Non-spontaneous Delivery Research Articles

Predicting Admission to Neonatal Care Unit at Mid-Pregnancy and Delivery Using Data from a General Obstetric Population.

Development and validation of risk prediction models at mid-pregnancy and delivery to predict admission to the neonatal care unit. We used data from all singleton deliveries at Cork University Maternity Hospital (CUMH), Ireland during 2019. Admission to the neonatal care unit was assumed if length of stay in the unit was > 24h. Multivariable logistic regression with backward stepwise selection was used to develop the models. Discrimination was assessed using the ROC curve C-statistic, and internal validation was assessed using bootstrapping techniques. We conducted temporal external validation using data from all singleton deliveries at CUMH during 2020. Out of 6,077 women, 5,809 (95.6%) with complete data were included in the analyses. A total of 612 infants (10.54%) were admitted to the neonatal care unit for > 24 hours. Six variables were informative at mid-pregnancy: male infants, maternal smoking, advancing maternal age, maternal overweight/obesity, nulliparity and history of gestational diabetes (C-statistic: 0.600, 95% CI: 0.567, 0.614). Seven variables were informative at delivery: male infants, nulliparity, public antenatal care, gestational age < 39 weeks', non-spontaneous vaginal delivery, premature rupture of membranes and time of birth between 17:01-07.59h (C-statistic: 0.738, 95% CI: 0.715, 0.760). Using these predictors, we developed nomograms to calculate individualised risk of neonatal care unit admission. Bootstrapping indicated good internal performance and external validation suggested good reproducibility. Our nomograms allow the user to quickly estimate individualised risk of neonatal care unit admission. Future research should aim to improve accuracy in early pregnancy to better assist counselling of parents.

The role of childhood adversity and prenatal mental health as psychosocial risk factors for adverse delivery and neonatal outcomes

ObjectiveExposure to adverse childhood experiences (ACEs) is a significant predictor for physical and mental health problems later in life, especially during the perinatal period. Prenatal common mental disorders (PCMDs) are well-established as a risk for obstetric interventions but knowledge on combined effects of multiple psychosocial risk factors is sparse. We aim to examine a comprehensive model of ACEs and PCMDs as risk factors for poor delivery and neonatal outcomes. MethodWith structural equation modeling, we examined direct and indirect pathways between psychosocial risk and delivery and neonatal outcomes in a prospective cohort from pregnancy to birth in Iceland. ResultsExposure to ACEs increased risk of PCMDs [β = 0.538, p < .001, CI: 0.195–1.154] and preterm delivery [β = 0.768, p < .05, CI: 0.279–1.007)]. An indirect association was found between ACEs and increased risk of non-spontaneous delivery [β = 0.054, p < .05, CI: 0.004–0.152], mediated by PCMDs. Identical findings were observed for ACEs subcategories. ConclusionACEs are strong predictors for mental health problems during pregnancy. Both ACEs and PCMDs diagnosis are associated with operative delivery interventions and neonatal outcomes. Findings underscore the importance of identifying high-risk women and interventions aimed at decreasing psychosocial risk during the prenatal period.

Observation of Risk Factors among Gestational Diabetes Mellitus Patients

Introduction: Gestational diabetes mellitus (GDM) is a common complication during pregnancy that affects both maternal and neonatal health outcomes. Identifying risk factors associated with GDM is crucial for early detection and intervention to improve pregnancy outcomes. Methods: This retrospective observational study was conducted at the Department of Gynecology, Gonoshasthaya Nagar Hospital, Dhaka, Bangladesh during the period of January 2019 to December 2019 with a total of 348 hospital patient records. Result: Of the 348 participants, 24.71% had GDM. Significant differences were observed between the groups in age, gravida, BMI distribution, family history of GDM, and previous history of GDM. Higher rates of non-spontaneous vaginal deliveries were found in the GDM group (36.05%) compared to the non-GDM group (22.52%). Age ≥35 years, obesity, family history of GDM, and history of GDM were significantly associated with GDM (p&lt;0.05). Conclusion: Our findings support the existing evidence that advanced maternal age, obesity, family history of GDM, and previous history of GDM are significant risk factors for GDM. These results highlight the importance of early screening and intervention for high-risk groups to prevent adverse pregnancy outcomes.

