Difficult Delivery Research Articles

A prediction scheme of mobility of cognitive femtocells LTE-A / LTE-UE under different speed scenarios

Cognitive Femtocells have been standardized suitably to the technical framing of the Fourth cohort compact project to place them inside and outside the cell. Cognitive femtocells expand the coverage area and meet the future demands of higher data rates. However, as a result of the massive deployment of cognitive femtocells, users experience additional delay and unnecessary deliveries. The different hand off mechanisms are 1. Hard handover (break before make) 2. Smooth or soft handover (make-before-break). This can seriously affect the quality of service (QoS) of jam sensitive applications, such as Voice over long-term evolution (VoLTE). The 4GPP LTE-A / LTE-UE wireless networks aim to provide uninterrupted movement and rapid transfer pillar for (Real Time) RT and non-RT application services under the giant vigour. The prediction of mobility is an effective technique to identify a domestic NodeB (eNB / HeNB) evolved in the future and improve the overall service quality of the network and satisfy the end user experience. The different hand over mechanisms are, the first sense of a difficult delivery or transfer is one in which an breathe link should be penetrate ahead a unused one is created. The second new 3G technologies use CDMA where it is possible to have adjoining cells at the same frequency and this opens the odds of boast a transfer or transfer from where it is not required to repair the connection. This is called soft transfer, and is defined as a handover in which a not used tie-in is established before the used one is released. The third type of delivery is called smoother delivery or transfer. In this case, a pristine signal is added or deleted from the spry signal group. It can also happen when a signal is replaced by a burly signal from another sector under the base station. This type of transfer is available within UMTS and CDMA2000. “The cognitive femtocell will do in the delivery mechanism is that it will detect the new channel to transmit the data. With this we can avoid the delivery handover mechanism”. This study investigates the role of mobility prediction in reducing the end-to-end delay of VoLTE and the delay of handover under different user equipment (UE) speeds in mixed femtocell and macrocell environments. We propose a mobility based forecasting scheme based on the user path and measurements of the received signal reference signal and the quality reference signal (RSRP / RSRQ) with mixed RT traffic and not RT and then estimated using a network model new. The survey analysis shows that the proposed scheme will reduce the delivery delay by 35% to keep VoLTE at the end of the delay.

Optimizing Percutaneous Coronary Intervention in Calcified Lesions: Insights From Optical Coherence Tomography of Atherectomy.

Optimal coronary stent implantation is among the few successful strategies in preventing stent failures, notably in-stent restenosis and stent thrombosis.1 Understanding the intravascular milieu is a prerequisite for optimization of percutaneous coronary intervention (PCI). Calcified lesions limit stent expansion, the most robust predictor of target lesion revascularization, and are thus associated with worst outcomes.2 Coronary angiography is a poor discriminator of calcium distribution and thickness. Reliance on angiography to guide PCI and define procedural success in severe coronary calcification is associated with poor outcomes.3 Both intravascular ultrasound and optical coherence tomography (OCT) enable detailed evaluation of cross-sectional calcium distribution (angle of calcium), and OCT provides additional information on calcium thickness. The combination of large calcium angle (>270°) and thickness (>670 μm) predicts nondilatable lesions.4 OCT is the ideal method to capture these parameters and indicate or defer the use of atherectomy before stent implantation and guide optimization of PCI. Preintervention OCT imaging delineates plaque constituents and provides accurate measurements of the minimal lumen area, lesion length, and reference vessel diameters, as well as visualization of the projected stent landing zones. These parameters can be used for procedural planning, including proper lesion preparation and stent sizing. Knowledge of plaque characteristics can be used to select a plaque modification strategy prior to stent implantation and to minimize stent edge dissection at the stent landing zone.5 Calcified lesions pose a bigger challenge, with difficult device delivery, suboptimal stent expansion, and increased procedural time and complications. Although atherectomy facilitates stent delivery and improves procedural success and acute lumen gain, long-term outcomes in severely calcified lesions are not improved with the routine use of angiographically guided ablative techniques in the drug eluting stent era.6 Indiscriminate use of atherectomy can also increase procedural complications. Intravascular frequency domain OCT is the …

The Relationship Between Women's Intention to Request a Labor Epidural Analgesia, Actually Delivering With Labor Epidural Analgesia, and Postpartum Depression at 6 Weeks: A Prospective Observational Study.

