Sexual Function the First Year Postpartum: A Mini-CommentaryRachel Pope MD, MPHUrology Insitute, Division of Female Sexual HealthUniversity Hospitals, Cleveland Medical Center11100 Euclid Avenue, Cleveland, OH 44106Rachel.pope@uhhospitals.orgRunning Title: Postpartum Sexual FunctionIn the first year postpartum, women tend to be burdened by physical exhaustion due to interrupted and lack of sleep, breastfeeding and the potential challenges therein, and chemically-induced anxiety and depression. Literature in the field of behavioral health has long-since described the high prevalence of postpartum mental health disturbances of 20% of all women, and the impact of mental health on quality of life documented world-wide (O’Hara MW et al. Perinatal mental illness: definition, description and aetiology. Best Pract Res Clin Obstet Gynaecol. 2014 Jan;28(1):3-12). Sexual dysfunction, however, is a lesser-known challenge and one that is notably under-reported and addressed in the medical literature, likely due to other dominating discomforts and an overall stigmatization of female sexual health. Furthermore, scheduled visits with medical providers rarely extend beyond six weeks postpartum and most women have not resumed sexual activity at this time.Sexual function is an important aspect of quality of life. There is straight-forward treatment for dysfunction and dyspareunia that may be caused by hypo-oestrogenized tissues and pelvic floor injuries. Cattani et al. highlight the experiences of women around the world through a comprehensive systematic review. It is not surprising then, that obstetric anal sphincter injuries (OASIS), episiotomies, and instrumental vaginal birth are all associated with sexual dysfunction and/or dyspareunia. While anal sphincter injuries affect approximately 6% of women (Jha S et al. Risk factors for recurrent obstetric anal sphincter injury (rOASI): a systematic review and meta-analysis. Int Urogynecol J. 2016 Jun;27(6):849-57.) and episiotomies continue to be on the decline, the paper by Cattani et al does show less dyspareunia among women who deliver by cesarean compared to spontaneous vaginal birth. One might assume this is related to the pelvic floor injuries. However, mode of delivery is not associated with overall sexual dysfunction. Strikingly, OASIS was associated with an odds ratio of 3 (1.28-7.03) for sexual dysfunction and 1.92 (1.47-2.52) for dyspareunia. While these injuries are not easily preventable, these data inform and strengthen the need for specialized clinics, follow-up care and increased attention to individuals who have sustained them (Madsen A, Hickman L, and Propst K. Recognition and Management of Pelvic Floor Disorders in Pregnancy and the Postpartum Period, Obstetrics and Gynecology Clinics of North America. 2021. 48; (3):571-584). For example, if an individual with a third or fourth degree laceration is identified as having increased risk for pain and dysfunction sexually, she should be counseled on this as to empower her to seek care should the concern arise. Lubricants, vaginal estrogens and DHEA can all be appropriately prescribed even if breastfeeding and could greatly improve her experience (Donders GGG, et al. Pharmacotherapy for the treatment of vaginal atrophy. Expert Opin Pharmacother. 2019 May;20(7):821-835.). Furthermore, this information underscores the need for women who have sustained a higher order laceration to present for pelvic floor physical therapy and rehabilitate as a preventive and therapeutic measure. Specialized clinics can help patients navigate this.Vaginal dryness from lactation is extremely common. This review only identified one study on vaginal dryness and sexual concerns. This does not indicate that vaginal dryness is not a problem, but rather that more research is indicated. Another unexplored variable is urinary incontinence. A large proportion of women experience urinary incontinence in the first year postpartum. It would be worth exploring the connection between UI and sexual dysfunction.Therefore, while this review represents progress in understanding the mechanism of sexual dysfunction and dyspareunia the first year postpartum, there is still more to be learned in the form of empiric evidence, especially regarding vaginal dryness and urinary incontinence.

