Comprehensive maternity support and shared care in Switzerland: Comparison of levels of satisfaction.

BACKGROUND: According to the woman-centred care model, continuous care by a midwife has a positive impact on satisfaction. Comprehensive support is a model of team midwifery care implemented in the large Geneva University Hospitals in Switzerland, which has organised shared care according to the biomedical model of practice. This model of care insures a follow up by a specific group of midwives, during perinatal period. AIM: The goal of this study was to evaluate the satisfaction and outcomes of the obstetric and neonatal care of women who received comprehensive support during pregnancy, childbirth and the postpartum period, and compare them to women who received shared care. METHODS: This was a prospective comparative study between two models of care in low risk pregnant women. The satisfaction and outcomes of care were evaluated using the French version of the Women's Experiences Maternity Care Scale, two months after giving birth. FINDINGS: In total, 186 women in the comprehensive support group and 164 in the control group returned the questionnaire. After adjustment, the responses of those in the comprehensive support programme were strongly associated with optimal satisfaction, and they had a significantly lower epidural rate. No differences were observed between the two groups in the mode of delivery. The satisfaction relative to this support programme was associated with a birth plan for intrapartum and postnatal care. CONCLUSIONS: Team midwifery had a positive impact on satisfaction, with no adverse effects on the obstetric and neonatal outcomes, when compared to shared care.

Prevalence of Hypertensive Phenotypes After Preeclampsia: A Prospective Cohort Study.

Preeclampsia is associated with increased cardiovascular and renal risk. The aim of this prospective cohort study was to characterize the early postpartum blood pressure (BP) profile after preeclampsia. We enrolled 115 women with preeclampsia and 41 women with a normal pregnancy in a prospective cohort study. At 6 to 12 week postpartum, we assessed the prevalence of different hypertensive phenotypes using 24-hour ambulatory BP monitoring (ABPM), as well as the risk of salt sensitivity and the variability of BP derived from ABPM parameters. Among patients with preeclampsia, 57.4% were still hypertensive at the office. Daytime ABP was significantly higher in the preeclampsia group (118.9±15.0/83.2±10.4 mm Hg) than in controls (104.8±7.9/71.6±5.3 mm Hg; P<0.01). Differences between groups were similar for nocturnal BP values. Fifty percent of preeclampsia women remained hypertensive on ABPM in the postpartum, of whom 24.3% were still under antihypertensive treatment; 17.9% displayed a white-coat hypertension and 11.6% had masked hypertension. In controls, 2.8% had white-coat hypertension; none had masked hypertension or needed hypertensive treatment. The prevalence of nondippers was similar 59.8% in the preeclampsia group versus 51.4% in controls. High-risk class of salt sensitivity of BP was increased in preeclampsia women (48.6%) compared with controls (17.1%); P<0.01. In conclusion, ABPM 6 to 12 weeks after delivery reveals a high rate of sustained ambulatory, nocturnal, and masked hypertension after preeclampsia. This finding may help identify women who should be included in a postpartum cardiovascular risk management program. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01095939.

[Out-of-hospital delivery : present state and perspectives]. / Accouchement extrahospitalier : état des lieux et perspectives.

Out-of-hospital delivery is rare in Switzerland and it accounted for 2,5 % of all the births in 2015. In Switzerland, out-of-hospital childbirth is not subject to any official regulations. It takes place mainly in midwifery units (1,6 %) and at home (0,9 %), by independent midwifes. One in six women needs to be transferred to a hospital because of complications. Perinatal mortality is higher in out-of-hospital childbirth and the hospital is the safest place to give birth. The level of intervention may be lower, maybe because the women choosing to give birth in alternative settings are at lower risk.

L'accouchement extrahospitalier est un phénomène rare en Suisse et concernait 2,5 % des naissances en 2015. En Suisse, il n'est pas soumis à une réglementation officielle. Il a lieu majoritairement en maison de naissance (1,6 %) puis à domicile (0,9 %), par une sage-femme indépendante. Parmi ces parturientes, une femme sur six doit être référée à une équipe hospitalière en raison de complications durant le travail. La mortalité périnatale est plus élevée lors d'un accouchement extrahospitalier, ce qui place l'hôpital comme le lieu le plus sûr pour accoucher. En contrepartie, le niveau d'intervention pourrait être plus bas quand l'accouchement est planifié hors de l'hôpital, mais ceci pourrait être dû au fait que ces femmes sont à bas risque.

