BJOG mini-commentary on BJOG-22-0097This manuscript by McCall et al reports that UK and France have very different approaches to managing women with PAS. More women in France received a uterus conserving approach. Major haemorrhage was more common in the UK series. The authors speculate that this may be related to treatment modality. The ACOG/SMFM committee opinion (Obstet Gynecol 2018;132:e259–75) recommends caesarean hysterectomy as the most generally accepted approach. Does this report imply that we should stop offering hysterectomies and recommend conservative treatment?Before we make up our mind, it is important to consider what else was different in the two cohorts. The case definitions used by UK OSS and PACCRETA investigators were different. However, the authors of the current report have included only those cases that satisfied a harmonised definition. UK prevalence (1.7/10 000) was significantly lower as compared to that from France (4.2/10 000). This raises the question: Is UK under-reporting or is France over-reporting? Screening studies may give some idea about the ‘true’ prevalence. A prevalence of 5.8/10 000 (Panaiotova et al, Ultrasound Obstet Gynecol 2019; 53: 101–106) was reported with screening for Caesarean scar pregnancies. Coutinho et al (Ultrasound Obstet Gynecol 2021; 57: 91–96) reported a prevalence of 3.8/10 000 with screening for PAS in late pregnancy. In both these reports all women had either placenta previa or a low-lying placenta. In contrast, placenta previa was present in 64% and 63% of women from UK and France, respectively. In this light, one would expect a higher, rather than lower prevalence of PAS as compared to the two screening studies. One explanation could be increasing Caesarean section rate and better awareness with time.A systematic review reported high (>90%) sensitivity for the detection of PAS using ultrasound in women at high risk of PAS (D’Antonio et al, Ultrasound Obstet Gynecol 2013; 42: 509–517). The prenatal detection was disappointingly low at < 50% in both UK and France. Before we begin to berate ourselves, it is noteworthy that these are 7-12 year-old data. The current study took place between May 2010 - April 2011(UK) and November 2013 - October 2015(France).What about the differences in median blood loss? Manual removal of the placenta was attempted in fewer women in France. Even then, unplanned hysterectomy was more common in the French group. The blood loss may be lower with conservative management, but this advantage should be weighed against the uncertainty about the possibility and timing of developing major haemorrhage in the post-operative period. Moreover, it is possible that the UK series had particularly severe cases as compared to the French cohort given the significantly lower prevalence. A head-to-head comparison of the two treatment modalities has never been reported. This will necessitate a unified definition and accurate prenatal detection. Such a study would be extremely challenging given the strong views of women regarding fertility preservation and of physicians regarding ongoing uncertainty with complications and personal experience. The jury is still out on this one.

Objective: To study the impact of shoulder dystocia (SD) simulation training on the SD management and the incidence of permanent brachial plexus birth injury (BPBI). Design: Retrospective observational study Setting: Helsinki University Women’s Hospital, Finland Sample: Deliveries with SD Methods: Multi-professional, regular and systematic simulation training for obstetric emergencies began in 2015 and SD was one of the main themes. A study was conducted to assess changes in SD management and the incidence of permanent BPBI. The study period was from 2010 to 2019; years 2010–2014 were considered the pre-training period and 2015–2019 the post-training period. Main outcome measures: The primary outcome measure was the incidence of permanent BPBI after the implementation of systematic simulation training. Also changes in the SD management were analysed. Results: During the study period, 113,085 vertex deliveries were recorded. The incidence of major SD risk factors (gestational diabetes, induction of labour, vacuum extraction) increased and was significantly higher for each of these (p <0.001) during the post-training period. The incidence of SD also increased significantly (0.01 vs 0.3%, p <0.001) during the study period, but the number of children with permanent BPBI decreased dramatically after the implementation of systematic simulation training (0.04 vs 0.02%, p <0.001). The most significant change in the management of SD was increased incidence of a successful delivery of the posterior arm. Conclusions: Systematic simulation-based training of midwives and doctors can translate into an improved individual and team performance and significantly reduce the incidence of permanent BPBI.

A document by Awol Yemane. Click on the document to view its contents.

