Non-cephalic Presentation Research Articles

Late preterm versus term external cephalic version: an audit of a single obstetrician experience.

Recent literature evaluating the optimal timing for external cephalic version (ECV) in non-cephalic presentation is limited and hampered by methodological issues. We aimed to compare late preterm ECV [term (36-37weeks of gestation] to term ECV ( > 37weeks). We conducted a retrospective cohort study of prospectively collected data of ECV procedures performed by a single operator during a 6year period. Maternal, ECV procedure, delivery and fetal characteristics were compared between preterm ECV and term ECV. Overall, 547 (91.6%) of ECVs were term ECV while 50 (8.4%) procedures were preterm ECV. Success rate of ECV was 72.0% in the preterm ECV group vs. 71.5% in the term ECV group, p = 0.93. Proportion of preterm delivery was higher among the preterm ECV group (8% vs. 0%, p < 0.001), so does the proportion of early term deliveries (36.0% vs. 22.8%, p = 0.03). The rate of low birth weight was higher among the preterm ECV group (10.0% vs. 3.11%, p = 0.01). Rates of Apgar score at 5min ≤ 8 were higher in the preterm ECV (4.0% vs. 0.5%, p = 0.007). Vaginal delivery and intrapartum cesarean delivery rates did not differ between study groups (72.0% vs. 73.2%, p = 0.83 and 10% vs. 8.4%, p = 0.69). Initiating ECV before term is associated with increased rate of preterm delivery, early term delivery and low birth weight. No effect was found in mode of delivery, intrapartum cesarean delivery, reversion and spontaneous version. We advocate against preterm ECV until future prospective trials will better delineate the effect of preterm ECV on maternal and neonatal outcomes.

The worst of both worlds—combined deliveries in twin gestations: a subanalysis of the Twin Birth Study, a randomized, controlled, prospective study

The reported incidence of combined twin delivery (vaginal delivery of twin A followed by cesarean delivery for twin B) ranges between 5% and 10%. These estimates are based mostly on small studies or retrospective data. We aimed to evaluate to incidence and risk factors for and outcomes of combined twin deliveries, using a subanalysis of the Twin Birth Study, a randomized, controlled, prospective study. The Twin Birth Study included women with twin gestation between 32+0 and 38+6 weeks, with the first twin in vertex presentation at randomization. Women were randomized to planned cesarean delivery or planned vaginal delivery. For the purpose of this subanalysis, we included women who had a vaginal delivery of twin A. Women who had a combined delivery (cesarean delivery for twin B) were compared with women who had a vaginal delivery of both twins. Our primary objective was to identify risk factors for combined twin deliveries. Our secondary objective was to assess the rate of fetal/neonatal death or serious neonatal morbidity in combined deliveries. Of the 2786 women included in the original study, 842 women delivered twin A by a vaginal delivery and were included in the current analysis, of whom 59 (7%) had a combined delivery. Women in the combined delivery group had a lower rate of nulliparity (22.0% vs 34.7%, P= 0.047) and higher rates of noncephalic presentation of twin B at delivery (61.0% vs 27.3%, P < 0.001) and spontaneous version from presentation at randomization of twin B (72.9% vs 44.3%, P < 0.0001). In a multivariable model, the only risk factor significantly associated with a combined delivery was transverse/oblique lie of twin B following delivery of twin A (adjusted odds ratio, 47.7; 95% confidence interval, 15.4-124.5). Twins B in the combined delivery group had a higher rate of fetal/neonatal death or serious neonatal morbidity (13.6% vs 2.3%, P < 0.001), 5-minute Apgar score <7, neonatal intensive care unit admission, abnormal level of consciousness, and assisted ventilation. Transverse/oblique lie of twin B following vaginal delivery of twin A is a risk factor for combined delivery. Combined delivery is associated with higher risk of adverse neonatal outcomes of twin B. These data may be used to better counsel women with twin gestation who consider a trial of labor.

