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Objective: To review current knowledge about emergency contraception (EC), including available options, their modes of action, efficacy, safety, and the effective provision of EC within a practice setting.Options: The combined estradiol-levonorgestrel (Yuzpe regimen) and the levonorgestrel-only regimen, as well as post-coital use of copper intrauterine devices, are reviewed.Outcomes: Efficacy in terms of reduction in risk of pregnancy, safety, and side effects of methods for EC and the effect of the means of access to EC on its appropriate use and the use of consistent contraception.Evidence: Studies published in English between January 1998 and March 2010 were retrieved though searches of Medline and the Cochrane Database, using appropriate key words (emergency contraception, post-coital contraception, emergency contraceptive pills, post-coital copper IUD). Clinical guidelines and position papers developed by health or family planning organizations were also reviewed.Values: The studies reviewed were classified according to criteria described by the Canadian Task Force on Preventive Health Care, and the recommendations for practice were ranked according to this classification (Table 1).Benefits, Harms, and Costs: These guidelines are intended to help reduce unintended pregnancies by increasing awareness and appropriate use of EC.Sponsor: The Society of Obstetricians and Gynecologists of Canada. [ABSTRACT FROM AUTHOR]

Objective: To improve awareness of the natural age-related decline in female and male fertility with respect to natural fertility and assisted reproductive technologies (ART) and provide recommendations for their management,and to review investigations in the assessment of ovarian aging.Options: This guideline reviews options for the assessment of ovarian reserve and fertility treatments using ART with women of advanced reproductive age presenting with infertility.Outcomes: The outcomes measured are the predictive value of ovarian reserve testing and pregnancy rates with natural and assisted fertility.Evidence: Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in June 2010, using appropriate key words (ovarian aging, ovarian reserve, advanced maternal age, advanced paternal age, ART). 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 into the guideline to December 2010.Values: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table).Benefits, Harms, and Costs: Primary and specialist health care providers and women will be better informed about ovarian aging and the age-related decline in natural fertility and about options for assisted reproductive technology. [ABSTRACT FROM AUTHOR]

Objectives: To decrease the likelihood that the practice of female genital cutting (FGC) be continued in the future and to improve the care of girls and women who have been subjected to FGC or who are at risk by providing (1) information intended to strengthen knowledge and understanding of the practice, (2) information regarding the legal issues related to the practice, (3) guidance for the management of its obstetrical and gynaecological complications, and (4) guidance on the provision of culturally competent care to girls and women affected by FGC., Options: Strategies for the primary, secondary, and tertiary prevention of FGC and its complications., Outcomes: The short- and long-term consequences of FGC., Intended Users: Health care providers delivering obstetrical and gynaecological care., Target Population: Women from countries where FGC is commonly practised and Canadian girls and women from groups who may practise FGC for cultural or religious reasons., Evidence: Published literature was retrieved through searches of PubMed, CINAHL, and the Cochrane Library in September 2010 using appropriate controlled vocabulary (e.g., Circumcision, Female) and key words (e.g., female genital mutilation, clitoridectomy, infibulation). Searches were updated and incorporated in the guideline revision December 2018., Validation Methods: 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., Benefits, Harms, and Costs: There are no anticipated harms or costs to health care facilities with implementation of this guideline. Benefits may include a greater willingness of women living with FGC to seek timely care., Summary Statements: RECOMMENDATIONS., (Copyright © 2019. Published by Elsevier Inc.)

