Increase In Delivery Rate Research Articles

Determinants of neonatal, postneonatal and maternal mortality on models of primary health

Abstract Background The state of São Paulo recorded a significant reduction in infant mortality, but the desired reduction in maternal mortality was not achieved. Knowledge of the factors with impact on these indicators would be of help in formulating public policies. The aims of this study were to evaluate the relations between socioeconomic and demographic factors, health care model and both infant mortality and maternal mortality in the state of São Paulo, Brazil. Methods In this ecological study, data from national official open sources were used. Analyzed were 645 municipalities in the state of São Paulo, Brazil. For each municipality, the infant mortality and maternal mortality rates were calculated for every 1000 live births, 2013. The association between these rates, socioeconomic variables, demographic models and the primary care organization model in the municipality were verified. We used the zero-inflated negative binomial model. Gross analysis was performed and then multiple regression models were estimated. For associations, we adopted “p” at 5%. Results The increase in the HDI of the city and proportion of Family Health Care Strategy implemented were significantly associated with the reduction in both infant mortality (neonatal + post-neonatal) and maternal mortality rates. In turn, the increase in birth and caesarean delivery rates were associated with the increase in infant and maternal mortality rates. Conclusions It was concluded that the Family Health Care Strategy model that contributed to the reduction in infant (neonatal + post-neonatal) and maternal mortality rates, and so did actors such as HDI and cesarean section. Thus, public health managers should prefer this model. Key messages Implementation of public policies with specific focus on attenuating these factors and making it possible to optimize resources, and not interrupting the FHS. Knowledge of the factors with impact on these indicators would be of help in formulating public policies.

Single-dose intrathecal analgesia: a safe and effective method of labor analgesia for parturients in low resource areas

BackgroundEpidural analgesia is often said the gold standard of the labor analgesia. But in the areas where the availability of epidural catheters, multiparameter monitors, trained staff is scarce, we need to rethink for single-dose intrathecal analgesia as an alternate yet effective method to provide labor analgesia. The combination we chose for single-shot spinal was heavy bupivacaine 2.5 mg + fentanyl 25 μg + morphine 250 μg, so as to provide an optimal time period of analgesia and lesser need for supplemental analgesics.MethodsThe prospective open-label study was conducted on 100 parturients. Group S (N = 50) received intrathecal injection of 0.5 ml of heavy bupivacaine (2.5 mg) and 0.5 ml of fentanyl (25 μg), and 1 ml of preservative free morphine (250 μg/ml) was given (total volume of 2 ml) using 26 G Quincke spinal needle. Group C (N = 50) were managed according to the institutional protocol of programmed labor for normal vaginal delivery. The duration of analgesia, VAS score, safety and side effects, and progress of labor was noted and compared.ResultsThe progress of labor, mode of delivery, and fetal parameters was similar in both the groups. But the parturients in the group S had lower VAS score with a pain-free period of 238.96 ± 21.88 min, without any noted side effects.ConclusionSingle-dose intrathecal analgesia with heavy bupivacaine 2.5 mg + fentanyl 25 μg + morphine 250 μg can be used efficaciously covering the complete duration of labor in both primigravida and multigravida with no increase in instrumental delivery or C-section rate or other side effects.Trial registrationInstitutional Ethics Committee, Indira Gandhi Medical College, Shimla. Number: ECR/533/IST/HP/2014. Registered on 12 August 2017

EGRPM: Energy efficient geographic routing protocol based on mobile sink in wireless sensor networks