Postpartum depression (PPD) is associated with pain during and after delivery, with studies showing reduced rates among women delivering with labor epidural analgesia (LEA). We hypothesized that women who intend to deliver with LEA but do not receive it are at higher risk for PPD at 6 weeks due to the combined experience of untreated labor pain and unmatched expectations during labor, and evaluated the interaction between labor plans related to LEA, satisfaction with pain control when actually delivering with LEA, and PPD at 6 weeks after delivery. A total of 1497 women with a vaginal delivery were enrolled into this prospective longitudinal study. Women's initial intention to deliver with or without LEA, how they subsequently delivered, and satisfaction with pain relief were recorded on postpartum day 1. Primary aim was selected as PPD at 6 weeks among women intending to deliver with but subsequently delivering without LEA compared with the rest of the cohort. Primary outcome was PPD at 6 weeks using the Edinburgh Postnatal Depression Scale; PPD was defined with a score ≥10 (scale from 0 to 30). Demographic and obstetric data were recorded. Fisher exact test was used for comparisons between groups. The interaction between intention and actual delivery with regard to LEA and PPD was tested. Overall, 87 of 1326 women completing the study at 6 weeks had PPD (6.6%). For the primary aim, 439 (29.3%) delivered without LEA, of which 193 (12.9%) had intended to deliver with LEA; the PPD rate among these women was 8.1%, which was not statistically different from the rest of the cohort (6.3%; odds ratio [OR], 1.30; 95% confidence interval [CI], 0.72-2.38; P = .41). A total of 1058 women (70.7%) delivered with LEA and 439 (29.3%) delivered without; therefore, 1169 (78.1%) delivered as intended and 328 (21.9%) did not (unmatched expectations). Evaluating the interaction between effects, there was a strong negative additive interaction between intending to deliver without LEA and actually delivering with LEA (risk difference = -8.6%, 95% CI, 16.2%-1.6%; P = .014) suggesting that unmatched intention effect is significantly associated with negative outcome. In multiple regression analysis, while intending to deliver with LEA (OR, 1.06; 95% CI, 1.01-1.11; P = .029) and actually delivering with LEA (OR, 1.07; 95% CI, 1.01-1.13; P = .018) both increased the odds for PPD, the multiplicative interaction was protective (OR, 0.92; 95% CI, 0.86-0.99; P = .022), after adjusting for cofactors. Our study results did not demonstrate a significant increase in the odds for PPD at 6 weeks among women who intended to deliver with LEA but subsequently delivered without. However, we identified a protective interaction between intended LEA use and actual use on the incidence of PPD. Our data suggest an increased risk when women do not deliver as intended, particularly when not initially intending to deliver with LEA. The relationship between unplanned LEA and PPD may be mediated by a physically difficult delivery rather than or in addition to negative emotions related to unmet expectations or a sense of personal failure; therefore, counseling women after delivery to address any negative perceptions may be useful.

The impact of pre- and perinatal factors on psychopathology in adulthood

Background: There is considerable evidence that pre- and post-natal factors are associated with a wide range of psychopathology in offspring during childhood and adolescence. Objective: The main aims of the present study were to examine the associations between pre- and perinatal factors and psychopathology in offspring during adulthood, and to explore whether family factors (i.e., family cohesion, mother's social support, and father's social support) mediate these relationships. Method: Information on pre- and perinatal events was collected from biological mothers of the participants (N = 315) when they were between 14 and 18 years who were then followed up until they reached age 30. Results: Maternal obstetric history and illness during first year were significant predictors of offspring anxiety disorder. Maternal emotional health predicted offspring affective disorder. Difficult delivery and breast feeding predicted disruptive disorder. The relationship between maternal obstetric history/emotional health and anxiety/affective disorder was no longer significant after controlling for family cohesion. Limitations: The information was based on maternal recall when their offspring were between 14 and 18 years which may be subjected to recall bias. Conclusion: The association between pre- and postnatal factors and psychopathology of offspring during adulthood is mediated by familial factors.

