Vaginal birth after cesarean: do California hospital policies follow national guidelines?

OBJECTIVE: To review whether California hospitals are adhering to national practice guidelines with regard to vaginal birth after cesarean (VBAC). STUDY DESIGN: We performed a content analysis of the American College of Obstetricians and Gynecologists (ACOG) and American Association of Family Physicians published guidelines and identified 39 specific recommendations, which were categorized into the following 5 content areas: patient criteria, procedure, staff and resources, uterine rupture or other complications, and miscellaneous clinical issues. We evaluated individual hospital policies with regard to adherence to 34 recommendations made specifically by ACOG. RESULTS: Of the 225 surveyed hospitals, 167 (74%) allow VBAC, and 22% of these (36 of 167) provided VBAC protocols for review. Approximately 80% of protocols included < 50% of the ACOG items (median, 13.5; range, 3-27 items). The highest percent adherence was observed in the procedure and staff and resources categories, where over two thirds of study hospitals exhibited 75-100% adherence. One third of participating hospitals were less adherent (0-25%) in the categories of patient criteria, uterine rupture or other complications, and miscellaneous clinical issues. CONCLUSION: In a sample of written VBAC protocols, we found a wide range of adherence to ACOG recommendations, as evidenced by the number and type of items explicitly documented in the protocols.     

Hypertensive disorders in pregnancy: a review of international guidelines

International collaboration could facilitate systematic development of guidelines to regulate and improve clinical practice. Insight into existing international guidelines regarding hypertensive disorders in pregnancy (HDP) is essential. Aim was to evaluate the content and quality of international clinical guidelines on HDP. Quality was assessed with the internationally validated Appraisal of Guidelines for Research and Evaluation (AGREE II) Instrument. Six guidelines were identified. Quality was moderate to high. Major flaws were applicability, editorial independence and stakeholder involvement. Recommendations differed considerably, particularly their extensiveness. The number of international HDP guidelines is small and the extensiveness of their recommendations varies considerably.     

Quality of guidelines on the management of diabetes in pregnancy: a systematic review

ABSTRACT: BACKGROUND: Diabetes during pregnancy can lead to severe risks for both mother and fetus when it is not managed properly. The use of rigorously developed guidelines with a robust implementation process can have a positive influence on the management of diabetes during pregnancy. This study aims to compare recommendations and assess the quality of clinical guidelines on gestational diabetes mellitus (GDM) and pre-existing diabetes mellitus during pregnancy. METHODS: Guidelines were selected by searching PubMed, the Guideline Clearing House and Google. All guidelines developed since 2000 on diabetes during pregnancy in English or Dutch were considered. Recommendations of the guidelines were compared. Furthermore, the quality was assessed by two authors independently, using the AGREE instrument. RESULTS: Eight guidelines were included. According to the AGREE instrument, the quality of most guidelines was low. The domains editorial independence, stakeholder involvement, and rigour of development had the lowest scores. Recommendations were mainly comparable on glycemic control, preconceptional counseling and prenatal care and labour. Differences between recommendations were found for screening on GDM and induction of labour. CONCLUSIONS: The quality of most guidelines concerning the management of diabetes during pregnancy needs to be improved. A more systematic approach in the development of these guidelines, more attention for updating procedures and piloting of the guidelines and involvement of target users and patients is recommended.     

Quality of Clinical Practice Guidelines for the Diagnosis and Treatment of Erectile Dysfunction: A Systematic Review