Original Manuscript ID: BJOG-21-1723.R1 Descriptive: The Impact of Respectful and Compassionate Bereavement Care Following Stillbirth Running Title: Respectful Bereavement Care After Stillbirth Author information: Mehali Patel, Senior Research Officer, Saving Babies’ Lives Team, Sands Contact Details: 07709602633 Mehali.patel@sands.org.uk Sands Office, CAN Mezzanine, 49-51 East Road, London, N1 6AH

BJOG Commentary  Title: Fetal movement trials: where is the evidence in settings with high burden of stillbirths?Authors: Natasha Housseine1,2, natasha.housseine@aku.edu, natasha.housseine@outlook.comJoyce Browne2, J.L.Browne@umcutrecht.nlNanna Maaløe3 nannam@sund.ku.dkBrenda Sequeira Dmello1,4 bseqdmello@gmail.comSam Ali2,5, alisambecker@gmail.comMuzdalifat Abeid1, muzdalifat.abeid@aku.eduTarek Meguid6, tarekmeguid@gmail.comMarcus J Rijken2,7,8, mrijken2@umcutrecht.nlHussein Kidanto1, hussein.kidanto@aku.edu Affiliations 1.      Aga Khan University, Medical College East Africa, Dar es Salaam campus2.      Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, The Netherlands3.      Global Health Section, Department of Public Health, University of Copenhagen, Denmark4.      Comprehensive Community Based Rehabilitation in Tanzania, Dar es salaam, Tanzania5.      Research Department, Ernest Cook Ultrasound Research and Education Institute (ECUREI), P.O. Box 7161, Kampala, Uganda6.      Child Health Unit, Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa7.      Vrouw en Baby department, University Medical Centre Utrecht, Utrecht University, The Netherlands8.      Obstetric department, Amsterdam University Medical Center, Amsterdam, The Netherlands Corresponding author:Natasha HousseineThe Aga Khan University Medical CollegeUfukoni Road, P. O. Box 38129, Dar es salaam, Tanzania Telephone: +255 745 338 950  Fetal movement (FM) is a sign of fetal life and wellbeing that is felt by the pregnant woman, and reduced FM is known to precede stillbirths (1,2). Therefore, healthcare providers may advise women to monitor and report if their babies’ movements are fewer than usual. In high-income countries (HIC), there has been a renewed interest in FM with a recent wave of large-scale randomised controlled clinical trials investigating its potential to reduce stillbirths. The My Baby’s Movement trial in Australia/New Zealand, and the Mindfetalness trial in Sweden investigated the effects of intervention aimed at increasing women’s awareness of FM (3,4). The British AFFIRM trial investigated the effects of an FM awareness package coupled with a standardised management protocol (5). The ongoing CEPRA study in the Netherlands, UK and Australia and aims to evaluate Cerebro Placental Ratio as an indicator for delivery in women with reduced FM (6). None of the completed trials, however, found significant reductions in stillbirths. Moreover, they showed conflicting results on some potential harmful consequences, such as increased rates of obstetric interventions. In this commentary, we reflect on these trials through a global lens, and we urgently call for more trials – but this time in settings suffering the majority (98%) of the world’s two million annual stillbirths. Importantly, the global applicability of these HIC trials is questionable. They were conducted in settings where women are aware of the importance of reduced FM and are empowered to access highest standards of care. The contextual realities of pregnancy care are vastly different in low- and middle-income countries (LMICs) where antenatal care and health education are substandard. Women lack health information to self-monitor and report reduced FM. Furthermore, antenatal clinics are often overcrowded and understaffed, with lack of supplies, clinical guidelines, and adequate training of health workers. Recent estimates show stillbirth rates as high as 22 per 1000 per total births in Sub-Saharan Africa, compared to less than 3 per 1000 in HICs (7). Given the downward trend of stillbirths reported in all the HIC trials, it is possible that the completed trials may be demonstrating a lack of evidence rather than a lack of effectiveness. We hypothesise that involving women in their care, through training on how to monitor their baby’s movement and when and how to respond coupled with strengthening healthcare workers’ respect and response to women’s concerns on reduced FM, is a low-cost intervention with potential to significantly reduce stillbirths in high-burden LMICs. Surprisingly, high-quality studies from LMICs that have assessed the effect of FM interventions on perinatal deaths are lacking (2). Of note, the authors of the above-mentioned trials did not consider the well-known major differences in clinical context globally as a limitation while discussing the generalisability of their findings. In fact, the latest My Baby’s Movement trial was not even published open access, limiting access to less privileged clinicians, researchers and policymakers (4). This lack of a global perspective on the international health crisis of preventable stillbirths is an epistemic injustice and a missed opportunity (8). We are concerned that the results of the above trials could prematurely prompt policies discouraging the use of FM awareness among pregnant women (9). It is thus crucial that the lack of generic applicability of these trials’ findings are stressed, and that their high-resource contexts are considered when developing global clinical guidelines and future research priorities. Notably, it has been seen too often how the unbalanced evidence production from HICs has had unintended harmful influences on clinical practice in LMICs (10). For instance, it appears that the breech trials