[Obstetric medicine : the success of a transdisciplinary approach to the maternal health]. / Gynécologie-obstétrique. Médecine interne obstétricale : le succès d'une approche transdisciplinaire de la santé maternelle.

Obstetric medicine is a specialty that addresses maternal health and medical complications during pregnancy. This emerging specialty responds to the increasing need for specialized intervention in cases of high risk pregnancies, at a time when pregnancies can occur at more advanced ages and where advances in therapeutics now allow to consider pregnancy in mothers with chronic illness. Furthermore, medical conditions specific to pregnancy, such as hypertensive disorders of pregnancy or gestational diabetes, are now recognized as emerging risk factors for cardiovascular, metabolic and renal diseases, for which longitudinal care beyond the maternity ward is of critical importance.

La médecine interne obstétricale est une spécialité dédiée à la santé maternelle et aux affections médicales de la grossesse. Il s'agit d'une spécialité novatrice, répondant à la demande croissante d'aide spécialisée dans la prise en charge des grossesses à haut risque, à une époque où l'âge de la grossesse est de plus en plus tardif et où les avancées thérapeutiques permettent d'envisager la grossesse en cas d'affection chronique. De plus, les complications médicales de la grossesse, telles que les hypertensions gravidiques ou le diabète gestationnel, sont désormais reconnues comme des facteurs de risque cardiovasculaires, métaboliques et rénaux émergents, pour lesquelles la continuité des soins à long terme est nécessaire.

Influence of obstetrical events on satisfaction and anxiety during childbirth: a prospective longitudinal study.

The aim of this study was to investigate the feelings of anxiety and satisfaction among 79 primiparas who had uncomplicated pregnancies, at the time of hospital admission and after birth, considering the mode of delivery, analgesia, and pain levels. Questionnaires were completed at admission to the hospital and two months after delivery, using the State-Trait Anxiety Inventory (STAI) state scale and the Labour Agentry Scale. The mean (SD) STAI state score was higher at admission (36.7 (10.7)) than 4 months after childbirth (32.1 (9.7)) (paired Student's t-test, t = 2.93; df = 78; p = .004). However, the postnatal anxiety was not associated with the mode of delivery, epidural or pain. Regarding the satisfaction with the expectations of control during childbirth, the mean (SD) score was higher before childbirth (166.0 (21.8)) than after (157.5 (33.5)) (paired Student's t-test, t = -2.28; df = 77; p = .03). The satisfaction with the childbirth experience was significantly associated with the expectations of childbirth and the mode of delivery, but not with analgesia or pain. The postnatal anxiety was associated with physical health, pain and the Edinburgh Postnatal Depression Scale score during the postpartum period. It is important to consider the temporality of perinatal anxiety in order to understand its causes. Our results indicate that the experience of childbirth was predicted in this sample by the antenatal expectations and delivery outcomes.

What is the optimal duration of oral misoprostol treatment for cervical ripening?

OBJECTIVES: To evaluate the number of misoprostol tablets needed to obtain a Bishop score (BS) ≥ 6 or a significant cervical change (≥2 points in BS) during cervical ripening. METHODS: Retrospective study of women with term singleton pregnancies and a BS < 6 taking oral misoprostol (20 µg first 2 doses followed by 40 µg every 2 h) for cervical ripening. RESULTS: We included 400 women, 72% nulliparous, mean age of 31.3 ± 5.9 years and 70% with a baseline BS ≤ 2. During cervical ripening, 61 (15.3%) achieved a BS ≥ 6 and 205 (51.3%) a significant change in BS. The incremental risk to achieve a BS ≥ 6 after 4 tablets was low (+3.25%) with an incremental probability of +12.75% for painful uterine contractions and +0.5% for abnormal fetal tracing (AFT). The incremental probability to achieve a significant change in BS after 7 tablets was low (+2.0%). 24.3% women delivered by cesarean section which likelihood significantly increased with maternal age <35 years, BMI ≥ 30, nulliparity, AFT, and baseline BS ≤ 2. CONCLUSIONS: The marginal benefit of giving more than 7 misoprostol tablets (14 h) during cervical ripening is very low.