Detection of high-risk pregnancies in low-resource settings: a case study in Guatemala

BackgroundMaternal and neonatal mortality is still very high at a global level, even though its reduction is a goal established among the Sustainable Development Goals by the United Nations. In order to improve prenatal care to address this challenge, this article proposes a strategy to detect and refer high risk pregnancies in rural setting through a portable ultrasound system combined with blood and urine strip tests.MethodsThe Healthy Pregnancy project was conceived as a single, explanatory and positivist case study, with a sample of ten thousand pregnant women attended by itinerant nurses of the Departments of Alta Verapaz and San Marcos. These nurses were trained and equipped with 31 portable ultrasound, and blood and urine tests to detect common obstetric pathology. Moreover, two obstetricians were responsible for remotely supervising the quality of prenatal care. Target communities were selected by the Health Directorates of the public health system from those that had the highest maternal mortality in previous years.ResultsThe project attended to 10,108 women in 2 years and 3 months. 55 twin gestations (0.54%) were diagnosed. Non-cephalic presentation was found in 14.87% of the pregnant women attended from week 32 onwards. 20 patients were referred for non-evolutive gestation. An 11.08% prevalence of anemia was detected. Urine infections were diagnosed in 16.43% of the cases. Proteinuria was detected in 2.6% of patients, but only 17 of them presented high blood pressure and were therefore referred with a suspected pre-eclampsia.DiscussionThe results obtained indicate that an intervention of these characteristics makes it possible to improve the quality of care of rural pregnant women in low and middle-income countries.ConclusionThe results show that with suitable equipment, training, and supervision, the nursing staff in charge of care in rural areas can identify and refer most of the obstetric risks in time, which may contribute to the reduction of maternal mortality.Trial registrationThis research was not registered because it is a case study in which the assignment of the medical intervention was not at the discretion of the investigators.

Screening for breech presentation using universal late-pregnancy ultrasonography: A prospective cohort study and cost effectiveness analysis.

BackgroundDespite the relative ease with which breech presentation can be identified through ultrasound screening, the assessment of foetal presentation at term is often based on clinical examination only. Due to limitations in this approach, many women present in labour with an undiagnosed breech presentation, with increased risk of foetal morbidity and mortality. This study sought to determine the cost effectiveness of universal ultrasound scanning for breech presentation near term (36 weeks of gestational age [wkGA]) in nulliparous women.Methods and findingsThe Pregnancy Outcome Prediction (POP) study was a prospective cohort study between January 14, 2008 and July 31, 2012, including 3,879 nulliparous women who attended for a research screening ultrasound examination at 36 wkGA. Foetal presentation was assessed and compared for the groups with and without a clinically indicated ultrasound. Where breech presentation was detected, an external cephalic version (ECV) was routinely offered. If the ECV was unsuccessful or not performed, the women were offered either planned cesarean section at 39 weeks or attempted vaginal breech delivery. To compare the likelihood of different mode of deliveries and associated long-term health outcomes for universal ultrasound to current practice, a probabilistic economic simulation model was constructed. Parameter values were obtained from the POP study, and costs were mainly obtained from the English National Health Service (NHS). One hundred seventy-nine out of 3,879 women (4.6%) were diagnosed with breech presentation at 36 weeks. For most women (96), there had been no prior suspicion of noncephalic presentation. ECV was attempted for 84 (46.9%) women and was successful in 12 (success rate: 14.3%). Overall, 19 of the 179 women delivered vaginally (10.6%), 110 delivered by elective cesarean section (ELCS) (61.5%) and 50 delivered by emergency cesarean section (EMCS) (27.9%). There were no women with undiagnosed breech presentation in labour in the entire cohort. On average, 40 scans were needed per detection of a previously undiagnosed breech presentation. The economic analysis indicated that, compared to current practice, universal late-pregnancy ultrasound would identify around 14,826 otherwise undiagnosed breech presentations across England annually. It would also reduce EMCS and vaginal breech deliveries by 0.7 and 1.0 percentage points, respectively: around 4,196 and 6,061 deliveries across England annually. Universal ultrasound would also prevent 7.89 neonatal mortalities annually. The strategy would be cost effective if foetal presentation could be assessed for £19.80 or less per woman. Limitations to this study included that foetal presentation was revealed to all women and that the health economic analysis may be altered by parity.ConclusionsAccording to our estimates, universal late pregnancy ultrasound in nulliparous women (1) would virtually eliminate undiagnosed breech presentation, (2) would be expected to reduce foetal mortality in breech presentation, and (3) would be cost effective if foetal presentation could be assessed for less than £19.80 per woman.

