Objective: To generate a global reference for caesarean section (CS) rates at health facilities.Design: Cross‐sectional study.Setting: Health facilities from 43 countries.Population/Sample: Thirty eight thousand three hundred and twenty‐four women giving birth from 22 countries for model building and 10 045 875 women giving birth from 43 countries for model testing.Methods: We hypothesised that mathematical models could determine the relationship between clinical‐obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three‐step approach to generate the global benchmark of CS rates at health facilities: creation of a multi‐country reference population, building mathematical models, and testing these models.Main outcome measures: Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate.Results: According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C‐Model, with summary estimates ranging from 0.832 to 0.844. The C‐Model was able to generate expected CS rates adjusted for the case‐mix of the obstetric population. We have also prepared an e‐calculator to facilitate use of C‐Model (www.who.int/reproductivehealth/publications/maternal_perinatal_health/c-model/en/).Conclusions: This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C‐Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS.Tweetable The C‐Model provides a customized benchmark for caesarean section rates in health facilities and systems.

In the active phase of the first stage of labour, does transcutaneous electrical nerve stimulation (TENS) relieve pain or change its location? Does TENS delay the request for neuraxial analgesia during labour? Does TENS produce any harmful effects in the mother or the foetus? Are women in labour satisfied with the care provided? Randomised trial with concealed allocation, assessor blinding for some outcomes, and intention-to-treat analysis. Forty-six low-risk, primigravida parturients with a gestational age > 37 weeks, cervical dilation of 4cm, and without the use of any medications from hospital admission until randomisation. The principal investigator applied TENS to the experimental group for 30minutes starting at the beginning of the active phase of labour. A second investigator assessed the outcomes in both the control and experimental groups. Both groups received routine perinatal care. The primary outcome was pain severity after the intervention period, which was assessed using the 100-mm visual analogue scale. Secondary outcomes included: pain location, duration of the active phase of labour, time to pharmacological labour analgesia, mode of birth, neonatal outcomes, and the participant's satisfaction with the care provided. After the intervention, a significant mean difference in change in pain of 15mm was observed favouring the experimental group (95% CI 2 to 27). The application of TENS did not alter the location or distribution of the pain. The mean time to pharmacological analgesia after the intervention was 5.0hours (95% CI 4.1 to 5.9) longer in the experimental group. The intervention did not significantly impact the other maternal and neonatal outcomes. Participants in both groups were satisfied with the care provided during labour. TENS produces a significant decrease in pain during labour and postpones the need for pharmacological analgesia for pain relief. NCT01600495.

Does massage relieve pain in the active phase of labour? Randomised trial with concealed allocation, assessor blinding for some outcomes, and intention-to-treat analysis. 46 women pregnant at ≥ 37 weeks gestation with a single fetus, with spontaneous onset of labour, 4-5cm of cervical dilation, intact ovular membranes, and no use of medication after admission to hospital. Experimental group participants received a 30-min lumbar massage by a physiotherapist during the active phase of labour. A physiotherapist attended control group participants for the same period but only answered questions. Both groups received routine perinatal care. The primary outcome was pain severity measured on a 100mm visual analogue scale. Secondary outcomes included the Short Form McGill Pain Questionnaire, pain location, and time to analgesic medication use. After labour, a blinded researcher also recorded duration of labour, route of delivery, neonatal outcomes, and the participant's satisfaction with the physiotherapist during labour. At the end of the intervention, pain severity was 52mm (SD 20) in the experimental group and 72mm (SD 15) in control group, which was significantly different with a mean difference of 20mm (95% CI 10 to 31). The groups did not differ significantly on the other pain-related outcome measures. Obstetric outcomes were also similar between the groups except the duration of labour, which was 6.8hr (SD 1.6) in the experimental group and 5.7hr (SD 1.5) in the control group, mean difference 1.1hr (95% CI 0.2 to 2.0). Patients in both groups were satisfied with the care provided by the physiotherapist. Massage reduced the severity of pain in labour, despite not changing its characteristics and location.

Among women in labour, does sequential application of non-pharmacological interventions relieve labour pain, shorten labour, and delay pharmacological analgesia use? Randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis. Eighty women admitted in labour at the end of a low-risk pregnancy. Participants in the experimental group received three interventions for up to 40minutes each in particular stages of labour: exercise on a Swiss ball at 4 to 5cm of cervical dilation; lumbosacral massage at 5 to 6cm dilation; and a warm shower at >7cm dilation. Participants in the control group received usual maternity unit care. Participants in both groups were encouraged to try not to avoid or delay use of pharmacological analgesia. Pain severity was reported on a visual analogue scale. Maternal and neonatal data were collected from official birth records. Satisfaction with care was recorded with a questionnaire. Some participants took analgesic medication before the study was complete, so pain was analysed with a last observation carried forward approach. In this analysis, the experimental group had significantly lower pain severity immediately after: exercises (MD 24mm, 95% CI 15 to 34), massage (14mm, 95% CI 4 to 25), and showering (17mm, 95% CI 5 to 29), which allowed delayed and reduced use of analgesic medication. Other significant benefits included: faster expulsion (MD 18minutes, 95% CI 5 to 30), improved neonatal status, and higher maternal satisfaction. No adverse effects were identified. This sequence of non-pharmacological interventions significantly reduced labour pain from 4cm to beyond 7cm of cervical dilation, as reflected in decreased and delayed use of analgesic medication. Women in labour could be encouraged to use these interventions, especially if they seek to minimise or delay use of analgesic medication. NCT01389128. [Gallo RBS, Santana LS, Marcolin AC, Duarte G, Quintana SM (2018) Sequential application of non-pharmacological interventions reduces the severity of labour pain, delays use of pharmacological analgesia, and improves some obstetric outcomes: a randomised trial. Journal of Physiotherapy 64: 33-40].

CONTEXT AND OBJECTIVE: One third of all cervical carcinomas occur during the reproductive period. Cervical carcinoma is the second greatest cause of death due to cancer during this phase. The estimated frequency of cervical cancer during pregnancy is one case for every 1,000 to 5,000 pregnancies. The aim here was to provide information about the difficulties in diagnosing and managing cervical neoplasia during pregnancy. MATERIALS: A systematic review of the literature was undertaken through the PubMed, Cochrane, Excerpta Medica (Embase), Literatura Latino Americana e do Caribe em Ciências da Saúde (Lilacs) and Scientific Electronic Library Online (SciELO) databases, using the following words: pregnancy, cervical cancer, diagnosis and management. RESULTS: There was a consensus in the literature regarding diagnosis of cervical carcinoma and management of preneoplastic lesions during pregnancy. However, for management of invasive carcinoma, there was great divergence regarding the gestational age taken as the limit for observation rather than immediate treatment. CONCLUSION: All patients with cytological abnormalities should undergo colposcopy, which will indicate and guide biopsy. Conization is reserved for patients with suspected invasion. High-grade lesions should be monitored during pregnancy and reevaluated after delivery. In cases of invasive carcinoma detected up to the 12th week of pregnancy, patient treatment is prioritized. Regarding diagnoses made during the second trimester, fetal pulmonary maturity can be awaited, and the use of chemotherapy to stabilize the disease until the time of delivery appears to be viable.