IntroductionClinical practice guidelines (CPGs) guide the diagnosis and treatment of erectile dysfunction using different methodologies. Nonetheless, the quality of published CPGs is unknown.AimTo evaluate the quality of CPGs for diagnosis and treatment of patients with erectile dysfunction.MethodsThe Medline, Embase, and LILACS databases were searched using structured strategies. The evidence was complemented by searches on websites of scientific societies and guideline developers. The CPG quality was assessed using the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument.Main Outcome MeasureThe outcome measure included the quality of CPGs in accordance with the AGREE II instrument score.Results17 guidelines met the selection criteria. 15 had recommendations for diagnosis, 16, had recommendations for treatment, and 1 included a follow-up. Most of the guidelines were developed in Europe (35.3%) and North America (29.4%), 2 were prepared by specialized groups (11.7%), and 1 was funded by public resources. The most common development method was the panel of experts (9 guides, 52.9%). 5 guidelines were of high quality as per the methodological rigor, as follows: Cancer Care Ontario 2016 (76.5%), European Urology Association 2018 (65.6%), American Urological Association 2018 (62.5%), American College of Physicians (62.5%), and Japanese Society for Sexual Medicine (60.4%). There was a significant relationship (P = .043) between the methodological quality of the guidelines and the funding source.Clinical ImplicationsBy knowing the quality of the clinical practice guidelines, users can make more objective decisions about their use, which has an impact on patient care.Strength & LimitationsHigh-quality CPGs frequently used in health-care practice were identified. Solely CPGs in Spanish, English, and Portuguese were included, which generates selection bias in the results.ConclusionsThe number of CPGs for erectile dysfunction developed using international standards that meet the AGREE II quality criteria is low. Scientific societies have a strong interest in developing guidelines on this topic, whereas the participation of governmental organizations is limited.Sandoval-Salinas C, Saffon JP, Corredor HA. Quality of Clinical Practice Guidelines for the Diagnosis and Treatment of Erectile Dysfunction: A Systematic Review. J Sex Med 2020;17:678–687.     

Guidelines for the management of pelvic pain associated with endometriosis: a systematic appraisal of their quality

BACKGROUND: Guidelines exist for the management of endometriosis. Validated and reliable appraisal tools exist to assess the quality of guidelines. OBJECTIVES: To systematically appraise the quality of guidelines for the management of pelvic pain associated with endometriosis. SEARCH STRATEGY: Guidelines were identified using a prospective protocol through a systematic search of MEDLINE (1951-2005), EMBASE (1974-2005), the Cochrane Library (2005, issue 2), known guideline websites and the World Wide Web. SELECTION CRITERIA: Type of document: guideline, consensus statement, care protocol or healthcare technology assessment produced by national or international professional organisations and societies or governmental agencies; subject: management of pelvic pain associated with endometriosis. DATA COLLECTION AND ANALYSIS: Two validated appraisal tools, Cluzeau and The Appraisal of Guidelines and Research and Evaluation (AGREE), were used to quantitatively assess the quality of guidelines. Areas evaluated included 'rigour of development', 'context and content' and 'application.' MAIN RESULTS: Eight of 596 potentially relevant citations identified met our inclusion criteria. The Cluzeau instrument quality score were the following: rigour of development, 53% (range 5-65%); context and content, 69% (range 29-79%) and application 20% (range 0-20%). The application dimension achieved significantly lower quality scores (P = 0.026 versus rigour of development and P = 0.017 versus context and content). The AGREE instrument quality scores were the following: scope and purpose, 68% (range 17-89%); stakeholder involvement, 33% (range 13-63%); rigour of development, 49% (range 10-81%); clarity of presentation, 55% (range 42-67%); applicability, 14% (range 0-28%) and editorial independence, 28% (range 8-67%). The applicability domain achieved significantly lower quality scores (P = 0.001 versus scope and purpose and P = 0.009 versus rigour of development). AUTHOR'S CONCLUSIONS: Guidelines for the management of pelvic pain associated with endometriosis do not comply with the recommendations for high-quality standards.     

Clinical practice guidelines for recurrent miscarriage in high-income countries: a systematic review