A wireless sensor network consists of a large number of nodes, sending sensed data to the base station or sink, either directly or through intermediate nodes. Multi-hop communication results in increased volume of traffic and depleting the energy of nodes adjacent to static sinks. A method of dealing with this challenge is using mobile sinks. Mobile sinks balance the load and distribute energy consumption throughout the network. This paper suggests a method to divide the network into some cells in a geographic way and applies two mobile sinks to gather the data sensed by these cell nodes. Based on the communication between cells and mobile sinks, the cells are divided into two categories: single-hop communication cells (SCCs) and multi-hop communication cells (MCCs). Mobile sinks move over two concentric diamond-shaped orbits in such a way that each half of the network is covered by a sink at a time. Initially, both sinks move in one direction and stay at particular intervals in the corners of the orbits to gather data from sensor nodes. When sinks are stationary, SCCs send data to the sinks directly, but MCCs apply the proposed routing algorithm (EGRPM) to send data to mobile sinks. The proposed approach is simulated by NS2 software. A comparison between the performance of EGRPM and conventional methods shows that applying EGRPM results in a significant decrease in average energy consumption and data delivery delay and causes a substantial increase in packet delivery rate and network lifetime.

Effect of Nursing Interpretation and Intervention of Intrapartum Cardiotocography on Pregnancy Outcomes

An important goal of intrapartum monitoring is preservation of fetal well-being by early detection and relief, when possible, of those conditions causing fetal distress and adverse outcomes. The aim: Assess the effectiveness of nursing interpretation and intervention of intrapartum cardiotocography on pregnancy outcomes. Design: Quazi experimental design. The sample: Was convenient sample of 120 cases divided into two groups (study, and control) each one is 60 cases (30 low risks, and 30 high risks). Tools: three different tools namely assessment sheet for the mother in first stage includesall significant data about the mother, intrapartum fetal monitoring assessment will be done using cardiotocography strip, and Apgar score at one and five minutes. The settings: Shebin Elkom Teaching and University hospitals-Egypt. The main findings were that no statistically significant relations for low risk cases that being handled with cardiotocography and fetal complications. Instrumental delivery and cesarean section rate for low risk cases in the study group is increased than for low risk in control group shows statistical significance difference. There were strong statistically significant relations between high risk fetal heart rate nursing interpretation and Apgar score in the first minute. Statistical significance to total complications during present labor to the mother. Conclusion: Continuous cardiotocography should recommended for high-risk pregnancies where there is an increased risk of prenatal adverse outcomes. Cardiotocography for low risk is associated with a significant increase in instrumental delivery and caesarean section rates compared with intermittent auscultation. Recommendations: continuous electronic fetal monitoring should be recommended for high-risk pregnancies where there is an increased risk of fetal compromise.

Impact of the introduction and withdrawal of financial incentives on the delivery of alcohol screening and brief advice in English primary health care: an interrupted time-series analysis.

To evaluate the impact of the introduction and withdrawal of financial incentives on alcohol screening and brief advice delivery in English primary care. Interrupted time-series using data from The Health Improvement Network (THIN) database. Data were split into three periods: (1) before the introduction of financial incentives (1January 2006-31March 2008); (2) during the implementation of financial incentives (1April 2008-31March 2015); and (3) after the withdrawal of financial incentives (1April 2015-31December 2016). Segmented regression models were fitted, with slope and step change coefficients at both intervention points. England. Newly registered patients (16+) in 500 primary care practices for 2006-16 (n=4 278 723). The outcome measures were percentage of patients each month who: (1) were screened for alcohol use; (2) screened positive for higher-risk drinking; and (3) were reported as having received brief advice on alcohol consumption. There was no significant change in the percentage of newly registered patients who were screened for alcohol use when financial incentives were introduced. However, the percentage fell (P<0.001) immediately when incentives were withdrawn, and fell by a further 2.96 [95% confidence interval (CI)=2.21-3.70] patients per 1000 each month thereafter. After the introduction of incentives, there was an immediate increase of 9.05 (95% CI=3.87-14.23) per 1000 patients screening positive for higher-risk drinking, but no significant further change over time. Withdrawal of financial incentives was associated with an immediate fall in screen-positive rates of 29.96 (95% CI=19.56-40.35) per 1000 patients, followed by a rise each month thereafter of 2.14 (95% CI=1.51-2.77) per 1000. Screen-positive patients recorded as receiving alcohol brief advice increased by 20.15 (95% CI=12.30-28.00) per 1000 following the introduction of financial incentives, and continued to increase by 0.39 (95% CI=0.26-0.53) per 1000 monthly until withdrawal. At this point, delivery of brief advice fell by 18.33 (95% CI=11.97-24.69) per 1000 patients and continued to fall by a further 0.70 (95% CI=0.28-1.12) per 1000 per month. Removing a financial incentive for alcohol prevention in English primary care was associated with an immediate and sustained reduction in the rate of screening for alcohol use and brief advice provision. This contrasts with no, or limited, increase in screening and brief advice delivery rates following the introduction of the scheme.

