Editor-in-chief's introduction to ANZJOG 64(2)

Welcome to the April 2024 issue of ANZJOG. Thank you to the many contributors to ANZJOG who have submitted manuscripts and contributed to the peer review process as this maintains the journal as a source of robust clinical science for clinicians and researchers in Australia and New Zealand and further afield.

This issue begins with two stimulating articles about severe maternal morbidity. Most of us are fortunate to live and work in locations with historically low rates of maternal mortality, although there remain lessons to be learned and improvements to be made from the rare but tragic maternal deaths that still occur. Although there are robust and well-resourced processes for review of maternal mortality, the recognition, review and reporting of severe maternal morbidity are much less systematic, resulting in missed opportunities for the detection and improvement of system-level weaknesses which underlie preventable severe adverse maternal outcomes. The review by Frost et al. provides an excellent overview of the current situation of maternal morbidity review in Australia. The authors conclude by outlining a number of key steps towards implementing a systematic maternal morbidity review jurisdictionally and nationally.¹ In their editorial, MacDonald et al. go further, calling upon us, clinicians and researchers, to make the case for progress in this area and to drive it.² Major change will require policy and resource attention from government, but we can take valuable action prior to that: to demonstrate why this is important, our willingness to work towards improvements in maternal and related health outcomes and to spur policymakers into action.

This issue also includes reports of two randomised controlled trials. Fahy et al. present their trial of placental cord drainage at caesarean section.³ This practice has been shown to reduce the duration of the third stage of labour at vaginal birth although without a clinically significant reduction in blood loss. The authors compared placental cord drainage to delayed cord clamping at planned caesarean section, finding no significant differences between the two groups, and concluded that this study supports the routine use of delayed cord clamping.

The second trial compared sonographer-performed ultrasound-guided embryo transfer versus standard embryo transfer, including rates of intrauterine air bubble visualisation, clinical pregnancy and live birth as outcomes.⁴ Of these, only air bubble visualisation was significantly different between the groups, with sonographer-performed ultrasound proving beneficial. Given the resource implications of sonographer assistance and the lack of impact on clinical outcomes, this study does not provide compelling evidence to change standard practice in routine cases.

Two groups present systematic reviews of gynaecological interest. Steele et al. assessed the outcomes after negative diagnostic laparoscopy in women with persistent pelvic pain.⁵ What limited evidence exists is conflicting, with studies demonstrating both improvement and deterioration in symptoms and quality of life after negative laparoscopy. The review identifies research gaps worthy of attention in the quest to better care for patients with what is frequently a debilitating and difficulty-to-manage condition.

Field et al. present their review of obstetric complications in pregnancies conceived using fresh versus natural thaw versus artificial thaw embryo transfer.⁶ This is an important undertaking, recognising the importance of assessing outcomes other than pregnancy and live birth rates given the clear associations between adverse late-pregnancy outcomes and long-term health consequences for both mother and offspring. The significant differences in adverse pregnancy outcomes observed between embryo transfer methods warrant further assessment to determine how assisted reproductive techniques should best be employed to ensure not only pregnancies but also healthy pregnancies.

White et al. present the concerning findings of their study on knowledge of clitoral anatomy among various groups of health professionals.⁷ With not a single respondent of 50 surveyed clinicians, notably including 10 consultant gynaecologists, able to name all of the major anatomical components of the clitoris and over half not able to name a single structure, it is clear that we have a long way to go in redressing the historical disregard of female sexual function.

This issue contains two articles relating to important aspects of stillbirth. The first examines the variation in causes of stillbirth in an ethnically diverse maternity service, finding placental-mediated stillbirths to be relatively overrepresented among stillbirth causes in non-Caucasian women.⁸ This finding is important as it provides insight into the mechanism of the observed increased rates of stillbirth, particularly late stillbirth, in non-Caucasian women and what strategies may be implemented to better identify fetuses at risk who can be targeted for increased surveillance or other preventative measures.

The second article provides information reading the intrapartum experiences of couples with antenatally recognised stillbirths.⁹ Although this evidence suggests that there is scope for improvement in care of these families, it is reassuring that the themes identified correlate closely with the existing clinical guidelines for bereavement care. It seems, therefore, that improvements in bereavement care are likely achievable with further education and implementation of existing resources.

I trust that you will find these and the other articles in this issue interesting.