Fetus In Vertex Presentation Research Articles

Novel, Group-Based Trajectories of Labor Progress in Nulliparous Women With Low-Risk Pregnancies

ObjectiveTo characterize labor progress among nulliparous women by applying group-based trajectory analysis and examining predictors of group membership. DesignRetrospective observational. SettingAn existing biobank and database from a birth hospital in Western Pennsylvania. ParticipantsNulliparous women with low-risk pregnancies at term gestation with singleton fetuses in vertex presentation (N = 401). MethodsWe characterized labor progress by applying group-based trajectory analysis. We conducted a multinomial logistic regression analysis to examine the relationships among labor trajectory groups and various demographic and clinical variables. ResultsWe identified three trajectories of labor in the group-based trajectory analyses: precipitously progressing (n = 76, 20.1%), average (n = 245, 59.1%), and slow progress (n = 80, 20.7%). Only gestational age at birth significantly predicted trajectory group membership, and an increased gestational age was associated with greater odds of belonging to the slower progress group (OR = 1.43, 95% CI [1.06, 1.92]). ConclusionWe identified multiple trajectories of labor progress in a sample of nulliparous women with low-risk pregnancies at term gestation. Gestational age may help predict the trajectory of labor.

Risk of postpartum hemorrhage with increasing first stage labor duration

With increasing rates of postpartum hemorrhage (PPH) in high-income countries, an important clinical concern is the impact of labor duration on the risk of PPH. This study examined the relationship between increasing active first stage labor duration and PPH and explored the role of second stage labor duration and cesarean delivery (CD) in this association. Including 77,690 nulliparous women with spontaneous labor onset, first stage labor duration was defined as the time from 5 cm to 10 cm, second stage duration from 10 cm dilation to birth and PPH as estimated blood loss > 1000 ml. Using modified Poisson regression for risk ratios (RR) and confidence intervals (CI), we found a 1.5-fold (RR, 1.53; 95% CI, 1.41‒1.66) increased PPH risk when first stage of labor exceeded 12.1 h compared to the reference (< 7.7 h). Mediation analysis showed that 18.5% (95% CI, 9.7‒29.6) of the increased PPH risk with a prolonged first stage (≥ 7.7 h) was due to a prolonged second stage (> 3 h) or CD. These results suggest that including first stage duration in intrapartum assessments could improve PPH risk identification in first-time mothers with a singleton fetus in vertex presentation at full term with spontaneous labor onset.

Time matters: Cervical ripening balloon for 6 versus 12 h-Retrospective comparison between two protocols.

Recently, two randomized controlled trials compared removal of cervical ripening balloon (CRB) after 6 versus 12 h. Their results showed similar Bishop score changes in both groups and a shorter time to delivery in the 6-h group. Neither of the studies was powered to show difference in mode of delivery. The aim of this study was to compare mode of delivery when the CRB was removed after 6 versus 12 h. A historical control study comparing induction of labor with a CRB between two time periods, one in which the CRB was removed after 12 h (12-h group), and the other in which it was removed after 6 h (6-h group). We included term pregnancies with a singleton fetus in vertex presentation. We excluded patients with a previous cesarean delivery, failed ripening with prostaglandins prior to CRB insertion, and any contraindication for vaginal delivery. The primary outcome was mode of delivery. Secondary outcomes included delivery within 24 h and other maternal and neonatal outcomes. We included 1704 patients, 914 in the 12-h group, and 717 in the 6-h group. Removal after 6 h was associated with a lower rate of cesarean and instrumental deliveries (28.6% vs 22.5%, and 12% vs 6.2%, respectively) and a higher rate of vaginal delivery within 24 h. All differences were statistically significant. Removing a cervical ripening balloon after 6 rather than 12 h is associated with reduced cesarean and instrumental delivery rates, and should be considered as a reasonable, and potentially superior alternative in labor induction protocols with intracervical ripening balloon.