Building a survivorship care plan delivery process: Experience in an academic center.

69 Background: The Institute of Medicine endorses delivery of survivorship care plans (SCPs) to the growing number of cancer survivors in order to improve the coordination of care between oncologists and primary care providers (PCPs). In response, the Commission on Cancer (COC) has increased the SCP delivery requirement to &gt;50% of eligible patients, a goal that is difficult to meet given limited resources. Here we outline the initiatives taken to achieve this goal at the University of New Mexico Comprehensive Cancer Center (UNMCCC). Methods: Prior to 2017, SCPs were not routinely delivered. Beginning 2017, providers were tasked to complete and deliver printed SCPs , resulting in a 17% rate of SCP completion. However, there was general lack of provider support and enthusiasm as the process was time consuming with no method for identifying eligible patients and tracking SCP delivery. In 2018, designated staff was assigned to partially complete the SCPs to assist providers, resulting in an increase in SCP delivery rate to 41%. However, the same barriers existed. SCP softwares, although available, were expensive. A cost effective process therefore was needed. A committee was then formed to create a system-wide process utilizing the existing electronic health record (EHR) MOSAIQ. ASCO based SCPs were created. Once providers identify eligible patients, an SCP electronic order was initiated. Designated staff then partially completes the SCPs based on review of medical records. The EHR extracts data items including demographics, PCP information, cancer type and stage. The EHR is programmed to flag SCPs ready for delivery which the provider then edits and approves. This system tracks multiple time points including referral, completion and delivery of SCPs. This new process was implemented in April 2019. Quarterly reviews are set to assess metrics. Results: Utilizing existing EHR (MOSAIQ), a new SCP delivery process was created that allows tracking of assembly, completion and timing of delivery. Conclusions: To overcome existing barriers to SCP completion and delivery, a new cost effective process was created utilizing existing staff and EHR resources. Institutional support is key to the success of this initiative.

Impact of the free healthcare initiative on wealth-related inequity in the utilization of maternal & child health services in Sierra Leone

BackgroundAs a result of financial barriers to the utilization of Maternal and Child Health (MCH) services, the Government of Sierra Leone launched the Free Health Care Initiative (FHCI) in 2010. This study aimed to examine the impact of the FHCI on wealth related inequity in the utilization of three MCH services.MethodsWe analysed data from 2008 to 2013 Sierra Leone Demographic Health Surveys (SLDHS) using 2008 SLDHS as a baseline. Seven thousand three hundred seventy-four and 16,658 women of reproductive age were interviewed in the 2008 and 2013 SLDHS respectively. We employed a binomial logistic regression to evaluate wealth related inequity in the utilization of institutional delivery. Concentration curves and indices were used to measure the inequity in the utilization of antenatal care (ANC) visits and postnatal care (PNC) reviews. Test of significance was performed for the difference in odds and concentration indexes obtained for the 2008 and 2013 SLDHS.ResultsThere was an overall improvement in the utilization of MCH services following the FHCI with a 30% increase in institutional delivery rate, 24% increment in more than four focused ANC visits and 33% increment in complete PNC reviews. Wealth related inequity in institutional delivery has increased but to the advantage of the rich, highly educated, and urban residents. Results of the inequity statistics demonstrate that PNC reviews were more equally distributed in 2008 than ANC visits, and, in 2013, the poorest respondents ranked by wealth index utilized more PNC reviews than their richest counterparts. For ANC visits, the change in concentration index was from 0.008331[95% CI (0.008188, 0.008474)] in 2008 to − 0.002263 [95% CI (− 0.002322, − 0.002204)] in 2013. The change in concentration index for PNC reviews was from − 0.001732 [95% CI (− 0.001746, − 0.001718)] in 2008 to − 0.001771 [95% CI (− 0.001779, − 0.001763)] in 2013. All changes were significant (p value < 0.001).ConclusionThe FHCI appears to be improving access to and utilization of MCH services, narrowing the inequity in ANC visits and PNC reviews, but is insufficient in addressing wealth- related inequity that exists for institutional deliveries. If Sierra Leone is to realize a significant reduction in maternal and child mortality rates, it needs to strengthen the effective implementation of FHCI considering incorporating a sector wide approach (SWAp) or a “Health in all Policy” framework to reach the less educated, rural residents and ensuring culturally sensitive quality services.

