Intrapartum Period Research Articles

Clinical characteristics and sequelae of intrapartum hypertension – a retrospective cohort study

BackgroundIn a significant proportion of pregnant women, elevated blood pressure may first present during the intrapartum period. This phenomenon, intrapartum hypertension, is often overlooked as blood pressure during delivery is attributed to labour pain, analgesic agents and haemodynamic changes. Thus the true prevalence and clinical significance of intrapartum hypertension remains unknown. This study sought to define the prevalence of intrapartum hypertension in previously normotensive women, identify associated clinical characteristics, and its impact on maternal and fetal outcomes.MethodsIn this single-center retrospective cohort study, all available partograms were reviewed over a 1-month period at an outer metropolitan hospital in Sydney (Campbelltown Hospital). Women with diagnosed hypertensive disorders of pregnancy during the incident pregnancy were excluded. A total of 229 deliveries were included in the final analysis. Intrapatum hypertension (IH) was defined as two or more systolic blood pressure (SBP)⩾140 mmHg or diastolic blood pressure (DBP)⩾90 mmHg during the intrapartum. Demographic data at the time of the first antenatal visit for the incident pregnancy as well as final maternal outcomes (intrapartum and post-partum) and fetal outcomes were collected. Statistical analyses were carried out using SPSSv27 with adjustments for baseline variables.ResultsAmongst 229 deliveries, 32 women (14%) had intrapartum hypertension. Older maternal age (p = 0.02), higher body mass index (p < 0.01) and higher diastolic blood pressure at the first antenatal visit (p = 0.03) were associated with intrapartum hypertension. A longer second stage of labour (p = 0.03), intrapartum non-steroidal anti-inflammatory medications (p < 0.01) and epidural anaesthesia (p = 0.03) were associated with intrapartum hypertension, while IV syntocin for labour induction was not. Women with intrapartum hypertension had a longer inpatient admission following delivery (p < 0.01), and elevated postpartum BP (p = 0.02) with discharge on antihypertensive medications (p < 0.01). Intrapartum hypertension was not associated with poor fetal outcomes, though subgroup analyses showed that women who had at least a single elevated blood pressure reading during the intrapartum experienced poorer fetal outcomes.ConclusionIn previously normotensive women, 14% developed intrapartum hypertension during delivery. This was associated with postpartum hypertension, longer maternal admission and discharge with antihypertensive medications. There was no difference in fetal outcomes.

Clinical presentation, maternal-fetal, and neonatal outcomes of early-onset versus late onset preeclampsia-eclampsia syndrome in a teaching hospital in a low-resource setting: A retrospective cohort study.

Pre-eclampsia-eclampsia syndrome remains the leading cause of maternal and neonatal mortality worldwide. Both from pathophysiologic and clinical stand points, early and late onset preeclampsia are thought to be two different disease entities. However, the magnitude of preeclampsia-eclampsia and maternal-fetal and neonatal outcomes of early and late onset preeclampsia are not adequately investigated in resource-limited settings. This study sought to examine the clinical presentation and maternal-fetal and neonatal outcome of these two entities of the disease in Ayder comprehensive specialized hospital, an academic setting in Tigray, Ethiopia, from January 1, 2015-December 31, 2021. A retrospective cohort design was employed. The patient charts were reviewed to see the baseline characteristics and their progress from the onset of the disease in the antepartum, intrapartum and postpartum periods. Women who developed pre-eclampsia before 34 weeks of gestation were defined as having early-onset pre-eclampsia, and those who developed at 34 weeks or later were identified as late-onset preeclampsia. We used chi-square, t-test and multivariable logistic regression analyses to determine differences between early- and late onset diseases in terms of clinical presentation, maternal-fetal, and neonatal outcomes. Among the 27,350 mothers who gave birth at the Ayder comprehensive specialized hospital, 1095 mothers had preeclampsia-eclampsia syndrome, with a prevalence of 4.0% (95% CI: 3.8, 4.2)]. Of the 934 mothers analyzed early and late onset diseases accounted for 253 (27.1%) and 681 (72.9%) respectively. Overall, death of 25 mothers was recorded. Women with early onset disease had significant unfavorable maternal outcomes including having preeclampsia with severity features (AOR = 2.92, 95% CI: 1.92, 4.45), liver dysfunction (AOR = 1.75, 95% CI: 1.04, 2.95), uncontrolled diastolic blood pressure (AOR = 1.71, 95% CI: 1.03, 2.84), and prolonged hospitalization (AOR = 4.70, 95% CI: 2.15, 10.28). Similarly, they also had increased unfavorable perinatal outcomes, including the APGAR score at the 5th minute (AOR = 13.79, 95% CI: 1.16, 163.78), low birth weight (AOR = 10.14, 95% CI 4.29, 23.91), and neonatal death (AOR = 6.82, 95% CI: 1.89, 24.58). The present study highlights the clinical differences between early versus late onset preeclampsia. Women with early-onset disease are at increased levels of unfavorable maternal outcomes. Perinatal morbidity and mortality were also increased significantly in women with early onset disease. Therefore, gestational age at the onset of the disease should be taken as an important indicator of the severity of the disease with unfavorable maternal, fetal, and neonatal outcomes.

