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This document provides evidence-based recommendations for various aspects of cesarean section (C.S.) procedures based on randomized trials and systematic reviews. It recommends that the operating table should have a 15 degree tilt to reduce hypotension, the Joel Cohen incision be used as it reduces time and morbidity, and blunt extension of the uterine incision to reduce blood loss and hemorrhage. Prophylactic antibiotics should be provided to reduce postoperative infections. External cephalic version should be offered for breech presentations, and C.S. offered if unsuccessful or contraindicated to reduce mortality and morbidity. Early breastfeeding and food/fluid intake should be encouraged for recovery when complications are absent.
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At the end of presentation, the participants should be able to understand the following:
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- Transverse lie has an incidence of about 1 in 300 births and is more common in multiparous women and preterm fetuses.
- Diagnosis involves abdominal and vaginal exams to identify the fetal parts in unusual positions.
- Spontaneous delivery is very rare and management typically involves external cephalic version to change the lie, followed by induction if successful. Cesarean delivery is required if version fails or the fetus is in distress.
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GRAND MULTIPARA
FIGO definition - GM taken as delivery of 5th to 9th Infant, 10th and above taken as great GM
Prevalence - Gulf countries and African sub-continent
Risks with increasing parity -
Maternal
Dysfunction labor
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Morbid adherence of placenta
Unstable lie & presentation
Precipitate deliveries
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Medical condition due to increasing age
Fetal
1 Low APGAR score
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- Common methods include membrane sweeping, amniotomy, prostaglandins like misoprostol and dinoprostone, and oxytocin administration.
- Indications include post-term pregnancy, pre-eclampsia, diabetes, and fetal growth restriction. Contraindications include malpresentations and previous uterine scarring.
- Factors like maternal and fetal well-being as well as cervical status via Bishop score are assessed prior to induction.
- Comp
Evidence based medicine
Evidence based medicine in health care delivery system and also evidence based medicine in public health,
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Management of ovarian cysts in postmenopausal women
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This document discusses strategies to reduce the rate of primary cesarean deliveries. It notes that the worldwide cesarean rate has risen dramatically in recent decades without clear evidence of improved outcomes. While cesareans can be lifesaving in some high-risk cases, they also carry greater risks than vaginal delivery for low-risk pregnancies. The document recommends various practices to promote vaginal birth over unnecessary primary cesareans, such as continuous labor support, midwifery care, breech version for breech babies, and addressing fear of childbirth through counseling.
Vbacs
This document discusses the history and risks/benefits of vaginal birth after cesarean (VBAC) versus elective repeat cesarean section. It notes that while VBAC was originally encouraged due to risks of multiple c-sections, safety concerns led to declining VBAC rates. VBAC carries risks of uterine rupture but reduces risks of respiratory issues compared to repeat c-section. Proper patient selection and access to emergency c-section are important to support a planned VBAC attempt. The risks and benefits should be discussed thoroughly to help each woman make an informed decision.
Cervical incompetence
Cervical incompetence, or premature cervical dilation, can complicate 0.1-2% of pregnancies and cause 15% of preterm births between 16-28 weeks. While the exact cause is often unknown, it may result from congenital cervical weakness, trauma, or DES exposure. Diagnosis is based on recurrent second trimester miscarriage without other identifiable causes. Treatment options include bed rest or a cervical cerclage procedure to stitch the cervix closed and prolong the pregnancy. Cerclage placement can be elective, urgent based on cervical shortening, or emergency if dilation has already begun. The McDonald and Shirodkar techniques are most common, with choice depending on cervical anatomy and prior trauma. Cer
Why to reduce cesarean section rate?
why to reduce the burden of cesarean section epidemic?. CS is overdone with no demonstrated benefits.
Hashem Q M12_2017 MRCOGP2 revision course
PART 2 MRCOG INTENSIVE REVISION COURSE
AMMAN, JORDAN 23-25 JANUARY 2017
Module 11: Management of delivery
Dr.5: Hashem Yaseen, MBBS, 4th year OG resident
Jordan University of Science and Technology, King Abdullah University Hospital,
Hashemmail@yahoo.com
How to reduce cs rate slideshare
how to reduce cesarean section rate is a hot topic. This presentation discusses various steps and fields that may lower CS rate.
