Non-cephalic Presentation Research Articles

Breech Presentation in Twins as a Risk Factor for Developmental Dysplasia of the Hip.

Introduction:Identifying risk factors associated with developmental dysplasia of the hip (DDH) is essential for early diagnosis and treatment. Breech presentation is a major DDH risk factor, possibly because of crowding of the fetus within the uterus. In multifetal pregnancy, fetuses are generally smaller than singletons, which may obscure the effect of breech presentation on fetal hips. Only a few studies have investigated the occurrence of DDH in multifetal pregnancies. In this study, we aimed to evaluate whether the breech presentation is a major risk factor of DDH in twin pregnancies.Methods:This retrospective study included 491 consecutive live births (after 23+0 weeks gestation) delivered through cesarean section with at least 1 baby with noncephalic presentation in single or twin pregnancies from April 2013 to October 2018. We analyzed the incidence of DDH and its associated factors, including sex, breech, and multifetal pregnancy, with a generalized linear mixed model.Results:The incidence of DDH was 12.5% in singleton with breech presentation, 9.8% in twin-breech presentation, and 0.7% in twin-cephalic presentation. Multivariate analysis showed that singleton-breech presentation (P=0.003), twin-breech presentation (P=0.003), and female sex (P=0.008) were independent risk factors for DDH.Conclusion:Breech presentation is an independent risk factor for DDH in twin pregnancies, although twin pregnancy itself is not an independent risk factor for DDH.

The state of birth asphyxia in Ethiopia: An umbrella review of systematic review and meta-analysis reports, 2020

BackgroundTo this date, there are 4 systematic reviews and meta-analyses studies about the burden and associated factors of birth asphyxia in Ethiopia. However, findings of these studies are inconsistent which is difficult to make use of the findings for preventing birth asphyxia in the country. Therefore, umbrella review of these studies is required to pool the inconsistent findings into a single summary estimate that can be easily referred by the information users in Ethiopia. MethodsPubMed, Science direct, web of science, data bases specific to systematic reviews such as the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects were searched for systematic reviews and meta-analyses (SRM) studies on the magnitude and risk factors of perinatal asphyxia in Ethiopia. The methodological quality of the included studies was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. The estimates of the included SRM studies on the prevalence and predictors of perinatal asphyxia were pooled and summarized with random-effects meta-analysis models. From checking PROSPERO, this umbrella review wasn't registered. ResultsWe included four SRM studies with a total of 49,417 neonates. The summary estimate for prevalence of birth asphyxia was 22.52% (95% CI = 17.01%–28.02%; I2 = 0.00). From the umbrella review, the reported factors of statistical significance include: maternal illiteracy [AOR = 1.96; 95% CI: 1.44–2.67], primiparity [AOR = 1.29; 95% CI: 1.03–1.62], antepartum hemorrhage [AOR = 3.43; 95% CI: 1.74–6.77], pregnancy induced hypertension [AOR = 4.35; 95% CI: 2.98–6.36], premature rupture of membrane [AOR = 12.27; 95% CI: 2.41, 62.38], prolonged labor [AOR = 3.18; 95% CI: 2.75, 3.60], meconium-stained amniotic fluid [AOR = 5.94; 95% CI: 4.86, 7.03], instrumental delivery [AOR = 3.39; 95% CI: 2.46, 4.32], non-cephalic presentation [AOR = 3.39; 95% CI: 1.53, 5.26], cord prolapse [AOR = 2.95; 95% CI: 1.64, 5.30], labor induction [AOR = 3.69; 95% CI: 2.26–6.01], cesarean section delivery [AOR = 3.62; 95% CI: 3.36, 3.88], low birth weight [AOR = 6.06; 95% CI: 5.13, 6.98] and prematurity [AOR = 3.94; 95% CI: 3.67, 4.21] at 95% CI. ConclusionThis umbrella review revealed high burden of birth asphyxia in Ethiopia. The study also indicated significant risk of birth asphyxia among mothers who were unable to read and write, primiparous mothers, those mothers having antepartum hemorrhage, pregnancy induced hypertension, premature rupture of membrane, prolonged labor, meconium-stained amniotic fluid, instrumental delivery, cesarean section delivery, non-cephalic presentation, cord prolapse and labor induction. Moreover, low birth weight and premature neonates were more vulnerable to birth asphyxia compared to their normal birth weight and term counterparts. Therefore, burden of birth asphyxia should be mitigated through special consideration of these risk mothers and neonates during antenatal care, labor and delivery. Mitigation of the problem demands the collaborative efforts of national, regional and local stakeholders of maternal and neonatal health.

