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Obstetrics & Gynaecology Evidence Update

20th February 2017

NICE  National Institute for Health and Care Excellence


Surgical site infections: prevention and treatment

Antenatal care for uncomplicated pregnancies

Oestrogen deficiency symptoms in postmenopausal women: conjugated oestrogens and bazedoxifene acetate

Blood transfusion
New and Updated Cochrane Systematic Reviews

Home uterine monitoring for detecting preterm labour
Authors' conclusions: Home uterine monitoring may result in fewer admissions to a neonatal intensive care unit but in more unscheduled antenatal visits and tocolytic treatment; the level of evidence is generally low to moderate. Important group differences were not evident when we undertook sensitivity analysis using only trials at low risk of bias. There is no impact on maternal and perinatal outcomes such as perinatal mortality or incidence of preterm birth.

Psychosocial interventions for supporting women to stop smoking in pregnancy
Authors' conclusions: Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy and the proportion of infants born low birthweight. Counselling, feedback and incentives appear to be effective, however the characteristics and context of the interventions should be carefully considered. The effect of health education and social support is less clear. New trials have been published during the preparation of this review and will be included in the next update.

Intermittent auscultation (IA) of fetal heart rate in labour for fetal well-being
Authors' conclusions: Using a hand-held (battery and wind-up) Doppler and intermittent CTG with an abdominal transducer without paper tracing for IA in labour was associated with an increase in caesarean sections due to fetal distress. There was no clear difference in neonatal outcomes (low Apgar scores at five minutes after birth, neonatal seizures or perinatal mortality). Long-term outcomes for the baby (including neurodevelopmental disability and cerebral palsy) were not reported. The quality of the evidence was assessed as moderate to very low and several important outcomes were not reported which means that uncertainty remains regarding the use of IA of FHR in labour.  
As intermittent CTG and Doppler were associated with higher rates of caesarean sections compared with routine Pinard monitoring, women, health practitioners and policy makers need to consider these results in the absence of evidence of short- and long-term benefits for the mother or baby.  Large high-quality randomised trials, particularly in low-income settings, are needed. Trials should assess both short- and long-term health outcomes, comparing different monitoring tools and timing for IA.

Hepatitis B immunoglobulin during pregnancy for prevention of mother-to-child transmission of hepatitis B virus
Authors' conclusions: Due to very low to low quality evidence found in this review, we are uncertain of the effect of benefit of antenatal HBIG administration to the HBV-infected mothers on newborn outcomes, such as HBsAg, HBV-DNA, and HBeAg compared with no intervention. The results of the effects of HBIG on HBsAg and HBeAg are surrogate outcomes (raising risk of indirectness), and we need to be critical while interpreting the findings. We found no data on newborn mortality or maternal mortality or both, or other serious adverse events. Well-designed randomised clinical trials are needed to determine the benefits and harms of HBIG versus placebo in prevention of MTCT of HBV.

Selective versus routine use of episiotomy for vaginal birth
Authors' conclusions: In women where no instrumental delivery is intended, selective episiotomy policies result in fewer women with severe perineal/vaginal trauma. Other findings, both in the short or long term, provide no clear evidence that selective episiotomy policies results in harm to mother or baby.  
The review thus demonstrates that believing that routine episiotomy reduces perineal/vaginal trauma is not justified by current evidence. Further research in women where instrumental delivery is intended may help clarify if routine episiotomy is useful in this particular group. These trials should use better, standardised outcome assessment methods.

Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour
Authors' conclusions: CTG during labour is associated with reduced rates of neonatal seizures, but no clear differences in cerebral palsy, infant mortality or other standard measures of neonatal wellbeing. However, continuous CTG was associated with an increase in caesarean sections and instrumental vaginal births. The challenge is how best to convey these results to women to enable them to make an informed decision without compromising the normality of labour.