Time from neuraxial anesthesia placement to delivery is inversely proportional to umbilical arterial cord pH at scheduled cesarean delivery

Neuraxial block-related hypotension and maternal obesity contribute to uterine hypoperfusion and decreased umbilical arterial pH at cesarean delivery. Between the time of anesthesia placement and delivery, the fetus may be exposed to a hypoperfused uterine environment without surgeon awareness of fetal compromise. We sought to evaluate neonatal umbilical arterial pH according to predelivery time intervals at scheduled term cesarean. We performed a retrospective cohort study of cesarean deliveries between September 2014 and February 2017. Singleton gestations undergoing scheduled cesarean delivery under spinal anesthesia between 37 and 41 weeks with a reassuring preoperative nonstress test were included. Time intervals between operative room entry, spinal anesthesia placement, skin incision, uterine incision, and delivery were calculated. The primary outcome was umbilical arterial pH. Demographic data, maternal blood pressures, predelivery time intervals, and delivery outcomes were analyzed according to umbilical arterial pH intervals of <7.0, 7.01-7.10, 7.11-7.20, 7.21-7.30, and >7.30. Umbilical cord gas analytes and neonatal outcomes were analyzed by spinal to delivery time. Stepwise linear regression was performed to identify predictors of decreasing umbilical arterial pH. Receiver-operator characteristic curves were calculated for spinal to delivery time and umbilical arterial pH <7.0 and 7.1. Among 527 included participants, median umbilical arterial pH was 7.27 [interquartile range, 7.23-7.29] and body mass index was 35 kg/m2 [interquartile range, 30-41]. Both maternal body mass index and hypotensive episodes increased with decreasing umbilical arterial pH (P <.001, P ≤ .02). All predelivery time intervals (operative room to delivery, spinal to skin, spinal to delivery, and uterine incision to delivery) increased as umbilical arterial pH interval decreased (P < .05 for all). In a stepwise linear regression, maternal body mass index, noncephalic presentation, spinal start to delivery interval, uterine incision to delivery interval, and maximum reduction in blood pressure from baseline were predictive of decreasing umbilical arterial pH after controlling for confounding variables (F [5,442]= 17.7, P= .0001], adjusted R2 of 0.157. When evaluated by spinal to delivery time, both umbilical arterial and venous pH and partial pressure of carbon dioxide decreased (P < .001 for all), but base deficit and neonatal outcomes were similar (P ≥ .7 for all). There were 2 cases of hypoxic-ischemic encephalopathy (0.38%). A receiver-operating characteristic curve demonstrated that a spinal start to delivery time greater than 27 minutes was associated with an umbilical arterial pH <7.1 (area under the curve, 0.74, 100% sensitivity, 21% specificity), and an interval greater than 30 minutes was associated with an umbilical arterial pH <7.0 (area under the curve, 0.80, 100% sensitivity, 33% specificity). Longer spinal-to-delivery and uterine incision-to-delivery time intervals were associated with decreasing umbilical arterial pH at scheduled term cesarean delivery. Efforts to minimize predelivery time following spinal placement could reduce the frequency of unanticipated neonatal acidemia.

Planned Mode of Delivery of Preterm Twins and Neonatal and 2-Year Outcomes.

