An Arterial Vaginal Bleed Resulting from Short-Term Pessary Use: A Case Report

BackgroundPessaries are commonly used for the management of pelvic organ prolapse. Complications are rare, with major complications usually related to long-term use and neglect. Complications related to short-term pessary use, as well as complications requiring surgical intervention, are even less common.CaseWe present the case of a 58-year-old postmenopausal woman who presented with acute, arterial vaginal bleeding requiring surgical intervention 3 weeks after being fitted for a pessary for management of pelvic organ prolapse.ConclusionSevere, short-term complications are rare, but can occur with pessary management of pelvic organ prolapse. To our knowledge, this is the first case to describe an acute arterial hemorrhage requiring surgical intervention following short-term placement of a vaginal pessary.     

Oral Ketoconazole and Miconazole Vaginal Pessary Treatment for Vaginal Candidosis

This prospective study was carried out on 250 patients having clinical and mycological evidence of vaginal candidosis. One hundred patients received ketoconazole orally (400 mg/day for 5 days), another 100 patients received miconazole vaginal pessary treatment (one 100 mg tablet locally for 14 days), while the other 50 patients received combination therapy of oral ketoconazole and miconazole vaginal tablets. Although all 3 regimens were significantly effective in relieving patients symptoms and physical signs, the combination therapy gave the best results. There was 98% symptomatic relief with the combination therapy in contrast to 82% and 78% in the oral ketocanozole and vaginal micronazole groups respectively (p less than 0.001). Mycological cure rates were also significantly higher in the combination therapy group (94% versus 80% and 76%). The relapse rate was least in the combination group 2% versus 8% and 12%. The combination therapy is recommended for the best results in vaginal candidosis.     

Guideline No. 394-Stillbirth Investigation

ObjectivesTo provide an investigation protocol to help health care providers determine the cause of a fetal death.OptionsConsideration has been given to protocols for the investigation of fetal death that are currently available in Canada and in other countries.OutcomesIdentification of possible causes of stillbirth and their relationship to future pregnancies.EvidenceArticles related to the etiology of fetal death were identified in a search of PubMed (June 2006 to September 2018), the Cochrane Library, and investigation protocols from the American College of Obstetricians and Gynecologists, the International Stillbirth Alliance Collaborative for Improving Classification of Perinatal Deaths, the Royal College of Obstetricians and Gynaecologists, the Queensland clinical guidelines, and the Reproductive Care Program of Nova Scotia.BenefitsTo provide better advice for women regarding possible causes of fetal death and implications for future pregnancies.ValidationThe evidence obtained was reviewed and evaluated by the Maternal-Fetal Medicine Committee and the Clinical Practice Obstetrics Committee of the Society of Obstetricians and Gynaecologists of Canada. The level of evidence and quality of the recommendation made was described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care.Recommendations

• 1A protocol should be used to investigate the possible cause of a fetal death (II-2A).
• 2The diagnostic workup after stillbirth should depend on the specific clinical features per case (II-2A).
• 3Parents should be advised that no specific cause is found in almost half of stillbirths (II-2B).
• 4Placental and cord examination, autopsy, and cytogenetic evaluation should be recommended to all parents, regardless of cultural background, to try to explain the cause of fetal death (II-2B).
• 5Autopsy examination may only be performed with the informed consent of the parents (III-A).
• 6In cases where parents do not consent for autopsy, minimally invasive postmortem examination should be offered using magnetic resonance imaging, where available, combined with less invasive histological tissue sampling (III-B).

     

Guideline No. 422d: Menopause and Sexuality

ObjectiveProvide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence.Target PopulationPerimenopausal and postmenopausal women.Benefits, Harms, and CostsTarget population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment.EvidenceDatabases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters.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 Audiencephysicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population.SUMMARY STATEMENTS

• 1Low sexual desire in combination with distress is most common in women in mid-life (high).
• 2Vaginal atrophy is a common cause of sexual pain in menopausal women (high).
• 3Sexual dysfunction in menopausal women can be categorized as disorders involving desire, arousal, pain, and orgasm. These categories often overlap (high).
• 4A brief sexual history is part of the evaluation of menopausal women (moderate).
• 5The treatment of sexual dysfunctions involves a multifaceted approach that addresses medical, psychological, and relationship issues (high).
• 6Local estrogen therapy treats genitourinary syndrome of menopause (high).
• 7Pelvic physiotherapy is an excellent adjuvant treatment for hypercontracted pelvic floor muscles (often referred to as vaginismus) and genito-pelvic pain (low).
• 8Flibanserin has been shown to improve desire in women (moderate).
• 9Transdermal testosterone has been shown to increase desire, arousal, and satisfying sexual events, and to decrease personal distress (high).
• 10Psychological therapies, including cognitive behavioural therapy, mindfulness-based therapy, couples’ therapy, and sexual therapies, are useful for treating sexual dysfunctions (moderate).
• 11Sexual dysfunction is common in patients with depression, those on selective serotonin reuptake inhibitors (SSRIs), women with primary ovarian insufficiency, and those with a history of breast cancer (high).