Intracellular generation of single-strand template increases the knock-in efficiency by combining CRISPR/Cas9 with AAV.

Targeted integration of transgenes facilitates functional genomic research and holds prospect for gene therapy. The established microhomology-mediated end-joining (MMEJ)-based strategy leads to the precise gene knock-in with easily constructed donor, yet the limited efficiency remains to be further improved. Here, we show that single-strand DNA (ssDNA) donor contributes to efficient increase of knock-in efficiency and establishes a method to achieve the intracellular linearization of long ssDNA donor. We identified that the CRISPR/Cas9 system is responsible for breaking double-strand DNA (dsDNA) of palindromic structure in inverted terminal repeats (ITRs) region of recombinant adeno-associated virus (AAV), leading to the inhibition of viral second-strand DNA synthesis. Combing Cas9 plasmids targeting genome and ITR with AAV donor delivery, the precise knock-in of gene cassette was achieved, with 13-14% of the donor insertion events being mediated by MMEJ in HEK 293T cells. This study describes a novel method to integrate large single-strand transgene cassettes into the genomes, increasing knock-in efficiency by 13.6-19.5-fold relative to conventional AAV-mediated method. It also provides a comprehensive solution to the challenges of complicated production and difficult delivery with large exogenous fragments.

Exploring full cervical dilatation caesarean sections–A retrospective cohort study

BackgroundThe rate of caesarean sections at full cervical dilatation with their high risk of morbidity continues to rise mirroring the overall increase in caesarean section rates internationally. ObjectivesThe objectives of this study were to determine the rate of full dilatation caesarean section in a tertiary referral unit and evaluate key labour, maternal and fetal factors potentially linked to those deliveries. We also assessed maternal and fetal morbidity at full dilatation sections. Where possible, these were compared with successful operative vaginal deliveries carried out in theatre to determine key differences. Study designRetrospective cohort study. We reviewed the rate of full dilatation caesarean section over a 10-year period. We analysed deliveries (caesarean sections or operative vaginal deliveries) in single cephalic pregnancies ≥34 weeks with contemporaneously collected data from our unit’s electronic database for 2015. ResultsThe rate of full dilatation caesarean section increased by over a third in the ten-year period (56/6947 (0.80%) vs 92/7378 (1.24%), p = 0.01). Of 84 full dilatation caesarean sections who met the inclusion criteria, 63 (75%) were nulliparous and the mean maternal age was 33 (±5) years. Oxytocin was used in the second stage in less than half of second stage caesarean sections (22 out of a recorded 57, 38.6%). There were more fetal head malposition (occipito-posterior, or occipito-transverse) at full dilatation caesarean section compared to successful operative vaginal deliveries (41/46 (89.1%) vs 2/21 (9.5), p < 0.001). The rate of significant postpartum haemorrhage (defined as estimated blood loss ≥1000 ml) was similar in both full dilatation caesarean section and operative vaginal deliveries. There was no difference in the mean birthweight at full dilatation caesarean sections compared to operative vaginal delivery (3.88 kg (2.80–5.33 kg) vs 3.48 kg (1.53–4.40 kg)). There was no difference in neonatal morbidity. ConclusionFetal head malposition is associated with a higher risk of full dilatation caesarean section. Interestingly, maternal and fetal morbidity were similar between full dilatation caesarean sections and anticipated difficult operative vaginal deliveries carried out in theatre. The management of labour in terms of the decision to use oxytocin judiciously in hope of correcting inefficient uterine contractions and continuous labour ward training, particularly the diagnosis of malposition and its correction may be beneficial in reducing the rate of full dilation caesarean sections.

The Use of Botulinum Toxin Injection for Brachial Plexus Birth Injuries: A Systematic Review of the Literature.