Breech.ppt
This document summarizes evidence and current perspectives on breech presentation and delivery. It discusses that breech occurs in 20% of pregnancies at 28 weeks and 4% at term. Perinatal mortality is increased with breech due to factors like prematurity and birth trauma. The Term Breech Trial found increased risks with vaginal breech delivery. However, some studies have questioned the Trial's conclusions. Elective c-section is often recommended now for term breech, though trial of vaginal delivery may be safe in some select cases. The document also reviews controversies, techniques, risks of different delivery modes, and the role of external cephalic version in attempting to turn breech babies.
Evidence based individual decision making
This document discusses evidence-based individual decision making (EBID) in obstetrics and gynecology. It emphasizes that evidence-based medicine (EBM) integrates the best available research evidence, clinical expertise, and patient values and preferences. While randomized controlled trials provide the strongest level of evidence, individual patient circumstances may differ. The document notes gaps between research evidence and clinical practice. It concludes that best research evidence, assessment of maternal risk, and good clinical judgment are needed to prevent adverse pregnancy outcomes through EBID.
vaginal birth after CS
This document provides guidance on counseling women considering a planned vaginal birth after cesarean (VBAC) versus elective repeat cesarean section. It outlines risk factors and success rates for VBAC, contraindications, intrapartum management recommendations, and discusses risks and benefits of both options to discuss with patients. Key factors that impact VBAC success rates and risks are previous vaginal delivery, induction, BMI over 30, gestational age, and birth weight. Continuous fetal monitoring and availability of emergency services are recommended for planned VBAC.
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This document discusses breech presentation and external cephalic version (ECV). It provides information on the causes and risks of breech presentation as well as management options. ECV is recommended to attempt to turn breech babies, with success rates around 50% depending on factors like multiparity. ECV carries a low risk of complications when performed by trained practitioners with safety precautions like ultrasound and monitoring. Planned c-section is recommended if ECV fails or is contraindicated due to risks, though some women may opt for planned vaginal delivery.
7042252.ppt
Cervical incompetence is premature dilation of the cervix during pregnancy before labor begins. It affects 0.1-2% of pregnancies and causes around 15% of preterm births between 16-28 weeks. While the cause is often unknown, it can be due to congenital weaknesses, prior trauma, or connective tissue disorders. Diagnosis relies on history of preterm births and physical findings like dilation of the cervix when not pregnant. Cervical cerclage placement is the standard treatment and involves surgically stitching the cervix closed to prevent premature dilation. The document discusses various cerclage techniques and their appropriate uses.
Assisted vaginal births, RCOG
This document provides recommendations to reduce the need for assisted vaginal birth and optimize outcomes when it is required. It recommends encouraging continuous support during labor, upright positions in the second stage of labor without epidural analgesia, and lateral positions with epidural analgesia. It also recommends delayed pushing, use of classification systems, consideration of risks and benefits, and ensuring ongoing care of the woman and family after birth.
Treatment and outcome of anatomical factors for abortions
The document discusses various anatomical factors that can contribute to recurrent pregnancy loss, including uterine anomalies like septate uterus, bicornuate uterus, and unicornuate uterus. It describes how these anomalies can increase risks of miscarriage and preterm birth. The document outlines surgical treatments like hysteroscopic septal resection and metroplasty that aim to correct anomalies and improve reproductive outcomes by reducing miscarriage and preterm birth rates. It also discusses cervical insufficiency and the use of cerclage procedures to treat this issue and prolong pregnancy.
Cesarean section
This document provides an overview of cesarean section (C-section). It defines a C-section as a surgical procedure to deliver babies through incisions in the abdominal and uterine walls after 28 weeks of gestation. The C-section rate in the US has risen from 5% in 1970 to 31.9% in 2016. While it poses risks, C-section can be the safest delivery method for some women and babies. The document then describes the personnel, procedures, types, indications, risks, and postoperative care of C-sections.
