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Since 1999, the AOM has produced evidence-based clinical practice guidelines (CPGs) consistent with the midwifery philosophy of care that reflect the values of the AOM, including informed choice, client as the primary decision-maker, choice of birthplace, and appropriate use of technology.
AOM CPGs are developed using the Values-Based Approach to CPG Development, a document that outlines the selection process for CPG topics, use of evidence, and development of recommendations.
This CPG provides a critical review of the research literature on the management of Group B Streptococcus during the neonatal period. Group B Streptococcus: Postpartum Management of the Neonate is the first AOM CPG developed using the GRADE methodology for guideline development. Three of the research questions developed to guide the Group B Streptococcus: Postpartum Management of the Neonate CPG addressed clinical findings that could be summarized in GRADE quality evidence and summary of findings tables. This app offers easy access to select content from the Association of Ontario Midwives' two Clinical Practice Guidelines on Group B Streptococcus.
A client resource available in English, French, Spanish, Farsi, Arabic and Simplified Chinese.
This CPG provides a critical review of the research literature on the screening, diagnosis and management of hypertensive disorders of pregnancy within the context of provision of midwifery care in Ontario. This summary offers convenient access to some of the most essential content of the above clinical practice guideline.
This app offers an overview of major midwifery-related aspects of the prevention, detection and management of hypertensive disorders of pregnancy.
This CPG provides a critical review of the research literature on the management of uncomplicated pregnancy in clients who have had a previous low-segment caesarean section.
This app serves as a reference tool for informed choice discussions with clients considering VBAC, with information on risks, benefits and other relevant considerations.
This CPG provides a critical review of the research literature on the management of prelabour rupture of membranes at term gestation.
This CPG provides a critical review of the research literature on the management of uncomplicated pregnancy in clients who have a pre-pregnancy body mass index less than 18.5 or greater than or equal to 30. This CPG provides a critical review of the research literature on the management of Group B Streptococcus during labour. This CPG provides a critical review of the research literature for clients reaching 41+0 weeks' gestation and beyond in an uncomplicated pregnancy and offers recommendations regarding management options.
To assess the safety and effect of epidural analgesia on the course of labour and delivery in Pakistani women, a retrospective case control study was conducted from November, 1986 to November, 1991 (5 years) at the Aga Khan University Medical Centre, Karachi. After obtaining institutional approval, charts of all patients having epidural analgesia for pain relief were reviewed. Table I shows the characteristics of patients receiv­ing epidural analgesia (cases) and those without (con­trols). This journal is a member of and subscribes to the principles of the Committee on Publication Ethics. ABCD sponsors treatment for those in need regardless of gender, race or creed, helping them to reach their full potential, to live life with dignity and to take their rightful place in their community. ABCD works through local Palestinian partners, the Bethlehem Arab Society for Rehabilitation (BASR) based in Beit Jala, The Sheepfold in Beit Sahour and two UNWRA Refugee Camps in Jalazone and Nour Shams. Funding is constantly needed for new projects and to update and refurbish existing facilities.
Demonstrates large uterine fibroid with speckled areas of high and low signal intensity (Red Arrow). Soft tissue mass and haemorrhage within a right tubular complex consistent with an ectopic pregnancy within the fallopian tube which is likely to have ruptured (Red Arrows). Right adnexal tubular cystic mass (Red Arrow) with peripheral high T1 signal intensity (White Arrows). 31 year old pregnant patient, at 36 weeks gestation presented with severe virilisation symptoms including a deep voice, with unknown cause. Well defined cystic tubular mass (Red Arrows) occupying the right side of the abdomen and upper pelvis. 30 year old pregnant patient, 14 weeks gestation, who presented for routine early pregnancy sonography. MRI features of the bilateral adnexal masses were consistent with mature cystic ovarian teratomas with no evidence to suggest malignant features. In left adnexa complex heterogeneous, predominantly cystic mass with high signal intensity within it, indicating a fatty component (Yellow Arrows). In right adnexa smaller cystic mass, with high signal intensity on T1WIs indicating fatty component (Yellow Arrows).
