Cephalic Presentation Research Articles

Frequency of fetal blood sampling, delivery mode and neonatal outcome after revised CTG-classification and updated lactate meter in Sweden: An observational study.

A revised cardiotocography (CTG) classification was implemented in Sweden in 2017. Simultaneously, an updated version of the lactate meter, Lactate Pro 2™, proved to measure 50% higher than the previous, necessitating new cutoffs for fetal blood sampling (FBS). We aimed to investigate frequencies of FBS, delivery modes, and neonatal outcomes. We hypothesized that with the revised CTG classification, which accepts more fetal heart rate patterns as normal than the previous, the frequency of FBS would be lower, the proportion of acidemia at FBS and adverse neonatal outcomes would be higher among sampled fetuses, but not among the entire laboring population, and the higher lactate readings might increase the proportion of cesarean delivery in general anesthesia and cesarean delivery above vacuum extraction. A population-based cohort study of electronic medical records of labors in Stockholm-Gotland during 2014-2015 and 2018-2019, including singleton pregnancies >34 weeks, cephalic presentation, with spontaneous or induced start of labor. Outcome measures were FBS frequency, proportion of fetal acidemia, delivery modes, and neonatal outcomes with comparison between the two periods among sampled and nonsampled fetuses. There were 28 841 and 30 192 births during the two periods. In the latter period, the FBS frequency was lower (8.2% vs. 11.9% [p < 0.001]), and the proportion of acidemia at FBS was higher, both among sampled fetuses (12.5% vs. 7.1% [p < 0.001]), and in the total population (1.0% vs. 0.8% [p = 0.022]). Immediate cesareans in general anesthesia due to fetal distress were more frequent among sampled fetuses (3.1% vs. 2.0% [p = 0.006]) but not among nonsampled fetuses (0.4 vs. 0.4%). Incidence of Apgar scores < 4 at 5 min was unchanged after FBS (p = 0.66) but higher among nonsampled newborns (0.2 vs. 0.1 [p = 0.033]). Apgar scores <7 at 5 min were more frequent among both sampled and nonsampled groups. After implementation of a revised CTG classification and a differently calibrated lactate meter in Sweden, the use of FBS was substantially lower. Acidemia at FBS and immediate cesarean due to fetal distress were more frequent among sampled fetuses but still low in the total laboring population. Low Apgar scores were more frequent among newborns both with and without FBS.

Development and internal validation of a model predicting successful trial of labour among pregnant individuals with previous one caesarean section: A cohort study (DEVI-CS model).

To develop and internally validate a model predicting successful trial of labour among pregnant women with previous caesarean scar. Cohort study. Tertiary care and teaching hospital. All pregnant women with one previous caesarean delivery, presenting with singleton pregnancies in cephalic presentation at a gestation age of 37weeks or more between 2018 and 2022. A stepwise multivariable logistic regression, followed by bootstrapping, was used to develop and validate the model. Success was defined as vaginal birth after caesarean section (VBAC) without complications for the mother and baby. Out of 4515 cases of TOLAC, 39.8% had a successful trial of labour. Maternal age (OR=0.950, 95%CI: 0.927-0.974), previous baby weight (OR=1.000, 95%CI: 1.000-1.001), indication of previous caesarean section such as breech presentation (OR=0.453, 95%CI: 0.315-0.652), failed induction (OR=0.346, 95%CI: 0.267-0.447), BISHOP score (OR=1.725, 95%Cl: 1.673-1.774) and induction of labour (OR=0.587, 95%CI: 0.466-0.741) were the strongest predictors of successful TOLAC. DEVI-CS model showed good discrimination with an area under the curve (AUC) of 0.928(95%CI: 0.921-0.936) and good agreement between predicted and observed probabilities. Decision curve analysis showed a net benefit between 5% and 90% between the predicted thresholds. The new DEVI-CS prediction model, based on easily captured clinical variables, can quantify the chances of a successful trial of labour after a previous caesarean section. It could aid in shared decision-making regarding the mode of delivery among women with planning the trial of labour after caesarean section.

Serial intrapartum ultrasound to predict vaginal delivery using angle of progression and head- progression distance in term nulliparous women.

