Ethical considerations in the management of infants with severe intraventricular hemorrhage

Intrinsic and extrinsic factors unique to neonatal care can complicate predictions of neurological outcomes for infants who suffer from severe intraventricular hemorrhage. While care decisions are driven by the same bioethical principles used in other domains, neurological prognostication can challenge concepts of futility, require careful examination of parental values, uncover biases and/or potentially compromise the best interests of the future child. In the following chapter we will review bioethical principles and relevant concepts, explore challenges to decision-making surrounding diagnoses of severe intraventricular hemorrhage and conclude with a brief review of practical approaches for counseling parents about neurodevelopmental impairment given the constraints of prognostic uncertainty and assumptions related to quality of life. We will argue that neurological findings alone, even in the setting of severe intraventricular hemorrhage, often do not constitute enough evidence for redirection of care but can be permissible when the entire neonatal condition is considered.     

Guideline No. 441: Antenatal Fetal Health Surveillance

ObjectiveTo summarize the current evidence and to make recommendations for antenatal fetal health surveillance (FHS) to detect perinatal risk factors and potential fetal decompensation in the antenatal period and to allow for timely intervention to prevent perinatal morbidity and/or mortality.Target populationPregnant individuals with or without maternal, fetal, or pregnancy-associated perinatal risk factors for antenatal fetal decompensation.OptionsTo use basic and/or advanced antenatal testing modalities, based on risk factors for potential fetal decompensation.OutcomesEarly identification of potential fetal decompensation allows for interventions that may support fetal adaptation to maintain well-being or expedite delivery.Benefits, harms, and costsAntenatal FHS in pregnant individuals with identified perinatal risk factors may reduce the chance of adverse outcomes. Given the high false-positive rate, FHS may increase unnecessary interventions, which may result in harm, including parental anxiety, premature or operative birth, and increased use of health care resources. Optimization of surveillance protocols based on evidence-informed practice may improve perinatal outcomes and reduce harm.EvidenceMedline, PubMed, Embase, and the Cochrane Library were searched from inception to January 2022, using medical subject headings (MeSH) and key words related to pregnancy, fetal monitoring, fetal movement, stillbirth, pregnancy complications, and fetal sonography. This document represents an abstraction of the evidence rather than a methodological review.Validation methodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).Intended audienceAll health care team members who provide care for or education to obstetrical patients, including maternal fetal medicine specialists, obstetricians, family physicians, midwives, nurses, nurse practitioners, and radiologists.SUMMARY STATEMENTS

• 1.Accurate and ongoing early identification of risk factors for potential fetal decompensation allows care providers to develop an individualized care plan to optimize fetal well-being (moderate).
• 2.The nonstress test (NST) may be used in conjunction with a review of the total clinical picture to assess fetal well-being. An NST should be used only in the presence of a clear indication or finding associated with increased risk of fetal hypoxemia (moderate).
• 3.Sonography can evaluate amniotic fluid, estimated fetal weight, biophysical profile/modified biophysical profile, and Doppler blood flows to provide information regarding fetal well-being in pregnancies at risk of fetal morbidity (moderate).
• 4.Interprofessional team communication and documentation should be clear, using accepted and defined terminology (high).

RECOMMENDATIONS

• 1.Care providers should review and document perinatal risk factors (prior pregnancy, fetal, maternal, familial) at the initial visit and update factors throughout pregnancy (strong, moderate).
• 2.Pregnant individuals should be advised of local resources and/or the need for transfer of care based on pregnancy risk factors (strong, moderate).
• 3.Regular prenatal visits should include assessment and documentation of the presence of fetal heart tones, uterine size, pregnancy concerns or risk factors, the plan of care, and the discussion with the pregnant individual (strong, moderate).
• 4.All pregnant individuals should be advised to regularly monitor fetal movements starting at 26 weeks gestation (conditional, low).
• 5.If a reduction of fetal movements is identified, regardless of the technique used to assess fetal movements, pregnant individuals should be advised to present to their care provider or local obstetrical unit immediately for further evaluation (strong, low).
• 6.The nonstress test (NST) should be administered and interpreted by appropriately trained health professionals (strong, high).
• 7.A ≥2 cm × 1 cm pocket of fluid by transabdominal sonography should be used as the criterion for the amniotic fluid component of the biophysical profile (strong, moderate).
• 8.To ensure patient safety, care providers should develop clear protocols locally to communicate and document changes in fetal status identified during antenatal fetal surveillance and escalation of care (strong, moderate).
• 9.Care providers should use non-routine antenatal fetal health surveillance modalities, such as an NST, biophysical profile, or fetal Doppler sonography, only in the presence of a clear indication or finding associated with increased risk of fetal hypoxemia (strong, moderate).