28 year old female pregnant patient, 20 weeks gestation, presented for routine antenatal sonography and bilateral adnexal cystic masses identified. Demonstrating complex cystic mass situated in the pelvis within the pouch of Douglas (Red Arrows), originating from the left ovary.
Demonstrating a complex right sided adnexal mass (within Red Arrows), multiple thick septations (Yellow Arrows), there are solid nodules on the septations (Blue Arrows).
MRI features demonstrate a right sided multi loculated cystic mass of ovarian origin with solid components which are suspicious for malignancy. Demonstrating loss of the high signal intensity in the macroscopic fat component of the mass on the right adnexal mass (Red Arrows) and on the left (Yellow Arrows).
Left solid adnexal mass, originating from the left ovary (Yellow Arrow), suggestive of malignancy. Defining the origin of a pelvic mass and localising it to the ovaries can often cause diagnostic uncertainty. Subserosal or submucosal leiomyomas may be pedunculated on long stalks and as a result appear adnexal in origin. They are a common cause for an apparent adnexal mass on USS and MRI proves helpful in distinguishing these from true ovarian masses. On MRI leiomyomas are well circumscribed lesions with low T2 signal intensity compared to myometrium. Sub serosal fibroids have a beak or claw shaped interface with the uterus and bridging vessels between the uterus and fibroid which are a useful diagnostic sign.
Red degeneration is the most common type of degeneration during pregnancy and occurs due to rapid growth with resulting haemorrhagic infarction. On USS these are seen as well circumscribed masses with areas of cystic change or heterogeneous echogenicity.
Doppler shows circumferential vascularity or absence of flow if a pedunculated leiomyoma is torted.


Red degeneration also has high T1signal intensity centrally and low T2 signal intensity peripherally. Central areas of high signal intensity (Yellow Arrow) surrounded by a low signal intensity corresponding to obstructed peripheral veins (Red Arrow). A heterotopic pregnancy is very rare and is one in which both an extra-uterine pregnancy and intra-uterine pregnancy develop simultaneously. MRI can also help distinguish between eccentric endometrial implantation and an interstitial ectopic pregnancy. MRI radiological findings include an adnexal mass with haemorrhagic fluid in the peritoneum which has high T1 signal intensity.
A pathological follicular cyst can measure up to 20cm and result from excessive accumulation of fluid or haemorrhage. Cysts are seen as a well defined cystic adnexal mass of low signal intensity on T1WIs and high signal intensity on T2WIs. There is prominent blood flow within the cyst wall and the thickness is variable measuring from 2 to 20 mm.
If the cyst contains predominantly intact red blood cells there is low signal intensity on T2WIs.
Theca Lutein Cysts also known as hyper reaction luteinalis are rare functional ovarian masses secondary to the overstimulation of the ovaries by endogenous or exogenous gonadotrophins. Due to its large size, may obstruct labour and if it does not spontaneously regress may require removal during pregnancy.
Massive ovarian oedema is characterised by marked enlargement of one or rarely both ovaries due to gross diffuse stromal oedema resulting in peripherally placed follicles. MRI shows an enlarged ovary that is hyperintense on T2WIs with multiple ovarian follicles seen pushed towards the peripheral cortex due to stromal oedema.
Some cysts demonstrate low signal intensity on T2WIs which is in keeping with blood products and are consistent with haemmorhagic cysts (Yellow Arrow). Bilateral ovarian enlargement caused bilateral vesicoureteric junction obstruction and bilateral hydronephrosis. The ovarian enlargement regressed post partum and the patients’ virilisation symptoms resolved. On USS endometriomas appear as single or multiple adnexal masses with diffuse low level internal echoes.
Characteristic findings are hyperechoic foci within the wall of an internally echogenic cyst. The cysts demonstrate homogenous high signal intensity on T1WIs and gradations of low signal on T2WIs.