Pregnancy With Uterine Fibroids: Obstetric Outcome at a Tertiary Care Hospital of Central India.

Uterine fibroids are the most frequent benign tumorof the female reproductive system, with a significantly lower frequency in pregnancy. This could be due to the fact that uterine fibroids are linked to infertility and low implantation rates following in vitro fertilization (IVF). The goal of this study was to look at the obstetrics outcomes of uterine fibroids and their consequences in a tertiary hospital. The current study was a observational cohort study that evaluated the cases of pregnancy with fibroid. Study was undertaken at the Department ofObstetrics and Gynecology (OBGY) at a medicalcollege in central India and it was conducted over a period of nine months from 1st November 2021 to 31st July 2022. All pregnant women who had an ultrasonography (USG)-documented uterine fibroid diagnosed prenatally or antenatally were enrolled. All demographic information, laboratory and USG results were noted and their mode of delivery, obstetric complications, if any, and neonatal outcomes were evaluated. A total of 110 cases were enrolled as per inclusion and exclusion criteria. The majority of patients (42.73%) were in the 26- to 30-year-old age group. In this study, the majority of cases were carried to term (80.9%). The most prevalent mode of delivery was caesarean section (61.82%). Major complications during pregnancy were threatened preterm labor (21.82%), and blood transfusion (20.00%), whereas postpartum hemorrhage (PPH) occurred in 9.09% cases, and 47 patients (42.72%) were asymptomatic throughout pregnancy.Major neonatal outcomes in our study wereneonatal intensive care unit (NICU) hospitalization (20%), required neonatal resuscitation (14.55%), and neonatal mortality occurring in 1.82% cases.Gestational age at termination of pregnancy, when compared with different characteristics of fibroid, like type (p value 0.663), location (p value 0.552) and number of fibroid (p value 0.112), did not show any significant association. Similarly, maternal complications also did not show significant association (p value >0.05) with different characters of fibroid. Conclusion: Pregnancies with fibroid are high-risk pregnancies that are linked to difficulties throughout the antepartum, intrapartum, and postpartum periods, as well as increased chances of cesarean delivery and PPH.

Development and validation of a prediction model for intrapartum cesarean delivery based on the artificial neural networks approach: a protocol for a prospective nested case–control study

IntroductionAlthough intrapartum caesarean delivery can resolve dystocia, it would still lead to several adverse outcomes for mothers and children. The obstetric care professionals need effective tools that can help them...

Process Evaluation of Facility Delivery Services in Northwest Ethiopia: In the Case of Public Health Centers.

Even if giving birth at health facility is vital for both the mothers and their newborns, the coverage of institutional delivery in Ethiopia is very low (50%). In that regard, several studies have shown the possible factors of low delivery service uptake from the patients' side, but evidences on delivery services at the health centers are meagre. This study aimed to evaluate the process of delivery services in public health centers of northwest Ethiopia. A case study evaluation design with an embedded mixed-method was used to evaluate institutional delivery in public health centers of Gondar city. Dimensions from the access (availability, accommodation, and acceptability) and implementation fidelity (compliance) frameworks were used. A total of 363 mothers, 32 document reviews, 32 direct observations, and 17 key informants were included. The qualitative data were transcribed, translated, coded, and analysed using a thematic analysis approach. The overall process of institutional delivery services was measured based on pre-determined judgmental criteria. The overall facility delivery process was 75.1%, judged by availability (78.5%), compliance (70.6%), accommodation (68.8%), and acceptability (80.2%) of services. Essential medicines in some of the health centers were stockout, insufficient delivery rooms and inadequate training of health workers on obstetric and newborn care were observed. Using partograph and examining vulval-perineal region for possible laceration during intrapartum period were less practiced. Residence (AOR: 0.13, 95% CI: 0.06-0.30), ANC 1 to 3 visits (AOR: 2.65, 95% CI: 1.05-6.74) and ANC4+ (AOR: 5.57, 95% CI: 2.09, 14.84) were factors affected acceptability of delivery services. Major constraints were in the accommodation of delivery services which needs a holistic effort from all stakeholders. Therefore, implementors with other stakeholders shall improve delivery rooms, facilitate training, and provide parenteral drugs as part of the obstetric and newborn care to improve the facility delivery services in Ethiopia.