Recurrent miscarriage affects 1–2% of women of reproductive age, depending on the definition used. A systematic review was conducted to identify, appraise and describe clinical practice guidelines (CPG) published since 2000 for the investigation, management, and/or follow-up of recurrent miscarriage within high-income countries. Six major databases, eight guideline repositories and the websites of 11 professional organizations were searched to identify potentially eligible studies. The quality of eligible CPG was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Tool. A narrative synthesis was conducted to describe, compare and contrast the CPG and recommendations therein. Thirty-two CPG were included, from which 373 recommendations concerning first-trimester recurrent miscarriage were identified across four sub-categories: structure of care (42 recommendations, nine CPG), investigations (134 recommendations, 23 CPG), treatment (153 recommendations, 24 CPG), and counselling and supportive care (46 recommendations, nine CPG). Most CPG scored ‘poor’ on applicability (84%) and editorial independence (69%); and to a lesser extent stakeholder involvement (38%) and rigour of development (31%). Varying levels of consensus were found across CPG, with some conflicting recommendations. Greater efforts are required to improve the quality of evidence underpinning CPG, the rigour of their development and the inclusion of multi-disciplinary perspectives, including those with lived experience of recurrent miscarriage.     

Guidelines informing counseling on female age-related fertility decline: a systematic review

PurposeTo identify, appraise, and assess clinical practice guidelines informing patient counseling on female age-related fertility decline.MethodsSearched electronic database records from January 1, 2006, to September 10, 2018, and professional society websites. The search terms included iterations of “guideline,” “counseling,” “preconception,” “age-related fertility decline,” and “reproductive life planning.” English-language professional organization guidelines addressing patient counseling on age-specific reproductive health topics were included. Assessed the methodological quality of included guidelines using the AGREE II instrument. Guidelines were categorized as high quality or low quality based on AGREE II scores. Extracted age-specific reproductive health recommendations of high-quality guidelines.ResultsThe search identified 2918 records. Nineteen records addressed counseling on age-related fertility decline; only 6 focused only on reproductive aging, with the remaining 13 covering related topics. Eleven met criteria for high quality. All high-quality guidelines had high “rigor of development” scores on AGREE II. Ten high-quality guidelines stated an age at which female fertility declines, ranging from 30 to “late 30s.” One recommended a specific age at which patients should be counseled. Five of eleven high-quality guidelines did not discuss the obstetric and perinatal risks of advanced maternal age.ConclusionsFew high-quality guidelines address counseling on female age-related fertility decline, and existing guidance on reproductive aging counseling is inconsistent and incomplete. Greater rigor of development and incorporation of age-specific counseling recommendations into clinical practice guidelines could lead to improved patient anticipatory guidance and more informed reproductive choices.     

What Is Recommended for Healthy Women During Pregnancy? A Comparison of Seven Prenatal Clinical Practice Guideline Documents

Background: Several countries have developed clinical practice guidelines for the content of prenatal care. This study examines the consistency of recommendations in clinical practice guidelines describing routine prenatal care. Methods: The recommendations for low-risk women in seven guideline documents were examined: two from Australia, two from the United States, two from Canada, and one from Germany. The recommendations were listed into the four areas of “general health screening and health promotion during pregnancy,”“organization of care,”“clinical tests and screening,” and “education specific for pregnancy.” Results: A total of 69 recommendations were identified within the seven documents, most of which fell within the “clinical tests and screening” domain. Notable differences were identified in the number of recommendations made within the same country. Of the 69 recommendations, only four were included in all seven documents. Conclusion: Little consistency was demonstrated within or among countries in terms of the content of their prenatal care guidelines, suggesting a need to reexamine their content and the evidence on which such recommendations are based.     

Use of systemic therapy in women with recurrent ovarian cancer--development of a national clinical practice guideline

OBJECTIVE: To develop a guidance document concerning the use of systemic therapy for women with recurrent ovarian cancer that would be applicable for the Canadian health care system. This will be done using a standardized systematic review process, guideline evaluation instruments, multi-disciplinary expert consensus opinion and evidence-rating systems. DATA SELECTION: The primary data sources were MEDLINE, National Guideline Clearinghouse and Cochrane Library. METHODS: Clinical practice guidelines, technology assessments, systematic reviews and randomized controlled trials addressing systemic therapy for women with recurrent ovarian cancer were eligible. DATA EXTRACTION: Data was identified and extracted by the methodology team and reviewed by the authors. Results were reviewed and discussed by members of an expert working group comprised of a multidisciplinary and geographic divergent group of practitioners. DATA SYNTHESIS: The existing 7 practice guidelines underwent formal evaluation for quality, currency and content using the AGREE tool. Recommendations with evidence-ratings were developed. This data was used by a pan-Canadian panel in an informal consensus process, which resulted in the initial draft of a guideline. The guideline team reviewed the draft and made further edits to ensure the guideline's appropriateness for a national context. Practitioner feedback was requested from 165 health care providers who treat ovarian cancer from across Canada. Overall response rate was 37% and was very positive. Comments were reviewed and the guideline was edited appropriately. CONCLUSION: The development of a national practice guideline on the use of systemic therapy for recurrent ovarian cancer was feasible using systematic literature review, expert consensus, guideline evaluation instruments, evidence-rating systems, independent internal and external review measures and final approval by a national discipline specific society (GOC). Recommendations for practice are offered.     

