Postpartum hemorrhage (PPH) remains the leading cause of maternal mortality globally. This global survey was conducted to identify any disparities in the causes, prevalence, treatment, and mortality burden of PPH, with the aim of proposing relevant recommendations to bridge these disparities and ultimately reduce the global maternal mortality and morbidity burden of PPH. A cross-sectional survey of maternity care providers worldwide was conducted by the World Association of Trainees in Obstetrics and Gynecology (WATOG) in collaboration with International Federation of Gynecology and Obstetrics (FIGO) Childbirth and PPH Committee. The study instrument was a 15-item structured electronic questionnaire, designed using Google Forms®. The questionnaire included multiple choice and short answer questions on the baseline characteristics of respondents, causes, prevalence, treatment modalities, and mortality from PPH. The questionnaire was electronically distributed via WATOG and FIGO social media channels to study participants. In total, 339 responses were received from 64 countries in six regions, including Africa, Asia, Europe, North America, South America, and Oceania. The majority (n = 182, 53.7%) of respondents reported seeing an average of at least 10 cases of PPH in their hospitals each month. More respondents in low- and middle-income countries (LMICs) in Africa and Asia reported seeing more than 10 PPH cases monthly, compared to those in high-income countries in Europe and America (57.1% vs. 49.2%, P < 0.001). Most (n = 318, 93.8%) respondents volunteered that their hospitals recorded less than five PPH-related maternal mortalities monthly. All (n = 8, 2.4%) respondents who reported more than five PPH-related maternal mortalities were based in LMICs in Africa. Only 133 (39.2%) respondents reported availability of the non-pneumatic anti-shock garment (NASG) in their hospitals. Of those who reported non-availability of the NASG, 60% were in LMICs. The most common treatment for intractable PPH were uterine compression sutures (n = 177, 52.2%) and hysterectomy (n = 128, 37.8%). Less than 1 in 10 (n = 30, 8.8%) reported availability of vascular ligation and embolization procedures. PPH remains a significant obstetric complication globally, with a higher morbidity and mortality burden in LMICs. There is an urgent need for concerted global efforts to reduce maternal morbidity and mortality from PPH, especially in LMICs.

The rising global rate of cesarean section (CS) has prompted renewed focus on vaginal birth after cesarean (VBAC) as a safe and effective alternative to repeat CS in properly selected women. The FIGO good practice recommendations provide evidence‐based recommendations to guide VBAC care. Success rates for VBAC range from 60% to 80%, with the highest likelihood in women with prior vaginal birth, non‐recurrent CS indications, interbirth intervals ≥18 months, BMI <30 kg/m 2 , and spontaneous labor onset. While uterine rupture is the primary concern, its risk remains low at approximately 0.3%–0.7% for women with one prior low transverse CS. Comparisons show that VBAC generally results in similar or better maternal and neonatal outcomes than planned repeat CS, including lower maternal mortality, fewer infections, and shorter hospital stays. This article emphasizes appropriate patient counseling, facility readiness for emergency CS, and continuous fetal monitoring during labor. With proper implementation, VBAC offers a valuable strategy to reduce unnecessary repeat surgeries, improve outcomes, and support informed maternal choice.

Postpartum hemorrhage (PPH), a leading cause of maternal mortality globally, disproportionately affects women in low- and middle-income countries (LMICs), highlighting the deep-rooted gender related inequities in healthcare access, quality, and outcomes. Despite being largely preventable and treatable, PPH continues to claim the lives of thousands of women annually, because of systemic failures, including inadequate maternal health infrastructure, under-resourced healthcare systems, and sociocultural norms that devalue women's health. Gender inequity is manifested in delayed care-seeking, a lack of decision-making autonomy, limited access to skilled birth attendants, and emergency obstetric care. Moreover, implicit biases and structural discrimination often limit investment in women-centered health interventions. This issue is compounded by socioeconomic disparities, educational gaps, and the underrepresentation of women's health priorities in policy and research agendas. Addressing PPH through a gender-equity lens is imperative to improve maternal health outcomes and achieve global health equity. This paper underscores the urgent need for integrated, gender-sensitive public health strategies to mitigate the burden of PPH and protect the rights and lives of women.