How do Slovenian women perceive midwifery competencies – Pilot study using the Slovenian version of midwifery profiling questionnaire (MidProQ)

ObjectiveThe role of the midwife is well defined and midwifery education is precisely prescribed in order that students gain all competencies that derive from the definition of midwifery profession. However in Slovenia, midwives do not practice the full scope midwifery, therefore the aim of the study was to explore whether women are aware of the role that midwives have. DesignIn order to study the lay people awareness of midwives’ role and competencies, a quanitative survey was performed using the validated Midwifery Profiling Questionnaire (MidProQ), designed by a Belgium research team of midwives, adapted to Slovenian circumstances. SettingAn online survey was performed, using the software 1KA. The link to the survey was distributed amongst groups of women via social media. ParticipantsSnow-ball sampling was used, recruiting women via gynaecology and obstetric forums. MeasurementsThe MidProQ is measuring the agreement of women with statements that describe competencies of midwives for prenatal, intrapartum and postnatal period. 228 fully fulfilled questionnaire were analysed with SPSS programme. FindingsOnly 43% of participants felt that midwives were capable of managing an uncomplicated pregnancy independently, however they clearly state their role in uncomplicated labour (93%). Most clearly recognised role of midwives in the postnatal period was breastfeeding counselling (89%). The role of the midwife is intertwined with the competencies of the obstetrician, who majority of participants still consider more competent for managing an uncomplicated pregnancy. Key conclusionsParticipants were not aware of all the fields where midwife could practice. Implications for practiceMore has to be done that lay public will recognize the potential of full scope midwifery practice, like promoting the profession via social media.

Quality intrapartum care expectations and experiences of women in sub-Saharan African Low and Low Middle-Income Countries: a qualitative meta-synthesis

BackgroundWoman-centred maternity care is respectful and responsive to women’s needs, values, and preferences. Women’s views and expectations regarding the quality of health services during pregnancy and childbirth vary across settings. Despite the need for context-relevant evidence, to our knowledge, no reviews focus on what women in sub-Saharan African Low and Low Middle-Income Countries (LLMICs) regard as quality intrapartum care that can inform quality guidelines in countries.MethodsWe undertook a qualitative meta-synthesis using a framework synthesis to identify the experiences and expectations of women in sub-Saharan African LLMICs with quality intrapartum care. Following a priori protocol, we searched eight databases for primary articles using keywords. We used Covidence to collate citations, remove duplicates, and screen articles using a priori set inclusion and exclusion criteria. Two authors independently screened first the title and abstracts, and the full texts of the papers. Using a data extraction excel sheet, we extracted first-order and second-order constructs relevant to review objectives. The WHO framework for a positive childbirth experience underpinned data analysis.ResultsOf the 7197 identified citations, 30 articles were included in this review. Women’s needs during the intrapartum period resonate with what women want globally, however, priorities regarding the components of quality care for women and the urgency to intervene differed in this context given the socio-cultural norms and available resources. Women received sub-quality intrapartum care and global standards for woman-centred care were often compromised. They were mistreated verbally and physically. Women experienced poor communication with their care providers and non-consensual care and were rarely involved in decisions concerning their care. Women were denied the companion of choice due to cultural and structural factors.ConclusionTo improve care seeking and satisfaction with health services, woman-centred care is necessary for a positive childbirth experience. Women must be meaningfully engaged in the design of health services, accountability frameworks, and evaluation of maternal services. Research is needed to set minimum indicators for woman-centred outcomes for low-resource settings along with actionable strategies to enhance the quality of maternity care based on women’s needs and preferences.