Hypertension in pregnancy: do consensus statements make a difference?

OBJECTIVES: (i) To document variation in management of hypertension in pregnancy; (ii) to determine whether this variation falls within current management guidelines; and (iii) to make recommendations for developing future guidelines. DESIGN: Questionnaire-based survey. SETTING: Australia and New Zealand. POPULATION: All specialist obstetricians. METHODS: Questionnaires were sent to 1198 obstetricians in Australia and New Zealand. Those returned by respondents currently in obstetric practice were analysed. Information was obtained on their current clinical practices relating to the diagnosis and management of hypertension in pregnancy. RESULTS: Of 1198 obstetricians surveyed, 973 (81%) replied. Of these, 686 (71%) were responsible for obstetric care. Considerable variation in practice was found, particularly in relation to the measurement of blood pressure, the determination of hypertension and significant proteinuria, and the decision to institute antihypertensive drug treatment. The recommendations of the Australasian 1993 Consensus Statement appeared to have had little influence on practice. There has been a striking increase in the use of magnesium sulphate for the prevention of convulsions in preeclampsia. CONCLUSIONS: There is significant variation in management of hypertensive pregnancies that differs from current guidelines. It is not known whether this diversity adversely affects clinical outcomes. Until further outcome evidence is available, consensus statements may be better confined to basic aspects of management for which there is high level evidence.     

Clinical Management Recommendations for Surveillance and Risk-Reduction Strategies for Hereditary Breast and Ovarian Cancer Among Individuals Carrying a Deleterious BRCA1 or BRCA2 Mutation

BackgroundIn Canada, there are wide variations in services for patients at risk for hereditary breast and ovarian cancer (HBOC), and clinical interventions and recommendations differ between regions and/or provinces. National strategies for the clinical management of HBOC exist in the United Kingdom, France, and Australia, and clinical programs in Canada would benefit from similar national recommendations and a consistent approach to clinical management. The National Hereditary Cancer Task Force developed recommendations to address the clinical management of patients at high risk of HBOC and related cancers. These recommendations are based on current practice in high-risk cancer clinics that provide care for individuals with known BRCA1 or BRCA2 mutations.MethodsCanadian consensus recommendations were generated by the National Hereditary Cancer Task Force and compared mainly with two recently published guidance documents on the clinical management of women with increased risk of HBOC, one from the United Kingdom and the other from France. After review of these documents and the associated supporting scientific evidence, the Canadian consensus recommendations were modified and rated using predefined criteria.ConclusionsThese recommendations pertain to (1) surveillance options including breast self-examination, clinical breast examination, breast surveillance by imaging, ovarian cancer surveillance, and surveillance for men; (2) risk-reduction strategies including prophylactic mastectomy, prophylactic salpingo-oophorectomy, and pharmacoprevention; and (3) the use of exogenous hormones. Regular updates should occur as new evidence becomes available.     

Twenty-five years after the FIGO guidelines for the use of fetal monitoring: Time for a simplified approach?

Twenty-five years after the FIGO Workshop that produced the “Guidelines for the use of fetal monitoring,” these remain the only broad international consensus effort in this field. Documents of a similar nature have been produced by national institutions, with subsequent updates of the initial concepts. The 3-class classification system has now been adopted by all the major guidelines, and while there are numerous similar features, and indeed many ideas were inspired by the FIGO guidelines, many key aspects still lack consensus. Making guidelines simpler and more objective may be an important step to guarantee a wide application and assimilation of the recommendations, as well as an enhanced reproducibility and increased memory retention.     

