Neonatal Morbidity Rates Research Articles

There is an obstetrical dilemma: Misconceptions about the evolution of human childbirth and pelvic form.

Compared to other primates, modern humans face high rates of maternal and neonatal morbidity and mortality during childbirth. Since the early 20th century, this "difficulty" of human parturition has prompted numerous evolutionary explanations, typically assuming antagonistic selective forces acting on maternal and fetal traits, which has been termed the "obstetrical dilemma." Recently, there has been a growing tendency among some anthropologists to question the difficulty of human childbirth and its evolutionary origin in an antagonistic selective regime. Partly, this stems from the motivation to combat increasing pathologization and overmedicalization of childbirth in industrialized countries. Some authors have argued that there is no obstetrical dilemma at all, and that the difficulty of childbirth mainly results from modern lifestyles and inappropriate and patriarchal obstetric practices. The failure of some studies to identify biomechanical and metabolic constraints on pelvic dimensions is sometimes interpreted as empirical support for discarding an obstetrical dilemma. Here we explain why these points are important but do not invalidate evolutionary explanations of human childbirth. We present robust empirical evidence and solid evolutionary theory supporting an obstetrical dilemma, yet one that is much more complex than originally conceived in the 20th century. We argue that evolutionary research does not hinder appropriate midwifery and obstetric care, nor does it promote negative views of female bodies. Understanding the evolutionary entanglement of biological and sociocultural factors underlying human childbirth can help us to understand individual variation in the risk factors of obstructed labor, and thus can contribute to more individualized maternal care.

Perinatal Morbidity in Healthy Obese Pregnant Individuals Delivered by Elective Repeat Cesarean at Term.

This study aimed to compare the risks of adverse perinatal outcomes by body mass index (BMI) categories in healthy pregnant individuals delivered by term elective repeat cesarean (ERCD) to describe an optimal timing of delivery in otherwise healthy patients at the highest-risk BMI threshold. A secondary analysis of a prospective cohort of pregnant individuals undergoing ERCD at 19 centers in the Maternal-Fetal Medicine Units Network from 1999 to 2002. Nonanomalous singletons undergoing prelabor ERCD at term were included. The primary outcome was composite neonatal morbidity; secondary outcomes included composite maternal morbidity and individual components of the composites. Patients were stratified by BMI classes and to identify a BMI threshold for which morbidity was the highest. Outcomes were then examined by completed week's gestation, between BMI classes. Multivariable logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI). A total of 12,755 patients were included in analysis. Patient's with BMI ≥ 40 had the highest rates of newborn sepsis, neonatal intensive care unit admissions, and wound complications. While a weight-related response was observed between BMI class and neonatal composite morbidity (p < 0.001), only those with BMI ≥ 40 had significantly higher odds of composite neonatal morbidity (aOR: 1.4, 95% CI: 1.0-1.8). In analyses of patients with BMI ≥ 40 (n = 1,848), there was no difference in the incidence of composite neonatal or maternal morbidity across weeks' gestation at delivery; however, as gestational age approached 39 to 40 weeks, rates of adverse neonatal outcomes decreased, only to increase again at 41 weeks' gestation. Of note, the odds of the primary neonatal composite were the highest at 38 weeks compared with 39 weeks (aOR: 1.5, 95% CI: 1.1-2.0). Neonatal morbidity is significantly higher in pregnant individuals with BMI ≥40 delivering by ERCD. Despite this increased perinatal morbidity, delivery prior to 39 and after 41 weeks in these patients is associated with increased neonatal risks. · Obese patients without additional comorbidities have higher rates of neonatal morbidity.. · Patients with BMI ≥ 40 carry the highest odds of poor perinatal outcomes.. · Earlier timing of delivery does not appear to reduce this risk..

Effect of delivery mode on admission to neonatal intensive care unit in healthy singleton pregnancies.

The aim of this study was to evaluate the short-term results of perinatal health in vaginal and cesarean deliveries and the indications for admission to the neonatal intensive care unit (NICU) in terms of healthy singleton pregnancies. In this study, 300 pregnant women who gave birth in our tertiary hospital was included. The records of newborns admitted to the NICU of these pregnant women were reviewed between January 1, 2019 and January 1, 2021. Durations of newborn hospitalizations and problems encountered during admission were recorded. The results were statistically evaluated. There was no significant difference between vaginal delivery and cesarean section groups in terms of the indications for admission to the NICU of term low-risk pregnant women (p=0.91, p=0.17). A higher admission in the NICU was found in the early term group. The early term group required more respiratory support compared to the full term group (p=0.02). When the groups were compared in terms of IV fluid treatment support, hypoglycemia or feeding difficulty, and jaundice requiring phototherapy, no significant difference was found. Withlimited data available for admission indications to the NICU of newborns born from term pregnancies, we found that the mode of delivery affects hospitalization indications of newborns, need for support, and Apgar scores. Early term delivery is associated with higher rates of neonatal morbidity and admission to the NICU. Better maternal care and prevention of factors that may lead to preterm birth will provide the prevention and management of these problems.

