Ultrasound in Obstetrics & GynecologyAccepted Articles Picture of the Month Echogenic lung: use of high frequency ultrasound and color Doppler to diagnose congenital peripheral bronchial obstruction L. Maurey, L. Maurey orcid.org/0009-0003-6898-6427 Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, FranceSearch for more papers by this authorM. Brasseur-Daudruy, M. Brasseur-Daudruy Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, FranceSearch for more papers by this authorF. Elbaz, F. Elbaz Department of Pediatrics, Rouen University Hospital, Rouen, FranceSearch for more papers by this authorS. Patrier, S. Patrier Department of anatomopathology, Rouen University Hospital, Rouen, FranceSearch for more papers by this authorV. Ickowicz, V. Ickowicz Department of Obstetrics and Gynecology, Belvedere Hospital, Mont Saint Aignan, FranceSearch for more papers by this authorS. Braund, S. Braund orcid.org/0000-0002-5626-3235 Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, FranceSearch for more papers by this authorE. Verspyck, Corresponding Author E. Verspyck [email protected] Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, FranceCorrespondence to: Prof. E. Verspyck, Department of Obstetrics and Gynecology, Rouen University Hospital and EA "NeoVasc" 4309, Laboratory of Microvascular Endothelium and Neonate Brain Lesions, Rouen Institute for Biomedical Research, European Institute for Peptide Research (IFR 23), University of Rouen, Rouen, France; Clinique Gynécologique et Obstétricale Rouen University Hospital-Charles Nicolle, 1 Rue de Germont 76031 Rouen Cedex – France, (e-mail: [email protected])Search for more papers by this author L. Maurey, L. Maurey orcid.org/0009-0003-6898-6427 Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, FranceSearch for more papers by this authorM. Brasseur-Daudruy, M. Brasseur-Daudruy Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, FranceSearch for more papers by this authorF. Elbaz, F. Elbaz Department of Pediatrics, Rouen University Hospital, Rouen, FranceSearch for more papers by this authorS. Patrier, S. Patrier Department of anatomopathology, Rouen University Hospital, Rouen, FranceSearch for more papers by this authorV. Ickowicz, V. Ickowicz Department of Obstetrics and Gynecology, Belvedere Hospital, Mont Saint Aignan, FranceSearch for more papers by this authorS. Braund, S. Braund orcid.org/0000-0002-5626-3235 Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, FranceSearch for more papers by this authorE. Verspyck, Corresponding Author E. Verspyck [email protected] Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, FranceCorrespondence to: Prof. E. Verspyck, Department of Obstetrics and Gynecology, Rouen University Hospital and EA "NeoVasc" 4309, Laboratory of Microvascular Endothelium and Neonate Brain Lesions, Rouen Institute for Biomedical Research, European Institute for Peptide Research (IFR 23), University of Rouen, Rouen, France; Clinique Gynécologique et Obstétricale Rouen University Hospital-Charles Nicolle, 1 Rue de Germont 76031 Rouen Cedex – France, (e-mail: [email protected])Search for more papers by this author First published: 11 March 2024 https://doi.org/10.1002/uog.27635 This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1002/uog.27635. AboutPDF ToolsExport 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 onEmailFacebookTwitterLinkedInRedditWechat Accepted ArticlesAccepted, unedited articles published online and citable. The final edited and typeset version of record will appear in the future. RelatedInformation

Objectives: To evaluate whether the quality scores validated for second -trimester ultrasound scan can be used for third -trimester ultrasound scan. Methods: Prospective multicenter ancillary study using data from the RECRET study. Nulliparous women, with no reported history, with second- and third -trimester ultrasound examinations performed by the same ultrasonographer and using the same ultrasound machine were recruited. The global score and the individual score of each ultrasound image were compared between second- and third -trimester ultrasound scan. The sample size was calculated for a non -inferiority (one-sided) paired Student t test. Results: 103 women with 1606 anonymized ultrasound images were included. The median term at second- and third -trimester ultrasound scan was 22.2 weeks gestation (22.0 -22.7) and 31.6 weeks gestation (30.7 -34.7), respectively. The mean global score of ultrasound images was comparable between the second- and the thirdtrimester ultrasound examination (32.37 +/- 2.62 versus 31.80 +/- 3.27, p = 0.13). Means scores for each biometric parameters i.e. head circumference, abdominal circumference, and femur diaphysis length were comparable. The scores for the four -chamber view (5.11 +/- 0.91 versus 5.36 +/- 0.75, p = 0.02) and the spine (4.18 +/- 1.17 versus 5.22 +/- 1.02, p < 0.001) were significantly lower in the third trimester compared to the second trimester. The score for the kidney image was significantly higher for third trimester images compared to second trimester images (4.73 +/- 0.51 versus 4.32 +/- 0.67, p < 0.001. Conclusions: Biometrics parameters quality scores images previously validated for the second trimester ultrasound scan can be also used for the third trimester scan. However, anatomical quality scores images performances may vary between the second and the third trimester scan.

