Delivery Unit Research Articles

May the indication for a previous cesarean section affect the outcome at trial of labor in women with induction of labor? Aretrospective cohort study.

Cesarean sections are increasing worldwide and are associated with altered risks of complications for both mother and child. Vaginal birth after cesarean section is associated with lower maternal and neonatal morbidity than in repeat cesarean section. Only a few studies have considered the indication for the previous cesarean section to be of importance for the outcome of subsequent labor. The aim of this study was to evaluate whether the indication for a previous cesarean section affects the outcomes at a subsequent delivery in women with induction of labor. This retrospective cohort study of the four largest delivery units in Stockholm during 2012-2015 included 1150 women with one previous cesarean section with induction of labor. women with induced labor and a previous cesarean section, singleton pregnancy, cephalic presentation, gestational age of ≥34 weeks. The women were grouped by indication for the previous cesarean section. mode of delivery (vaginal birth after previous cesarean section or repeat cesarean section). induction to delivery time, postpartum hemorrhage, uterine rupture. Neonatal outcomes: birth weight, Apgar score <7, arterial umbilical cord blood gas pH <7.0. Our study found that the indication of labor dystocia at the previous cesarean section, increased the risk of repeat cesarean section (aOR 5.35; 95% CI: 1.64-17.50) in women with induction of labor. Other risk factors for repeat cesarean section were birth weight >4000 g, maternal BMI ≥30 or if vaginal prostaglandin was used as the method for induction of labor. A previous vaginal delivery and use of oxytocin increased the chance of a vaginal delivery in this group of women. Our study showed that the indication for the previous cesarean section affects the outcome in the subsequent delivery in women with induction of labor. If the indication for the previous cesarean section was labor dystocia, the risk of repeat cesarean section was increased.

Implementing a Labor and Delivery Cell Salvage Protocol in Patients at Increased Risk of Hemorrhage: A Pilot Study.

Postpartum hemorrhage (PPH) contributes significantly to maternal morbidity and mortality. The use of cell salvage has been implemented in operating rooms across the world, but only a limited number of institutions have protocols for use of cell salvage during vaginal hemorrhage at the time of vaginal delivery. Observations suggest that blood salvaged from vaginal delivery is comparable to blood salvaged during cesarean delivery. Using pre-validated protocols of cell salvage, we sought to assess the feasibility and potential benefit of implementing cell salvage in our Labor and Delivery unit in all patients at high risk of hemorrhage. This was a prospective pilot study conducted from April 2022 to December 2022 on the Labor and Delivery floor at Mount Sinai Hospital in New York City. A total of 50 participants were identified for cell salvage after vaginal delivery during the study period.The mean age of participants was 34.4 years (SD 5.5).We utilized acell salvage technique at the time of vaginal delivery in patients at high risk of PPH. We employed simple descriptive statistics and examined sums and percentages (and means and standard deviations, where appropriate). A simple equation was used to determine the average cell salvaged volume in each delivery and describe potential values. The HEMAsavR™device (Ecomed Solutions, Mundelein, IL, USA) was used as a standby system to be used at the time of the vaginal delivery. Fifty participants were identified for the cell salvage protocol as described. Despite a diversity of clinical risk factors, the sample consisted ofpredominately non-Hispanic White patients. The mean quantitative blood lossof cell salvaged samples was 157.2 mL(SD 153.0). We identified that, on average, >33% of vaginally shed blood could be used for cell salvage and improve patient blood management. The implementation of cell salvage in our Labor and Delivery unit was feasible and easy to perform. We identified that a significant volume of blood would be available for cell salvage. Further studies should be done to evaluate the benefit of cell salvage to improve postpartum recovery.