Anemia affects 32 million pregnant women globally, contributing annually to more than 115 000 maternal deaths and 591 000 perinatal deaths worldwide. Low- and middle-income countries (LMICs) bear the highest burden of anemia in pregnancy, with nearly 50% of affected pregnant women. It is now 2025, which is WHO's target year for a 50% reduction in maternal anemia, and the global prevalence of anemia in pregnancy remains more than twice the target of 15%. This calls for a renewed global focus on optimal approaches for reducing the burden and complications of anemia in pregnancy. In this FIGO Childbirth and Postpartum Hemorrhage (PPH) Committee paper, current best evidence on anemia in pregnancy has been reviewed and synthesized, to make recommendations on screening, diagnosis, prevention, and treatment of anemia in pregnancy. We recommend that all pregnant women should be screened for anemia in pregnancy at booking and again at 28 weeks of pregnancy, with a full blood count (FBC), or packed cell volume/hemoglobin concentration in settings where FBC is not available. A hemoglobin concentration cutoff of less than 11 g/dL in all trimesters of pregnancy and during the postpartum period, as well as in all settings and populations, is recommended for the diagnosis of anemia in pregnancy. Routine iron and folic acid supplementation, either alone, or as components of multiple micronutrient supplements, is also recommended during pregnancy. We also made recommendations for malaria and anti-helminthic chemoprophylaxis, hemoglobinopathy screening, iron, folate, and multiple micronutrient supplementation, and blood transfusion in pregnant women with hemoglobinopathies. Finally, the relationship between anemia and postpartum hemorrhage is highlighted.

Cesarean birth (CB) rates are increasing globally, with a current prevalence of 21.1% and a projected prevalence of 28.5% by 2030. Conversely, assisted vaginal birth (AVB) rates are declining, with reported rates of less than 10% in low- and middle-income countries (LMICs) and 10%-15% in high-income countries (HICs). In some African countries, AVB rates are as low as <1%. Declining AVB rates are attributable to lack of appropriate skills, equipment, and trained personnel, especially in LMICs, fear of litigation, and misconceptions that CB is safer, paucity of local guidelines and policies encouraging AVB, and increasingly accessible, acceptable, and safer CB techniques, amongst others. Optimizing appropriate care and decision making around CB and mode of birth is now a public health priority, especially given the significantly higher morbidity and mortality associated with CB compared to vaginal birth. Increasing AVB rates can potentially reduce CB rates, therefore improving maternity safety. This paper reviews the current best evidence on AVB and makes recommendations for good practice, including indications and prerequisites for AVB, who to determine who is suitable for AVB, choice of instrument, sequential application of instrument, when to abandon AVB, analgesia, antibiotic prophylaxis and episiotomy for AVB, special situations such as fetal macrosomia, maternal viral infections, previous CB, and risks and benefits of AVB versus second stage CB. An AVB safety checklist is included to reduce the risk of complications. We conclude by recommending that all maternity care providers and skilled birth attendants, including obstetricians, obstetric trainees/residents, interns, and midwives, should be trained and competent to perform AVB, to potentially reduce the current CB epidemic and its associated higher mortality and morbidity.

The incidence of cesarean section is dramatically increasing worldwide, whereas the training opportunities for obstetrician/gynecologists to manage complex cesarean section appear to be decreasing. This may be attributed to changing working hours directives and the increasing use of laparoscopy for gynecological surgical procedures, including in gynecological oncology. Various situations can create surgical difficulties during a cesarean section; however, two of the most frequent are complications from previous cesarean (myometrial defects, with or without placental intrusion and peritoneal adhesions) and the high risk of postpartum hemorrhage (uterine overdistension, abnormal placentation, uterine fibroids). Careful surgical dissection, with safe mobilization of the bladder and exposure of the anterior and lateral surfaces of the uterus, are pivotal steps for resolving the technical difficulties inherent in performing a complex cesarean section. We propose a standardized surgical protocol for women at risk of complex cesarean, including the antenatal identification of increased surgical risk, paramedian access to the pelvis, bladder dissection and mobilization, and the selection of a bleeding control strategy, considering uterine anatomy and the arterial pedicles involved in blood loss, which should be tailored to the individual case. We propose preoperative surgical planning to include consideration of the most common situations encountered during a complex cesarean, which facilitates anticipating an appropriate response for common possible scenarios, and can be adapted for low-, middle-, and high-resource settings. This protocol also highlights the importance of self-evaluation, continuous learning, and improvement activities within surgical teams.

SynopsisFIGO and the International Confederation of Midwives produced two joint statements endorsing WHO guidelines on prevention and treatment of postpartum hemorrhage.