无创产前检测国际指南与中国规范

随着二代测序技术在产前筛查临床应用的开展,国际上一些有影响力的学术组织相继发表和不断更新了关于该技术的应用指南和共识。国家卫生计生委组织专家总结我国的无创产前检测(NIPT)试点工作经验,结合国际国内的临床研究成果制定了我国《孕妇外周血胎儿游离DNA产前筛查与诊断技术规范》。该技术规范主要包括开展孕妇外周血胎儿游离DNA产前筛查与诊断技术的基本要求、适用范围、临床服务流程、检测技术流程以及质量控制指标等内容。为规范、有序地在我国开展该技术进行产前筛查和产前诊断提供了依据。     

Vaginal birth after cesarean delivery: practice patterns of obstetrician-gynecologists

OBJECTIVE: To assess obstetrician-gynecologists' current practice patterns and opinions regarding vaginal birth after cesarean delivery (VBAC). STUDY DESIGN: Questionnaires were mailed to a random sample of 1,200 American College of Obstetricians and Gynecologists (ACOG) fellows in July 2003. Information was gathered on percentage of cesarean and VBAC deliveries performed, factors influencing changes in these rates in the past 5 years, hospital protocol regarding VBAC and factors influencing the recommendation of VBAC. RESULTS: Fifty-three percent of questionnaires were returned to ACOG after 3 mailings. Approximately 49% of respondents reported that they were performing more cesarean deliveries than they were 5 years earlier. The primary reasons for this increase were the risk of liability and patient preference for delivery method. More than 25% of physicians reported that they practiced in hospitals that do not follow the ACOG guidelines with respect to resources and immediate availability. Almost all (98.2%) respondents agreed that they knew the risks and benefits of VBAC. However, only 61% reported feeling competent in determining which patients will have a successful VBAC. CONCLUSION: Obstetrician-gynecologists seem to be aware of the risks and benefits of VBAC; however, there is some doubt as to who should be offered a trial of labor and what predicts a successful VBAC.     

A multidisciplinary evidence-based guideline for minimally invasive surgery.

The Dutch Society for Endoscopic Surgery together with the Dutch Society of Obstetrics and Gynecology initiated a multidisciplinary working group to develop a guideline on minimally invasive surgery to formulate multidisciplinary agreements for minimally invasive surgery aiming towards better patient care and safety. The guideline development group consisted of general surgeons, gynecologists, an anesthesiologist, and urologist authorized by their scientific professional association. Two advisors in evidence-based guideline development supported the group. The guideline was developed using the "Appraisal of Guidelines for Research and Evaluation" instrument. Clinically important aspects were identified and discussed. The best available evidence on these aspects was gathered by systematic review. Recommendations for clinical practice were formulated based on the evidence and a consensus of expert opinion. The guideline was externally reviewed by members of the participating scientific associations and their feedback was integrated. Identified important topics were: laparoscopic entry techniques, intra-abdominal pressure, trocar use, electrosurgical techniques, prevention of trocar site herniation, patient positioning, anesthesiology, perioperative care, patient information, multidisciplinary user consultation, and complication registration. The text of each topic contains an introduction with an explanation of the problem and a summary of the current literature. Each topic was discussed, considerations were evaluated and recommendations were formulated. The development of a guideline on a multidisciplinary level facilitated a broad and rich discussion, which resulted in a very complete and implementable guideline.     

Guidelines for good practice in PGD: programme requirements and laboratory quality assurance

The Preimplantation Genetic Diagnosis International Society (PGDIS) was organized in October 2002, with the purpose of encouraging and co-ordinating research, education and training in this multidisciplinary field, requiring a close collaboration of obstetricians, fertility specialists, embryologists and human geneticists. One of the major tasks of PGDIS is to advance the safety and accuracy of PGD and to encourage its adoption into clinical practice for improvement of genetic practices and reproductive medicine. In this context, PGDIS published voluntary guidelines applicable for any centre offering PGD in 2004, and these guidelines are now being updated and extended based on the present extensive PGD experience. The application of these guidelines is intended to further benefit patients and provide guidance to the laboratory staff. As in previous guidelines, PGDIS presents this document being aware that differences in national regulations exist that can affect local PGD practice. The document contains recent consensus points of general application that promote quality biopsy procedures and laboratory practice, enabling PGD centres to offer an improved clinical outcome to their patients. A variety of aspects related to a safe working system have been taken into consideration, based on the assumption that a quality programme depends on the cooperation of the whole PGD team.     