     

Technical Update No. 433: eHealth Solutions for Urinary Incontinence Among Women

ObjectiveThe purpose of this technical update is to establish the state of the science regarding emerging and novel electronic health (eHealth) and mobile health (mHealth) solutions for urinary incontinence among women.Target populationWomen over 18 years with urinary incontinence.OptionsWebsites and mobile health applications are useful in the conservative care of urinary incontinence. Relevant care providers should be familiar with such tools, particularly those that use motivational principles for behaviour change, which can be used as adjunct tools for urinary incontinence care. Telemedicine is an effect mode to provide services for the conservative care of urinary incontinence.OutcomesUse of eHealth and mHealth solutions has potentially significant health outcomes for patients, providers, and global health systems. Broader use of telemedicine, in and of itself, could improve care access and reduce costs incurred by patients and the health care system.Benefits, Harms, and CostsEvidence for the efficacy of eHealth and mHealth technologies and applications for urinary incontinence ranges from weak to strong. However, the research landscape for many of these novel solutions is developing rapidly. Furthermore, these options have minimal or no harm and confer an established cost benefit and care access benefit.EvidenceThe Cochrane Library, Medline, EMBASE, CENTRAL databases (from January 2014 to April 2019) were searched to find articles related to conservative care of urinary incontinence in women (over 18 years) and studies on eHealth and mHealth interventions for urinary incontinence. Articles were appraised, and the collective evidence was graded.Validation methodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).Intended audienceRelevant primary care providers and medical specialists, including physicians, nurses, midwives, and pelvic health physiotherapists.SUMMARY STATEMENTS

• 1.Electronic and mobile health interventions for urinary incontinence are growing, both in their availability in the health care market and in the science to support their use (moderate).
• 2.Electronic health interventions offered in conjunction with pelvic floor muscle training, either self-directed or directed by a health care provider (physiotherapist), may provide a marginal benefit in symptom improvement for stress urinary incontinence among women (low).
• 3.Application- and web-based programming for urinary incontinence should include traditional components of self-management programs, including motivational strategies to support behavioural interventions (high).
• 4.Bladder diaries are the most studied electronic health tool for overactive bladder and urge urinary incontinence. The acceptability and feasibility of these mobile health solutions has been established (low).
• 5.There is limited research on how electronic health interventions improve urge urinary incontinence and overactive bladder (low).
• 6.Telehealth can be an effective platform for patient education and counselling on conservative and surgical management of uncomplicated stress urinary incontinence (high).

RECOMMENDATIONS

• 1.Mobile health solutions, such as applications that incorporate evidence-based, motivational, behavioural intervention principles, should be recommended to women with stress urinary incontinence if tailored in-person care is not available or accessible (strong, high).
• 2.There is currently insufficient evidence to recommend the routine use of electronic health interventions that include a physical device to improve stress urinary incontinence symptoms (conditional, very low).
• 3.Electronic health interventions may be recommended to complement stress urinary incontinence treatment, but providers should familiarize themselves with the specific interventions recommended, since they vary significantly in terms of composition, cost, and benefit (conditional, very low).
• 4.Health care providers remain the key knowledge translators and advisors on overactive bladder and urge urinary incontinence; they should not assume that patients will get the information they need from a website (strong, moderate).
• 5.Health care providers may recommend web-based self-management programs that incorporate evidence-based motivational behavioural intervention principles if tailored in-person care is not available or accessible to patients (strong, low).
• 6.Application-based bladder diaries may be used as an alternative to traditional bladder diaries as a self-monitoring tool (conditional, low).
• 7.Follow-up visits for uncomplicated stress urinary incontinence may be considered in women who are comfortable with this platform (strong, low).
• 8.Although there is insufficient evidence to recommend virtual or telehealth consultation for routine pessary care instructions, these platforms can be considered on a case-by-case basis depending on the patient’s comfort with pessary self-care (conditional, very low).
• 9.Surgical counselling for stress urinary incontinence via telehealth or virtual platforms may be considered for women who are comfortable with shared decision-making on these platforms (strong, moderate).
• 10.Post-operative virtual visits may be offered as an alternative to in-person visits after uncomplicated surgery for stress urinary incontinence (strong, moderate).