This good clinical practice paper provides an overview of the current evidence around second stage care, highlighting the challenges and the importance of maintaining high-quality, safe, and respectful care in all settings. It includes a series of recommendations based on best available evidence regarding length of second stage, judicious use of episiotomy, and the importance of competent attendants and adequate resource to facilitate all aspects of second stage management, from physiological birth to assisted vaginal delivery and cesarean at full dilatation. The second stage of labor is potentially the most dangerous time for the baby and can have significant consequences for the mother, including death or severe perineal trauma or fistula, especially where there are failures to recognize and repair. This paper sets out principles of care, including the vital role of skilled birth attendants and birth companions, and the importance of obstetricians and midwives working together effectively and speaking with one voice, whether to women or to policy makers. The optimization of high-quality, safe, and personalized care in the second stage of labor for all women globally can only be achieved by appropriate attention to the training of birth attendants, midwives, and obstetricians. FIGO is committed to this aim alongside the WHO, ICM, and all FIGO's 132 member societies.

Introduction Previous novel COVID-19 pandemics, SARS and middle east respiratory syndrome observed an association of infection in pregnancy with preterm delivery, stillbirth and increased maternal mortality. COVID-19, caused by SARS-CoV-2 infection, is the largest pandemic in living memory.Rapid accrual of robust case data on women in pregnancy and their babies affected by suspected COVID-19 or confirmed SARS-CoV-2 infection will inform clinical management and preventative strategies in the current pandemic and future outbreaks.Methods and analysis The pregnancy and neonatal outcomes in COVID-19 (PAN-COVID) registry are an observational study collecting focused data on outcomes of pregnant mothers who have had suspected COVID-19 in pregnancy or confirmed SARS-CoV-2 infection and their neonates via a web-portal. Among the women recruited to the PAN-COVID registry, the study will evaluate the incidence of: (1) miscarriage and pregnancy loss, (2) fetal growth restriction and stillbirth, (3) preterm delivery, (4) vertical transmission (suspected or confirmed) and early onset neonatal SARS-CoV-2 infection.Data will be centre based and collected on individual women and their babies. Verbal consent will be obtained, to reduce face-to-face contact in the pandemic while allowing identifiable data collection for linkage. Statistical analysis of the data will be carried out on a pseudonymised data set by the study statistician. Regular reports will be distributed to collaborators on the study research questions.Ethics and dissemination This study has received research ethics approval in the UK. For international centres, evidence of appropriate local approval will be required to participate, prior to entry of data to the database. The reports will be published regularly. The outputs of the study will be regularly disseminated to participants and collaborators on the study website (https://pan-covid.org) and social media channels as well as dissemination to scientific meetings and journals.Study registration number ISRCTN68026880.

International Journal of Gynecology & ObstetricsVolume 150, Issue 1 p. 134-134 Correspondence Correspondence: Adverse effect of delayed pushing on postpartum blood loss in nulliparous women with epidural analgesia Alison Wright, Alison Wright NHS, Royal Free London Hospital, London, UKSearch for more papers by this authorAnwar H. Nassar, Corresponding Author Anwar H. Nassar an21@aub.edu.lb Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon Correspondence: Anwar H. Nassar, American University of Beirut Medical Center, Department of Obstetrics and Gynecology, Beirut, Lebanon. Email: an21@aub.edu.lbSearch for more papers by this authorFIGO Safe Motherhood & Newborn Health Committee Alison Wright, Alison Wright NHS, Royal Free London Hospital, London, UKSearch for more papers by this authorAnwar H. Nassar, Corresponding Author Anwar H. Nassar an21@aub.edu.lb Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon Correspondence: Anwar H. Nassar, American University of Beirut Medical Center, Department of Obstetrics and Gynecology, Beirut, Lebanon. Email: an21@aub.edu.lbSearch for more papers by this authorFIGO Safe Motherhood & Newborn Health Committee First published: 04 May 2020 https://doi.org/10.1002/ijgo.13190Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume150, Issue1SPECIAL SECTION: FROM THE FIGO PRETERM BIRTH WORKING GROUPJuly 2020Pages 134-134 RelatedInformation

Several factors contribute to the suboptimal care that pregnant refugees receive in host countries. Obstetricians should empower women to receive the dignified services they deserve.