The question remains as to whether future randomised trials should measure efficacy (the intrinsic value of continuous CTG in trying to prevent adverse neonatal outcomes under optimal clinical conditions) or effectiveness (the effect of this technique in routine clinical practice).

Along with the need for further investigations into long-term effects of operative births for women and babies, much remains to be learned about the causation and possible links between antenatal or intrapartum events, neonatal seizures and long-term neurodevelopmental outcomes, whilst considering changes in clinical practice over the intervening years (one-to-one-support during labour, caesarean section rates). The large number of babies randomised to the trials in this review have now reached adulthood and could potentially provide a unique opportunity to clarify if a reduction in neonatal seizures is something inconsequential that should not greatly influence women's and clinicians' choices, or if seizure reduction leads to long-term benefits for babies. Defining meaningful neurological and behavioural outcomes that could be measured in large cohorts of young adults poses huge challenges. However, it is important to collect data from these women and babies while medical records still exist, where possible describe women's mobility and positions during labour and birth, and clarify if these might impact on outcomes. Research should also address the possible contribution of the supine position to adverse outcomes for babies, and assess whether the use of mobility and positions can further reduce the low incidence of neonatal seizures and improve psychological outcomes for women.

Medical treatments for incomplete miscarriage
Authors' conclusions:The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Further studies, including long-term follow-up, are clearly needed to confirm these findings. There is an urgent need for studies on women who miscarry at more than 13 weeks' gestation.

Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing
Authors' conclusions: Contrary to continued use in some clinical areas, we found no evidence of benefit for the use of the admission CTG for low-risk women on admission in labour.

Furthermore, the probability is that admission CTG increases the caesarean section rate by approximately 20%. The data lacked power to detect possible important differences in perinatal mortality. However, it is unlikely that any trial, or meta-analysis, will be adequately powered to detect such differences. The findings of this review support recommendations that the admission CTG not be used for women who are low risk on admission in labour. Women should be informed that admission CTG is likely associated with an increase in the incidence of caesarean section without evidence of benefit.

Evidence quality ranged from moderate to very low, with downgrading decisions based on imprecision, inconsistency and a lack of blinding for participants and personnel. All four included trials were conducted in developed Western European countries. One additional study is ongoing.

The usefulness of the findings of this review for developing countries will depend on FHR monitoring practices. However, an absence of benefit and likely harm associated with admission CTG will have relevance for countries where questions are being asked about the role of the admission CTG.

Future studies evaluating the effects of the admission CTG should consider including women admitted with signs of labour and before a formal diagnosis of labour. This would include a cohort of women currently having admission CTGs and not included in current trials.

Cochrane Clinical Answers Pregnancy & Childbirth
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UpToDate - What's new in Obstetrics & Gynaecology
DynaMed Plus

Topic: Hysterectomy

  • Ovarian conservation during hysterectomy for benign conditions associated with decreased risk of mortality compared to bilateral oophorectomy in premenopausal women (BMJ 2017 Feb 6)
  • Nerve-sparing radical hysterectomy associated with similar survival, decreased time to micturition, and shorter hospital stay compared to conventional radical hysterectomy in women with early-stage cervical cancer (Maturitas 2016 Dec)

Topic: Abnormal uterine bleeding

  • Transcutaneous electrical nerve stimulation reduces procedural pain in women having office-based hysteroscopy without sedation (Obstet Gynecol 2017 Feb)

Topic: Ovarian cancer

  • SGO/ASCO clinical practice guideline on neoadjuvant chemotherapy for newly diagnosed, advanced ovarian cancer (National Guideline Clearinghouse 2017 Feb 13)
  • FoundationFocus CDxBRCA companion diagnostic for use with Rubraca (rucaparib) FDA approved for use in women with advanced ovarian cancer whose tumors have deleterious BRCA mutation (FDA Press Release 2016 Dec 19)