To assess neonatal and 2-year outcomes for preterm twins born after planned vaginal delivery compared with planned cesarean delivery. Women with preterm cephalic first twins delivered after preterm labor or preterm prelabor rupture of membranes from 24 0/7 to 34 6/7 weeks of gestation, with both fetuses alive at the beginning of labor, were identified from the national prospective population-based Etude Epidémiologique sur les Petits Ages Gestationnels 2 cohort study. Planned vaginal delivery was defined as vaginal delivery or cesarean delivery performed during labor. Planned cesarean delivery was considered if performed during labor for the indication of preterm twins or before labor whatever the indication. A propensity score analysis was used to compare planned vaginal delivery and planned cesarean delivery. Outcomes analyzed separately for the first and second twins were survival at discharge, survival at discharge without severe morbidity, and survival at 2 years of corrected age without neurosensory impairment. Among the 932 women with a twin pregnancy, 549 were excluded mainly as a result of the first twin in noncephalic presentation, cause of delivery other than preterm labor or preterm prelabor rupture of membranes, at least one twin died before labor, and gestational age at delivery less than 24 weeks of gestation. The planned vaginal delivery group included 276 women and the planned cesarean delivery group 107. For first and second twins, survival at discharge (97.7% vs 98.3% and 95.6% vs 97.1%, respectively), survival at discharge without severe morbidity (91.6% vs 88.8% and 90.3% vs 84.5%, respectively), and survival at 2 years of corrected age without neurosensory impairment (96.0% vs 95.4% and 92.9% vs 90.8%, respectively) did not differ significantly between the planned vaginal delivery and planned cesarean delivery groups. Propensity score analysis showed that planned cesarean delivery was not associated with improved outcomes with the caveat that the infrequency of death and disability limited the statistical power of the study to detect potentially clinically meaningful differences between planned modes of delivery. Planned cesarean delivery for women in preterm labor or with preterm prelabor rupture of membranes was not associated with improved neonatal outcomes or 2-year outcomes.

Maternal and foetal medical conditions during pregnancy as determinants of intrapartum stillbirth in public health facilities of Addis Ababa: a case-control study.

Introductionglobally, intrapartum stillbirth accounts for 1 million deaths of babies annually, representing approximately one-third of global stillbirth toll. Intrapartum stillbirth occurs due to causes ranging from maternal medical and obstetric conditions; access to quality obstetric care services during pregnancy; and types, timing and quality of intrapartum care. Different medical conditions including hypertensive & metabolic disorders, infections and nutritional deficiencies during pregnancy are among risk factors of stillbirth. Ethiopia remains one of the 10 high-burden stillbirth countries with estimated rate of more than 25 per 1000 births.Methodsa case-control study using primary data from chart review of medical records of women who experienced intrapartum stillbirth in 23 public health facilities of Addis Ababa during the period July 1, 2010 - June 30, 2015 was conducted. Data was collected from charts of all cases of intrapartum stillbirth meeting the inclusion criteria and randomly selected charts of controls in two to one (2:1) control to case ratio.Resultschronic medical conditions including diabetes, cardiac and renal diseases were less prevalent (1%) among the study population whereas only 6% of women experienced hypertensive disorder during the pregnancy in review. Moreover, 6.5% of the study population had HIV infection where being HIV negative was protective against intrapartum stillbirth (aOR 0.37, 95% CI 0.18-0.78). Women with non-cephalic foetal presentation during last ANC visit were three times more at risk of experiencing intrapartum stillbirth whereas singleton pregnancy had strong protective association against intrapartum stillbirth (p<0.05).Conclusionuntreated chronic medical conditions, infection, poor monitoring of foetal conditions and multiple pregnancy are among important risk factors for intrapartum stillbirth.

27: Externally validated induction score from a prospective population-based cohort study in 94 maternity units

No induction score has emerged as a standard to substitute the Bishop score, especially in case of cervical ripening. The objective of our study was to build a score to predict the risk of cesarean section, from a population-based dataset especially designed for induction analysis purpose. We used the dataset from the prospective multicenter observational French population-based cohort study MEDIP (Methods of Induction of Labor and Perinatal outcomes), which had for objective to collect national data about labor induction practices. For the present study, we excluded all patients with twin pregnancies, non-cephalic presentations, previous c-section, premature deliveries, and cases of induction without cervical ripening. A total of 1 692 patients were analyzed and randomly split in a derivation dataset of 1 024 patients (60%) and an internal validation set of 668 patients (40%). Statistical analyses were performed by using a Bayesian approach. Variables with a probability of being associated with cesarean delivery (Prob OR > 1) greater than 0.90 (i.e. indicating an increased risk of cesarean delivery) were entered in the multivariate model, and then maintained in the final model depending on the Deviance Information Criterion. When available, results from previous studies from literature were used to build informative prior distributions on the log(OR). The score was validated using the internal validation set, and an external dataset from the Consortium for Safe Labor database (NIH database that includes labor and delivery information collected from 19 hospitals across the US from 2002 through 2008). The validation of the model was assessed using AUC and a graphical representation of the calibration. The multivariate model for prediction of c- section in case of induction after cervical ripening is reported in Table 1. The 50 points induction score is displayed in Figure 1. On the external validation set, the AUC for the present score, the Levine score (Levine et al., AJOG 2017), and the modified Bishop score are respectively 0.81 [0.79-0.82], 0.76 [0.75-0.78] and 0.71 [0.70-0.73]. We developed an easy-to-use, externally validated and efficient score to predict c-section after labor induction with cervical ripening.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