Cesarean delivery rates, costs and readmission of childbirth in the new cooperative medical scheme after implementation of an episode-based bundled payment (EBP) policy

BackgroundIn the past decade, the rate of cesarean delivery increased dramatically in rural China under the fee-for-service (FFS) system. In September 2011, the New Cooperative Medical Scheme (NCMS) agency in Yong’an county in Fujian province of China adopted a policy of reforming payment for childbirth by transforming the FFS payment into episode-based bundled payment (EBP), which made the cesarean deliveries less profitable. Thus, this study was conducted to determine the effect of EBP policy on reducing cesarean use and controlling delivery costs for rural patients in the NCMS.MethodsData from the inpatient information database of the NCMS agency from January 2010 to March 2013 was collected, in which Yong’an county was employed as a reform county and 2 other counties as controls. We investigated the effects of EBP on cesarean delivery rate, costs of childbirth and readmission for rural patients in the NCMS using a natural experiment design and difference in differences (DID) analysis method.ResultsThe EBP reform was associated with 33.97% (p<0.01) decrease in the probability of cesarean delivery. The EBP reform, on average, reduced the total spending per admission, government reimbursement expenses per admission, and out-of-pocket (OOP) payments per admission by ¥ 649.61, ¥ 575.01, and ¥ 74.59, respectively. The OOP payments had a net decrease of 14.24% (p<0.01); whereas the OOP payments as a share of total spending had a net increase of 8.72% (p<0.01). There was no evidence of increase in readmission rates.ConclusionsThese results indicate that the EBP policy has achieved at least a short-term success in lowering the increase of cesarean delivery rate and costs of childbirth. Considering both the cesarean rate and the OOP payments as a share of total spending after the reform were still high, China still has a long way to go to achieve the ideal level of cesarean rate and improve the benefits of deliveries for rural population.

Replica Reduced Routing Protocol for Intermittent Connected Networks in Emergency Scenarios

In an Intermittent Connected Networks / Opportunistic Networks, routing protocols follow store-carry-forward routing mechanism to deliver messages to destination. One of the application scenarios which makes use of opportunistic networks to route the packet from source to destination is an Emergency Search and Rescue operation where rescuer nodes get partitioned frequently and carry out their rescue activities in different locations. As wireless device has a short transmission range, communication between any two partitioned networks occurs only through the node mobility. The Probability based Routing, provides high packet delivery rate with high overhead. In this paper, a new technique called Replica Reduced and Energy-based routing protocol (REB) is proposed to control the replicas and increase the packet delivery ratio in emergency scenarios. Through simulation, this article demonstrates that the proposed system increases delivery rate and reduces overhead and energy consumption considerably, resulting in increased life span of the network.

Can the primary health care model affect the determinants of neonatal, post-neonatal and maternal mortality? A study from Brazil