Most brachial plexus birth injuries (BPBIs) are caused by traction on the brachial plexus during a difficult delivery. Fortunately, the possibility of complete recovery from such an incident is relatively high, with only 10% to 30% of patients having prolonged and persistent disability. These patients have muscle imbalances and co-contractions typically localized around the shoulder and elbow. These imbalances and co-contractures cause abnormal motor performances and bone/joint deformities. Typically, physical/occupational therapies are the conventional therapeutic modalities but are often times inadequate. Botulinum toxin A (BTX-A) injections into targeted muscles have been used to combat the muscular imbalances and co-contractions. With compliance to PRISMA guidelines, a systematic review was performed to identify studies published between 2000 and 2017 that used BTX-A to treat neonatal brachial plexus palsies. Ten studies were included, involving 325 patients. Three groups of indications for the use of BTX-A were identified: (1) internal rotation/adduction contracture of the shoulder; (2) elbow flexion lag/elbow extension lag; and (3) forearm pronation contracture. The included studies show an overall beneficial effect of BTX-A in treating co-contractures seen in patients with BPBI. Specifically, BTX-A is shown to reduce internal rotation/adduction contractures of the shoulder, elbow flexion/extension contractures, and forearm pronation contractures. These beneficial effects are blunted when used in older patients. Nevertheless, BTX-A is a useful treatment for BPBIs with a relatively low-risk profile.

Clavicle Fracture Is Not Predictive of the Need for Microsurgery in Brachial Plexus Birth Palsy.

Brachial plexus birth palsy (BPBP) and clavicle fractures occur concurrently as well as in isolation during difficult deliveries. The concept that concurrent clavicle fracture may spare nerve injury has been advocated. Our aim was to compare those children with BPBP presenting to a tertiary care center with and without concurrent clavicle fractures and assess the utility of the presence of a clavicle fracture as a predictor of injury severity in children with BPBP. Records of all patients belonging to a large prospective multicenter cohort study of infants with BPBP (Treatment and Outcomes of Brachial Plexus Injuries study) were analyzed for demographic information and birth information including risk factors, comorbidity, presence of clavicle fracture, and injury severity. The records of 639 children with BPBP were examined. Thirteen patients were excluded for incomplete data. Ninety-six children who sustained concurrent birth fracture and BPBP were identified (15%). Of these, 57 sustained clavicle fractures (9%), 44 sustained humerus fractures, and 4 sustained other fractures. Of the demographic factors analyzed, only the presence of gestational diabetes was found to be significantly higher in those children with fractures versus those without. The presence of a clavicle fracture did not change the rate of microsurgical intervention, nor did clavicle fracture rates differ by Toronto score, suggesting that there was no difference in injury severity between the 2 groups. In a large multicenter prospective study, 9% of children presenting with BPBP also sustained a clavicle fracture at birth. The presence of a clavicle fracture did not correlate with the severity of brachial plexus injury. We suggest that in study populations of children with severe enough BPBP to present to a tertiary care center, compared with studies collected in the obstetric population, the presence of a clavicle fracture is neither protective from nerve injury nor predictive of injury severity. Level 2-prognostic.

Bilateral Obstetric Fracture of the Clavicle: A Rare Clinical Case

Obstetric trauma is considered to be a complication of difficult deliveries. They generally concern 5 to 7 new born baby among 1000 live births. Obstrecal fracture of the clavicle is one of the most common lesions of obstetric trauma. It is usually unilateral and occurs after a dystocic birth. Bilateral involvement of the clavicles during obstetric trauma is rare. We report a case of bilateral obstetrical fracture of the clavicle during a eutocic delivery with favorable evolution.