     

The impact of prematurity and associated comorbidities on clinical outcomes in neonates with congenital heart disease

Prematurity is a common risk factor in children, affecting approximately 10% of live births, globally. It is more common in children with critical congenital heart disease (CCHD) and carries important implications in this group of patients. While outcomes have been improving over the years, even late preterm birth is associated with worse outcomes in children born with critical congenital heart disease compared to those without. Infants with both prematurity and CCHD are at particularly high risk for important comorbidities, including: necrotizing enterocolitis, intraventricular hemorrhage, white matter injury, neurodevelopmental anomalies and retinopathy of prematurity. Lesion-specific intensive care management of these infants, interventional and peri-operative management specifically tailored to their needs, and multidisciplinary care all have the potential to improve outcomes in this challenging group.     

Racial and ethnic disparities in outcomes after NICU discharge: An equity-focused model

Significant racial and ethnic disparities exist in birth outcomes and complications related to prematurity. However, little is known about racial and ethnic variations in health outcomes after premature infants are discharged from the neonatal intensive care unit (NICU). We propose a novel, equity-focused conceptual model to guide future evaluations of post-discharge outcomes that centers on a multi-dimensional, comprehensive view of health, which we call thriving. We then apply this model to existing literature on post-discharge inequities, revealing a need for rigorous analysis of drivers and strength-based, longitudinal outcomes.     

Artificial intelligence in perinatal diagnosis and management of congenital heart disease

Prenatal diagnosis and management of congenital heart disease (CHD) has progressed substantially in the past few decades. Fetal echocardiography can accurately detect and diagnose approximately 85% of cardiac anomalies. The prenatal diagnosis of CHD results in improved care, with improved risk stratification, perioperative status and survival. However, there is much work to be done. A minority of CHD is actually identified prenatally. This seemingly incongruous gap is due, in part, to diminished recognition of an anomaly even when present in the images and the need for increased training to obtain specialized cardiac views. Artificial intelligence (AI) is a field within computer science that focuses on the development of algorithms that “learn, reason, and self-correct” in a human-like fashion. When applied to fetal echocardiography, AI has the potential to improve image acquisition, image optimization, automated measurements, identification of outliers, classification of diagnoses, and prediction of outcomes. Adoption of AI in the field has been thus far limited by a paucity of data, limited resources to implement new technologies, and legal and ethical concerns. Despite these barriers, recognition of the potential benefits will push us to a future in which AI will become a routine part of clinical practice.     

No. 381-Assisted Vaginal Birth

ObjectivesTo provide evidence-based guidelines for safe and effective assisted vaginal birth.OutcomesPrerequisites, indications, contraindications, along with maternal and neonatal morbidity associated with assisted vaginal birth.EvidenceMedline database was searched for articles published from January 1, 1985, to February 28, 2018 using the key words “assisted vaginal birth,” “instrumental vaginal birth,” “operative vaginal delivery,” “forceps delivery,” “vacuum delivery,” “ventouse delivery.” The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on Preventive Health Care.ValidationThese guidelines were approved by the Clinical Practice Obstetrics Committee and the Board of the Society of Obstetricians and Gynaecologists of Canada.Recommendations

• 1The need for assisted vaginal birth can be reduced by: dedicated and continuous support during labour (I-A), oxytocin augmentation of inadequate labour (I-A), delayed pushing in women with an epidural (I-A), increased time pushing in nulliparous women with an epidural (I-B), as well as optimization of fetal head position through manual rotation (I-A).
• 2Encouraging safe and effective assisted vaginal birth by experienced and skilled care providers may be a useful strategy to reduce the rate of primary Caesarean delivery (II-2B).
• 3Safe and effective assisted vaginal birth requires expertise in the chosen method, comprehensive assessment of the clinical situation alongside clear communication with the patient, support people, and health care personnel (III-B).
• 4Practitioners performing assisted vaginal birth should have the knowledge, skills, and experience necessary to assess the clinical situation, use the selected instrument, and manage complications that may arise from assisted vaginal birth (II-2B).
• 5Obstetrical trainees should receive comprehensive training in assisted vaginal birth and be deemed competent prior to independent practice (III-B).
• 6When assisted vaginal birth is deemed to have a higher risk of not being successful, it should be considered a trial of assisted vaginal birth and be conducted in a location where immediate recourse to Caesarean delivery is available (III-B).
• 7The physician should determine the instrument most suitable to the clinical circumstances and their level of skill. Vacuum and forceps are associated with different short- and long-term benefits and risks. Unsuccessful delivery is more likely with vacuum than forceps (I-A).
• 8Planned sequential use of instruments is not recommended as it may be associated with an increased risk of perinatal trauma. If an attempted vacuum is unsuccessful, the physician should consider the risks of proceeding to an attempted forceps delivery versus Caesarean section (II-2B).
• 9Restrictive use of mediolateral episiotomy is supported in assisted vaginal birth (II-2B).
• 10A debrief should be done with the patient and support people immediately following an attempted or successful assisted vaginal birth. If this is not possible, ideally this should be done prior to hospital discharge and include the indication for assisted vaginal birth, management of any complications, and the prognosis for future deliveries (III-B).
• 11In a subsequent pregnancy, patients should be encouraged to consider spontaneous vaginal birth. However, care planning should be individualized and patient preference respected (II-3B).