BackgroundThe state of São Paulo recorded a significant reduction in infant mortality from 1990 to 2013, but the desired reduction in maternal mortality was not achieved. Knowledge of the factors with impact on these indicators would be of help in formulating public policies. The aims of this study were to evaluate the relations between socioeconomic and demographic factors, health care model and both infant mortality (considering the neonatal and post-neonatal dimensions) and maternal mortality in the state of São Paulo, Brazil.MethodsIn this ecological study, data from national official open sources were used to conduct a population-based study. The units analyzed were 645 municipalities in the state of São Paulo, Brazil. For each municipality, the infant mortality (in both neonatal and post-neonatal dimensions) and maternal mortality rates were calculated for every 1000 live births, referring to 2013. Subsequently, the association between these rates, socioeconomic variables, demographic models and the primary care organization model in the municipality were verified. For statistical analysis, we used the zero-inflated negative binomial model. Gross analysis was performed and then multiple regression models were estimated. For associations, we adopted “p” at 5%.ResultsThe increase in the HDI of the city and proportion of Family Health Care Strategy implemented were significantly associated with the reduction in both infant mortality (neonatal + post-neonatal) and maternal mortality rates. In turn, the increase in birth and caesarean delivery rates were associated with the increase in infant and maternal mortality rates.ConclusionsIt was concluded that the Family Health Care Strategy was a Primary Care organization model that contributed to the reduction in infant (neonatal + post-neonatal) and maternal mortality rates, and so did actors such as HDI and cesarean section. Thus, public health managers should prefer this model when planning the organization of Primary Care services for the population.

Maternal outcomes in case of cesarean before 32 weeks of gestation: A retrospective observational study

Introduction: In recent years, active neonatal care in case of prematurity leads to an increase of cesarean delivery rate. Data remains sparse on maternal morbidity induced by preterm cesarean section and especially before 32 week of gestation.

802: The effect of epidural analgesia on second stage length and delivery mode.

To examine the effect of epidural analgesia on the length of the second stage in a contemporary cohort of parturients and to establish risk factors for a prolonged second stage. A retrospective cohort study of all live singleton vaginal deliveries in a single tertiary center between 2011 and 2016. The 5%, 50% and 95% percentiles of second stage length were calculated stratified by parity and epidural analgesia during labor. Multivariate logistic regression analysis was used to assess risk factors for a prolonged second stage. During the 6-year study period, 46,638 deliveries met inclusion criteria. The 95th percentile of second stage length for primiparous women and multiparous women without epidural was 162 minutes and 40 minutes, respectively. Epidural use increased the 95th percentile of second stage length by 59 and 87 minutes in primiparous and multiparous women, respectively. It was associated with more than a two-fold increase in rates of a prolonged second stage (p<0.001, OR 2.03, CI 1.83-2.26), and more than a three-fold increase in instrumental delivery rates (p<0.001, OR 3.36, CI 2.89-3.91) regardless of parity, but did not increase rates of cesarean delivery. Primiparity was an independent risk factor for a prolonged second stage (OR 4.45, CI 4.10-4.85). Epidural use prolongs the length of the second stage of labor and increases rates of instrumental delivery in both primiparous and multiparous women.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

A pressure drop model of U-typed reduction chamber for iron ore suspension roasting

A pressure drop model for a U-typed reduction chamber was proposed from the pressure balance law to predict pressure in the bottom of fluidization chamber under its stable operation state. During steady roasting, the feeding particles descend in moving-bed mode in the supply chamber, while the particles move upwards in fluidization mode in the fluidization chamber. A cold test system was established and operated to study the performance of the U-typed reduction chamber using alumina particles with average diameters of 70.77 μm, 101.09 μm and 146.66 μm, respectively. Experiments revealed that the pressure in the bottom part of fluidization chamber decreased with the increased fluidizing air velocity, while increased with the increase of delivery rate. Besides, the particles height of supply chamber would be automatically adjusted according to the system pressure balance. The simulated pressure drop was in good agreement with experimental data giving an average deviation of 7.30%, demonstrating the validity of proposed algebraic model. Therefore, it can be used to predict the pressure in the bottom of fluidization chamber for the U-typed reduction chamber.