Lower uterine segment thickness to prevent uterine rupture and adverse perinatal outcomes: a multicenter prospective study.

BACKGROUND: Choice of delivery route after previous cesarean delivery can be difficult because both trial of labor after cesarean delivery and elective repeat cesarean delivery are associated with risks. The major risk that is associated with trial of labor after cesarean delivery is uterine rupture that requires emergency laparotomy. OBJECTIVE: This study aimed to estimate the occurrence of uterine rupture during trial of labor after cesarean delivery when lower uterine segment thickness measurement is included in the decision-making process about the route of delivery. STUDY DESIGN: In 4 tertiary-care centers, we prospectively recruited women between 34 and 38 weeks of gestation who were contemplating a vaginal birth after a previous single low-transverse cesarean delivery. Lower uterine segment thickness was measured by ultrasound imaging and integrated in the decision of delivery route. According to lower uterine segment thickness, women were classified in 3 risk categories for uterine rupture: high risk (<2.0 mm), intermediate risk (2.0-2.4 mm), and low risk (≥2.5 mm). Our primary outcome was symptomatic uterine rupture, which was defined as requiring urgent laparotomy. We calculated that 942 women who were undergoing a trial of labor after cesarean delivery should be included to be able to show a risk of uterine rupture <0.8%. RESULTS: We recruited 1856 women, of whom 1849 (99%) had a complete follow-up data. Lower uterine segment thickness was <2.0 mm in 194 women (11%), 2.0-2.4 mm in 217 women (12%), and ≥2.5 mm in 1438 women (78%). Rate of trial of labor was 9%, 42%, and 61% in the 3 categories, respectively (P<.0001). Of 984 trials of labor, there were no symptomatic uterine ruptures, which is a rate that was lower than the 0.8% expected rate (P=.0001). CONCLUSION: The inclusion of lower uterine segment thickness measurement in the decision of the route of delivery allows a low risk of uterine rupture during trial of labor after cesarean delivery.

Health education and clinical care of immigrant women with female genital mutilation/cutting who request postpartum reinfibulation.

OBJECTIVE: To evaluate the percentage of women with female genital mutilation/cutting who request postpartum reinfibulation, and to assess outcomes after specific care and counseling. METHODS: A retrospective review was undertaken of consecutive medical files of immigrant women with FGM/C who attended a center in Geneva, Switzerland, between April 1, 2010, and January 8, 2014. The number of postpartum reinfibulation requests and outcomes were assessed. If a patient requests postpartum reinfibulation despite receiving detailed information and counseling, a longer follow-up is arranged for further counseling. RESULTS: Among 196 women with FGM/C, 8 (4.1%) requested postpartum reinfibulation. All eight were of East African origin, had FGM/C type III, and received a longer and more targeted follow-up than did those who did not request reinfibulation. After at least 1year of follow-up, none of the eight was willing to undergo reinfibulation. One woman who attended the clinic only once during her first pregnancy consulted the emergency ward of the study center 3years later because of postcoital bleeding following infibulation performed in her home country a few months after her second delivery in Switzerland. CONCLUSION: Specific care and counseling for women with FGM/C type III can improve the acceptability of defibulation without reinfibulation.

Patient enrollment and logistical problems top the list of difficulties in clinical research: a cross-sectional survey.

BACKGROUND: Many medical research projects encounter difficulties. The objective of this study was to assess the self-reported frequency of difficulties encountered by medical researchers while conducting research and to identify factors associated with their occurrence. METHODS: The authors conducted a cross-sectional survey in 2010 among principal investigators of 996 study protocols approved by the Research Ethics Committee in Geneva, Switzerland, between 2001 and 2005. The authors asked principal investigators to rate the level of difficulty (1: none, to 5: very great) encountered across the research process. RESULTS: 588 questionnaires were sent back (participation rate 59.0 %). 391 (66.5 %) studies were completed at the time of the survey. Investigators reported that the most frequent difficulties were related to patient enrollment (44.3 %), data collection (26.7 %), data analysis and interpretation (21.5 %), collaboration with caregivers (21.0 %), study design (20.4 %), publication in peer-reviewed journal (20.2 %), hiring of competent study personnel (20.2 %), and getting funding (19.2 %). On average, investigators reported 2.8 difficulties per project (SD 2.8, range 0 to 12). In multivariable analysis, the number of difficulties was higher for studies initiated by public sponsors (vs. private), single center studies (vs. multicenter), and studies about treatment, diagnosis or prognosis (i.e., clinical vs. other studies). CONCLUSIONS: Medical researchers reported substantial logistical difficulties in conducting clinical research.