from HICs have led to policy change also in LMICs with increased use of caesarean section in case of breech presentation. However, the risk ratios of vaginal breech births versus caesarean sections differ dramatically between high-resource and low-resource settings with lower surgical safety in LMICs (11,12).The prevailing constraints in LMICs should stimulate innovation and creativity to design low-cost solutions that strengthen three areas 1) FM awareness and monitoring; 2) diagnosis to identify babies truly at risk, and 3) care provision protocols of pregnant women with reduced FM to improve perinatal outcomes. While such strategies or their evidence base are often lacking in LMICs, there is some evidence about possible low-cost diagnostic approaches to assess fetal risk following reduced FM: for example, measuring maternal blood pressure, fetal heart rate, and fundal height (13), or antenatal (hand-held) ultrasound to detect and monitor high-risk pregnancies. Measuring fetal blood flow in Doppler ultrasound studies has also been useful particularly in detecting growth restriction (6,14).  Involving women and health workers in studies will ensure consideration of health-system constraints and allow these to be embedded in the design, implementation, and evaluation of any new intervention. If proven effective, this will increase the chance of seamless integration of the intervention into existing care, positive perceptions by providers and pregnant women- and not increase the burden on already overwhelmed healthcare workers.  Unfortunately, maternal perception of FM is still too often the only signal of complications in the absence of regular high-quality antenatal checks (15)– and there are possibly many babies’ lives lost by ignoring this danger sign. Given the burden of need and the context-specific realities that determine interventions’ effectiveness, we hope these recent waves of FM trials will continue into LMICs to investigate if and how FM awareness coupled with context-tailored management protocol can reduce stillbirths.    Contribution to AuthorshipNH conceived and wrote the first draft. JB, NM, BSD and MJR contributed to subsequent drafting of the manuscript. All authors revised the commentary for important intellectual content and approved the final version to be published and agree to be accountable for all aspects of the work. Details of ethics approvalNo ethics approval applicable for this commentary FundingThere was no financial support for this commentary Disclosure of interests  Reference1.        Bekiou A, Gourounti K. Reduced Fetal Movements and Perinatal Mortality. Mater Sociomed. 2020;32(3). 2.        Hayes DJL, Smyth R, Heazell AEP. Investigating the significance and current state of knowledge and practice of absent or reduced fetal movements in low and lower middle-income countries : a scoping review. 2019;3:1–12. 3.        Akselsson A, Lindgren H, Georgsson S, Pettersson K, Steineck G, Skokic V, et al. Mindfetalness to increase women’s awareness of fetal movements and pregnancy outcomes: a cluster-randomised controlled trial including 39 865 women. BJOG An Int J Obstet Gynaecol. 2020 Jun 1;127(7):829–37. 4.        Flenady V, Gardener G, Ellwood D, Coory M, Weller M, Warrilow KA, et al. My Baby’s Movements: a stepped-wedge cluster-randomised controlled trial of a fetal movement awareness intervention to reduce stillbirths. BJOG An Int J Obstet Gynaecol. 2022 Jan 1;129(1):29–41. 5.        Norman JE, Heazell AEP, Rodriguez A, Weir CJ, Stock SJE, Calderwood CJ, et al. Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM): a stepped wedge, cluster-randomised trial. www.thelancet.com. 2018;392. 6.        Damhuis SE, Ganzevoort W, Duijnhoven RG, Groen H, Kumar S, Heazell AEP, et al. The CErebro Placental RAtio as indicator for delivery following perception of reduced fetal movements, protocol for an international cluster randomised clinical trial; the CEPRA study. BMC Pregnancy Childbirth. 2021 Dec 1;21(1). 7.        Hug L, You D, Blencowe H, Mishra A, Wang Z, Fix MJ, et al. Global, regional, and national estimates and trends in stillbirths from 2000 to 2019: a systematic assessment. Lancet. 2021 Aug 28;398(10302):772–85. 8.        Bhakuni H, Abimbola S. Epistemic injustice in academic global health. Lancet Glob Heal. 2021;9:e1465–70. 9.        Walker KF, Thornton JG. Encouraging awareness of fetal movements is harmful. Lancet. 2018 Nov 3;392(10158):1601–2. 10.      Maaløe N, Ørtved AMR, Sørensen JB, Sequeira Dmello B, van den Akker T, Kujabi ML, et al. The injustice of unfit clinical practice guidelines in low-resource realities. Lancet Glob Heal. 2021;9(6):e875–9. 11.      van Roosmalen J, Meguid T. The dilemma of vaginal breech delivery worldwide. Lancet. 2014;338(9932): 12.      Sobhy S, Arroyo-Manzano D, Murugesu N, Karthikeyan G, Kumar V, Kaur I, et al. Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis. Lancet. 2019 May 11;393(10184):1973–82. 13.      Housseine N, Rijken MJ, Weller K, Nassor NH, Gbenga K, Dodd C, et al. Development of a clinical prediction model for perinatal deaths in low resource settings. eClinicalMedicine. 2022 Feb;44:101288. 14.      Ali S, Kawooya MG, Byamugisha J, Kakibogo IM, Biira EA, Kagimu AN, et al. Middle cerebral arterial flow redistribution is an indicator for intrauterine fetal compromise in late pregnancy in low-resource settings: a prospective cohort study. BJOG An Int J Obstet Gynaecol. 2022 Feb 4; 15.      World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience [Internet]. 2016 [cited 2020 Jul 30]. Available from: https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/ ‘This article has a Video Abstract presented by Natasha Housseine.’