Objective. - To recommend the most appropriate biometric charts for the detection of antenatal growth abnormalities and postnatal growth surveillance. Methods. - Elaboration of specific questions and selection of experts by the organizing committee to answer these questions; analysis of the literature by experts and drafting conclusions by assigning a recommendation (strong or weak) and a quality of evidence (high, moderate, low, very low) and for each question; all these recommendations have been subject to multidisciplinary external review (obstetrician gynecologists, pediatricians). The objective for the reviewers was to verify the completeness of the literature review, to verify the levels of evidence established and the consistency and applicability of the resulting recommendations. The overall review of the literature, quality of evidence and recommendations were revised to take into consideration comments from external reviewers. Results. - Antenatally, it is recommended to use all WHO fetal growth charts for EFW and common ultrasound biometric measurements (strong recommendation; low quality of evidence). Indeed, in comparison with other prescriptive curves and descriptive curves, the WHO prescriptive charts show better performance for the screening of SGA (Small for Gestational Age) and LGA (Large for Gestational Age) with adequate proportions of fetuses screened at extreme percentiles in the French population. It also has the advantages of having EFW charts by sex and biometric parameters obtained from the same perspective cohort of women screened by qualified sonographers who measured the biometric parameters according to international standards. Postnatally, it is recommended to use the updated Fenton charts for the assessment of birth measurements and for growth monitoring in preterm infants (strong recommendation; moderate quality of evidence) and for the assessment of birth measurements in term newborn (expert opinion). Conclusion. - It is recommended to use WHO fetal growth charts for antenatal growth monitoring and Fenton charts for the newborn. (C) 2022 CNGOF. Published par Elsevier Masson. All rights reserved.

ObjectifL’objectif est de proposer les référentiels de courbes biométriques les plus appropriés aux pratiques de soins en France pour le dépistage des anomalies de la croissance ante et postnatales.Matériel et méthodeIl a été élaboré des questions précises, et des experts ont été désignés par le comité d’organisation pour répondre à ces questions. Une analyse de la littérature a été réalisée par des experts aboutissant à la rédaction de recommandations en affectant une recommandation (forte ou faible) et une qualité de la preuve (élevée, modérée, basse, très basse) pour chaque affirmation. L’ensemble de ces recommandations ont été ensuite soumises à une relecture externe multidisciplinaire (gynécologues obstétriciens, pédiatres). L’objectif fixé aux relecteurs était de vérifier l’exhaustivité de la revue de la littérature, de vérifier les niveaux de preuve établis et la concordance et l’applicabilité des recommandations qui en sont issues. L’ensemble de la revue de la littérature, de la qualité de la preuve et des recommandations ont été revus à la lumière des commentaires des relecteurs extérieurs.RésultatsEn anténatal, il est recommandé d’utiliser les courbes de biométries élémentaires et d’estimation de poids fœtal (EPF) de l’Organisation mondiale de la santé (OMS) (recommandation forte ; qualité de preuve faible). En effet, en comparaison avec les autres courbes prescriptives et les courbes descriptives, le référentiel prescriptif OMS montre de meilleures performances pour le dépistage des PAG (Petit pour l’âge gestationnel) et GAG (Gros pour l’âge gestationnel) avec des proportions adéquates de fœtus dépistés aux percentiles extrêmes en population française. Il présente également, comme avantages, de disposer de courbes d’EPF par sexe et de biométries, obtenues à partir d’une même cohorte prospective de femmes, dépistées par des échographistes qualifiés, qui ont mesuré les paramètres biométriques suivant les standards internationaux. En postnatal, il est recommandé d’utiliser les courbes actualisées de Fenton pour l’évaluation des mensurations à la naissance et la surveillance de la croissance chez le nouveau-né prématuré (recommandation forte ; qualité de preuve modérée) et pour l’évaluation des mensurations à la naissance chez le nouveau-né à terme (avis d’expert).ConclusionsIl est recommandé d’utiliser l’ensemble des courbes biométriques de l’OMS en antenatal et les courbes de mensurations de Fenton pour le nouveau-né qu’il soit prématuré ou non.

