Mater Mothers Research Articles

Prelabour myocardial deformation and cardiac output in fetuses that develop intrapartum compromise at term: a prospective observational study

Objective: Redistribution of cardiac output is responsible for the “brain sparing” effect seen during periods of acute or chronic fetal stress. We investigated the relationship between prelabour cardiac function in fetuses that subsequently developed intrapartum fetal compromise (IFC).Methods: A blinded, prospective, observational, cohort study, at Mater Mother’s Hospital, Brisbane, Australia. A cohort of 284 women with uncomplicated singleton pregnancies underwent ultrasound every 2 weeks from 36 weeks until delivery. Fetal cardiac output was assessed by conventional Doppler ultrasound and myocardial deformation was measured using velocity vector imaging.Results: Two hundred and seventy three women were included in the final analysis, of which 19% had an emergency operative delivery for intrapartum fetal compromise (IFC). Global left ventricular strain (−12.1%, interquartile ranges (IQR) − 10.3 to −14% versus 13%, IQR −11.3 to −14.2%, p = .01) and strain rate (−1.00, IQR 0.85–1.16 s−1 versus −1.11, IQR −1.00 to −1.21 s−1, p < .001) were lower in fetuses that required any emergency operative delivery for IFC compared to those that did not. Global longitudinal right ventricular strain rate was lower in fetuses that developed IFC (−1.04 ± 0.22 s−1 versus 1.13 ± 0.22 s−1, p < .001), whereas global right ventricular strain did not show any significance differences between the two groups. Additionally, left ventricular cardiac output was lower in fetuses that developed IFC or had a composite neonatal morbidity (560 ± 44 mL/min versus 617 ± 72 mL/min, p < .001) or (581 ± 44 mL/min versus 612 ± 72 mL/min, p < .01), respectively.Conclusion: Lower global left ventricular strain and strain rate and cardiac output are associated with IFC and poorer condition of the newborn. Assessment of fetal cardiac function may be useful for risk stratification for intrapartum fetal compromise in apparently “low risk” term pregnancies.

Is the fetal cerebroplacental ratio better that the estimated fetal weight in predicting adverse perinatal outcomes in a low risk cohort?

Objective: In high-risk pregnancies combining the cerebro–placental ratio (CPR) with the estimated fetal weight (EFW) improves the identification of vulnerable fetuses. The purpose of this study was to assess the CPR and EFW’s ability to predict adverse obstetric and perinatal outcomes in a low-risk pregnancy, when measured late in gestation.Methods: This was a retrospective study of women who birthed at Mater Mothers Hospitals, Brisbane, Australia between 2010 and 2015. We included all nonanomalous singleton pregnancies that had an ultrasound scan performed between 36 and 38 weeks gestation. Excluded was any major congenital abnormality, aneuploidy, multiple pregnancy, preterm birth, maternal hypertension, or diabetes. The primary outcome was a severe composite neonatal outcome (SCNO) defined as severe acidosis (umbilical cord artery pH <7.0, cord lactate ≥6 mmol/L, cord base excess ≤-12 mmol/L) Apgar score ≤3 at 5 minutes, admission to the neonatal intensive care unit (NICU), and death. A low CPR was defined as <10th centile for gestation and small for gestational age (SGA) was defined as an EFW <10th centile and appropriate for gestational age (AGA) was defined as EFW ≥10th centile.Results: Of 2425 pregnancies, 13.2% (321/2425) had a fetus with a CPR <10th centile and 13.7% (332/2425) with an EFW <10th centile. Both a low CPR and SGA predicted the SCNO. Individually a low CPR and SGA had sensitivity for detection of SCNO of 23.3% and 24.7%, respectively which increased to 36.7% when combined. Both were associated with emergency caesarean for nonreassuring fetal status (NRFS), as well as early-term birth and admission to NICU. Stratifying the population into EFW <10th centile and EFW ≥10th centile, a low CPR maintained its association with the SCNO, early-term birth and emergency caesarean for NRFS in the cohort with an EFW <10th centile but SCNO lost its association with a low CPR in the EFW >10th cohort. Stratifying the population into CPR <10th centile and CPR >10th centile, a low EFW was associated with early-term birth, induction of labor, admission to NICU, and the SCNO.Conclusions: In a low-risk cohort both the CPR and EFW individually and in combination predicts adverse obstetric and perinatal outcomes when measured late in pregnancy. However, the predictive value was enhanced when both were used in combination.