RECOMMENDATIONS

• 1The patient's problem should be categorized as related to desire, arousal, pain, or orgasm, in order to facilitate treatment and to triage care (strong, moderate).
• 2Health care providers should include a sexual screening history and physical examination in the initial evaluation of menopausal women (strong, low).
• 3Vaginal estrogens, lubricants and moisturizers, vaginal dehydroepiandrosterone, and ospemifene may be used as treatments for vaginal atrophy related to menopause (strong, high).
• 4For postmenopausal women with hypoactive sexual desire disorder, the best current options include managing pain, addressing any biopsychological factors, counselling, and prescribing transdermal testosterone (off-label) or flibanserin (strong, moderate).
• 5Patients with breast cancer and symptomatic genitourinary syndrome of menopause can be offered local vaginal estrogen if local lubricants and moisturizers are ineffective, after consulting with the patient's oncologist (conditional, moderate).

     

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).

     

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).

     

Guideline No. 393-Diabetes in Pregnancy

ObjectivesThis guideline reviews the evidence relating to the diagnosis and obstetrical management of diabetes in pregnancy.OutcomesThe outcomes evaluated were short and long-term maternal outcomes including pre-eclampsia, Caesarean section, future diabetes and other cardiovascular complications; and fetal outcomes including congenital anomalies, stillbirth, macrosomia, birth trauma, hypoglycemia and long-term effects.EvidencePublished literature was retrieved through searches of PubMed and The Cochrane Library using appropriate controlled vocabulary (MeSH terms “diabetes” and “pregnancy”). Where appropriate, results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits but results were limited to English or French language materials.ValuesThe quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care.Summary Statements

• 1The adverse outcomes associated with diabetes in pregnancy are substantially associated with hyperglycemia as well as the co-existing metabolic environment. Women with pre-existing diabetes should receive preconception care to optimize blood sugar control and other co-morbidities. Outcomes for the fetus/neonate and the mother in both pre-gestational diabetes mellitus and gestational diabetes mellitus pregnancies are improved by multidisciplinary management whose goal is achieving optimal blood sugar control and appropriate fetal surveillance (II-2).
• 2Retrospective studies indicate that women with pre-gestational diabetes mellitus have an increased risk of stillbirth before 40 weeks of gestation when compared with the general obstetrical population. Similarly, large recent cohort and simulation studies of women with gestational diabetes mellitus pregnancies also indicate a higher risk of stillbirth between 36-39 weeks gestation (II-2).
• 3Women with gestational diabetes mellitus have a higher risk of pre-eclampsia, shoulder dystocia, Caesarean section and large for gestational age infants (II-2).
• 4Treatment of women with gestational diabetes mellitus and optimization of glycemic control reduces the risk of pre-eclampsia, shoulder dystocia, and large for gestational age infants (I).
• 5The occurrence of gestational diabetes mellitus increases the risk of developing type 2 diabetes in the future for the mother (II-2).