Retrospective Analysis of Patients with Genitourinary Fistula

Objective: To present the outcomes of patients treated at a tertiary center for a diagnosis of genitourinary fistula secondary to gynecological and obstetric etiologies.Study Design: In this retrospective study, analysis was made of 18 patients with a diagnosis of genitourinary fistula in a tertiary center between January 2006 and June 2016. Patient data were taken from the archives and patient histories. A record was made of examinations, diagnostic methods such as cystoscopy and fistulography and appropriate medical treatments, demographic data, intraoperative and post-operative complications, duration of hospital stay, surgical operations and types, diameter and location of fistulas.Results: Of the 18 cases, 14 were secondary to obstetric trauma. In 10 of these 14 cases, fistula had developed after difficult vaginal delivery and in four cases, after caesarean section. Four of the 18 cases were secondary to gynecological surgeries, namely hysterectomy and cystocele repairs. Vesicovaginal fistulas were repaired transvaginally while vesicouterine fistulas and bilateral ureterovaginal fistulas were repaired transabdominally. The mean hospital stay was 3.8±1.5 days (2-7 days). Patients were followed up closely in the first 3 months and recurrence developed in only one case.Conclusion: Fistulas secondary to gynecological procedures are uncommon while fistulas secondary to inadequate perineal care, insufficient labor monitoring and difficulties in vaginal delivery techniques are more prevalent in Turkey. Thorough evaluation, using all diagnostic tools for complete diagnosis, understanding the pathophysiology and choosing the best surgical procedure are mandatory to obtain good outcomes after the surgical

Intrapartum transperineal ultrasound used to predict cases of complicated operative (vacuum and forceps) deliveries in nulliparous women.

The objective of this study was to investigate the predictive value of intrapartum transperineal ultrasound in the identification of complicated operative (vacuum or forceps) deliveries in nulliparous women. Prospective observational study of nulliparous women with an indication for operative delivery who underwent intrapartum transperineal ultrasound before fetal extraction. Managing obstetricians were blinded to the ultrasound data. Intrapartum transperineal ultrasound was performed immediately before blade application, both at rest and concurrently with contractions and active pushing. Operative delivery was classified as complicated when one or more of the following situations occurred: three or more tractions; a third-/fourth-degree perineal tear; significant bleeding during the episiotomy repair; major tear or significant traumatic neonatal lesion. A total of 143 nulliparous women were included in the study (82 vacuum-assisted deliveries and 61 forceps-assisted deliveries), with 20 fetuses in occiput posterior position. Forty-seven operative deliveries were classified as complicated deliveries (28 vacuum-assisted deliveries, 19 forceps-assisted deliveries). No differences in obstetric, intrapartum or neonatal characteristics were observed between the study groups, with the following exceptions: birthweight (3229±482 uncomplicated deliveries vs. 3623±406 complicated deliveries; p<0.003) and number of vacuum tractions (1.4 uncomplicated deliveries, 4.5 complicated deliveries; p<0.0005). The strongest predictors of a complicated delivery, using the area under the receiver-operating characteristics curve (AUC), were the angle of progression with active pushing (AoP2) (AUC 86.9%) and the progression distance with active pushing (PD2) (AUC 74.5%). The optimal cut-off value for predicting a difficult operative delivery was an AoP2 of 153.5° (sensitivity 95.2%; false-positive rate 5.9%) or PD2 of 58.5mm (sensitivity 95.2%; false-positive rate 7.1%). The sonographic parameters AoP2 and PD2 can be used to predict cases of complicated operative deliveries in nulliparous women.

From "apparent death" to "birth asphyxia": a history of blame.

Since the sixteenth century, competition between midwives and surgeons has created a culture of blame around the difficult delivery. In the late seventeenth century, 100 years before oxygen was discovered, researchers associated "apparent death of the newborn" with impaired respiratory function of the placenta. The diagnosis "birth asphyxia" replaced the term "apparent death of the newborn" during the mass phobia of being buried alive in the eighteenth century. This shifted the interpretation from unavoidable fate to a preventable condition. Although the semantic inaccuracy ("pulselessness") was debated, "asphyxia" was not scientifically defined until 1992. From 1792 the diagnosis was based on a lack of oxygen. "Blue" and "white" asphyxia were perceived as different disorders in the eighteenth, and as different grades of the same disorder in the nineteenth century. In 1862, William Little linked birth asphyxia with cerebral palsy, and although never confirmed, his hypothesis was accepted by scientists and the public. Fetal well-being was assessed by auscultating heart beats since 1822, and continuous electronic fetal monitoring was introduced in the 1960s without scientific assessment. It neither diminished the incidence of birth asphyxia nor of cerebral palsy, but rather raised the rate of cesarean sections and litigation against obstetricians and midwives.

