Objective To assess the maternal and neonatal effects of upright compared with recumbent positions during delivery, in terms of defined outcome variables. Design A randomised controlled trial. Setting St Monica's Nursing Home, a midwife based maternity unit in Cape Town, South Africa. Participants Five hundred and seventeen women of low obstetrical risk assigned to deliver at the nursing home. Results The trial showed that women who adopted the upright posture for delivery experienced less pain, perineal trauma and fewer episiotomies than those who delivered in the supine position. Conclusion The data suggest that in women of low obstetrical risk, choice of posture during delivery may be encouraged.

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RESEARCHBackground. Venous thromboembolism (VTE) is associated with considerable morbidity and mortality in the absence of thromboprophylaxis. Method. The Southern African Society of Thrombosis and Haemostasis reviewed the available literature and comprehensive evidencebased guidelines on the prevention of VTE in obstetrics and gynaecology. A draft document was produced and revised by consensus agreement by a panel of professionals from various specialties. The recommendations were adjudicated by an independent international expert to avoid local bias. Results and conclusion. We present concise, practical thromboprophylaxis guidelines for the clinical management of patients in obstetrics and gynaecology. Recommendations reflect current best practice, which it is hoped will lead to improved anticoagulation practice in this group of patients. Venous thromboembolism (VTE) is associated with considerable morbidity, and mortality in the absence of thromboprophylaxis. Pulmonary embolism (PE) is the leading cause of maternal death worldwide. S Afr J Obstet Gynaecol[1] Further, PE is the cause of ~20% of deaths following hysterectomy.[2] The prevalence of deep vein thrombosis (DVT) in patients having major gynaecologic surgery ranges between 15% and 40%. [3] There are a few randomised trials to guide the management of this group of patients. Recommendations in this guideline therefore reflect current best practice. Management should be individualised according to the risk-benefit ratio and cost. MethodsOn behalf of the Southern African Society of Thrombosis and Haemostasis, a representative guideline panel of professionals from various specialities reviewed the available literature on the prevention of VTE in obstetrics and gynaecology. Recommendations presented are in accordance with the more comprehensive evidence-based guidelines namely the 9th edition of the American College of Chest Physicians (ACCP), [4] the Green Top guidelines of the Royal College of Obstetricians and Gynaecologists (RCOG), [5] the American College of Obstetricians and Gynecologists (ACOG), [6] the Society of Obstetricians and Gynaecologists of Canada (SOGC), [7] Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) [8] and the European Society of Regional Anaesthesia (ESRA) Guidelines on Anticoagulation and Regional Anaesthesia.[9] Many of these recommendations are formulated in the absence of strong evidence and the guidelines were also prepared in conjunction with systematic reviews and observational studies. A draft document was produced and revised by consensus agreement. The guidelines were adjudicated and co-authored by an independent international expert to avoid local bias. VTE in gynaecology Oestrogen and VTE riskOestrogen use increases the risk of VTE as a class effect which is dose dependant.[10] The risk of VTE is dependent on the route of administration. There is lower associated risk with transdermal and intra-uterine hormonal therapy as well as the progesterone-only oral contraceptive. [11,12] Gynaecological surgery...

OBJECTIVE To assess the safety and efficacy of pelvic floor muscle electrostimulation (ES) in women with stress urinary incontinence (SUI) or mixed UI (MUI, urge and interstitial cystitis), using a new portable electrostimulator (Miniaturo, Biocontrol Medical Inc., Yehud, Israel) which delivers different forms of stimulation for treating these two conditions. PATIENTS AND METHODS For SUI the stimulator is activated on demand only by a sudden increase in intra‐abdominal pressure; for frequency and urgency a milder, continuous ES is used. The intensity of ES can be adjusted according to the patient's sensation. Women were enrolled into the study after satisfying inclusion criteria and pad testing; 23 participated in two study groups, i.e. 16 with SUI and seven with MUI (severe frequency, urgency and urge, and mild SUI). The pelvic floor muscles were stimulated through an electrode inserted paraurethrally, positioned similarly in all patients. In patients with SUI and MUI a pressure sensor was also inserted into the rectum, to record intra‐abdominal pressure. Stimulation was applied for 1–4 h in patients with SUI and for 6 h in those with MUI. The evaluation was based on urinary symptoms (frequency, urgency, leaking episodes), quality‐of‐life questionnaires and pad tests at baseline and during stimulation. RESULTS All patients in both groups improved significantly; of the 16 patients with SUI, nine were completely dry during ES, and the remaining seven had a reduced mean pad weight, from 23 to 6 g (74%). There was no significant reduction in pad weight after sham ES (17 g before vs 24.2 g after). In four patients with SUI who continued ES for 4 h the mean cumulative stimulation time (calculated from the stimulator memory) was 3 min (1.3% of 4 h). In the MUI group there were no leakage episodes during ES and significant reductions in voiding variables (Student's t‐test) in all. The mean (Sd) voiding frequency, urinary urgency and leaking episodes decreased from 8.1 (4.2) to 1.9 (1.5), 6.4 (2.3) to 0.7 (1.3) and 2.1 (0.7) to 0.7 (0.5) (all P < 0.001), respectively. CONCLUSIONS The concept of this ES system for treating UI is promising; this study supports the efficacy of this form of ES but no conclusions about clinical efficacy are possible at this stage, and thus a trial to evaluate the safety and efficacy of this implantable device is ongoing.

OBJECTIVETo assess the results of peripheral electrostimulation of pelvic floor muscles in patients with overactive bladder (OAB) symptoms, and to describe a novel surgical technique for inserting a specially designed implantable electrostimulator which can deliver different forms of muscle stimulation through a para-urethral electrode. PATIENTS AND METHODSThe study included seven women with OAB (mean age 59 years) who had frequency (including nocturia), urgency and urge incontinence for ≥ 1 year, and in whom conventional treatment failed. The antepubic technique was used to implant the electrostimulator and a para-urethral electrode. The patients' urinary symptoms and quality of life (King's College Hospital incontinence questionnaire) were compared before and after surgery, and possible complications monitored. RESULTSThe mean (range) follow-up was 14.5 (13-17) months in six and 10 months in the seventh patient (stimulator removed because of infection). The mean (range) frequency of 15 (13-23) voids/24 h before surgery decreased to 9 voids/24 h (i.e. by 40%) afterward. All patients had leakage episodes because of urgency (4-15 times/day) before surgery, which ceased in five afterward; these patients used no further pads. In the remaining two patients urgency incontinence continued after surgery, but with significantly fewer leakage episodes, from 15 and 12 per day before to 6.7 and 4 afterward, respectively. The mean degree of urgency (graded 0-3) decreased from 2 to 1.4 after surgery, and quality of life improved significantly. Urodynamic studies showed a greater mean maximum detrusor capacity, from 135 mL before to 189 mL after implanting the stimulator. CONCLUSIONSThe good results (over a follow-up of 1 year) in patients with OAB symptoms treated by the present electrostimulator should encourage further clinical studies in such patients. A trial to evaluate the efficacy of pelvic floor muscle electrostimulation in a broad spectrum of diseases of the lower urinary tract causing symptoms similar to OAB has been started. KEYWORDSperipheral electrostimulation system, antepubic surgery, overactive bladder, women There are three interesting but diverse topics in this section. Authors from Tel-Aviv and Capetown describe a novel surgical technique for implanting a new electrostimulation system for treating overactive bladder in the female. This is followed by a classification of symptomatic nocturia from Japan, which also looks at the distribution of nocturia, with special attention to duration of time in bed. Finally, there is an interesting paper on the association between congenital adrenal hyperplasia and LUTS.