Complications maternelles des césariennes avant 32 semaines d’aménorrhée : étude rétrospective observationnelle

ObjectivesIn recent years, active neonatal care in case of prematurity leads to an increase of cesarean delivery rate. Data remains sparse on maternal morbidity induced by preterm cesareans and especially before 32 weeks of gestation. The main aim of this study was to evaluate per-partum maternal morbidity in case of cesarean performed before 32 week of gestation. As secondary objectives, we assessed post-partum maternal morbidity and factors associated with maternal morbidity. MethodsThis is a retrospective single-center study conducted in a tertiary care unit between 2014 and 2016 including cesareans performed before 32 week of gestation in the study period. The primary outcome was a composite criterion of per partum maternal morbidity including post-partum hemorrhage, blood transfusion, general anesthesia, surgical wounds and maternal death. The secondary outcome was the post-partum maternal morbidity, defined by a composite criterion including hospitalization more than 7 days, infectious disease, wall and digestive complication and venous thromboembolic disease. ResultsTwo hundred and eleven women were included. Maternal morbidity occurred in 21.3% in per partum and in 20.4% in post-partum. The factors associated with per partum morbidity were low-lying placenta (OR=4.40 [1.01–19.09]) and non-fetal indication of cesarean (OR=2.10[1.01–4.42]). The factors associated with post-partum morbidity were twin-pregnancy (OR=2.90 [1.12–7.54]), general anesthesia (OR=4.19 [1.68–10.49]) and non-cephalic fetal presentation (OR= 2.70 [1.23–5.93]). ConclusionThe maternal morbidity of cesareans before 32 week of gestation is more than 20%. This study confirms the high maternal morbidity associated with caesareans performed before 32 weeks of gestation.

A Semi-Empirical Performance Study of Two-Hop DSRC Message Relaying at Road Intersections

This paper is focused on a vehicle-to-vehicle (V2V) communication system operating at a road intersection, where the communication links can be either line-of-sight (LOS) or non-line-of-sight (NLOS). We present a semi-empirical analysis of the packet delivery ratio of dedicated short-range communication (DSRC) safety messages for both LOS and NLOS scenarios using a commercial transceiver. In a NLOS scenario in which the reception of a safety message may be heavily blocked by concrete buildings, direct communication between the on-board units (OBUs) of vehicles through the IEEE 802.11p standard tends to be unreliable. On the basis of the semi-empirical result of safety message delivery at an intersection, we propose two relaying mechanisms (namely, simple relaying and network-coded relaying) via a road-side unit (RSU) to improve the delivery ratio of safety messages. Specifically, we designed RSU algorithms to optimize the number of relaying messages so as to maximize the message delivery ratio of the entire system in the presence of data packet collisions. Numerical results show that our proposed relaying schemes lead to a significant increase in safety message delivery rates.

Induction of labor using one dose vs multiple doses of misoprostol: a randomized controlled trial

Misoprostol is a common agent that is used to ripen the cervix and induce labor, yet there is no clear evidence of the optimal number of doses needed to achieve a higher rate of vaginal delivery. Our primary objective was to compare the rate of vaginal delivery within 24 hours between a 1-dose and a multiple-dose regimen of misoprostol for the induction of labor. A randomized controlled trial was conducted from March 2016 to March 2017 that compared a single dose to up to 4 doses of misoprostol. Randomization was stratified by parity. Women with a singleton pregnancy ≥37 weeks gestation with intact membranes who had been admitted for labor induction with a Bishop score ≤6 were included. Our primary outcome was the rate of vaginal delivery within 24 hours. Secondary outcomes included time to vaginal delivery, cesarean delivery rate, and maternal and neonatal morbidity. Based on a power of 80%, an alpha of .05, and the assumption that 50% of women in the multiple-misoprostol group would deliver vaginally in 24 hours, a sample size of 220 patients was needed to detect a 20% increase in vaginal delivery rate within 24 hours in the 1-misoprostol group. Continuous variables were compared with the use of the Mann-Whitney test. Categoric variables were compared with the use of the Fisher's exact test. Probability values <.05 were considered statistically significant. Two hundred fifty women were assigned randomly. Demographics and clinical characteristics were similar between groups. In the univariate analysis, there was no difference in the rate of vaginal delivery within 24 hours between the 1-misoprostol group and the multiple-dose group (41.7% vs 44.7%, respectively; P=.698) or time to vaginal delivery (1187 min vs 1321 min, respectively; P=.202). The 1-misoprostol group had a greater cesarean delivery rate (35.8% vs 22.8%; P=.034). In a Poisson regression that controlled for Bishop score before the initiation of oxytocin, parity, gestational age, body mass index, estimated fetal weight, artificial rupture of membrane at <6 cm, and Foley balloon placement, the treatment group was no longer associated with cesarean delivery rate. Instead, a Bishop score of <4 before the initiation of oxytocin and nulliparity were associated significantly with cesarean delivery rate. In this first randomized controlled trial in the literature to compare a single with a multiple dosing of misoprostol, we found that the 1-dose regimen is an acceptable alternative for the induction for labor, especially for multiparous women and for patients with a Bishop score >4 after the first dose.