Evidence based induction of labor
This document summarizes guidelines for induction of labor from several sources. It discusses best practices for confirming gestational age, considering medical indications, accepting maternal request, proceeding over maternal refusal, timing of induction, and monitoring during labor induction. It also provides evidence-based recommendations on methods of induction such as membrane sweeping, cervical assessments, amniotomy, oxytocin administration, and fetal monitoring. The document synthesizes evidence from multiple systematic reviews and clinical guidelines to provide comprehensive guidance on safe and effective labor induction practices.
V bac discussion
This document discusses vaginal birth after cesarean (VBAC) and provides guidelines on when it is appropriate and safe. It defines VBAC and outlines the benefits of reducing morbidity for both mother and baby compared to repeat cesarean sections. Risk factors for uterine rupture are identified such as previous classical or complicated uterine scars. Ultrasound can assess lower uterine segment thickness which may predict rupture risk. Induction or augmentation of labor in VBAC is associated with higher rupture rates. Close monitoring during labor is important to quickly identify signs of rupture. VBAC is generally safe for one previous low transverse incision but risks are higher for two or more prior sections.
Cesarean section hennawy
This document provides information on performing a Cesarean section (C-section). It begins by defining a C-section and explaining the different types based on gestational age. It then discusses techniques to reduce operating time and costs. Common causes of C-sections are listed, along with reasons for increasing C-section rates. Preoperative testing, positioning, catheterization, skin preparation, draping, and abdominal entry techniques are outlined. Regional versus general anesthesia options are presented. The document concludes by describing uterine incision techniques and addressing central placenta praevia.
Obesity in pregancy
This document discusses obesity in pregnancy and provides recommendations for management. It defines obesity as a BMI over 30 kg/m2 and notes obesity is associated with increased risks of complications during pregnancy, delivery, and postpartum. The document recommends regular ultrasounds starting at 28 weeks to monitor fetal growth, screening for gestational diabetes and preeclampsia, encouraging exercise during pregnancy, and planning for potential challenges with anesthesia, incision technique, and wound closure during a cesarean delivery if needed. Postpartum care should address risks of complications like wound issues and difficulties with breastfeeding.
Ecv rcog2006
This document discusses external cephalic version (ECV), a procedure used to manually turn a breech baby into a head-down position before birth. It notes that ECV reduces the need for cesarean section and that success rates range from 30-80%. Factors that increase the likelihood of success include multiparity, uterine relaxation, an unengaged breech, and a palpable fetal head. Complications are rare but can include placental abruption or emergency cesarean. ECV is generally safe when performed after 36 weeks of gestation.
Management-of-Postterm-Pregnancy
Management of postterm pregnancy involves balancing risks to the fetus and mother. Postterm is defined as past 42 weeks gestation. Accurately dating the pregnancy is important to avoid false diagnosis. Risks to the fetus include stillbirth, meconium aspiration, and macrosomia. Risks to the mother include dystocia and infection. Studies show inducing labor at 41 weeks reduces stillbirths without increasing C-sections. Methods of antenatal testing after 41 weeks are debated, though monitoring is recommended. While an unfavorable cervix was viewed as a risk factor for C-section, recent evidence suggests underlying issues may be more important. Further research is needed to determine the optimal time for induction to minimize risks
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Management of poor ovarian response
The document discusses the definition and management of poor ovarian response. Poor response is generally defined as women with low ovarian reserve or a poor response to ovarian stimulation. As women age, their ovarian reserve declines resulting in fewer remaining eggs. The infertility specialist aims to assess biological age by measuring remaining egg count. Treatment options discussed include clomiphene citrate, letrozole, metformin, gonadotropins, ovarian drilling, and various IVF protocols tailored for poor responders. No single treatment guarantees success, and expectations must be managed through counseling.
High responders
This document discusses strategies for preventing severe ovarian hyperstimulation syndrome (OHSS) during in vitro fertilization treatment. It describes the pathogenesis of OHSS and risk factors. Methods for prevention discussed include using a mild stimulation protocol, metformin treatment, coasting by withholding gonadotropins before triggering ovulation, using a GnRH antagonist protocol instead of agonist, cryopreserving all embryos, and administering intravenous albumin or hydroxyethyl starch after oocyte retrieval to reduce risk. The document concludes that OHSS is a preventable complication through various medical interventions and protocols.