Comparative study between the roles of intrauterine misoprostol versus the sublingual route for prevention of postpartum blood loss in elective cesarean sections: a randomized controlled trial

BackgroundThe prostaglandin E1 analog “misoprostol” is a drug that has powerful ecbolic effects and can be beneficial in the prevention and treatment of postpartum hemorrhage, which is the leading cause of maternal mortality worldwide.ObjectivesTo assess the value of adding intrauterine misoprostol together with intravenous oxytocin injection compared with sublingual misoprostol together with intravenous oxytocin injection during elective cesarean section to reduce blood loss intraoperatively and prevent postpartum hemorrhage.MethodsA total of 192 pregnant women were counseled and recruited from the labor and delivery unit at Kasr Al Aini Hospital, Cairo University, and equally randomized into two groups. Group (A) included 96 women who received intrauterine misoprostol (400 mg) + oxytocin. Group (B) included 96 women who received sublingual misoprostol (400 mg) + oxytocin. The primary outcome of our study was estimation of the amount of blood loss during and after cesarean delivery. The secondary outcomes were the incidence of PPH within the first 6 h after labor, the need for blood transfusion, the need for any supplementary ecbolic drugs, the need for additional surgical intervention for PPH, changes in hematocrit and hemoglobin in both groups after delivery, and the incidence of side effects of the study medications.ResultsWe observed a significant discrepancy between the two groups in terms of postoperative Hb and Hct, postoperative differences (pre- and post-Hb and post-Hct) and EBL favoring the intrauterine group. However, no significant difference was observed between the groups with respect to excessive blood loss > 1000 ml in the 1st six hours, the need for supplementary ecbolics, the necessity for blood or blood prod, the need for additional surgical intervention (for PPH) or side effects.ConclusionIntrauterine misoprostol combined with oxytocin intravenous infusion is more effective than sublingual misoprostol combined with oxytocin intravenous infusion in lowering intraoperative blood loss and preventing postpartum hemorrhage in elective cesarean section.Trial registrationThis trial was retrospectively registered with the ClinicalTrials.gov Registry on 12-April-2024 (registration number: NCT06364098).

Peripheral Use of Vasopressors in Shock: Clinical Considerations and Recommendations for Use in Obstetrics.

This study aimed to evaluate the safety of peripheral administration of vasopressor agents among patients with circulatory shock. We reviewed the published literature evaluating the use of peripheral norepinephrine in patients with shock and proposed a protocol for use in labor and delivery units. Peripheral administration of norepinephrine is a safe and potentially lifesaving intervention for patients in labor and delivery with extremely low complication rates. Adoption of a protocol for peripheral administration of vasopressors in labor and delivery is safe and may prevent life threatening delays in hemodynamic resuscitation. · Administering vasopressors through a peripheral line is safe and helps avoid delays in care.. · An established protocol is essential for the safe peripheral administration of vasopressors.. · Understanding continuous blood pressure monitoring is crucial for managing critically ill patients..

Labor Nurses' Experiences During the COVID-19 Pandemic

Abstract Purpose: The purpose of this study was to describe labor and delivery nurses' experiences in caring for patients during the COVID-19 pandemic. Methods: We used a descriptive phenomenological design and purposeful sampling to recruit experienced labor and delivery nurses for flexible semi-structured face-to-face audiotaped interviews. Constant comparison was used to analyze data. Results: Ten nurses employed in a labor and delivery unit in two acute care hospitals in southern Texas participated and were interviewed from June through August 2022. The mean age of nurse participants was 36.5 years. Seven had over 5 years' experience as a labor and delivery nurse before the pandemic. Five distinct themes were identified: Psychological stress during COVID-19; Feelings of satisfaction and gratitude; Resilience and readiness for positive change; Patient-centered care; and Interprofessional collaboration. Clinical Implications: These findings build on our understanding of key determinants contributing to labor and delivery nurses' ability to adjust to the unprecedented and chaotic working conditions during the COVID-19 pandemic and highlighted several factors that could influence nurses' resilience and job satisfaction.