Term small-for-gestational-age infants from low-risk women are at significantly greater risk of adverse neonatal outcomes

Small-for-gestational-age infants (birthweight <0th centile) are at increased risk of perinatal complications but are frequently not identified antenatally, particularly in low-risk women delivering at term (≥37 weeks gestation). This is compounded by the fact that late pregnancy ultrasound is not the norm in many jurisdictions for this cohort of women. We thus investigated the relationship between birthweight <10th centile and serious neonatal outcomes in low-risk women at term. We aimed to determine whether there is a difference of obstetric and perinatal outcomes for small-for-gestational-age infants, subdivided into fifth to <10th centile and less than the fifth centile cohorts compared with an appropriate-for-gestational age (birthweight 10th-90th centile) group at term. This was a retrospective analysis of data from the Mater Mother's Hospital in Brisbane, Australia, for women who delivered between January 2000 and December 2015. Women with multiple pregnancy, diabetes mellitus, hypertension, preterm birth, major congenital anomalies, and large for gestational age infants (>90th centile for gestational age) were excluded. Small-for-gestational-age infants were subdivided into 2 cohorts: infants with birthweights from the fifth to <10th centile and those less than the fifth centile. Serious composite neonatal morbidity was defined as any of the following: Apgar score ≤3 at 5 minutes, respiratory distress syndrome, acidosis, admission into the neonatal intensive care unit, stillbirth, or neonatal death. Univariate and multivariate analyses were performed using generalized estimating equations to compare obstetric and perinatal outcomes for small-for-gestational-age infants compared with appropriate-for-gestational age controls. The final study comprised 95,900 infants. Five percent were between the fifth and <10th centiles for birthweight and 4.3% were less than the fifth centile. The rate of serious composite neonatal morbidity was 11.1% in the control group, 13.7% in the fifth and <10th centile, and 22.6% in the less than the fifth centile cohorts, respectively. Even after controlling for confounders, both the fifth to <10th centiles and less than the fifth centile cohorts were at significantly increased risk of serious composite neonatal morbidity compared with controls (odds ratio, 1.25, 95% confidence interval, 1.15-1.37, and odds ratio, 2.20, 95% confidence interval, 2.03-2.39, respectively). Infants with birthweights <10th centile were more likely to have severe acidosis at birth, 5 minute Apgar score ≤3 and to be admitted to the neonatal intensive care unit. The serious composite neonatal morbidity was higher in infants less than the fifth centile compared with those in the fifth to <10th centile cohort (odds ratio, 1.71, 95% confidence interval, 1.52-1.92). The odds of perinatal death (stillbirth and neonatal death) were significantly higher in both small-for-gestational age groups than controls. After stratification for gestational age at birth, the composite outcome remained significantly higher in both small-for-gestational-age cohorts and was highest in the less than the fifth centile group at 37+0 to 38+6 weeks (odds ratio, 3.32, 95% confidence interval, 2.87-3.85). The risk of perinatal death was highest for infants less than the fifth centile at 37+0 to 38+6 weeks (odds ratio, 5.50, 95% confidence interval, 2.33-12.98). Small-for-gestational-age infants from term, low-risk pregnancies are at significantly increased risk of mortality and morbidity when compared with appropriate-for-gestational age infants. Although this risk is increased at all gestational ages in infants less than the fifth centile for birthweight, it is highest at early-term gestation. Our findings highlight that early-term birth does not necessarily improve outcomes and emphasize the importance of identifying this cohort of infants.

Reference centiles for the middle cerebral artery and umbilical artery pulsatility index and cerebro-placental ratio from a low-risk population – a Generalised Additive Model for Location, Shape and Scale (GAMLSS) approach