New labor curves of dilation and station to improve the accuracy of predicting labor progress

BackgroundThe diagnosis of failure to progress, the most common indication for intrapartum cesarean delivery, is based on the assessment of cervical dilation and station over time. Labor curves serve as references of expected changes in dilation and fetal descent. The labor curves of Friedman, Zhang et al and others are based on time alone and derived from mothers with spontaneous labor onset. However, labor induction is now common, and clinicians also consider other factors when assessing labor progress. Labor curves that consider the use of induction and other factors that influence labor progress have the potential to be more accurate and closer to clinical decision-making. ObjectiveTo compare the prediction errors of labor curves based on a single factor (time) or multiple clinically relevant factors using 2 modeling methods: mixed-effects regression, a standard statistical method, and Gaussian processes, a machine learning method. Study designThis was a longitudinal cohort study of changes in dilation and station based on data from 8022 births in nulliparous women with a live, singleton, vertex presenting fetus at ≥35 weeks of gestation with a vaginal delivery. New labor curves of dilation and station were generated with 10-fold cross-validation. External validation was performed using a geographically independent group. Model variables included time from the first exam in the 20 hours before delivery; dilation, effacement and station recorded at the previous examination; cumulative contraction counts; and use of epidural anesthesia and labor induction. To assess model accuracy, we calculated the differences between each model’s predicted value and its corresponding observed value. These prediction errors were summarized using mean absolute error and root mean squared error statistics. Results(1) Dilation curves based on multiple parameters were more accurate than those derived from time alone. (2) The mean absolute error with the multifactor methods were better (lower) than those from the single-factor methods [0.826 cm (95% CI, 0.820–0.832) for the multifactor machine learning and 0.893 cm (95% CI, 0.885–0.901) for the multifactor mixed-effects method and 2.122 cm (95% CI, 2.108–2.136) for the single-factor methods; P<0.0001 for both comparisons]. (3) The root mean squared errors with the multifactor methods were also better (lower) than those from the single-factor methods [1.126 cm (95% CI, 1.118–1.133) P<0.0001 for the machine learning and 1.172cm (95% CI, 1.164–1.181) for the mixed-effects method and 2.504 cm (95% CI, 2.487–2.521) for the single-factor; P<0.0001 for both comparisons]. (4) The multifactor machine learning dilation models showed small but statistically significant improvements in accuracy compared to the mixed-effects regression models (P<0.0001). (5) The multifactor machine learning method produced a curve of descent with a mean absolute error of 0.512 cm (95% CI, 0.509–0.515) and a root mean squared error of 0.660 cm (95% CI, 0.655–0.666). (6) External validation using independent data produced similar findings. Conclusions(1) Cervical dilation models based on multiple clinically relevant parameters showed improved (lower) prediction errors compared to models based on time alone; (2) the mean prediction errors were reduced by more than 50%; and (3) a more accurate assessment of departure from expected dilation and station may help clinicians optimize intrapartum management.

Outpatient balloon catheter vs inpatient prostaglandin for induction of labor: a randomized trial

Approximately 1 in 4 pregnant women undergo induction of labor. Meta-analyses have shown that mechanical methods of induction of labor are safe and effective, as is starting induction in an outpatient setting. However, few studies have evaluated outpatient balloon catheter induction in comparison with pharmacologic methods. This study aimed to determine whether women who underwent outpatient induction of labor with a balloon catheter would have a lower cesarean delivery rate than women who underwent inpatient induction of labor with vaginal prostaglandin E2 without an increase in adverse maternal or neonatal events. This was a superiority randomized controlled trial. The eligibility criteria were pregnant women (nullipara and multipara) with a live singleton fetus in vertex presentation with any medical comorbidity who underwent planned induction of labor at term and who had an initial modified Bishop Score of 0 to 6 at 1 of 11 public maternity hospitals in New Zealand. The intervention groups were outpatient single balloon catheter induction in comparison with inpatient vaginal prostaglandin E2 induction. The primary hypothesis was that participants who started their induction at home with a balloon catheter would have a lower risk for cesarean delivery than participants who started their induction with prostaglandins and remained in hospital throughout. The primary outcome was cesarean delivery rate. Participants were randomized using a centralized secure online randomization website in a 1:1 ratio, stratified by parity and hospital. The participants and outcome assessors were not blinded to group allocation. An intention-to-treat analysis with adjustment for stratification variables was used. A total of 539 participants were randomized to outpatient balloon catheter induction, and 548 participants were randomized to inpatient prostaglandin induction; the mode of birth was reported for all participants. The cesarean delivery rate was 41.0% among participants allocated to outpatient balloon induction and 35.2% among those allocated to inpatient prostaglandin induction (adjusted odds ratio, 1.27; 95% confidence interval, 0.98-1.65). Women in the outpatient balloon catheter group were more likely to have artificial rupture of membranes and to received oxytocin and an epidural. No differences were found in the rates of adverse maternal or neonatal events. Outpatient balloon catheter induction was not found to reduce the cesarean delivery rate when compared with inpatient vaginal prostaglandin E2 induction. However, the use of balloon catheters in an outpatient setting does not seem to increase the rate of adverse events for mothers or babies and can be offered routinely.

