Fourth-degree Perineal Lacerations Research Articles

Influence of the second stage of labor on maternal and neonatal outcomes in vaginal births after caesarean section: a multicenter study in Germany

BackgroundThe American College of Obstetricians and Gynecologists (ACOG) introduced a new standard of care in 2014, extending the duration of the second stage of labor in order to reduce caesarean delivery (CD) rates and its severe complications. The aim of the present study is to evaluate success rates of trial of labor after caesarean section (TOLAC), as well as maternal and neonatal outcomes after the establishment of the recent guidelines.MethodsA retrospective study was performed at two large departments in Germany from January 2008 to January 2018. Patients undergoing TOLAC were divided into two groups. Group I (958 patients) was constituted before the establishment of the current guidelines, and Group II (588 patients) after the establishment of the guidelines. A subgroup analysis was performed to compare neonatal outcomes after successful TOLAC and operative vaginal delivery with those after failed TOLAC and secondary CD.ResultsThe success rate of vaginal births after cesarean section (VBAC) fell from 66.4% in Group I to 55.8% in Group II (p < 0.001). The median duration of the second stage of labor was statistically significantly longer in Group II than in Group I (79.3 ± 61.9 vs. 69.3 ± 58.2 min) for patients without previous vaginal birth. The incidence of operative vaginal delivery decreased from Group I to Group II (9.6% vs. 6.8%). The incidence of third- and fourth-degree perineal lacerations, blood loss and emergency CD were similar in the two groups. Concerning the neonatal outcome, our groups did not differ significantly in regard of rates of umbilical artery cord pH < 7.1 (p = 0.108), the 5-min Apgar scores below 7 (p = 0.224) and intubation (p = 0.547). However, the transfer rates to the neonatal care unit were significantly higher in Group II than in Group I (p < 0.001). Neonatal outcomes did not differ significantly in the subgroup analysis.ConclusionExtending the second stage of labor does not necessarily result in more vaginal births after TOLAC. Maternal and neonatal outcomes were similar in both groups. Further studies will be needed to evaluate the role of operative vaginal delivery and the duration of the second stage of labor in TOLAC.

Differences in obstetrical care and outcomes associated with the proportion of the obstetrician’s shift completed

Understanding and improving obstetrical quality and safety is an important goal of professional societies, and many interventions such as checklists, safety bundles, educational interventions, or other culture changes have been implemented to improve the quality of care provided to obstetrical patients. Although many factors contribute to delivery decisions, a reduced workload has addressed how provider issues such as fatigue or behaviors surrounding impending shift changes may influence the delivery mode and outcomes. The objective was to assess whether intrapartum obstetrical interventions and adverse outcomes differ based on the temporal proximity of the delivery to the attending's shift change. This was a secondary analysis from a multicenter obstetrical cohort in which all patients with cephalic, singleton gestations who attempted vaginal birth were eligible for inclusion. The primary exposure used to quantify the relationship between the proximity of the provider to their shift change and a delivery intervention was the ratio of time from the most recent attending shift change to vaginal delivery or decision for cesarean delivery to the total length of the shift. Ratios were used to represent the proportion of time completed in the shift by normalizing for varying shift lengths. A sensitivity analysis restricted to patients who were delivered by physicians working 12-hour shifts was performed. Outcomes chosen included cesarean delivery, episiotomy, third- or fourth-degree perineal laceration, 5-minute Apgar score of <4, and neonatal intensive care unit admission. Chi-squared tests were used to evaluate outcomes based on the proportion of the attending's shift completed. Adjusted and unadjusted logistic models fitting a cubic spline (when indicated) were used to determine whether the frequency of outcomes throughout the shift occurred in a statistically significant, nonlinear pattern RESULTS: Of the 82,851 patients eligible for inclusion, 47,262 (57%) had ratio data available and constituted the analyzable sample. Deliveries were evenly distributed throughout shifts, with 50.6% taking place in the first half of shifts. There were no statistically significant differences in the frequency of cesarean delivery, episiotomy, third- or fourth-degree perineal lacerations, or 5-minute Apgar scores of <4 based on the proportion of the shift completed. The findings were unchanged when evaluated with a cubic spline in unadjusted and adjusted logistic models. Sensitivity analyses performed on the 22.2% of patients who were delivered by a physician completing a 12-hour shift showed similar findings. There was a small increase in the frequency of neonatal intensive care unit admissions with a greater proportion of the shift completed (adjusted P=.009), but the findings did not persist in the sensitivity analysis. Clinically significant differences in obstetrical interventions and outcomes do not seem to exist based on the temporal proximity to the attending physician's shift change. Future work should attempt to directly study unit culture and provider fatigue to further investigate opportunities to improve obstetrical quality of care, and additional studies are needed to corroborate these findings in community settings.