807: A Novel prediction model for external cephalic version success

Breech presentation accounts for 3% to 4% of term pregnancies. Breech vaginal delivery has become less accepted following the publication of the Term Breech Trial in 2000. Successful external cephalic version (ECV) can reduce the rates of non-cephalic delivery and cesarean section (CS), but does not lack complications. Currently, maternal consultation on ECV success is limited to quoted success rates, varying from 35-83% in different studies. Clinical predictive factors have been identified for successful ECV, but have yet to be integrated in a predictive model, potentially assisting in the precise counselling of gravidas with non-cephalic presentation. A case-control study of patients who underwent ECV from January 2011 to July 2018, at a single tertiary center. Successful ECV was compared in a single and multivariate analysis using demographic and clinical independent variables to failed ECV group. A model predicting ECV success algorithm was assembled based on probability calculations extracted from the multivariate analysis. 701 women underwent ECV during the study period. ECV success rate was 60.34%. Characteristics of success & failure groups are shown on Table 1. Complication rate was 7.7% (n=54), of which 77.7% (n=42) were transient changes in fetal heart rate, 0.28% (n=2) suspected abruption and one case of neonatal anemia following ECV. Emergency post procedural CS rate was 1.2%. There were no cases of fetal demise. Positive predictors of successful ECV were Parity ≥1 (RR=4.55, CI 3.19-6.49), AFI≥200mm (RR=2.4, CI 1.33-4.46). Anterior placentation and maternal weight ≥ 70 kg were found to be negative predictors (RR=0.34, CI 0.236-0.479 and RR=0.59, CI 0.41-0.85 respectively). Subsequently a prediction algorithm was built on probability calculations based on the 4 predictors of ECV success; parity (0 or ≥1), AFI (<100, 100-200, >200), placentation (anterior, non-anterior) and maternal weight (<70kg, ≥70 kg). Use of the predictive model enabled excellent prediction of patient specific ECV success rates from 7% up to 95%. An algorithm for prediction of successful ECV based on clinical maternal parameters is presented.

Is moxibustion effective in reducing non-cephalic presentations at birth?

Is moxibustion effective in reducing non-cephalic presentations at birth?

External cephalic version at term: a cohort study of 18years' experience.

To analyse the outcome of referrals for external cephalic version (ECV). Retrospective cohort study of prospectively collected data. Major university hospital, UK. Women with non-cephalic presentation at term and no prior caesarean, referred to a specialist clinic. Details of referrals, ECV attempts, and perinatal outcomes were prospectively collected and analysed. Multivariate binary logistic regression models were created to determine independent predictors of ECV success, reversion, and spontaneous version. External cephalic version success rates, predictors of success and cephalic presentation at birth, and perinatal outcomes. Three thousand eight had confirmed breech presentation; 2614 women underwent ECV. Ineligibility for ECV occurred in 117 breech presentations (3.9%), and 297 eligible women (10.2%) declined it. ECV was successful in 1280 (49.0%, 95% CI 47.0-50.9%) (40% in nulliparous women; 64% in others); 1234 (97.3%) were cephalic at birth. Spontaneous version after failure occurred in 4.3% and was more common in multiparas (aOR 2.47, 95% CI 1.43-4.26) and those with a posterior fetal back (aOR 6.09, 95% CI 1.90-19.53). Reversion after successful ECV occurred in 2.2%. In women with a successful ECV whose fetus remained cephalic at birth, 85.7% delivered vaginally. The corrected perinatal mortality of the ECV cohort was 0.12%. External cephalic version has a low complication rate and is effective for most breech presentations, enabling vaginal birth and avoiding caesarean section. External cephalic version can safely be performed with most breech presentations.