Objective: The primary aim of this study was to create reference ranges for the fetal Middle Cerebral artery Pulsatility Index (MCA PI), Umbilical Artery Pulsatility Index (UA PI) and the Cerebro–Placental Ratio (CPR) in a clearly defined low-risk cohort using the Generalised Additive Model for Location, Shape and Scale (GAMLSS) method.Methods: Prospectively collected cross-sectional biometry and Doppler data from low-risk women attending the Mater Mother’s Hospital, Maternal and Fetal Medicine Department in Brisbane, Australia between January 2010 and April 2017 were used to derive gestation specific centiles for the MCA PI, UA PI and CPR. All ultrasound scans were performed between 18 + 0 and 41 + 6 weeks gestation with recorded data for the MCA PI and/or UA PI. The GAMLSS method was used for the calculation of gestational age-adjusted centiles. Distributions and additive terms were assessed and the final model was chosen on the basis of the Global Deviance, Akaike information criterion (AIC) and Schwartz bayesian criterion (SBC), along with the results of the model and residual diagnostics as well as visual assessment of the centiles themselves.Results: Over the study period 6013 women met the inclusion criteria. The MCA PI was recorded in 4473 fetuses, the UA PI in 6008 fetuses and the CPR was able to be calculated in 4464 cases. The centiles for the MCA PI used a fractional polynomial additive term and Box-Cox t (BCT) distribution. Centiles for the UA PI used a cubic spline additive term with BCT distribution and the CPR used a fractional polynomial additive term and a BCT distribution.Conclusion: We have created gestational centile reference ranges for the MCA PI, UA PI and CPR from a large low-risk cohort that supports their applicability and generalisability.

Birth-weight centiles and the risk of serious adverse neonatal outcomes at term.

Birth-weight is an important determinant of perinatal outcome with low birth-weight being a particular risk factor for adverse consequences. To investigate the impact of neonatal sex, mode of birth and gestational age at birth according to birth-weight centile on serious adverse neonatal outcomes in singleton term pregnancies. This was a retrospective cohort study of singleton term births at the Mater Mother's Hospital, Brisbane, Australia. Serious adverse neonatal outcome was defined as a composite of severe acidosis at birth (pH ≤7.0 and/or lactate ≥6 mmol/L and/or base excess ≤-12 mmol/L), Apgar <3 at 5 min, neonatal intensive-care unit admission and antepartum or neonatal death. The main exposure variable was birth-weight centile. Of the 69,210 babies in our study, the overall proportion of serious adverse neonatal outcomes was 9.1% (6327/69,210). Overall, neonates in the <3rd birth-weight centile category had the highest adjusted odds ratio (OR) for serious adverse neonatal outcomes [OR 3.53, 95% confidence interval (CI) 3.06-4.07], whilst those in the ≥97th centile group also had elevated odds (OR 1.51, 95% CI 1.30-1.75). Regardless of birth modality, smaller babies in the <3rd centile group had the highest adjusted OR and predicted probability for serious adverse neonatal outcomes. When stratified by sex, male babies consistently demonstrated a higher predicted probability of serious adverse neonatal outcomes across all birth-weight centiles. The adjusted odds, when stratified by gestational age at birth, were the highest from 37+0 to 38+6 weeks in the <3rd centile group (OR 5.97, 95% CI 4.60-7.75). Low and high birth-weights are risk factors for serious adverse neonatal outcomes. The adjusted OR appears to be greatest for babies in the <3rd birth-weight centile group, although an elevated risk was also found in babies within the ≥97th centile category.

Maternal demographic factors associated with emergency caesarean section for non-reassuring foetal status.

This study aimed to determine maternal and obstetric factors associated with emergency caesarean section (CS) for non-reassuring foetal status (NRFS). This was a retrospective analysis of term singleton births between January 2007 and December 2015 at the Mater Mother's Hospital in Brisbane. The study group comprised all cases of emergency CS for NRFS, and the control cohort comprised all other births meeting the inclusion criteria but excluding those in the study cohort. Over the study period, there were 74,177 births fulfilling the inclusion criteria. The overall rate of emergency CS for NRFS was 4.2% (3132/74,177). Multivariate analysis showed that being overweight and obese, Indian and "other" ethnicity, artificial reproductive techniques, smoking, induction of labour and gestation at 39-42 weeks were associated with an increased risk, whereas being underweight, female sex, hypertension and birth without labour conferred a lower risk. Many maternal and obstetric factors were associated with emergency CS for NRFS and influenced adverse perinatal outcomes. Recognition of these risk factors could help risk stratify women prior to labour.