Knowledge, attitude and experience of episiotomy practice among obstetricians and midwives: a cross-sectional study from China

ObjectiveEpisiotomy is still performed widely by obstetricians and midwives in some Chinese maternity units, but the reasons are unknown. This study aims to determine the knowledge, attitude and experience towards...

Shoulder dystocia and composite adverse outcomes for the maternal-neonatal dyad

Although the neonatal morbidity associated with shoulder dystocia are well known, the maternal morbidity caused by this obstetrical emergency is infrequently reported. This study aimed to assess the composite adverse maternal and neonatal outcomes among vaginal deliveries (at 34 weeks or later) with and without shoulder dystocia. This is a secondary analysis of the Consortium of Safe Labor, an observational obstetrical cohort of all vaginal deliveries occurring at 19 hospitals (from 2002-2008) and for which data on the occurrence of shoulder dystocia were available. The composite adverse maternal outcome included third- or fourth-degree perineal laceration, postpartum hemorrhage (>500 cc blood loss for a vaginal delivery and >1000 cc blood loss for cesarean delivery), blood transfusion, chorioamnionitis, endometritis, thromboembolism, admission to intensive care unit, or maternal death. The composite adverse neonatal outcome included an Apgar score of <7 at 5 minutes, a birth injury, neonatal seizure, hypoxic ischemic encephalopathy, or neonatal death. A multivariable Poisson regression was used to estimate the adjusted relative risks with 95% confidence intervals. The area under the receiver operating characteristic curve was constructed to determine if clinical factors would identify shoulder dystocia. Of the 228,438 women in the overall cohort, 130,008 (59.6%) met the inclusion criteria, and among them, shoulder dystocia was documented in 2159 (1.7%) cases. The rate of composite maternal morbidity was significantly higher among deliveries with shoulder dystocia (14.7%) than without (8.6%; adjusted relative risk, 1.71; 95% confidence interval, 1.64-2.01). The most common maternal morbidity with shoulder dystocia was a third- or fourth-degree laceration (adjusted relative risk, 2.82; 95% confidence interval, 2.39-3.31). The risk of composite neonatal morbidity with shoulder dystocia (12.2%) was also significantly higher than without shoulder dystocia (2.4%) (adjusted relative risk, 5.18; 95% confidence interval, 4.60-5.84). The most common neonatal morbidity was birth injury (adjusted relative risk, 5.39; 95% confidence interval, 4.71-6.17). The area under the curve for maternal characteristics to identify shoulder dystocia was 0.66 and it was 0.67 for intrapartum factors. Although shoulder dystocia is unpredictable, the associated morbidity affects both mothers and newborns. The focus should be on concurrently averting the composite morbidity for the maternal-neonatal dyad with shoulder dystocia.

Effects of Fourth-Degree Perineal Lacerations on Women’s Physical and Mental Health

ObjectiveTo describe the physical and emotional effects of fourth-degree perineal lacerations that occur during childbirth. DesignDescriptive phenomenology. SettingInternet survey. ParticipantsEighteen women from the United States, the United Kingdom, Australia, and Canada who sustained fourth-degree perineal lacerations during childbirth. MethodsWomen were recruited from the Facebook support group Mothers With 4th Degree Tears. Participants were asked to describe the physical and emotional effects of these severe birth injuries on their daily lives. I analyzed these data using Colaizzi’s method for phenomenological analysis. ResultsThe devastating effects of these birth-related injuries permeated all aspects of the lives of participants. Participants did not receive adequate information about their perineal lacerations, and clinicians often dismissed their concerns. Some participants struggled with postpartum depression and posttraumatic stress disorder. I identified seven themes that described the effects of fourth-degree perineal lacerations: Why Wasn’t I Informed I Had This Injury?; The Unthinkable: Fecal Incontinence and So Much More; It Has Cost Me So Much; Seeking Relief: Enduring Surgery After Surgery; Why Didn’t Anyone Ask Me About My Mental Health?; To Have More Children, That Is The Question; And Are there Any Positives In All Of This? ConclusionWomen need information to prepare for recovery from their severe perineal injuries related to what to expect, how to care for themselves, and what resources are available. Clinicians have a responsibility to provide a caring environment in which women feel safe to disclose any problems they are experiencing as a result of their perineal injuries. Little, if any, attention is focused on women’s mental health by clinicians or researchers as women struggle with the aftermath of fourth-degree perineal lacerations.

