Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstétrique et gynécologie du Canada : JOGC
-
This guideline reviews the evidence relating to the potential benefits of the vaginal hysterectomy (VH) and supracervical hysterectomy (SCH) versus total abdominal hysterectomy (TAH) with respect to postoperative sexual function, urinary function, and peri- and postoperative complications. Laparoscopic options are not included in this guideline. ⋯ 1. Vaginal hysterectomy is generally considered the first choice of surgical approach for most benign indications for hysterectomy, as it is associated with lower rates of morbidity, fewer postoperative complications, and a faster recovery time than abdominal hysterectomy. (I-A). 2. Women contemplating a vaginal, laparoscopic, or abdominal hysterectomy for the management of benign uterine disease should be reassured that hysterectomy is usually associated with improved quality of life, including improved sexual function, whether or not the cervix is removed. (I-B). 3. Supracervical hysterectomy should not be recommended as a superior technique to total abdominal hysterectomy for the prevention of postoperative lower urinary tract symptoms. (I-B). 4. Although supracervical hysterectomy may be associated with less blood loss and a shorter surgical time, these parameters have not been found to be clinically significant, and supracervical hysterectomy should not be recommended as a superior technique to total abdominal hysterectomy for the prevention of peri- and postoperative complications. (I-B). 5. Women considering a supracervical hysterectomy should be counselled that they may continue experiencing cyclic vaginal bleeding following the surgery. (I-B). 6. Women must be advised that they require routine cytological screening following a supracervical hysterectomy. (II-B). 7. Women who require a hysterectomy and who have a current or significant history of abnormal cervical cytological results should be counselled on the advantages of vaginal hysterectomy or total abdominal hysterectomy over supracervical hysterectomy. (I-B).
-
J Obstet Gynaecol Can · Dec 2009
Outcomes of elective labour induction and elective caesarean section in low-risk pregnancies between 37 and 41 weeks' gestation.
To compare maternal and neonatal outcomes after elective induction of labour and elective Caesarean section with outcomes after spontaneous labour in women with low-risk, full-term pregnancies. ⋯ Elective induction leads to more unplanned Caesarean sections in nulliparous women and to increased postpartum complications for both nulliparous and multiparous women. Elective Caesarean section has increased maternal and neonatal risks.
-
J Obstet Gynaecol Can · Oct 2009
Review Practice GuidelineActive management of the third stage of labour: prevention and treatment of postpartum hemorrhage.
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. ⋯ 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).
-
J Obstet Gynaecol Can · Sep 2009
Review Practice GuidelineEvaluation of prenatally diagnosed structural congenital anomalies.
To provide information to genetic counsellors, midwives, nurses, and physicians who are involved in the prenatal care of women dealing with prenatally diagnosed isolated or multiple structural congenital anomalies. ⋯ 1. When a fetal structural anomaly is identified, the pregnant woman should be offered a timely consultation with a trained genetic counsellor and with a maternal-fetal medicine specialist and/or a medical geneticist. The counselling should be unbiased and respectful of the patient's choice, culture, religion, and beliefs. (III-A) 2. Patients should be informed that prenatal ultrasound at 18 to 20 weeks can detect major structural anomalies in approximately 60% of such cases. (II-2A) 3. When a fetal structural anomaly is suspected or identified, a referral to a tertiary ultrasound unit should be made as soon as possible to optimize therapeutic options. (II-2A) 4. In ongoing pregnancies with fetal structural anomalies, ultrasound examination should be repeated (at a frequency depending on the anomaly) to assess the evolution of the anomaly and attempt to detect other anomalies not previously identified, as this may influence the counselling as well as the obstetrical or perinatal management. (II-2B) 5. Once a fetal structural anomaly is identified by 2-D ultrasound, other imaging techniques such as fetal echocardiography, 3-D obstetrical ultrasound, ultrafast fetal MRI, and, occasionally, fetal X-ray and fetal CT scan (using a low-dose protocol) may be helpful in specific cases. (II-2A) 6. Parental imaging should be considered in specific cases, depending on the fetal anomaly identified (e.g., potential dominant inheritance). (III-A) 7. Parental blood testing and invasive prenatal testing may also be required to clarify the diagnosis for a fetus with isolated or multiple structural anomalies. (II-2A) 8. Women should receive information regarding the abnormal ultrasound findings in a clear, sympathetic, and timely fashion, and in a supportive environment that ensures privacy. Referral to the appropriate pediatric or surgical subspecialist(s) should be considered to provide the most accurate information possible concerning the anomaly or anomalies and the associated prognosis. (II-2 B) 9. Parents should be informed that major or minor fetal structural anomalies, whether isolated or multiple, may be part of a genetic syndrome, sequence, or association, despite a normal fetal karyotype. (III-A) 10. If early or urgent postnatal management may be required, delivery at a centre that can provide the appropriate neonatal care should be considered. (III-A) 11. When any congenital structural anomaly has been identified prenatally, a comprehensive newborn assessment is essential for diagnosis and counselling on the etiology, prognosis, and recurrence risk for future pregnancies, especially when the etiology has not been clearly identified prenatally. (III-A) 12. In cases of termination of pregnancy, stillbirth, or neonatal death, the health professional should encourage the performance of a complete autopsy by a perinatal or pediatric pathologist to provide maximum information on the diagnosis and etiology of the structural fetal anomaly or anomalies. When a complete autopsy is refused, the health professional should encourage the performance of at least a partial or external autopsy (including X-rays and photographs). (III-A) VALIDATION: This committee opinion has been prepared by the Genetics Committee of the SOGC and approved by the Executive of the SOGC.