Removal of Isolated Cannabis Use as an Order Indication for Urine Drug Screening (UDS) Eliminates Racial Inequity in Maternal UDS Testing and Reporting to Child Protective Services

Abstract Black patients on labor and delivery (L&amp;D) units are more likely to undergo urine drug screening (UDS) and subsequent mandated reporting to child protective services (CPS), which can result in increased separation of the parent and infant, contributes to systemic inequities, and erodes the patient/provider relationship. These disparities are driven by a testing indication of isolated cannabis use (ICU), which based on previous data from our institution, disproportionately selects Black patients for testing. In October 2022, the Barnes-Jewish Hospital (St. Louis, MO) L&amp;D unit removed ICU as a UDS indication; concurrently, we implemented an electronic health record (EHR)-based order question requiring providers to select an indication for testing. The objective of this study was to analyze the impact of this intervention on racial equity in UDS testing and CPS reporting. Data on deliveries, UDS testing, and CPS reports were obtained from the EHR, and data for deliveries occurring during the pre- (1/1/2020-9/30/2022; 33 months) vs. post-implementation (10/1/2022-2/1/2024; 16 months) periods was compared. There were a total of 9,187 and 4,757 deliveries during the pre- and post-implementation periods, respectively. At baseline, there were more deliveries by Black patients in the pre-implementation (47.8%) vs. post-implementation (44.0%) period (p&amp;lt;0.001); there was no difference in age, multiparity, or neonatal outcomes between the two periods. In the pre-intervention period, 29.2% of Black and 13.8% of White patients had UDS testing (p&amp;lt;0.001), and 7.6% of Black and 4.1% of White patients underwent reporting to CPS (p&amp;lt;0.001); in the post-intervention period, 4.5% of Black and 3.6% of White patients had UDS testing (p=0.52), and 4.2% of Black and 3.5% of White patients underwent reporting to CPS (p=0.52). 34.6% vs. 67.8% of UDSs in the pre- and post-implementation were positive for any non-cannabis compound, respectively (p&amp;lt;0.001). In conclusion, removing ICU as an order indication dramatically improves racial equity in UDS testing and CPS reporting on a L&amp;D floor, and improves the pre-test probability of UDS testing for non-cannabis compounds.

Multilayer patch functionalized microfibrillated cellulosic paper sensor for sweat glucose monitoring.

Electrochemical analysis of glucose monitoring without painful blood collection provides a new noninvasive route for monitoring glucose levels. Thus, in this study, biobased cellulosic papers (methylated and phosphorylated one) based glucose monitoring sensor is developed. To achieve high hydrophilicity, microfibrillated cellulose (MFC) were functionalized using hexokinase mediated phosphorylation (-OH to -[Formula: see text]). The instinctive increased surface charge density from 36.2 ± 3.4 to 118.4 ± 1.2 µmol/g and decrease contact angle (45°-22°) confirms the increased hydrophilicity of paper. Furthermore, functionalized phos-MFC paper increase the capillary flow of sweat, required low quantity (1µl) of sweat for accurate analysis of glucose level. Additionally, chemically induced methyl groups (-CH3) make the sensor more barrier to other chemicals. In addition, a multilayer patch design combined with sensor miniaturization was used to lead to an increase in the efficiency of the sweat collection and sensing processes. Besides, this paper sensor integrated with artificial transdermal drug delivery unit (agarose gel as skin) for monitoring glucose levels in sweat. The patch monitoring system increase the accuracy of sensing with fluctuation in sweat vol. (1-4µl), temperature (20-70 °C), and pH (4.0-7.0). In addition, temperature dependency artificial transdermal delivery (within agarose gel) of drug metformin agrees the measurement accuracy of sensor, called "switch system" without any error. As a result, the reported MFC paper based multi-patch disposable sensing system provides a novel closed-loop solution for the noninvasive sweat-based management of diabetes mellitus.