During pregnancy solid components within an endometrioma can either demonstrate the rare occurrence of malignant transformation or ectopic decidualisation. The latter is detected on MRI when the decidualised endometrioma shows similarity in signal intensity and texture to the decidualised endometrium in the uterus. This finding coupled with smooth lobulation and prominent vascularity on Doppler imaging of solid components is more suggestive of ectopic decidualisation than malignant transformation or an ovarian malignancy (16).
Pregnant patients with symptoms refractive to initial therapy in whom there is diagnostic uncertainty may benefit from imaging with MRI which has been shown to be superior to TVS in radiological assessment. On USS is has a characteristic thick wall cystic “sausage” shaped appearance and contains complex fluid.
On MRI there is a ‘sausage’- shaped distended adnexal tubular structure containing fluid of variable character. Contains incomplete smooth septae (Yellow Arrows) characteristic of a dilated fallopian tube (FT). There are no specific sonographic features and the diagnosis is reliant upon comparison with the contralateral ovary. There is enlargement and wall thickening of the ipsilateral fallopian tube by greater than 10 mm. Benign Cystic Teratoma also known as a dermoid cyst is the most common germ cell neoplasm of the ovary. The liquid sebaceous material within the cyst is similar to fat density and is high signal intensity on T1WIs. An obstetric labor complication is a difficulty or abnormality that arises during the process of labor or delivery. It is a condition of hire to follow all instructions that come with the pool to avoid damage, which includes keeping pets away from the pool! The TENS machine is a drug-free, mobile and non-invasive pain management tool with personal control over your pain relief. The period of hire commences 2 weeks before the due date and continues until 2 weeks after. The cost of hire for a 4 week period is $65 including electrodes. I am an Independent Midwife and Lactation Consultant (IBCLC) servicing Melbourne and surrounding areas in Victoria, Australia. For a complete analysis of the research relevant to the midwife's management of Group B Streptococcus in the postpartum period, along with citations, readers are encouraged to refer to the full guideline.
This supplement describes the GRADE methodology and offers guidance on interpreting recommendations made using GRADE.
For a complete analysis of the research relevant to HDP and midwifery practice along with citations, readers are encouraged to refer to the full guideline.
All patients (n=64) who received epidural analgesia for labour (cases) were compared with randomly selected patients (nd 8) who did not receive epidural analgesia during labour (controls). The advantages of regional blocks include improved quality of pain relief, control of hypertension and ease of obstetric manipulation in second stage2. The use of epidural analgesia is on the increase because it is more effective and results in greater patient satisfaction than other methods used alone or in combination6.
On right ovary, benign cyst and the left adnexal mass demonstrates MRI characteristics of a mucinous ovarian benign cystadenoma.
The TENS impulses work by stimulating release of endorphins, the body’s natural pain relieving hormone and by stimulating the nerves to block pain signals before they reach the brain. The cases and controls were matched for age, height, body mass index, parity, use of oxytocin, presentation and weight of the foetus.
It allows the woman to remain aware and awake and it can be used throughout parturition even if caesarean section is required7.
There are multiple soft tissue excrescences (White Arrows) at the posterior aspect of the mass.


In Pakistan the experience with this mode of pain relief and its effect on the course of labour and delivery is limited, probably due to the belief amongst patients and physicians alike, that despite its established safety within western hospital practice, epidural analgesia continues to be a difficult and dangerous technique in the third world. Of the 6677 patients who did not have epidural analgesia during labour, a control group of 118 patients ‘was selected randomly after excluding patients delivered by elective caesarean section.
With increasing awareness amongst patients in developing countries, there is a growing demand to provide epidural blocks. Lumbar epidural analgesia in labour relation to foetal malposition and instrumental delivery. The effect of epidural analgesia on labour and delivery in Chinese women: a preliminary experience. These were surgically removed post partum and the radiological findings were confirmed on histology. Moreover, its safe conduct necessitates the presence of an experienced 24 hours obstetric anaes­thetic service not committed to other duties, which is very demanding in face of shortage of trained anaesthetists. The majority of patients who received epidural analgesia were offered this mode of pain relief primarily on their own request. Primigravid patients were twice as often delivered instru­mentally than multigravid patients in both groups. The documentation of experi­ence with this form of pain relief in labour in women from developing countries is limited.
