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Adding metformin to insulin therapy in women with insulin-resistant diabetes mellitus with pregnancy seems to be effective in proper glycemic control in a considerable proportion of women, along with benefits of reduced hospital stay, reduced frequency of maternal hypoglycemia as well as reduced frequency of neonatal hypoglycemia, NICU admission and neonatal respiratory distress syndrome.

It is true that we really do not know the safest way to manage labour and delivery after obstetric fistula repair, and I am sure that some women would be good candidates for a trial of vaginal delivery postobstetric fistula repair. As Dr Harrison notes, provision of a waiting hostel for pregnant women to enable them timely access to care during labour/delivery is key.It is interesting to note that of the patients from Dr Harrison's paper, the deliveries postobstetric fistula repair had the poorest outcomes with regards to (among other parameters) 'worst fetal results'. Even with care, the results from attempted delivery can be poor.Where we work in northern Ethiopia, the delivery care in the neighbouring hospital is stretched, being under-resourced and understaffed. After consultation with all parties involved in these patients' care, it seemed that the safest option for these women in this setting was to opt for a Caesarean delivery. This was in the hope of negating the risks of delivery in an understaffed delivery setting, a possible poor fetal outcome or a reopening of the repaired fistula.I entirely agree with Dr Harrison's comment that prevention of obstetric fistula is a priority. Many organisations have safe childbirth as their aim. To that end a new foundation is being established in Australia seeking to place volunteer obstetrician and midwife teams in hospitals in Ethiopia to train the local staff in safe emergency obstetric care. In areas where there is no access to health services, then to build a three-tiered obstetric care 'network'. The first tier being with trained and equipped birth attendants in the villages delivering low risk women to the second or third tier to await their deliveries. The second tier consists of waiting areas and delivery posts equipped to deal with intermediate deliveries but in radio and ambulance contact to the third tier, consisting of a fully functioning maternity hospital.Construction of a pilot network is underway and we hope to have it functioning early next year. We hope to have one such network for every 500 000 population, so that 1 day all women can have access to medical care during labour if needed. This of course has to be coupled with education for people to access these services, but the aim is hopefully 1 day to see obstetric fistula as a thing of the past. j Gum chewing stimulates early return of bowel motility after caesarean section Sir, Simple, obvious and cheap solutions to common problems are always welcome. However, despite this trial of chewing gum and bowel motility following caesarean section 1 being registered with the international database of clinical trials, no mention is made in the methodology as to the ingredients of the substance administered for medicinal purposes, which in this case is chewing gum. Many so-called 'sugar free' chewing gums contain substances such as sorbitol that are known to cause diarrhoea.2 The authors only briefly suggest that the beneficial effect of the gum resulted from a physiological 'cephalic-vagal mechanism', a...

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Gum chewing after CS is safe, well tolerated, and associated with rapid resumption of intestinal motility and shorter hospital stay; with potential impact on reducing the overall healthcare costs in case of routine implementation.

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Drotaverine hydrochloride was used effectively and safely to shorten the duration of the first stage of labor among nulliparous women with active spontaneous labor. ClinicalTrials.gov: NCT01639027.

Uterine compression suturing was found to be associated with a risk of postpartum uterine synechiae formation, which may subsequently affect future fertility.