257. Risk ok maternal near miss with elective caesarean delivery in women with hypertension in pregnancy in Brazil

Introduction Hypertensive disorders of pregnancy (HDP) contribute significantly to maternal near miss (MNM), most of them are preventable and associated with some delay in obstetric care little use of evidence-based guidelines. Objective The aim of this study is to analyse the association between elective caesarean section (CS) and MNM in women with HDP. Methodology This study is based on data from Birth in Brazil Survey, a nationwide hospital-based study conducted between 2011 and 2012, including 23,894 women. The women selected had 34–42 weeks, and were attended in public hospitals. Cases of placenta previa, HIV, multiple pregnancy, foetal distress before labour and non-cephalic presentation were excluded. A directed acyclic graph was constructed to select the variables for minimum adjustment. Multiple logistic regression analysis was performed to evaluate the association between MNM and elective CS. Results The prevalence of HDP was 12.6% (2999). After exclusions, 1950 women were analyzed, 54% had an elective CS and 10.5% induction of labour. MNM was associated with elective CS (OR 2.2, 95% CI 1.1–4.5), age ⩾ 35 years (OR 2.0, CI 95% 1.0–4.1), and nullipara (OR 2.0, 95% CI, 1.1–3.9). In the multiple logistic regression woman undergoing elective CS had as odds ratio of 2.13 (95% CI 1.02–4.43) for MNM, even controlled by maternal age, parity, gestational age at birth, schooling and other comorbidities. Discussion HDP represents a high prevalence and is the main cause of maternal morbidity and mortality in the country. The rate of induction of labour was low comparing with developed countries, where rates as high as 70–80% are observed. The option for elective CS by providers and/or women rather than induction of labour may be associated with a higher risk for women’s health. Women with HDP should be counselled that elective CS could lead to MNM.

Preterm premature rupture of membranes: Which criteria contraindicate home care management?

Home care management offers a suitable alternative to hospitalization for management of preterm premature rupture of membranes (PPROM). Eligibility criteria have not been clearly established. Our aim was to determine predictive factors of complication during home care management of PPROM in order to define optimal eligibility criteria. Retrospective cohort study of all women with singleton pregnancies with PPROM managed as outpatients between 2009 and 2015. Complications were defined as the occurrence of one of these events: fetal death, placental abruption, umbilical cord prolapse, delivery outside maternity hospital, neonatal death. In all, 187 women with PPROMs were managed as outpatients, of whom 12 had a complication (6.4%). In the "complication" group, gestational age at diagnosis (P=0.006) and at delivery (P<0.001) were lower, with no difference in latency between these two events. Three criteria significantly increased the risk for a severe complication: PPROM occurring before 26weeks (P=0.008), non-cephalic fetal presentation (P=0.02) and oligoamnios (P=0.02). When unfavorable criteria were associated with PPROM, the risk was increased (1 criterion, odds ratio [OR]1.6; 2 criteria, OR6.9 and 3 criteria, OR32.8). Combination of these three criteria is an indication for conventional hospitalization to limit maternal and fetal morbidity. When two criteria are combined, home care should be discussed for each case. If only one unfavorable criteria is present, outpatient management is suitable. To validate these results, a prospective randomized study should be conducted.

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

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

In which groups of pregnant women can the caesarean delivery rate likely be reduced safely in the USA? A multicentre cross-sectional study

ObjectivesTo identify obstetrical subgroups in which (1) the caesarean delivery (CD) rate may be reduced without compromising safety and (2) CD may be associated with better perinatal outcomes.DesignA multicentre cross-sectional...