Risks of stillbirth, neonatal mortality, and severe neonatal morbidity by birthweight centiles associated with expectant management at term

Determining the optimal time of birth at term is challenging given the ongoing risks of stillbirth with increasing gestation vs the risks of significant neonatal morbidity at early-term gestations. These risks are more pronounced in small infants. This study aimed to evaluate the risks of stillbirth, neonatal mortality, and severe neonatal morbidity by comparing expectant management with delivery from 37+0 weeks of gestation. This was a retrospective cohort study evaluating women with singleton, nonanomalous pregnancies at 37+0 to 40+6 weeks' gestation in Queensland, Australia, delivered from 2000 to 2018. Rates of stillbirth, neonatal death, and severe neonatal morbidity were calculated for <3rd, 3rd to <10th, 10th to <25th, 25th to <90th, and ≥90th birthweight centiles. The composite risk of mortality with expectant management for an additional week in utero was compared with rates of neonatal mortality and severe neonatal morbidity. Of 948,895 singleton, term nonanomalous births, 813,077 occurred at 37+0 to 40+6 weeks' gestation. Rates of stillbirth increased with gestational age, with the highest rate observed in infants with birthweight below the third centile: 10.0 per 10,000 (95% confidence interval, 6.2-15.3) at 37+0 to 37+6 weeks, rising to 106.4 per 10,000 (95% confidence interval, 74.6-146.9) at 40+0 to 40+6 weeks' gestation. The rate of neonatal mortality was highest at 37+0 to 37+6 weeks for all birthweight centiles. The composite risk of expectant management rose sharply after 39+0 to 39+6 weeks, and was highest in infants with birthweight below the third centile (125.2/10,000; 95% confidence interval, 118.4-132.3) at 40+0 to 40+6 weeks' gestation. Balancing the risk of expectant management and delivery (neonatal mortality), the optimal timing of delivery for each birthweight centile was evaluated on the basis of relative risk differences. The rate of severe neonatal morbidity sharply decreased in the period between 37+0 to 37+6 and 38+0 to 38+6 weeks, particularly for infants with birthweight below the third centile. Our data suggest that the optimal time of birth is 37+0 to 37+6 weeks for infants with birthweight <3rd centile and 38+0 to 38+6 weeks' gestation for those with birthweight between the 3rd and 10th centile and >90th centile. For all other birthweight centiles, birth from 39+0 weeks is associated with the best outcomes. However, large numbers of planned births are required to prevent a single excess death. The healthcare costs and acceptability to women of potential universal policies of planned birth need to be carefully considered.

Male infants are at higher risk of neonatal mortality and severe morbidity.

While a male infant is usually born with a higher birthweight than his female counterpart, he is more at risk of variety of adverse perinatal outcomes. Indeed, throughout life, females exhibit a marked survival advantage compared to males. The aetiology for such pertinent sex disparity remains unclear and is likely multifactorial. The aim of this study was to investigate obstetric and perinatal outcomes by infant sex from 28 weeks in a contemporary, large Australian birth cohort. A 14-year retrospective cohort study of 130 133 births over 28 weeks gestation from a single tertiary centre. Male infants had overall higher rates of neonatal mortality (0.12% vs 0.06%, P < 0.001) and severe neonatal morbidity (12% vs 9.1%, P < 0.001) (adjusted odds ratio (aOR) 1.41, 95% CI 1.35-1.47). The odds of overall perinatal mortality (stillbirth and neonatal death) were higher for male infants (aOR 1.30, 95% CI 1.08-1.56). The difference in severe neonatal morbidity when stratified by gestational age at birth only remained significant from >35 weeks gestation. Regardless of infant sex, rates of neonatal mortality and morbidity were lowest at 39 weeks gestation. Rates of preterm birth and operative birth were also higher for male infants. Our study demonstrates significant disparities in clinical outcomes by infant sex with males at a disadvantage to female infants.

Effect of Prior Cesarean Section Delivery on Intrapartum Cesarean Section Outcomes [ID: 1372249