Difficult Deliveries in Cesarean Section.

Cesarean section rate has been on the rise. It is commonly perceived as a simple and safe alternative to difficult vaginal birth. However, there are situations during C section where delivery of fetus may be difficult. This can cause maternal and fetal complications. To avoid such mishaps, anticipation of potential difficulties and planning in advance can be fruitful. This amounts to mobilization of a good team of anesthetist, assistant and skilled neonatologist. Proper technical skills are needed not only to use the equipment but to deal with such situations for safe delivery of the fetus. The training in technical skills can be imparted through drill protocols under C section skills. This way, one should try and accomplish safe atraumatic fetal delivery.

Perceptions and experiences of women seeking treatment for obstetric fistula.

To understand patients' perspectives on the causative factors and preventive measures of obstetric fistula; and the effect of fistula on the victims' psycho-social, sexual, and economic well being. A questionnaire-based interview of 215 women with obstetric fistula admitted for treatment in 17 hospitals in India was carried out during 2010-2011. Responses of participants from poor, medium, and better performing states were categorized into pre-coded themes and compared. The majority of the women were from rural areas (75.3%), multiparous (68.8%), and with less than high school education (82.2%). The majority (70.7%) of the women reported attempt at home delivery by untrained persons. Poor awareness of where and when to seek care when faced with a difficult delivery, and poor quality of care in facilities were perceived as important causative factors. Delivery by trained providers and early referral of women with problems during labor were identified as important preventive factors. Spouses and families were supportive of treatment in spite of economic hardships, but most (79.5%) patients felt socially isolated after developing fistula. Poor awareness regarding delivery care among the women indicates a need for increasing birth preparedness in the community. Patients' perceptions of poor quality of care in facilities need to be addressed urgently. Psychological evaluation and counseling should be offered to fistula patients, to help them cope with adverse psycho-social and economic circumstances. The results of this study may provide insights for prevention and management of fistula, and may help to improve patient care and services.

Traumatic Head Injury in Pediatric Head Trauma

The cause of the traumatic head injury (THI) and the capacity of the brain to respond to trauma depend on the age of the patient. The most common abnormality seen in newborns after birth trauma is the subdural hematoma, which is usually posteriorly located, caused by tearing of the tentorium and venous structures after difficult delivery. At this age, intradural hematomas may occur within the opposing layers of the falx and tentorium, which are loosely attached. Doctors should be aware of complications such as intraparenchymal hemorrhage, subarachnoidal hemorrhage (in this case, hydrocephalus may follow), epidural hematomas and fractures. Children under 2 years of age, particularly small infants, have large heads, weak neck muscles, thin and deformable skull and nonfused sutures. This last feature leads to a greater degree of intracranial expansion. In case of cerebral swelling, the calvarium expands, but the brain does not herniate infratentorially. However, the perimesencephalic cistern can be obliterated and the brain stem compressed. In addition, the lack of myelination makes the parenchyma more compressible and permits, at least partially, the absorption of impact. As a consequence, less damage occurs. The same unmyelinated white matter is however unfortunately sensitive to shearing injury, i.e., diffuse axonal injury (DAI). In addition, exclusive to this age group is the risk of a growing skull fracture. A further complication after THI in all age-groups with fractures and associated dura laceration is meningitis. After the age of 2, and especially within adolescents, DAI is more common and results from stress to axons during severe trauma, such as may occur in a motor vehicle accident. DAI is always multiple, regardless whether or not magnetic resonance imaging (MRI) recognizes more than one lesion. In this group, computed tomography (CT) and MRI findings do not differ from those seen in the adult population.