Objectifs: La présente directive clinique vise à diminuer la probabilité que la pratique de l'excision génitale féminine (EGF) se poursuive et à améliorer les soins prodigués aux filles et aux femmes qui ont subi une EGF ou qui risquent d'en subir une en fournissant (1) des renseignements destinés à améliorer les connaissances et la compréhension de la pratique, (2) des renseignements sur les enjeux juridiques liés à cette pratique, (3) des directives relatives au traitement des complications obstétricales et gynécologiques connexes et (4) des directives sur la compétence culturelle dans la prestation de soins aux filles et femmes touchées par l'EGF., Options: Des stratégies de prévention primaire, secondaire et tertiaire de l'EGF et de ses complications. RéSULTATS: Les conséquences à court et à long terme de l'EGF., Utilisateurs Cibles: Les fournisseurs de soins de santé qui fournissent des soins obstétricaux et gynécologiques., Population Cible: Les femmes originaires de pays où l'EGF est couramment pratiquée ainsi que les filles et femmes canadiennes issues de groupes où l'EGF est parfois pratiquée pour des motifs culturels ou religieux. DONNéES PROBANTES: Des recherches ont été effectuées en septembre 2010 dans le moteur PubMed et les bases de données CINAHL et Cochrane Library au moyen d'une terminologie contrôlée appropriée (p. ex. Circumcision, Female) et de mots-clés en anglais (p. ex. female genital mutilation, clitoridectomy, infibulation) afin de rassembler la littérature publiée sur le sujet. Les recherches ont été mises à jour et intégrées à la révision de la directive clinique en décembre 2018. MéTHODES DE VALIDATION: La qualité des données probantes contenues dans le présent document a été évaluée en fonction des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs. AVANTAGES, PRéJUDICES, ET COûTS: Aucun coût ni préjudice n'est anticipé pour la mise en œuvre de cette directive clinique dans les établissements de santé. Au nombre des avantages, la directive pourrait inciter les femmes ayant subi une EGF à solliciter rapidement des soins. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS., (Copyright © 2019. Published by Elsevier Inc.)

Objectif: Analyser les aspects cliniques de l'hémorragie postpartum (HPP) et fournir des lignes directrices visant à guider les cliniciens pour ce qui est de la prévention et de la prise en charge de l'HPP. La présente directive clinique est une mise à jour de la directive clinique précédente de la Société des obstétriciens et gynécologues du Canada (SOGC) sur l'HPP, publiée en avril 2000. RéSULTATS: Des recherches ont été menées dans Medline, PubMed, la Cochrane Database of Systematic Reviews, le ACP Journal Club et le BMJ Clinical Evidence afin d'en tirer les articles pertinents, en portant une attention particulière aux essais comparatifs randomisés (ECR), aux analyses systématiques et aux directives cliniques publiées entre 1995 et 2007. Chaque article a été analysé en vue d'en assurer la pertinence et nous avons fait l'acquisition du texte intégral, lorsque cela s'avérait pertinent. Chacun des articles intégraux a fait l'objet d'une évaluation critique en fonction de l'échelle Jadad et des définitions de qualité des résultats émises par le Groupe d'étude canadien sur les soins de santé préventifs., Valeurs: La qualité des résultats a été établie en fonction des critères décrits par le Groupe d'étude canadien sur les soins de santé préventifs., Commanditaire: La Société des obstétriciens et gynécologues du Canada., Recommandations: Prévention de l'hémorragie postpartum., (Copyright © 2018. Published by Elsevier Inc.)

Objective: To review the clinical aspects of postpartum hemorrhage (PPH) and provide guidelines to assist clinicians in the prevention and management of PPH. These guidelines are an update from the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical practice guideline on PPH, published in April 2000., Evidence: Medline, PubMed, the Cochrane Database of Systematic Reviews, ACP Journal Club, and BMJ Clinical Evidence were searched for relevant articles, with concentration on randomized controlled trials (RCTs), systematic reviews, and clinical practice guidelines published between 1995 and 2007. Each article was screened for relevance and the full text acquired if determined to be relevant. Each full-text article was critically appraised with use of the Jadad Scale and the levels of evidence definitions of the Canadian Task Force on Preventive Health Care., Values: The quality of evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care., Sponsor: The Society of Obstetricians and Gynaecologists of Canada., Recommendations: Prevention of Postpartum HemorrhageTreatment of PPHRecommendations were quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1)., (Copyright © 2018. Published by Elsevier Inc.)

Objective: To establish national guidelines for the assessment of women's sexual health concerns and the provision of sexual health care for women., Evidence: Published literature was retrieved through searches of PubMed, CINAHL, and the Cochrane Library from May to October 2010, using appropriate controlled vocabulary (e.g., sexuality, "sexual dysfunction," "physiological," dyspareunia) and key words (e.g., sexual dysfunction, sex therapy, anorgasmia). Results were restricted, where possible, to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 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. Each article was screened for relevance and the full text acquired if determined to be relevant. The evidence obtained was reviewed and evaluated by the members of the Expert Workgroup established by The Society of Obstetricians and Gynaecologists of Canada., Values: The quality of evidence was evaluated and recommendations made using the use of criteria described by the Canadian Task Force on Preventive Health Care (Table)., (Copyright © 2018. Published by Elsevier Inc.)

