrait pas etre utilisee en raison du risque accru d'enterocolite necrosante que courent les nouveau-nes exposes a cet antibiotique. L'amoxicilline utilisee sans acide clavulanique est sure. (I-A) 8.Les femmes qui connaissent une RPMP devraient faire l'objet d'un depistage visant les infections des voies urinaires, les infections transmissibles sexuellement et le statut de porteuse de streptocoques du groupe B, et elles devraient etre traitees au moyen d'antibiotiques appropries lorsque ce depistage donne des resultats positifs. (II-2B)

Objectives: To review the physiology of breech birth; to discern the risks and benefits of a trial of labour versus planned Caesarean section; and to recommend to obstetricians, family physicians, midwives, obstetrical nurses, anaesthesiologists, pediatricians, and other health care providers selection criteria, intrapartum management parameters, and delivery techniques for a trial of vaginal breech birth.

Objective It is contended that routine induction of labour at 41 completed weeks of gestation reduces, or at least does not increase, a woman's chance of Caesarean section (CS), compared with expectant management. We wanted to know if this was true in our own hospital. Methods We performed a retrospective review of 1367 nulliparous women who had reached 41+0 weeks undelivered with a live, singleton, fetus with a cephalic presentation. The women comprised two non-randomized contemporaneous cohorts: in one group, expectant management was planned, and in the second group the intention was to induce labour at 41 weeks. The primary outcome measure was the rate of CS in each group. Results Of 645 women in whom expectant management was planned, 17.7% delivered by CS. Of 722 women in whom induction of labour was planned, 21.3% delivered by CS ( P = 0.09). Of the total of 907 women in whom expectant management was planned or who laboured spontaneously before planned induction could be carried out, 16.6% delivered by CS. Of 460 women in whom induction was planned and actually carried out, 25.4% delivered by CS ( P = 0.001). Conclusion The contention that routine induction of labour at 41 weeks reduces a woman's chance of delivery by Caesarean section was not supported by the findings of our study. Inducing labour may actually increase the nulliparous woman's risk of delivery by CS.

Objective This document summarizes the limited experience of SARS in pregnancy and suggests guidelines for management. Outcomes Cases reported from Asia suggest that maternal and fetal outcomes are worsened by SARS during pregnancy. Evidence Medline was searched for relevant articles published in English from 2000 to 2007. Case reports were reviewed and expert opinion sought. Values Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care.