Assessment of left ventricular function using the Myocardial Performance Index in term fetuses that develop intrapartum compromise

Objective: To investigate the relationship between the prelabour left ventricular Myocardial Performance Index (LVMPI) and intrapartum fetal compromise (IFC) in low-risk term pregnancies.Methods: A blinded, prospective observational cohort study at the Mater Mother’s Hospital, Brisbane, Australia. A cohort of 284 women with uncomplicated singleton pregnancies underwent fortnightly ultrasound from 36 weeks until delivery. The LVMPI was assessed by conventional Doppler ultrasound and correlated with intrapartum outcomes. The LVMPI was also correlated with other Doppler indices of fetal wellbeing.Results: Two hundred and seventy-three women were included in the final analysis, the median LVMPI was higher in fetuses that required any emergency operative delivery for IFC (0.56, 0.52–0.60 versus 0.54, 0.50–0.58, p = .007). The left ventricular cardiac output (LVCO) and cerebroplacental ratio (CPR) were lower in fetuses that required any emergency operative delivery for IFC compared to those that did not (164 ± 19 ml/min/kg versus 181 ± 30 ml/min/kg, p < .001) (1.63 + 0.30 versus 1.90 + 0.50, p < .001), respectively. The LVMPI was inversely correlated with the CPR (r = −0.20, p < .01), MCA PI (r = −0.29, p < .01), and LVCO (r = −0.22, p < .01).Conclusions: Higher global LVMPI is associated with a higher risk for IFC and poorer condition of the newborn.

Impact of shoulder dystocia, stratified by type of manoeuvre, on severe neonatal outcome and maternal morbidity.

Shoulder dystocia is an uncommon and unpredictable obstetric emergency. It is associated with significant neonatal, maternal and medico-legal consequences. To ascertain the impact shoulder dystocia has on severe neonatal and maternal outcomes specific to the type of manoeuvre. This was a retrospective study of 48021 term singleton vaginal deliveries the Mater Mothers' Hospital in Brisbane between 2007 and 2015. Maternal and neonatal outcomes were compared between deliveries complicated by shoulder dystocia and those uncomplicated. Deliveries complicated by shoulder dystocia are associated with low Apgar scores (≤3) at five minutes (odds ratio (OR) 5.25, 95% CI 3.23-8.56, P<0.001), acidosis (OR 3.10, 95% CI 2.76-3.50, P<0.001), postpartum haemorrhage (OR 2.28, 95% CI 1.90-2.75, P<0.001) and perineal trauma (OR 1.92, 95% CI 1.54-2.39, P<0.001). Compared to McRoberts' manoeuvre and suprapubic pressure alone, the odds of serious neonatal outcome are increased with internal rotational manoeuvres (OR 3.82, 95% CI 2.54-5.74, P<0.001) and delivery of the posterior arm (OR 4.49, 95% CI 3.54-5.69, P<0.001). The OR of maternal injury is 2.07 (95% CI 1.77-2.45, P<0.001), 2.26 (95% CI 1.21-4.21, P<0.001) and 2.29 (95% CI 1.58-3.32, P<0.001) with McRoberts'/suprapubic pressure, internal rotation and posterior arm delivery, respectively. Brachial plexus injuries and fractures complicate 1.4 and 0.9% of deliveries, with the risk of injury increasing when greater than one manoeuvre is required. The risk of neonatal and maternal trauma is strongly associated with the number and types of manoeuvres. Given the associated implications, adequate antenatal counselling, simulation training and enhanced labour surveillance are essential.

Cerebroplacental ratio in pregnancies complicated by gestational diabetes mellitus.

To assess the relationship between the cerebroplacental ratio (CPR) and intrapartum and perinatal outcomes in pregnancies complicated by gestational diabetes mellitus (GDM). This was a retrospective cohort study of women with a non-anomalous singleton pregnancy diagnosed with GDM who delivered at Mater Mothers' Hospital between 2007 and 2015. CPR was measured in 1089 cases between 34 + 0 and 36 + 6 weeks' gestation. CPR values were compared between groups categorized according to GDM treatment (by diet, oral hypoglycemic agent (OHA) or insulin). The association between CPR and intrapartum and perinatal outcomes was evaluated. No difference in CPR was observed between treatment groups. Fetuses with CPR < 10th centile were significantly more likely to have adverse composite perinatal outcome (odds ratio (OR) = 2.93 (95% CI, 1.95-4.40)), preterm delivery and low birth weight than fetuses with CPR ≥ 10th centile (all P < 0.001). These associations were present regardless of the type of GDM treatment. Fetuses of women with insulin-controlled GDM had poorer neonatal outcomes than did fetuses of women treated with OHA or dietary control alone. The risk of adverse outcome was significantly increased in the insulin-treated group (OR = 1.75 (95% CI, 1.34-2.28); P < 0.001), which also had higher rates of preterm delivery and higher birth weight. Regardless of the type of treatment, a low CPR is associated with poorer neonatal outcome in women with GDM. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Demographic characteristics and pregnancy outcomes in adolescents - Experience from an Australian perinatal centre.