Induction of labour at or near term for suspected fetal macrosomia.

Editorial note: It has been brought to the authors' attention that there may be an error in the data (Analysis 1.9). This is currently under investigation, and a correction will be made if the data are found to be incorrect. Details can be found in the comments. BACKGROUND: Women with a suspected large-for-dates fetus or a fetus with suspected macrosomia (birthweight greater than 4000 g) are at risk of operative birth or caesarean section. The baby is also at increased risk of shoulder dystocia and trauma, in particular fractures and brachial plexus injury. Induction of labour may reduce these risks by decreasing the birthweight, but may also lead to longer labours and an increased risk of caesarean section. OBJECTIVES: To assess the effects of a policy of labour induction at or shortly before term (37 to 40 weeks) for suspected fetal macrosomia on the way of giving birth and maternal or perinatal morbidity. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016), contacted trial authors and searched reference lists of retrieved studies. SELECTION CRITERIA: Randomised trials of induction of labour for suspected fetal macrosomia. DATA COLLECTION AND ANALYSIS: Review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We contacted study authors for additional information. For key outcomes the quality of the evidence was assessed using the GRADE approach. MAIN RESULTS: We included four trials, involving 1190 women. It was not possible to blind women and staff to the intervention, but for other 'Risk of bias' domains these studies were assessed as being at low or unclear risk of bias.Compared to expectant management, there was no clear effect of induction of labour for suspected macrosomia on the risk of caesarean section (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.76 to 1.09; 1190 women; four trials, moderate-quality evidence) or instrumental delivery (RR 0.86, 95% CI 0.65 to 1.13; 1190 women; four trials, low-quality evidence). Shoulder dystocia (RR 0.60, 95% CI 0.37 to 0.98; 1190 women; four trials, moderate-quality evidence), and fracture (any) (RR 0.20, 95% CI 0.05 to 0.79; 1190 women; four studies, high-quality evidence) were reduced in the induction of labour group. There were no clear differences between groups for brachial plexus injury (two events were reported in the control group in one trial, low-quality evidence). There was no strong evidence of any difference between groups for measures of neonatal asphyxia; low five-minute infant Apgar scores (less than seven) or low arterial cord blood pH (RR 1.51, 95% CI 0.25 to 9.02; 858 infants; two trials, low-quality evidence; and, RR 1.01, 95% CI 0.46 to 2.22; 818 infants; one trial, moderate-quality evidence, respectively). Mean birthweight was lower in the induction group, but there was considerable heterogeneity between studies for this outcome (mean difference (MD) -178.03 g, 95% CI -315.26 to -40.81; 1190 infants; four studies; I(2) = 89%). In one study with data for 818 women, third- and fourth-degree perineal tears were increased in the induction group (RR 3.70, 95% CI 1.04 to 13.17).For outcomes assessed using GRADE, we based our downgrading decisions on high risk of bias from lack of blinding and imprecision of effect estimates. AUTHORS' CONCLUSIONS: Induction of labour for suspected fetal macrosomia has not been shown to alter the risk of brachial plexus injury, but the power of the included studies to show a difference for such a rare event is limited. Also antenatal estimates of fetal weight are often inaccurate so many women may be worried unnecessarily, and many inductions may not be needed. Nevertheless, induction of labour for suspected fetal macrosomia results in a lower mean birthweight, and fewer birth fractures and shoulder dystocia. The unexpected observation in the induction group of increased perineal damage, and the plausible, but of uncertain significance, observation of increased use of phototherapy, both in the largest trial, should also be kept in mind.Findings from trials included in the review suggest that to prevent one fracture it would be necessary to induce labour in 60 women. Since induction of labour does not appear to alter the rate of caesarean delivery or instrumental delivery, it is likely to be popular with many women. In settings where obstetricians can be reasonably confident about their scan assessment of fetal weight, the advantages and disadvantages of induction at or near term for fetuses suspected of being macrosomic should be discussed with parents.Although some parents and doctors may feel the evidence already justifies induction, others may justifiably disagree. Further trials of induction shortly before term for suspected fetal macrosomia are needed. Such trials should concentrate on refining the optimum gestation of induction, and improving the accuracy of the diagnosis of macrosomia.