Objective: Vaginal birth after caesarean (VBAC) has been suggested to be associated with an increased risk of obstetric anal sphincter injury (compared with primiparous women who birth vaginally). However, prior studies have been small, or used outdated methodology. We set out to validate whether the risk of obstetric anal sphincter injury among women having their first VBAC is greater than that among primiparous women having a vaginal birth. Design: State-wide retrospective cohort study. Setting: Victoria, Australia. Population: All births (455,000) between 2009-2014. Methods: The risk of severe perineal injury between first vaginal birth and first vaginal birth after previous caesarean section was compared, after adjustment for potential confounding variables. Covariates were examined using logistic regression for categorical data and Wilcoxon rank-sum test for continuous data. Missing data were handled using multiple imputation; the analysis was performed using regression adjustment and Stata v16 multiple imputation and teffects suites. Results: Women having a VBAC (n=5,429) were significantly more likely than primiparous women (n=123,353) to sustain a 3rd or 4th degree tear during vaginal birth (7.1 vs 5.7%, p<0.001). After adjustment for mode of birth, body mass index, maternal age, infant birthweight, episiotomy and epidural, there was a 21% increased risk of severe perineal injury (relative risk 1.21 (95%CI 1.07 – 1.38)). Conclusions: Women having their first vaginal birth after caesarean section have a significant increased risk of sustaining a 3rd or 4th degree tear, compared with primiparous women having a vaginal birth. Patient counselling and professional guidelines should reflect this increased risk.

Obstetric care for women that use antidepressants in pregnancyLine Kolding, MD, PhDVera Ehrenstein, MPH, DSc, ProfessorLars Pedersen, MSc, PhD, ProfessorPuk Sandager, MD, PhD, Associate ProfessorOlav B. Petersen, MD, PhD, ProfessorNiels Uldbjerg, MD, DMSc, ProfessorLars H. Pedersen, MD, PhD, ProfessorCorresponding:Lars Henning PedersenAarhus University Hospital / Aarhus UniversityPalle Juul-Jensens Blvd. 99, 8200 Aarhus N, DenmarkEmail: lhp@clin.au.dkPhone: +45 50526512We are grateful to Drs. Braillon and Bewley for their interest in our recent paper in the BJOG 1 and would like to elaborate on some of the important points they raise.We agree with Braillon and Bewley on the urgent need for improved pharmacovigilance of medication in pregnancy in general, and for antidepressants in particular. There are excellent international collaborations (e.g., the EuroCat) and local initiatives (e.g., the Swedish JanusInfo), but clinically we’re often forced to rely on very limited information indeed. Systematic international recording as suggested by Braillon and Bewley would represent an important step forward.On a smaller scale, we are establishing an automated surveillance system based on curated data that include information on both pre- and postnatally diagnosed malformations. We have, however, faced substantial legal and bureaucratic challenges, and have been forced to use data from the Central Denmark Region only, instead of national data. The surveillance system is consequently based on information on approx. 75,000 pregnancies, and even though it has the potential to aide clinical management, it is a drop in the ocean of the huge potential of for instance a comparable European collaboration.In our study, we used ≥2 redeemed prescriptions to define exposure with a prevalence 1.1%.1 The prevalence of pregnant women that redeemed ≥1 prescription was 3.2% (p. 3/ Table S1), and even though this is likely an overestimation due to non-adherence, the estimates are in line with previously reported prevalences in Scandinavia.2Braillon and Bewley emphasise the need to also consider non-pharmacological treatment of some pregnant women with depression and, further, to provide evidence-based and individualised treatment of women in the reproductive ages. Optimal individualised care will definitely result in non-pharmacological treatment of some pregnant women but, reversely, will cause yet other women to continue or initiate pharmacological treatment. This is in line with what is almost a truism in this field, that the potential harmful foetal effects must be balanced against the potential benefits of a pharmacological treatment, but it is no easy task. Pregnant women might overestimate the foetal risks associated with use of medication3 and discontinue important treatment, on the other hand some may use medication when there may be a better alternative for them. Regardless, we need to provide optimal obstetric care for the pregnant women that choose treatment with antidepressants. If our results are correct, prenatal follow-up of pregnant women treated with venlafaxine may include targeted foetal heart scans, even though the underlying causal explanation for the observed association with cardiac malformations is undetermined.1. Kolding L, Ehrenstein V, Pedersen L, Sandager P, Petersen OB, Uldbjerg N, et al. Antidepressant use in pregnancy and severe cardiac malformations: Danish register-based study. BJOG. 2021 May 25.2. Zoega H, Kieler H, Norgaard M, Furu K, Valdimarsdottir U, Brandt L, et al. Use of SSRI and SNRI Antidepressants during Pregnancy: A Population-Based Study from Denmark, Iceland, Norway and Sweden. PLoS One. 2015;10(12):e0144474.3. Wolgast E, Lindh-Åstrand L, Lilliecreutz C. Women’s perceptions of medication use during pregnancy and breastfeeding—A Swedish cross-sectional questionnaire study. Acta Obstetricia et Gynecologica Scandinavica. 2019;98(7):856-64.