Recommendations 

• 1The “preferred screening and diagnostic 2-step” approach for gestational diabetes mellitus from Diabetes Canada's 2018 guidelines is endorsed. All pregnant women should be offered screening between 24-28 weeks using a standardized non-fasting 50-g glucose challenge screening test (GCT) with plasma glucose (PG) measured 1 hour later (III-B).
  • 1.1If the value is <7.8 mmol/L, no further testing is required.
  • 1.2If the value of the GCT is 7.8–11.0, a 2-hour 75-g oral glucose tolerance test with fasting PG (FPG), 1-hour PG, 2-hour PG should be performed.Gestational diabetes mellitus is diagnosed if 1 value is met or exceeded:
    • iFPG ≥5.3 mmol/L
    • ii1-h PG ≥10.6 mmol/L
    • iii2-h PG ≥9.0 mmol/L
  • 1.3If the value of the GCT is ≥11.1 mmol/L, gestational diabetes mellitus is diagnosed
• 2The “alternative 1-step diagnostic” approach from Diabetes Canada's 2018 guidelines is acceptable. In this strategy pregnant women should be offered testing between 24-28 weeks using a standardized 2-hour 75-g oral glucose tolerance test with fasting plasma glucose (FPG), 1-hour plasma glucose (PG), 2-hour PG (III-B).Gestational diabetes mellitus is diagnosed if 1 value is met or exceeded:
  • iFPG ≥5.1 mmol/L
  • ii1-h PG ≥10.0 mmol/L
  • iii2-h PG ≥8.5 mmol/L
  It is recognized that the use of different diagnostic thresholds for the “preferred” and “alternate” strategies could cause confusion in certain settings. Despite this the committee has identified the importance of remaining aligned with the current Diabetes Canada guidelines as being a priority. It is thus recommended that each care centre strategically align with one of the two strategies and implement protocols to ensure consistent and uniform reporting of test results.
• 3If there is a high risk of gestational diabetes mellitus based on multiple risk factors, screening or testing should be offered during the first half of the pregnancy and repeated at 24-28 weeks gestation if initially normal. If for any reason it was missed or if there is a clinical suspicion of later onset gestational diabetes, a screening or diagnostic test should be performed (II-2B).
• 4Women with pre-existing or gestational diabetes mellitus should be provided with care by a multidisciplinary team aimed at attaining and then maintaining euglycemia (II-2B).
• 5For patients with pre-gestational diabetes mellitus or gestational diabetes mellitus, starting at 28 weeks as a baseline, with subsequent serial assessment of fetal growth every 3-4 weeks is suggested to assess the effect of maternal glycemic control on fetal growth rate and amniotic fluid volume (II-2B).
• 6Initiation of weekly assessment of fetal well-being at 36 weeks is recommended in pre-gestational diabetes mellitus and in gestational diabetes mellitus. It is also reasonable to consider weekly fetal assessment for women with diet controlled gestational diabetes mellitus beginning at 36 weeks. Acceptable methods of assessment of fetal well-being near term can include the non-stress test, non-stress test + amniotic fluid index, biophysical profile or a combination of the above (III-A).
• 7If co-morbid factors are present such as obesity, evidence of suboptimal glycemic control, large for gestational age (>90%), previous stillbirth, hypertension or small for gestational age (<10%) are present, earlier onset and/or more frequent fetal health surveillance is recommended. In specific cases where fetal growth restriction is suspected, the addition of umbilical artery and fetal middle cerebral artery Doppler assessment may be helpful (II-2A).
• 8Pregnant women with gestational diabetes mellitus or with pre-gestational diabetes mellitus should be offered induction between 38-40 weeks of gestation depending on their glycemic control and other co-morbidity factors (II2-B).
• 9Antenatal corticosteroid therapy should be administered to women with insulin-treated gestational diabetes mellitus and pregestational diabetic women at the same dosage, according to the same indications, and in the same gestational age range as that recommended for non-diabetic women (Skoll A, et al. No. 364-Antenatal Corticosteroid Therapy for Improving Neonatal Outcomes. J Obstet Gynaecol Can 2018;40:1219-39). When administered to women with preexisting or poorly controlled diabetes, close maternal glycemic surveillance is recommended (III-B). Following the first dose of betamethasone, the following insulin adjustments are recommended as per Diabetes Canada guidelines (Diabetes Canada Clinical Practice Guidelines Expert C, et al. Diabetes and Pregnancy. Can J Diabetes 2018;42 Suppl 1:S255-S82):
  • •Day 1: Increase the night insulin dose by 25%
  • •Days 2 and 3: Increase all insulin doses by 40%
  • •Day 4: Increase all insulin doses by 20%
  • •Day 5: Increase all insulin doses by 10% to 20%
  • •Days 6 and 7: Gradually taper insulin doses to pre-betamethasone doses
• 10If not previously done, in women with threatened preterm labour requiring betamethasone, a screening and diagnostic test for gestational diabetes mellitus should be performed either before or at least 7 days after the administration of betamethasone (III-B).
• 11Women with GDM should be offered testing with a 75-g oral glucose tolerance test between 6 weeks and 6 months postpartum to detect prediabetes and diabetes (Diabetes Canada Clinical Practice Guidelines Expert C, et al. Diabetes and Pregnancy. Can J Diabetes 2018;42 Suppl 1:S255-S82) (II-2A).
  • 11.1 Normal
    • iFasting plasma glucose (FPG) <6.1 mmol/L
    • ii2h <7.8 mmol/L
    • iiiHbA_1C <6.0%
  • 11.2 Pre-diabetic
    • iFPG 6.1-6.9 mmol/L or
    • ii2h plasma glucose (PG) 7.8-11.0 mmol/L or
    • iiiHbA_1C 6.0-6.4%
  • 11.3 Type 2 Diabetes mellitus
    • iFPG ≥ 7.0 mmol/L
    • iiRandom PG or 2h PG ≥11.1 mmol/L
    • iiiHbA_1C ≥6.5%
• 12Breastfeeding is strongly recommended after delivery for all women with pre-gestational diabetes mellitus or gestational diabetes mellitus (II-2A).