Do mediolateral episiotomies reduce incidence of third-/fourth-degree perineal lacerations when compared with standard midline episiotomy?

Do mediolateral episiotomies reduce incidence of third-/fourth-degree perineal lacerations when compared with standard midline episiotomy?

Elective Labor Induction at 39 Weeks of Gestation Compared With Expectant Management: Factors Associated With Adverse Outcomes in Low-Risk Nulliparous Women.

To evaluate characteristics associated with adverse outcomes in low-risk nulliparous women randomized to elective labor induction at 39 weeks of gestation or expectant management. We conducted a secondary analysis of women randomized during the 38th week to induction at 39 weeks of gestation or expectant management. Deliveries before 39 weeks of gestation and those not adherent to study protocol or with fetal anomalies were excluded. A composite of adverse outcomes (perinatal death or severe neonatal complications), third- or fourth-degree lacerations, and postpartum hemorrhage were evaluated. Log binomial regression models estimated relative risks and 95% CIs for associations of outcomes with patient characteristics including randomly assigned treatment group. Interactions between patient characteristics and treatment group were tested. Of 6,096 women with outcome data, 5,007 (82.1%) met criteria for inclusion in this analysis. Frequency of the perinatal composite was 252 (5.0%), 166 (3.3%) for third- or fourth-degree perineal laceration, and 237 (4.7%) for postpartum hemorrhage. In multivariable analysis, intended labor induction at 39 weeks of gestation was associated with a reduced perinatal composite outcome (4.1% vs 6.0%; adjusted relative risk [aRR] 0.71; 95% CI 0.55-0.90), whereas increasing body mass index (BMI) was associated with an increased perinatal composite outcome (aRR 1.04/unit increase; 95% CI 1.02-1.05). Decreased risk of third- or fourth-degree perineal laceration was observed with increasing BMI (aRR 0.96/unit increase; 95% CI 0.93-0.98) and in Black women compared with White women (1.2% vs 3.9%; aRR 0.34; 95% CI 0.19-0.60). Increased risk of postpartum hemorrhage was observed in Hispanic women compared with White women (6.3% vs 4.0%; aRR 1.64; 95% CI 1.18-2.29). Patient characteristics associated with adverse outcomes were similar between treatment groups (P for interaction >.05). Compared with expectant management, intended induction at 39 weeks of gestation was associated with reduced risk of adverse perinatal outcome. Patient characteristics associated with adverse outcomes were few and similar between groups. ClinicalTrials.gov, NCT01990612.

Association of abnormal first stage of labor duration and maternal and neonatal morbidity