Frequency and severity of prehospital obstetric events encountered by emergency medical services in the United States

BackgroundPrehospital obstetric events encountered by emergency medical services (EMS) can be high-risk patient presentations for which suboptimal care can cause substantial morbidity and mortality. The frequency of prehospital obstetric events is unclear because existing descriptions have reported obstetric and gynecological conditions together, without delineating specific patient presentations. Our objective was to identify the types, frequency, and acuity of prehospital obstetric events treated by EMS personnel in the US.MethodsWe conducted a cross-sectional analysis of EMS patient care records in the 2018 National EMS Information System dataset (n=22,532,890). We focused on EMS activations (i.e., calls for service) for an emergency scene response for patients aged 12-50 years with evidence of an obstetric event. Type of obstetric event was determined by examining patient symptoms, the treating EMS provider’s impression (i.e., field diagnosis), and procedures performed. High patient acuity was ascertained by EMS documentation of patient status and application of the modified early obstetric warning system (MEOWS) criteria, with concordance assessed using Cohen’s kappa. Descriptive statistics were calculated to describe the primary symptoms, impressions, and frequency of each type of obstetric event among these activations.ResultsA total of 107,771 (0.6%) of EMS emergency activations were identified as involving an obstetric event. The most common presentation was early or threatened labor (15%). Abdominal complaints, including pain and other digestive/abdomen signs and symptoms, was the most common primary symptom (29%) and primary impression (18%). We identified 3,489 (3%) out-of-hospital deliveries, of which 1,504 were preterm. Overall, EMS providers documented 34% of patients as being high acuity, similar to the MEOWS criteria (35%); however, there were high rates of missing data for EMS documented acuity (19%), poor concordance between the two measures (Cohen’s kappa=0.12), and acuity differences for specific conditions (e.g., high acuity of non-cephalic presentations, 77% in EMS documentation versus 53% identified by MEOWS).ConclusionPrehospital obstetric events were infrequently encountered by EMS personnel, and about one-third were high acuity. Additional work to understand the epidemiology and clinical care of these patients by EMS would help to optimize prehospital care and outcomes.

A Systematic Review and Meta-analysis of Clinical Trials of Neuraxial, Intravenous, and Inhalational Anesthesia for External Cephalic Version

(Anesth Analg. 2020;131:1800–1811) External cephalic version (ECV) is a procedure used on parturient women at term during vaginal delivery of noncephalic fetal presentation. Data suggests that successful ECV at term decreases the rate of cesarean delivery and overall financial cost without increasing neonatal complications. While several interventions have been shown to increase the efficacy of ECV, there is no consensus regarding anesthetic care in association to ECV. This study aims to analyze data to compare maternal and fetal outcomes of ECV techniques (with and without inhalational, neuraxial, and intravenous anesthesia) and the association with cesarean delivery rates.

