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This chapter summarizes the clinical management of obesity in pregnancy, based on evidence where it exists, and highlights the areas where further research is needed. Obese women who are pregnant are recognized as a high-risk group by both the American College of Obstetricians and Gynecologists (ACOG) and the Royal College of Obstetricians and Gynaecologists (RCOG) and should therefore be referred for appropriate antenatal care. All obese women should receive a dietary assessment and nutritional counseling. Obstetric ultrasound is used widely in the developed world for pregnancy dating, detection of higher order pregnancies and fetal anomaly, and estimation of fetal growth. Obesity is a well-recognised risk factor for gestational diabetes mellitus, and pre-gestational diabetes is more prevalent in obese women. It has long been recognized that hypertensive disorders are more prevalent in the obese population. The anesthetist plays an important role in the care of the obese parturient.
Antenatal care for women with a low-risk pregnancy is predominately provided by midwives supported by maternity support workers and other professionals. The National Institute for Health and Clinical Excellence (NICE) has published guidance on the routine care of the healthy pregnant woman, outlining a schedule of appointments and the type of screening available. The care pathway provides details of antenatal care for women with an uncomplicated pregnancy. The establishment of Maternity Direct under the aegis of NHS Direct in certain parts of the country has led to a reduction in antenatal admissions. Midwives are the specialists of normality, and are trained to diagnose pregnancy and assess and monitor women holistically throughout the antenatal period. The majority of maternity services are using the Royal College of Obstetricians and Gynaecologists (RCOG) Maternity Dashboard. Maternity services should audit the percentage of women who booked by the 12th completed week of pregnancy.
The Royal College of Obstetricians and Gynaecologists (RCOG) published its document Standards in Maternity Care in 2008 which is being used widely by commissioners, providers and policy makers. The document sets out the principles of quality-assured maternity services. This chapter identifies some key indicators as exemplars, although it is recommended to make use of the whole document. Prepregnancy care for women with social needs is essential. Prepregnancy care can improve outcomes in high-risk pregnancies regardless of whether the high-risk status is of medical or social aetiology. From a public health perspective, the identification of anomalies can improve perinatal morbidity and mortality, as conditions may be identified early in pregnancy and managed accordingly. Current approaches for the prevention of hypoxic ischaemic encephalopathy include antenatal identification and monitoring of fetal growth restriction and electronic fetal monitoring accompanied by intrapartum fetal blood sampling.
This chapter presents a discussion between Sean Kehoe, Donna Dickenson, Diana Mansour, Maya Unnithan, and Peter Braude. Each participant discusses points on reproductive ageing and the society's perceptions between men and women, commercialization of the HER2, BRCA1, and BRCA2 genes, and the role of the Royal College of Obstetricians and Gynaecologists (RCOG). People often think STIs [sexually transmitted infections] are infections only of the young women. According to Braude, we are working towards bringing in stem cell coordinators, who will help reach an agreement on what kind of things would be reasonable to do - and that is not only about women. What RCOG can do is to look with a 'gender lens' - because it will bring up other lenses around social justice. Dickenson says that we should oppose body shopping for both sexes and can act together and have a stronger chance of success.
The purpose of setting standards for overall patient care is to address variations in care, to prevent inappropriate care and to address issues of inequity which have been reported in the past. The Royal College of Obstetricians and Gynaecologists (RCOG) takes a lead in developing evidence-based service standards to support local implementation protocols in all areas of gynaecological practice. Implementation of these standards should be supported by undertaking a constantly evolving audit cycle and by having multidisciplinary involvement to measure performance. The direction of travel of the National Health Service (NHS) is now for a patient-focused and quality-assured service, where patients' experience will influence service delivery models. The authors understand that professional bodies and NICE will be working together in developing a framework for service accreditation using some of the evidence used in their standards document.
Age-related changes in sperm output develop gradually without any evidence of sudden onset. Female fecundity starts to decline after 30 years of age and is greatly reduced after age 40 years. The effect of male age on fecundity remains controversial and few studies show a similar trend in men. The effect of ageing of the male partner on the risk for miscarriage has been studied extensively, although many studies are retrospective, span long observational periods and fail to control properly for maternal age effects, or have small sample sizes. The Royal College of Obstetricians and Gynaecologists (RCOG) recommends the British Andrology Society guideline of limiting the age of sperm donors to 40 years. Paternal ageing does not affect the risk of miscarriage, and increased paternal age on its own is not an indication for prenatal diagnosis since the absolute risk for genetic anomalies in offspring is low.
Gynaecological operative laparoscopy has progressed significantly over the past two decades. The process of laparoscopic surgery should be based on an appropriate risk management system that allows for improved quality of care. Regarding women with severe endometriosis, specialist referral centres should be developed. Units performing laparoscopic surgery should adopt recommendations and guidelines from scientific bodies (RCOG, NICE, BSGE) and should benchmark their audited activity against the national standards. The main components for consideration when developing models of service in laparoscopic surgery include: gynaecology outpatients, pre-operative preparation, operative and post-operative. Laparoscopic training can be developed and augmented with the use of simulators or laparoscopic trainers. Laparoscopic surgery necessitates a team approach between surgical, nursing and technical support staff. Audit of length of stay, analgesia requirement, complication rate and re-admission rate help to redesign and configure the service.
Reproductive ageing in women is caused by declining number and quality of oocytes. The Royal College of Obstetricians and Gynaecologists (RCOG) should promote the view of a shared responsibility in addressing the problems associated with reproductive ageing and encourage an acknowledgement that personal and social circumstances play a role rather than placing blame on individuals. The RCOG should urge greater transparency and accuracy in depicting assisted reproductive technology success rates, including the cost and clinical efficiency of full cycles (full cycle implies cryopreservation of embryos). There are no contraceptive methods contraindicated by age alone. Older women may use combined hormonal contraception unless they have co-existing diseases or risk factors. Further research is needed into characterisation of existing and novel ovarian biomarkers to provide clinically useful prediction of current and future fertility. National data collection covers live births and terminations of pregnancy but should be expanded to include information about miscarriage.
Reproductive rights remain one of the most important issues for different kinds and different phases of women's movements, but they do not exhaust the ethical concerns of moral philosophers concerned about women's position, any more than they do the range of concerns proper to the Royal College of Obstetricians and Gynaecologists (RCOG). The RCOG should lobby for a lower breast cancer screening age and for genetic testing enabling a more targeted approach, while opposing the growing commercialisation of genetic testing, and oppose genetic patents that particularly affect women, for example patents on the BRCA1, BRCA2 and HER2 genes. The RCOG should back a safe sex campaign and more funding for sexual health clinics aimed at women over reproductive age. It is neither patronising nor paternalistic for the RCOG to use its specialist knowledge, legitimacy and clout to prevent the 'lady from vanishing'.
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