Improving Amniotic Fluid Index with L-Arginine Supplementation

Background: Oligohydramnios, characterized by a low Amniotic Fluid Index (AFI), is associated with adverse pregnancy outcomes, including fetal growth restriction, preterm labor, and low birth weight. Effective interventions for improving AFI are critical, particularly in resource-limited settings. L-Arginine, a nitric oxide precursor, has shown promise in enhancing uteroplacental circulation and increasing AFI. This study aimed to evaluate the efficacy of L-Arginine supplementation in improving AFI and associated maternal and neonatal outcomes in pregnant women with oligohydramnios in Bangladesh. Methods: This study was conducted at Islami Bank Hospital over one year (July 2023 to June 2024), involving 90 pregnant women diagnosed with oligohydramnios. Participants received daily L-Arginine supplementation, and AFI was measured before and after the intervention. Maternal and neonatal outcomes, including gestational age at delivery, birth weight, and neonatal intensive care unit (NICU) admissions, were recorded. Statistical analysis was performed using paired t-tests, with p &lt; 0.05 considered statistically significant. Results: The mean AFI increased significantly from 5.4 cm (SD ±1.7) before the intervention to 8.6 cm (SD ±2.1) after supplementation, with a mean difference of 3.2 cm (p &lt; 0.001). Low birth weight was observed in 20% of the neonates, while 17.78% required NICU admission. There was a notable improvement in neonatal outcomes with L-Arginine supplementation. Conclusion: L-Arginine supplementation significantly improved AFI and neonatal outcomes, making it a viable intervention for managing oligohydramnios in pregnant women. Further research is recommended to confirm these findings in larger populations.

Perception of Women Toward Childbirth Positions Among Women on Postnatal Unit at Jimma Medical Center, South West Ethiopia: A Phenomenological Qualitative Study

Objective: To explore the perceptions of women toward child birthing positions among women on the postnatal unit at Jimma Medical Center, Jimma town, Ethiopia, in 2020. Design: A descriptive phenomenological approach was employed among women from the postnatal unit and maternity care providers from the labor and delivery unit. Setting: Jimma Medical Center, south-west Ethiopia Participants: 40 study participants were selected purposively. 30 postnatal women were recruited for both an in-depth interview and a focus group discussion. From maternity health care providers, 10 health professionals were interviewed. Results: This study involved 30 study participants for in-depth interviews and one focus group discussion with 10 participants. Regarding the variables influencing the use of alternative birth positions in the medical facility, responses were obtained from both women and medical professionals. The women were placed in common supine positions because they were ignorant of other birth positions, because they were passive in allowing themselves to be in the position that they preferred, and because medical professionals lacked the necessary knowledge and expertise to provide alternative birth positions. Conclusion and Recommendations: The women were coerced to take birth positions against their will by healthcare providers. Thus, evidence-based alternative birth positions should be made available and implemented in order to enhance the practice of healthcare providers.

Dual-continuous microneedle patch integrating transdermal delivery of pH-sensitive licorzinc MOFs and Zn2+ hydrogel sensors for treating alopecia areata

Licorzinc is a commonly used immunomodulator, but faces poor water solubility, high oral dose, and side effects of zinc accumulation by long-term administration. Herein, a new licorzincform was developed by adsorbing glycyrrhizic acid (GA) into zeolitic imidazolate framework-8 (GA@ZIF-8) with superior solubility and acid-responsive drug release properties. Then, a dual-continuous microneedle patch was developed for simultaneous transdermal delivery of GA@ZIF-8 and monitoring Zn2+ in local tissues, where dissolving microneedles as a drug delivery unit were fabricated from hyaluronic acid. In contrast, swollen hydrogel microneedles as a diagnostic unit were prepared from double cross-linking of N-acryloyl-glycinamide and α-methylacrylic acid and hybridized with Eu3+ and terpyridine (TPy). The microneedles for transdermal GA@ZIF-8 delivery were completely dissolved in 2 min, which improved the cyclophosphamide-induced hair follicle recession in mice by reducing CD8+NKG2D+ T cells infiltration, inhibiting Jak receptor activation, and decreasing IL-15 and IFN-γ. Additionally, as a sensor unit, the microneedles rapidly absorbed water swelled when stabbed into the skin, and fluoresced red when exposed to 365 nm light. Zn2+ in the inter tissue fluid competes with Eu3+ in the TPy-Eu3+ complex and coordinates with Tpy, which triggers a change in fluorescence. Notably, the detection Zn2+concentration range was 10–8 M–10–1 M, and it was not disturbed by metal ions including Na+, K+, Mg2+, and Ca2+, suggesting that it is competent to be applied as a real-time chemosensor of Zn2+. Collectively, this newly designed system with both therapeutic and diagnostic functions provides a new strategy for treating zinc-related diseases.