Predictors of Success of External Cephalic Version and Cephalic Presentation at Birth Among 1253 Women With Noncephalic Presentation Using Logistic Regression and Classification Tree Analyses

(Acta Obstet Gynecol Scand. 2017;96(8):1012–1020) While external cephalic version (ECV) can reduce the likelihood of cesarean birth and noncephalic presentation, many women are not offered, or they decline ECV due to low reported success rates. Factors which predict successful ECV have been studied and identified, but further study of the outcomes for clinically relevant groupings of women are lacking. This study used classification and regression tree (CART) analyses to divide observations into subgroups based on the factor that best separates those with and without a certain outcome. This resulted in a flow chart that may be helpful to clinicians predicting factors of successful ECV.

Delivery of the second twin: influence of presentation on neonatal outcome, a case controlled study

BackgroundSpontaneous vaginal twin delivery after 32nd week of gestation is safe when first twin presenting cephalic. Aim of this study is to identify obstetric factors influencing the condition of second twin and to verify whether non-cephalic presentation and vaginal breech delivery of the second twin is safe.MethodsThis is a retrospective case controlled cohort study of 717 uncomplicated twin deliveries ≥32 + 0 weeks of gestation from 2005 to 2014 in two tertiary perinatal centers. Obstetric parameters were evaluated in three groups with descriptive, univariate logistic regression analysis for perinatal outcome of second twins.ResultsThe three groups included twins delivered by elective cesarean section ECS (n = 277, 38.6%), by unplanned cesarean section UPC (n = 233, 32.5%) and vaginally (n = 207, 28.9%). Serious adverse fetal outcome is rare and we found no differences between the groups. Second twins after ECS had significant better umbilical artery UA pH (p < 0.001) and better Apgar compared to UPC (p = 0.002). Variables for a fetal population “at risk” for adverse neonatal outcome after vaginal delivery (UA pH < 7.20, Apgar 5´ < 9) were associated with higher gestational age (p = 0.001), longer twin-twin interval (p = 0.05) and vacuum extraction of twin A (p = 0.04). Non-cephalic presentation of second twins was not associated (UA pH < 7.20 OR 1.97, CI 95% 0.93–4.22, p = 0.07, Apgar 5´ < 9 OR 1.63, CI 95% 0.70–3.77, p = 0.25, Transfer to neonatal intermediate care unit p = 0.48). Twenty-one second twins (2,9%) were delivered by cesarean section following vaginal delivery of the first twin. Even though non-cephalic presentation was overrepresented in this subgroup, outcome variables were not significantly different compared to cephalic presentation.ConclusionsEven though elective cesarean means reduced stress for second twins this seems not to be clinically relevant. Non-cephalic presentation of the second twin does not significantly influence the perinatal outcome of the second twin but might be a risk factor for vaginal-cesarean birth.

Electronic fetal monitoring is more important than freedom of maternal position in labour: FOR: Position in labour is important but EFM can be vital.