Objective: To establish national guidelines for the assessment of women's sexual health concerns and the provision of sexual health care for women., Evidence: Published literature was retrieved through searches of PubMed, CINAHL, and the Cochrane Library from May to October 2010, using appropriate controlled vocabulary (e .g., sexuality, "sexual dysfunction," "physiological," dyspareunia) and key words (e .g ., sexual dysfunction, sex therapy, anorgasmia). Results were restricted, where possible, to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 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. Each article was screened for relevance and the full text acquired if determined to be relevant. The evidence obtained was reviewed and evaluated by the members of the Expert Workgroup established by The Society of Obstetricians and Gynaecologists of Canada., Values: The quality of evidence was evaluated and recommendations made using the use of criteria described by the Canadian Task Force on Preventive Health Care (Table)., (Copyright © 2017. Published by Elsevier Inc.)

Objective: To establish national standards of care for the screening and recording of alcohol use and counselling on alcohol use of women of child-bearing age and pregnant women based on the most up-to-date evidence., Evidence: Published literature was retrieved through searches of PubMed, CINAHL, and the Cochrane Library in May 2009 using appropriate controlled vocabulary (e.g., pregnancy complications, alcohol drinking, prenatal care) and key words (e.g., pregnancy, alcohol consumption, risk reduction). Results were restricted to literature published in the last five years with the following research designs: systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no language restrictions. Searches were updated on a regular basis and incorporated in the guideline to May 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment (HTA) and HTA-related agencies, national and international medical specialty societies, clinical practice guideline collections, and clinical trial registries. Each article was screened for relevance and the full text acquired if determined to be relevant. The evidence obtained was reviewed and evaluated by the members of the Expert Workgroup established by the Society of Obstetricians and Gynaecologists of Canada. The quality of evidence was evaluated and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care., Values: The quality of evidence was rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table 1)., Sponsor: The Public Health Agency of Canada and the Society of Obstetricians and Gynaecologists of Canada., Endorsement: These consensus guidelines have been endorsed by the Association of Obstetricians and Gynecologists of Quebec; the Canadian Association of Midwives; the Canadian Association of Perinatal, Women's Health and Neonatal Nurses (CAPWHN); the College of Family Physicians of Canada; the Federation of Medical Women of Canada; the Society of Rural Physicians of Canada; and Motherisk., Summary Statements: RECOMMENDATIONS., (Copyright © 2017. Published by Elsevier Inc.)

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

Objective: Our aim is to provide health care professionals in Canada with the knowledge and tools to provide culturally safe care to First Nations, Inuit, and Métis women and through them, to their families, in order to improve the health of First Nations, Inuit, and Métis., Evidence: Published literature was retrieved through searches of PubMed, CINAHL, Sociological Abstracts, and The Cochrane Library in 2011 using appropriate controlled vocabulary (e.g.,cultural competency, health services, indigenous, transcultural nursing) and key words (e.g., indigenous health services, transcultural health care, cultural safety). Targeted searches on subtopics (e.g., ceremonial rites and sexual coming of age) were also performed. The PubMed search was restricted to the years 2005 and later because of the large number of records retrieved on this topic. Searches were updated on a regular basis and incorporated in the guideline to May 2012. Grey (unpublished) literature was identified through searching the websites of selected related agencies (e.g., Campbell Collaboration, Social Care Online, Institute for Healthcare Improvement)., 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).