Postnatal Attachment and General Health in Easy, Preterm, and Difficult Delivery: A Comparative Study

Postnatal Attachment and General Health in Easy, Preterm, and Difficult Delivery: A Comparative Study

Urinary fistula-A continuing problem with changing trends.

Objective:Urinary fistula is a distressing complication after difficult vaginal deliveries, obstetric, and gynecologic surgeries. The present study describes a single center’s experience in the management of urinary fistula at a tertiary care hospital. It was performed to analyze the etiology of genitourinary fistula, to assess the outcome after surgical repair, and to determine the changing trends in the etiology and management of urinary fistula.Material and Methods:This retrospective study was conducted over 5 years in the department of obstetrics and gynecology, All India Institute of Medical Sciences, New Delhi. Twenty patients who underwent surgical repair of urinary fistula were included in the study and analyzed for their etiology, presentation, site, size, previous failed repair, approach of surgical repair, and outcome. The findings of the present study were compared with a previous study at our center to determine the changing trends of urinary fistula.Results:The mean age of the study population was 37.05±8.08 years. The majority (65%) of the fistulae occurred following gynecologic surgeries, whereas 25% were due to obstructed labor, and 10% after cesarean section for other indications. The vaginal approach was used in all except one case of uterovesical fistula, which was repaired abdominally. The outcome was successful in 85% of cases. The success rate was similar in primary versus previous failed repair (p=0.270).Conclusion:The most common cause of urinary fistula in the present study was gynecologic surgery. The vaginal approach can be used even in cases with previous failed repairs with a high success rate.

Predicting the difficulty of operative vaginal delivery by ultrasound measurement of fetal head station

Clinical assessment of fetal head station is difficult and subjective; it is mandatory before attempting operative vaginal delivery. The principal objective of our study was to assess whether measurement of the perineum-to-skull ultrasound distance was predictive of a difficult operative vaginal delivery. Secondary objectives included evaluation of the interobserver reproducibility of perineum-to-skull ultrasound distance and comparison of this measurement and digital examination in predicting a difficult operative delivery. This was a prospective cohort study including all cases of operative vaginal deliveries in singleton pregnancies in cephalic presentation >34 weeks' gestation, from 2012 through 2015. All data were entered prospectively in a medical record system specially devised to meet the requirements of this study. Of the 659 patients in whom perineum-to-skull ultrasound distance was measured prior to operative vaginal delivery, 120 (18%) met the composite criterion for a difficult extraction. Perineum-to-skull ultrasound distance measurement of ≥40 mm was significantly associated with the occurrence of a difficult extraction based on the composite criterion, after adjustment for parity, presentation type, and fetal macrosomia (odds ratio, 2.38; 95% confidence interval, 1.51-3.74; P=.0002). The intraclass correlation coefficient between the perineum-to-skull ultrasound distance measured by the first operator and that measured by the second operator was 0.96 (95% confidence interval, 0.95-0.97; P < .0001). Based on the receiver operating characteristic curve analyses, perineum-to-skull ultrasound distance was a more accurate predictor of difficult operative delivery than digital vaginal examination (P= .036). Measurement of the perineum-fetal skull ultrasound distance is a reproducible and predictive index of the difficulty of instrumental extraction. Ultrasound is a useful supplementary tool to the usual clinical findings.

Massive hemopericranium following trivial trauma in a child with hypofibrinogenemia: A case report and review of the literature

Subgaleal hematoma is a potentially life-threatening extracranial bleed that occurs most commonly in neonates after difficult instrumental deliveries. Its occurrence beyond the neonatal period is rare and is often associated with head trauma involving tangential or radial forces applied to the scalp causing emissary veins traversing the subgaleal space to be ruptured. Large progressive subgaleal hematoma due to trivial head trauma in a 5-years-old child of hypofibrinogenemia with no reported literature is interesting to describe.

96: Ultrasound measurement of the perineum-fetal head distance as a predictive factor of difficult vaginal operative delivery

96: Ultrasound measurement of the perineum-fetal head distance as a predictive factor of difficult vaginal operative delivery