Access to maternal health services during COVID-19 pandemic, re-examining the three delays among pregnant women in Ilubabor zone, southwest Ethiopia: A cross-sectional study.

BackgroundAll women require access to high-quality care during pregnancy, labor, and after childbirth. The occurrence of delay at any stage is one of the major causes of maternal mortality. There is, however, a scarcity of data on women’s access to maternal health services during the COVID-19 pandemic. Therefore, the goal of this study was to assess the magnitude of delays in maternal health service utilization and its associated factors among pregnant women in the Ilubabor zone during the COVID-19 pandemic.MethodsA facility-based cross-sectional study was conducted among 402 pregnant women selected by systematic random sampling. Data were analyzed using IBM SPSS Statistics version 26. Descriptive and summary statistics were used to describe the study population. Bivariate and multivariable logistic regression analyses were performed to identify factors associated with the outcome variables. Adjusted odds ratio with respective 95% CI was used to report significant covariates.ResultsA total of 402 pregnant women participated in this study. The median age of the respondents was 25 years (IQR = 8). On average, a woman stays 1.76 hours (SD = 1.2) to make a decision to seek care. The prevalence of first, second and third delay were 51%, 48%, and 33.3%, respectively. Being unmarried [AOR (95% CI)], [0.145 (0.046–0.452)], being unemployed [AOR (95% CI)], [4.824 (1.685–13.814)], age [AOR (95% CI)], [0.227 (0.089–0.0579)], fear of COVID-19 [AOR (95% CI)], [1.112 (1.036–1.193)], urban residence [AOR (95% CI)], [0.517 (0.295–0.909)], and lack of birth preparedness [AOR (95% CI)], [6.526 (1.954–21.789)] were significantly associated with first delay. Being unmarried [AOR (95% CI)], [5.984 (2.930–12.223)], being unemployed [AOR (95% CI)], [26.978 (3.477–209.308)], and age [AOR (95% CI)], [0.438 (0.226–0.848)] were significantly associated with second delay. Having lengthy admission [AOR (95% CI)], [7.5 (4.053–13.878)] and non-spontaneous vaginal delivery [AOR (95% CI)], [1.471 (1.018–1.999)] were significantly associated with third delay.ConclusionThis study identified a significant proportion of mothers experiencing delays, although there were no data to suggest exacerbated delays in utilizing maternal health services due to fear of the COVID-19 pandemic. The proportion of maternal delay varies with different factors. Improving the decision-making capacity of women is, therefore, essential.

Predictors of Non-Spontaneous Vaginal Delivery Among Mothers Who Gave Birth in Wachemo University Specialized Hospital, Hossana, Ethiopia, 2021.

IntroductionNon-spontaneous vaginal delivery, such as cesarean delivery and operative vaginal deliveries, provides births other than regular vaginal pregnancy. In taking effective steps to minimize the caesarean section rate and the issues associated with it, it would be useful to examine the determinants of instrumental deliveries and their key indications. Therefore, this study aimed to determine magnitude and related factors of non-spontaneous vaginal delivery.MethodsFacility-based analytical cross-sectional study design was used. A total sample size of 383 was used. All mothers who gave birth during data collection period and fulfill inclusion criteria were included in the study. Interviewer-administered data collection method was used. Data were entered in Epi-data and exported to SPSS to analyze both descriptive and advanced analysis.ResultsAbout 24.4% of mothers’ mode of delivery was non-spontaneous vaginal delivery. Those mothers whose occupation was housewives were 2.8 times more likely to give birth through non-spontaneous vaginal delivery than mothers whose occupation was teachers (AOR = 2.8 95% CI 1.103–7.261). Mothers with grand multipara were less likely to give birth through non-spontaneous vaginal delivery than nulliparous (AOR = 0.10 95% CI 0.022–0.468) and primipara (AOR = 0.17 95% CI 0.041–0.671). Mothers with complications during pregnancy were 3 times more likely to give birth via non-spontaneous vaginal delivery than mothers without complications during pregnancy. Mothers with non-macrosomic neonates and female neonatal sex were less likely experiencing to give birth through non-spontaneous vaginal delivery as compared to their respective reference groups.ConclusionMagnitude of non-spontaneous vaginal delivery was high in this study. Being a housewife, having complications during pregnancy, nullipara and primipara, macrosomic fetus and male neonate were associated with outcome variable. Attention should be given for the housewives, experiencing complication during pregnancy, a fetus with big weight and male neonatal sex in order to minimize risks of non-spontaneous delivery.