Oxytocin versus prostaglandins for labour Induction of women with an unfavourable cervix after 24 hours of cervical ripening (OPIC): protocol for an open multicentre randomised non-inferiority trial

IntroductionIt remains uncertain whether the most appropriate management for women with an unfavourable cervix after 24 hours of cervical ripening is repeating the ripening procedure or proceeding directly to induction...

Grand multiparity, is it a help or a hindrance in a trial of labor after cesarean section (TOLAC)?

Objective Parity is a prognostic variable when considering trial of labor after cesarean section (TOLAC). This study aimed to determine whether grandmultiparous patients are at increased risk of poor TOLAC outcomes such as uterine rupture. Study design A retrospective cohort was conducted at a single university-affiliated medical center with approximately 10,000 deliveries per year. The study group included women post one cesarean section who attempted TOLAC carrying a singleton fetus in vertex presentation. We divided the cohort into three groups: group 1 – women who had a parity of 1; group 2 – parity of 2–4; group 3 – parity of 5 and above. The primary outcome was successful VBAC. Secondary outcomes included mode of delivery, uterine rupture, and combined maternal and neonatal adverse outcomes. Data were analyzed using Fisher’s exact test, Chi-square test, ANOVA, and paired t-test. Results Five thousand four hundred and forty-seven women comprised the study group: group 1 – 879 patients, group 2 – 2374 patients, and group 3 − 2194 patients. No significant between-group differences were found in gestational age at delivery. Rates of a successful VBAC were 80.6%, 95.4%, and 95.5%, respectively. Group 1 were more likely to have a failed TOLAC compared to group 2 (OR 5.02, 95% CI 3.9–6.5, p<.001) and group 3 (OR 5.17, 95% CI 4.0–6.7, p<.001). There was no increased risk of failed TOLAC when comparing groups 2 and 3 (OR 1.03; 95% CI 0.8–1.4, p=.89). Operative delivery rate differed significantly between all three groups; 25.1%, 6.2%, and 3.6%, for groups 1, 2, and 3, respectively (p<.001). The rate of uterine rupture was significantly higher in group 1 compared to group 2 (1.02% vs. 0.29% p=.02) and group 3 (1.02% vs. 0.2%, p=.01, respectively). There were no differences between group 2 and group 3 (0.29% vs. 0.2% p=.78). Conclusions Grandmultiparity is not associated with an increased risk of uterine rupture during TOLAC.

Contextualizing disparities in NTSV cesarean rates with county-level data

The rate of cesarean births among nulliparous women with a term singleton fetus in vertex presentation (NTSV) is a quality indicator for perinatal care. Black women are disproportionately affected by high rates of unplanned cesarean birth and are at increased risk for the associated complications. We sought to describe disparities in the county-level NTSV cesarean birth rate in the United States to understand how cesarean disparities vary by place.

Maternal and Neonatal Morbidity After Attempted Operative Vaginal Delivery.