BJOG-21-0667.R1: Our Guidelines Are Not Good EnoughAlexandra Wojtaszewskaa, Martin HirschbaWatford General Hospital, Watford, United KingdombOxford Endometriosis CaRe Centre, Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford, United Kingdom.Declarations of interest: noneFinancial support received: noneBJOG-21-0667.R1: Our Guidelines Are Not Good EnoughAmoah et al. highlight the lack of high-quality fibroid guidelines in their appraisal of uterine fibroid management guidelines. This paper sheds light on the association between low quality research informing low quality clinical guidance. The authors included nine national and international guidelines on fibroid management in their analysis and screened 189 recommendations and statements made across these documents. Guideline quality was assessed using the AGREE-II instrument and no high-quality guidelines were identified. No guidelines reported involvement of patients with fibroids in their development and across all guidelines consensus was reached on only three (1.6%) of 189 statements. The authors explored the quality of evidence base behind the recommendations concluding that 25.3% were developed from good-quality evidence while 27.7% were based on lowest quality evidence (expert opinion or clinical consensus).These findings of poor quality and high discrepancy between guideline recommendations for fibroids are not unique to the condition. Other systematic reviews found similar results when analysing guidelines for management of endometriosis (Hirsch et al. BJOG 2018;125:556-564) and uncomplicated birth (Zhao et al. BJOG 2020;127:789-797).When writing or updating guidelines, locally or nationally, authors must consider how to ensure highest possible quality. There are several validated tools for quality assessment available (including AGREE II, ADAPTE, AMTAR and INAHTA and iCAHE Guideline Quality Checklists).The landscape for guideline development is changing. The rapid development of novel technologies requires a prompt response and evaluation of not only efficacy but the wider environmental impact and health economic assessment. The current system of laborious static single point assessments of evidence-based medicine producing clinical guidelines every few years is no longer appropriate. The National Institute for Health and Care Excellence (NICE) acknowledge the need for proactive, fluid, and flexible processes to enable the digitalisation of health systems to inform practice through real-world evidence (NICE 2021, The NICE Strategy 2021 to 2026 ). Guidelines will respond in a dynamic manner to population changes using contemporaneous evaluation of clinical data available from digitalised care systems. We look forward to integrated care systems delivering population-based healthcare on a regional basis. Guidelines will extend across health, social care, and public health focusing on health prevention, reducing health inequality, and delivering those interventions that offer the greatest benefit.As highlighted by this study, the development of guidelines without standardised methods is commonplace. This may lead to exclusion of beneficial treatments, a paucity of comparable recommendations, recommendations based on poor quality data, and poor patient outcomes. Looking to the future we do not see the need to fix a fractured guideline development system but rather build a new one. We must adapt and adopt the integration of digitalised real-world health system data to facilitate rapid and robust clinical decisions on a regional or national basis.