Developing Guidelines and Maintaining Quality in Antenatal Care

Clinical practice guidelines are mandated by American College of Nurse‐Midwives Standards for the Practice of Midwifery. Guidelines should be evidence‐based and pertinent to the population served. Guidelines assist midwifery practices in the evaluation and maintenance of quality care. The development of clinical practice guidelines should be rigorous and scientific. There are several sources available to midwives to aid in the development of practice guidelines.     

剖宫产后阴道分娩相关问题

剖宫产后再次妊娠的分娩方式始终是一个具有争议的产科问题。随着我国全面实施“二孩”政策,剖宫产后阴道分娩问题越来越受到关注。目前,多个妇产科学术机构已达成共识：计划性剖宫产后阴道分娩对于大多数一次子宫下段剖宫产史的产妇是一种安全的选择。文章就剖宫产后阴道分娩的相关循证医学证据进行讨论,并为有剖宫产后阴道试产意愿的产妇制定产前、产时管理方案。     

Development of an evidence-based domestic violence guideline: supporting perinatal women-centred care in Japan

Objective

to develop an evidenced-based, women-centred care clinical guideline designed to assist midwives and other health-care providers in Japanese hospitals, clinics and midwifery offices, in identifying and supporting potential or actual perinatal victims of domestic violence.

Design

systematic review and critical appraisal of extant research; structured assessment of clinical guideline development.

Method

systematic and comprehensive literature search. Appraisal of Guidelines for Research and Evaluation (AGREE) was used to assess the guideline development for purposes of assuring methodological quality.

Findings

electronic searches of medical and nursing databases between February and December 2003 retrieved 2392 articles. Selected as evidence were 157 articles yielding 28 recommendations aligned to clinical assessment questions.

Key conclusions

using expert consensus and external reviews, recommendations were generated that provided the at-risk perinatal group with the best possible practice available to prevent further harm.

Implications for practice

the evidenced-based clinical guideline fosters a supportive environment for educating health-care providers on domestic violence, and to improve clinic access for at-risk perinatal women. Information on domestic violence and a negotiated midwife–client safety plan can be initiated for potential or actual victims of domestic violence, and is achieved through understanding the risks of the woman and her fetus or baby, while respecting the woman's intention.     

Vaginal birth after Cesarean rates are declining rapidly in the rural state of Maine.

OBJECTIVE: The American College of Obstetricians and Gynecologists (ACOG) revised its practice bulletin on vaginal birth after Cesarean (VBAC) in October 1998 and July 1999 to require the presence of a surgeon, anesthesiologist and operating personnel throughout the trial of labor for patients with prior Cesarean. This study measures the change in VBAC rates from 1998 to 2001 and examines possible reasons for this change. STUDY DESIGN: We examined birth certificate and hospital data in the State of Maine from 1998 to 2001. Hospital-specific rates for primary Cesareans, total Cesareans, repeat Cesareans and vaginal deliveries after previous Cesarean were obtained. Additionally, we surveyed current obstetric-care providers in Maine regarding reasons for change in VBAC rates at their institutions. RESULTS: VBAC rates declined by over 50% from 30.1 to 13.1%. The total Cesarean rate climbed from 19.4 to 24.0%. The most commonly reported reason for decrease in VBAC varied depending on whether a practitioner's hospital met ACOG guidelines. CONCLUSION: A marked decline in VBAC occurred after the change in ACOG vaginal birth after Cesarean policy. Multiple factors have contributed to this decline, including patients refusing VBAC after counseling and inability of institutions to meet ACOG guidelines.