Preoperative Multidisciplinary Team Huddle Improves Communication and Safety for Unscheduled Cesarean Deliveries: A System Redesign Using Improvement Science.

Optimal communication between care teams is a critical component in providing safe, timely, and appropriate patient care. Labor and delivery (L&D) units experience rapidly changing clinical scenarios often requiring escalation in care and unplanned cesarean deliveries (CDs). The University of Cincinnati Medical Center (UCMC) is a 550-bed academic level 4 maternal care center with a 13-bed L&D unit in Cincinnati, OH. There are approximately 2500 deliveries/y with a CD rate of 33%. The L&D unit is staffed with dedicated anesthesia personnel 24 hours a day. In our L&D unit, there was widespread dissatisfaction with multidisciplinary communication surrounding unscheduled CD. Near-miss safety events in our obstetric unit were attributed to preoperative communication failures. Initial surveys identified challenges in preoperative communication among nursing, anesthesiology, and obstetric teams leading to potential risk for compromised care. Using the UC Health Performance Improvement Way, we first sought to understand the process leading up to unscheduled CD. Change ideas were developed based on observed failures in communication. Interventions were tested and refined through iterative plan-do-study-act (PDSA) cycles. One key intervention was the introduction of a bedside, multidisciplinary, patient-centered, pre-CD huddle attended by nursing, anesthesia, and obstetrics representatives using a standard checklist for critical information. Qualitative patient feedback was elicited to inform change efforts. We compared patient and procedure characteristics from the baseline and huddle implementation phases. Our primary outcome measure was the satisfaction of care team members with communication around unscheduled CD. A secondary outcome was the general anesthesia (GA) rate for unscheduled CD. Our key process measure was adherence to the preoperative huddle. We tracked decision-to-incision interval (DTI) as a balancing measure. Huddle adherence reached 96% for unscheduled CD within 6 months of testing and implementation. A combined survey of anesthesia, nursing, and obstetrics showed that satisfaction scores related to unscheduled CD communication improved from 3.3/5 to 4.7/5 after huddle implementation. The rate of GA use and the median DTI remained unchanged. Patients felt more engaged and reported positive experiences by being a part of the huddle discussion. In an academic obstetric unit, communication failures surrounding unscheduled CD were identified as a contributor to staff dissatisfaction and perception of safety risk. Implementation of a bedside multidisciplinary pre-CD huddle improved communication between teams and contributed to creating a culture of safety without causing significant delays in care.

Obstetric outcomes among rural parturients across US urban and rural hospitals.

The objective of this study is to evaluate severe maternal morbidity (SMM) of rural parturients delivering at rural compared to urban hospitals in the US. We identified patients aged 18-40 years in a multi-institutional claims database who lived in a rural ZIP code and delivered at a rural or urban hospital between October-December of 2015 and October-December of 2022. The primary outcome was SMM, and the secondary outcome was SMM exclusive of blood transfusions. We combined exact ZIP code matching and propensity score matching to compare SMM risk among patients living in the same rural community and delivering in urban as compared to rural hospitals. A total of 214 296 patients from 571 ZIP codes were identified, including 47% delivering at rural facilities and 53% delivering at urban facilities. The SMM rate was 1.1% (0.3% excluding blood transfusions). After matching, urban versus rural delivery was associated with increased odds of SMM other than blood transfusion (odds ratio 2.44; 95% confidence interval 1.81-3.28), but was not associated with differences in risk of any SMM. There was no evidence of reduced SMM for rural patients delivering at an urban rather than a rural hospital. SMM exclusive of blood transfusions was increased for rural patients delivering at urban hospitals after matching on ZIP code and predictors of urban hospital delivery. Our findings undermine the assumption that delivery at a rural facility has inherently greater risks relative to delivery at an urban facility. As some health systems face challenges to maintain rural labor and delivery units, patient safety must be considered if confronted with the possibility of unit or hospital closures.