INTRODUCTION: Intrapartum cesarean deliveries (CDs) are associated with higher rates of maternal and neonatal morbidity than scheduled CDs. In patients undergoing trial of labor after cesarean (TOLAC), perceived added difficulty of intrapartum CD may influence provider decisions on labor management. We sought to evaluate the effect of prior CD on operative times and maternal/neonatal outcomes among those undergoing intrapartum CD. METHODS: This is a retrospective cohort study of all singleton, nonanomalous fetuses delivered by intrapartum CD at a tertiary care center from June 2018 to April 2019. CD was categorized as intrapartum if it occurred after the patient was admitted in spontaneous labor or received an induction agent. The primary outcome was time from skin incision to delivery. Secondary outcomes were composite measures of maternal (postpartum hemorrhage, bowel or bladder injury, transfusion, endomyometritis, intensive care unit admission, readmission, wound complications) and neonatal (neonatal intensive care unit admission, respiratory support, therapeutic hypothermia, neonatal mortality, and fetal acidemia) morbidity. We compared these outcomes between women with and without history of prior CD. Multivariable logistic regression was used to control for potential confounders. RESULTS: Of 374 intrapartum CDs, 270 (72%) were in patients without prior cesarean section and 104 (28%) were in patients undergoing TOLAC. Operative times were significantly longer in women with a prior CD including time from skin incision to delivery (9 [interquartile range (IQR) 7–13] versus 6 minutes [IQR 3–8], P&lt;.001) and total procedure time (63 [IQR 52–79] versus 55 minutes [IQR 45–65], P&lt;.001). Composite maternal (adjusted relative risk [aRR] 1.04, 95% CI 0.62–1.74) and neonatal (aRR 1.01, 95% CI 0.63–1.64) morbidity did not differ between groups. CONCLUSION: Although associated with longer operative times, history of a prior CD does not significantly increase maternal or neonatal morbidity among women undergoing intrapartum CD. Therefore, the threshold to perform an intrapartum CD in those undergoing TOLAC should be similar to those without a prior CD.

A Randomized Trial of the Effects of Ambient Operating Room Temperature on Neonatal Morbidity.

Newborn hypothermia has been implicated in neonatal morbidity without randomized evidence that it compromises the infant. Our objective was to determine if a difference in operating room temperature at cesarean birth impacts neonatal morbidity. Women undergoing cesarean delivery of a liveborn infant without major malformations were included. The institutional preexisting operating room temperature of 20°C (67°F) was compared with an experimental group of 24°C (75°F) by cluster randomization assigned on a weekly basis. Newborn hypothermia was defined as axillary temperature on arrival to the nursery of less than 36.5°C (<97.7°F). The primary outcome was a composite of neonatal morbidity including respiratory support, sepsis, hypoglycemia, and neonatal death. Between November 2016 and May 2018, 5,221 women had cesarean deliveries at Parkland Hospital with 2,817 randomized to the standard care group and 2,404 to the experimental group. The rate of neonatal composite morbidity did not differ between the groups: standard care 398 (14%) versus experimental 378 (16%), p = 0.11. This was despite a significant decrease in the rate of neonatal hypothermia: standard care 1,195 (43%) versus experimental 414 (18%), p < 0.001. There was no difference in the composite outcome for preterm infants (<37 wk) between the groups: standard care 194 (49%) versus experimental 185 (54%), p = 0.25. An 8°F increase in operating room temperature was significantly associated with a reduced rate of neonatal hypothermia, although this decrease was not associated with a significant improvement in neonatal morbidity. However, the increase in operating room temperature was met with resistance from obstetricians and operating room personnel. This trial is registered (registration no.: NCT03008577).

A randomized clinical trial of antibiotic treatment duration in preterm premature rupture of membranes: 7 days versus until delivery.

Antibiotic treatment in preterm premature rupture of membranes (PPROM) can prolong the interval from membrane rupture to delivery and improve neonatal outcomes; however the duration of antibiotic treatment for PPROM has rarely been compared in prospective studies. To investigate the optimal duration of antibiotic treatment for PPROM, we performed a randomized controlled trial comparing neonatal morbidity and infantile neurological outcomes between two groups of PPROM patients who received antibiotic treatment for 7 days or until delivery. This prospective randomized study included patients who were diagnosed with PPROM between 22+0 weeks and 33+6 weeks of gestation. The enrolled patients were randomly assigned to receive intravenous cefazolin (1 g dose every 12 hours) and oral clarithromycin (500 mg dose every 12 hours) for 7 days or until delivery. The study protocol was registered at clinicaltrials.gov (NCT01503606). The primary outcome was neonatal composite morbidity, and the secondary outcome was neurological outcomes at 12 months of corrected age. We enrolled 150 patients and allocated 74 and 76 of them to the 7-day and until-delivery groups, respectively. Analysis was done by per protocol. After excluding cases lost to follow-up or with protocol violations, 63 (7-day regimen) and 61 (until-delivery regimen) PPROM patients and their babies were compared. There was no significant difference in pregnancy outcomes, including gestational age at delivery and interval from rupture of membranes (ROM) to delivery, between the two groups. Among the neonatal outcomes, bronchopulmonary dysplasia, intraventricular hemorrhage, retinopathy of prematurity, necrotizing enterocolitis, and proven neonatal sepsis did not differ between the groups. However, the rate of respiratory distress syndrome (RDS) (32.8% vs. 50.8%, P=.039) and composite neonatal morbidities (34.4% vs. 53.9%, P=.026) were lower in the until-delivery group compared to the 7-day group. This difference remained statistically significant after a multivariable analysis adjusting for maternal age, twin pregnancy, use of antenatal corticosteroids, the ROM to delivery interval, and gestational age at delivery. Infantile neurological outcomes were evaluated in 70% of the enrolled patients and did not differ between the groups. Overall, until-delivery regimen of cefazolin and clarithromycin in PPROM showed lower incidence of composite neonatal morbidities, and of RDS compared to the 7-day regimen and both regimens showed otherwise similar other individual neonatal morbidities and infantile neurological outcomes.