     

The most immature infants: Is evidence-based practice possible?

IntroductionAt extremely low gestational ages, preterm infants are markedly physiologically immature, thus their responses to common clinical interventions may differ from more mature preterm babies. This study was performed to describe the evidence base which is available to make care decisions for such infants.MethodsA literature search of recent large neonatal randomized controlled trials (RCTs) was performed to determine the representation of infants <25 weeks of gestation, and whether it is clear if the overall results applied to the most immature infants.ResultsAmong 30 multi-centre RCTs in neonatology from the last 5 years, many excluded the most immature infants, and those that included them rarely presented the impacts of the intervention on the most at-risk group. Over 25,000 infants of under 32 weeks gestational age (GA) were included in these trials. Eight trials presented results of the primary outcome for infants of <26 weeks GA (n = 2,152) and a further four trials for infants <25 weeks, n = 711.ConclusionThe evidence base for treatment decisions for the highest risk infants in the NICU is severely limited. RCTs in extremely preterm infants should not exclude the highest risk group, and lower limits of gestational age (or body weight) should be avoided, any infant receiving intensive care should be eligible regardless of how immature. The results among the most immature infants should be presented separately, or be easily available, in order to build a database of effective treatments among infants of 22,23, and 24 weeks GA.     

Consensus Statement No. 434: Simulation in Obstetrics and Gynaecology

ObjectiveTo provide a comprehensive and current overview of the evidence for the value of simulation for education, team training, patient safety, and quality improvement in obstetrics and gynaecology, to familiarize readers with principles to consider in developing a simulation program, and to provide tools and references for simulation advocates.Target populationProviders working to improve health care for Canadian women and their families; patients and their families.OutcomesSimulation has been validated in the literature as contributing to positive outcomes in achieving learning objectives, maintaining individual and team competence, and enhancing patient safety. Simulation is a well-developed modality with established principles to maximize its utility and create a safe environment for simulation participants. Simulation is most effective when it involves interprofessional collaboration, institutional support, and regular repetition.Benefits, Harms, and CostsThis modality improves teamwork skills, patient outcomes, and health care spending. Upholding prescribed principles of psychological safety when implementing a simulation program minimizes harm to participants. However, simulation can be an expensive tool requiring human resources, equipment, and time.EvidenceArticles published between 2003 and 2022 were retrieved through searches of Medline and PubMed using the keywords “simulation” and “simulator.” The search was limited to articles published in English and French. The articles were reviewed for their quality, relevance, and value by the SOGC Simulation Working Group. Expert opinion from relevant seminal books was also considered.Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).Intended AudienceAll health care professionals working to improve Canadian women’s health, and relevant stakeholders, including granting agencies, physician/nursing/midwifery colleges, accreditation bodies, academic centres, hospitals, and training programs.Recommendations

• 1.Health care professionals in obstetrics and gynaecology should understand the value of both in situ and off-site simulation as a tool for education, patient safety, and quality improvement at both the team and individual levels (strong, moderate).
• 2.Health care professionals in obstetrics and gynaecology should be aware of the overall cost reduction associated with the use of simulation (strong, moderate).
• 3.Stakeholders at all levels must commit to an ongoing simulation program, including identifying, training, and supporting simulation advocates, as well as securing adequate funding. This approach leads not only to organizational readiness but also to quality improvement and positive culture change (strong, moderate).
• 4.Providers of obstetrical and gynaecological care should be familiar with key simulation modalities and principles of how to advance knowledge using simulation (conditional, low).
• 5.Purposeful simulation activities must be based on local needs assessments and knowledge gaps (conditional, low).
• 6.Interprofessional/interdisciplinary teams should participate in the design, implementation, and evaluation of team training and in situ simulation programs (strong, high).
• 7.Debriefing must be promoted as a fundamental component of the experiential learning process. Team debriefing/peer debriefing with a written guide can be as effective (as an alternative) as expert debriefing (strong, high).
• 8.Psychological safety must be established for all personnel within the simulation and the debriefing (strong, moderate).
• 9.Program evaluation, a system to measure the efficacy of a learning activity, must be included in the planning of simulation activities to assess whether the targeted outcomes of the program were achieved (strong, moderate).
• 10.Simulation-based activities should be designed in a culturally sensitive and socially responsible way, similar to all other aspects of health professionals’ education (strong, low).

