The edition · Obstetrics & Gynaecology
Which cut, which estrogen, which bloods
Episiotomy type pulls in opposite directions at an assisted birth; age at menopause survives as a cardiovascular marker where parity does not; and a bolus regimen that halves the work at caesarean.
The edition in brief
Today's obstetrics and gynaecology edition turns on three decisions a clinician makes without much thought. The first is what kind of episiotomy to make at an operative vaginal delivery. A secondary analysis of 5,277 American operative vaginal deliveries found sphincter injury in one in five, and episiotomy overall associated with higher odds — but the two types separate sharply. Midline episiotomy at vacuum delivery was associated with more sphincter injury regardless of previous vaginal birth; mediolateral was associated with less in women without a previous vaginal birth. The direction, not the act, is what the data speak to. The second is what to do with a reproductive history. A meta-analysis of 34 observational studies found later menopause associated with fewer cardiovascular events (0.94 per five years, 95% CI 0.90 to 0.98) while parity, age at first birth and pregnancy loss showed no clear association. Certainty was low to very low throughout, so this refines what to record rather than what to prescribe. A pooled analysis of 28 studies describes what marks posterior reversible encephalopathy syndrome in pre-eclampsia — higher transaminases and lower platelets — with heterogeneity so extreme that the pooled incidence figure should not be read as a risk estimate. A small randomised non-inferiority trial found a modified phenylephrine bolus regimen at elective caesarean needed a median of three physician interventions against six for a variable-rate infusion, with no difference in maternal or neonatal outcomes. The edition closes on combined oral contraception, and the argument that natural-estrogen formulations should now be the first offer to a woman starting the pill.
At an assisted birth, the type of episiotomy points in opposite directions
If an episiotomy is needed at an operative vaginal delivery, make it mediolateral — and expect no benefit from cutting at all in a woman who has delivered vaginally before.
Age at menopause holds up as a cardiovascular marker; parity and pregnancy loss do not
Carry age at menopause into the cardiovascular risk conversation; leave parity, age at first birth and past pregnancy loss out of it.
Transaminases and platelets mark the pre-eclamptic woman who develops PRES
Rising transaminases and falling platelets in a pre-eclamptic woman with neurological symptoms should lower your threshold for imaging.
A bolus phenylephrine regimen at caesarean, with half the interventions
Where a variable-rate pump is not practical, a 100 μg phenylephrine bolus at spinal repeated below 90% of baseline systolic is a defensible regimen for elective caesarean.
Examine the sphincter after every assisted birth, not only the ones that look torn
Do a systematic per-rectal examination after every operative vaginal delivery, before you begin repairing anything.
Which estrogen for a woman starting the pill for the first time
For a woman starting a combined pill for the first time, ask for a natural-estrogen formulation where it is available and affordable; leave established users alone.
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