Malpresentation of the Fetus in Singleton Pregnancies after In Vitro Fertilization

BACKGROUND: There are some data in the literature that show an increased incidence of breech presentation and other non-cephalic presentations in vitro fertilization (IVF) singleton pregnancies compared to spontaneous ones. AIM: The purpose of our study was to compare IVF and spontaneous singleton pregnancies in terms of frequency of breech presentation and its impact on the mode of delivery. Furthermore, we wanted to study the rate of transverse and oblique lie in both groups. MATERIALS AND METHODS: We conducted a prospective and retrospective study at “Maichin Dom” University Hospital in Sofia, Bulgaria for the period from January 2013 to December 2017 and analyzed 402 singleton IVF pregnancies and compared them with 523 spontaneous singleton pregnancies. The primary outcome was a breech presentation of the fetus. RESULTS: We found a significantly higher rate of breech presentation in IVF compared to spontaneous pregnancies (p < 0.001). According to gestational age, the difference between the groups persisted when the pregnancy was at least the 32nd week of gestation. We found no difference in the frequency of vaginal birth in the two groups when the fetus was in breech presentation CONCLUSION: IVF singleton pregnancies are associated with a higher risk of breech presentation. Further research is needed to determine the factors contributing to the higher incidence of breech presentation among patients undergoing IVF.

Spontaneous version after preterm prelabor rupture of membranes

Background Preterm prelabor rupture of membranes (PPROM), defined as rupture of membranes before the onset of labor at < 37 weeks’ gestation, affects approximately 3% of all pregnancies. For PPROM prior to 34 weeks’ gestation, in the absence of contraindications to expectant management, antibiotics are administered to increase the latency period and reduce the incidence of maternal and neonatal infection. The latency period additionally provides an opportunity for fetal presentation to change, which impacts the mode of delivery. It is important to better understand the incidence of spontaneous version after PPROM to enhance patient counseling with regard to the mode of delivery. Objective To determine the incidence of discordant fetal presentation, resulting from spontaneous version, between admission for PPROM and time of delivery for cephalic and non-cephalic fetuses among patients diagnosed with PPROM prior to 34 weeks’ gestation and to compare characteristics of those with and without discordant fetal presentation. Study Design We performed a retrospective cohort study of singleton pregnancies diagnosed with PPROM identified using ICD-9/10-CM codes, < 34 weeks’ gestation, admitted to a tertiary care center’s antepartum service from 2011-2018. Patients were included if the fetal presentation was documented by ultrasound within 48 h of admission and PPROM, and delivery occurred >24 h after PPROM. Data are presented as proportions, median (interquartile range) or risk ratio and 95% confidence interval. Results We included 209 patients. Patient age, body mass index, parity, and race/ethnicity were similar among patients with cephalic and non-cephalic fetal presentations at admission. Patients with cephalic presentation at time of PPROM presented at a later gestational age than patients with a non-cephalic presentation. Among patients with a cephalic presentation at admission, the incidence of non-cephalic presentation at delivery was 11.7% (19/162), whereas with non-cephalic presentation at admission, the incidence of cephalic presentation at delivery was 21.3% (10/47). While there was an increased risk of spontaneous version resulting in a discordant presentation at delivery with non-cephalic presentation, this relationship was attenuated and not significant when adjusted for gestational age at time of PPROM.​ Patients with discordant presentation presented with PPROM at an earlier gestational age and had a longer latency period compared to patients with a concordant presentation. Patient age, body mass index, amniotic fluid assessment at admission, and infant birth weight were similar in those with and without a change in fetal presentation. Conclusion Discordant fetal presentation resulting from spontaneous version from cephalic to non-cephalic presentation after PPROM occurred in 11.7% (19/162) of patients, while discordant presentation from non-cephalic to cephalic presentation occurred in 21.3% (10/47) of patients. Given the limited published data on spontaneous version after PPROM these results may impact patient counseling.

Acupressure and Acupuncture Use in the Peripartum Period.

Acupuncture is the procedure of inserting fine needles into specific points on the body for therapeutic purposes. Acupuncture and its derivatives (acupressure, moxibustion, electroacupuncture, and transcutaneous electric nerve stimulation on acupoints) are a popular treatment choice in the peripartum period (32 wk' gestation to 14 d postdelivery). There is substantial research evidence supporting acupuncture and its derivatives in the peripartum period. Benefits in the use of acupressure to reduce labor pain intensity and a reduction in the duration of labor with acupressure have been found. There is mixed evidence for the use of both moxibustion and moxibustion with acupuncture for noncephalic presentations and for acupressure for reducing intraoperative nausea. There is limited evidence available on acupuncture use in women with high-risk pregnancies or multifetal gestations.