Prognostic models
1. Prognostic models can help predict the chances of conceiving naturally, conceiving with interventions like IUI or IVF, and the chances of live birth from IVF.
2. Key factors in these models include female age, duration of infertility, cause of infertility, ovarian reserve tests, and data from previous treatment cycles.
3. Existing prediction models have been shown to have good discrimination and calibration for outcomes like IUI or IVF success, though individual patient preferences must also be considered in treatment decisions.
GnRH antagonists
The document discusses changing protocols for in vitro fertilization (IVF) from gonadotropin-releasing hormone (GnRH) agonists to GnRH antagonists. Some key points discussed include:
1) GnRH antagonists are associated with a lower risk of ovarian hyperstimulation syndrome (OHSS) compared to GnRH agonists.
2) While efficacy outcomes like live birth and pregnancy rates are similar between the two protocols, GnRH antagonists require fewer gonadotropin ampoules and have a shorter duration of stimulation.
3) Based on multiple randomized controlled trials and meta-analyses, it is justified to shift from GnRH agonists to GnRH antagonists for IVF
Poor
As a woman ages, her ovarian function and egg reserve naturally decline. Every woman is born with a finite number of eggs that decreases over time. Rather than focus on a woman's calendar age, infertility specialists are more concerned with her biological age, as measured by the number of eggs remaining in her ovaries, which is called her ovarian reserve.
Infertility
Infertility affects couples worldwide, with an average incidence of about 15%. Evaluation of both female and male partners is essential to determine the cause, which can be female factors, male factors, or a combination. Treatment options depend on the cause and range from ovulation-inducing drugs, surgery, and assisted reproductive technologies like in vitro fertilization.
So much evidence 1
The document discusses the need for an evidence-based approach in obstetrics and gynecology. It notes that while there is a lot of research evidence available, much of it is not applied in practice. It proposes creating an "Evidence Base Community" to better manage and disseminate research evidence to help close the gap between evidence and practice. This community would work on tasks like engaging stakeholders, developing guidelines, and implementing strategies to improve women's health outcomes based on the best available evidence.
So much evidence 1
The document discusses the need for an evidence-based approach in obstetrics and gynecology. It notes that while there is a lot of research evidence available, much of it is not applied in practice. It proposes creating an "Evidence Base Community" to better manage and disseminate research evidence to help close the gap between evidence and practice. This community would work on tasks like engaging stakeholders, developing guidelines, and implementing strategies to improve women's health outcomes based on the best available evidence.
Contraception
The document discusses contraceptive options for a 42-year-old diabetic woman whose IUD expelled twice previously. The best option is a progestin implant like Implanon, which is category 2 for medical eligibility and has an extremely low failure rate. Implants are effective, long-lasting, and help regulate menstruation without increasing diabetes risk.
Management of poor ovarian response
This document discusses the management of poor or hyper ovarian response in IVF treatment. It covers topics such as predicting ovarian reserve, definitions of poor response, protocols for poor and hyper responders, and techniques like coasting to help prevent ovarian hyperstimulation syndrome. Coasting, where gonadotropin administration is stopped but down regulation continued, is an effective way to prevent OHSS while still allowing for embryo retrieval and transfer. GnRH antagonist protocols may also help lower the risk of OHSS compared to long agonist protocols. There is no single best protocol, and treatments should be individualized based on patient factors and expectations.
Thromboprophylaxis
The document discusses guidelines for thromboprophylaxis during pregnancy, birth, and the postpartum period for women at risk of venous thromboembolism. It outlines risk factors and recommendations for prophylactic treatment with low molecular weight heparins during pregnancy and after delivery based on risk level. Guidelines also provide directions on administering low molecular weight heparins around regional anesthesia techniques and delivery by cesarean section.