Signaling of Phoenixin via GPR173 and the Paradox of Increased Vasopressin Secretion in Preeclampsia

Preterm birth affects over 15 million pregnancies annually worldwide, and is associated with severe health risks for both mother and child. The leading cause of clinically indicated, non-spontaneous preterm delivery is preeclampsia, which can lead to maternal and fetal morbidity and mortality if not appropriately and promptly managed. At this time, the only “cure” for preeclampsia is delivery of the fetus and associated products of conception, which presents the clinical challenge of weighing the risks versus benefits of delivery if the pregnancy is preterm. The etiology of preeclampsia is multifactorial and incompletely understood. However, several carefully conducted studies have implicated the paradoxical secretion of the posterior pituitary hormone, arginine vasopressin (AVP) as a potential causative factor. Women with preeclampsia exhibit elevated plasma levels of AVP even in the face of the ongoing hypertension and hyponatremia, and infusion of AVP into pregnant rodents recapitulated multiple features of preeclampsia. The reason for the inappropriately elevated AVP in preeclampsia is unknown. Using a bioinformatic algorithm, our group identified a novel peptide that is conserved across multiple species, and named it phoenixin (PNX) (PMID 22963497). Our published data demonstrate a reproductive role of the peptide, and indicate that hypothalamic and pituitary PNX expression is modulated by sex hormones (PMID 27440717). Likewise, we recently have demonstrated that cerebroventrcular administration of PNX elevated plasma AVP levels in rats (PMID 29364701). Using the RNAscope approach we have now demonstrated that the receptor for PNX, identified by our group as GPR173 (PMID 27440717), is expressed by AVP neurons. Importantly expression of GPR173 increased across pregnancy in the rat hypothalamus coincident with increased AVP production and release (PMID 27330717). These data strongly suggest that PNX, acting through GPR173, could act as a molecular link between sex hormones and AVP secretion. In addition, we now demonstrate that central injection of PNX increases blood pressure, likely through PNX-induced elevation in AVP secretion. We hypothesize that the paradox of increased AVP secretion in the hyponatremic and hypervolemic state of preeclampsia is due to exaggerated PNX signaling in hypothalamus via GPR173 on AVP neurons and possibly on GPR173 expressing neurons in autonomic centers in hindbrain.

Trait mindfulness during pregnancy and perception of childbirth

Women’s subjective childbirth experience is a risk factor for postpartum depression and childbirth-related posttraumatic stress symptoms. Subjective childbirth experience is influenced not only by characteristics of the childbirth itself but also by maternal characteristics. A maternal characteristic that may be associated with a more positive childbirth experience is trait mindfulness. The current study aimed to assess this association and to assess whether trait mindfulness during pregnancy had a moderating role in the possible association between non-spontaneous delivery and perception of childbirth. A subsample of 486 women, participating in a longitudinal prospective cohort study (Holistic Approach to Pregnancy and the first Postpartum Year study), completed the Three Facet Mindfulness Questionnaire-Short Form at 22 weeks of pregnancy. Women completed the Childbirth Perception Scale and the Edinburgh Postnatal Depression Scale between 7 and 21 days postpartum. The mindfulness facets acting with awareness and non-reacting were significantly associated with a more positive perception of childbirth, after adjusting for covariates. Moderation analyses showed a significant interaction between acting with awareness and non-spontaneous delivery and non-judging and non-spontaneous delivery. Non-spontaneous delivery was associated with a more negative perception of childbirth for low/medium scores of acting with awareness and non-judging, but not for high scores on these mindfulness facets. Trait mindfulness during pregnancy may enhance a positive perception of childbirth. Because this is among the first studies examining the association between maternal dispositional mindfulness and perception of childbirth, future research is needed to confirm the results of the current study.