Associations between self-reported obstetric complications and experience of care: a secondary analysis of survey data from Ghana, Kenya, and India

BackgroundAlthough several indicators have been proposed to measure women’s experience of care in health facilities during the intrapartum period, it is unknown if these indicators perform differently in the context of obstetric emergencies. We examined the relationship between experience of care indicators from the Person-Centered Maternity Care (PCMC) scale and obstetric complications.MethodsWe used data from four cross-sectional surveys conducted in Kenya (rural: N = 873; urban: N = 531), Ghana (N = 531), and India (N = 2018) between August 2016 and October 2017. The pooled sample included 3953 women aged 15–49 years who gave birth within 9 weeks prior to the survey. Experience of care was measured using the PCMC scale. Univariate, bivariate, and multivariable analyses were conducted to examine the associations between the composite and 31 individual PCMC indicators with (1) obstetric complications; (2) severity of complications; and (3) delivery by cesarean section (c-section).Results16% (632) of women in the pooled sample reported obstetric complications; and 4% (132) reported having given birth via c-Sect. (10.5% among those with complications). The average standardized PCMC scores (range 0–100) were 63.5 (SD = 14.1) for the full scale, 43.2 (SD = 20.6) for communication and autonomy, 67.8 (SD = 14.1) for supportive care, and 80.1 (SD = 18.2) for dignity and respect sub-scales. Women with complications had higher communication and autonomy scores (45.6 [SD = 20.2]) on average compared to those without complications (42.7 [SD = 20.6]) (p < 0.001), but lower supportive care scores, and about the same scores for dignity and respect and for the overall PCMC. 18 out of 31 experience of care indicators showed statistically significant differences by complications, but the magnitudes of the differences were generally small, and the direction of the associations were inconsistent. In general, women who delivered by c-section reported better experiences.ConclusionsThere is insufficient evidence based on our analysis to suggest that women with obstetric complications report consistently better or worse experiences of care than women without. Women with complications appear to experience better care on some indicators and worse care on others. More studies are needed to understand the relationship between obstetric complications and women’s experience of care and to explore why women who deliver by c-section may report better experience of care.

Computerized insulin protocol for intrapartum and postpartum glucose management in gravidas with Type 1 diabetes

Computerized insulin infusion calculators (IICC) improve glucose control in non-pregnant populations. Our IICC is an insulin sensitivity coefficient-based algorithm relying on point of care (POC) glucose values and the rate of change which allows for dynamic changes in insulin resistance. We evaluated the effectiveness of an IICC in achieving intrapartum and postpartum euglycemia in gravidas with Type 1 diabetes mellitus (T1DM). This retrospective study included gravidas with T1DM managed intrapartum and postpartum with IICC between 2016-2020. Patients were excluded if insulin infusion or POC glucose values were not available. Insulin infusion rate, POC glucose and neonatal data were obtained from the electronic medical record. Our primary outcome was the percentage of hourly glucose values within goal in the intrapartum period (80-119 mg/dL), and postpartum period (80-179 mg/dL). Secondary outcomes included intrapartum mild hyperglycemia (120-179 mg/dL) and hypoglycemia (< 60 mg/dL), hyperglycemia (≥ 180 mg/dL) for both time periods, and select neonatal outcomes. 39 patients (47 pregnancies) were included for analysis. Mean maternal age was 29.5 ± 5.3 years and first trimester HbA1c was 7.2 ± 1.4%. 39.3% (n=471) of the intrapartum glucose values and 68.7% (n=929) of the postpartum glucose values were in target (p< .0001)(Figure 1). The incidence of intrapartum mild hyperglycemia was 545 (46.3%). The incidence of hypoglycemia was 2.7% for both time periods while the incidence of hyperglycemia was 9.3% and 18.6% intrapartum and postpartum, respectively. Figure 2 shows the mean POC glucose values. Twenty-four (51.1%) neonates were admitted to the neonatal intensive care unit and 22 (46.8%) had hypoglycemia requiring dextrose infusion. To our knowledge, this is the first descriptive study of IICC use intrapartum and postpartum. The IICC performed better at achieving postpartum versus intrapartum glucose control, while having low rates of hyperglycemia and hypoglycemia. Development of a pregnancy specific IICC may improve peripartum glycemic control.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Prevalence of Stillbirths during COVID-19 Pandemic at a Tertiary Referral Centre in Central Kerala, India: A Cross-sectional Study