Objective: To evaluate objective and subjective outcomes of patients who underwent sacrocolpopexy using autologous rectus fascia to provide more data regarding non-mesh alternatives in pelvic organ prolapse surgery. Design: Cohort study with retrospective and prospective data. Setting: A single academic medical center. Population: Women who underwent abdominal sacrocolpopexy using autologous rectus fascia between January 2010 and December 2019 Methods: Patients were recruited for a follow-up visit including completing the Pelvic Floor Distress Inventory (PFDI) and Pelvic Organ Prolapse Quantification (POPQ) exam. Demographic and clinical characteristics were collected. Main Outcome Measures: Composite failure, anatomic failure, symptomatic failure, and retreatment. Results: During the study period, 132 women underwent sacrocolpopexy using autologous rectus fascia. Median follow-up time was 2.2 years. Survival analysis showed that composite failure was 0.8% (CI 0.1-5.9%) at 12 months, 3.5% (CI 1.1-10.7%) at 2 years, 13.2% (CI 7.0-24.3%) at 3 years, and 28.3% (CI 17.0-44.8%) at 5 years. Anatomic failure was 0% at 12 months, 1.4% (CI 0.2-9.2%) at 2 years, 3.1% (CI 0.8-12.0%) at 3 years, and 6.8% (CI 2.0-22.0%) at 5 years. Symptomatic failure rate was 0% at 12 months, 1.3% (CI 0.2-9.0%) at 2 years, 2.9% (CI 0.7-11.3%) at 3 years, and 13.1% (CI 5.3-30.3%) at 5 years. Retreatment rate was 0.8% (CI 0.1-5.9%) at 12 months and 2 years, 9.4% (CI 4.2-20.3%) at 3 years, and 13.0% (CI 6.0-27.2%) at 5 years. Conclusions: Autologous rectus fascia sacrocolpopexy may be considered a safe and effective alternative for patients who desire to avoid synthetic mesh.

BJOG-21-0722 Statistical associations versus causal inference.Øjvind Lidegaard, professor 11Department of Gynaecology, Rigshospitalet, University of Copenhagen, DenmarkMany clinicians are of the opinion that observational studies may provide only “statistical associations”, but not “causal inference”. And further, that only randomized designs ensure causal interpretation. For the same reason, many medical journals have made rules for all observational studies finding significant statistical associations to be presented as just “associations” often emphasizing that a causal inference is not possible.I hereby sign up to the growing group of epidemiologists, who are of the opinion that just well confounder controlled observational studies are the very design most often providing convincing evidence of a causal interference. Prospective cohort studies better than retrospective case-control studies, but even the latter design has given us important knowledge of risk factors of rare clinical outcomes such as thrombotic diseases, a long list of cancers, obstetrical complications, including latest stillbirths.In a new original Swedish study, Heiddis Valgeirsdottir et al. demonstrate in a nationwide historical follow-up study, that women with polycystic ovary syndrome (PCOS) once pregnant have a 50% increased risk of experiencing stillbirth, as compared to women without PCOS (1). Further, that the rate ratio of stillbirth between women with and without PCOS increased by increasing gestational age, peaking at 42 weeks with 4.3 deaths per 1000 ongoing pregnancies in women with PCOS versus 1.0 deaths per 1000 ongoing pregnancies in women without PCOS.Any such association should certainly be controlled for a long list of potential confounders, the most important being maternal age, calendar year, parity, hypertensive disorders, diabetes, and educational length. Adiposity (BMI) was undertaken in an additional adjustment, because this covariate correctly could be considered as both a confounder (adiposity being a risk factor for stillbirth, and PCOS women more often being adipose), but also as a mediator; women with PCOS are more likely to develop adiposity due to their PCOS. The authors chose carefully to present the BMI adjusted results as the main results, thereby if anything underestimating the risk of stillbirths in women with PCOS.This is far from the first contribution from Scandinavian National Health Registers, identifying and quantifying risk factors for different diseases. We should always be aware that some unknown or unmeasured potential confounders not being controlled for, could reduce (or enhance) the results, and that other research groups should confirm the Swedish findings. A causal inference was made more likely with a suggested biomedical mechanism by which PCOS could confer such a risk. But already with this new carefully provided observational evidence, we should reasonably consider pregnant women with PCOS not to go too far beyond term, to prevent stillbirths in this group, which according to the study results accounts about 5% of all stillbirths. A pragmatic first recommendation could be induction of women with PCOS at 41 gestational weeks.Valgeirsdottir H et al. BJOG 2021; 128: xxx-xxx.

