Cut mediolateral, or do not cut at all

The edition in brief

Today's obstetrics and gynaecology edition opens with combined oral contraception, where a clinical review argues that natural-oestrogen formulations now have a good enough safety profile to be the default for a woman starting the pill for the first time. A meta-analysis of 28 studies in pre-eclampsia and eclampsia reports a pooled posterior reversible encephalopathy syndrome incidence of 38.68% with extreme heterogeneity, but a consistent and usable signal: women who developed the syndrome had markedly higher transaminases and lower platelet counts. A second pooled analysis, of 53 studies and 33,694 lupus pregnancies, gives an absolute risk of structural cardiovascular malformation in offspring of 3.29%, with an adjusted odds ratio of 1.70 against healthy controls once confounders were accounted for, and congenital heart block clustering in anti-SSA/Ro-positive mothers. A small non-inferiority trial finds that a modified prophylactic phenylephrine bolus regimen at elective caesarean needed fewer physician interventions than a variable-rate infusion, not more, which removes the usual practical objection to boluses where no syringe pump is available. The practice-changer is a secondary analysis of the MFMU APEX cohort: obstetric anal sphincter injury complicated 20.1% of operative vaginal deliveries, any episiotomy carried an adjusted odds ratio of 1.45, but the direction reversed by type. Midline episiotomy at vacuum delivery was associated with more sphincter injury; mediolateral episiotomy was associated with less, in women who had not delivered vaginally before. The edition closes with a bedside reminder about the age of the platelet count before neuraxial anaesthesia in pre-eclampsia.