Contemporary guidelines for labor management do not characterize abnormal labor on the basis of maternal and/or neonatal morbidity. In this study, we aimed to evaluate the association of abnormal duration of the first stage of term labor and the risk of maternal and neonatal morbidity. We conducted a retrospective analysis of prospectively collected data of all consecutive women admitted for delivery at a single center at ≥37 weeks and 0 to 7 days of gestation with singleton, nonanomalous, vertex infants from 2010 to 2015, who reached 10 cm cervical dilation. Multivariable logistic regression compared odds ratios for maternal and neonatal outcomes among women above and below the 90th, 95th, and 97th percentiles for first stage of labor duration. Receiver operating characteristic curves estimated the association between first stage of labor duration and maternal morbidity. Maternal morbidity was a composite of maternal fever, hemorrhage, transfusion, or endomyometritis; prolonged second stage of labor duration; and third- or fourth-degree perineal laceration. Neonatal morbidity was a composite of hypothermic therapy, need for mechanical ventilation, respiratory distress syndrome, meconium aspiration syndrome, birth injury or trauma, and neonatal seizure or sepsis. Of 6823 women included in this study, 682 were anticipated to have first stage of labor duration above the 90th percentile cutoff point, which was associated with an increased risk of composite maternal morbidity, maternal fever, postpartum transfusion, prolonged second stage of labor duration, third- or fourth-degree perineal laceration, and cesarean or operative vaginal delivery (P≤.02) and an increased risk of composite neonatal morbidity, respiratory distress syndrome, need for mechanical ventilation, and neonatal sepsis (P≤.03). Composite maternal morbidity was 2.2 (95% confidence interval, 1.8-2.7), 1.9 (95% confidence interval, 1.4-2.4), and 1.8 (95% confidence interval, 1.3-2.5) times more likely to occur among women above the 90th, 95th, and 97th percentile, respectively, for first stage of labor duration from 4 to 10 cm. Composite neonatal morbidity was 2.6 (95% confidence interval, 2.1-3.2), 2.2 (95% confidence interval, 1.7-2.9), and 1.9 (95% confidence interval, 1.3-2.8) times more likely to occur among infants delivered by women above the 90th, 95th, and 97th percentiles for first stage of labor duration from 4 to 10 cm. Receiver operating characteristic curves among all women from 4 to 10 cm and 6 to 10 cm, including when stratified by parity and type of labor onset, had an area under the curve of 0.51 to 0.62 and 0.53 to 0.71 for maternal and neonatal morbidity, respectively. Thus, duration of labor has moderate predictive ability, at best, for composite maternal or neonatal morbidity. No curve demonstrated a clear point at which adverse maternal or neonatal outcomes increased that could be used to define abnormal labor. The benefit of expectantly managing a prolonged first stage of labor with duration above the 90th percentile in anticipation of vaginal delivery must be weighed against the increased risk of composite maternal and neonatal morbidity. Risks associated with performing cesarean delivery as an alternative management for women with prolonged first stage of labor duration must also be considered.

Analgesic use after vaginal delivery in women with perineal lacerations: a retrospective cohort study

Objective: To evaluate opioid consumption among parturients with varying degrees of perineal lacerations.Methods: This was a retrospective analysis of women who delivered vaginally at our institution from 1 January 2014 to 12 April 2015. We collected information regarding the degree of perineal lacerations (no lacerations, first-/second-degree, third-/fourth-degree), analgesic consumption, and postpartum pain scores. The primary outcome was opioid use from 0–48 h postpartum. Univariate and multivariable regression analyses were performed to test for the association of laceration severity with opioid use.Results: We included 5598 women in the analysis; 1948 had no lacerations, 3434 had first-/second-degree lacerations, and 216 had third-/fourth-degree lacerations. In univariate analysis, parturients with third-/fourth-degree lacerations had significantly higher use of opioids within 48 h postpartum (53.2%) compared to women with no lacerations (30.03%) or first-/second-degree lacerations (28.6%) (p < .001). In the multivariable analysis, women with third-/fourth-degree lacerations had higher odds of opioid use than those without laceration [OR (95% CI) = 2.61 (1.75–3.85), p < .001]. In pairwise comparisons, those with third-/fourth-degree lacerations had higher odds of opioid use than those without lacerations [OR (95% CI) = 3.55 (2.20–5.74)], and those with first-/second-degree lacerations [OR (95% CI) = 2.15 (1.49–3.10)] (p < .001). Oxycodone equivalent consumption was significantly different among groups with a median (IQR) of 5.00 mg (0.00–27.50), 0.00 mg (0.00–5.00) and 0.00 mg (0.00–5.00) in women with third-/fourth-degree, first-/second-degree, and no lacerations, respectively, during the 0–48 h postpartum (p < .001).Conclusion: The use of opioids and opioid doses are higher in women with third-/fourth-degree perineal lacerations compared to those with first-/second-degree or no lacerations.

Adverse outcomes of childbirth in high-risk maternity hospitals

Abstract Objectives: to analyze adverse outcomes in teaching maternity hospitals in Maceió, Alagoas, Brazil. Methods: a cross-sectional, retrospective and analytical study was carried out with a random sample of 480 medical records of postpartum women in 2016 using the Adverse Outcome Index: in-hospital maternal death, neonatal in-hospital death&gt; 2500g and&gt; 37 weeks, uterine rupture, unplanned maternal admission to intensive care unit, delivery trauma to the newborn, return to the operating room, admission to an intensive neonatal unit with &gt;2500g and &gt; 37 weeks for more than one day, Apgar &lt;7 at the fifth minute, maternal hemotransfusion and fourth-degree perineal laceration. The data were analyzed using the Statistical Package for Social Sciences software version 22.0. Results: the results showed a 21% rate of adverse outcomes, at a rate of 26.4 for every 1,000 births, with a greater occurrence of neonatal intensive care admission with&gt;2500g and&gt;37 weeks for more than one day (52. 5%), maternal blood transfusion (20.8%) and unplanned maternal admission in intensive care (17.8%). Conclusions: the evaluation of adverse outcomes evidenced a high proportion of births with undesirable results, which allowed the analysis of the outlook of unfavorable outcomes related to safety in maternity wards through the use of indicators.