Intrapartum Epidural Analgesia and Low Apgar Score Among Singleton Infants Born at Term: A Propensity Score Matched Study

(Acta Obstet Gynecol Scand. 2020;99:1155–1162) While the infant mortality in at-term births is low in Western countries, a recent trend has developed wherein birth asphyxia (based on low Apgar score) is the leading cause of death in term infants in the Netherlands who were admitted to a neonatal intensive care unit (NICU). Therefore, additional attention should be given to term neonates with low Apgar scores, and research on NICU admission should be emphasized as part of the assessment of perinatal health in this group of patients. The underlying risks for asphyxia include hypertensive disorders, maternal diabetes (both preexisting and gestational), non-cephalic presentation at birth, prolonged second stage of labor, and intrapartum epidural analgesia (EA). As EA is not generally used in the Netherlands, although its popularity has slowly increased in recent years, this environment is ideal for analyzing the effects of EA on full-term infants. This study aimed to assess the effects of EA on low Apgar score and subsequent NICU admission in term, singleton births and to analyze other underlying risk factors.

Perinatal Outcomes After Undergoing External Cephalic Version

: The external cephalic version (ECV) represents the standard for pregnancies at term with a non-cephalic presentation as it avoids planned caesareans. The aim of this study was to assess the caesarean rate and prognostic factors at birth after undergoing ECV, which was compared with scheduled caesareans for a non-cephalic presentation (SCG) and spontaneous cephalic presentations at birth (GG). No difference was observed between the caesarean rate of the ECV (n=65) and the GG (n=3711) groups (9.84% and 14.47%, respectively, p-value=0.30), and neither was found between the ECV group and both the GG and SCG (n=76) groups in the Apgar scores and postpartum pH, but for the five-minute Apgar score (9.98 and 9.84 in the ECV and SCG groups, respectively, p-value=0.04). This study provides further evidence for clinical practice regarding good perinatal outcomes after undergoing ECV. Further research is required to consistently prove the increase in the intrapartum caesarean rate after ECV that has been previously described in the literature, which has not been found in the present study. Keywords: External Cephalic Version, Breech Presentation, Caesarean Rate, Perinatal Outcomes, Apgar Score, Postpartum Ph.

Obstetric Outcome in Adolescents-(A Single Centre Experience Over 10 Years from Jan 2006-Dec 2015)

The aim of this study is to determine whether young adolescents aged 11-19 years have an increased risk of cesarean or operative delivery, as well as maternal or neonatal delivery-related morbidity, compared to young adults aged 20- 24 years in the tertiary hospital Royal Hospital in period from January 2006 to December 2015. It is a retrospective cohort study and we include all women delivered in royal hospital in that period of time and aged from 14 to 25 years and gestational age more than 24 week’s singleton pregnancy and cephalic presentation during labour. We exclude maternal Age &gt; 25 years and Gestation age ≤24 weeks, Non-cephalic presentation and Multiple pregnancy. By this study, there is no significant outcome complication among adolescent age group pregnancy compare to adult group except IUGR and NICU admissions.

Predictors of cerclage failure in singleton pregnancies with a history of preterm birth and a sonographic short cervix

To identify predictors of ultrasound-indicated cerclage failure in singleton pregnancies for preventing extremely preterm birth. A retrospective cohort study included 96 singleton pregnancies with ultrasound-indicated McDonald cerclage in women with prior preterm birth (PTB) and cervical shortening. Descriptive statistics were calculated at baseline and logistic regression analyses were performed to identify the factors associated with cerclage failure. In all, 28 (29%) of them suffered preterm delivery at <28 weeks. Multivariate analysis identified cervical dilation, noncephalic presentation, and platelet-lymphocyte ratio (PLR) as independent predictors of cerclage failure (OR, 3.12, 95%CI, 1.01-9.66; OR, 5.81, 95%CI, 1.04-32.53; OR, 1.02, 95%CI, 1.01-1.03, respectively). The efficacy of these predictors was evaluated using a receiver operating characteristics. The area under the curve was 0.87 (95%CI: 0.78-0.96, P<0.001) with a sensitivity of 78.6% and specificity of 88.2%. Our findings indicated that cervical dilation, fetal presentation, and PLR were valuable predictors of cerclage failure in singleton pregnancies with a history of PTB and a sonographic short cervix. Theresultscan be potentially usedto assess the prognosis of patients after cerclage and alert clinicians to considerenhanced surveillance and administration of individuals at an increased risk.