Public health authorities have been alarmed by the progressive rise in rates of Caesarean section in Canada, approaching one birth in three in several provinces. We aimed therefore to consider what were preventable obstetrical interventions in women with a low-risk pregnancy and to propose an analytic framework for the reduction of the rate of CS. We obtained statistical variations of CS rates over time, across regions, and within professional practices from MED-ÉCHO, the Quebec hospitalization database, from 1969 to 2009. Data were extracted from a recent systematic review of the cascade of obstetrical interventions to calculate the population-attributable fractions for each intervention associated with an increased probability of CS. We thereby identified expectant management (as an alternative to labour induction) and planned vaginal birth after CS as the leading strategies for potentially reducing rates of CS in women at low risk. For vaginal birth after CS, an increase to its 1995 level could lower the current CS rate of 23.2% (2009 to 2010) to 21.0%. Other alternatives to obstetrical interventions with a potential for lowering CS rates included non-pharmacological pain control methods (such as continuous support during childbirth) in addition to usual care, intermittent auscultation of the fetal heart (instead of electronic fetal monitoring), and multidisciplinary internal quality assessment audits. We believe, therefore, that the concept of preventable CS is supported by empirical evidence, and we identified realistic strategies to maintain a CS rate in Quebec near 20%.

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

Objective: To review the clinical aspects of ovarian hyperstimulation syndrome and provide recommendations on its diagnosis and clinical management., Outcomes: These guidelines will assist in the early recognition and management of ovarian hyperstimulation. Early recognition and prompt systematic supportive care will help avert poor outcomes., Evidence: Medline, Embase, and the Cochrane database were searched for relevant articles, using the key words "ovarian hyperstimulation syndrome" and "gonadotropins," and guidelines created by other professional societies were reviewed., Values: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table 1).

Objective: To provide current and emerging evidence on oral contraceptives and the risk of venous thromboembolism., Evidence: Articles published in English from 2005 were retrieved through searches of PubMed and Medline, using the following terms: venous thromboembolism, VTE, contraception, oral contraceptives, hormonal contraception. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to May 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 by the Canadian Task Force on Preventive Health Care (Table).

Objectives: To review the etiology and incidence of and associative factors in the formation of adhesions following gynaecological surgery. To review evidence for the use of available means of adhesion prevention following gynaecological surgery., Options: Women undergoing pelvic surgery are at risk of developing abdominal and/or pelvic adhesive disease postoperatively. Surgical technique and commercial adhesion prevention systems may decrease the risk of postoperative adhesion formation., Outcomes: The outcomes measured are the incidence of postoperative adhesions, complications related to the formation of adhesions, and further intervention relative to adhesive disease., Evidence: Medline, EMBASE, and The Cochrane Library were searched for articles published in English from 1990 to March 2009, using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, cohort studies, and meta-analyses specifically addressing postoperative adhesions, adhesion prevention, and adhesive barriers. Searches were updated on a regular basis and incorporated in the guideline to March 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 quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care.

Objective: To formulate clinical recommendations for the assessment of endometrial thickening when it is found on ultrasound in a postmenopausal patient without bleeding., Outcomes: Ensure that women with asymptomatic thickening and endometrial polyps found on ultrasound are managed appropriately., Evidence: Published literature was retrieved through searches of English language articles from the EMBASE, Cochrane, and PubMed databases for relevant peer-reviewed articles dating from 1970 to 2009, using appropriate controlled vocabulary (e.g., "asymptomatic endometrial thickness," "endometrial cancer," "postmenopausal bleeding," "transvaginal ultrasonography," "endometrial biopsy" and "endometrial polyp"). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to April 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 level of evidence was determined according to the criteria established by the Canadian Task Force on Preventative Health Care (Table). Recommendations are ranked according to this method., Benefits, Harms, and Costs: It is anticipated that the adoption of these recommendations would save postmenopausal women unnecessary anxiety, pain, and risk of procedural complication. It is also expected to decrease the cost to the health system by eliminating unnecessary interventions.