914: Second stage of labor: Maternal and perinatal outcomes of cesarean versus attempted operative vaginal delivery

Among women who reach the second stage of labor and require operative delivery, little data exists on the maternal and perinatal outcomes based on attempted operative vaginal delivery (OVD) vs cesarean delivery (CD) without attempted OVD. The objective of this study was to compare the maternal and perinatal outcomes among these two groups. This is a secondary analysis of data from a multicenter prospective study for women enrolled in the Cesarean Registry. We compared the maternal and perinatal outcomes based on whether OVD was attempted or CD was performed without attempt. This study includes singleton, at > 37 weeks, pregnancies that were eligible for OVD (10cm dilated and +2 station). Exclusion criteria included those who underwent CD in second stage with primary indication of non-reassuring fetal heart rate tracing and those with anomalous fetuses. Primary outcome was composite maternal morbidity and secondary outcome was composite neonatal morbidity. A multivariable Poisson regression analysis was used to examine the association between attempt of OVD and outcomes, while adjusting for potential confounding factors that were different between groups at a p value of < 0.1 in univariate analysis. A total of 1,432 women met the inclusion criteria: 1,025 (71%) had an attempted OVD and 407 underwent CD without attempt (39%). Women who attempted OVD were more likely to have composite maternal morbidity (aRR 2.93, 95% CI 1.92-4.49), mostly from third and fourth degree perineal lacerations (Table 1). There was no significant difference in rates of composite neonatal morbidity between groups; however, neonatal birth injury was significantly more frequent in the group who had an attempted OVD (aRR 4.79, 95% CI 1.85-12.42)(Table 2). In women reaching the second stage, CD without attempt was associated with lower maternal morbidity and less neonatal birth injury. Given that OVD training is declining in residency programs, these data may have clinical implications regarding counseling of patients eligible for OVD.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

515: Racial disparities in postpartum opioid prescribing for women undergoing cesarean section

To determine the association between inpatient postpartum opioid use, amount of opioids prescribed at discharge, and racial demographics. This retrospective cohort study identified women undergoing cesarean delivery at a single tertiary academic institution between July 2018 and October 2018 with any inpatient opioid order within the electronic medical record. Women with postoperative wound complications, third and fourth degree perineal lacerations, cesarean hysterectomy, or a known history of opioid abuse were excluded. The primary outcome was the number of oxycodone 5 mg tablets prescribed at discharge, stratified by race. Race was categorized as “Black” and “White,” with other identities excluded due to low absolute numbers of each. Women in the highest and lowest quartiles of inpatient opioid tablet use were compared using multivariable logistic regression. A sensitivity analysis was performed for women who received zero postoperative oxycodone tablets. A total of 268 women were included. The median number of oxycodone tablets consumed following delivery was seven (IQR: 2.5–12 tablets). White women were more likely to deliver at higher maternal age (median 32 vs. 30; p< 0.01) and lower maternal BMI (31.6 vs. 34.5; p=0.02). White women were also significantly more likely to have private insurance (p < 0.01). No significant difference between black and white women was noted in the total number of inpatient opioid tablets consumed (0, 1-6, 7-12, or >13) nor in number of opioid tablets prescribed at discharge. Women who consumed zero tablets inpatient (n=38) received a range of 0-30 tablets at discharge, with no difference between the two groups. At our large, academic hospital, patient race does not impact inpatient opioid use or opioid prescribing practices.

