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3 4 An evaluation of caesarean sections by the American College of Obstetricians and Gynecologists reported that first time mothers with term singleton cephalic pregnancies and women with a previous caesarean section account for the greatest increase in rates of caesarean section and much of the variation between institutions.5 Higher rates of caesarean delivery are associated with increased maternal and neonatal morbidity. 6 Rising rates of caesarean deliveries are assumed to have been driven by obstetricians, reflecting medicolegal concerns about vaginal birth after previous caesarean section (VBAC), vaginal breech delivery, and fetal distress in labour. In contrast, over a similar time period there has been increased emphasis on involvement of patients in making medical decisions.7-9 The traditional paternalistic model of care is based on the premise that the obstetrician knows best and by taking the lead on decisions could reduce anxiety and risk for the mother and her baby. 10 The shared model of medical decision making, in which clinician and patient exchange information, reveal preferences for treatment, and jointly come to a decision, is now promoted in preference to other models. [10][11][12] Decision aids are designed to help people select between various treatment strategies by providing information on the options and outcomes relevant to a person's health. A Cochrane review has reported that decision aids can improve knowledge and realistic expectations, reduce decisional conflict, and increase active participation in decision making. 13 A recent consensus process identified key aspects of quality of patients' decision aids relating to content, development, and effectiveness. 14 Determining the optimal mode of delivery for a woman who has experienced a previous caesarean section requires consideration of the risks and benefits of

Objective To explore women's experiences of decision making about mode of delivery after previous caesarean section. Design A qualitative interview study.Setting Two city maternity units in southwest England and Eastern Scotland.Sample Twenty-one women who had recently delivered a baby and whose previous child was delivered by caesarean section.Methods Semi-structured interviews analysed using the framework approach.Main outcome measures Women's views on the influence of uncertainty on decision making, issues concerning information provision and decision-making roles.Results Experiences of decision making varied considerably. Some women were certain about choosing either vaginal birth after caesarean or repeat elective caesarean section, others were very uncertain and for some this uncertainty persisted after the birth. Information was most commonly provided by hospital doctors (mainly consultants) and more often related to procedural issues rather than possible health risks and benefits. Women felt they had to actively seek information rather than it being provided routinely. Most women were able to make their own decision about mode of delivery. Health professionals generally took a supportive role whichever mode of delivery was chosen. Although many women were comfortable with this approach, some felt they would have liked more guidance.Conclusion On the whole, women experienced having control over the decision about planned mode of delivery. For many, making this decision was difficult and for some it was the cause of prolonged anxiety. Women were often making the decision without being provided with comprehensive and specific information about possible health risks and benefits. We are currently conducting a randomised controlled trial to investigate whether access to a decision aid is beneficial to women in this situation.Keywords Caesarean section, decision making, qualitative methods, vaginal birth after caesarean.Please cite this paper as: Emmett C, Shaw A, Montgomery A, Murphy D on behalf of the DiAMOND study group. Women's experience of decision making about mode of delivery after a previous caesarean section: the role of health professionals and information about health risks.

Background: Glycaemic control in women with diabetes is critical to satisfactory pregnancy outcome. A systematic review of two randomised trials concluded that there was no clear evidence of benefit from very tight versus tight glycaemic control for pregnant women with diabetes.

Severity of the neonatal abstinence syndrome does not appear to differ according to whether mothers are on high- or low-dose methadone maintenance therapy.

Women frequently report medication use in early pregnancy. Women and prescribers need to be aware of the lack of pregnancy safety data for many medications, and the need for pre-pregnancy planning. Prescribers should ensure that optimal medications are used when treating women of childbearing potential with chronic medical disorders.

Objective To compare the maternal and neonatal outcomes of operative vaginal delivery in relation to the use of episiotomy. Design Pilot randomised controlled trial (RCT).Setting Two urban maternity units in Scotland and England.Sample Nulliparous women anticipating a singleton cephalic vaginal delivery were recruited in the antenatal period.Methods If an operative vaginal delivery was required in the second stage of labour, women were randomised to either routine (in all cases) or restrictive (only if tearing apparent) use of episiotomy.Main outcome measures The primary outcome was anal sphincter tearing (third or fourth degree). Secondary outcomes included postpartum haemorrhage (PPH), neonatal trauma and pelvic floor symptoms up until 10 days postpartum.Results In a group of 317 women requiring operative vaginal delivery, 200 were randomised: 99 to routine use of episiotomy and 101 to restrictive use. There were small differences in the rates of anal sphincter tears (8.1% routine versus 10.9% restrictive, OR 0.72, 95% CI 0.28-1.87) and primary PPH (36.4% routine versus 26.7% restrictive, OR 1.57, 95% CI 0.86-2.86). Neonatal trauma was similar between the two groups (45.5% routine versus 43.6% restrictive, OR 1.08, 95% CI 0.62-1.89), as was prolonged catheterisation, urinary incontinence, faecal incontinence, perineal infection and prolonged hospital admission.Conclusions This pilot study does not provide conclusive evidence that a policy of routine episiotomy is better or worse than a restrictive policy. A definitive RCT is feasible but will require a large sample size to inform clinical practice.Keywords Anal sphincter tears, episiotomy, operative vaginal delivery, randomised controlled trial.Please cite this paper as: Murphy D, Macleod M, Bahl R, Goyder K, Howarth L, Strachan B. A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study.