Study of early neonatal outcomes in babies delivered through meconium-stained amniotic fluid in a rural teaching hospital

Background: When the fetus is in a state of stress meconium is passed presence of meconium in amniotic fluid is potentially a serious Sign of fatal compromise, frequency of meconium strained amniotic fluid ranges from 5-22%. MSAF results in higher rate of cesarean delivery, NICU admission rate, respiratory distress, PPHN and neonatal death. The primary objectives of the study were to estimate the incidence of Meconium aspiration syndrome &amp; Respiratory distress among babies born through meconium-stained amniotic fluid (MSAF) along with studying the outcomes at the end of 7 days.Methods: This was a prospective study undertaken in mediciti institute of medical sciences, Ghanpur Medchal Mandal from Jan 2018 to June 2019. Data was collected in a predetermined proforma after institutional ethical committee clearance and appropriate informed consent.Results: During this period 1972 neonates were delivered of which 216 babies were born through MSAF. 18 were excluded for non-cephalic presentation, multiple gestation or congenital anomalies.198 babies were included in the study (96 male and 102 female). 18 neonates (10.2%) needed resuscitation at birth. 85 (42.9%) had thick MSAF. 43 of them developed respiratory distress (21.7%). 10 babies were ventilated. Seizures, hyperbilirubinemia, thrombocytopenia were more common among babies with thick MSAF. Mortality was 1%.Conclusions: Thick meconium-stained amniotic fluid was associated with low Apgar score, higher rate of emergency cesarean section and meconium aspiration syndrome. Primigravida mothers, maternal hypothyroidism and oligohydramnios were important risk factors associated with MAS.

715 Cost-Effectiveness of external cephalic version for term breech presentation: a single center experience

Breech presentation occurs in 3–4% of term pregnancies and is an indication for almost one-fifth of primary cesarean deliveries. External cephalic version(ECV) has been considered as an alternative to cesarean delivery for those who wish to undergo a trial of labor and have no contraindication to vaginal delivery. The objective of this study is to determine the effect of external cephalic version on the cesarean section rate and to calculate the cost savings associated with successful version It is a retrospective study of all women with a singleton pregnancy and non-cephalic presentation who had an attempted ECV at or after 36 weeks of gestation at a single tertiary center. After approval by our institutional IRB, Patients’ charts were reviewed from January 2012 to December 2017 Overall 372 women underwent ECV during the study period, of whom 324 were eligible for analysis. ECV was successful in 237(73.1 %) of the 324 attempted versions and unsuccessful in 87 (26.9%). Eighty-one percent of patients (n=193)who had successful versions were delivered vaginally and 19 % (n=44) by cesarean section. Of the 87 women with unsuccessful version, seven patients (7.8%) were noted to have cephalic presentation when they presented in labor and were delivered vaginally.The cesarean section rate was significantly lower in the patients who had successful ECV (n=44, 18.6%) compared to those who had failed ECV (n=80, 92%, P- < 0.001)(Fig 1 ). The resulting total number of vaginal deliveries (n = 200) allowed for a 34.6% savings in the total cost of these deliveries, and 96.5% of these savings were attributed to successful ECV. Overall, the average cost and cost savings of the study population were $4,366,096 and $2,228,764 respectively(Fig 2). No major fetal or maternal complications were observed. ECV significantly reduces the cesarean section rate and the cost associated with delivery in patients with breech presentation at term. It should be considered a safe alternative to the cesarean section for all the patients with breech presentation if there are no contraindicationsView Large Image Figure ViewerDownload Hi-res image Download (PPT)