To assess severe short-term maternal and neonatal morbidity and pelvic floor disorders at 6 months postpartum after attempted operative vaginal delivery according to the instrument used. We conducted a prospective study of women with live, singleton, term fetuses in vertex presentation. Patients attempted operative vaginal delivery in a French tertiary care university hospital from December 2008 through October 2013. We used multivariable logistic regression and propensity score methods to control for indication bias and compare outcomes associated with vacuum-assisted or forceps- or spatula-assisted delivery. Severe maternal and neonatal morbidity were composite primary endpoints. Symptoms of urinary incontinence (UI) and anal incontinence (AI) were assessed 6 months after delivery by validated self-administered questionnaires. Among 2,128 attempted operative vaginal deliveries, 30.7% (n=654) used vacuum and 69.3% (n=1,474) used forceps or spatulas. Severe maternal morbidity occurred in 5.4% (n=35; 95% CI 3.8-7.4) of vacuum attempts and 10.5% (n=154; 95% CI 8.3-12.1) of forceps or spatula attempts (P<.001); severe neonatal morbidity occurred in 8.4% (n=55; 95% CI 6.4-10.8) and 10.2% (n=155; 95% CI 8.7-11.8), respectively (P=.2). Although attempted operative vaginal deliveries with forceps or spatula were significantly associated with more frequent severe maternal morbidity (adjusted odds ratio [aOR] 1.99 95% CI 1.27-3.10) in the multivariable logistic regression analysis, this association was no longer significant after propensity score matching (aOR 1.46 95% CI 0.72-2.95). Attempted operative vaginal deliveries with forceps or spatula were not significantly associated with more frequent severe neonatal morbidity after multivariable logistic regression or propensity score matching. Among the 934 women (43.9%) who responded to questionnaires at 6 months, the prevalence of symptoms of UI and AI were 22.7% and 22.0%, respectively, with no significant differences between the groups. In singleton term pregnancies, neither severe short-term maternal or neonatal morbidity nor UI or AI were more frequent after attempted operative vaginal delivery by forceps or spatulas than by vacuum after controlling for indication bias with a propensity score analysis.

The effect of two midwives during the second stage of labour to reduce severe perineal trauma (Oneplus): a multicentre, randomised controlled trial in Sweden

Severe perineal trauma (SPT) affecting the anal sphincter muscle complex is a serious complication following childbirth, associated with short-term and long-term maternal morbidity. Effective preventive strategies are still scarce. The aim of the Oneplus trial was to test the hypothesis that the presence of a second midwife during the second stage of labour, with the purpose of preventing SPT, would result in fewer injuries affecting the anal sphincter than if attended by one midwife. In this multicentre, randomised, controlled parallel group, unmasked trial done at five obstetric units in Sweden, women were randomly assigned to be assisted by either one or two midwives in late second stage. Nulliparous women and women planning the first vaginal birth after caesarean section who were age 18-47 years were randomly assigned to an intervention when reaching the second stage of labour. Further inclusion criteria were gestational week 37+0, carrying a singleton live fetus in vertex presentation, and proficiency in either Swedish, English, Arabic, or Farsi. Exclusion criteria were a multiple pregnancy, intrauterine fetal demise, a planned caesarean section, or women who were less than 37 weeks pregnant. Randomisation to the intervention group of two midwives or standard care group of one midwife (1:1) was done using a computer-based program and treatment groups were allocated by use of sealed opaque envelopes. All women and midwives were aware of the group assignment, but the statistician from Clinical Studies Forum South, who did the analyses, was masked to group assignment. Midwives were instructed to implement existing prevention models and the second midwife was to assist on instruction of the primary midwife, when asked. Midwives were also instructed to complete case report forms detailing assistance techniques and perineal trauma prevention techniques. The primary outcome was the proportion of women who had SPT, for which odds ratios (ORs) and 95% CIs were calculated, and logistic regression was done to adjust for study site. All analyses were done according to intention to treat. The trial is registered with ClinicalTrials.gov, NCT0377096. Between Dec 10, 2018, and March 21, 2020, 8866 women were assessed for eligibility, and 4264 met the inclusion criteria and agreed to participate. 3776 (88·5%) of 4264 women were randomly assigned to an intervention after reaching the second stage of labour. 1892 women were assigned to collegial assistance (two midwives) during the second stage of labour and 1884 women were assigned to standard care (one midwife). 13 women in each group did not meet the inclusion criteria and were excluded. After further exclusions, 1546 women spontaneously gave birth in the intervention group and 1513 in the standard care group. 1546 women in the intervention group and 1513 in the standard care group were included in the intention-to-treat analysis of the primary outcome. There was a significant reduction in SPT in the intervention group (3·9% [61 of 1546] vs 5·7% [86 of 1513]; adjusted OR 0·69 (0·49-0·97). The presence of two midwives during the active second stage can reduce SPT in women giving birth for the first time. The Swedish Research Council for Health, Working Life and Welfare; Jan Hains Research Foundation; and Skane County Council's Research and Development Foundation.