[Introduction in Switzerland of preimplantation genetic testing: progress or downward spiral?]. / Gynecologie. Introduction en Suisse des analyses sur le patrimoine génétique de l'embryon: progrès ou dérive?

The Swiss law on Assisted Reproductive Techniques (LPMA) has been modified in order to authorize preimplantation genetic diagnosis (PGD). PGD has been performed for 20 years. Switzerland is one of the last european countries where it is still prohibited. As a result, couples carrying a severe inherited disease and infertile couples with recurrent implantation failure or miscarriage have to cross the borders in order to have access to the appropriate treatments. Despite the recent popular approval to change the Constitution, the new LPMA cannot be implemented as the opponants have launched a referendum in order to obtain a more restrictive law. If they succeed, the affected couples will be left with a scientifically obsolete law that will not allow them to have access to an effective and compassionate treatment.

Population differences and the effect of vaginal progesterone on preterm birth in women with threatened preterm labor (.).

OBJECTIVE: Threatened preterm labor (tPTL) is a complication of pregnancy. Identification of women and clinical definition differs between countries. This study investigated differences in tPTL and effectiveness of vaginal progesterone to prevent preterm birth (PTB) between two countries. METHODS: Secondary analysis of a randomized controlled trial (RCT) from Argentina and Switzerland comparing vaginal progesterone to placebo in women with tPTL (n = 379). Cox proportional hazards analysis was performed to compare placebo groups of both countries and to compare progesterone to placebo within each country. We adjusted for baseline differences. Iatrogenic onset of labor or pregnancy beyond gestational age of interest was censored. RESULTS: Swiss and Argentinian women were different on baseline. Risks for delivery <14 days and PTB < 34 and < 37 weeks were increased in Argentina compared to Switzerland, HR 3.3 (95% CI 0.62-18), 54 (95% CI 5.1-569) and 3.1 (95% CI 1.1-8.4). In Switzerland, progesterone increased the risk for delivery <14 days [HR 4.4 (95% CI 1.3-15.7)] and PTB <37 weeks [HR 2.5 (95% CI 1.4-4.8)], in Argentina there was no such effect. CONCLUSION: In women with tPTL, the effect of progesterone may vary due to population differences. Differences in populations should be considered in multicenter RCTs.

Obstetric care of women with female genital mutilation attending a specialized clinic in a tertiary center.

OBJECTIVE: To study the obstetric outcomes of women attending a specialized clinic for women with female genital mutilation (FGM). METHODS: The medical charts of women with FGM who consecutively attended a specialized clinic between 2010 and 2012 were reviewed retrospectively. The present study focused on women attending for obstetric reasons. The outcome measures were type of delivery, reason for cesarean delivery or assisted delivery, blood loss, episiotomy, perineal tear, duration of the second stage of labor, postpartum complications, weight of the neonate, and Apgar score. Outcomes were compared between women with FGM type III who underwent defibulation, and patients with FGM type I and II. RESULTS: The clinic was attended by 129 women, 84 perinatally. Obstetric outcomes were similar to average outcomes for women without FGM presenting at the same department and in Switzerland generally. Specifically, 20 women had a cesarean delivery. An assisted delivery was performed for 18 patients; among these, only eight had experienced obstructed labor. No statistically significant differences were found for the outcome measures when women with FGM type III were compared to FGM type I and II. CONCLUSIONS: Routine obstetric follow-up combined with specialized care for women with FGM, including defibulation, can avoid inappropriate obstetric practices and reduce obstetric complications known to be associated with FGM.

Awareness of Cytomegalovirus Infection among Pregnant Women in Geneva, Switzerland: A Cross-sectional Study.