Over the past decade, intrapartum ultrasound (ITU) has been in the global limelight for labour monitoring. The use of the same in clinical settings of low- and middle-income countries (LMIC's) however, is limited. Till date, angle of progression (AOP) stands as the most studied parameter. Very few studies, most from developed countries, have shown that other ITU measurements could also hold relevance to labour and delivery. In recent times, serial ITU has also garnered some attention and could possibly be a better predictor of labour outcome. This study aimed to compare the predictive accuracies of AOP and head PD for vaginal delivery and to investigate whether the rate of change of serially measured AOP and head PD in the first stage is predictive of vaginal delivery. A prospective observational study was conducted on 90 nulliparous women between April 2023 and July 2024 at a tertiary teaching hospital in South India. Participants had singleton pregnancies in cephalic presentation between 37-40weeks with regular contractions, and cervical dilation≥3 cm. Exclusion criteria included prior LSCS and abnormal cardiotocography. Intrapartum ultrasound was performed twice, once at recruitment and 3-5h apart, to measure AOP and PD. Statistical analysis included ROC curve plotting for diagnostic accuracy of AOP and PD in predicting vaginal delivery. Of the 90 participants, 71 (78.9%) delivered vaginally and 19 (21.1%) had caesarean sections. AOP≥120° and PD≥2.7cm at≥6 cm cervical dilation showed a strong correlation with vaginal delivery, with sensitivity and specificity of 70.4% and 94.7%, and 63.4% and 89.5% respectively. Change (delta) in AOP>10° had the highest diagnostic accuracy (81%), with a positive predictive value of 92.2%. ITU offers valuable insights into labour progression. AOP and PD, particularly at cervical dilation of≥6 cm, are predictive of vaginal delivery. Delta AOP serves as the most accurate predictor. Incorporating ITU into routine labour management enhances clinical decision-making, helping reduce unnecessary interventions and caesarean deliveries.

Effect of Prophylactic Intravenous Tranexamic Acid on Blood Loss After Vaginal Delivery: A Randomized Control Study.

To determine the effect of prophylactic intravenous tranexamic acid on blood loss after vaginal delivery in women at low risk of postpartum hemorrhage. Prospective randomized controlled study (RCT registration: researchregistry10144). Over the study duration of 12 months, a total of 226 parous women with singleton vaginal delivery at term pregnancy with cephalic presentation participated in the study. Participants with pre-existing medical complications and obstetric complications were excluded from the study. Additionally, patients with a previous history of thromboembolism and allergy to tranexamic acid were also excluded from the study. The study participants were divided into two groups based on the intervention considered. This was done with a computer-based random table generator. Group A received an intervention of 10 mL (1 g) of intravenous tranexamic acid while the other group received 10 mL of normal saline as a placebo immediately after delivery of the fetus. Blood loss was calculated by measuring the weights of blood-soaked gauze, gowns, sheets, and tampons before and after delivery. Hemoglobin and hematocrit were done before and 12 h after delivery. Total number of participants were 226. The mean calculated blood loss and the mean measured blood loss was significantly less in Group A in comparison to Group B (379.17 ± 46.89 mL in Group A and 426.66 ± 58.45 mL in Group B, p < 0.001), (247.88 ± 67.03 mL in Group A and 368.95 ± 58.54 mL in group B, p < 0.001). Similarly, the mean decrease of hemoglobin after delivery was lower for Group A (1.45 ± 0.14) than for Group B (1.74 ± 0.24). The use of prophylactic intravenous tranexamic acid is associated with reduced blood loss after vaginal delivery. Furthermore, research needs to be done.

Cesarean section in Suriname using robson classification: a two-year nationwide cross-sectional study on rates, risk factors and perinatal outcomes of cesarean section