TYPE OF ARTICLE: LETTER TO EDITOR

Objectives: We evaluated radiotherapy planning CT-based radiomics for predicting clinical endpoints [tumor complete response (CR), 5-year overall survival (OS), hypohemoglobin, and leucopenia] after intensity-modulated radiation therapy (IMRT) in locally advanced cervical cancer (LACC). Methods: This study retrospectively collected 257 LACC patients treated with IMRT from 2014 to 2017. Patients were allocated into the training/validation sets (3:1 ratio) using proportional random sampling, resulting in the same proportion of groups in the two sets. We extracted 254 radiomic features from each of the gross target volume (GTV), pelvis, and sacral vertebrae in planning CT images. The sequentially backward elimination support vector machine algorithm was used for feature selection and endpoint prediction. Model performance was evaluated using area under the curve (AUC). Results: A combination of 10 clinicopathological parameters and 34 radiomic features achieved the best performance for predicting CR [validation balanced accuracy: 80.79%]. For OS, 54 radiomic features showed good prediction accuracy [validation balanced accuracy: 85.75%], and the threshold value of their scores can stratify patients into the low-risk and high-risk groups (P<0.001). The clinical and radiomic models were also predictive of hypohemoglobin and severe leucopenia [validation balanced accuracies: 70.96% and 69.93%]. Conclusion: This study demonstrated that combining clinicopathological parameters with CT-based radiomics had good predictive value for treatment outcomes and hematologic toxicities to radiotherapy in LACC. The prediction of clinical endpoints prior to radiotherapy may assist the radiation therapists to select the optimal therapeutic strategy with the minimal toxicity and best curative effect.