BACKGROUND: Cytomegalovirus (CMV) is the most frequent cause of congenital infection and commonly associated with sensorineural deficit. At present, there is neither prophylaxis nor treatment during pregnancy. The objective of this study was to evaluate the level of awareness regarding CMV infection and its consequences in women delivering at the University of Geneva Hospitals (Geneva, Switzerland). METHODS: The study consisted of a validated questionnaire completed by women in the immediate postpartum period. RESULTS: The questionnaire was completed by 59% (314/528) of delivering women. Only 39% (123/314) knew about CMV and 19.7% (62/314) had received information about preventive measures. Women were more aware about other congenital diseases, such as toxoplasmosis (87%); human immunodeficiency virus (99%); syphilis (85.5%); rubella (92.3%); and group B Streptococcus (63%). Factors associated with CMV awareness were Swiss nationality, high education level, employment in health care or with children, and being followed by an obstetrician. Regarding quality of information, few were aware of the main CMV complications (deafness, 25.2%; mental retardation, 34.5%). Among those informed about CMV, most (74.6%) knew about preventive measures. Among these, 82.5% thought that these were easily applicable. CONCLUSIONS: Most women were unaware of CMV infection and its potential risks during pregnancy. It is crucial to improve CMV information given to pregnant women to prevent the risks for the fetus/newborn.

Induction of labour versus expectant management for large-for-date fetuses: a randomised controlled trial.

BACKGROUND: Macrosomic fetuses are at increased risk of shoulder dystocia. We aimed to compare induction of labour with expectant management for large-for-date fetuses for prevention of shoulder dystocia and other neonatal and maternal morbidity associated with macrosomia. METHODS: We did this pragmatic, randomised controlled trial between Oct 1, 2002, and Jan 1, 2009, in 19 tertiary-care centres in France, Switzerland, and Belgium. Women with singleton fetuses whose estimated weight exceeded the 95th percentile, were randomly assigned (1:1), via computer-generated permuted-block randomisation (block size of four to eight) to receive induction of labour within 3 days between 37(+0) weeks and 38(+6) weeks of gestation, or expectant management. Randomisation was stratified by centre. Participants and caregivers were not masked to group assignment. Our primary outcome was a composite of clinically significant shoulder dystocia, fracture of the clavicle, brachial plexus injury, intracranial haemorrhage, or death. We did analyses by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00190320. FINDINGS: We randomly assigned 409 women to the induction group and 413 women to the expectant management group, of whom 407 women and 411 women, respectively, were included in the final analysis. Mean birthweight was 3831 g (SD 324) in the induction group and 4118 g (392) in the expectant group. Induction of labour significantly reduced the risk of shoulder dystocia or associated morbidity (n=8) compared with expectant management (n=25; relative risk [RR] 0·32, 95% CI 0·15-0·71; p=0·004). We recorded no brachial plexus injuries, intracranial haemorrhages, or perinatal deaths. The likelihood of spontaneous vaginal delivery was higher in women in the induction group than in those in the expectant management group (RR 1·14, 95% CI 1·01-1·29). Caesarean delivery and neonatal morbidity did not differ significantly between the groups. INTERPRETATION: Induction of labour for suspected large-for-date fetuses is associated with a reduced risk of shoulder dystocia and associated morbidity compared with expectant management. Induction of labour does not increase the risk of caesarean delivery and improves the likelihood of spontaneous vaginal delivery. These benefits should be balanced with the effects of early-term induction of labour. FUNDING: Assistance Publique-Hôpitaux de Paris and the University of Geneva.

[Pregnancy care in women older than 40 years and after egg donation]. / Gynécologie-obstétrique. Suivi des grossesses chez les femmes âgées de plus de 40 ans et après don d'ovocytes.

Pregnancies in older women are increasing. These women often have comorbidities. These pregnancies, spontaneous, after IVF or egg donation are at high risk of complications, particularly hypertension, preeclampsia, gestational diabetes, low birth weight, and delivery by cesarean section. Women with Turner syndrome can conceive only by egg donation and are at very high risk of cardiovascular complications. Screening of these comorbidities and pregnancy care by maternal-fetal medicine specialists, with pluridisciplinary collaboration, are mandatory. Delivery in a tertiary care center able to offer optimal care to the mothers and their newborns is recommended.

Female genital mutilation/cutting type IV in Cambodia: a case report.

Nontherapeutic female genital modifications can cause short- and long-term consequences. Caregivers should promote women's self knowledge on genitals' anatomy and physiology, and psychophysical and sexual health. They should also inform on possible negative consequences of vulvar nontherapeutic alterations requested and avoid the medicalization of female genital mutilation.