Quality of Pregnancy Dating and Obstetric Interventions During Labor: Retrospective Database Analysis.

BackgroundThe correct dating of pregnancy is critical to support timely decisions and provide obstetric care during birth. The early obstetric ultrasound assessment before 14 weeks is considered the best reference to assist in determining gestational age (GA), with an accuracy of ±5 to 7 days. However, this information is limited in many settings worldwide.ObjectiveThe aim of this study is to analyze the association between the obstetric interventions during childbirth and the quality of GA determination, according to the first antenatal ultrasound assessment, which assisted the calculation.MethodsThis is a hospital-based cohort study using medical record data of 2113 births at a perinatal referral center. The database was separated into groups and subgroups of analyses based on the reference used by obstetricians to obtain GA at birth. Maternal and neonatal characteristics, mode of delivery, oxytocin augmentation, and forceps delivery were compared between groups of pregnancies with GA determination at different reference points: obstetric ultrasound assessment 14 weeks, 20 weeks, and ≥20 weeks or without antenatal ultrasound (suboptimal dating). Ultrasound-based GA information was associated with outcomes between the interest groups using chi-square tests, odds ratios (OR) with 95% CI, or the Mann-Whitney statistical analysis.ResultsThe chance of nonspontaneous delivery was higher in pregnancies with 14 weeks ultrasound-based GA (OR 1.64, 95% CI 1.35-1.98) and 20 weeks ultrasound-based GA (OR 1.58, 95% CI 1.31-1.90) when compared to the pregnancies with ≥20 weeks ultrasound-based GA or without any antenatal ultrasound. The use of oxytocin for labor augmentation was higher for 14 weeks and 20 weeks ultrasound-based GA, OR 1.41 (95% CI 1.09-1.82) and OR 1.34 (95% CI 1.04-1.72), respectively, when compared to those suboptimally dated. Moreover, maternal blood transfusion after birth was more frequent in births with suboptimal ultrasound-based GA determination (20/657, 3.04%) than in the other groups (14 weeks ultrasound-based GA: 17/1163, 1.46%, P=.02; 20 weeks ultrasound-based GA: 25/1456, 1.71%, P=.048). Cesarean section rates between the suboptimal dating group (244/657, 37.13%) and the other groups (14 weeks: 475/1163, 40.84%, P=.12; 20 weeks: 584/1456, 40.10%, P=.20) were similar. In addition, forceps delivery rates between the suboptimal dating group (17/657, 2.6%) and the other groups (14 weeks: 42/1163, 3.61%, P=.24; 20 weeks: 46/1456, 3.16%, P=.47) were similar. Neonatal intensive care unit admission was more frequent in newborns with suboptimal dating (103/570, 18.07%) when compared with the other groups (14 weeks: 133/1004, 13.25%, P=.01; 20 weeks: 168/1263, 13.30%, P=.01), excluding stillbirths and major fetal malformations.ConclusionsThe present analysis highlighted relevant points of health care to improve obstetric assistance, confirming the importance of early access to technologies for pregnancy dating as an essential component of quality antenatal care.

Effects of prenatally diagnosed congenital heart disease on timing and mode of delivery

Purpose: Prenatal diagnoses of congenital heart disease (CHD) may prompt non-spontaneous delivery (NSD). This may predispose infants and mothers to unnecessary risks associated with Caesarean section (CS) or planned induction of labor (IOL). However, there is no consensus on the appropriate mode of delivery for a fetus with known CHD. In addition, most fetuses with CHD are not at increased intrapartum risk or unable to tolerate spontaneous labor (SL). We hypothesize that a prenatal CHD diagnosis is positively correlated with the infant';s likelihood of …

Avoiding late preterm deliveries to reduce neonatal complications: an 11-year cohort study