     

Trauma-informed care and ethics consultation in the NICU

Trauma-informed care responds to our current understanding of the ways in which people's traumatic life experiences influence both their health and their interactions with the health care system. Many ethics consults arise because those past traumatic life experiences are not recognized and addressed. In this paper, we present a NICU case that led to an ethics consultation about end-of-life decisions for a dying baby. We illustrate the ways in which a trauma-informed approach helped doctors, nurses and ethics consultants to better understand and care for the mother and baby.     

Binaural beats reduce feeling of pain and discomfort during colonoscopy procedure in not-sedated patients: A randomized control trial

Background and purposeThis study aimed to determine the effect of Binaural Beats(BB)on feeling of pain, and patient comfort during colonoscopy without sedation.Materials and methodsIt is a randomized, controlled, double-blind procedural study of 115 patients that underwent colonoscopy without sedation. The patients were randomly assigned into the experimental group (n = 42) and the control group (n = 48) that were given BB starting 5 min before and continuing until the end of the colonoscopy procedure without any intervention other than routine nursing care. Measures of the state of anxiety (VAS-Anxiety scale) administered before the procedure, and measures of feeling of pain (Visual Analogue scale VAS-pain), Satisfactory and Willingness to repeat the procedure as Likert scales were also collected soon after the colonoscopy procedure.ResultsFeeling of pain was lower and scores of the level of comfort were higher in the experimental group when compared to the control group (p < 0.05).ConclusionsBB is an effective and safe method for reducing pain and improving patient comfort in cases undergoing colonoscopy without sedation. Since BB method is a non-pharmacological, non-invasive, inexpensive and simple method without any side effects, it may be used to reduce the feeling of pain and discomfort for non-sedated patients undergoing colonoscopy.     

Efficacy and safety of Buyang-Huanwu-Tang (Boyang-Hwano-Tang) in patients with vascular dementia: A systematic review and meta-analysis

BackgroundBuyang-Huanwu-Tang (Boyang-Hwano-Tang, BHT) is a widely used traditional Chinese herbal medicine for treating ischemic stroke in South Korea and China. Its efficacy in vascular dementia has been reported. There has been no comprehensive systematic review of BHT for vascular dementia.MethodsWe searched 15 electronic databases from inception to November 25, 2021. We included only randomised controlled clinical trials. Studies that used BHT alone or with Western medicine were included. Two independent reviewers conducted the screening, data extraction, and the Cochrane risk of bias and quality of evidence assessment. A meta-analysis was performed.ResultsA total of 18 eligible trials with 1254 participants were included. Of these, 15 were included in the meta-analysis. The pooled results suggested that BHT alone (mean difference [MD] 1.31; 95% confidence interval [CI] −2.94 to 5.56; P = 0.55) was similar to Western medicine alone in terms of the Mini-Mental State Examination(MMSE). Additive BHT therapy showed a significant improvement in the MMSE (MD 1.42; 95% CI 0.28 to 2.56; P = 0.01), Hasegawa Dementia Scale score (MD 3.91; 95% CI 2.87 to 4.94; P < 0.001) and total effective rate (risk ratio 1.35; 95% CI 1.20 to 1.52; P < 0.001). The overall risk of bias was unclear or high. The quality of evidence was very low to moderate. Only four studies reported minor or no adverse events.ConclusionsThe results support the clinical use of BHT for the improvement of cognitive function in patients with vascular dementia. The methodological quality of the included studies was relatively poor. Therefore, further rigorously designed trials are required.     