Introduction: Stillbirth is defined as a baby born with no signs of life after a given threshold. It is a sensitive indicator of quality of care received by the mother during antepartum and intrapartum period. There has been a renewed focus on stillbirth in the backdrop of COVID-19 pandemic, as pregnant women are at an increased risk for severe form of COVID-19 and are associated with adverse perinatal outcomes. Aim: To estimate the prevalence of stillbirths and its characteristics during the pandemic and also, to classify the causes of stillbirths according to the International Classification of Diseases for use in Perinatal Mortality (ICD-PM) classification. Materials and Methods: This cross-sectional study was conducted in the Department of Obstetrics and Gynaecology at Government Medical College, Thrissur, Kerala, India, during the COVID-19 pandemic from 1st August 2021 to 30th July 2022. A total of 106 mothers, who gave birth to stillbirths after 28 weeks of gestation were included in the study. When gestational age was not sure, stillbirth weighing more than 500 grams was considered as the inclusion criteria. Foetus, placenta, cord and membranes were examined after the delivery. The parameters studied were age, domicile, income, gestational age, order of pregnancy, mode of delivery, timing of foetal death, baby weight, gender, presence of anomalies and maternal medical complications. The causes were classified according to International Classification of Diseases-10-to Perinatal Mortality (ICD-PM) classification system. Categorical variables were assessed by Chi-square test and continuous variables were assessed by unpaired Student’s t-test. Results: There were 106 stillbirths with a Stillbirth Rate (SBR) of 38.78 per 1000 births. Major proportions of stillbirths were antepartum. Mean maternal age was 28.7±4.7 years. There were 73 (68.86) rural women and 33 (31.1%) urban women with stillbirths. A total of 90 (84.9%) cases were referral, while 16 (15.1%) were registered in the Institute for antenatal care. A total of 67 (63.2%) stillborns were male babies, but there was no significant difference in SBR, according to the order of pregnancy. Causes were classified according to the ICDPM classification system. Hypertensive disorders in pregnancy (36.79%) and the foetal growth restriction (39.62%) were the common maternal and foetal condition identified among the cases. There were 22 COVID-19 positive cases, but they were also having hypertension as co-morbidity. Conclusion: In present study, antepartum stillbirth was the commonest type and occurred mostly in referral cases from periphery. Hypertensive diseases in pregnancy and foetal growth restriction were the leading causes. Early detection of high-risk conditions and timely referral, may reduce the rate of stillbirth.

Elucidating the Ruling Relations of Nurses’ Work in Labor and Delivery: An Institutional Ethnography

Obstetrics is a well-known area for malpractice and medical-legal claims, specifically as they relate to injuries the baby suffers during the intrapartum period. There is a direct implication for nurses’ work in labor and delivery because the law recognizes that monitoring fetal well-being during labor is a nursing responsibility. Using institutional ethnography, we uncovered how two powerful ruling discourses, namely biomedical and medical-legal risk discourses, socially organize nurses’ fetal surveillance work in labor and delivery through the use of an intertextual hierarchy and an ideological circle.

Adverse Maternal and Perinatal Outcomes of Meconium-Stained Amniotic Fluid in Term Labor at Hospitals in South Gondar Zone, Northwest Ethiopia: A Prospective Cohort Study.

The passage of meconium during labor increased the chance of undesirable birth outcomes. The adverse effects of meconium are worsening in resource-limited countries. In Ethiopia, there is an argument concerning meconium's negative effects and management on pregnant women and their babies. Therefore, this study was intended to assess the adverse maternal and perinatal outcomes of meconium in term labor in the South Gondar Zone, Ethiopia. A prospective cohort study was conducted using 580 laboring mothers (145 exposed and 435 nonexposed groups). A two-stage sampling method was implemented to get study subjects. The data were collected using an interviewer-administered structured questionnaire and a medical chart review. SPSS version 25 was used for data analysis. Chi-squared and Fisher's exact tests were used to compare the two groups' differences. The strength of the association was measured using relative risk with a 95% CI. There was more operative delivery (28.3% versus 5.3%), puerperal sepsis (79.54% versus 2.06%), nonreassuring fetal heart rate pattern (29.7% versus 2.1%), meconium aspiration syndrome (7.58% versus 0.68%), neonatal sepsis (9% versus 4.1%), perinatal asphyxia (13.8% versus 7.6%), admission to the neonatal intensive care unit (23.4% versus 3.2%), and early neonatal deaths (4.8% versus 1.4%) among meconium stained groups as compared to the clear amniotic fluid groups. Meconium-stained amniotic fluid significantly increased adverse maternal and perinatal outcomes in Ethiopia. The risk of perinatal asphyxia, nonreassuring fetal heart rate pattern, neonatal sepsis, meconium aspiration syndrome, admission to the NICU, early neonatal death, operative delivery, and puerperal sepsis were significantly higher in meconium-exposed groups. Special attention should be given to meconium-exposed mothers during the intrapartum period and in postnatal follow-up.