BackgroundOptimizing CS performance is a global health priority, given the maternal and perinatal morbidity and mortality associated with both underuse and overuse. This study aims to (1) determine the facility-based CS rate in Suriname and explore which women are most likely to undergo a CS and (2) classify all CS by the WHO Robson classification and analyze the perinatal outcomes.MethodsAn observational, cross-sectional study in Suriname, using nationwide birth registry data that included all hospital births in 2020 and 2021 (≥ 27 weeks of gestation). We used multivariate logistic regression analysis to assess maternal and perinatal characteristics associated with CS. We described cesarean births according to the Robson-10 classification and used descriptive statistics to analyze CS frequencies and perinatal outcomes.ResultsWe analyzed the 18,917 women who gave birth in Surinamese hospitals, with an overall 23.9% CS rate (n = 4522/18,917). The highest CS rates were seen among women with a previous CS (69.3%, aOR 16.2, 95% CI 14.4–18.2), BMI > 40 (47.0%, aOR 5.1, 95% CI 4.0–6.5), newborn with a birthweight from or above 4,000 g (37.3%, 2.2, 95% CI 1.6–3.0) and women giving birth at hospital IV (38.5%, aOR 1.8, 95% CI 1.6–2.0). Hindustani women were more likely to give birth by CS compared to Maroon women (aOR 1.6, 95% CI 1.4–2.0). The largest contribution to the overall CS rate was Robson group 5 (i.e. multiparous women with a previous CS and a singleton term pregnancy in cephalic presentation, 30.5%, n = 1,378). Robson group 2 and 4 (i.e. pre-labor CS, or CS after induction, among term women without previous CS and cephalic presentation) contributed to 21.8% (n = 985) of all CS performed. Robson group 1 and 3 (i.e. during spontaneous labor CS among term women without previous CS and cephalic presentation) accounted for 23.3% (n = 1,052) of all CS cases.ConclusionThe facility-based CS rate in Suriname is 24%, with substantial intra-country and inter-hospital variations. These disparities underscore the need for targeted interventions addressing both overuse and underuse of CS. Preventative measures should prioritize promoting safe VBAC, increasing assisted vaginal birth, preventing first-time CS and ongoing monitoring of trends and regular case audits.

The effect of maternal and fetal weight on the risk of emergency cesarean section in nulliparous women.

Although many studies based on different ethnic groups have analyzed the impact of maternal and infant weight on overall cesarean section rates in recent years, research on the impact of maternal and infant weight on emergency cesarean section (EmCS) rates is lacking, especially in the Chinese population. This study aimed to analyze whether maternal and fetal weight could influence the risk of EmCS. A total of 8427 nulliparous women who delivered vaginally (full-term, singleton, and cephalic presentation) were included in this study and divided into the normal vaginal delivery (VD) and EmCS groups. Of 8427 cases, 909 (10.8%) were delivered by EmCS because of failed VD. Compared with pregnant women with a normal body mass index, the risk of EmCS in overweight women increased significantly (P < .001). Birth weight > 3550 g was associated with an increased risk of EmCS. Subgroup analyses showed that among women with underweight and normal weight, old age, inadequate gestational weight gain, and large for gestational age were independent high-risk factors for EmCS (P < .05), whereas small for gestational age was the low-risk factor. Compared with the fetal distress group, the weight of newborns in the nonfetal distress group was significantly higher (P < .001), and the main cause of EmCS in women with macrosomia, large for gestational age, or birth weight ≥ 3550 g was fetal distress (P < .05). The prepregnancy maternal and fetal weights can affect the risk of EmCS. Weight management should be enhanced to control gestational weight gain according to the prepregnancy body mass index to reduce the risk of EmCS due to failed VD.

High Cesarean Section Rates during Labor Induction in Low Risk, Late-Term Cephalic Pregnancies in a Tertiary Centre

Background: The cesarean section rate is high in countries such as Türkiye, Egypt, and Brazil. The aims of this study were to determine whether the cesarean section rate during labor induction is high in late-term cephalic pregnancies and to evaluate the related factors. Methods: This retrospective descriptive study was conducted with 254 patients with a cephalic fetal presentation who were admitted in the labor unit of a tertiary center for induction of labor (IOL) at ≥41 0/7 weeks of gestation. The patients were evaluated in terms of demographic characteristics, Bishop score, labor induction method (dinoprostone or oxytocin administration), IOL duration, vaginal delivery rate, cesarean section rate, indication for cesarean delivery, 5-min Apgar score, fetal requirement for neonatal resuscitation, oxygen treatment, and neonatal intensive care unit admission. Results: The study population comprised 254 patients, of whom 181 (71.3%) had a vaginal delivery and 73 (28.7%) had a cesarean delivery. To evaluate the factors that affect labor induction failure and cesarean indication, the patients were divided into two groups: the nulliparous (n: 122) and multiparous (n: 132). The cesarean section rates in the nulliparous and multiparous groups were 44.3% (n: 54/122) and 14.4% (n: 19/132), respectively. According to the multivariate logistic regression, being nulliparous, having a male fetus were found to be the associated risk factors for cesarean delivery (p &lt; 0.05). Conclusions: The study results suggest that the cesarean section rate during labor induction is higher in low-risk, late-term cephalic pregnancies. Nulliparity, male fetal sex were risk factors for cesarean delivery.