Pattern of vitamin d receptor polymorphism
This document discusses a study that examined the relationship between vitamin D receptor (VDR) gene polymorphisms and postmenopausal osteoporosis in Egyptian women. The study analyzed FOKI and BSMI polymorphisms in 50 postmenopausal osteoporotic patients and 20 age-matched healthy controls. It found that the FF genotype of FOKI was more common in controls while the ff genotype was associated with lower bone mineral density and higher risk of osteoporosis in patients. It also found that the BB genotype of BSMI was more frequent in controls and conferred a protective effect, while the bb genotype was overrepresented in patients. The study concludes that VDR gene polymorphisms play an important role
So much evidence
This document discusses evidence-based practice in obstetrics and gynecology. It notes that while there are many systematic reviews, randomized controlled trials, and guidelines available, barriers still exist that prevent clinicians from fully incorporating research evidence into practice. These barriers include a lack of time and interest in research among some clinicians. The document also discusses challenges in determining which study findings are both statistically and clinically significant. It emphasizes that evidence-based practice requires integrating the best available research with clinical expertise and patient preferences. Successful implementation of evidence-based practices requires commitment from leadership, resources, and changes to existing practices.
Why to know statistics
1) Statistics are important to understand data collected in research projects, summarize large datasets, and make evidence-based decisions.
2) Key statistical concepts include measures like relative risk, odds ratios, and confidence intervals which are used to evaluate research results and size of treatment effects.
3) Proper statistical analysis and reporting of values like p-values, absolute risk reduction, and number needed to treat are needed to accurately interpret results and clinical significance.
Uterine sarcoma
Uterine sarcoma is a rare and challenging type of cancer that grows rapidly. It accounts for 2-5% of uterine malignancies and is diagnosed in about 17 per 1000 women annually. Risk factors include prior pelvic radiation and black race. Long-term tamoxifen use also increases the risk. The most common presenting symptom is vaginal bleeding. Surgery is the primary treatment but the benefits of adjuvant radiation and chemotherapy are unclear due to limited data. Prognosis is generally poor, especially for later stages, and more research is needed to determine optimal adjuvant therapies.
Systematic review
A systematic review is a structured review that pools the results of multiple studies on a topic using meta-analysis. It aims to summarize evidence from studies addressing a specific clinical question in a rigorous, unbiased manner to explain differences among studies on the same question. Systematic reviews are considered the highest level of evidence and are needed because individual studies may have biases or low statistical power to detect effects.
Statistics & infertility
The document discusses statistics related to infertility including prevalence rates, conception rates in the first year, success rates of fertility procedures like IUI, IVF, and ICSI which range from 10-50% depending on the procedure. It also mentions factors that can impact fertility treatment success like a woman's age, number of embryos transferred, and if it is a woman's first treatment or a subsequent one after a previous pregnancy.
Research methodology 101
1. The document discusses common pitfalls in research studies related to reproductive medicine and how to avoid them.
2. Key pitfalls include problems with study design, sampling, operationalization, and generalizability. Randomized controlled trials (RCTs) are recommended to properly assess treatment efficacy.
3. When conducting RCTs, intention-to-treat analysis and accounting for loss to follow up are important to avoid bias. The primary outcome measure and unit of analysis must also be appropriately defined.
Randomised controlled trials
Randomized controlled trials (RCTs) are considered the gold standard for clinical research. An RCT involves randomly assigning participants into experimental and control groups to receive different interventions. Randomization aims to make the groups comparable to limit bias. It reduces the influence of unknown factors and ensures the only difference between groups is the intervention being tested. RCTs can be single blind, double blind, or triple blind depending on who is aware of group assignments. They provide the most powerful and least biased assessments of clinical interventions.
Paternal age
This study examined the effect of advanced paternal age on outcomes of intracytoplasmic sperm injection (ICSI) cycles. The researchers compared ICSI outcomes between males aged 50 years or older (Group A) and males under 50 years old (Group B), matching females by age. Fertilization rates were significantly higher in Group B, but clinical pregnancy rates did not differ significantly between the groups. Within Group A, outcomes also did not differ significantly between those aged 50-59 (Group A1) and those aged 60 or older (Group A2). The study concludes that while advanced paternal age is associated with lower fertilization rates, it does not negatively impact pregnancy rates from ICSI.
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