Evaluation of Respiratory Problems According to Week of Delivery: A Comparative Analysis in Infants of Gestational Age 37 Weeks

Background: Cesarean section deliveries at 37 weeks gestational period are incredibly high in Turkey. In order to determine the antenatal characteristics, respiratory morbidity and mortality cases, we have conducted a retrospective cohort study on this population. Methods: 514 infants encountering clinical signs of respiratory distress within 24 hours were enrolled. To compare the differences, infants were categorized into three groups as: late-preterm, early-term and full-term infants. Demographic and clinical data were explored. Results: Early-term infants represented higher RDS rates (13.1%; P = 0.033 for early-term and full-term infants; P = 0.338 for early-term and late-preterm infants), meconium aspiration syndrome (P < 0.001 for early-term and late-preterm infants; P < 0.001 for early-term and full-term infants) and lower Apgar scores at 5 minutes (6.1 ± 1.98; P < 0.001 for early-term and full-term infants; P = 0.642 for early-term and late-preterm infants). They necessitated conventional mechanical ventilation more often compared to late-preterm and full-term neonates (39.3%; P = 0.050, P = 0.042); however late-preterm infants represented longer intubation periods (P = 0.014, P < 0.001) and intensive care stays (P < 0.001; P < 0.001). Conclusions: Early-term neonates encounter respiratory problems, morbidities and significant respiratory distress syndrome rates similar to the rates of late preterm neonates and seemed to have a tendency to hypoxic deliveries with low Apgar scores. Considering the increasing delivery rate at this period, real estimates should be investigated in large, multi-centered prospective studies in terms of both short and long term outcomes.

Are minimally invasive approaches to ectopic pregnancy underutilized?

Non-tubal ectopics account for approximately 10% of all ectopic pregnancies. The incidence is increasing, largely owing to the increase in caesarean section delivery rates and utilization of assisted reproductive techniques (Kirk et al. Ultrasound Obstet Gynecol 2006;27:430–7). As non-tubal ectopics tend to carry a higher morbidity largely because of their delayed diagnosis and the technically difficult surgical technique required to remove them, identifying the best method of treatment and recognizing that minimally invasive techniques have a high rate of success are necessary to optimize patient outcomes. The retrospective study by Ramkrishna et al. BJOG 2018;125:567–75 spanning over 11 years examined 100 nontubal ectopic pregnancies with a primary outcome of success of first-line management and frequency of unplanned intervention, and is the largest report of its kind. Treatment modalities included medical (local KCl or methotrexate injection, or systemic methotrexate), surgical, or combined medical and surgical. Primary management was determined to be successful if no further, unplanned interventions were required. Caesarean scar, cornual, and interstitial ectopics represented the majority of cases. Notably, beta-hcg level, presence of fetal heartbeat, and size of mass at the time of presentation – often implicating factors in pursuing surgical management as a primary option – did not predict treatment success. The authors found that systemic methotrexate or intrasac injection with either methotrexate or KCl proved superior when compared with surgical management (88% versus 54%), which has been shown in prior studies (Verma U et al. Fertil Steril 2011;96:1391–5 e1; Hunt SP et al. Reprod Biomed 2016;33:79–84). Another important point demonstrated here is that the mean time to discharge from treatment was not significantly different from those with a primary surgical approach, which would argue against proceeding with ‘definitive surgical treatment’ for a ‘faster’ endpoint. They appropriately recognize a limitation of this study is its retrospective nature and likelihood to select out surgically emergent cases that may not have required further intervention. Additionally, given advances in ultrasound and other imaging modalities over the past decade allowing for earlier diagnosis, success rates of minimally invasive techniques are likely to be higher than stated and will continue to improve over time. Examination of the published literature yields no standardized protocols for management of nontubal ectopic pregnancies. Minimally invasive management techniques are often underutilized, either because of lack of training in intrasac injection or lack of recognition of their high rates of success alone or in combination with systemic methotrexate. When possible, these cases should be referred and managed in an experienced tertiary care centre with access to blood transfusion and emergent radiologic interventional procedures. In summary, this retrospective cohort study adds to the important, albeit limited body of literature supporting minimally invasive approaches in the hemodynamically stable patient with a nontubal ectopic pregnancy. Reports such as this could aid in developing a protocol that leads providers to consider medical, fertility-sparing-based approaches as first line treatment in these often clinically complicated patients. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