Preterm Birth and Small-for-Gestational Age Neonates among Prepregnancy Underweight Women: A Case-Controlled Study.

The aim of our study was to investigate whether prepregnancy underweight body mass index (BMI) is associated with preterm birth (PTB) and small-for-gestational age (SGA). This retrospective case-control study included 814 women with live singleton fetuses in vertex presentation that gave birth between January 2016 and November 2016 in two tertiary care hospitals. The study group (n = 407) comprised all women whose prepregnancy BMI was underweight (<18.5 kg/m2) and who delivered during the study period. A control group (n = 407) was established with women whose prepregnancy BMI was normal (18.5–24.9 kg/m2) by matching age and parity. Univariate and multivariate analyses were performed to compare PTB and SGA associated with prepregnancy underweight BMI. Compared with the control group, the study group had higher rates of overall PTB (10.1% vs. 5.7%, p = 0.02), iatrogenic PTB (4.2% vs. 1.5%, p = 0.02), and SGA (22.1% vs. 11.1%, p < 0.001). In a multivariable analysis, prepregnancy underweight BMI was associated with PTB (aOR 2.32, 95% CI 1.12–4.81) and with SGA (aOR 2.38, 95% CI 1.58–3.58). In singleton pregnancies, women’s prepregnancy underweight compared with normal BMI was associated with an increase in PTB and in SGA neonates. Identifying this specific high-risk group is pragmatic and practical for all physicians, and they should be aware about perinatal outcome among underweight women.

Maternal and Neonatal Outcomes in Twin Deliveries with Prolonged Second-Stage Duration of the Presenting Twin: a Retrospective Cohort Study.

To assess the risk of adverse maternal and neonatal outcomes as a function of the presenting twin second-stage duration. A retrospective cohort study of deliveries taking place in an academic medical center between 2005 and 2019. The study group included women with twin pregnancies with the first fetus in vertex presentation, who attempted vaginal delivery with epidural analgesia and attained the second stage of labor. Prolonged second stage (PSS) was defined as when exceeding the 95th percentile of presenting twin second-stage duration recorded among all parturients who achieved spontaneous vaginal deliveries in our center during the study period, stratified by parity: 3 h in nulliparas and 1 h in multiparas. Women with and without PSS were compared. The primary outcome was a composite of adverse maternal outcomes. A univariate analysis was conducted and followed by multivariate analysis. During the study period, 1,337 parturients (36% of twin deliveries) met study criteria, of these 22% (298) were nulliparous and 78% (1,039) were multiparous. The second stage of labor of the presenting twin was prolonged in 41 (13.8%) of the nulliparas and 64 (6.2%) multiparas. Prolonged second stage was associated with episiotomy, chorioamnionitis, endometritis, and blood product transfusion, as well as vacuum deliveries of the first and second twin, second-stage cesarean, and a higher rate of composite adverse maternal outcome in nulliparous (41.5% vs. 20.2%, p<0.01) and with higher rates of episiotomy, postpartum hemorrhage, and vacuum deliveries of the first and second twin, but a similar rate of composite adverse maternal outcome in multiparous women (7.8% vs. 9.3%, p=0.68); moreover, the composite adverse neonatal outcome was not increased in nulliparous (36.6% vs. 38.5%, p=0.81) nor in multiparous women (21.9% vs. 23.6%, p=0.75). Prolonged second stage of labor of the presenting twin was associated with an adverse composite maternal outcome in nulliparous and with postpartum hemorrhage in multiparous. Further larger studies are warranted to reinforce our findings.