Racial and Ethnic Trends in Cesarean Delivery on Maternal Request.

To evaluate race and ethnicity differences in rates of cesarean delivery on maternal request (CDMR) in nulliparous, term, singleton, vertex presentation (NTSV) cesarean deliveries. We conducted a retrospective cohort study of NTSV cesarean deliveries within our institution from 2016 to 2020. The primary outcome was CDMR and the primary predictor was maternal race and ethnicity. Multivariable logistic regression models were used to evaluate associations between race and ethnicity, CDMR, and various maternal and perinatal factors. Among 12,351 NTSV cesarean deliveries, 594 (4.81%) underwent CDMR; 4605 (37.28%) identified as non-Hispanic White, 3731 (30.21%) as Asian/Hawaiian/Pacific Islander, 2840 (22.99%) as Hispanic, 785 (6.36%) as Black, and 390 (3.16%) as multiple races/American Indian/Alaskan Native. Adjusted models showed increased odds of CDMR among non-Hispanic White people. Multiple races/American Indian/Alaskan Native people had the lowest odds of CDMR compared to non-Hispanic White people (adjusted OR [aOR] = 0.48, 95% CI 0.26-0.82), followed by Asian/Hawaiian/Pacific Islander (aOR = 0.58, 95% CI 0.47-0.72), Black (aOR = 0.61, 95% CI 0.40-0.89), and Hispanic (aOR = 0.70, 95% CI 0.55-0.88) people. Non-Hispanic White people undergo CDMR more frequently compared to Asian/Hawaiian/Pacific Islander, Black, and Hispanic people. Our findings are notable in light of the growing body of research demonstrating that White people have the lowest odds of cesarean delivery overall. Profound racial disparities in maternal obstetric outcomes exist in the United States. It is well established that non-Hispanic Black people have disproportionately higher cesarean birth rates and higher rates of birth complications, including maternal death. Racial and ethnic differences in rates of primary elective cesarean delivery, or cesarean delivery on maternal request, are not well understood. This research shows that non-Hispanic White people have more cesarean deliveries on maternal request than other racial and ethnic groups among low-risk nulliparous patients.

Developmental Dysplasia of the Hip: Factors Related to the Diagnosis and Characteristics of Selective Screening for its Detection.

Breech presentation, family history, and physical examination are the most recognized risk factors for DDH, which form the basis of selective screening. However, this approach can lead to late diagnosis, invasive treatments, and complications. This study analyzes the effectiveness of selective screening and identifies additional factors related to DDH. A retrospective case-control analytical study is designed, including children who are assessed through screening between 2012 and 2019. The variables examined include clinical and gestational characteristics, as well as examination findings. Descriptive analysis is conducted, followed by univariate analysis using Chi-squared, Fisher's exact, or Student's T tests. For multivariate analysis, the "all set" user command is employed. Sensitivity, specificity, and ROC curve are calculated, with a significance level set at p < 0.05. StataIC 16 and SAS System 9.4 are used. 762 children are included in the study, of which 33 are diagnosis with DDH. A total of 8,191 models are developed to predict DDH. The best logistic regression model identified the following independent predictors of dysplasia: newborn weight (OR 1.2, 95% CI 1.1-1.4), female sex (OR 3.9; 95% CI 1.4-10.9), cephalic presentation (OR 17.8; 95% CI 2.3-137.3), primiparity (OR 2.6; 95% CI 1.1-5.7), and examination (OR 149.6; 95% CI 18-1121.4). This model correctly classifies 83.6% patients (ROC curve 0.86). In selective screening, examination is the only identified risk factor for DDH, yet its sensitivity does not exceed 10%. This study proposed a total of 8191 models to predict DDH. The identified predictors include female sex, birth weight, cephalic presentation, and primiparity. While physical examination is the primary risk factor, it detects only decentred hips. The low sensitivity of selective screening raises questions about whether it remains the most appropriate method for identifying DDH in current practice.