1173: Inpatient opioid use and prescribing practices after cesarean delivery

To quantify the association between inpatient use of opioids and amount prescribed at discharge following cesarean delivery. This retrospective cohort study identified women undergoing cesarean delivery at a single tertiary academic institution between July 2018 and October 2018 with any inpatient opioid order in the electronic medical record. Women with postoperative wound complications, third and fourth degree perineal lacerations, cesarean hysterectomy, or a known history of opioid abuse were excluded. The electronic medical record was reviewed to determine the number of postoperative oxycodone 5 mg tablets taken as an inpatient and dispensed at hospital discharge. The primary outcome was the number of oxycodone 5 mg tablets prescribed at discharge. Women in the highest and lowest quartiles of inpatient opioid tablet use were compared using multivariable logistic regression. A sensitivity analysis was performed for length of stay. A total of 268 women were included; the median number of oxycodone tablets consumed following delivery was seven (IQR: 2.5–12 tablets). No difference was found in inpatient opioid usage between race, maternal age, payor type, maternal BMI, or discharge provider type (intern, resident, or attending). All patients in the highest quartile of use (>12 tablets consumed; n=74) and 85% of those in the lowest quartile of use (< 2.5 tablets consumed; n=67) received at least 10 tablets on discharge. This difference was not statistically significant. The difference remained non-significant when a cutoff of 20 tablets was used. Excluding women discharged after post-operative day five did not change our findings. At our large, academic hospital, providers prescribe a consistent number of oxycodone tablets at discharge, regardless of inpatient usage. We suggest that providers more closely review inpatient usage and prescribe a scalar quantity at discharge.

787: The effect of neuraxial morphine (Duramorph) on postpartum pain after a severe perineal laceration

Postpartum pain has negative consequences on maternal-infant bonding, future narcotic abuse, and development of chronic pain. With the rise of the opioid epidemic, it is important to find novel approaches in managing this pain. This pilot study investigates the use of neuraxial morphine (Duramorph) in postpartum pain control after a severe perineal laceration. A single-blind randomized controlled trial (NCT03926559) was conducted on parturients admitted to the obstetric service at Augusta University Medical Center. Patients were enrolled if they had an epidural and if they had a second, third, or fourth degree perineal laceration that was identified immediately postpartum. Participants were randomized to receive either 2mg of Duramorph or sham injection of no drug within 30 minutes after their perineal laceration repair, prior to the removal of their epidural. Primary outcomes were perineal pain at 24 and 48 hours postpartum as measured on a 11-point Numerical Rating Scale (NRS-11). Secondary outcomes were amount of additional oral narcotics used in morphine milliequivalents (MME) over 24 and 48 hours postpartum, and maternal satisfaction as measured on a Likert (1-10) scale. Between 04/2019 to 08/2019, 154 patients were consented, of which 78 patients had a severe perineal tear and were eligible for the study. 58, 13, and 7 patients had second, third, and fourth degree perineal tears respectively. Baseline demographic characteristics between the groups were comparable. As seen in Table 1, there was a statistically significant reduction in pain scores at 24 hours in women who received Duramorph compared to sham for all perineal tears. There was also a statistically significant decrease in narcotic use at 24 hours, as well as an increase in maternal satisfaction for all perineal tear groups in the Duramorph group compared to sham (Table 2). The use of Duramorph in the immediate postpartum setting may alleviate pain in the first 24 hours and may also decrease the number of oral narcotics consumed during the early postpartum period.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

968: Extending the second stage of labor in nulliparous women with epidural analgesia: a cost-effectiveness analysis

In an effort to prevent primary cesarean deliveries, ACOG has recommended an increase of one hour in the time spent in the second stage before diagnosing a prolonged second stage of labor. In nulliparous women with epidural analgesia, this translates to an increase from 3 to 4 hours. A subsequent small randomized trial of nulliparous and multiparous women showed an increased rate of spontaneous vaginal delivery by extending the second stage by one hour. The purpose of this study is to examine the differences in outcomes with an extended second stage and determine if this new recommendation is cost effective. A cost-effectiveness analysis model was built using TreeAge Pro 2019 software with model inputs derived from the literature. We used a theoretical cohort of 152,000 women, approximately the number of nulliparous U.S. women reaching 3 hours of second stage with an epidural. We compared maternal outcomes and costs associated with expectant management of the second stage until 4 hours versus delivery at 3 hours. Perinatal outcomes included mode of delivery, chorioamnionitis, postpartum hemorrhage, third- and fourth-degree perineal lacerations and maternal deaths. Secondary outcomes included cost per quality-adjusted life years (QALY; willingness-to-pay threshold set to $100,000/QALY). Sensitivity analyses were performed to determine the robustness of baseline assumptions. In a cohort of 152,000 women, expectant management to 4 hours was the dominant strategy as it was cost saving and resulted in more overall QALYs (Table 1). Sensitivity analysis indicated that expectant management until 4 hours was cost-effective as long as the probability of cesarean delivery at 4 hours was below 41.8%, and was the dominant strategy below 38.2% (baseline input: 19.5%). Expectant management of the second stage of labor until 4 hours is a cost-effective strategy to prevent primary cesarean deliveries, decrease costs, and improve maternal outcomes.