A new index for obstetrics safety and quality of care: integrating cesarean delivery rates with maternal and neonatal outcomes

Cesarean delivery rates have been used as obstetrical quality indicators. However, these approaches do not consider the accompanying maternal and neonatal morbidities. A challenge in the field of obstetrics has been to establish a valid outcomes quality measure that encompasses preexisting high-risk maternal factors and associated maternal and neonatal morbidities and is universally acceptable to all stakeholders, including patients, healthcare providers, payers, and governmental agencies. This study aimed to (1) establish a new single metric for obstetrical quality improvement among nulliparous patients with term singleton vertex-presenting fetus, integrating cesarean delivery rates adjusted for preexisting high-risk maternal factors with associated maternal and neonatal morbidities, and (2) determine whether obstetrician quality ranking by this new metric is different compared with the rating based on individual crude and/or risk-adjusted cesarean delivery rates. The single metric has been termed obstetrical safety and quality index. This was a cross-sectional study of all nulliparous patients with term singleton vertex-presenting fetuses delivered by 12 randomly chosen obstetricians in a single institution. A review of all records was performed, including a review of maternal high-risk factors and maternal and neonatal outcomes. Maternal and neonatal medical records were reviewed to determine crude and adjusted cesarean delivery rates by obstetricians and quantify maternal and neonatal complications. We estimated the obstetrician-specific crude cesarean delivery rates and rates adjusted for obstetrician-specific maternal and neonatal complications from logistic regression models. From this model, we derived the obstetrical safety and quality index for each obstetrician. The final ranking based on the obstetrical safety and quality index was compared with the initial ranking by crude cesarean delivery rates. Maternal and neonatal morbidities were analyzed as ≥1 and ≥2 maternal and/or neonatal complications. These 12 obstetricians delivered a total of 535 women; thus, 1070 (535 maternal and 535 neonatal) medical records were reviewed to determine crude and adjusted cesarean delivery rates by obstetricians and quantify maternal and neonatal complications. The ranking of crude cesarean delivery rates was not correlated (rho=0.05; 95% confidence interval,-0.54 to 0.60) to the final ranking based on the obstetrical safety and quality index. Of note, 8 of 12 obstetricians shifted their rank quartiles after adjustments for high-risk maternal conditions and maternal and neonatal outcomes. There was a strong correlation between the ranking based on ≥1 maternal and/or neonatal complication and ranking based on ≥2 maternal and/or neonatal complications (rho=0.63; 95% confidence interval, 0.08-0.88). Ranking based on crude cesarean delivery rates varied significantly after considering high-risk maternal conditions and associated maternal and neonatal outcomes. Therefore, the obstetrical safety and quality index, a single metric, was developed to identify ways to improve clinician practice standards within an institution. Use of this novel quality measure may help to change initiatives geared toward patient safety, balancing cesarean delivery rates with optimal maternal and neonatal outcomes. This metric could be used to compare obstetrical quality not only among individual obstetricians but also among hospitals that practice obstetrics.

Outcomes of Expectant Management of Term Prelabor Rupture of Membranes

ObjectiveTo assess rates of induction/augmentation of labor, maternal infection, neonatal outcomes, and time to birth when women were expectantly managed after term prelabor rupture of membranes (PROM) at home or in the hospital. DesignRetrospective, descriptive study based on a review of data from a hospital midwifery service database and chart review. SettingA large Midwest hospital with 4,700 births annually. ParticipantsWe used the cases of women who received midwifery care, experienced term PROM, and had singleton fetuses in the vertex position. MethodsWe conducted an analysis of maternal and neonatal outcomes with term PROM using data from a midwifery service quality improvement database. We compared characteristics and outcomes between management plans (immediate induction, expectant hospital, and expectant home) using chi-square, analysis of variance, and independent t-tests. ResultsPROM occurred in 281 (12%) of the 2,357 women cared for by the midwifery service between January 2016 and December 2018. One hundred fifty women (53.3%) opted to wait for labor onset at home, 102 (36.3%) were expectantly managed in the hospital, 21 (7.5%) were admitted for immediate induction of labor, and 8 (2.8%) were admitted for immediate cesarean birth. The rate of spontaneous labor onset was not significantly different between the two expectant management groups or between nulliparous and multiparous women. A total of 88 (34.9%) women who were expectantly managed ultimately had their labors induced. Rates of chorioamnionitis and endometritis were not significantly different between the expectant management groups in this study or compared with national averages. There was no difference in NICU admissions or Apgar scores below 7. The mean time from PROM to birth was significantly shorter in the expectant management in hospital group (27.3 hours) than in the expectant management at home group (33.5 hours). ConclusionExpectant management at home or in the hospital is appropriate for low-risk pregnant women with term PROM. Women for whom this option is appropriate include those with term singleton fetuses in vertex presentation with reassuring fetal heart rates and confirmed clear amniotic fluid. Acceptable time frames for home management include up to 24 hours for women with negative group B streptococcus cultures and up to 12 hours for those with positive cultures.