There is universal acceptance (except perhaps by ‘free-birthers’) that there is a likely benefit from some form of fetal surveillance during labour. Currently, the choice is between intermittent auscultation and continuous electronic fetal monitoring (cEFM). Even intermittent ‘auscultation’ is commonly performed using a portable Doppler ultrasound fetal heart detector, the only sensible option if the mother is very obese. Although meta-analyses have shown a statistically significant 30% reduction in stillbirth attributed to asphyxia when cEFM is used rather than auscultation (Vintzileos et al. Obstet Gynecol 1995;85:149–55) and a statistically significant 50% reduction in neonatal convulsions (Thacker et al. Obstet Gynecol 1995;86:613–20), the 2014 UK National Institute of Health and Clinical Excellence guidelines still recommend intermittent auscultation for women ‘without risk factors’ (https://www.nice.org.uk/guidance/cg190). But how many women have/develop risk factors? I analysed 29 443 births from 1988 to 1998 at the West London/Chelsea and Westminster Hospitals and found that 74% had at least one risk factor where cEFM is recommended (maternal age ≥40, diabetes, cardiac or renal disease, antepartum haemorrhage, diastolic blood pressure ≥90 mmHg, non-cephalic presentation, induced or augmented labour, epidural anaesthesia, pyrexia, meconium staining of the amniotic fluid, or labour >12 hours). So in only 26% was cEFM not indicated at some time during labour. How important is posture in labour? I accept that the supine position should be avoided. Williams in 1952 illustrated the adverse effect on uterine activity of the supine position compared with sitting (frequency of contractions doubled and active pressure halved [J Obstet Gynaecol Br Emp 1952; 59:635–641]) and this was corroborated in 1960 by Caldeyro-Barcia (Am J Obstet Gynecol 1960;80:284–90), in 1978 by Turnbull (figure 4.11, Scientific Basis of Obstetrics and Gynaecology, 1978;79–108) and by my personal observations (unpublished). But does any particular position other than supine confer an advantage? Is gravity helpful? Mendez-Bauer suggested in 1975 that standing improved progress in labour, but his comparison was with the supine position (J Perinat Med 1975;3:89–100). When challenged to repeat the study comparing standing with lateral recumbency, he found no difference (Roberts et al. J Reprod Med 1984;29:477–81). In human childbirth, where the baby has to be pushed through a birth canal commonly smaller than the unmoulded fetal head, the driving force is uterine contractions, not gravity. This is elegantly demonstrated by the fact that labour in a birthing pool, where the effect of gravity is negated by the buoyancy of the water, has the same duration as labour on dry land (Cluett & Burns. Cochrane Database Syst Rev 2009;(2):CD000111). These data support the 2014 NICE recommendation that women should be discouraged from being supine but encouraged to adopt any other position they find comfortable. Some women value freedom to move, but in many cases, cEFM is vitally important, and with telemetry there is, in any case, no reason why maternal movement should be restricted. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Does external cephalic version for breech presentation performed prior to an estimated gestational age of 37 weeks offer any benefits or pose any risks compared with external cephalic version performed at term?

EVIDENCE-BASED ANSWER Compared with term external cephalic version, preterm (<37 weeks' gestation) external cephalic version decreases the rate of noncephalic presentation at birth by 19% and the rate of vaginal breech birth by 56%, but increases the risk of late preterm birth by 50% (SOR: A, systematic review of RCTs). The 2016 American College of Obstetrician and Gynecologists guidelines for the management of external cephalic version recommend offering the procedure near term. In comparison, the 2010 guidelines from the Royal College of Obstetricians and Gynaecologists recommend external cephalic version at 36 weeks for nulligravidas and 37 weeks for multigravidas (SOR: C, systematic guidelines).

Perceptions, careseeking, and experiences pertaining to non-cephalic births in rural Sarlahi District, Nepal: a qualitative study

BackgroundIn low-resource settings, a significant proportion of fetal, neonatal, and maternal deaths can be attributed to intrapartum-related complications. Certain risk factors, such as non-cephalic presentation, have a particularly high risk of complications. This qualitative study describes experiences around non-cephalic births and highlights existing perceptions and care-seeking behavior specific to non-cephalic presentation in rural Sarlahi District, Nepal.MethodsWe conducted in-depth interviews with 34 individuals, including women who recently gave birth to a non-cephalic infant and female decision-makers in their households. We also conducted two focus groups with mothers (have two or more children, with at least one child under age five) and two focus groups with grandmothers in the community.ResultsSeveral women described scenes of obstructed labor and practices like provision of unspecified injections early in labor to assist with the delivery. There were reports of arduous care-seeking processes from primary health centers to tertiary facilities, and mixed quality of care among home birth attendants and facility-based health workers respectively. Very few women were aware of the fetal presentation prior to delivery, and we identified no consistent understanding among participants of the risks of and care strategies for non-cephalic births. Risk perception around non-cephalic presentation varied widely. Some participants were acutely aware of potential dangers, while others had not heard of non-cephalic birth. Many interviewees said that the position in which a pregnant woman sleeps could impact the fetal position. Several participants had either taken or heard of medication intended to rotate the fetus into the correct position.ConclusionsOur findings suggest the mixed quality of and access to care associated with non-cephalic birth and a lack of consistent understanding of the risk of and care for non-cephalic births in rural Nepal. The high risk of the condition and the recommended tertiary care present a dilemma in low-resource settings; the logistical difficulties and the mixed quality of care make care-seeking and referral decisions complex. While public health stakeholders strive to improve the quality of and access to the formal health system, those players must also be sensitive to the potential negative implications of promoting institutional care-seeking.