Objective: to establish national standards of care for the screening and recording of alcohol use and counselling on alcohol use of women of child-bearing age and pregnant women based on the most up-to-date evidence., Evidence: published literature was retrieved through searches of PubMed, CINAHL, and the Cochrane Library in May 2009 using appropriate controlled vocabulary (e.g., pregnancy complications, alcohol drinking, prenatal care) and key words (e.g., pregnancy, alcohol consumption, risk reduction). Results were restricted to literature published in the last five years with the following research designs: systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no language restrictions. Searches were updated on a regular basis and incorporated in the guideline to May 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment (HTA) and HTA-related agencies, national and international medical specialty societies, clinical practice guideline collections, and clinical trial registries. Each article was screened for relevance and the full text acquired if determined to be relevant. The evidence obtained was reviewed and evaluated by the members of the Expert Workgroup established by the Society of Obstetricians and Gynaecologists of Canada. The quality of evidence was evaluated and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care., Values: the quality of evidence was rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table 1)., Sponsor: the Public Health Agency of Canada and the Society of Obstetricians and Gynaecologists of Canada., Endorsement: these consensus guidelines have been endorsed by the Association of Obstetricians and Gynecologists of Quebec; the Canadian Association of Midwives; the Canadian Association of Perinatal, Women's Health and Neonatal Nurses (CAPWHN); the College of Family Physicians of Canada; the Federation of Medical Women of Canada; the Society of Rural Physicians of Canada; and Motherisk. SUMMARY STATEMENTS: 1. There is evidence that alcohol consumption in pregnancy can cause fetal harm. (II-2) There is insufficient evidence regarding fetal safety or harm at low levels of alcohol consumption in pregnancy. (III) 2. There is insufficient evidence to define any threshold for low-level drinking in pregnancy. (III) 3. Abstinence is the prudent choice for a woman who is or might become pregnant. (III) 4. Intensive culture-, gender-, and family-appropriate interventions need to be available and accessible for women with problematic drinking and/or alcohol dependence. (II-2)., Recommendations: 1. Universal screening for alcohol consumption should be done periodically for all pregnant women and women of child-bearing age. Ideally, at-risk drinking could be identified before pregnancy, allowing for change. (II-2B) 2. Health care providers should create a safe environment for women to report alcohol consumption. (III-A) 3. The public should be informed that alcohol screening and support for women at risk is part of routine women's health care. (III-A) 4. Health care providers should be aware of the risk factors associated with alcohol use in women of reproductive age. (III-B) 5. Brief interventions are effective and should be provided by health care providers for women with at-risk drinking. (II-2B) 6. If a woman continues to use alcohol during pregnancy, harm reduction/treatment strategies should be encouraged. (II-2B) 7. Pregnant women should be given priority access to withdrawal management and treatment. (III-A) 8. Health care providers should advise women that low-level consumption of alcohol in early pregnancy is not an indication for termination of pregnancy. (II-2A).

The measurement of the lower uterine segment (LUS) seems to be the best technique available to estimate the risk of uterine rupture, but there is a great heterogeneity in the techniques used. It appears necessary to standardize the interventions and their teaching prior to extending the use of the LUS measurement to clinical settings beyond well-defined research purposes.

A woman's alcohol use during pregnancy is one of the top preventable causes of birth defects and developmental disabilities that are known as fetal alcohol spectrum disorders (FASD). The social and economic burden of FASD is substantial. Lifetime direct tangible costs per individual related to health care, education and social services in Canada have been estimated to be $1.4 million. Screening women of child-bearing age and pregnant women and recording their alcohol consumption is a practical process to identify and evaluate women at-risk and to identify potentially exposed infants. The FASD Advisory Workgroup proposes the following three levels of screenings which should be done on consenting women: Level I screening involves practice-based approaches that can be used by health care providers when talking to women about alcohol use, such as motivational interviewing and supportive dialogue. Level II screening includes a number of structured questionnaires that can be used with direct questioning (TLFB) or indirect /masked screening (AUDIT, BMAST / SMAST, CAGE, CRAFFT, T-ACE, TWEAK). Level III screening includes laboratory-based tools that can be used to confirm the presence of a drug, its level of exposure and determine the presence of multiple drugs. There are challenges and limitations in the use of the screening and assessment tools outlined. For example, the single question about alcohol use and the various questionnaires rely on a woman to provide details about her alcohol use. There is no consensus on the appropriate screening to use across Canada as each provincial / territorial jurisdiction, health care organization and healthcare provider uses a variety of formal and informal screening tool. In addition, there are inconsistent processes across Canada for the recording of the alcohol use in a woman's chart and the transfer of the information to the infant and the child's health records. The FASD Advisory Workgroup proposes eleven recommendations to improve the screening and recording processes for alcohol use in women of child-bearing age and pregnant women.