Risk factors for severe postpartum haemorrhage: A population-based retrospective cohort study.

Severe postpartum haemorrhage (PPH) is a serious clinical problem that is increasing in incidence. To identify risk factors for severe PPH. Population-based retrospective cohort study of all women who gave birth in Victoria in 2009-2013 using the validated Victorian Perinatal Data Collection. Three multivariable logistic regression models estimated the adjusted risk of severe PPH. Adjusted odds ratios (aOR) and their 95% confidence intervals are reported. The primary outcome was severe PPH (estimated blood loss of ≥1500mL). Severe PPH occurred in 1.4% of all births (n=5122). Maternal characteristics significantly associated with severe PPH included: multiple pregnancy; older maternal age; overweight/obesity; first births. Other risk factors included placental complications, macrosomia, instrumental vaginal birth, third and fourth degree perineal lacerations, in-labour caesarean section, birth at a gestation other than 37-41weeks, duration of labour 12 to <24h, and use of oxytocin infusions in labour. Planned pre-labour caesarean section was associated with reduced odds of severe PPH. Severe PPH also occurred in 0.7% (n=104) of women with none of the identified risk factors. Numerous risk factors for severe PPH are identified but some cases are not modifiable or predictable. Limiting use of oxytocin infusions in labour to cases with clear indications, and strategies to prevent severe perineal lacerations would prevent some severe PPHs. Close surveillance of all women in the hours immediately following birth is crucial to detect and manage excessive blood loss and reduce severe PPH and associated morbidity.

Operative vacuum vaginal delivery: effect of compliance with recommended checklist

Purpose Even if the prerequisites and the technique of vacuum extraction are largely established, the role of a checklist in this field has not been tested. To evaluate the role of a checklist implementation on the compliance with the recommended rules in operative vacuum vaginal delivery (OVD) and on maternal and perinatal outcomes. Materials and methods Retrospective cohort study on OVD between January 2012 and December 2015 at two hospitals with a tradition of teaching of OVD. A checklist for OVD was introduced in 2014. Three rules had to be recorded: fetal head station and position determination, no more than four tractions, and no more than three cup applications. Adverse maternal outcomes included third- and fourth-degree perineal tears. Adverse neonatal outcome included asphyxia, need for neonatal resuscitation, NICU admission, major head injuries, scalp injuries, and bone or brachial plexus injuries. Results Introduction of a checklist for OVD resulted in an increase in the compliance with the rules (83.3 versus 62.8%, p < .001). Cases in which the rules were respected had lower incidence of third- and fourth-degree perineal lacerations after controlling for episiotomy, nulliparity, and indication for OVD (OR = 0.4, 95% CI 0.18–0.89), but similar rates of failure of OVD (2.1 versus 2.2%, p = 1) and adverse neonatal outcome (10.8 versus 11.7%, p=.71). Conclusion Knowledge and documented compliance with a checklist of recommended rules in OVD may assist in achieving a lower rate of severe perineal and anal sphincter injury but does not alter the success of the procedure or neonatal outcome.

The association between interpregnancy interval and severe maternal morbidities using revised national birth certificate data: A probabilistic bias analysis.

Severe maternal morbidity continues to be on the rise in the US. Short birth spacing is a modifiable risk factor associated with maternal morbidity, yet few studies have examined this association, possibly due to few available data sources to examine these rare events. To examine the association between interpregnancy interval (IPI) and severe maternal morbidity using near-national birth certificate data and account for known under-reporting using probabilistic bias analysis. We used revised 2014-2017 birth certificate data, restricting to resident women with a non-first-born singleton birth. We examined the following: (a) maternal blood transfusion, (b) admission to intensive care unit (ICU), (c) uterine rupture (among women with a prior caesarean delivery) and (d) third- or fourth-degree perineal laceration (among vaginal deliveries) by IPI categories (<6, 6-11, 12-17, 18-23, 24-59 and 60+months). Risk ratios and 95% confidence intervals were estimated using log-binomial regression, adjusting for select maternal characteristics. Probabilistic bias analyses were performed. Compared with IPI 18 to 23months, adjusted models revealed that the risk of maternal transfusion followed a U-shaped curve with IPI, while risk of ICU admission and perineal laceration increased with longer IPI. Risk of uterine rupture was highest among IPI <6months. With the exception of maternal transfusion, these findings persisted regardless of the extent or type of misclassification examined in bias analyses. Associations between IPI and maternal morbidity varied by outcome, even after adjusting for misclassification of SMM. Differences across maternal health outcomes should be considered when counselling and making recommendations regarding optimal birth spacing.