Frequency of Post-Partum Hemorrhage and Associated Factors in Primiparous Women

Background: Postpartum hemorrhage refers to excessive blood loss during or after delivery, it defined as blood loss greater than or equal to 1000 ml or blood loss within 24 hours after the birth. The objective of this study is to investigate frequency of post-partum hemorrhage and associated factors in primiparous women. Materials and Methods: A hospital based cross sectional study was conducted among 104 women aged 18-48 years, during six months (01/Oct/2022 to 30/March/2023). Women diagnosed post-partum hemorrhage and admitted in Nangarhar university teaching hospital (gestational age 36-42 weeks) were included in the study. Findings: Among 104 women, who were observed, mean age was 25.70 ± 5.24, most affected (71.15%) age group interval was (20 to 29-year age group). About 63(60.60%) were Primiparous and (39. 40%) women were multi parous. About fourth-five (80.80%), two third (67.30%), and one -third (31.70%) of participant were, illiterate and house wives, lived in rural areas and expressed as the economic condition as poor, respectively. Conclusion: History of pre-delivery anemia, maternal age, prolong labor, type of delivery, oxytocin use, low economic status, low education level and hypertension in pregnancy were associated factors for postpartum hemorrhage. 20-29-year age group, atony of uterus, prolonged labour, use of oxytocin, toxemia of pregnancy, and C/S delivery was statistically significant risk factors between primiparous and multiparous women. Close observation in antenatal, pre partum periods and intrapartum period is needed to identify women who have associated factors and early intervention to prevent post-partum hemorrhage.

The impact of the COVID-19 pandemic on perinatal services and maternal mental health in the UK.

COVID-19 has created many challenges for women in the perinatal phase. This stems from prolonged periods of lockdowns, restricted support networks and media panic, alongside altered healthcare provision. We aimed to review the evidence regarding the psychological impact on new and expecting mothers following changes to antenatal and postnatal service provision within the UK throughout the pandemic. We conducted a narrative literature search of major databases (PubMed, Medline, Google Scholar). The literature was critically reviewed by experts within the field of antenatal and perinatal mental health. Changes to service provision, including the introduction of telemedicine services, attendance of antenatal appointments without partners or loved ones, and lack of support during the intrapartum period, are associated with increased stress, depression and anxiety. Encouraging women and their partners to engage with aspects of positive psychology through newly introduced digital platforms and virtual service provision has the potential to improve access to holistic care and increase mental well-being. An online course, designed by Imperial College Healthcare NHS Trust in response to changes to service provision, focuses on postnatal recovery inspiration and support for motherhood (PRISM) through a 5-week programme. So far, the course has received positive feedback. The pandemic has contributed to increased rates of mental illness among pregnant and new mothers in the UK. Although the long-term implications are largely unpredictable, it is important to anticipate increased prevalence and complexity of symptoms, which could be hugely detrimental to an already overburdened National Health Service.

Obesity in Pregnancy: A Comprehensive Review of Influential Guidelines.