A document by Mary Kinney. Click on the document to view its contents.

Letter to the Editor RE: Modification of oxytocin use through a coaching-based intervention based on the WHO Safe Childbirth Checklist in Uttar Pradesh, India: a secondary analysis of a cluster randomized controlled trialAvir Sarkar, MD1; Shalini Venkatappa, MD1; Isha Wadhawan, MD, Diplomate to ABOG21 – Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India2 – Department of Obstetrics and Gynecology, Fortis Escorts Hospital, Faridabad, Haryana, IndiaCorresponding author: Avir SarkarAddress: House number 12, Block F, NIT-3, Faridabad, Haryana-121001, IndiaE mail: avirsarkar93@gmail.comType of article: Letter to the EditorWord count: 464Number of references: 2Conflict of interest between authors: None declared

Fertility preservation for women with ovarian endometriosis: it is time to adopt it as routine practice

Time for action- oxytocin & uterotonics are life-saving AND dangerous: a commentaryDeborah ArmbrusterUnited States Agency for International DevelopmentWashington, DC (currently based in Indonesia)Global Health Bureau/Maternal, Child and Nutrition Office/Maternal and Newborn Division+1 202 746-5453darmbruster@usaid.gov

Commentary on: LAPAROSCOPIC MYOMECTOMY USING LOOP LIGATION FOR GIANT INTRACERVICAL MYOMAS: A NOVEL SURGICAL TECHNIQUE.Authors: Shengke Wang, Dongdong Wang, Qihong Huang, Fujie Zhao.Journal: BJOG: An International Journal of Obstetrics & GynaecologyINTRACERVICAL FIBROID REMOVAL: A MYOMECTOMY REASONED ON BIOLOGICAL BASES .Dr. Andrea Tinelli, MD, Prof, PhDVeris delli Ponti Hospital, Obstetrics and Gynecology Department, Scorrano, Lecce, Italy; Laboratory of Human Physiology,Phystech BioMed School, Faculty of Biological & Medical Physics,Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow Region, Russia.Tel: +39-3392074078; E-mail:andreatinelli@gmail.com; ORCID: 0000-0001-8426-8490Anatomically, uterine corpus, isthmus and cervix compose one organ, but functionally they attend different function during pregnancy and labor. The uterine cervix is mainly composed connective tissue and extracellular matrix, that allow the pregnancy to come to an end, up to the onset of labor, when cervical ripening and dilatation occur to deliver the fetus. The cervical innervations and the different neurotransmitters and neuropeptides expression involved in cervical ripening suggest that the cervix plays a key role in pregnancy maintenance, labor initiation, pain and delivery; this can also be supported by previous studies that showed that cervical ripening is also a neuroimmune-mediate inflammatory reaction involveing the hypogastric nerve [Di Tommaso S “et al”, 2017;18(2):140-148].Neuropeptides are signaling peptides that are produced by neural, endocrine and/or immune cells: all of these hormones are involved in a variety of biological processes, not only enhancing uterine contractility and modulating pain trigger, but also possessing anti-inflammatory, antioxidative stress and tumorigenic properties. Particularly, they contribute with changes in muscle contractility, uterine peristalsis and muscular healing and may be involved also in the uterine fibroids’ pathophysiology [Tinelli A “et al”; 2020;21(5):440-442].Uterine fibroids are generally distributed over the body and fundus of the uterus, they are surrounded by a fibroneurovascular network rich of neurotransmitters, the myoma pseudocapsule, a neurovascular bundle separating fibroid from the myometrium, and allowing less bleeding during myomectomy and better subsequent myometrial healing after removal [Tinelli A “et al”; Curr Protein Pept Sci. 2017;18(2):129-139]. For this reason, the correct myomectomy which enucleates fibroid inside its pseudocapsule has been called ”intracapsular” and has remarkable early and late biological - muscular advantages, during and after surgery [Tinelli A “et al”.; JSLS 2012;16(1):119-29].Cervical fibroids are infrequent, but often create significant problems during myomectomy, as, during the removal there can be intraoperative and late complications, such as massive bleeding and scarring fibrosis with all the repercussions on pregnancy and childbirth [Malvasi A “et al”; 2013;29(11):982-8.].Wang “et al” [Wang “et al”; BJOG 2021] proposed their intracervical myomectomy for large intracervical myomectomy on 12 patients, basing on biology of the myoma pseudocapsule. They performed a laparoscopic myomectomy putting a loop ligation along the junction of the pseudocapsule and cervix, pulling the loop it at this position; then, they performed a traction and enucleation within the fibroid wound cavity directly closes the fibroid cavity, with the surrounding vascular network bounded in the knot after ligation of the pseudocapsule without dead space, and preventing injury to nearby tissues.During fibroid enucleation, loop ligation of the pseudocapsule glides along the tumor body and operates within the fibroid wound cavity, with no cervical tissue involved during enucleation. The neurovascular bundles of the fibroid pseudocapsule are protected and spared during myomectomy and the side of the pseudocapsule attached to the fibroid was bound tightly in the loop to achieve hemostasis. This technique results less invasive and would promote fertility in case of cervical myomectomy, not requiring additional pelvic dissection and allowing to operate directly in the cervix sparing adjacent tissues and pseudocapsule.