Objective: To review the clinical aspects of postpartum hemorrhage (PPH) and provide guidelines to assist clinicians in the prevention and management of PPH. These guidelines are an update from the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical practice guideline on PPH, published in April 2000., Evidence: Medline, PubMed, the Cochrane Database of Systematic Reviews, ACP Journal Club, and BMJ Clinical Evidence were searched for relevant articles, with concentration on randomized controlled trials (RCTs), systematic reviews, and clinical practice guidelines published between 1995 and 2007. Each article was screened for relevance and the full text acquired if determined to be relevant. Each full-text article was critically appraised with use of the Jadad Scale and the levels of evidence definitions of the Canadian Task Force on Preventive Health Care., Values: The quality of evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care., Sponsor: The Society of Obstetricians and Gynaecologists of Canada., Recommendations: Prevention of Postpartum Hemorrhage 1. Active management of the third stage of labour (AMTSL) reduces the risk of PPH and should be offered and recommended to all women. (I-A) 2. Oxytocin (10 IU), administered intramuscularly, is the preferred medication and route for the prevention of PPH in low-risk vaginal deliveries. Care providers should administer this medication after delivery of the anterior shoulder. (I-A) 3. Intravenous infusion of oxytocin (20 to 40 IU in 1000 mL, 150 mL per hour) is an acceptable alternative for AMTSL. (I-B) 4. An IV bolus of oxytocin, 5 to 10 IU (given over 1 to 2 minutes), can be used for PPH prevention after vaginal birth but is not recommended at this time with elective Caesarean section. (II-B) 5. Ergonovine can be used for prevention of PPH but may be considered second choice to oxytocin owing to the greater risk of maternal adverse effects and of the need for manual removal of a retained placenta. Ergonovine is contraindicated in patients with hypertension. (I-A) 6. Carbetocin, 100 microg given as an IV bolus over 1 minute, should be used instead of continuous oxytocin infusion in elective Caesarean section for the prevention of PPH and to decrease the need for therapeutic uterotonics. (I-B) 7. For women delivering vaginally with 1 risk factor for PPH, carbetocin 100 microg IM decreases the need for uterine massage to prevent PPH when compared with continuous infusion of oxytocin. (I-B) 8. Ergonovine, 0.2 mg IM, and misoprostol, 600 to 800 microg given by the oral, sublingual, or rectal route, may be offered as alternatives in vaginal deliveries when oxytocin is not available. (II-1B) 9. Whenever possible, delaying cord clamping by at least 60 seconds is preferred to clamping earlier in premature newborns (< 37 weeks' gestation) since there is less intraventricular hemorrhage and less need for transfusion in those with late clamping. (I-A) 10. For term newborns, the possible increased risk of neonatal jaundice requiring phototherapy must be weighed against the physiological benefit of greater hemoglobin and iron levels up to 6 months of age conferred by delayed cord clamping. (I-C) 11. There is no evidence that, in an uncomplicated delivery without bleeding, interventions to accelerate delivery of the placenta before the traditional 30 to 45 minutes will reduce the risk of PPH. (II-2C) 12. Placental cord drainage cannot be recommended as a routine practice since the evidence for a reduction in the duration of the third stage of labour is limited to women who did not receive oxytocin as part of the management of the third stage. There is no evidence that this intervention prevents PPH. (II-1C) 13. Intraumbilical cord injection of misoprostol (800 microg) or oxytocin (10 to 30 IU) can be considered as an alternative intervention before manual removal of the placenta. (II-2C) TREATMENT OF PPH: 14. For blood loss estimation, clinicians should use clinical markers (signs and symptoms) rather than a visual estimation. (III-B) 15. Management of ongoing PPH requires a multidisciplinary approach that involves maintaining hemodynamic stability while simultaneously identifying and treating the cause of blood loss. (III-C) 16. All obstetric units should have a regularly checked PPH emergency equipment tray containing appropriate equipment. (II-2B) 17. Evidence for the benefit of recombinant activated factor VII has been gathered from very few cases of massive PPH. Therefore this agent cannot be recommended as part of routine practice. (II-3L) 18. Uterine tamponade can be an efficient and effective intervention to temporarily control active PPH due to uterine atony that has not responded to medical therapy. (III-L) 19. Surgical techniques such as ligation of the internal iliac artery, compression sutures, and hysterectomy should be used for the management of intractable PPH unresponsive to medical therapy. (III-B) Recommendations were quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1).