Rizvi for their invaluable advice and critical review of the manuscript and all the consultants and labour room staff for their untiring efforts during the period of this study. At the Aga Khan University Medical Centre, Karachi, epidural analgesia has been used in labour sporadically. Our series, though small, is an initial step in the evaluation of safety and effect of epidural analgesia in labouring Pakistani women in a tertiary care setting in Karachi. By now we have collected enough cases to study the effectiveness and complications of this procedure in the local population. After exclusion of any contraindications the patients were prehydrated with 500 cc of lactated Ringer’s solution. In this study the rate of anaesthetic complications was acceptably low and quality of analgesia good.
In this study, we are presenting the results of data collected between November, 1986 and November, 1991. A cardiotopographic foetal heart rate trace was obtained to rule out any evidence of foetal distress. The duration of labour was not significantly longer in the epidural group (Table II) despite the higher percentage of primigravidain this group (Table I).
With the patient in left lateral or sitting position the epidural space was entered at the L 2-3 or L 3-4 interspace with 16-gauge Touhy needle using the loss of resistance technique. Foetal outcome as assessed by apgar scores (Table II) was unaffected by use of epidural block.
An epidural catheter was advanced 2-4 cm into the epidural space and the Touhy needle was withdrawn. These findings are in conformity with those from studies in the West7 as well as that of Chinese women4. A bacterial filter was attached to the other end of the epidural catheter and a 2 ml test dose of 1% plain lignocaine solution was administered. The higher rate of instrumental delivery (Table III) is also in conformity with findings of other studies1-4,7. When correct placement was confirmed, the first dose of Bupivacaine solution was administered. The increase in instrumental delivery is usually attributed to inability of the mother to push well in second stage as well as to higher rate of malposition. In our series the malposition rate of 25% was similar to that noted by Hoult et al3 in the U.K.
Five- eight mls were instilled with the patient in the left lateral position where the patient was kept for 5 mm.
This rate was significantly higher than in the control popula­tion (Table HI) and is, therefore, likely to have contrib­uted to the higher instrumental delivery rate. Then the patient was turned to right lateral position and a further 5-8 mls of Bupivacaine was injected. The increase in malposition rate in the epidural group is probably due to the decrease in tone of the pelvic floor muscles as a result of lumbar epidural block.
This interferes with the normal mechanism of labour in that the occiput will not be so easily rotated anteriorly when the presenting part is pushed against the gutter normally formed by the unrelaxed levator ani muscles. Eighty percent of patients in our series with mal position had a Kjelland’s rotation forceps delivery. Blood pressure and pulse were monitored at 5 mi intervals for half hour and then half hourly through­out labour. An epidural block facilitates such manipulation because of good analgesia and pelvic floor relaxation. The management of labour in the epidural group and the control group was uniform in accordance with our manual of labour ward management5. In our series none of the babies delivered with rotational forceps required admission to Neonatal Intensive Care Uflit.
The parameters studied in both groups were age, height, weight, parity, presentation of foetus, gestational age at delivery, duration of labour, position of foetal vertex at delivery, mode of delivery, birth weight of neonate and its apgar scores at one and five minutes. The Chi-square test with yates's correction and the Students t-test were used for statistical analysis of difference between epidural and control groups.
However, this was not the case in our series where caesarean rates were not significantly different (P> 0.05) in the epidural and control groups (Table III). Epidural analgesia, in our series, was found to be safe and effective but it was associated with a higher incidence of assisted vaginal delivery. Although the study size is small, it seems that in the presence of an obstetric anaesthetic service the tech­nique of epidural analgesia is acceptable in Pakistan.



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