Incidence of Methicillin Resistant Staphylococcus Aureus in Mother-Neonates Pair in the Delivery Units of Three Secondary Healthcare Facilities in Zaria, Kaduna State, Nigeria

Incidence of Methicillin Resistant Staphylococcus Aureus in Mother-Neonates Pair in the Delivery Units of Three Secondary Healthcare Facilities in Zaria, Kaduna State, Nigeria

Metformin and small for gestational age babies: findings of a randomised placebo-controlled clinical trial of metformin in gestational diabetes (EMERGE).

Gestational diabetes mellitus (GDM) is associated with adverse perinatal outcomes because of suboptimal glucose management and glucose control and excessive weight gain. Metformin can offset these factors but is associated with small for gestational age (SGA) infants. We sought to identify risk factors for SGA infants, including the effect of metformin exposure on SGA status. In this prespecified secondary analysis of the EMERGE trial, which evaluated the effectiveness of metformin vs placebo in treating GDM and found reduced gestational weight gain and longer time to insulin initiation with metformin use, we included women with a live-born infant and known infant birthweight and gestational age at delivery. We compared the numbers of SGA infants in both groups and explored baseline predictive factors to help identify those at highest risk of delivering an SGA infant. Baseline maternal characteristics were similar between SGA and non-SGA pregnancies. On multivariable-adjusted regression, no baseline maternal variables were associated with SGA status. Mothers of SGA infants were more likely to develop pre-eclampsia or gestational hypertension (18.2% vs 2.0%, p=0.001; 22.7% vs 5.4%, p=0.005, respectively); after multivariable adjustment, pre-eclampsia was positively associated with SGA status). Among SGA pregnancies, important perinatal outcomes including preterm birth, Caesarean delivery and neonatal care unit admission did not differ between the metformin and placebo groups (20.0% vs 14.3%, p=1.00; 50.0% vs 28.6%, p=0.25; 13.3% vs 42.9%, p=0.27, respectively). Pre-eclampsia was strongly associated with SGA infants. Metformin-exposed SGA infants did not display a more severe SGA phenotype than infants treated with placebo. Clinical Trials.gov NCT02980276; EudraCT number: 2016-001644-19.

Analisis Tingkat Kepuasan Masyarakat Terhadap Program Pengembangan Pendidikan dan Kreativitas Anak (Pendikresa) di Kota Samarinda

Children’s education and creativity development program is carried out by the schools around the company areas embodies the company commitment related to the world of education in Samarinda. The aim of this research is to upgrade the service providers in improving the quality of services in Pendikresa Program. The sampling method used is Survey method. The data analysis methods used in this survey were descriptive analysis, customer satisfaction index and importance performance analysis. The results of the analysis illustrated that the survey on Community Satisfaction, underdone by Public Service Delivery Unit shows a figure of 71.20. It can be seen that this number fulfills the category of the value range 60% &lt; IKM ≤ 80% which illustrates that the IKM value is in the "Good" criteria. The IPA analysis shows what included in the priority quadrant of improvement program, these include indicators such as : the openness of information regarding to program of the implementation procedures; the ease of program procedures; the accuracy of the implementation program schedule; the effectiveness of program implementation; the technical competency of program implementers; the managerial competency of program managers; the discipline and responsibility of program managers; the clarity of complaints handling procedures; and the clarity of complaint handling time; and) the facilitation procurement of supporting facilities or infrastructure program.

Prevention of NICU Admission Hypothermia in Moderate- and Late-Preterm Infants.