BackgroundLate preterm (LPT) newborns, defined as those born between 34 0/7 and 36 6/7 gestational weeks, have higher short- and long-term morbidity and mortality than term infants (≥37 weeks). A categorization to justify a non-spontaneous LPT delivery has been proposed to distinguish evidence-based from non-evidence-based criteria. This study aims to describe rates and temporal trends of non-spontaneous LPT neonates delivered according to evidence-based or non-evidence-based criteria and to evaluate the number of avoidable LPT deliveries, including severe neonatal morbidity rates and associated risk factors.MethodsRetrospective cohort study including all LPT neonates born at a Swiss university maternity unit between January 1, 2002 and December 31, 2012. Trends of LPT neonates and neonatal complications were assessed across time using Poisson regression and risk factors for neonatal complications by logistic regression.ResultsAmong 40,609 singleton live births, 4223 (10.5%) were preterm and 2017 (4.9%) LPT. In the latter group, 26.2% were non-spontaneous (evidence-based: 12.0%; non-evidence-based: 14.2%). The most frequent indications for evidence-based non-spontaneous LPT delivery were severe preeclampsia (51.8%) and abnormal fetal tracing (24.7%). Indications for non-evidence-based non-spontaneous LPT deliveries were hemorrhage (36.2%) and mild preeclampsia (15.7%). LPT birth rates remained stable over time. The rate of neonatal complications after non-evidence-based LPT birth remained high over time (43.8% vs. 43.5% in 2002 and 2012, respectively; P = 0.645), whereas the annual proportion of neonatal complications overall showed a decreasing trend (from 38.0% in 2002 to 33.5% in 2012; P = 0.051).ConclusionsLPT birth rates were stable over time, but neonatal complications remained high, particularly after non-evidence-indicated LPT birth. A total of 287 LPT births could have been potentially avoided if an evidence-based protocol for delivery indications had been used. Efforts should be made to avoid non-spontaneous LPT births in order to reduce neonatal complications.

Breastfeeding Determinants in Healthy Term Newborns.

Breastfeeding is the normative standard for infant feeding. Despite its established benefits, different factors can affect breastfeeding rates over time. The purpose of this study was to evaluate breastfeeding determinants in healthy term newborns during the first three months of life. A prospective, observational, single-center study was conducted in the nursery of Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico in Milan, Italy. The mother-baby dyads that were admitted to the Clinic in January and February 2017 were enrolled. Only healthy term babies with birth weight ≥10th percentile for gestational age were included. Data were collected through medical records and questionnaires administered during the follow-up period. Then, we fitted univariate and multivariate logistic models and calculated odds ratios. 746 dyads were included but 640 completed the study. The factors found to be favoring breastfeeding were a previous successful breastfeeding experience, a higher level of education of the mother, attending prenatal classes, no use of pacifier, rooming in practice, and breastfeeding on demand. Factors acting negatively on breastfeeding were advanced maternal age, non-spontaneous delivery, perception of low milk supply, mastitis, and nipple fissures. This study highlights the need to individualize the assistance provide to breastfeeding mothers, paying special attention to personal experiences.

Immediate delivery or expectant management in gestational diabetes at term: the GINEXMAL randomised controlled trial.

To evaluate maternal and perinatal outcomes after induction of labour versus expectant management in pregnant women with gestational diabetes at term. Multicentre open-label randomised controlled trial. Eight teaching hospitals in Italy, Slovenia, and Israel. Singleton pregnancy, diagnosed with gestational diabetes by the International Association of Diabetes and Pregnancy Study Groups criteria (IADPSGC), between 38+0 and 39+0 weeks of gestation, without other maternal or fetal conditions. Patients were randomly assigned to induction of labour or expectant management and intensive follow-up. Data were analysed by 'intention to treat'. The primary outcome was incidence of caesarean section. Secondary outcomes were maternal and perinatal mortality and morbidity. A total of 425 women were randomised to the study groups. The incidence of caesarean section was 12.6% in the induction group versus 11.7% in the expectant group. No difference was found between the two groups (relative risk, RR 1.06; 95% confidence interval, 95% CI 0.64-1.77; P = 0.81). The incidence of non-spontaneous delivery, either by caesarean section or by operative vaginal delivery, was 21.0 and 22.3%, respectively (RR 0.94; 95% CI 0.66-1.36; P = 0.76). Neither maternal nor fetal deaths occurred. The few cases of shoulder dystocia were solved without any significant birth trauma. In women with gestational diabetes, without other maternal or fetal conditions, no difference was detected in birth outcomes regardless of the approach used (i.e. active versus expectant management). Although the study was underpowered, the magnitude of the between-group difference was very small and without clinical relevance. Immediate delivery or expectant management in gestational diabetes at term?