Obesity is one of the most common clinical entities complicating pregnancies and is associated with short- and long-term consequences for both the mother and the offspring. The aim of this study were to review and compare the most recently published influential guidelines on the management of maternal obesity in the preconceptional, antenatal, intrapartum, and postpartum period. A descriptive review of guidelines from the American College of Obstetricians and Gynecologists, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynecologists of Canada, the Royal College of Obstetricians and Gynecologists, and the Royal Australian and New Zealand College of Obstetricians and Gynecologists on obesity in pregnancy was carried out. There is an overall agreement among the reviewed guidelines regarding the importance of prepregnancy weight loss with behavioral modification, optimization of gestational weight gain, and screening for comorbidities in improving pregnancy outcomes of obese women. Women with previous bariatric surgery should be screened for nutritional deficiencies and have a closer antenatal surveillance, according to all guidelines. In addition, folic acid supplementation is recommended for 1 to 3 months before conception and during the first trimester, but several discrepancies were identified with regard to other vitamins, iodine, calcium, and iron supplementation. All medical societies recommend early screening for gestational diabetes mellitus and early anesthetic assessment in obese women and suggest the use of aspirin for the prevention of preeclampsia when additional risk factors are present, although the optimal dosage is controversial. The International Federation of Gynecology and Obstetrics, Society of Obstetricians and Gynecologists of Canada, Royal College of Obstetricians and Gynecologists, and Royal Australian and New Zealand College of Obstetricians and Gynecologists point out that specific equipment and adequate resources must be readily available in all health care facilities managing obese pregnant women. Moreover, thromboprophylaxis and prophylactic antibiotics are indicated in case of cesarean delivery, and intrapartum fetal monitoring is justified during active labor in obese patients. However, there are no consistent protocols regarding the fetal surveillance, the monitoring of multiple gestations, the timing and mode of delivery, and the postpartum follow-up, although weight loss and breastfeeding are unanimously supported. Obesity in pregnancy is a significant contributor to maternal and perinatal morbidity with a constantly rising global prevalence among reproductive-aged women. Thus, the development of uniform international protocols for the effective management of obese women is of paramount importance to safely guide clinical practice and subsequently improve pregnancy outcomes.

Maternal Healthcare Services in a Rural Area of Haryana during the COVID-19 Pandemic: A Community-Based Study.

It is well documented that the utilization of maternal healthcare services during pregnancy and childbirth plays a significant role in reducing maternal morbidity and mortality. Disruptions in maternal healthcare services during the coronavirus disease 2019 (COVID-19) pandemic have been reported. However, there is a paucity of literature from rural areas, as most of the previous studies are either record-based or conducted in tertiary care centers. This study aimed to determine the proportion of women who received the recommended maternal healthcare services during the COVID-19 pandemic and to study various factors associated with the utilization of services. In this community-based study, we assessed the utilization of maternal healthcare services among 520 women residing in the Ballabgarh Block of District Faridabad, Haryana, whose antenatal, intrapartum, and postnatal period coincided with the first wave of COVID-19 pandemic. Domiciliary visits were made, and women were interviewed retrospectively regarding maternal healthcare services utilized by them. The antenatal care (ANC) cards were reviewed, and details were corroborated. Full ANC was received by 15.3% of women, and 45% of women had less than four antenatal visits. 30.9% of participants had cesarean delivery. The proportion of cesarean delivery in private facilities was significantly higher than in government facilities [Odds Ratio (OR) (95% Confidence intervals (CI)) =10.04 (5.87-17.19); P < 0.001]. In multivariate logistic regression, gravidity was negatively associated with full ANC [OR (95% CI) =0.43 (0.25-0.74); P = 0.002]. Fewer women received the recommended maternal healthcare services during the COVID-19 pandemic. Detailed assessment of health systems and factors affecting routine healthcare services, during the pandemic, can help improve the readiness and response in the future.

Management of hypertension during pregnancy: A meta-analysis

Gestational hypertension, chronic hypertension, preeclampsia, and preeclampsia superimposed on pre-existing hypertension are the four categories into which the National High Blood Pressure Education Program of the NHLBI divides hypertensive disorders of pregnancy. Pregnant women with hypertension are at risk for death, renal failure, heart failure, hepatic rupture, cerebral edema, and cerebrovascular accidents. The foetuses of hypertension mothers are at risk for stillbirth, intrauterine growth restriction, and preterm birth difficulties after delivery due to maternal symptoms. When the diastolic pressure is greater than 90 to 110 mm Hg or the systolic pressure is greater than 140 to 170 mm Hg, most doctors start antihypertensive medication. A pre-pregnancy assessment for women with chronic hypertension should focus on end-organ damage, medication history, possible secondary causes of hypertension, and counselling on pregnancy's hazards. Women need to be monitored during their pregnancies, as well as during the intrapartum and postpartum periods.