Adolescent pregnancy is defined as pregnancy in girls aged 10-19years and can be associated with increased risks. To investigate obstetric and perinatal outcomes in a cohort of adolescent girls from a major Australian tertiary centre. This was a nine-year retrospective cohort study of women who birthed at the Mater Mother's Hospital (MMH) in Brisbane, Australia between 1 January 2007 and 31 December 2015. The adolescent cohort was aged <19years and the control group was aged 20-24years. Over the study period the total study cohort comprised 8904 women. Of these, the adolescent cohort consisted of 1625 girls (18.2%) and the control group consisted of 7279 women (81.8%). Adolescents were more likely to be nulliparous, single, of Indigenous ethnicity or to have refugee status. They had higher rates of smoking, asthma, diabetes mellitus and thyroid disease. They were more likely to have an uncomplicated spontaneous vaginal delivery but were less likely to have an intact perineum and had higher rates of pre-term delivery and low birth weight babies. There were no differences in rates of postpartum haemorrhage. Teenage pregnancy results in poorer obstetric and perinatal outcomes. A focus on optimising maternal health care and providing culturally appropriate antenatal and intrapartum care is imperative to improving outcomes.

The relationship between the five minute Apgar score, mode of birth and neonatal outcomes

Objective: To investigate the relationship between the five-minute Apgar score categories (low, intermediate, and normal), mode of birth and neonatal outcomes.Methods: This was a retrospective cross sectional study of term singleton deliveries at Mater Mothers’ Hospital in Brisbane, Australia between January 2007 and December 2015. The five minute score was subdivided in to three categories – low (0–3), intermediate (4–6), and normal (≥7). These were correlated with adverse neonatal outcomes and mode of birth. The referent cohort was the normal Apgar group.Results: The study cohort consisted of 39,258 births with a recorded five minute Apgar score. Of these, 38,705 (98.6%) neonates had a normal (≥7) Apgar score, 439 (1.1%) had an intermediate score (4–6) and 114 (0.3%) had a low (0–3) score. Neonatal complications including respiratory distress, feeding problems, hypothermia, and seizures were all significantly associated with both low and intermediate Apgar scores. Emergency operative birth (caesarean and instrumental) conveyed a higher risk of low and intermediate scores and poorer neonatal outcomes.Conclusions: Low and intermediate five minute Apgar scores were strongly associated with mode of birth and poorer neonatal outcomes.

The fetal cerebro-placental ratio in diabetic pregnancies is influenced more by the umbilical artery rather than middle cerebral artery pulsatility index

ObjectiveThis study aimed to assess the relationship between the cerebro-placental ratio (CPR) and intrapartum and perinatal outcomes in pregnancies complicated by pre-existing insulin dependent diabetes (pT1DM) mellitus, pre-existing non-insulin dependent diabetes mellitus (pT2DM) and gestational diabetes mellitus (GDM). Study designThis was a retrospective cohort study of 1281 women with diabetes mellitus birthing at the Mater Mothers’ Hospital in Brisbane between 2007 and 2015. The CPR in non-anomalous singleton fetuses was measured between 34+0 and 36+6 weeks gestation and compared between types of DM treatment groups and correlated with intrapartum and perinatal outcomes. ResultsOf the study cohort, 9.7% (124/1281) had pT1DM, 5.3% (68/1281) had pT2DM and 85.0% (1089/1281) had GDM. Of women with pT2DM and GDM, 61.8% (42/68) and 28.9% (315/1089) respectively, required insulin during pregnancy. Women with pT1DM had an increased odds of having a CPR <5th centile (OR 3.73, 95%CI: 1.90-6.96, p=0.0001) or a CPR <10th centile (OR 3.01, 95% CI: 1.80–4.91, p<0.0001) respectively. The odds of a UA PI >90th centile (OR 2.69, 95% CI: 1.60–4.39, p=0.0001) was higher in the pT1DM cohort. There was however no significant difference in the mean MCA PI between the three groups. Stratification by CPR centiles (<10th centile vs. ≥10th centile) demonstrated a lower birth weight in the CPR <10th centile cohort for all DM categories. The proportion of neonates with birth weights <10th centile were higher in the CPR <10th centile cohort with the GDM cohort having an odds ratio of 8.28 (95% CI 4.22–16.13, p<0.0001) of this complication. The CPR <10th centile cohort also had a greater proportion of adverse composite neonatal outcome regardless of type of DM. ConclusionsRegardless of the type of DM, a low CPR was associated with poorer neonatal outcomes. Women with pT1DM also had the highest mean UA PI and lowest mean CPR despite no difference in the mean MCA PI between the three groups.