Association between Antenatal Vulvovaginitis and Birth-Related Perineal Trauma

Statement of the Problem Birth-related perineal trauma commonly affects women who give birth vaginally and adversely affects postpartum recovery. In general, women who had diagnostic of antenatal vulvovaginitis are more likely to have these injuries; however there is no robust evidence that support such association. Objective: To identify whether antenatal vulvovaginitis is associated with perineal trauma in normal birth. Method: A cross-sectional study with 100 primiparous women, at least 18 years of age, who gave birth to a single, live, full-term fetus in vertex presentation at a midwife-led birth center. Data were collected from the antenatal and birth record and by structured interview of the participants. Results: mean of participants’ age 23.1 years (SD: 4.8), 16% of labor induced with misoprostol, 54% of synthetic oxytocin infusion in labor, 83% of lithotomy birth position, 98% of “hands on” maneuver, 75% of perineal trauma (70.7% first degree and 29.3% second degree laceration), 54% of antenatal vulvovaginitis (42% treated in the antenatal period), mean of newborn birth weight, head and thoracic circumference: 3.102g (SD: 385), 33.3 cm (SD: 1.2) and 32.2 cm (SD: 1.7), respectively. Only the variables antenatal vulvovaginites and newborn birth weight and head circumference were associated with perineal trauma. Women who had antenatal vulvovaginitis were 4.7 more likely to have perineal trauma compared to those without vulvovaginitis, regardless of the newborn birth weight and head circumference. Each increase of 100g in the newborn’s birth weight and 1cm in the head circumference increased by 21% and 51% the chance of maternal perineal trauma in childbirth, respectively. There was no association between treating antenatal vulvovaginitis and perineal trauma or antenatal vulvovaginitis and perineal trauma severity. Conclusion: It is necessary to prevent antenatal vulvovaginites, as well as to offer special perineal care to women who had antenatal vulvovaginitis and to those who have had or is pregnant with a large baby.

Observational Descriptive Study of Clinical Outcomes on Extremely Obese Pregnant, Nulliparous Women Carrying a Single Term Fetus in Vertex Presentation (NTSV)

Observational Descriptive Study of Clinical Outcomes on Extremely Obese Pregnant, Nulliparous Women Carrying a Single Term Fetus in Vertex Presentation (NTSV)

Postpartum Hemorrhage and Very Advanced Maternal Age [28M

INTRODUCTION: Postpartum hemorrhage (PPH) is an important cause of maternal morbidity. Identifying women at increased risk for PPH can help reduce morbidity. The aim of this study was to determine if women over 45 years (very advanced maternal age, VAMA) are at increased risk for PPH. METHODS: Retrospective study of term, nulliparous women with singleton fetuses in vertex presentation who delivered at Kaiser Permanente Northern California Hospitals from 2010-2017 with complete data recorded. Incidence of PPH (estimated blood loss &gt;500 cc for vaginal delivery, &gt;1,000 cc for cesarean delivery, or other definitive chart evidence) among women over 45 years was compared to incidence of PPH among younger women. Logistic regression was used to adjust for confounders. RESULTS: There were 98,922 women included, including 177 women over 45 years. PPH occurred in 33.3% of women &gt;45 years as compared to 15.6% of women 45 years had significantly increased odds of PPH as compared to women &lt;35 years (OR 1.88, 95% CI 1.35–2.61). CONCLUSION: These data demonstrate that VAMA is an independent risk factor for PPH. This knowledge provides physicians with an opportunity to counsel patients over 45 years regarding the risk for PPH and to prepare for delivery with strategies including optimization of blood count, planning for delivery location and procurement of appropriate blood products before delivery.