     

Guideline No. 395-Female Genital Cutting

ObjectivesTo decrease the likelihood that the practice of female genital cutting (FGC) be continued in the future and to improve the care of girls and women who have been subjected to FGC or who are at risk by providing (1) information intended to strengthen knowledge and understanding of the practice, (2) information regarding the legal issues related to the practice, (3) guidance for the management of its obstetrical and gynaecological complications, and (4) guidance on the provision of culturally competent care to girls and women affected by FGC.OptionsStrategies for the primary, secondary, and tertiary prevention of FGC and its complications.OutcomesThe short- and long-term consequences of FGC.Intended UsersHealth care providers delivering obstetrical and gynaecological care.Target PopulationWomen from countries where FGC is commonly practised and Canadian girls and women from groups who may practise FGC for cultural or religious reasons.EvidencePublished literature was retrieved through searches of PubMed, CINAHL, and the Cochrane Library in September 2010 using appropriate controlled vocabulary (e.g., Circumcision, Female) and key words (e.g., female genital mutilation, clitoridectomy, infibulation). Searches were updated and incorporated in the guideline revision December 2018.Validation MethodsThe quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care.Benefits, Harms, and CostsThere are no anticipated harms or costs to health care facilities with implementation of this guideline. Benefits may include a greater willingness of women living with FGC to seek timely care.SUMMARY STATEMENTS

• 1Female genital cutting is internationally recognized as a harmful practice and a violation of girls’ and women's rights to life, physical integrity, and health (II-3).
• 2The immediate and long-term health risks and complications of female genital cutting can be serious and life-threatening (II-3).
• 3Female genital cutting continues to be practised in many countries, particularly in sub-Saharan Africa, Egypt, and Sudan (II-3).
• 4Global migration patterns have brought female genital cutting to Europe, Australia, New Zealand, and North America, including Canada (II-3).
• 5Performing or assisting in female genital cutting is a criminal offense in Canada (III).
• 6Reporting to appropriate child welfare protection services is mandatory when a child has recently been subjected to female genital cutting or is at risk of being subjected to the procedure (III).
• 7There is concern that female genital cutting continues to be perpetuated in receiving countries, mainly through the act of re-infibulation (III).
• 8There is a perception that the care of women with female genital cutting is not optimal in receiving countries (III).
• 9Female genital cutting is not considered an indication for cesarean section (III).

RECOMMENDATIONS

• 1Health care providers must be careful not to stigmatize women who have undergone female genital cutting (III-A).
• 2Requests for re-infibulation should be declined (III-B).
• 3Health care providers should strengthen their understanding and knowledge of female genital cutting and develop greater skills for the management of its complications and the provision of culturally competent care to girls and women who have undergone genital cutting (III-A).
• 4Health care providers should use their knowledge and influence to educate and counsel families against having female genital cutting performed on their daughters and other family members (III-A).
• 5Health care providers should advocate for the availability of and access to appropriate support and counselling services (III-A).
• 6Health care providers should lend their voices to community-based initiatives seeking to promote the elimination of female genital cutting (III-A).
• 7Health care providers should use interactions with patients as opportunities to educate women and their families about female genital cutting and other aspects of women's health and reproductive rights (III-A).
• 8Research into female genital cutting should be undertaken to explore women's perceptions and experiences of accessing sexual and reproductive health care in Canada (III-A). The perspectives, knowledge, and clinical practice of health care providers with respect to female genital cutting should also be studied (III-A).
• 9Information and guidance on female genital cutting should be integrated into the curricula for nursing students, medical students, residents, midwifery students, and students of other health care professions (III-A).
• 10Key practices in providing optimal care to women with female genital cutting include:
  • adetermining how the woman refers to the practice of female genital cutting and using this terminology throughout care (III-C).
  • bdetermining the female genital cutting status of the woman and clearly documenting this information in her medical record (III-C).
  • censuring the availability of a well-trained, trusted, and neutral interpreter who can ensure confidentiality and who will not exert undue influence on the patient-physician interaction when providing care to a woman who faces language challenges (III-C).
  • densuring the proper documentation of the woman's medical history in her record to minimize the need for repeated medical histories and/or examinations and to facilitate the sharing of information (III-C).
  • eproviding the woman with appropriate and well-timed information, including information about her reproductive system and her sexual and reproductive health (III-C).
  • fensuring the woman's privacy and confidentiality by limiting attendants in the room to those who are part of the health care team (III-C).
  • gproviding woman-centred care focused on ensuring that the woman's views and wishes are solicited and respected, including a discussion of why some requests cannot be granted for legal or ethical reasons (III-C).
  • hhelping the woman to understand and navigate the health system, including access to preventive care practices (III-C)
  • iusing prenatal visits to prepare the woman and her family for delivery (III-C).
  • jwhen referring, ensuring that the services and/or practitioners who receive the referral can provide culturally competent and sensitive care, paying special attention to concerns related to confidentiality and privacy (III-C).