475 Comparison between medical and mechanical cervical ripening in obese nulliparous women-A randomized controlled trial

Obesity has been associated with adverse maternal and neonatal outcomes. Data regarding the optimal method of induction in this population is limited with contradicting results. In the current study we aimed to compare between medical and mechanical methods of induction in obese pregnant women. A randomized controlled trial conducted from June 2016 to July 2020. Nulliparous women with a pre-pregnancy BMI>30, singleton term pregnancies and a bishop score<5 with an indication for induction of labor were eligible for the study. Exclusion criteria included a previous cesarean section (CS), multiple pregnancy or non-cephalic presentation. Participants were randomized to either mechanical induction with a cervical ripening balloon (CRB) or a 10 mg vaginal Dinoprostone insert. The primary outcome was delivery rate within 24 hours. Secondary outcomes included time to delivery, CS rate, and 2 composites of maternal and neonatal outcomes. A total of 164 women participated in the study, 83 in the CRB group and 81 in the PGE2 group. There was a significant difference in the rate of deliveries within 24 hours, the time to delivery and the rate of need for additional induction between the PGE2 and CRB groups (45% vs. 71%, p=0.017 and 49.3±6.8 hours vs. 23.5±5.9 hours, p=0.003 and 59.2% vs. 14.4%, p<0.0001 respectively). There were no differences in the rate of vaginal delivery or other secondary outcomes (Table 2). CRB leads to expeditious delivery compared to PGE2 in obese nulliparous women without affecting other obstetric outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

541 Characteristics associated with trial of labor among women with twin pregnancies

This study aims to identify patient and health care system factors associated with undergoing trial of labor (TOL) among patients with twin gestations. This is a retrospective cohort study of patients with twin gestations who received care at a large tertiary care center from 2000-2016. Patients with a prior uterine scar or contraindication to vaginal delivery (e.g. monoamniotic gestation or non-cephalic presenting twin) were excluded from analysis. Maternal and clinical characteristics were compared among patients who underwent TOL versus those who did not undergo TOL. Multivariable logistic regression models included characteristics chosen a priori based on clinical experience and those with bivariable associations with p <0.1. An a priori plan was also made to investigate interactions between parity and other factors identified to be significant in the primary models. Of 1,888 eligible patients, 80.7% (N=1524) underwent TOL. Those undergoing TOL were more likely to be younger, multiparous, and have an MFM as the delivering provider (p<0.001). Hypertensive disorders of pregnancy were less prevalent among patients undergoing TOL (20.2% vs. 27.8%, p=0.002). There were no differences in self-identified race/ethnicity or insurance status between comparison groups. In multivariable analysis (Table), advanced maternal age (AMA; aOR 0.55, 95% CI 0.40-0.74) and nulliparity (aOR 0.36, 95% CI 0.25-0.52) conferred a lower odds of TOL, while having an MFM provider (aOR 2.74, 95% CI 1.55-4.83) was associated with higher odds. Interaction analyses demonstrated no significance in interaction effects between parity and other characteristics of TOL. In this cohort with a high rate of TOL for women with twin gestations, patient and provider characteristics are associated with undergoing TOL. These findings suggest that provider comfort with twin vaginal delivery may influence route of delivery decision making in patients with twins. Further investigation is needed to understand how provider experience and counseling impacts patient decision making in this context.

External cephalic version - A 10-year review of practice

IntroductionFollowing the term breech trial (TBT), the incidence of Caesarean section secondary to breech presentations increased, from 76.9 % to 89.7 %. External Cephalic Version (ECV) is a safe effective method to reduce non-cephalic presentation at time of delivery. MethodsRetrospective audit of all the ECV procedures performed at a tertiary women’s hospital between Jan 2010 and Jan 2020. ResultsThe success rate of ECV was 54.5 %. The rate of vaginal birth following successful ECV was 73.6 % and rate of Caesarean 26.4 %, compared to 96.4 % for those with unsuccessful ECV (P < 0.0001). Factors found to be associated with increased success rates was the use of Intravenous terbutaline (P = 0.03), fetal birth weight ≥3.5 kg (P = 0.0001) and when the procedure is performed by an experienced operator who performed over 20 ECV procedures (P < 0.0001). ConclusionECV is a safe and effective procedure to reduce Caesarean section rates secondary to breech presentation. A dedicated ECV clinic with experienced operators and the use of intravenous terbutaline could improve success rate of ECV and reduce the number of Caesareans for breech presentation.