“I didn't feel like I could trust her and that felt really risky”: a phenomenographic exploration of how Australian Midwives describe intrapartum risk

ObjectiveConcepts of intrapartum risk are not well explored in the Australian context. In response to an increasing focus on risk in maternity care, we sought to obtain insight into what Australian midwives conceptualised as intrapartum risk. DesignThe research was conducted using a phenomenographic approach. Following ethical approval, in-depth semi-structured interviews were used to determine the qualitatively different ways midwives conceptualise intrapartum risk. SettingThis project was undertaken across different midwifery practice settings in Australia. ParticipantsAustralian midwives (n=14) with expertise in caring for women in the intrapartum period volunteered to participate in the study. FindingsWhen discussing their experience of intrapartum risk, midwives focused on the external horizon of the woman as the risk, that included the internal horizons of being labelled as clinically high risk, working relationships within transdisciplinary risk and institutional risk. Risks were orientated toward the woman as well as to the midwives. Key conclusionsThe midwives in this study conceptualised that intrapartum risk was associated with the woman including being labelled as high risk in addition to certain challenges within the midwife-woman relationship, particularly if there was a lack of reciprocal trust. Implications for practiceThis study supports current evidence that improved collaborative professional relationships are integral to safety in maternity care. It reinforces continuity of midwifery care as important, and particularly as a way of mitigating intrapartum risk. Further research is required to inform what challenges experienced in the midwife-woman relationship contribute to concepts of risk.

Sorting Out the Risks and Benefits of the #797 Recommended Intrapartum Vancomycin Dosing Approach.

ACOG Committee Opinion #797 proposed intrapartum vancomycin dosing guidelines in the absence of thorough evaluation of its risk versus benefit profile on the maternal and neonatal systems. The previously published serum and cord-blood concentration-time data of vancomycin given to mothers in the intrapartum period was analyzed in this work with a two-compartment pharmacokinetic (PK) model. Monte Carlo simulation was used to establish exposure for the studied population for doses of 1000 mg to 2000 mg every 8 h for gestational ages (GA) of 33 to 40 weeks and for birth times up to 4-h intervals. Probabilities of target attainment (PTA) were calculated for efficacy and toxicity indices unique to the peripartum maternal and neonatal population. Neonatal evaluations indicate uniformly high PTAs for the evaluated dosing regimens when the efficacy target is considered. On the other hand, the PTAs for potentially nephrotoxic exposure is expected to reach undesirable levels when three or more doses were to be administered. The risk is profoundly high in GA below 36 weeks and birth times beyond 20 h after the initiation of intrapartum prophylaxis and with doses greater than 1250 mg. Maternal vancomycin exposures seem reasonable up to two intrapartum doses given at 8 h intervals when the dose is kept to 1250 mg or less. Most mothers (up to 83%) who receive three or more doses of the commonly administered regimens are subjected to nephrotoxic exposures. Thus, it appears that the current recommendations by #797 for dosing of vancomycin pose considerable risk to mother and newborn alike, especially in cases with lengthy duration of preterm labor. Capping of doses at 1250 mg may be considered to minimize the need for therapeutic drug monitoring (TDM) interventions. Alternatively, and irrespective of the baseline maternal renal function, TDM for all cases requiring more than two doses of 1500 mg or higher must be assured.

Limiting adverse birth outcomes in resource-limited settings (LABOR): protocol of a prospective intrapartum cohort study.

Background: Each year, nearly 300,000 women and 5 million fetuses or neonates die during childbirth or shortly thereafter, a burden concentrated disproportionately in low- and middle-income countries. Identifying women and their fetuses at risk for intrapartum-related morbidity and death could facilitate early intervention. Methods: The Limiting Adverse Birth Outcomes in Resource-Limited Settings (LABOR) Study is a multi-country, prospective, observational cohort designed to exhaustively document the course and outcomes of labor, delivery, and the immediate postpartum period in settings where adverse outcomes are frequent. The study is conducted at four hospitals across three countries in Ghana, India, and Zambia. We will enroll approximately 12,000 women at presentation to the hospital for delivery and follow them and their fetuses/newborns throughout their labor and delivery course, postpartum hospitalization, and up to 42 days thereafter. The co-primary outcomes are composites of maternal (death, hemorrhage, hypertensive disorders, infection) and fetal/neonatal adverse events (death, encephalopathy, sepsis) that may be attributed to the intrapartum period. The study collects extensive physiologic data through the use of physiologic sensors and employs medical scribes to document examination findings, diagnoses, medications, and other interventions in real time. Discussion: The goal of this research is to produce a large, sharable dataset that can be used to build statistical algorithms to prospectively stratify parturients according to their risk of adverse outcomes. We anticipate this research will inform the development of new tools to reduce peripartum morbidity and mortality in low-resource settings.