Alternative to Intensive Management of the Active Phase of the Second Stage of Labor: A Multicenter Randomized Trial (Phase Active du Second STade Trial) Among Nulliparous Women With an Epidural

ABSTRACT The optimal management of second stage of labor, with its passive and active phases, remains controversial. In France, delayed pushing during the active phase is recommended because of the belief that, based on older data, the fetus is at higher risk during the active phase. It is possible that uterine contractions combined with maternal pushing can lead to cord compression and reduce placental perfusion and oxygenation, which can induce acidosis and fetal heart rate abnormalities, resulting in the need for medical intervention, such as operative vaginal delivery (OVD) or episiotomy. In countries where the active phase is limited, women are encouraged to push as strongly as possible to speed delivery. However, if the active second stage of labor is prolonged, this intensive management may increase fetal hypoxia. The aim of this study was to examine the effect of moderate pushing versus intensive pushing in the second stage of labor on the risk of neonatal morbidity. This was a multicenter, randomized controlled trial at 13 French maternity units between January 2017 and May 2020. Included were nulliparous, adult women who had spontaneous or induced, uncomplicated delivery of a singleton fetus at ≥37 weeks of gestation. Excluded were women with a psychiatric condition, a disease contraindicating intensive expulsive efforts, or any uterine surgical scar, as well as those with a fetus that was small for gestational age, had congenital abnormalities, or had abnormal heart rate. Eligible women were randomized into 2 groups: the intervention group was instructed to push moderately only during the active phase of the second stage of labor, and the control group was instructed to push intensively during the same phase following French recommendations. Midwives asked the intervention group to push 2 times during each contraction and to take a break with no pushing in 1 of 5 contractions. No limit was set on pushing duration. The control group was asked to push 3 times per contraction without breaks. After 30 minutes of pushing, the midwife contacted an obstetrician to consider operative delivery. The primary outcome was a composite of neonatal acidosis, a 5-minute Apgar score &lt;7, and/or severe neonatal trauma. Secondary neonatal outcomes were transfer to the neonatology unit or intensive care unit need for resuscitation at birth and need for hypothermia. Secondary maternal outcomes were mode of delivery, postpartum hemorrhage (PPH), and severe PPH. The trial was stopped prematurely because of difficulties obtaining an adequate sample size. Of the 3380 women initially planned, 1710 (50.6%) were included. Ultimately, the intention-to-treat analysis included 809 women in each group. The neonatal morbidity rates for the intervention group and control group were 18.9% and 20.6%, respectively (risk ratio [RR] 0.92; 95% confident interval [CI], 0.75–1.12; P = 0.38). No significant differences were observed for neonatal transfer or need for resuscitation. All but 16 women delivered vaginally. The intervention or moderate pushing group had a longer pushing duration than the control or intensive pushing group (38.8 ± 26.4 vs 28.6 ± 17.0 minutes; P &lt; 0.001) and lower episiotomy rate (13.5% vs 17.8%; RR, 0.76; 95% CI, 0.60–0.95; P = 0.02). The rates of OVD were 21.1% in the intervention group and 24.8% in the control group (RR, 0.85; 95% CI, 0.71–1.02; P = 0.08). No significant differences were observed for PPH or severe PPH. During the active stage of labor, encouraging women to push moderately versus intensively was not associated with decreased neonatal morbidity. Although the pushing duration was longer among women instructed to push moderately, the rate of episiotomy was lower.

EBNEO commentary: Fluid balance as a critical factor in neonatal outcomes.