A 3-Dimensional Anatomical Education Model in Postpartum Perineal Laceration Care: A Pre-Post Intervention Study.

The aim of this study was to investigate the effects of postpartum patients introduction to and interaction with a virtual 3-dimensional (3D) pelvic model on the self-care, knowledge, and anxiety parameters. The model was designed from computed tomography data displaying the involvement of the levator ani in a fourth-degree perineal laceration. This 3D model was used to educate postpartum day 1 patients at the bedside. Patient data were collected using a pre and post questionnaire assessing knowledge, anxiety, and confidence in perineal wound self-care. Thirty-six patients were enrolled with a median age of 28.5 years (interquartile range, 31, 21.75 years) and a median parity of 1 (interquartile range, 2, 1). Patient use of the tool significantly decreased patient anxiety regarding perineal lacerations (P < 0.01) and significantly increased patient knowledge on what part of their vagina was lacerated during vaginal delivery (P < 0.01). Reviewing a 3D model of perineal lacerations with patients on postpartum day 1 is associated with less anxiety and increased knowledge of pelvic floor anatomy. These pilot data represent a preliminary investigation into the relations between 3D model of perineal lacerations and a range of patient outcomes.

Outcomes of operative vaginal delivery managed by residents under supervision and attending obstetricians: a prospective cross-sectional study

To assess both severe maternal and neonatal mortality and morbidity after attempted operative vaginal deliveries by residents under supervision and by attending obstetricians. Secondary analysis of a 5-year prospective study with cross-sectional analysis including 2192 women with live singleton term fetuses in vertex presentation who underwent an attempted operative vaginal delivery in a tertiary care university hospital. Obstetricians who attempted or performed an operative vaginal delivery were classified into 2 groups according to their level of experience: attending obstetricians (who had 5 years or more of experience) and obstetric residents (who had less than 5 years of experience) under the supervision of an attending obstetrician. We used multivariate logistic regression and propensity score methods to compare outcomes associated with attending obstetricians and obstetric residents. Severe maternal morbidity was defined as third- or fourth-degree perineal laceration, perineal hematoma, cervical laceration, extended uterine incision for cesareans, postpartum hemorrhage >1500 mL, surgical hemostatic procedures, uterine artery embolization, blood transfusion, infection, thromboembolic events, admission to the intensive care unit, or maternal death; severe neonatal morbidity was defined as a 5-minute Apgar score <7, umbilical artery pH <7.00, need for resuscitation or intubation, neonatal trauma, intraventricular hemorrhage greater than grade 2, neonatal intensive care unit admission for more than 24 hours, convulsions, sepsis, or neonatal death. High prepregnancy body mass index, high dose of oxytocin, manual rotation, persistent occiput posterior or transverse positions, operating room delivery, midpelvic delivery, forceps, and spatulas were significantly more frequent in deliveries managed by attending obstetricians than residents whereas a second-stage pushing phase longer than 30 minutes was significantly more frequent in deliveries managed by residents. The rate of severe maternal morbidity was 7.8% (115/1475) for residents vs 9.9% (48/484) for attending obstetricians; for severe neonatal morbidity, the rates were 8.3% (123/1475) vs 15.1% (73/484), respectively. In the univariate, multivariable, and sensitivity analyses, attempted operative vaginal delivery managed by a resident was significantly and inversely associated with severe neonatal but not maternal morbidity. After propensity score matching, delivery managed by a resident was not significantly associated with severe maternal morbidity (adjusted odds ratio, 0.74; 95% confidence interval, 0.39-1.38) and was no longer associated with neonatal morbidity (adjusted odds ratio, 0.51; 95% confidence interval, 0.25-1.04). Management of attempted operative vaginal deliveries by residents under the supervision of attending obstetricians, compared with by the attending obstetricians themselves, does not appear to be associated with either maternal or neonatal morbidity. These reassuring results support the continued use of residency programs for training in operative vaginal deliveries under the supervision of attending obstetricians.