Objectives To review the physiology of breech birth; to discern the risks and benefits of a trial of labour versus planned Caesarean section; and to recommend to obstetricians, family physicians, midwives, obstetrical nurses, anaesthesiologists, pediatricians, and other health care providers selection criteria, intrapartum management parameters, and delivery techniques for a trial of vaginal breech birth. Options Trial of labour in an appropriate setting or delivery by pre-emptive Caesarean section for women with a singleton breech fetus at term. Outcomes Reduced perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short- and long-term maternal morbidity and mortality. Evidence Medline was searched for randomized trials, prospective cohort studies, and selected retrospective cohort studies comparing planned Caesarean section with a planned trial of labour; selected epidemiological studies comparing delivery by Caesarean section with vaginal breech delivery; and studies comparing long-term outcomes in breech infants born vaginally or by Caesarean section. Additional articles were identified through bibliography tracing up to June 1, 2008. Values The evidence collected was reviewed by the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the criteria and classifications of the Canadian Task Force on Preventive Health Care. Validation This guideline was compared with the 2006 American College of Obstetrician's Committee Opinion on the mode of term singleton breech delivery and with the 2006 Royal College of Obstetrician and Gynaecologists Green Top Guideline: The Management of Breech Presentation. The document was reviewed by Canadian and International clinicians with particular expertise in breech vaginal delivery. Sponsors The Society of Obstetricians and Gynaecologists of Canada. Summary Statements 1.Vaginal breech birth can be associated with a higher risk of perinatal mortality and short-term neonatal morbidity than elective Caesarean section. (I) 2.Careful case selection and labour management in a modern obstetrical setting may achieve a level of safety similar to elective Caesarean section. (II-1) 3.Planned vaginal delivery is reasonable in selected women with a term singleton breech fetus. (I) 4.With careful case selection and labour management, perinatal mortality occurs in approximately 2 per 1000 births and serious short-term neonatal morbidity in approximately 2% of breech infants. Many recent retrospective and prospective reports of vaginal breech delivery that follow specific protocols have noted excellent neonatal outcomes. (II-1) 5.Long-term neurological infant outcomes do not differ by planned mode of delivery even in the presence of serious short-term neonatal morbidity. (I) Recommendations Labour Selection Criteria 1.For a woman with suspected breech presentation, pre- or early labour ultrasound should be performed to assess type of breech presentation, fetal growth and estimated weight, and attitude of fetal head. If ultrasound is not available, Caesarean section is recommended. (II-1A) 2.Contraindications to labour include a.Cord presentation (II-3A) b.Fetal growth restriction or macrosomia (I-A) c.Any presentation other than a frank or complete breech with a flexed or neutral head attitude (III-B) d.d. Clinically inadequate maternal pelvis (III-B) e.Fetal anomaly incompatible with vaginal delivery (III-B) 3.Vaginal breech delivery can be offered when the estimated fetal weight is between 2500g and 4000g. (II-2B) Labour Management 4.Clinical pelvic examination should be performed to rule out pathological pelvic contraction. Radiologic pelvimetry is not necessary for a safe trial of labour; good progress in labour is the best indicator of adequate fetal-pelvic proportions. (III-B) 5.Continuous electronic fetal heart monitoring is preferable in the first stage and mandatory in the second stage of labour. (I-A) When membranes rupture, immediate vaginal examination is recommended to rule out prolapsed cord. (III-B) 6.In the absence of adequate progress in labour, Caesarean section is advised. (II-1A) 7.Induction of labour is not recommended for breech presentation. (II-3B) Oxytocin augmentation is acceptable in the presence of uterine dystocia. (II-1A) 8.A passive second stage without active pushing may last up to 90 minutes, allowing the breech to descend well into the pelvis. Once active pushing commences, if delivery is not imminent after 60 minutes, Caesarean section is recommended. (I-A) 9.The active second stage of labour should take place in or near an operating room with equipment and personnel available to perform a timely Caesarean section if necessary. (III-A) 10.A health care professional skilled in neonatal resuscitation should be in attendance at the time of delivery. (III-A) Delivery Technique 11.The health care provider for a planned vaginal breech delivery needs to possess the requisite skills and experience. (II-1A) 12.An experienced obstetrician-gynaecologist comfortable in the performance of vaginal breech delivery should be present at the delivery to supervise other health care providers, including a trainee. (I-A) 13.The requirements for emergency Caesarean section, including availability of the hospital operating room team and the approximate 30-minute timeline to commence a laparotomy, must be in accordance with the recommendations of the SOGC Policy Statement, "Attendance at Labour and Delivery" (CPG No. 89; update in press, 2009). (III-A) 14.The health care provider should have rehearsed a plan of action and should be prepared to act promptly in the rare circumstance of a trapped after-coming head or irreducible nuchal arms: symphysiotomy or emergency abdominal rescue can be life saving. (III-B) 15.Total breech extraction is inappropriate for term singleton breech delivery. (II-2A) 16.Effective maternal pushing efforts are essential to safe delivery and should be encouraged. (II-1A) 17.At the time of delivery of the after-coming head, an assistant should be present to apply suprapubic pressure to favour flexion and engagement of the fetal head. (II-3B) 18.Spontaneous or assisted breech delivery is acceptable. Fetal traction should be avoided, and fetal manipulation must be applied only after spontaneous delivery to the level of the umbilicus. (III-A) 19.Nuchal arms may be reduced by the Lovset or Bickenbach manoeuvres. (III-B) 20.The fetal head may deliver spontaneously, with the assistance of suprapubic pressure, by Mauriceau-Smellie-Veit manoeuvre, or with the assistance of Piper forceps. (III-B) Setting and Consent 21.In the absence of a contraindication to vaginal delivery, a woman with a breech presentation should be informed of the risks and benefits of a trial of labour and elective Caesarean section, and informed consent should be obtained. A woman's choice of delivery mode should be respected. (III-A) 22.The consent discussion and chosen plan should be well documented and communicated to labour-room staff. (III-B) 23.Hospitals offering a trial of labour should have a written protocol for eligibility and intrapartum management. (III-B) 24.Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should not be abandoned. They should be provided the best possible in-hospital care. (III-A) 25.The Society of Obstetricians and Gynaecologists of Canada (SOGC), in collaboration with the Association of Professors of Obstetrics and Gynaecology (APOG), The College of Family Physicians of Canada (CFPC), and The Canadian Association of Midwives (CAM) should revise the training requirements at the undergraduate and postgraduate levels. SOGC will continue to promote training of current health care providers through the MOREOB, ALARM (Advances in Labour and Risk Management), and other courses. (III-A) 26.Theoretical and hands-on breech birth training simulation should be part of basic obstetrical skills training programs such as ALARM, ALSO (Advanced Life Support Training in Obstetrics), and MOREOB to prepare health care providers for unexpected vaginal breech births. (III-B)