With this study, Starr and colleagues add to the growing body of literature recognising the importance of fluid status in neonates.1-3 Utilising the weight-change method for estimating fluid balance, which is the preferred method in neonates,4 they found that fluid balance is independently associated with the need for mechanical ventilation at post-natal day 14 and the composite outcome of severe bronchopulmonary dysplasia (BPD) or death. All neonates undergo a period of adaptation of fluid and electrolyte homeostasis after birth, with a contraction of the extracellular fluid (ECF) compartment, driven by natriuretic diuresis and transepidermal losses in preterm infants. This phase ends with maximum weight loss or negative fluid balance.5 Very low birth weight and extremely low birth weight infants can experience 10%–15% negative fluid balance, with this phase lasting up to 8 days.5, 6 Clinicians should allow for ECF contraction while maintaining intravascular fluid volume, achieving a negative sodium balance, maintaining normal serum electrolyte levels and providing sufficient calories to meet maintenance needs.5, 6 Achieving this requires close monitoring of daily intake and output, weight changes and electrolyte concentrations, while thoughtfully adjusting prescribed fluid intake. In the same patient cohort as the present study, Valentine and colleagues analysed weight loss and fluid administration.7 They found that a maximum weight loss of 5–15% within the first post-natal week was associated with decreased odds of developing necrotising enterocolitis (NEC), while an average total fluid administration of >150 mL/kg BW/day over the first post-natal week was associated with increased risk of NEC and patent ductus arteriosus (PDA) requiring surgery. They suggested cautious limitation of total fluid administration and allowing for moderate weight loss in the first post-natal week.7 A 2014 Cochrane review recommended careful restriction of fluid intake in preterm neonates to meet physiological needs without causing dehydration rather than a practice of liberal fluid intake, citing that restricted fluid intake significantly reduced the risks of PDA and NEC, with trends towards reduced risk of BPD, intra-ventricular haemorrhage and death.8 No discussion about fluid status is complete without addressing electrolytes, specifically sodium. Dysnatremias are common in critically ill patients and are associated with mortality and hospital length of stay.9 Preterm infants are at particular risk for dysnatremias given immature renal tubules, fluid shifts, insensible losses and exposure to parenteral nutrition. In an analysis of a contemporary large neonatal cohort, dysnatremias were common in the first week of life, occurring in half of the cohort.9 In adjusted models, the occurrence of hypernatremia and combined hypo- and hypernatremia in the first week of life was associated with an increased risk of mortality in neonates with normal renal function.9 Weight changes, fluid intake, electrolyte status—this is quite the fine balance. When does physiologic weight loss become pathologic? Clearly, there are many variables and outcomes to consider. Starr and colleagues provide potential targets for this complex problem. In efforts to reduce rates of BPD and other neonatal morbidities, fluid balance is emerging as a critical factor. URL LINK: https://ebneo.org/ebneo-commentary-fluid-balance-and-neonatal-outcomes/ None. None.

A new method for customized fetal growth reference percentiles.

Customized fetal growth charts assume birthweight at term to be normally distributed across the population with a constant coefficient of variation at earlier gestational ages. Thus, standard deviation used for computing percentiles (e.g., 10th, 90th) is assumed to be proportional to the customized mean, although this assumption has never been formally tested. In a secondary analysis of NICHD Fetal Growth Studies-Singletons (12 U.S. sites, 2009-2013) using longitudinal sonographic biometric data (n = 2288 pregnancies), we investigated the assumptions of normality and constant coefficient of variation by examining behavior of the mean and standard deviation, computed following the Gardosi method. We then created a more flexible model that customizes both mean and standard deviation using heteroscedastic regression and calculated customized percentiles directly using quantile regression, with an application in a separate study of 102, 012 deliveries, 37-41 weeks. Analysis of term optimal birthweight challenged assumptions of proportionality and that values were normally distributed: at different mean birthweight values, standard deviation did not change linearly with mean birthweight and the percentile computed with the normality assumption deviated from empirical percentiles. Composite neonatal morbidity and mortality rates in relation to birthweight < 10th were higher for heteroscedastic and quantile models (10.3% and 10.0%, respectively) than the Gardosi model (7.2%), although prediction performance was similar among all three (c-statistic 0.52-0.53). Our findings question normality and constant coefficient of variation assumptions of the Gardosi customization method. A heteroscedastic model captures unstable variance in customization characteristics which may improve detection of abnormal growth percentiles. ClinicalTrials.gov identifier: NCT00912132.

Effect of an Exclusive Human Milk Diet on the Gut Microbiome in Preterm Infants

The effect of using an exclusive human milk diet compared with one that uses bovine products in preterm infants is uncertain, but some studies demonstrate lower rates of key neonatal morbidities. A potential mediating pathway is the gut microbiome. To determine the effect of an exclusive human milk diet on gut bacterial richness, diversity, and proportions of specific taxa in preterm infants from enrollment to 34 weeks' postmenstrual age. In this randomized clinical trial conducted at 4 neonatal intensive care units in the United Kingdom from 2017 to 2020, microbiome analyses were blind to group. Infants less than 30 weeks' gestation who had only received own mother's milk were recruited before 72 hours of age. Statistical analysis was performed from July 2019 to September 2021. Exclusive human milk diet using pasteurized human milk for any shortfall in mother's own milk supply and human milk-derived fortifiers (intervention) compared with bovine formula and bovine-derived fortifier (control) until 34 weeks' postmenstrual age. Fortifier commenced less than 48 hours of tolerating 150 mL/kg per day. Gut microbiome profile including alpha and beta diversity, and presence of specific bacterial taxa. Of 126 preterm infants enrolled in the study, 63 were randomized to control (median [IQR] gestation: 27.0 weeks [26.0-28.1 weeks]; median [IQR] birthweight: 910 g [704-1054 g]; 32 [51%] male) and 63 were randomized to intervention (median [IQR] gestation: 27.1 weeks [25.7-28.1 weeks]; median [IQR] birthweight: 930 g [733-1095 g]; 38 [60%] male); 472 stool samples from 116 infants were analyzed. There were no differences in bacterial richness or Shannon diversity over time, or at 34 weeks between trial groups. The exclusive human milk diet group had reduced relative abundance of Lactobacillus after adjustment for confounders (coefficient estimate, 0.056; P = .03), but not after false discovery rate adjustment. There were no differences in time to full feeds, necrotizing enterocolitis, or other key neonatal morbidities. In this randomized clinical trial in preterm infants using human milk-derived formula and/or fortifier to enable an exclusive human milk diet, there were no effects on overall measures of gut bacterial diversity but there were effects on specific bacterial taxa previously associated with human milk receipt. These findings suggest that the clinical impact of human milk-derived products is not modulated via microbiomic mechanisms. ISRCTN trial registry identifier: ISRCTN16799022.