Background: Biologic medications, specifically the TNF-α inhibitors, have become increasingly prevalent in the treatment of chronic inflammatory disease (CID) in pregnancy. Objective: To determine pregnancy outcomes in women with CID exposed to biologics during pregnancy. Search strategy: PubMed and EMBASE databases were searched through January 1998-July 2021. Selection criteria: Peer reviewed, English language cohort, case-control, cross-sectional studies, and case series which contained original data. Data collection and analysis: Two authors independently conducted data extraction and assessed study quality. A meta-analysis of proportions using a random-effects model was used to pool outcomes. Linear regression analysis was used to compare the mean of proportions of outcomes across exposure groups using the ‘treated’ group as the reference category. All studies were evaluated using an appropriate quality assessment tool described by McDonald et al. Main Results: 35 studies, 11172 pregnancies, were eligible for inclusion. Analysis showed pooled proportions for congenital malformations: treated 4%(95% CI 0.03-0.4) vs disease matched 4%(0.03-0.05).Preterm delivery treated 12%(0.10-0.14) vs disease matched 10%(0.09-0.12) Severe neonatal infection: treated 5%(0.03-0.07) vs disease matched 5%(0.02-0.07) Low birth weight: treated 10%(0.07-0.12) vs disease matched 8%(0.07-0.09) The pooled Miscarriage: treated 13%(0.10-0.15) vs disease matched 8%(0.04-0.11) Pre-eclampsia; treated 1%(0.01-0.02) vs disease matched 1%(0.00-0.01). No statistical differences in proportions were observed. Conclusion: We demonstrated comparable pregnancy outcomes in pregnancies exposed to biologics, disease matched controls and CID free pregnancies. Overall, women receiving biologics in pregnancy may be reassured regarding their safety.