Objectives: To optimize the management of adnexal masses and to assist primary care physicians and gynaecologists determine which patients presenting with an ovarian mass with a significant risk of malignancy should be considered for gynaecologic oncology referral and management., Options: Laparoscopic evaluation, comprehensive surgical staging for early ovarian cancer, or tumour debulking for advanced stage ovarian cancer., Outcomes: To optimize conservative versus operative management of women with possible ovarian malignancy and to optimize the involvement of gynaecologic oncologists in planning and delivery of treatment., Evidence: Published literature was retrieved through searches of PubMed or MEDLINE, CINAHL, and the Cochrane Library, using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified by searching the web sites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies., Recommendations: 1. Primary care physicians and gynaecologists should always consider the possibility of an underlying ovarian cancer in patients in any age group who present with an adnexal or ovarian mass. (II-2B) 2. Appropriate workup of a perimenopausal or postmenopausal woman presenting with an adnexal mass should include evaluation of symptoms and signs suggestive of malignancy, such as persistent pelvic/abdominal pain, urinary urgency/frequency, increased abdominal size/bloating, and difficulty eating. In addition, CA125 measurement should be considered. (II-2B) 3. Transvaginal or transabdominal ultrasound examination is recommended as part of the initial workup of a complex adnexal/ovarian mass. (II-2B) 4. Ultrasound reports should be standardized to include size and unilateral/bilateral location of the adnexal mass and its possible origin, thickness of septations, presence of excrescences and internal solid components, vascular flow distribution pattern, and presence or absence of ascites. This information is essential for calculating the risk of malignancy index II score to identify pelvic mass with high malignant potential. (IIIC) 5. Patients deemed to have a high risk of an underlying malignancy should be reviewed in consultation with a gynaecologic oncologist for assessment and optimal surgical management. (II-2B).

Background: In the fall of 2007, the controversy about the contraceptive use of depot-medroxyprogesterone acetate (DMPA) and its potential impact on skeletal health reached the media in the province of Quebec, Canada, thereby becoming a matter of concern for the lay public and physicians. In order to discuss this subject openly, the National Institute of Public Health of Quebec (INSPQ) organized a scientific meeting on February 15, 2008, with targeted physicians delegated by their medical associations in the fields of general practice, obstetrics and gynaecology, rheumatology, orthopaedic surgery, physiatry and endocrinology., Study Design: Participants reviewed the scientific literature using the study classification method according to the level of evidence, reviewed published guidelines of medical societies and organizations on the subject and reached a consensus position. This manuscript presents a review of the literature and describes the consensus position of the targeted medical associations., Results: The consensus position adopted by all the targeted medical associations determined that DMPA was a cost-effective contraceptive option that must be considered in the light of the clinical situation and preference of each woman. Candidates for injectable contraception should be informed that the use of DMPA is associated with a slight decrease in bone mineral density (BMD), which is largely, if not completely, reversible. There should not be an absolute limit to the length of time that the DMPA contraceptive is used, regardless of the woman's age. Monitoring BMD is not recommended among users of DMPA for contraceptive purposes. Finally, the consensus statement declared that, although supplements of calcium and vitamin D are beneficial for skeletal health for women in general, such supplementation should not be recommended solely based on a woman's use of DMPA., Conclusion: Given the scientific evidences, DMPA use remains a valid contraceptive option for women. Its potential impact on BMD must be balanced against the significant individual, familial and social consequences of unintended pregnancy.

Through its partnership program with professional obstetrics and gynaecology associations in resource-poor environments, the Society of Obstetricians and Gynaecologists of Canada has developed a model for capacity assessment and development. The use of this model in Guatemala, Haiti, and Uganda has demonstrated its potential for facilitating cultural shifts in the perception of reproductive care, for providing clinical expertise in promoting educational activities, for enabling enhanced technical capacity, for political engagement, and for broad-based community and professional engagement.