Perinatal risk factors for low and moderate five-minute Apgar scores at term

ObjectiveTo evaluate the specific maternal and perinatal variables associated with a low (≤3) or moderate (4–6) Apgar score, compared to a high (≥7) score. Study designThis was a retrospective, cohort study of 58429 term singleton babies born at the Mater Mother’s Hospital in Brisbane, Australia in 2007–2013. Maternal demographics, socio-economic status using the Australian Socioeconomic Index for Areas (SEIFA) score, obstetric factors, and birth outcomes were compared for neonates grouped into three categories based on their five-minute Apgar: low (≤3), moderate (4–6) and high (≥7). The low- and moderate-score cohorts were individually compared to the high-score cohort using both univariate and multivariate analysis. ResultsLogistic regression analysis confirmed that of the variables analysed, only maternal public insurance status (OR 2.1, 95% CI 1.5–3.1), breech presentation (OR 2.4, 95% CI 1.1–4.6), other non-cephalic presentation (OR 9.5, 95% CI 2.2–25.4), intramuscular narcotic use (OR 2.3, 95% CI 1.5–3.5), and presence of meconium (OR 3.7, 95% CI 2.5–5.4) were significantly associated with low Apgar scores. Variables significantly associated with a moderate score were: SEIFA ≤50th centile (OR 1.6, 95% CI 1.2–2.0) and 61st to 70th centile (OR 1.31, 95% CI 0.9–1.8) categories, maternal public insurance status (OR 2.7, 95% CI 2.2–3.3), nulliparity (OR 2.0, 95% CI 1.7–2.5), emergency caesarean birth (OR 2.6, 95% CI 2.1–3.2), instrumental birth (OR 2.3, 95% CI 1.9–2.9), and presence of meconium (OR 2.6, 95% CI 2.1–3.2). ConclusionsFactors associated with low and moderate Apgar scores vary in type and degree of influence. Distinctions in the perinatal background can help predict newborn compromise and accelerate delivery of care.

\u201cNot just a normal mum\u201d: a qualitative investigation of a support service for women who are pregnant subsequent to perinatal loss

BackgroundFollowing previous perinatal loss, women in a subsequent pregnancy may experience heightened emotions, such as anxiety and fear, with a range of longer-term implications. To support these women, the Mater Mothers’ Bereavement Support Service in Brisbane, Australia, developed a Pregnancy After Loss Clinic (PALC) as a specialised hospital-based service. The present study investigated the experiences of mothers with previous perinatal loss in relation to: (a) their subsequent pregnancy-to-birth journey, and (b) the PALC service. Such research seeks to inform the ongoing development of effective perinatal services.MethodA qualitative interview-based research design was employed with a purposive sample of 10 mothers who had previously experienced perinatal loss and who attended the Mater Mothers’ PALC during their subsequent pregnancy in 2015. All mothers had subsequently delivered a live baby and were in a relationship with the father of the new baby. Women were aged between 22 and 39 years, primiparous or multiparous, and from a range of cultural backgrounds. Semi-structured interviews, conducted either at the hospital or by telephone by an experienced, independent researcher, lasted between 20 min and one hour. All interviews were audio-recorded and transcribed verbatim, with participant names changed. Interviews were analysed using content analysis by two researchers who were not involved in the service delivery or data gathering process.ResultsSeven themes were identified from the interview material: The overall experience, The unique experience of first pregnancy after loss, Support from PALC, Experiences of other services, Recommendations for PALC services, Need for alternative services, and Advice: Mother to mother.ConclusionsParticipants spoke positively of the PALC services for themselves and their families. Anxieties over their subsequent pregnancy, and the desire for other health professionals to be more understanding were frequently raised. Recommendations were made to extend the PALC service and to develop similar services to support access for other families experiencing perinatal loss.