Objective: To compare the incidences of early and late onset neonatal sepsis, including group B streptococcus (GBS) and Escherichia coli (E.coli) before and after implementation of universal screening. Design: Retrospective cohort study Setting: Eight public hospitals with obstetrics services under the Hospital Authority and 31 Maternal and Child Health Centres (MCHC) under the Department of Health in Hong Kong Population: 460552 women attending routine antenatal service from 2009 to 2020. Methods: Universal culture-based GBS screening was offered to eligible women since 2012. Total maternity, births, GBS screening tests, GBS isolated in maternal genital tract, neonatal sepsis with positive blood or cerebrospinal fluid were retrieved from clinical and laboratory database of the Hospital Authority using clinical data analysis and reporting system (CDARS) and clinical system of MCHCs. Main outcome measures: Maternal GBS colonisation rate, early onset GBS disease, early onset E. coli infection, late onset GBS disease, and late onset E. coli infection Results: Of 318740 women with universal culture-based screening, 63767 women (20.0%) were screened positive. After implementation of GBS screening, the incidences of both early and late onset neonatal sepsis reduced significantly, including those caused by GBS. There was no change in the incidence of early onset E.coli sepsis, while the incidence of late onset E.coli sepsis reduced. Conclusions: Universal culture-based GBS screening in Hong Kong has been successful in prevention of early and late onset neonatal sepsis, including those caused by GBS. E.coli has become more common than GBS in early neonatal sepsis, although the incidence remained similar.

Dr Manvi Verma (ORCID ID: 0000-0001-5971-2940)Article Type: Letter to the Editor“Re: Impact of the availability of midurethral slings on treatment strategies for stress urinary incontinence: a cost-effectiveness analysis”Dr Manvi Verma1, Dr Jaya Chaturvedi2M.Ch. Student in Cosmetic Gynaecology, Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, IndiaProfessor & Head, Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Objective To determine if stillbirth aggregates in families and quantify its familial risk using extended pedigrees. Design State-wide matched case-control study. Setting Utah, United States. Population Stillbirth cases (n=9 404) and live-birth controls (18 808) between 1978 and 2019. Methods Using the Utah Population Database, a population‐based genealogical resource linked with state fetal death and birth records, we identified high-risk pedigrees with excess familial aggregation of stillbirth using the Familial Standardized Incidence Ratio (FSIR). Stillbirth odds ratio (OR) for first-degree relatives (FDR), second-degree relatives (SDR), and third-degree relatives (TDR) of parents with a stillbirth and live-birth were estimated using logistic regression models. Results We identified 390 high-risk pedigrees with evidence for excess familial aggregation (FSIR≥2.00 and P-value<0.05). FDRs, SDRs and TDRs of affected parents had 1.14-fold (95% confidence interval [CI]: 1.04-1.26), 1.22-fold (95% CI: 1.11-1.33), and 1.15-fold (95% CI: 1.08-1.21) higher stillbirth odds compared to FDRs, SDRs and TDRs of unaffected parents, respectively. Parental sex-specific analyses showed male FDRs, SDRs and TDRs of affected fathers had 1.22-fold (95% CI: 1.02-1.47), 1.38-fold (95% CI: 1.17-1.62), 1.17-fold (95% CI: 1.05-1.30) higher stillbirth odds compared to those of unaffected fathers, respectively. FDRs, SDRs and TDRs of affected mothers had 1.12-fold (95% CI: 0.98-1.28), 1.09-fold (95% CI: 0.96-1.24), and 1.15-fold (95% CI: 1.06-1.24) higher stillbirth odds compared with those of unaffected mothers, respectively. Conclusions We provide evidence for familial aggregation of stillbirth. Our findings warrant investigation into genes associated with stillbirth and underscore the need to design large-scale studies to determine its genetic architecture.

Letter to Editor:

A document by Angélica Diniz. Click on the document to view its contents.

A document by Christos Iavazzo. Click on the document to view its contents.