Topic: Breech presentation

  • Addition of neuraxial analgesia to tocolysis to facilitate ECV may increase procedural success, cephalic presentation during labor, and vaginal delivery rates and decrease cesarean delivery rates in women with breech or transverse fetal presentation (Am J Obstet Gynecol 2016 Sep)

Topic: Female sexual dysfunction

  • Dehydroepiandrosterone vaginal insert FDA approved to treat women with dyspareunia (FDA Press Release 2016 Nov 17)
Topic: Preterm labor
  • Management based on fFN testing might reduce risk of preterm birth in women with singleton pregnancies and threatened preterm labor at 23-34 weeks gestation (Am J Obstet Gynecol 2016 Oct
Topic: Labor and delivery (list of topics)
  • ACOG Committee Opinion 679 on immersion in water during labor and delivery (Obstet Gynecol 2016 Nov
Topic: Atrophic vaginitis
  • vaginal estrogen cream, ring, and tablet associated with similar improvement in symptoms of vaginal atrophy in postmenopausal women (Cochrane Database Syst Rev 2016 Aug 31)
Topic: Asthma during pregnancy
  • National Asthma Council Australia (NACA) guideline on asthma in pregnant women (NACA 2016)
Topic: Tubal sterilization
  • Guidance for use of hysteroscopically-placed permanent tubal implants for female sterilization (including Essure System for Permanent Birth Control) (FDA 2016 Oct 31)
Topic: Surgery for urinary incontinence
  • Transobturator mesh sling may have lower risk of early complications than retropubic mesh sling, and both may have lower risk of early complications and subsequent prolapse surgery, but not incontinence surgery, than nonmesh open colposuspension in women with urinary incontinence (Lancet 2016 Dec 20 early online)
Topic: Contraception overview
  • ASRM guideline on combined hormonal contraception and the risk of venous thromboembolism (Fertil Steril 2017 Jan)
Recently published reports, guidelines and statistics

Facilitating women’s choice of midwife
The Royal College of Midwives has published Facilitating women’s choice of midwife: RCM guidance: practical approaches to managing with flexibility.  This guidance is designed to help midwives and their managers to better meet the needs of responding to women’s wishes for a specific midwife to be present at the birth of their baby.

Perinatal mental health services
The London Mental Health Clinical Network and Healthy London Partnership have published Perinatal mental health services for London: guide for commissioners.  This document supports commissioners in London to provide high quality, equitable, timely and effective perinatal mental health services. 

Screening tests during and after pregnancy information for people with learning disabilities
Public Health England has published eight easy read guides explaining the screening tests offered during and after pregnancy for people with learning disabilities. These easy guides are adapted from the Screening tests for you and your baby booklet

State of maternity services
The Royal College of Midwifery has published State of Maternity Services Report 2016. The report examines emerging issues and trends in relation to maternity services.  It highlights that over a third of the UK’s NHS midwives are nearing retirement age; the increase in births to older mothers, who may require more care throughout their pregnancies;  and rates of obesity which are placing additional demands on maternity services

NICE surveillance reports
NICE Surveillance Reports provide a summary of new evidence published related to a guideline and provide an in depth commentary on a selection of this evidence.  They include the decision that NICE has taken about the need to update the relevant clinical guideline in light of new evidence. Contraception after pregnancy guidance
A new guideline Contraception after pregnancy has been published by the Faculty of Sexual and Reproductive Healthcare.  The guideline aims to guide healthcare professionals to inform and support the women in their care to make planned choices about future pregnancies and improve maternal and child outcomes through optimum spacing between children.

Information sourced with thanks to HEES Daily Health Bulletin 
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Table of Contents

American Journal of Obstetrics & Gynecology
Archives of Gynecology & Obstetrics
BJOG: An International Journal of Obstetrics and Gynaecology
Clinical Obstetrics and Gynecology
European Journal of Obstetrics & Gynecology and Reproductive Biology
Obstetrics & Gynecology
Prenatal diagnosis
Ultrasound in obstetrics and gynaecology
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