Complications of planned home births in the Czech Republic.

This study evaluated complications that can occur during planned home births that require transfer to the hospital. These factors were assessed to improve the current status of deliveries performed outside health care facilities in the Czech Republic. This prospective cohort study included data on 105 cases of complicated home births during 2017 to 2021 using an online form accessible to all hospital maternity wards in the Czech Republic. Planned home births were complicated by fetal/neonatal causes, maternal causes, and combined fetomaternal complications in 28 (26.7%), 20 (19%), and 2 (1.9%) cases, respectively. The need for transfer was most often realized after the birth of the fetus (86; 81.9%); however, it was realized during birth in 19 (18.1%) cases. The following complications were noted most often: postpartum hemorrhage (23; 21.9%); neonatal asphyxia (17; 16.2); placental retention (14; 13.3%); birth injury (12; 11.4%); neonatal hypothermia (5; 4.8%); and placental birth (5; 4.8%). Indications for transfer during labor were as follows: labor obstruction (10; 9.5%); fetal hypoxia (5; 4.8%); bleeding during labor (2; 1.9%); preeclampsia (1; 0.9%); and fetal malformation (1; 0.9%). Perinatal death occurred in 8 (7.6%) cases. Permanent neonatal morbidity occurred in 4 (3.8%) cases. Patients with home birth complications were transferred to the hospital most often after the birth of the fetus. The low proportion of transfers during childbirth is caused by the unprofessional management of planned home births, resulting in a high number of perinatal deaths and high rate of permanent neonatal morbidity.

Hematologic abnormalities and pregnancy outcomes in pregnant women with COVID-19

Background: Since declaring coronavirus disease 19 as a pandemic by the World Health Organization, a great concern was directed toward pregnant women and their fetuses. Despite the substantial impact of COVID-19 disease on pregnancy, there is a scarcity of national researches discussing this important issue. Objectives: To study the relationship between peripheral blood abnormalities and COVID-19 in pregnant women. Patients and methods: A case control study was conducted in the labour wards of Baghdad Teaching Hospital in the Medical complex / Baghdad /Iraq during the period from 1st of February till 31st of July, 2021. Fifty pregnant women diagnosed with COVID-19 disease were compared to 50 healthy pregnant women as controls. The pregnant women enrolled in the study were tested by COVID-19-Reverse transcription RT-PCR test upon admission to hospital. The confirmation of COVID-19 diagnosis was done according to the Iraqi guidelines approved by the Iraqi Ministry of Health. Results: Dyspnea was a significant clinical presentation of pregnant women with COVID-19 disease. Those women had abnormal white blood cell count, lymphocytopenia, high neutrophil to lymphocyte ratio, high platelets to lymphocyte ratio and mild to moderate anemia which were significant when compared to controls. The maternal and neonatal morbidity and mortality rates were higher among pregnant women with COVID-19 disease. Abnormalities in peripheral blood system parameters like lymphocyte count, neutrophils count, platelets count and hemoglobin level were predictors of maternal morbidity and mortality. Conclusions: The clinical presentations and hematological abnormalities are useful in the diagnosis of COVID-19 disease in pregnant women and may be used as predictors of maternal and neonatal morbidity and mortality.