Risk factors for neonatal mortality at Moewardi Hospital, Surakarta

Background Neonatal mortality remains a major concern indeveloping countries. Identifying potential risk factors is importantin order to decrease the neonatal mortality rate. In MoewardiHospital, Surakarta, the risk factors for neonatal mortality havenot been assessed.Objective To evaluate potential risk factors of n eonatalmortality.Methods We reviewed medical records of all neonates hospitalizedin the neonatal intensive care unit (NICU) at Dr. MoewardiHospital from January to December 2011. Analyzed variables weresex, birth weight, gestational age, maternal age, place of delivery,mode of delivery, and sepsis. Data were analyzed by Chi square andbinary logistic regression with 95% confidence intervals (CI).Results Out of841 neonates, the mortality rate was 212 (25.2%).Univariate logistic regression revealed that the significant riskfactors for neonatal mortality were preterm (OR 4.41 ; 95%CI4.24 to 4.57; P=0.0001) , low bir th weight (OR 4.30; 95%CI4.13 to 4.47; P=0.0001), sepsis (OR 2.99; 95%CI 2.81 to 3.17;P=0.0001), maternal age 2:35 years (OR 1.53; 95%CI 1.37 to1.70), and non-spontaneous delivery (OR 1.67; 95%CI 1.50 to1.84). Further multivariate regression analysis revealed that thesignificant risk factors were preterm (OR 2.2 7; 95%CI 2.05 to 2.48;P=0.0001), low birth weight (OR 2.49; 95%CI 2.27 to 2.71; P=0.0001), and sepsis (OR 2.50; 95%CI 2.30 to 2.69; P= 0.0001).Conclusion The risk factors for neonatal mortality in the NICUare preterm, low birth weight, and sepsis.

Risk factors for neonatal mortality at Moewardi Hospital, Surakarta

Background Neonatal mortality remains a major concern indeveloping countries. Identifying potential risk factors is importantin order to decrease the neonatal mortality rate. In MoewardiHospital, Surakarta, the risk factors for neonatal mortality havenot been assessed.Objective To evaluate potential risk factors of n eonatalmortality.Methods We reviewed medical records of all neonates hospitalizedin the neonatal intensive care unit (NICU) at Dr. MoewardiHospital from January to December 2011. Analyzed variables weresex, birth weight, gestational age, maternal age, place of delivery,mode of delivery, and sepsis. Data were analyzed by Chi square andbinary logistic regression with 95% confidence intervals (CI).Results Out of841 neonates, the mortality rate was 212 (25.2%).Univariate logistic regression revealed that the significant riskfactors for neonatal mortality were preterm (OR 4.41 ; 95%CI4.24 to 4.57; P=0.0001) , low bir th weight (OR 4.30; 95%CI4.13 to 4.47; P=0.0001), sepsis (OR 2.99; 95%CI 2.81 to 3.17;P=0.0001), maternal age 2:35 years (OR 1.53; 95%CI 1.37 to1.70), and non-spontaneous delivery (OR 1.67; 95%CI 1.50 to1.84). Further multivariate regression analysis revealed that thesignificant risk factors were preterm (OR 2.2 7; 95%CI 2.05 to 2.48;P=0.0001), low birth weight (OR 2.49; 95%CI 2.27 to 2.71; P=0.0001), and sepsis (OR 2.50; 95%CI 2.30 to 2.69; P= 0.0001).Conclusion The risk factors for neonatal mortality in the NICUare preterm, low birth weight, and sepsis.