Intrapartum intervention rates and perinatal outcomes following induction of labour after 41 + 0 weeks compared to expectant management

Objective: There is limited evidence regarding the incidence of intrapartum fetal compromise in women who are induced compared to those managed expectantly. The aim of this study was to investigate intrapartum and perinatal outcomes in women who were induced at >41 + 0 weeks compared to an expectantly managed cohort.Methods: This was a retrospective cohort study of singleton, non-anomalous pregnancies delivering between 41 + 0 to 43 + 0 weeks at the Mater Mothers’ Hospital, Brisbane. We compared outcomes between women who were induced and those that laboured spontaneously.Results: Six thousand five hundred and one women met the inclusion criteria. Three thousand five hundred and eighty-eight women (55.2%) underwent IOL and 2913 women (44.8%) were managed expectantly. Higher rates of emergency caesarean section (29.4% versus 18.5%, p < 0.001) and higher rates of instrumental birth (20.2% versus 17.7%, p = 0.012) were found in the IOL cohort. The odds of requiring an emergency CS for non-reassuring fetal status was increased (OR 1.51, 95% CI 1.21–1.90). Other than a high proportion of neonatal acidosis in the IOL cohort, there were no differences in perinatal outcomes between the two groups.Conclusion: IOL > 41 weeks compared to expectant management results in higher rates of emergency caesarean section mainly due to intrapartum fetal compromise.

The relationship between maternal placental growth factor levels and intrapartum fetal compromise

IntroductionWhilst some cases of intrapartum fetal compromise are the result of unpredictable catastrophic events, the majority arise from an unrecognised reduction in feto-placental reserve in otherwise healthy pregnancies. There is currently no reliable technique prior to labour that identifies the at-risk fetus. We aimed to investigate the relationship between maternal levels of serum placental growth factor (PlGF) and intrapartum fetal compromise in term pregnancies prior to labour. Secondary outcomes were caesarean delivery for intrapartum fetal compromise and adverse neonatal outcomes. MethodsA blinded, prospective, cross sectional study set at Mater Mother's Hospital, Brisbane, Australia. Maternal PlGF concentration was assessed fortnightly from 36 weeks until delivery in 378 low-risk pregnant women. Antenatal and intrapartum care was managed according to local protocols and guidelines, and intrapartum and neonatal outcomes were recorded. ResultsPregnancies that developed intrapartum fetal compromise had lower PlGF than those that did not. PlGF concentration was also lower amongst pregnancies that developed intrapartum fetal heart rate abnormalities, were delivered with abnormal cord gases or Apgar ≤7 at 5 min. Additionally, PlGF levels were lower in pregnancies with an adverse composite neonatal outcome. DiscussionLower maternal PlGF concentration is associated with intrapartum fetal compromise and poorer condition of the newborn. Maternal PlGF levels may be useful as a component of a risk stratification tool for intrapartum fetal compromise in apparently 'low risk' term pregnancies prior to labour.

Comparison of maternal and neonatal outcomes from full-dilatation cesarean deliveries using the Fetal Pillow or hand-push method

ObjectiveTo compare maternal and neonatal outcomes of full-dilatation cesarean deliveries using the Fetal Pillow or hand- push method. MethodsA retrospective cohort study included data from all women who underwent full-dilatation cesarean deliveries at term that involved the use of the Fetal Pillow or the hand-push method at Mater Mothers’ Hospital, Brisbane, Australia between May 1, 2013 and March 31, 2015. Maternal (estimated blood loss, need for blood transfusion, uterine angle extension, and duration of stay in hospital following delivery) and neonatal outcomes (5-minute Apgar score below 7, cord arterial pH, admission to neonatal intensive care unit, and need for endotracheal intubation) were compared between the two treatment methods. ResultsOf 361 cesarean deliveries performed at full dilation during the study period, clinicians documented the use of a Fetal Pillow in 91 deliveries and use of the hand-push method in 69. Lower mean intra-operative blood loss (P=0.026), a shorter duration of postpartum hospital admission (P=0.002), and higher mean cord arterial pH (P=0.003) were observed in the Fetal Pillow group. ConclusionThe Fetal Pillow appears to be a safe and effective aid for the delivery of the fetal head during cesarean deliveries at full dilatation.

Impact of Maternal Body Mass Index on Intrapartum and Neonatal Outcomes in Brisbane, Australia, 2007 to 2013.