Objective To determine the contribution of perinatal events to cerebral palsy in children born at full term. Methods The delivery records of a cohort of babies born at full term in one tertiary care hospital over an 11-year period were reviewed. The obstetric history and neonatal chart of each baby admitted to the Neonatal Intensive Care Unit was then examined. For those babies whose stay in the NICU was because of encephalopathy, brain injury, asphyxia with organ dysfunction, serious infection, or prolonged respiratory support, a review of their medical records was undertaken to determine how many subsequently developed cerebral palsy. Results Of 36 368 babies born at term, 20 were later diagnosed as having cerebral palsy in which the causative insult likely occurred just before, during, or shortly after labour and delivery. This is an incidence of cerebral palsy arising from perinatal events of 0.55 per 1000 deliveries. Only six cases, however, were deemed to have been possibly preventable by better obstetric care. Conclusion In our hospital, perinatal events are an important cause of cerebral palsy in children born at full term, but few cases are potentially preventable.

To examine perinatal outcomes among nulliparous women with a second stage of labour lasting more than three hours.We conducted a retrospective review of all nulliparous women over a 14-year period who had a term, live, singleton, cephalic fetus ≥ 2500 g and who had a second stage of labour lasting at least three hours. Outcome measures included five-minute Apgar score7, cord arterial pH7.10, admission to the NICU, neonatal seizures, and neonatal death. Rates of serious long-term neurologic morbidity were also analyzed. Outcomes were compared with those of a similar cohort of women who delivered after less than three hours in the second stage.During the study period, 1515 women met the inclusion criteria. The majority of women (67%) delivered vaginally, after up to 10 hours in the second stage of labour. The overall rate of Caesarean section was low (15.7%). The rate of permanent neurologic impairment was 2.6 per 1000 deliveries.Among nulliparous women, 84% were spared a possibly difficult Caesarean section in the second stage of labour or a potentially difficult operative vaginal delivery by allowing a longer second stage. However, surviving neonates had a higher risk of permanent neurologic handicap. Our study indicates that the optimal management of the second stage of labour remains controversial.

Vaginal colonization and symptomatic vaginitis involving Candida albicans is common during pregnancy (1,2); however, infection of the amniotic fluid in the presence of intact membranes is encountered rarely in obstetrical practice and mostly recognized retrospectively (3). C albicans is able to cross intact fetal membranes (4) and several case reports describe the isolation of the organism from amniotic fluid in amniocentesis specimens obtained before placement of emergency cervical cerclage (2,5). We present three cases in which C albicans was not isolated on culture from the precerclage amniotic fluid, but was isolated from the postcerclage amniotic fluid. The present cases were identified during a retrospective review of all cases of emergency cerclage at our institution and approval was granted through the Research Ethics Board at the University of Manitoba (Winnipeg, Manitoba).