Between 2013 and 2015, cardiovascular diseases became one of the two leading causes of maternal mortality, with 36 deaths (13.7% of maternal deaths). The overall maternal mortality ratio for cardiovascular diseases is 1.5 per 100,000 live births, stable compared to the 2010-2012 period. The etiologies in order of decreasing frequency are: pre-existing cardiomyopathies (n = 10), aortic dissections (n = 9), peripartum cardiomyopathies (n = 6), myocardial infarction (n = 4), valvular cardiopathies (n = 4). Non-optimal care occurred in 72% of cases, increasing since the previous triennium (50%). Similarly, there is a significant increase in the proportion of preventable deaths (possibly or probably) from 35% to 66%. In women with known cardiovascular disease, the lack of multidisciplinary prepregnancy assessment and pregnancy follow-up is most frequent. In patients with unknown cardiovascular disease, the lack of diagnosis of a cardiac event is the most common failure. Cardiovascular conditions or cardiovascular risk factors should be investigated in early pregnancy in order to monitor and refer women to appropriate maternity hospitals. Recent dyspnea, worsening at the end of pregnancy and postpartum, should suggest a cardiac complication. In presence of chest pain, aortic dissection should be considered with the same degree of emergency as myocardial infarction or pulmonary embolism. Cardiac ultrasonography, chest CT, Nt-proBNP and troponin should be considered in case of chest pain or recent dyspnea. Women with cardiac symptoms should be referred to an emergency department (not necessarily to the local maternity) for a complete cardiovascular check-up. (C) 2020 Elsevier Masson SAS. All rights reserved.

La grossesse et le post-partum constituent une période a très haut risque thromboembolique veineux qui semble se prolonger bien au-delà des classiques 6–8 semaines après l’accouchement. L’embolie pulmonaire (EP) reste une des trois principales causes de mort maternelle (MM) directe dans la plupart des pays développés. Entre 2013 et 2015, 23 décès maternels ont été causés par une complication thromboembolique veineuse (TEV) (20 embolies pulmonaires et 3 thrombophlébites cérébrales), soit 8,8 % des morts maternelles et un ratio de mortalite maternelle de 1,0 pour 100 000 naissances vivantes (IC 95 % 0,6–1,4). Ce résultat est stable sur 10 ans. Concernant le moment du décès, 1 décès est survenu après une 1 IVG, 35 % (8/23) pendant une grossesse évolutive (dont quatre avant 22 SA), et 61 % (14/23) après un accouchement. Parmi les 23 décès par TEV, 17 % (5/23) sont survenus en dehors d’une structure de soins (domicile, voie publique). L’âge moyen était de 32,3 ans et 7 femmes (30 %) étaient âgées de≥35 ans. Six patientes étaient obèses (27 %). Le taux d’évitabilité est de 34,8 % (contre 50 % en 2007–2009 et en 2010–2012), réparti en « peut-être évitables » (sept cas) ou « probablement évitables » (un cas). Les facteurs d’évitabilité sont l’inadéquation des soins dans 34,8 % des cas (8/23), des facteurs organisationnels dans un cas (1/23) et un défaut d’interaction de la patiente avec le système de soins dans deux cas (2/23). Tous décès confondus (évitables et non évitables), les soins ont été considérés comme non optimaux dans 59 %. Cette proportion est supérieure au taux d’évitabilité car certains soins considérés comme sous optimaux n’ont pas eu d’influence sur certains décès considérés comme inévitables.