Short-Term Neonatal Outcomes in Diamniotic Twin Pregnancies Delivered after 32 Weeks and Indications of Late Preterm Deliveries

We sought to compare neonatal outcomes in twin pregnancies following moderately preterm birth (MPTB), late preterm birth (LPTB), and term birth and determine the indications of LPTB. We performed a retrospective cohort study. MPTB was defined as delivery between 32(0/7) and 33(6/7) weeks and LPTB between 34(0/7) and 36(6/7) weeks. The composite neonatal adverse respiratory outcome was defined as respiratory distress syndrome and/or bronchopulmonary dysplasia. The composite neonatal adverse nonrespiratory outcome included early onset culture-proven sepsis, necrotizing enterocolitis, retinopathy of prematurity, intraventricular hemorrhage, or periventricular leukomalacia. LPTB cases were categorized as spontaneous (noniatrogenic), evidence-based iatrogenic, and non-evidence-based (NEB) iatrogenic. Of the 747 twin deliveries during the study period, 453 sets met the inclusion criteria with 22.7% (n = 145) MPTB, 32.1% (n = 206) LPTB, and 15.9% (n = 102) term births. Compared with term neonates, the composite neonatal adverse respiratory outcome was increased following MPTB (relative risk [RR] 24; 95% confidence interval [CI] 3.0 to 193.6) and LPTB (RR 13.7; 95% CI 1.8 to 101.8). Compared with term neonates, the composite neonatal adverse nonrespiratory outcome was increased following MPTB (RR 22.3; 95% CI 3.9 to 127.8) and LPTB (RR 5.5; 95% CI 1.1 to 27.6). Spontaneous delivery of LPTB was 63.6% (n = 131/206) and the rate of iatrogenic delivery was 36.4% (n = 75/206). The majority, 66.6% (n = 50/75), of these iatrogenic deliveries were deemed NEB, giving a total of 24.2% (50/206) NEB deliveries in LPTB group. Our data demonstrate a high rate of late preterm birth among twin pregnancies, with over half of nonspontaneous early deliveries due to NEB indications. Although our morbidity data will be helpful to providers in counseling patients, our finding of high NEB indications underscores the need for systematic evaluation of indications for delivery in LPTB twin deliveries. Furthermore, this may lead to more effective LPTB rate reduction efforts.

151: Epidural analgesia during labor: impact on rates of cesarean and instrumental vaginal delivery: the results of a nationwide cohort study in the Netherlands

In the Netherlands, the use of epidural anesthesia (EA) during labor has more than doubled in the last few years from 5.4% in 2003, to 11.4%. in 2008. The effects of EA on the mode of delivery remains controversial. The aim of this study was to study the use of EA in relation to non-spontaneous deliveries in term deliveries with a fetus in cephalic presentation in a nationwide cohort.

Risk Factors for RhD Immunisation Despite Antenatal and Postnatal Anti-D Prophylaxis

Despite routine antenatal and postnatal administration of anti-D immunoglobulin (Ig) during pregnancy and delivery in a previous pregnancy, 0.1% to 0.3% of women are found to have Rhesus D (RhD) antibodies in their next pregnancy. The primary aim of this case-control study was to identify causative risk factors for rhesus D (RhD) immunization in the next pregnancy among women who had received adequate antenatal and postnatal anti-D prophylaxis in the previous pregnancy. A second aim was to evaluate the preventive effect of additional administration of anti-D Ig in such women with risk factors. Data obtained from the nationwide Dutch antenatal anti- D-prophylaxis program identified 42 new cases of RhD-immunized parae-1, detected with first-trimester screening, despite documented evidence of adequate antenatal and postnatal prophylaxis during the previous pregnancy. The controls were 339 parae-1 without red cell antibodies. Data on risk factors and other information was provided by the obstetric care worker and/or telephone interviews with the women. The primary study outcome measures were risk factors for RhD immunization. Multivariate analysis showed that statistically significant independent risk factors for RhD immunization were postmaturity (≥42 weeks of completed gestation) (odds ratio [OR], 3.07; 95% confidence interval [CI], 1.02-9.02), nonspontaneous delivery (assisted vaginal delivery or cesarean section) (OR, 2.23; 95% CI, 1.04-4.74), and age (OR, 0.89/yr; 95% CI, 0.80-0.98). Pregnancy-related red blood cell transfusion was almost significant; the OR was 3.51, with a 95% CI of 0.97 to 12.7. A condition related to increased feto-maternal hemorrhage and/or insufficient levels of anti-D Ig was observed in at least half of the failures of anti-D Ig prophylaxis. These findings provide direct evidence of causative risk factors for RhD immunization in the next pregnancy of women who had received adequate antenatal and postnatal anti-D prophylaxis in their previous pregnancy. The data show that RhD immunization may be further reduced by routine administration of extra anti-D Ig in these women.