ОТКЛОНЕНИЕ МАССЫ ТЕЛА ПРИ РОЖДЕНИИ КАК ФАКТОР РИСКА ДЛЯ ЗДОРОВЬЯ РЕБЕНКА

Significance. The problems of public health deterioration are of great importance for the state socio-economic potential. The most vulnerable group is the child population in the first years of life, especially during the neonatal period. Accordingly, effects of the birth weight deviation on the child health are a focus of high research interest. Purpose. To assess the body weight of born alive newborns, and identify effects of the deviation of body weight at birth on the child health in the Northwestern Federal District. Material and methods. Based on official statistics for 2017-2021, distribution of children by birth weight, neonatal morbidity rates in Russia, the Northwestern Federal District as a whole and its regions in dynamics have been analyzed. A nonparametric Spearman rank-order correlation method was used to assess effects of the baby weight at birth on the newborn health. Statistical data processing was carried out using MS Office-2016 and StatSoft-Statistica 10.0 software packages. Results. The Northwestern Federal District is characterized by a higher, in comparison with the Russian Federation, share of children with a birth weight of more than 4000 g (11.33% vs. 10.12%; p&lt;0.05) and less than 2500 g (6.15% vs. 6.05%; p&lt;0.05). In the Federal district, there is a negative growth dynamic in the share of newborns with high body weight and low birthweight of less than 1500 g. The average District neonatal morbidity rate significantly exceeds the national average (413.8‰ vs. 315.5‰; p&lt;0.05), and tends to increase due to the increased neonatal morbidity in almost all regions of the Federal district. The correlation analysis has identified a direct strong relationship between the number of children born sick and got ill, and the number of babies with low and high weight at birth (rxy=0.83-0.99). Conclusion. The increased number of underweight babies and newborns born with a body weight of 4000 g or more is a regional risk factor for a high incidence rate in the District regions.

Residency Experience With Physical Examination- and Ultrasound-Indicated Cerclage: A Single Center Retrospective Study.

Background: Cervical insufficiency, the dilation of the cervix in the absence of contractions or labor, can cause second-trimester pregnancy loss or preterm birth. Cervical cerclage is a common treatment for cervical insufficiency and has 3 indications for placement: history, physical examination, and ultrasound. The purpose of this study was to compare pregnancy and birth outcomes for physical examination- and ultrasound-indicated cerclage. Methods: We conducted a retrospective observational descriptive review of second-trimester obstetric patients with transcervical cerclage performed by residents at a single tertiary care medical center from January 1, 2006, to January 1, 2020. We present data on all patients and compare outcomes between the 2 study groups: patients who received physical examination-indicated cerclage vs those who received ultrasound-indicated cerclage. Results: Cervical cerclage was placed on 43 patients at a mean gestational age of 20.4 ± 2.4 weeks (range, 14 to 25 weeks) and with a mean cervical length of 1.53 ± 0.5 cm (range, 0.4 to 2.5 cm). With a latency period of 11.8 ± 5.7 weeks, mean gestational age at delivery was 32.1 ± 6.2 weeks. Fetal/neonatal survival rates were comparable: 80% (16/20) for the physical examination group compared to 82.6% (19/23) for the ultrasound group. No differences were found between groups for gestational age at delivery-31.5 ± 6.8 in the physical examination group vs 32.6 ± 5.8 in the ultrasound group (P=0.581)-or for preterm birth <37 weeks-65.0% (13/20) in the physical examination group vs 65.2% (15/23) in the ultrasound group (P=1.000). Rates of maternal morbidity and neonatal intensive care unit morbidity were similar between the groups. No cases of immediate operative complications or maternal deaths occurred. Conclusion: Pregnancy outcomes for physical examination- and ultrasound-indicated cerclage placed by residents at a tertiary academic medical center were similar. Fetal/neonatal survival and preterm birth rates were favorable for physical examination-indicated cerclage when compared to other published studies.

Timing of neonatal mortality and severe morbidity during the postnatal period: a systematic review.

The objective of this review was to determine the timing of overall and cause-specific neonatal mortality and severe morbidity during the postnatal period (1-28 days). Despite significant focus on improving neonatal outcomes, many newborns continue to die or experience adverse health outcomes. While evidence on neonatal mortality and severe morbidity rates and causes are regularly updated, less is known on the specific timing of when they occur in the neonatal period. This review considered studies that reported on neonatal mortality daily in the first week; weekly in the first month; or day 1, days 2-7, and days 8-28. It also considered studies that reported on timing of severe neonatal morbidity. Studies that reported solely on preterm or high-risk infants were excluded, as these infants require specialized care. Due to available evidence, mixed samples were included (eg, both preterm and full-term infants), reflecting a neonatal population that may include both low-risk and high-risk infants. MEDLINE, Embase, Web of Science, and CINAHL were searched for published studies on December 20, 2019, and updated on May 10, 2021. Critical appraisal was undertaken by two independent reviewers using standardized critical appraisal instruments from JBI. Quantitative data were extracted from included studies independently by two reviewers using a study-specific data extraction form. All conflicts were solved through consensus or discussion with a third reviewer. Where possible, quantitative data were pooled in statistical meta-analysis. Where statistical pooling was not possible, findings were reported narratively. A total of 51 studies from 36 articles reported on relevant outcomes. Of the 48 studies that reported on timing of mortality, there were 6,845,490 live births and 47,551 neonatal deaths with timing known. Of the 34 studies that reported daily deaths in the first week, the highest proportion of deaths occurred on the first day (first 24 hours, 38.8%), followed by day 2 (24-48 hours, 12.3%). Considering weekly mortality within the first month (n = 16 studies), the first week was the highest mortality (71.7%). Based on data from 46 studies, the highest proportion of deaths occurred on day 1 (39.5%), followed closely by days 2-7 (36.8%), with the remainder occurring between days 8-28 (23.0%). In terms of causes, birth asphyxia accounted for the highest proportion of deaths on day 1 (68.1%), severe infection between days 2-7 (48.1%), and diarrhea between days 8-28 (62.7%). Due to heterogeneity, neonatal morbidity data were described narratively. The mean critical appraisal score of all studies was 84% (SD = 16%). Newborns experience high mortality throughout the entire postnatal period, with the highest mortality rate in the first week, particularly on the first day. Ensuring regular high-quality postnatal visits, particularly within the first week after birth, is paramount to reduce neonatal mortality and severe morbidity.