The impact of introducing ambulance and delivery fees in a rural hospital in Tanzania

BackgroundAccess to health care facilities is a key requirement to enhance safety for mothers and newborns during labour and delivery. Haydom Lutheran Hospital (HLH) is a regional hospital in rural Tanzania with a catchment area of about two million inhabitants. Up to June 2013 ambulance transport and delivery at HLH were free of charge, while a user fee for both services was introduced from January 2014. We aimed to explore the impact of introducing user fees on the population of women giving birth at HLH in order to document potentially unwanted consequences in the period after introduction of fees.MethodsRetrospective analysis of data from a prospective observational study. Data was compared between the period before introduction of fees from February 2010 through June 2013 and the period after from January 2014 through January 2017. Logistic regression modelling was used to construct risk-adjusted variable-life adjusted display (VLAD) and cumulative sum (CUSUM) plots to monitor changes.ResultsA total of 28,601 births were observed. The monthly number of births was reduced by 17.3% during the post-introduction period. Spontaneous vaginal deliveries were registered less frequently with a decrease of about 17/1000 births in non-cephalic presentations. Labour complications and caesarean sections increased with about 80/1000 births. There was a reduction in newborns with birth weight less than 2500 g. The observed changes were stable over time. For most variables, a significant change could be detected after a few weeks.ConclusionAfter the introduction of ambulance and delivery fees, an increase in labour complications and caesarean sections and a decrease in newborns with low birthweight were observed. This might indicate that women delay the decision to seek skilled birth attendance or do not seek help at all, possibly due to financial reasons. Lower rates of births in a safe health care facility like HLH is of great concern, as access to skilled birth attendance is a key requirement in order to further reduce perinatal mortality. Therefore, free delivery care should be a high priority.

Maternal and fetal characteristics to predict c-section delivery: A scoring system for pregnant women

Introduction:Cesarean section is one of the most common obstetrical interventions that has been performed at an increasing rate globally, due to both medical and non-medical reasons. This study aims to develop a prediction tool for pregnant women potentially needing c-section, such that necessary preparations from the mothers, families, and health providers can be made.Methods:A total of 603 pregnant women were recruited in the first phase of c-section prediction tool development. The association between the maternal and fetal factors on the risk of c-section were analyzed, followed by a stepwise multivariate regression analysis. In the next phase, 61 pregnant women were enrolled for external validation. Discrimination was assessed using area under the curve. The calibration plot was then made and assessed using the Hosmer–Lemeshow test.Results:There were 251 (41.6%) cases of vaginal delivery and 352 (58.4%) of c-section assessed. Multivariate analysis showed that gestational age < 37 wg (OR: 1.66, 95% CI: 1.10–2.51), pre-pregnancy body mass index (underweight) (OR: 0.40, 95% CI: 0.22–0.76), no history of vaginal delivery (OR: 2.66, 95% CI: 1.76–4.02), history of uterine surgery (OR: 8.34, 95% CI: 4.54–15.30), obstetrical complications (OR: 5.61, 95% CI: 3.53–8.90), birthweight ⩾ 3500 g (OR: 4.28, 95% CI: 2.16–8.47), and non-cephalic presentation (OR: 2.74, 95% CI: 1.53–4.89) were independently associated with c-section delivery. Those parameters were included in a 7-item scoring tool, with consecutive predictive scores of 1,–1,2,3,3,2,2,1. The area under the curve result was 0.813 (95% CI: 0.779–0.847), indicating a good predictive ability. The external validation showed AUC: 0.806, 95% CI: 0.694–0.917, Hosmer–Lemeshow test p = 0.666 and calibration plot coefficient of r = 0.939.Conclusion:A total of 7 maternal-fetal factors were found to be strongly associated with c-section delivery, including gestational age < 37, maternal underweight body mass index, previous uterine surgery, obstetrical complications, birthweight ⩾ 3500, history of vaginal delivery, and non-cephalic presentation. Using these factors, a prediction tool was developed and validated with good quality.