Obstetric Outcomes by Hospital Volume of Operative Vaginal Delivery

Characterizing hospital-level factors associated with adverse outcomes following operative vaginal delivery (OVD) is crucial for optimizing obstetric care. To assess the association between hospital OVD volume and adverse outcomes. This was a retrospective cohort study of OVDs in California between 2008 and 2020. OVD was determined using birth certificate and International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes. This study used linked vital statistics and hospital discharge data from California. The study included singleton, nonanomalous, full-term deliveries with vertex presentation. Data analysis was performed between June 10 and October 23, 2024. Hospital OVD volume was categorized by the proportion of OVDs performed among all deliveries, grouped into low (<5.2%), medium (5.2%-7.4%), and high (≥7.4%) volume. Adverse outcomes for birthing individuals included obstetric anal sphincter injuries, cervical lacerations, and postpartum hemorrhage. Neonatal outcomes included shoulder dystocia, subgaleal hemorrhage, intracranial hemorrhage, facial nerve injury, and brachial plexus injury (BPI). χ2 and multivariable Poisson regression analyses were used to assess the association between hospital OVD volume and outcomes. Among 306 818 OVDs (mean [SD] birthing parent's age, 28.5 [6.2] years; 155 157 patients with public insurance [50.6%]), hospitals with low OVD volume had an increased proportion of obstetric anal sphincter injury compared with hospitals with medium and high volumes (12.16% [7444 patients] vs 11.07% [10 709 patients] vs 9.45% [14 064 patients]). Hospitals with low volume also had a higher proportion of adverse neonatal outcomes, including shoulder dystocia (3.84% [2351 patients] vs 3.50% [3386 patients] vs 2.80% [4160 patients]), subgaleal hemorrhage (0.27% [165 patients] vs 0.18% [172 patients] vs 0.10% [144 patients]), and BPI (0.41% [251 patients] vs 0.30% [291 patients] vs 0.20% [301 patients]) compared with hospitals with medium and high volume. In multivariable analyses, low OVD volume remained associated with increased risk of obstetric anal sphincter injury (adjusted risk ratio [aRR], 1.36; 95% CI, 1.14-1.62), shoulder dystocia (aRR, 1.30; 95% CI, 1.10-1.52), subgaleal hemorrhage (aRR, 2.57; 95% CI, 1.55-4.24), and BPI (aRR, 1.73; 95% CI, 1.30-2.2.29) compared with hospitals with high OVD volume. After multivariable analysis, medium OVD volume remained associated with increased risk of subgaleal hemorrhage (aRR, 1.72; 95% CI, 1.04-2.86) and BPI (aRR, 1.35; 95% CI, 1.02-1.79) compared with high OVD volume. This study found that undergoing OVD at hospitals with low OVD volume was associated with adverse perinatal outcomes compared with hospitals with medium and high OVD volumes. Further exploration of the reasons for these differences and prevention of these differences is needed to improve obstetric outcomes.

Perineal deformation during forceps, vacuum and OdonAssist™ assisted vaginal deliveries: A simulation study based on advanced image processing.

The aim of this study was to analyse influence of the fetal head position and the type of instrument used (forceps, vacuum, OdonAssist™) on perineal deformation, during simulated vaginal deliveries monitored by stereophotogrammetry. An exploratory study was conducted using mannequins simulating vaginal births. Fifty simulated deliveries were performed with different fetal head positions and instruments: Pajot's forceps, Kiwi-vacuum, and OdonAssist™. Stereophotogrammetry measured perineal deformations called equivalent strains Eeq. Eeq during spontaneous deliveries were minimal, average, and maximal at 0.8%, 5.8%, and 11.6%, respectively. Assisted vaginal births (AVB) showed slightly higher strains compared to spontaneous deliveries. In the occipito-posterior position (OP), strains were significantly higher (p<0.05). Equivalent strain Eeq trend towards higher mean (6.7±0.6%) and maximum (12.3±0.8%) with forceps compared to other methods in the occiput anterior position (OA), especially against spontaneous (mean: 5.3±0.5% and max: 9.9±0.6; p=0.06), vacuum AVB (mean: 4.6±1.0% and max: 9.4±0.1%, p=0.06) and OdonAssist™ AVB (mean: 3.8±0.9% and max: 8.8±1.0%, p=0.06). Forceps induced greater strains compared to vacuum and OdonAssits™. In OP position, OdonAssist™ tend to lower mean equivalent strain Eeq compared to spontaneous vaginal deliveries (4.9±0.6% vs 6.4±0.5%, p=0.06). Results confirmed increased mechanical perineal stress for OP fetal position and for forceps assisted deliveries compared to others devices. The OdonAssist™ may offer a less invasive alternative, reducing perineal strains. Stereophotogrammetry provides valuable data on the mechanical effects of childbirth.