ObjectifsÉtablir un état des lieux sur la définition, le diagnostic, les facteurs de risque, les symptômes, et les traitements de l’isthmocèle.MéthodesRevue de la littérature, réflexions critiques, et conseils pragmatiques.RésultatsLa définition de l’isthmocèle n’est pas consensuelle. Certains proposent une indentation ≥ 2mm du myomètre de la cicatrice de césarienne, mais cet aspect présent chez plus de la moitié des utérus cicatriciels ne prend pas en compte les symptômes de la femme. La méthode de diagnostic la plus performante semble être l’échographie±hystérosonographie. Les situations à risque d’isthmocèle sont l’utérus multicicatriciel, la césarienne pendant le travail avec une incision trop basse, et l’utérus rétroversé. Les symptômes de l’isthmocèle sont des saignements gynécologiques anormaux et des douleurs pelviennes, et leur présence signe le « syndrome de la cicatrice de césarienne ». Les risques d’une grossesse en cas d’isthmocèle ont été peu étudiés, mais elle ne semble pas contre-indiquée, même si l’isthmocèle n’est pas traité. Le traitement de l’isthmocèle est avant tout chirurgical, conservateur, et semble réservé aux patientes symptomatiques, et aux infertilités secondaires en échec de traitement. Les patientes avec myomètre résiduel≥2,5mm peuvent bénéficier d’un traitement hystéroscopique de première intention, tandis qu’on proposera un abord cœlioscopique ou vaginal dans les autres cas.ConclusionsUne définition pragmatique de l’isthmocèle maladie en incluant la présence de symptômes est le pré-requis nécessaire à la prise en charge des femmes. Le traitement est avant tout chirurgical, conservateur ou non suivant le désir de grossesse ultérieur.

Pregnancy and postpartum represent periods at very high risk of venous thromboembolism disease which appears to extend well beyond the classic 6-8 weeks after childbirth. Pulmonary embolism (PE) is still one of the three leading causes of direct maternal death (MM) in most developed countries. Between 2013 and 2015, 23 maternal deaths were caused by a venous thromboembolic complication (VTE) (20 pulmonary embolism and 3 cerebral thrombophlebitis), representing 8.8 % of maternal deaths and a Maternal Mortality Ratio of 1.0 per 100,000 live births (95 % CI 0.6-1, 4) which is stable over the last 10 years. Regarding the timing of death, 1 death occurred after abortion, 35 % (8/23) during an ongoing pregnancy (including four before 22 WG), and 61 % (14/23) after childbirth. Among the 23 deaths from VTE, 17 % (5/23) occurred outside a healthcare center (home, street). The mean age was 32.3 and 7 women (30 %) were >= 35 years old. Six patients were obese (27 %). The preventability rate is 34.8 % (compared to 50 % in 2007-2009 and 2010-2012), The preventability factors involve the inadequacy of care in 34.8 % of cases (8/23), organizational factors in one case (1/23) and a lack of interaction of the patient with the health care system in two cases (2/23). Care was considered non-optimal in 59 % of these deaths. This proportion is higher than the preventability rate because suboptimal care sometimes did not influence the final outcome. (C) 2020 Published by Elsevier Masson SAS.

Objectives. - To review the definitions, diagnostic methods, risk factors, symptoms, and treatments for caesarean scar niche. Methods. - Review of the literature, critical reflection, and pragmatic advice. Results. - There is no consensus on the definition of caesarean scar niche. Some suggest an indentation >= 2 mm of the myometrium of the caesarean scar, but this is present in more than half of women with caesarean history and takes no account of woman's symptoms. The most popular diagnostic method is ultrasound + hysterosonography. Risks factors for niche are multiple Caesareans, Cesarean during labor with too low incision, and retroverted uterus. Symptoms include abnormal gynaecologic bleeding and pelvic pain, and their presence establish the "Caesarean scar syndrome". The risks of pregnancy with niche is poorly studied, but pregnancy is not contraindicated, even if the niche is untreated. The treatment of caesarean scar niche is mainly surgery and conservative. The former should be reserved for symptomatic patients, and those with secondary infertility and fertility treatment failure. Patients with residual myometrium thickness >= 2.5 mm may benefit from first-line hysteroscopic treatment, whereas a laparoscopic or vaginal approach could be offered in other cases. Conclusions. - A pragmatic definition of caesarean scar niche as a disease including symptoms is the necessary prerequisite for the management of women. The treatment is mainly surgical, or conservative depending on the desire for subsequent pregnancy. (C) 2021 Elsevier Masson SAS. All rights reserved.