Objectives: To determine clinical and laboratory features of pregnant woman with COVID-19 who require respiratory support. To recommend a management strategy that optimises maternal and fetal outcomes. Design: An observational cohort study of 7000 maternities between 1st March and 1st July 2020. Setting: Five maternity centres across a maternal medicine network in north-central London, UK Population: 69 pregnant women with confirmed acute SARS-COV2 Methods: Review of electronic healthcare records Main Outcome Measures: Clinical and laboratory features, maternal and fetal outcomes. Results: Respiratory support was needed by 15/69 . This cohort was more likely to present with dyspnoea (10/15 vs 10/54, p<0.001), a lower lymphocyte count (0.90.1 vs 1.40.1 x 109 cells/L; p<0.01) and hypokalaemia (3.80.1 vs 4.00.1 mmol/l, p<0.05). Radiological evidence of lung consolidation did not identify women in need of respiratory support. Women on respiratory support underwent childbirth at an earlier gestation than those who did not (36+4 vs 39+5 weeks, p<0.001), and required emergency c-section (6/15 vs 8/54, p<0.05). Childbirth did not improve respiratory function in those with severe disease, with 3 women remaining on invasive ventilation despite childbirth. Conclusions: Routine clinical data can identify pregnant women at risk of severe COVID-19. Pregnant women should be offered the same treatment as non-pregnant patients but iatrogenic childbirth should not be the default for women with severe disease. We propose a management pathway for pregnant women with severe COVID-19.

Background Pregnant women represent a potentially high-risk population in the COVID-19 pandemic. Objective To summarize clinical characteristics and outcomes among pregnant women hospitalized with COVID-19. Search strategy Relevant databases were searched up until May 29, 2020. Selection criteria Case series/reports of hospitalized pregnant women with laboratory-confirmed COVID-19. Data collection and analysis PRISMA guidelines were followed. Methodologic quality was assessed via NIH assessment tools. Main results Overall, 63 observational studies of 637 women (84.6% in third trimester) with laboratory-confirmed SARS-CoV-2 infection were included. Most (76.5%) women experienced mild disease. Maternal fatality, stillbirth, and neonatal fatality rates were 1.6%, 1.4%, and 1.0%, respectively. Older age, obesity, diabetes mellitus, and raised serum D-dimer and interleukin-6 were predictive of poor outcomes. Overall, 33.7% of live births were preterm, of which half were iatrogenic among women with mild COVID-19 and no complications. Most women underwent cesarean despite lacking a clear indication. Eight (2.0%) neonates had positive nasopharyngeal swabs after delivery and developed chest infection within 48 hours. Conclusions Advanced gestation, maternal age, obesity, diabetes mellitus, and a combination of elevated D-dimer and interleukin-6 levels are predictive of poor pregnancy outcomes in COVID-19. The rate of iatrogenic preterm birth and cesarean delivery is high; vertical transmission may be possible but has not been proved.

Objectives To determine the prevalence of burnout in doctors practising obstetrics and gynaecology, and assess the association with defensive medical practice and self-reported well-being.Design Nationwide online cross-sectional survey study; December 2017–March 2018.Setting Hospitals in the UK.Participants 5661 practising obstetrics and gynaecology consultants, specialty and associate specialist doctors and trainees registered with the Royal College of Obstetricians and Gynaecologists.Primary and secondary outcome measures Prevalence of burnout using the Maslach Burnout Inventory and defensive medical practice (avoiding cases or procedures, overprescribing, over-referral) using a 12-item questionnaire. The odds ratios (OR) of burnout with defensive medical practice and self-reported well-being.Results 3102/5661 doctors (55%) completed the survey. 3073/3102 (99%) met the inclusion criteria (1462 consultants, 1357 trainees and 254 specialty and associate specialist doctors). 1116/3073 (36%) doctors met the burnout criteria, with levels highest amongst trainees (580/1357 (43%)). 258/1116 (23%) doctors with burnout reported increased defensive practice compared with 142/1957 (7%) without (adjusted OR 4.35, 95% CI 3.46 to 5.49). ORs of burnout with well-being items varied between 1.38 and 6.37, and were highest for anxiety (3.59, 95% CI 3.07 to 4.21), depression (4.05, 95% CI 3.26 to 5.04) and suicidal thoughts (6.37, 95% CI 95% CI 3.95 to 10.7). In multivariable logistic regression, being of younger age, white or ‘other’ ethnicity, and graduating with a medical degree from the UK or Ireland had the strongest associations with burnout.Conclusions High levels of burnout were observed in obstetricians and gynaecologists and particularly among trainees. Burnout was associated with both increased defensive medical practice and worse doctor well-being. These findings have implications for the well-being and retention of doctors as well as the quality of patient care, and may help to inform the content of future interventions aimed at preventing burnout and improving patient safety.