The management of congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a structural birth defect that with varying degrees of severity that results in significant neonatal morbidity and mortality. CDH occurs in 1:2,500 live births, and despite the advances in prenatal diagnosis and neonatal intensive care, the mortality and morbidity rate in infants with CDH is significant. In this article, we tried to summarize the main modalities of diagnosis, prognosis and medical treatment in CDH cases, found in specialty literature.

Fetal Movement Counting in Prolonged Pregnancies: The COMPTAMAF Prospective Randomized Trial.

In prolonged pregnancies, the risks of neonatal morbidity and mortality are increased. The aim of this trial was to assess the benefits of maternal information about fetal movement (FM) counting on neonatal outcomes in prolonged pregnancy. It was a prospective, single center, randomized, open-label study conducted from October 2019 to March 2022. Intention-to-treat analyses were performed on 278 patients randomized into two 1:1 groups (control group and FM counting group). The primary outcome was a composite score of neonatal morbidity (presence of two of the following items: fetal heart rate abnormality at delivery, Apgar score of &lt;7 at 5 min, umbilical cord arterial pH of &lt;7.20, and acute respiratory distress with mutation in neonatal intensive care unit). There was no significant difference between the two groups in the rate of neonatal morbidity (14.0% in the FM counting group versus 22.9% in the standard information group; p = 0.063; OR 0.55, 95% CI 0.29-1.0). In this study, fetal movement counting for women in prolonged pregnancy failed to demonstrate a significant reduction in adverse neonatal outcomes.

Impact of placenta accreta spectrum (PAS) pathology on neonatal respiratory outcomes in cesarean hysterectomies

Objective Placenta accreta spectrum (PAS) is a continuum of disorders characterized by the pathologically adherent placenta to the uterine myometrium. Delivery by cesarean hysterectomy at 34–36 weeks is recommended to mitigate the risks of maternal morbidity. Iatrogenic preterm delivery, has potential neonatal implications; late preterm infants are at risk for significant respiratory morbidity. Neonatal outcomes in PAS neonates are not well described in the literature, we aimed to investigate these outcomes. Methods A case-control study was performed with 107 cases of pathology-confirmed PAS patients with singleton, non-anomalous, viable pregnancies, compared to 76 cases of placenta previa with prior cesarean section who underwent repeat cesarean section. All patients were delivered through our institution’s Placenta Accreta Program from 2005 to 2020. Rates of neonatal respiratory morbidity and related outcomes were analyzed. Results Maternal characteristics and antenatal complications were similar between groups, as were gestational age, steroid exposure, and emergent delivery. PAS was associated with increased use of general anesthesia (20 vs. 54%, p = .001), larger estimated blood loss (1875 vs. 6077 ml, p = .008), and longer post-operative stays (4.8 vs. 7.3 days, p = .01). PAS was also associated with neonatal increased rates of high flow nasal cannula (HFNC) (41 vs. 58%, p = .02), intubation (17 vs. 37%, p = .008), and duration of respiratory support (0 vs. 2 days, p = .03). There were no differences in rates of continuous positive airway pressure (CPAP)/positive pressure ventilation (PPV) (21 vs. 22%, p = .85), anemia, hyperbilirubinemia, or NICU length of stay. Multivariate analysis adjusting for general anesthesia demonstrated this variable confounded the impact of PAS pathology in respiratory outcomes the risk of the respiratory composite (adjusted odds ratio (aOR) 0.57, 95% CI [0.11, 2.82]), use of HFNC (aOR 0.33, 95% CI [0.08–1.48]), and intubation (aOR 1.29, 95% CI [0.25–6.75]), were no longer significant. Conclusions Based on these results, we conclude that PAS neonates have higher rates of respiratory morbidity and that general anesthesia is a significant contributor to these respiratory outcomes. This is important for the antenatal counseling of cases of PAS, especially if general anesthesia is anticipated or requested. Furthermore, it supports efforts to limit general anesthesia exposure of neonates when necessary.