OBJECTIVES:To determine the optimal management of singleton breech presentation.MATERIALS AND METHODS:The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted.RESULTS:In France, 5% of women have breech deliveries (Level of Evidence [LE3]). One third of them have a planned vaginal delivery (LE3) of whom 70% deliver vaginally (LE3). External cephalic version (ECV) is associated with a reduced rate of breech presentation at birth (LE2), and with a lower rate of cesarean section (LE3) without increases in severe maternal (LE3) and perinatal morbidity (LE3). It is therefore recommended to inform women with a breech presentation at term that ECV could be attempted from 36 weeks of gestation (Professional consensus). In case of breech presentation, planned vaginal compared with planned cesarean delivery might be associated with an increased risk of composite perinatal mortality or serious neonatal morbidity (LE2). No difference has been found between planned vaginal and planned cesarean delivery for neurodevelopmental outcomes at two years (LE2), cognitive and psychomotor outcomes between 5 and 8 years (LE3), and adult intellectual performances (LE4). Short and long term maternal complications appear similar in case of planned vaginal compared with planned cesarean delivery in the absence of subsequent pregnancies. A previous cesarean delivery results for subsequent pregnancies in higher risks of uterine rupture, placenta accreta spectrum and hysterectomy (LE2). It is recommended to offer women who wish a planned vaginal delivery a pelvimetry at term (Grade C) and to check the absence of hyperextension of the fetal head by ultrasonography (Professional consensus) to plan their mode of delivery. Complete breech presentation, previous cesarean, nulliparity, term prelabor rupture of membranes do not contraindicate planned vaginal delivery (Professionnal consensus). Term breech presentation is not a contraindication to labor induction when the criteria for acceptance of vaginal delivery are met (Grade C).CONCLUSION:In case of breech presentation at term, the risks of severe morbidity for the child and the mother are low after both planned vaginal and planned cesarean delivery. For the French College of Obstetricians and Gynecologists (CNGOF), planned vaginal delivery is a reasonable option in most cases (Professional consensus). The choice of the planned route of delivery should be shared by the woman and her caregiver, respecting the right to woman's autonomy.

Nos principaux objectifs étaient, à l’aide d’une revue de littérature, de préciser les facteurs de risque, les modalités du diagnostic précoce et de la prévention des lésions obstétricales du sphincter de l’anus (LOSA). Les principaux facteurs de risques des LOSA sont la nulliparité, l’accouchement instrumental, une présentation postérieure, l’épisiotomie médiane, une seconde phase du travail longue et la macrosomie fœtale. L’origine asiatique, une distance ano-vulvaire courte, une hyperlaxité ligamentaire, l’absence de contrôle de l’expulsion, la non-visualisation du périnée ou les manœuvres pour une dystocie des épaules semblent également être des facteurs de risque. Il existe un risque de sous-diagnostic des LOSA en salle de travail. L’expérience de l’accoucheur est un facteur protecteur. La prévention secondaire repose sur la formation des professionnels de la naissance à la reconnaissance et à la réparation des LOSA. La prévention primaire des LOSA repose sur la formation des professionnels aux manœuvres de la deuxième partie du travail ; il faut, si possible, éviter les extractions instrumentales. L’épisiotomie médiolatérale pourrait avoir un rôle préventif dans les accouchements à haut risque de LOSA. Il manque encore un modèle prédictif robuste permettant une utilisation sélective de l’épisiotomie.Our main objectives were to identify risk factors, methods for early diagnosis, and prevention of obstetric anal sphincter injuries (OASIs), using a literature review. The main risk factors for OASIs are nulliparity, instrumental delivery, posterior presentation, median episiotomy, prolonged second phase of labor and fetal macrosomia. Asian origin, short ano-vulvar distance, ligamentous hyperlaxity, lack of expulsion control, non-visualization of the perineum or maneuvers for shoulder dystocia also appear to be risk factors. There is a risk of under-diagnosis of OASIs in the labor ward. Experience of the accoucheur is a protective factor. Secondary prevention is based on the training of birth professionals in recognition and repair of OASIs. Primary prevention of OASIs is based on training in the maneuvers of the second phase of labor; if possible, instrumental extractions should be avoided. Mediolateral episiotomy may have a preventive role in high-risk OASIs deliveries. A robust predictive model is still lacking to allow a selective use of episiotomy.