The Obstetrician & GynaecologistVolume 21, Issue 1 p. 7-9 Commentary Managing burnout in obstetrics and gynaecology Katie Cresswell MRCOG, Specialist Registrar Department of Obstetrics and Gynaecology, North Middlesex University Hospital, London, N18 1QX UKSearch for more papers by this authorRadha Graham MRCOG, Specialist Registrar Department of Obstetrics and Gynaecology, Homerton University Hospital, London, E9 6SR UKSearch for more papers by this authorAlison Wright FRCOG, Consultant Obstetrician and Gynaecologist Department of Obstetrics and Gynaecology, Royal Free NHS Foundation Trust, London, NW3 2QG UKSearch for more papers by this authorTony Garelick FRCPsych, Consultant Psychiatrist DocHealth, BMA House, London, WC1H 9JP UKSearch for more papers by this authorWai Yoong MD FRCOG, Corresponding Author Consultant Obstetrician and Gynaecologist waiyoong@nhs.net Department of Obstetrics and Gynaecology, North Middlesex University Hospital, London, N18 1QX UKCorrespondence: Wai Yoong. Email: waiyoong@nhs.netSearch for more papers by this author Katie Cresswell MRCOG, Specialist Registrar Department of Obstetrics and Gynaecology, North Middlesex University Hospital, London, N18 1QX UKSearch for more papers by this authorRadha Graham MRCOG, Specialist Registrar Department of Obstetrics and Gynaecology, Homerton University Hospital, London, E9 6SR UKSearch for more papers by this authorAlison Wright FRCOG, Consultant Obstetrician and Gynaecologist Department of Obstetrics and Gynaecology, Royal Free NHS Foundation Trust, London, NW3 2QG UKSearch for more papers by this authorTony Garelick FRCPsych, Consultant Psychiatrist DocHealth, BMA House, London, WC1H 9JP UKSearch for more papers by this authorWai Yoong MD FRCOG, Corresponding Author Consultant Obstetrician and Gynaecologist waiyoong@nhs.net Department of Obstetrics and Gynaecology, North Middlesex University Hospital, London, N18 1QX UKCorrespondence: Wai Yoong. Email: waiyoong@nhs.netSearch for more papers by this author First published: 29 October 2018 https://doi.org/10.1111/tog.12535Citations: 1 This article is published with the permission of the Controller of HMSO and the Queen’s Printer for Scotland. [The copyright line for this article was changed on 15 March 2019 after original online publication] Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume21, Issue1January 2019Pages 7-9 This article also appears in:Training RelatedInformation

We are not aware of a report detailing the complex obstetrical and medical management of twin pregnancy in the context of HIV infection and early post-liver transplantation period. Here we describe the successful outcome of a twin pregnancy in a 28-year-old HIV-positive female receiving antiretroviral therapy and immunosuppressive therapy who was the recipient of a liver transplant for previous drug-induced liver failure.

OBJECTIVE:To determine the incidence and factors associated with the development of bowel, urinary and sexual symptoms following obstetric anal sphincter injury (OASIS). STUDY DESIGN:A prospective cohort study involving 435 women who sustained OASIS, over a five-year period, in a large UK teaching hospital. Details of bowel, urinary and sexual function were documented using a structured questionnaire. The outcome measures included the incidence of symptoms following OASIS and factors which modify the risk of developing symptoms. RESULTS:The majority (96%) of women were faecally continent three months after primary OASIS repair. Nevertheless, 34.2% reported faecal urgency, 25% suffered poor flatal control, and nearly 30% reported pain and bleeding on defaecation. Sixteen percent of women reported stress urinary incontinence, 15% experienced urgency and 20% reported urinary frequency. Fifty-seven percent of women had resumed intercourse but 32% of those women reported dyspareunia. Women who developed faecal symptoms were significantly more likely to develop urinary symptoms. Advancing maternal age and the use of forceps, in particular rotational forceps, significantly increase the risk of developing faecal and urinary symptoms. CONCLUSIONS:Obstetric anal sphincter injuries continue to be responsible for significant morbidity, with approximately 30% of women reporting faecal, urinary or sexual symptoms, three months postpartum. This large prospective UK study provides up-to-date information relating to factors which increase the likelihood of such symptoms occurring. These data are useful for counselling and targeting more intensive follow up to women at higher risk of developing symptoms.