Objective: To provide evidence-based guidance for women and their health care providers on the management of missed or delayed hormonal contraceptive doses in order to prevent unintended pregnancy., Evidence: Medline, PubMed, and the Cochrane Database were searched for articles published in English, from 1974 to 2007, about hormonal contraceptive methods that are available in Canada and that may be missed or delayed. Relevant publications and position papers from appropriate reproductive health and family planning organizations were also reviewed. The quality of evidence is rated using the criteria developed by the Canadian Task Force on Preventive Health Care., Benefits, Harms, and Costs: This committee opinion will help health care providers offer clear information to women who have not been adherent in using hormonal contraception with the purpose of preventing unintended pregnancy., Sponsors: The Society of Obstetricians and Gynaecologists of Canada. SUMMARY STATEMENTS: 1. Instructions for what women should do when they miss hormonal contraception have been complex and women do not understand them correctly. (I) 2. The highest risk of ovulation occurs when the hormone-free interval is prolonged for more than seven days, either by delaying the start of combined hormonal contraceptives or by missing active hormone doses during the first or third weeks of combined oral contraceptives. (II) Ovulation rarely occurs after seven consecutive days of combined oral contraceptive use. (II) RECOMMENDATIONS: 1. Health care providers should give clear, simple instructions, both written and oral, on missed hormonal contraceptive pills as part of contraceptive counselling. (III-A) 2. Health care providers should provide women with telephone/electronic resources for reference in the event of missed or delayed hormonal contraceptives. (III-A) 3. In order to avoid an increased risk of unintended pregnancy, the hormone-free interval should not exceed seven days in combined hormonal contraceptive users. (II-A) 4. Back-up contraception should be used after one missed dose in the first week of hormones until seven consecutive days of correct hormone use are established. In the case of missed combined hormonal contraceptives in the second or third week of hormones, the hormone-free interval should be eliminated for that cycle. (III-A) 5. Emergency contraception and back-up contraception may be required in some instances of missed hormonal contraceptives, in particular when the hormone-free interval has been extended for more than seven days. (III-A) 6. Back-up contraception should be used when three or more consecutive doses/days of combined hormonal contraceptives are missed in the second and third week until seven consecutive days of correct hormone use are established. For practical reasons, the scheduled hormone-free interval should be eliminated in these cases. (II-A) 7. Emergency contraception is rarely indicated for missed combined hormonal contraceptives in the second or third week of the cycle unless there are repeated omissions or failure to institute back-up contraception after the missed doses. In cases of repeated omissions of combined hormonal contraceptives, emergency contraception may be required, and back-up contraception should be used. Health care professionals should counsel women in these situations on alternative methods of contraception that do not demand such stringent compliance. (III-A).

Through capacity-building initiatives with obstetrics and gynaecology organizations in Guatemala, Haiti, and Uganda, the Society of Obstetricians and Gynaecologists of Canada has developed the organization capacity improvement framework (OCIF), a model for strengthening associations' essential organizational capacities. The OCIF focuses on capacity development within the organization over time, rather than on individual training and short-term outcomes. A cycle of assessing, planning, implementing, and measuring improvement builds rigour into the process while encouraging participation, understanding, and commitment to sustainable capacity development.

Objective: To provide guidelines for the health care provider on the diagnosis and clinical management of postmenopausal osteoporosis., Outcomes: Strategies for identifying and evaluating high-risk individuals, the use of bone mineral density (BMD) and bone turnover markers in assessing diagnosis and response to management, and recommendations regarding nutrition, physical activity, and the selection of pharmacologic therapy to prevent and manage osteoporosis., Evidence: MEDLINE and the Cochrane database were searched for articles in English on subjects related to osteoporosis diagnosis, prevention, and management from March 2001 to April 2005. The authors critically reviewed the evidence and developed the recommendations according to the Journal of Obstetrics and Gynaecology Canada's methodology and consensus development process., Values: The quality of evidence is rated using the criteria described in the report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice are ranked according to the method described in this report., Sponsors: The development of this consensus guideline was supported by unrestricted educational grants from Berlex Canada Inc., Lilly Canada, Merck Frosst, Novartis, Novogen, Novo Nordisk, Proctor and Gamble, Schering Canada, and Wyeth Canada.