Objective To examine the association of DNA copy number variants (CNVs) with pathologic placental lesions (PPLs) in stillborn fetuses. Design A secondary analysis of stillbirth cases in the Stillbirth Collaborative Research Network case-control study. Setting Multicenter, 59 hospitals in 5 geographic regions in the USA. Population 387 stillbirth cases (2006-2008). Methods Using standard definitions, PPLs were categorized by type including maternal and fetal vascular, inflammatory and immune/idiopathic lesions. Using single-nucleotide polymorphism array, CNVs of at least 500 kb were detected. CNVs were classified into two groups: normal, defined as no CNVs>500 kb or benign CNVs, and abnormal, defined as pathogenic or variants of unknown clinical significance. Main outcome measures The proportions of abnormal CNVs and normal CNVs were compared between stillbirth cases with and without PPLs using the Wald Chi-squared test. Results Of 387 stillborn fetuses, 327 (84.5%) had maternal vascular PPLs and 60 (15.6%) had abnormal CNVs. Maternal vascular PPLs were more common in stillborn fetuses with abnormal CNVs compared with those with normal CNVs (81.7% vs. 64.2%; p=0.008). The proportions of fetal vascular, maternal/fetal inflammatory, and immune/idiopathic PPLs were similar among stillborn fetuses with abnormal CNVs compared to those with normal CNVs. Pathogenic CNVs in stillborn fetuses with maternal vascular PPLs spanned several genes with known relevant mechanisms. Conclusions Abnormal placental/fetal CNVs were associated with maternal vascular PPLs in stillborn fetuses. Findings may provide insight on the mechanisms of specific genetic abnormalities associated with placental dysfunction and stillbirth.

Objective To establish pregnancy-specific reference ranges for fasting and postprandial total serum bile acids (TSBA) levels. Design Cross-sectional study. Setting Tertiary care university hospital. Population Healthy pregnant women at term admitted to the Obstetrics Department over one year. Exclusion criteria were an established diagnosis of intrahepatic cholestasis of pregnancy (ICP) or any co-existing condition of increased risk for ICP. Methods and Main Outcome Measures Both fasting and postprandial TSBA levels were measured in 612 women (528 fasting and 377 postprandial samples). Results Reference intervals of 4.4-14.1 µmol/L for fasting TSBA, and 4.7-20.2 µmol/L for postprandial TSBA were established. The postprandial values were significantly higher than the fasting measurements, with a mean increase of 1.77 µmol/L (22%). A correlation between fasting TSBA levels and postprandial levels was found, as well as with fetal gender, parity, and the use of assisted reproductive technologies. A seasonal pattern was noticed for both fasting and postprandial TSBA, with the highest values in the winter season (p < 0.01 and 0.02, respectively). Conclusions Normal pregnancy is a sub-cholestatic state and is associated with a physiological elevation of TSBA levels, therefore a higher threshold should be considered for the diagnosis of ICP. We suggest using the upper reference limit observed in our healthy pregnant population (fasting ≥14 µmol/L and postprandial ≥20 µmol/L). As the fasting measurement is more specific for the diagnosis, and the postprandial is essential for severity assessment, it is recommended to measure both values, rather than use random samplings. Funding No funding to declare.

Objectives: To examine the association between racial origin and preeclampsia(PE) and gestational hypertension(GH) after adjustment for factors in maternal characteristics and medical history in screening study from the Fetal Medicine Foundation (FMF) in England, and to perform a systematic review and meta-analysis of studies on PE. Methods: In the FMF data regression analysis was performed to examine the association between racial origin and PE or GH. Literature search to December 2021 was carried out to identify peer-reviewed publications on race and PE. Main outcome measure: Relative risk of PE and GH in women of black, South Asian and East Asian racial origin by comparison to white women. Results: In the FMF study there were 168,966 singleton pregnancies without major abnormalities delivering at ≥24 weeks’ gestation. In black women the respective risk of total-PE and preterm-PE was 2-fold and 2.5-fold higher and risk of GH was 25% higher, in South Asian women there was a 1.5-fold higher risk of preterm-PE but not total-PE, and in East Asian women there was no significant difference in risk of hypertensive disorders. The literature search identified 19 studies that provided data on several million of pregnancies, but 17 were at moderate or high-risk of bias and only three provided risks adjusted for some maternal characteristics; consequently, these studies did not provide accurate contribution of different racial groups to the prediction of PE. Conclusion: In women of black and South Asian origin the risk of PE, after adjustment for confounders, is higher than in white women