The aim of this study was to evaluate the influence of maternal body mass index on intrapartum and neonatal outcomes at one of the largest maternity hospitals in Australia. A retrospective cross-sectional study of 55,352 term singleton deliveries at the Mater Mothers' Hospital in Brisbane, Australia, was conducted. The study cohort was stratified into six groups based on the World Health Organization's body mass index classification. The normal body mass index category was the reference group for all comparisons. Multivariate logistic regression was used to examine the effect of maternal body mass index, adjusted for maternal age, ethnicity, parity, and preexisting conditions (e.g., diabetes mellitus and hypertension), on selected intrapartum and neonatal outcomes. Women in the overweight and Obese I, II, and III categories were more likely to have chronic or gestational hypertension/preeclampsia, and preexisting or gestational diabetes mellitus. They also had an increased risk for induction of labor, elective and emergency cesarean, and postpartum hemorrhage. Underweight women were less likely to require induction of labor and emergency cesarean. Infants born to women with increased body mass index were more likely to require neonatal resuscitation, neonatal intensive care unit admission, and have lower Apgar scores at 5 minutes. There is an increased risk of adverse intrapartum and neonatal outcomes for women who are overweight and obese, with the risks increasing with rising body mass index. Appropriately targeted weight management strategies and health education may yield improved maternal and perinatal outcomes if effectively implemented before pregnancy. These may particularly be of benefit in the teenage cohort that has yet to embark on pregnancy.

The association between a low cerebro-umbilical ratio at 30–34 weeks gestation, increased intrapartum operative intervention and adverse perinatal outcomes

IntroductionThe aim of this study was to investigate the relationship between the cerebro-umbilical ratio (CUR), measured at 30–34 weeks, and adverse intrapartum and perinatal outcomes. MethodsThis was a retrospective cross-sectional cohort study of women delivering at the Mater Mothers’ Hospital in Brisbane, Australia. Fetal Doppler indices for 1224 singleton pregnancies were correlated with maternal demographics and intrapartum and perinatal outcomes. Only women who attempted vaginal delivery were included in the study. ResultsInfants delivered by emergency cesarean section for fetal compromise had the lowest median CUR, 1.65 (IQR 1.17–2.12), compared to any other delivery group. The proportion of infants with a CUR ≤1 who required emergency cesarean section for fetal compromise was 33.3% compared to 9.3% of infants with a CUR >1 (adjusted OR 6.92 (95% CI 2.04–25.75), p<0.001). However, the detection rate of CUR ≤1 as a predictor for emergency cesarean delivery for fetal compromise was poor (18.9%). Detection rates increased in cohorts of infants born within two weeks of the scan or with birth weights <10th centile or <5th centile. Additionally, a CUR ≤1 was associated with lower median birth weight, higher rates of admission to the neonatal critical care unit and increased neonatal mortality. DiscussionThis study suggests that a CUR ≤1, measured at 30–34 weeks, is associated with a greater risk of emergency cesarean delivery for fetal compromise and a number of other adverse perinatal outcomes. The association was strongest in low birth weight babies.

Surgical management of abnormally invasive placenta: a retrospective cohort study demonstrating the benefits of a standardized operative approach.

Abnormally invasive placenta is a major cause of maternal morbidity and mortality. The aim of this study was to assess the effectiveness of a standardized operative approach performed by gynecological oncologists in the surgical management of abnormally invasive placenta. We performed a retrospective analysis of all cases of morbid placental adherence managed at the Mater Mothers' Hospitals, Brisbane, Australia between January 2000 and June 2013. A standard operative approach involving extensive retro-peritoneal and bladder dissection before delivery of the fetus, was undertaken when a gynecological oncologist was present at the start of the procedure. Main outcome measures were estimated blood loss, transfusion requirements, and maternal and neonatal morbidity. The study includes 98 cases of histologically confirmed abnormally invasive placenta. Median estimated blood loss for the entire cohort was 2150 mL (range 300-11 500 mL). Women were divided into three groups, (1) those who had a gynecological oncologist present at the start of the procedure (group 1; n = 43), (2) those who had a gynecological oncologist called in during the procedure (group 2; n = 23), and (3) those who had no gynecological oncologist involved (group 3; n = 32). Group 2 had a significantly higher blood loss than the other groups (p = 0.001) (median 4400 mL). Transfusion requirements were higher in groups 2 and 3 compared with group 1 (p = 0.004). Other maternal and neonatal morbidity was similar across all three groups. This study supports the early presence of a gynecological oncologist at delivery when abnormally invasive placenta is suspected and demonstrates that a "call if needed" approach is not acceptable for these complex cases.