Guideline No. 439: Diagnosis and Management of Vasa Previa

ObjectiveTo summarize the current evidence and to make recommendations for diagnosis and classification of vasa previa and for management of women with this diagnosis.Target populationPregnant women with vasa previa or low-lying fetal vessels.OptionsTo manage vasa previa in hospital or at home, and to perform a cesarean delivery preterm or at term, or to allow a trial of labour when a diagnosis of vasa previa or low-lying fetal vessels is suspected or confirmed.OutcomesProlonged hospitalization, preterm birth, rate of cesarean delivery, and neonatal morbidity and mortality.Benefits, harms, and costsWomen with vasa previa or low-lying fetal vessels are at an increased risk of maternal and fetal or postnatal adverse outcomes. These outcomes include a potentially incorrect diagnosis, need for hospitalization, unnecessary restriction of activities, an early delivery, and an unnecessary cesarean delivery. Optimization of diagnostic and management protocols can improve maternal and fetal or postnatal outcomes.EvidenceMedline, Pubmed, Embase, and the Cochrane Library were searched from inception to March 2022, using medical subject headings (MeSH) and keywords related to pregnancy, vasa previa, low-lying fetal vessels, antepartum hemorrhage, short cervix, preterm labour, and cesarean delivery. This document presents an abstraction of the evidence rather than a methodological review.Validation methodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).Intended audienceObstetric care providers, including obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, and radiologists.Tweetable AbstractUnprotected fetal vessels in placental membranes and cord that are close to the cervix, including vasa previa, need careful characterization by sonographic examination and evidence-based management to reduce risks to the baby and the mother during pregnancy and delivery.SUMMARY STATEMENTS

• 1.A marginal sinus or a loop of cord above the cervix are frequent causes of an incorrect diagnosis of vasa previa (low).
• 2.Depending on gestational age when vasa previa or low-lying fetal vessels are diagnosed, these conditions will resolve closer to the time of delivery in a large proportion of women (moderate).
• 3.Most women with vasa previa have an associated risk factor (moderate).
• 4.Depending on individual patient factors, vasa previa can be safely managed on an outpatient basis in many women (moderate).
• 5.Bed rest or reduced activity does not improve outcomes in women with vasa previa and can be harmful. However, sexual intercourse/insertion of foreign bodies in vagina or rectum have potential for harm, particularly in the third trimester (low).

RECOMMENDATIONS

• 1.The physician interpreting an obstetric sonographic examination should classify fetal vessels <2 cm from the cervical os as vasa previa (strong, moderate).
• 2.The physician interpreting an obstetric sonographic examination should classify vessels between 2 and 5 cm from the cervical os as low-lying fetal vessels (conditional, low).
• 3.The obstetric sonographic provider should use transvaginal sonography with colour mapping and pulsed-wave Doppler to diagnose vasa previa or other related variants (strong, moderate).
• 4.When a diagnosis of vasa previa or low-lying fetal vessels is made remote from delivery, the obstetric care provider should confirm the diagnosis closer to the time of delivery (strong, moderate).
• 5.The obstetric sonographic provider should assess the placental cord insertion site in all women at the routine second trimester fetal anatomical scan (conditional, moderate).
• 6.The physician interpreting an obstetric sonographic examination should not diagnose an abnormality of placental morphology, location, placental cord insertion, or vasa previa before the routine second trimester obstetrical sonographic scan (conditional, moderate).
• 7.The obstetric sonographic provider should perform targeted screening for vasa previa in all women with a risk factor (strong, moderate).
• 8.The obstetric care provider should consider hospitalization in women with vasa previa at 32 weeks of gestation, and in women with additional risk factors for early delivery, such as multiple gestation or a short cervix, before 32 weeks (conditional, moderate).
• 9.In women with vasa previa and a singleton pregnancy, the obstetric care provider should perform a cesarean delivery at 35⁰ to 35⁶ weeks. They should consider an earlier delivery if there are additional risk factors for preterm delivery (strong, moderate).
• 10.In women with vasa previa and a twin pregnancy, the obstetric care provider should consider a cesarean delivery at 33⁰ to 34⁶ weeks for dichorionic twins and at 32⁰ to 33⁶ weeks for monochorionic twins. They should consider an earlier delivery if there are additional risk factors for preterm delivery, such as higher-order multiple pregnancy or a short cervix (conditional, low).
• 11.In women with low-lying fetal vessels, the obstetric care provider should consider a cesarean delivery at 37⁰ to 38⁶ weeks for a singleton pregnancy and at 36⁰ to 37⁶ weeks for dichorionic twins (conditional, low).
• 12.In women with vasa previa, the obstetric care provider should consider timely access to an operating room, an obstetrician, an anesthetist, and an appropriate neonatal intensive care unit when deciding location of admission for observation or delivery (conditional, low).