Objective: To explore the duration of the active phase of the second stage of labour in relation to maternal prepregnant body mass index (BMI). Design: Retrospective cohort study. Setting: Labour wards of three Norwegian university hospitals, 2012-2019. Population: Nulliparous and parous women without previous caesarean section with a live singleton foetus in cephalic presentation and spontaneous onset of labour, corresponding to the Ten Group Classification System (TGCS) group 1 and 3. Methods: Women were stratified to BMI groups according to WHO classification, and estimated median duration of the active phase of the second stage of labour was calculated using Kaplan-Meier analyses. We performed stratified analyses in women with and without epidural analgesia and oxytocin augmentation. Finally, we calculated the Hazard Ratio (HR) of delivery using Cox regression analyses. Caesarean sections and operative vaginal deliveries during the active phase were censored. Main Outcome Measures: Estimated median duration of the active phase of second stage of labour. Results: The final study population comprised 23516 women in TGCS group 1 and 27255 in group 3. Increasing BMI was associated with shorter estimated median duration of the active phase in both TGCS groups. The pattern remained when performing stratified analyses for epidural and oxytocin analgesia. The HR for delivery increased significantly with increasing BMI analysed as a continuous variable; HR 1,019 (95%CI 1.016-1.023) in TGCS group 1 and HR 1,017 (95%CI 1.014-1.020) in TGCS group 3. Conclusion: Increasing BMI was associated with shorter estimated median duration of the active second stage Funding: None.

The surgical management of prolapse has undergone a meandering path, with innovation, controversy and legislation all being encountered en route. Some of the dust is now settling with respect to the role of mesh implant surgery, and whilst it continues to have albeit a contracted role, there is very much a new direction set on native tissue and non-mesh repairs with the advent of techniques such as laparoscopic suture hysteropexy, cervicopexy and colporrhaphy.The authors of this paper present the largest series of women undergoing autologous fascia sacrocolpopexy for the treatment of moderate-severe prolapse. Learning from the past, two key questions that must always be answered when evaluating any new procedure are safety and efficacy. For both these measures, the authors show encouraging results comparable with current gold-standard, mesh augmented repairs.The use of autologous fascia has been well established to treat women with urinary incontinence -the pubovaginal / rectus fascial sling (Mcguire EJ et al . Pubovaginal sling procedure for stress incontinence. J Urol.  1978;119:82–4) – the use of which has resurged following the widespread suspension of synthetic sling procedures. Reports of autologous fascial support of the vaginal vault however are limited to a few short-term case series.This series involves 132 women, followed up for a median of 2.2 years; the authors present five-year data with comparable success rates to those reported in the landmark CARE study (Nygaard I, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse.JAMA . 2013 May 15;309(19):2016-24) without the complication of mesh erosion.The mixed bag of patient types and concomitant surgery in this study underscores the myriad of pathology and presenting symptoms to the pelvic floor surgeon; sadly, this reality hinders forensic evaluation of the single procedure. It is noted that around three-quarters of the women in the study were having primary prolapse surgery, with a similar proportion undergoing some form of hysterectomy coupled with autologous fascial vault support. Other sacrocolpopexy series have involved women the majority who have already had primary procedures, are without a uterus and represent an already failed and perhaps more difficult to successfully treat group (Maher C, et al. Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev. 2016 Oct 1;10(10):CD012376.) The addition of a hysterectomy, as well as the harvesting of autologous fascia inevitably means a lengthening of procedure time compared to those usually quoted for women undergoing laparoscopic vault suspension procedures of hysteropexy or sacrocolpopexy.The complexities of pelvic floor patients and their symptoms mean that additionally nearly 2/3 of the patients had Burch colposuspensions performed at the time of index surgery. The unpredictability of pelvic floor surgery on bladder symptoms is amply demonstrated by around 1/3 of women complaining of stress incontinence and a third suffering overactive bladder symptoms following the procedure. It’s clear that functional improvements do not always go hand in hand with anatomical correction for the pelvic floor patient.Many women remain alarmed by the adverse reports of mesh augmentation surgery in gynaecology (Izett-Kay ML, et al ’What research was carried out on this vaginal mesh?’ Health-related concerns in women following mesh-augmented prolapse surgery: a thematic analysis. BJOG . 2021 Jan;128(1):131-139). Contemporary best practice involves distilling out irrefutable principles such as recognising the importance of appropriate apical support which is usually optimally achieved abdominally, as well as an awareness of risks of surgery, careful counselling regarding mesh and being able to offer evidence-based alternatives. This paper provides valuable long-term data for a further promising meshless surgical technique.