A Six Year Review of Caesarean Sections at Olabisi Onabanjo University Teaching Hospital Sagamu, South West Nigeria

Caesarean section is one of the most commonly performed major operative procedures. There appears to be an increase in the rate of caesarean delivery in our environment, the safety of the procedure has also improved over decades. However, the procedure is still associated with some complications. The aim of this study was to determine the rate, indications and complications of caesarean sections in Olabisi Onabanjo University Teaching Hospital (OOUTH) Sagamu, Ogun State, Nigeria. This was a six year retrospective study of all caesarean deliveries in OOUTH between January 1st 2009 and December 31st 2014. Relevant informationwas retrieved from the medical records and case notes using a purpose designed proforma. The data was analyzed using IBM-SPSS windows version 21. A total of 1390 caesarean section were performed out of 4219 deliveries during the period of review giving a caesarean section rate of 32.9%. The commonest indication was previous caesarean section (25.2%), followed by obstructed labour (17.0%). Maternal complications occurred in 23.1% of the subjects with wound infection being the commonest. Birth asphyxia was the commonest foetal complication. This study demonstrates a high caesarean section rate in OOUTH. Efforts geared towards reducing primary caesarean sections by encouraging instrumental delivery in nulliparous women and improving skills in destructive vaginal delivery for obstructed labour with intrauterine fetal death will assist in reversing the trend.Keywords: Caesarean section rate, Indications, Complications

Do Differences Exist Between Groups With Varying Numbers of Abnormal Values on the Glucose Tolerance Test? [15L

INTRODUCTION: To determine whether patients with one abnormal value on the glucose tolerance test (GTT) have different outcomes compared to patients with varying numbers of abnormal values. METHODS: We conducted a retrospective chart review of women undergoing a glucose challenge test (GCT) followed by a GTT from July 2010-July 2015. Patients with pre-gestational diabetes were excluded. Primary outcomes were infant birth weight and mode of delivery. Secondary outcomes included shoulder dystocia, NICU admission, and development of preeclampsia. Data was analyzed via multivariable regression models. RESULTS: 5,913 charts were reviewed. 5,124 patients had a normal GCT. 499 had an abnormal GCT and zero abnormal values on the GTT (Group 0). 147 had one abnormal value on the GTT (Group 1), and 143 had two or more abnormal values on the GTT (Group 2). After controlling for maternal age, infant sex, and gestational age, group 0 had a significant increase in rate of cesarean delivery, birth weight, NICU admission, shoulder dystocia and preeclampsia compared to patients with a normal GCT. Group 1 had a significant increase in rate of cesarean delivery, birth weight, NICU admission and preeclampsia when compared to group 0. No significant differences in outcomes existed between group 1 and group 2, the treated gestational diabetics. CONCLUSION: Glucose intolerance is a spectrum with an increasing number of abnormal GTT values leading to an increased likelihood of poor outcomes. Patients with an abnormal GCT should be counseled on potential maternal and neonatal morbidities and the potential to modify outcomes with treatment.