Background Antenatal Care (ANC) is one of the key care-packages required to reduce global maternal and perinatal mortality and morbidity Objectives To identify the essential components of ANC and develop signal functions Search strategy MESH headings for databases including Cinahl, Cochrane, Global Health, Medline, PubMed, and Web of Science Selection Criteria Papers and reports on content of ANC published from 2000-2020 Data collection and Analysis Narrative synthesis of data and development of signal function through 7 consensus-building workshops with 184 stakeholders Main Results A total of 221 papers and reports are included from which 28 essential components of ANC were extracted and used to develop 15 signal functions with the equipment, medication and consumables required for implementation of each. Signal functions for the prevention and management of infectious diseases (malaria, HIV, tuberculosis, syphilis and tetanus) can be applied depending on population disease burden. Screening and management of pre-eclampsia, gestational diabetes, anaemia, mental and social health (including intimate partner violence) are recommended universally. Three signal functions adress monitoring of foetal growth and wellbeing and identification and management of obstetric complications. Promotion of health and wellbeing via education and support for nutrition, cessation of substance abuse, uptake of family planning, recognition of danger signs and birth preparedness are included as essential components of ANC. Conclusions New signal functions have been developed which can be used for monitoring and evaluation of content and quality of ANC. Country adaptation and validation is recommended.

Letter to the Editor, BJOG Title:Prophylactic negative wound pressure dressing (NWPD) after caesarean – an extended debate to include surgical aspectsRe: Hyldig N, Joergensen JS, Lamont RF, Moller S, Vinter CA. Prophylactic negative pressure wound therapy in obese women undergoing caesarean section: a commentary on new evidence that fuels the debate. BJOG 2021; https://doi.org/10.1111/1471-0528.16750.Author: Mr. Shashikant L SHOLAPURKARMD, DNB, MRCOGDept of Obstetrics & Gynaecology,Royal United Hospital, Bath, BA1 3NG, UKEmail: s.sholapurkar@nhs.netTel: 07906620662Word count: 500Corresponding Author: Mr. Shashikant L SHOLAPURKARMD, DNB, MRCOGDept of Obstetrics & Gynaecology,Royal United Hospital, Bath, BA1 3NG, UKStatement of interest: The author has no conflict of interest or funding to declare.

Objective To study the preferences and risk tolerance of women suffering from deep endometriosis (DE) with bowel involvement when they have to choose between conservative or surgical. Design Labelled Discrete Choice Experiment (DCE). Setting Dutch academic and non-academic hospitals and online recruitment. Population or Sample A total of 169 patients diagnosed with DE of the bowel. Methods Baseline characteristics and the fear for surgery were collected. Women were asked to rank attributes and choose between hypothetical conservative (medication) or surgical treatment in different choice sets (scenarios). Each choice set offered different levels of all treatment attributes. Data were analysed by using multinomial logistic regression. Main Outcome Measures The following attributes; effect/or risk on pain, fatigue, pregnancy, endometriosis lesions, mood swings, osteoporosis, temporary stoma and permanent intestinal symptoms were used in this DCE. Results In the ranking osteoporosis is the least important attribute, while in the DCE, a lower chance of osteoporosis is one of the most important drivers when choosing a conservative treatment. Women with previous surgery show less fear for surgery compared to women without surgery. The low anterior resection syndrome is almost equally important for patients as the chance of pain reduction. Pain reduction has higher importance than improving fertility chances even in women with a future child wish. Conclusions The risk of suffering from LARS as a result of treatment is almost equally important as the reduction of pain symptoms. Women with previous surgery experience less fear for surgery compared to women without a surgical history.

Mini commentary on BJOG-21-0235.R1The Project Appropriate Birth: significance of the Robson classification in confronting the caesarean section