New Delivery Chair for Vaginal Delivery

Objectives: Compared to different upright positions, delivery in recumbent position in bed may increase the likelihood of operative delivery and other delivery complications, and also decrease levels of maternal self-control. A new delivery chair has been developed to facilitate a variety of upright positions during labour. A randomized controlled trial was conducted to evaluate the impact of the delivery chair use on selected obstetrical and neonatal outcomes, compared to traditional recumbent position. Methods: A total of 1477 women with uncomplicated singleton pregnancy ≥ 34 gestational weeks with fetus in vertex presentation were enrolled in the study: 776 in the delivery chair group, and 701 in the control group. Results: An intention-to-treat analysis showed no differences between the groups in any of the outcomes used. Of the women in the delivery chair group, 251 used the chair throughout the second stage. An as-treated analysis was performed between these 251 women and their counterparts in the control group. Women using the delivery chair had a shorter second stage of delivery, fewer episiotomies, and less need for vacuum extraction, with no difference in blood loss or neonatal outcome. However, women using the delivery chair had more third-degree tears (11 cases, or 4.4%, vs. 9 cases, or 1.8%). Conclusion: The novel delivery chair can be safely used for vaginal delivery. More attention should be given to perineal support to prevent perineal tears. There is a need for multicentre trials of the delivery chair using standardized measurements of outcomes, including maternal pain, maternal self-control, and overall satisfaction.

Term spontaneous trial of labor in nulliparous women of short stature: A hospitals-based cohort study

ObjectivesTo study the mode of delivery in a well selected cohort of short nulliparous women. Study designHospitals-based cohort study between 2010-2018. The threshold (150 cm, i.e 2,3°p), for the short stature was chosen before the analysis by corresponding to – 2SD of the average population size distribution of all women who delivered over the same period: 2010–2018.Were included nulliparous women with a heigh ≤ 150 cm in term spontaneous labor with a single livung fetus in vertex presentation without malformation.Exclusion criteria were: multiparous, scarred uterus, twin pregnancy, induced labor, preterm delivery (< 37 W P), non-vertex pregnancy, medical termination of pregnancy, stillbirth, severe fetal malformations, pre-labor cesarean, and late dating ultrasound.The main outcome was the mode of delivery. Univariate and multivariate analysis adjusted on potential confounding variable were performed to investigate the risk of intrapartum CS. Results178 nulliparous women were included. The mean height was 148 cm. The rate of spontaneous vaginal delivery, operative vaginal delivery a nd intrapartum CS were :35,4 %, 35,4 % and 29,2 % respectively.Intrapartum CS was performed during the first stage labor in 15 (28, 8 %) women and during the second stage in 37 (71, 2 %) women. An arrest of labor was significantly more frequent in the active labor than the early labor stage: 62,1 % vs. 33.3 % (p = 0, 02).In univarate analysis were associated with intrapartum CS : Gestational diabetes, birthweight> 3,5 kg, individual adjusted birthweight >90°p, occiput posterior, oxytocin use, cephalic circumference.After adjustment on birthplace and overweight (BMI over 25), only a birthweight > 3,5 kg remains associated with the risk of intrapartum CS (aOR4.3 ;95 %CI 1.96–10.2). ConclusionAn attempt of vaginal birth is a reasonable option for short stature women. Maternal height could be included in the selection criteria for planned birth center or home birth.The customized gestational-related optimal weigh could be useful to identify large of gestational age fetus.

Outpatient Expectant Management of Term Prelabor Rupture of Membranes: A Retrospective Cohort Study.

To examine outcomes among women with prelabor rupture of membranes (PROM) who declined induction and chose outpatient expectant management compared with those admitted for induction. This is a retrospective cohort study of term women with singleton, vertex-presenting fetuses who presented with PROM between July 2016 and June 2017 and were eligible for outpatient expectant management (n = 166). The primary outcomes were time from PROM to delivery and time from admission to delivery. Maternal and neonatal outcomes were also compared between groups. Multivariable linear regressions were used to assess time differences between groups, adjusting for known maternal and pregnancy characteristics. Compared with admitted patients, women managed expectantly at home had significantly longer PROM to delivery intervals (median 29.2 vs. 17 hours, p < 0.001), but were more likely to deliver within 24 hours of admission (95.1 vs. 82.9%, p = 0.004). In the adjusted analysis, PROM to delivery was 7 hours longer (95% confidence interval [CI]: 3.9-10.0) and admission to delivery was 5.3 hours shorter (95% CI: 2.8-7.7) in the outpatient expectant management cohort. There were no differences in secondary outcomes. Outpatient management of term PROM is associated with longer PROM to delivery intervals, but shorter admission to delivery intervals.