Neonatal hypothermia is a common and preventable cause of neonatal morbidity and mortality. Although hypothermia prevention has been extensively studied in infants <32 weeks' gestation, the authors of few studies have targeted moderate- and late-preterm infants (MLPIs) in the delivery room. This quality improvement initiative was conducted from June 2019 to June 2023 at the Massachusetts General Hospital NICU and Labor and Delivery Unit. All inborn MLPIs 32 + 0/7 to 36 + 6/7 weeks' gestation admitted to the NICU were included. We expanded thermoregulatory measures typically used in protocols for infants <32 weeks' gestation, including increasing delivery room ambient temperature to 74°F and thermal mattress use. The primary outcome was hypothermia (<36.5°C) after NICU admission. The balancing measure was hyperthermia (≥38 °C). During the study period, there were 566 inborn MLPIs with a mean gestational age of 34 + 3/7 weeks and a mean birth weight of 2269 g. Special cause variation in neonatal hypothermia incidence was observed with a decrease from a mean baseline of 27% to 7.8% postintervention. Special cause variation was observed in hyperthermia incidence, with an increase from 1.4% to 6.2% postintervention largely initially associated with noncompliance with the protocol for thermal mattress removal. The expansion of several thermoregulation techniques commonly used in infants <32 weeks' gestation, particularly thermal mattress use, was associated with a decreased incidence of NICU admission hypothermia in MLPIs, with an increase in mild hyperthermia predominantly associated with concomitant polyethylene wrap use.

Safety of different cord clamping strategies in the early postnatal period

BackgroundThis study aimed to evaluate the effect of ICC (cord clamping within the first 15 s), DCC (delayed cord clamping at 60 s), and cut-UCM (cut-umbilical cord milking, cord clamping within the first 15 s) groups on oxygen saturation (SpO2), heart rate (HR), and perfusion index (PI) up to 10 min after birth in newborn infants. MethodsWe conducted this randomized clinical trial in the delivery unit of a University Hospital with 189 infants born between 35 and 42 weeks of gestation. Participants were randomly assigned to one of three groups: ICC, DCC, and cut-UCM. The primary outcomes measured were SpO2, HR, and PI at the 1st, 3rd, 5th, and 10th minutes after birth. We utilized ANOVA and Bayesian calculations in this study. ResultsThere was no difference between the ICC, DCC, and cut-UCM groups in SpO2, HR, and PI values at the 1st, 3rd, 5th, and 10th minutes of life, which did not significantly alter between the three groups in one-way ANOVA. Bayesian repeated-measure ANOVA calculations showed that SpO2 and heart rate results at the 1st, 3rd, 5th, and 10th minutes did not differ between ICC, DCC, and cut-UCM techniques with strong evidence. At the 3rd minute, PI was slightly higher in the DCC and cut-UCM groups compared to the ICC group, with anecdotal evidence. We found no difference between DCC and cut-UCM regarding the 3rd-minute PI, with moderate evidence. ConclusionUmbilical clamping procedures (ICC, DCC, and cut-UCM) did not affect SpO2 and HR in the first ten minutes of life, but 3rd-minute PI values were slightly higher in DCC and cut-UCM compared with ICC among late preterm and term neonates.

Changing diagnostic criteria for gestational diabetes (CDC4G) in Sweden: A stepped wedge cluster randomised trial.