Can We Use the Bishop Score as a Prediction Tool for the Mode of Delivery in Primiparous Women at Term Before the Onset of Labor?

The Bishop score serves as an evaluation system performed by digital vaginal examination (DVE) to determine cervical ripening. The scoring system includes cervical dilatation, position, effacement and consistency of the cervix and fetal head station1. Nowadays, the Bishop score is frequently used as an important parameter for the prediction of successful induction of labor. Objective: Our objective was to demonstrate the role of the Bishop scoring system in prediction of the mode of delivery in primiparous women at term before the onset of labor. Method: We included in this study unselected primiparous women at term, after 37 weeks of gestation, who presented to the Prenatal Diagnostic Unit (PDU) of the University Emergency County Hospital of Craiova. We excluded from the study multiparous patients, pregnancies with a planned Caesarean section delivery (CD), non-cephalic presentations and multiple pregnancies, twin pregnancies and those with detected fetal anomalies. The protocol included weekly DVEs until delivery for all patients, to determine the evolution of the Bishop score at term and in the week before delivery, and potential correlations with delivery outcome. To reduce clinical bias, the DVEs were performed by three experienced obstetricians involved in the research. Results: Statistical analysis yielded a 4 to 6 Bishop score in all weekly examinations. At 37 weeks of gestation, the majority of primiparous women had a Bishop score of 4, with no significant differences between the primiparous who delivered vaginally and the ones where Caesarean section was necessary. During the following weekly evaluations, we noted a slight turn to a Bishop score of 6 for most of them, without any significant differences between the two groups. However, at 41 weeks of gestation, there was a significant higher Bishop score in the group of primiparous women who delivered vaginally. Conclusion: In our study, the use of the Bishop score failed as a prediction tool for the mode of delivery in primiparous women at term before the onset of labor, at a gestational age less than 40 weeks. Therefore, Bishop score should not be used to counsel regarding the probability of an uncomplicated vaginal delivery (VD) before the onset of labor.

Congenital uterine anomalies and perinatal outcomes: a retrospective single-center cohort study

Congenital uterine anomalies result from the abnormal differentiation, migration, fusion and canalization of Mullerian ducts with a prevalence of 1-10% for unselected population, 2-8% for infertile women and 5-30% for women with a history of miscarriage. Uterine anomalies are implicated as cause of reduced fertility as well as early pregnancy loss. Moreover, their presence is related to an increased risk of preterm birth, abnormal fetal presentation, cesarean delivery, placental abruption and small-for-gestational age infants. The presented study aims to evaluate the correlation between congenital uterine anomalies and poor perinatal outcomes. This was a retrospective, single-center cohort study including 29 women with congenital uterine anomalies. The control group included 100 women hospitalized for delivery with normal uterine morphology. Primary perinatal outcome was preterm birth (delivery before the 37th week of gestation); secondary endpoints were fetus small for gestational age (SGA) (&lt; 10th percentile weight) and fetal abnormal presentation (non-cephalic presentation at the end of pregnancy). Data are presented as median or frequency. Correlations were compared using Mann-Whitney or Pearson’s chi square test. Statistical tests were considered significant if P &lt; 0.05. Preterm birth, fetal abnormal presentation, small for gestational age fetuses were significantly higher (P &lt; 0.001) in the congenital uterine malformations group. Congenital uterine anomalies are associated with poor perinatal outcomes; moreover, our study shows that type of malformations mostly associated with worse reproductive outcomes are the septate uterus and sub-septate uterus.