Objective: To evaluate which risk factors for RhD immunization remain, despite adequate routine antenatal and postnatal RhIg prophylaxis (1000 IU RhIg) and additional administration of RhIg. Assessment of the prevalence of RhD immunizations. Design: Prospective cohort Setting: The Netherlands. Population: Two-year nationwide cohort. Methods: RhD-negative women in their first RhD immunized pregnancy and their foregoing non-immunized pregnancy. Risk factors for RhD immunization were compared with population data. Main outcomes measures: Risk factors for FMH and subsequently RhD immunization, prevalence of RhD immunizations. Results: The prevalence of newly detected RhD immunizations was 0.31% (79/25,170) of all RhD-negative pregnant women in the Netherlands. After exclusion, 193 women remained. Significant risk factors found in the group of 113 parous women (previous pregnancy >16 weeks, RhD positive child) were; caesarean section (CS) (OR 1.7, 95% CI 1.1-2.6), perinatal death (OR 3.5, 95% CI 1.1-10.9), gestational age over 42 weeks (OR 6.1, 95% CI 2.2-16.6), postnatal bleeding (>1000mL) (OR 2.0 95% CI 1.1-3.6), surgical removal of the placenta (SRP) (OR 4.3, 95% CI 2.0-9.3). The miscarriage rate in the group of women without a previous RhD positive child was significantly higher than in the Dutch population (35% vs 12.5% p<0.001). Conclusion: Complicated deliveries, including cases of major bleeding and surgical interventions (CS, SRP) need to be recognized as risk factor, requiring determination of FMH volume and adjustment of RhIg dosing. Miscarriage may be an additional risk factor for RhD immunization, requiring further studies. Funding: This research was partly funded by a grant from Sanquin Amsterdam.

Sir,We welcome Gurol‐Urganci I and Bidwell et al’s evaluation of the impact of the care bundle to reduce obstetric anal sphincter injury (OASI) published in your August edition last year.[1] The article reports much needed evidence on the efficacy of an intervention that has already taken hold in many maternity services across the country.Despite the article’s timely nature, we would like to voice our disappointment in the quality of the evidence of support for the care bundle Meulen and Thakar et al provide, and the recommendations made. The article fails to consider important evidence in this area of maternity care prompting this response. In particular, the authors miss the opportunity to contextualise the relatively low-level evidence they take from five articles – reporting three Scandinavian cohort studies and one educational intervention study on manual assistance during the final part of the second stage of labour (including gripping the baby’s chin through the perineum) - with the compelling findings from the Cochrane review on Perineal techniques during the second stage of labour for reducing perineal trauma. [2] This omission is important because the Cochrane review indicates that warm compresses have a bigger positive effect on OASI than the OASI care bundle reported by Meulen and Thakar et al’s. Furthermore, the Cochrane review provides evidence suggesting that hands off the perineum may protect women from episiotomy; an outcome which Meulen and Thakar et al acknowledge remained unchanged despite the third component in the care bundle aiming to ‘use of episiotomy when clinically indicated’. The selective nature of the evidence quoted, undermines the credibility of inferences that can be made from the findings. We suggest therefore, that caution should be taken when reading the authors conclusions.Our second concern rests upon the authors failure to account for the surprisingly small positive effect of the care bundle compared with the Scandinavian studies they quote. Meulen and Thakar et al report a 0.3% decrease in OASI compared with a 3.6% reduction;[3]3% reduction;[4] a 2.6% reduction for low risk women;[5] and a 2.1% reduction in the various observational studies [6] Such a small effect in an open trial could easily be caused by ascertainment bias. Again, the quality of the previous Scandinavian studies make interpretation difficult but the marked difference in results between Scandinavia and England suggests caution should be taken when reading the authors conclusions.Our final concern pertains to women’s experience of the care bundle. Not only is the acceptability of the intervention not considered in this evaluation – a significant oversight given the conspicuous lack of evidence on this – there are ethical issues within the evaluation that deserve attention. The intervention description in figure 1 claims that women were informed about what could be done to reduce OASI. This does not appear to be entirely true given the lack of consideration of warm compresses and hands off to protect against episiotomy. Even more unsettling is the statement ‘MPP should be used unless the woman objects’, implying little consideration for autonomy and informed consent.For the above reasons, we are not only disappointed with the BJOG article but with the professional stakeholder investment in the intervention which seems to have been widely and uncritically supported, with some support even being somewhat evangelical, despite the limited evidence for support.Signatures,