The World Health Organisation (WHO) 2013 diagnostic criteria for gestational diabetes mellitus (GDM) has been criticised due to the limited evidence of benefits on pregnancy outcomes in different populations when switching from previously higher glycemic thresholds to the lower WHO-2013 diagnostic criteria. The aim of this study was to determine whether the switch from previous Swedish (SWE-GDM) to the WHO-2013 GDM criteria in Sweden following risk factor-based screening improves pregnancy outcomes. A stepped wedge cluster randomised trial was performed between January 1 and December 31, 2018 in 11 clusters (17 delivery units) across Sweden, including all pregnancies under care and excluding preexisting diabetes, gastric bypass surgery, or multifetal pregnancies from the analysis. After implementation of uniform clinical and laboratory guidelines, a number of clusters were randomised to intervention (switch to WHO-2013 GDM criteria) each month from February to November 2018. The primary outcome was large for gestational age (LGA, defined as birth weight >90th percentile). Other secondary and prespecified outcomes included maternal and neonatal birth complications. Primary analysis was by modified intention to treat (mITT), excluding 3 clusters that were randomised before study start but were unable to implement the intervention. Prespecified subgroup analysis was undertaken among those discordant for the definition of GDM. Multilevel mixed regression models were used to compare outcome LGA between WHO-2013 and SWE-GDM groups adjusted for clusters, time periods, and potential confounders. Multiple imputation was used for missing potential confounding variables. In the mITT analysis, 47 080 pregnancies were included with 6 882 (14.6%) oral glucose tolerance tests (OGTTs) performed. The GDM prevalence increased from 595/22 797 (2.6%) to 1 591/24 283 (6.6%) after the intervention. In the mITT population, the switch was associated with no change in primary outcome LGA (2 790/24 209 (11.5%) versus 2 584/22 707 (11.4%)) producing an adjusted risk ratio (aRR) of 0.97 (95% confidence interval 0.91 to 1.02, p = 0.26). In the subgroup, the prevalence of LGA was 273/956 (28.8%) before and 278/1 239 (22.5%) after the switch, aRR 0.87 (95% CI 0.75 to 1.01, p = 0.076). No serious events were reported. Potential limitations of this trial are mainly due to the trial design, including failure to adhere to guidelines within and between the clusters and influences of unidentified temporal variations. In this study, implementing the WHO-2013 criteria in Sweden with risk factor-based screening did not significantly reduce LGA prevalence defined as birth weight >90th percentile, in the total population, or in the subgroup discordant for the definition of GDM. Future studies are needed to evaluate the effects of treating different glucose thresholds during pregnancy in different populations, with different screening strategies and clinical management guidelines, to optimise women's and children's health in the short and long term. The trial is registered with ISRCTN (41918550).

Complex obstetrical surgery: building a team and defining roles

As the number of placenta accreta spectrum (PAS) cases continues to rise, the gap in surgical skills in labor and delivery units becomes more apparent. Recent scholarly work has highlighted the diminishing advanced surgical skills among obstetricians-gynecologists, particularly among new graduates. Therefore, it has become a practice in many institutions to refer complex cesarean deliveries (CD) and obstetrical hysterectomies to subspecialists, specifically gynecologic oncologists. Hence, in this commentary, we propose a process whereby key personnel within departments of obstetrics and gynecology are identified, and their appropriate level of involvement in cases of complex obstetrical surgery is delineated. In doing so, we describe the surgical skills expected from each provider level so that the CD complexity level can be matched to specific surgical expertise. Through this process, an obstetrician-led complex obstetrical surgery team is formed. Ultimately, the goal of this process is twofold: first, to return cases with higher levels of surgical complexity back to obstetricians, and second, to reduce the surgical back-up burden from gynecology subspecialists such as gynecologic oncologists.

Labor patterns of spontaneous first-stage labor in Chinese women with normal neonatal outcomes.

Friedman's standards, developed almost 50 years ago, may no longer align with the needs of today's obstetric population and current pregnancy management practices. This study aims to analyze contemporary labor patterns and estimate labor duration in China, focusing on first-stage labor data from Chinese parturients with a spontaneous onset of labor. This retrospective observational study utilized data from electronic medical records of a tertiary hospital in Changsha, Hunan. Out of a total of 2,689 parturients, exclusions were made for multiple gestations, preterm, post-term, or stillbirth, cesarean delivery, non-vertex presentation, and neonatal intensive care unit admission. Average labor curves were constructed by parity using repeated-measure analysis, and labor duration was estimated through interval-censored regression, stratified by cervical dilation at admission. We performed an analysis to assess the impact of oxytocin augmentation and amniotomy on labor progression and conducted a sensitivity analysis using women with complicated outcomes. Nulliparous women take over 180 minutes for cervical dilation from 3 to 4 cm, and the duration from 5 to 6 cm exceeds 145 minutes. Multiparous women experience shorter labor durations than nulliparous. Labor acceleration is observed after 5 cm in nulliparous, but no distinct inflection point is evident in the average labor curve. In the second stage of labor, the 95th percentile for nulliparous, with and without epidural analgesia, is 142 minutes and 127 minutes, respectively. These findings provide valuable insights for the reassessment of labor and delivery processes in contemporary obstetric populations, including current Chinese obstetric practice.