Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstétrique et gynécologie du Canada : JOGC
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To review the use of transvaginal ultrasound for the diagnosis of placenta previa and recommend management based on accurate placental localization. ⋯ 1. Transvaginal sonography, if available, may be used to investigate placental location at any time in pregnancy when the placenta is thought to be low-lying. It is significantly more accurate than transabdominal sonography, and its safety is well established. (11-2A) 2. Sonographers are encouraged to report the actual distance from the placental edge to the internal cervical os at TVS, using standard terminology of millimetres away from the os or millimetres of overlap. A placental edge exactly reaching the internal os is described as 0 mm. When the placental edge reaches or overlaps the internal os on TVS between 18 and 24 weeks' gestation (incidence 2-4%), a follow-up examination for placental location in the third trimester is recommended. Overlap of more than 15 mm is associated with an increased likelihood of placenta previa at term. (ll-2A) 3. When the placental edge lies between 20 mm away from the internal os and 20 mm of overlap after 26 weeks' gestation, ultrasound should be repeated at regular intervals depending on the gestational age, distance from the internal os, and clinical features such as bleeding, because continued change in placental location is likely. Overlap of 20 mm or more at any time in the third trimester is highly predictive of the need for Caesarean section (CS). (llI-B) 4. The os-placental edge distance on TVS after 35 weeks' gestation is valuable in planning route of delivery. When the placental edge lies > 20 mm away from the internal cervical os, women can be offered a trial of labour with a high expectation of success. A distance of 20 to 0 mm away from the os is associated with a higher CS rate, although vaginal delivery is still possible depending on the clinical circumstances. (ll-2A) 5. In general, any degree of overlap (> 0 mm) after 35 weeks is an indication for Caesarean section as the route of delivery. (ll-2A) 6. Outpatient management of placenta previa may be appropriate for stable women with home support, close proximity to a hospital, and readily available transportation and telephone communication. (ll-2C) 7. There is insufficient evidence to recommend the practice of cervical cerclage to reduce bleeding in placenta previa. (llI-D) 8. Regional anaesthesia may be employed for CS in the presence of placenta previa. (II-2B) 9. Women with a placenta previa and a prior CS are at high risk for placenta accreta. If there is imaging evidence of pathological adherence of the placenta, delivery should be planned in an appropriate setting with adequate resources. (II-2B) VALIDATION: Comparison with Placenta previa and placenta previa accreta: diagnosis and management. Royal College ofObstetricians and Gynaecologists, Guideline No. 27,October 2005.The level of evidence and quality of recommendations are described using the criteria and classifications of the Canadian Task Force on Preventive Health Care (Table).
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J Obstet Gynaecol Can · Mar 2007
Practice GuidelineA report on best practices for returning birth to rural and remote aboriginal communities.
During the last four decades, policies and practices based on modern obstetrical techniques and knowledge have replaced traditional practices in many rural and remote Aboriginal communities. As most of these communities do not have obstetrical facilities or staff, women often have to leave their communities to give birth. ⋯ 1. Physicians, nurses, hospital administrators, and funding agencies (both government and non-government) should ensure that they are well informed about the health needs of First Nations, Inuit, and Métis people and the broader determinants of health. 2. Aboriginal communities and health institutions must work together to change existing maternity programs. 3. Plans for maternal and child health care in Aboriginal communities should include a "healing map" that outlines the determinants of health. 4. Midwifery care and midwifery training should be an integral part of changes in maternity care for rural and remote Aboriginal communities. 5. Protocols for emergency and non-emergency clinical care in Aboriginal communities should be developed in conjunction with midwifery programs in those communities. 6. Midwives working in rural and remote communities should be seen as primary caregivers for all pregnant women in the community.