Risk factors for RhD immunisation despite antenatal and postnatal anti-D prophylaxis.

ObjectiveTo identify risk factors for Rhesus D (RhD) immunisation in pregnancy, despite adequate antenatal and postnatal anti-D prophylaxis in the previous pregnancy. To generate evidence for improved primary prevention by extra administration of anti-D Ig in the presence of a risk factor.DesignCase–control study.SettingNation-wide evaluation of the Dutch antenatal anti-D-prophylaxis programme.PopulationCases: 42 RhD-immunised parae-1, recognised by first-trimester routine red cell antibody screening in their current pregnancy, who received antenatal and postnatal anti-D Ig prophylaxis (gifts of 1000 iu) in their first pregnancy. Controls: 339 parae-1 without red cell antibodies.MethodsData were collected via obstetric care workers and/or personal interviews with women.Main outcome measureSignificant risk factors for RhD immunisation in multivariate analysis.ResultsIndependent risk factors were non-spontaneous delivery (assisted vaginal delivery or caesarean section) (OR 2.23; 95% CI:1.04–4.74), postmaturity (≥42 weeks of completed gestation: OR 3.07; 95% CI:1.02–9.02), pregnancy-related red blood cell transfusion (OR 3.51; 95% CI:0.97–12.7 and age (OR 0.89/year; 95% CI:0.80–0.98). In 43% of cases, none of the categorical risk factors was present.ConclusionsIn at least half of the failures of anti-D Ig prophylaxis, a condition related to increased fetomaternal haemorrhage (FMH) and/or insufficient anti-D Ig levels was observed. Hence, RhD immunisation may be further reduced by strict compliance to guidelines concerning determination of FMH and accordingly adjusted anti-D Ig prophylaxis, or by routine administration of extra anti-D Ig after a non-spontaneous delivery and/or a complicated or prolonged third stage of labour.

Role of a second stage partogram in predicting the outcome of normal labour

Management of the second stage of labour is dictated by arbitrary time limits rather than true measures of progress. No partogram is available for second stage of labour. To evaluate a partogram designed for use for the second stage of labour. This prospective cross-sectional analytical study included low-risk pregnant women with singleton fetuses with vertex presentations at term. From onset of the second stage, vaginal examinations were performed every 30 min until delivery. A scoring system developed by Sizer et al. was used based on station and position of fetal head. Scores were plotted on a second stage partogram and used to predict labour outcomes, such as duration of second stage and mode of delivery. Of 79 women examined, 73 had spontaneous vaginal delivery. Of the remaining six, four required oxytocin infusion and other two required vacuum extraction. The median durations of the second stage of labour for primigravidas (n = 34) and multigravidas (n = 45) were 35 and 25 min, respectively. The median Sizer's partogram score at the onset of second stage was 4. Multiple regression analysis showed that the partogram score (r2 = 0.27) and gravidity (r2 = 0.10) were independent predictors of duration of the second stage. There was a significant association between second stage progress plotted to the right of the partogram line and non-spontaneous delivery (P = 0.01). The second stage partogram score at onset can predict the duration of second stage. Poor progress plotted on the partogram is associated with non-spontaneous delivery.

Classification trees: A possible method for maternity risk grouping

Pregnancy, although being one of the most natural processes in our evolution, still remains subject to numerous complications and potential high risk. Complications at birth, such as the need for a caesarean section or the use of forceps, are not uncommon. An early warning of possible complications would greatly benefit both medical professionals and the expectant mother. Classification tree analysis uses selected independent variables to group pregnant women according to a dependent variable in a way that reduces variation. In this study, data on 3902 births were analysed to create risk groups for a number of complications, including the risk of a non-spontaneous delivery (a complicated birth) and premature delivery. From an overall risk of 23% of a non-spontaneous delivery, the classification tree was able to find statistically significant risk groups ranging from 7% to 65%. The resulting classification rules have been incorporated into a developed database tool to help quantify associated risks and act as an early warning system of possible complications to individual pregnant women.