L’objectif de ces RPC était d’analyser l’ensemble des interventions possibles au cours de la grossesse et de l’accouchement permettant de prévenir les lésions obstétricales du sphincter anal (LOSA) et les symptômes périnéaux postnataux. Ces recommandations ont été élaborées selon la méthode décrite dans le guide méthodologique de la HAS. En cas d’antécédent de maladie de Crohn, de LOSA, de mutilation sexuelle, ou de lésion péri-anale, un examen clinique prénatal du périnée est recommandé (Accord Professionnel). Juste après l’accouchement, il est recommandé d’examiner le périnée à la recherche d’une LOSA (Grade B) ; en cas de doute diagnostique, il est recommandé de demander un second avis (Grade C). En cas de LOSA, Il est recommandé de décrire de manière détaillée les lésions (avec leur degré) ainsi que leur réparation (Grade C). Le massage périnéal pendant la grossesse doit être encouragé chez les femmes souhaitant le pratiquer (Grade B). Aucune intervention avant le dégagement de la présentation n’a clairement démontré son efficacité pour réduire le risque de lésions périnéales. Il est recommandé de contrôler manuellement le dégagement de la présentation céphalique et de soutenir le périnée postérieur afin de diminuer le risque de LOSA (Grade C). Au cours d’un accouchement normal, la pratique d’une épisiotomie n’est pas recommandée pour réduire le risque de LOSA (Grade A). En cas d’accouchement instrumental, une épisiotomie peut être indiquée pour éviter une LOSA (Grade C). Lorsqu’une épisiotomie est réalisée, il est recommandé de choisir une incision médiolatérale (Grade B). Il est recommandé d’expliquer l’indication et de recueillir l’accord de la femme avant de pratiquer une épisiotomie. Il n’est pas recommandé de proposer une césarienne programmée en prévention primaire de lésions ou de dysfonctions périnéales (Grade B). Au cours de la grossesse et à nouveau en salle de travail, il est recommandé de s’intéresser aux attentes et d’informer les femmes sur les modalités de l’accouchement. The objective of these clinical practice guidelines was to analyse all of the interventions during pregnancy and childbirth that might prevent obstetric anal sphincter injuries (OASIS) and postnatal pelvic floor symptoms. These guidelines were developed in accordance with the methods prescribed by the French Health Authority (HAS). A prenatal clinical examination of the perineum is recommended for women with a history of Crohn's disease, OASIS, genital mutilation, or perianal lesions (professional consensus). Just after delivery, a perineal examination is recommended to check for OASIS (Grade B); if there is doubt about the diagnosis, a second opinion should be requested (Grade C). In case of OASIS, the injuries (including their severity) and the technique for their repair should be described in detail (Grade C). Perineal massage during pregnancy must be encouraged among women who want it (Grade B). No intervention conducted before the start of the active phase of the second stage of labour has been shown to be effective in reducing the risk of perineal injury. The crowning of the baby's head should be manually controlled and the posterior perineum manually supported to reduce the risk of OASIS (Grade C). The performance of an episiotomy during normal deliveries is not recommended to reduce the risk of OASIS (Grade A). In instrumental deliveries, episiotomy may be indicated to avoid OASIS (Grade C). When an episiotomy is performed, a mediolateral incision is recommended (Grade B). The indication for episiotomy should be explained to the woman, and she should consent before its performance. Advising women to have a caesarean delivery for primary prevention of postnatal urinary or anal incontinence is not recommended (Grade B). During pregnancy and again in the labour room, obstetrics professionals should focus on the woman's expectations and inform her about the modes of delivery.