Measurement of angle of progression by trans perineal-ultrasound in labour to predict mode of delivery in nulliparous women.

The objective of the study was to assess whether the measurement of the angle of progression in nulliparous women in labour can predict the mode of delivery. This prospective observational study was conducted at Benazir Bhutto Hospital, Rawalpindi Medical University from 16th February to 25th March 2024. Nulliparous pregnant women in the active first stage of labour with singleton pregnancy and cephalic presentation were included in the study after taking informed consent. The angle of progression (AOP) was measured by trans-perineal ultrasound using the curvilinear probe. The primary outcome was the mode of delivery in relation to angle of progression. Seventy-eight patients were included in the study. Angle of progression was wider in patients who underwent vaginal delivery and narrower in patients who underwent cesarean section. AOP of 121 or more is associated with 86.6% of vaginal delivery and an angle of progression of 70 or less is associated with 83.3% of cesarean section. The angle of progression is a reliable tool for predicting the mode of delivery. Wider angle is associated with vaginal delivery and a narrower angle is associated with cesarean section.

Maternal and perinatal outcomes after implementation of a more active management in late- and postterm pregnancies in Sweden: A population-based cohort study.

The risk of perinatal death and severe neonatal morbidity increases gradually after 41 weeks of pregnancy. We evaluated maternal and perinatal outcomes after a national shift from expectancy and induction at 42+0 weeks to a more active management of late-term pregnancies in Sweden offering induction from 41+0 weeks or an individual plan aiming at birth or active labour no later than 42+0 weeks. Women with a singleton pregnancy lasting 41+0 weeks or more with a fetus in cephalic presentation (N = 150,370) were included in a nationwide, register-based cohort study. Elective cesarean sections were excluded. Outcomes during period 1, January 2017 to December 2019 (before the shift) versus outcomes during period 2, January 2020 to October 1, 2023 (after the shift) were analysed. For comparison, outcomes of pregnancies lasting 39+0 to 40+6 weeks (N = 358,548) were also studied. Primary outcomes were: First, peri/neonatal death (stillbirth or neonatal death before 28 days); second, composite adverse peri/neonatal outcome (peri/neonatal death, Apgar score <4 at 5 min, hypoxic ischemic encephalopathy grades 1-3, meconium aspiration syndrome, birth trauma, or admission to a neonatal intensive care unit (NICU) ≥4 days); third, composite adverse peri/neonatal outcome excluding admission to NICU; and fourth, emergency cesarean section. Secondary outcomes included the components of the primary composite outcomes. Relative risks (RRs) with 95% confidence intervals (CIs) for binary outcomes period 2 versus period 1 were computed using modified Poisson regression analyses with adjustments for maternal age, parity, body mass index (BMI), smoking, and educational level. Induction rates among pregnancies lasting 41+0 weeks or more increased from 33.7% in period 1 to 52.4% in period 2. Mean (standard deviation) gestational age at birth decreased from 290.7 (2.9) days to 289.6 (2.3) days. Infants born during period 2 were at lower risk of peri/neonatal death compared to infants born during period 1; 0.9/1,000 versus 1.7/1,000 born infants (adjusted RR 0.52; 95% CI [0.38, 0.69]; p < 0.001), and they had a lower risk of having the composite adverse neonatal outcome, both including (50.5/1,000 versus 53.9/1,000, adjusted RR 0.92; 95% CI [0.88, 0.96]; p < 0.001) or excluding NICU admission (18.5/1,000 versus 22.5/1,000, adjusted RR 0.79; 95% CI [0.74, 0.85]; p < 0.001). The cesarean section rate increased from 10.5% in period 1 to 11.9% in period 2 (adjusted RR 1.07; 95% CI [1.04, 1.10]; p < 0.001). For births at 39 to 40 weeks the adjusted RR for peri/neonatal death was 0.86 (95% CI [0.72, 1.02]). One limitation of the study is that we had no data on to what extent monitoring of fetal health was performed. A more active management of pregnancies lasting 41+0 weeks or more was associated with a decrease in peri/neonatal deaths, and a decrease in composite adverse peri/neonatal outcomes. Increased rate of emergency cesarean sections was observed. Women with pregnancies advancing towards 41 gestational weeks should be given balanced information on the benefits and risks of induction of labour at 41 weeks compared to expectant management until 42 weeks and be offered induction of labour at 41 weeks or active surveillance of pregnancies from 41 weeks in order to decrease peri/neonatal mortality.

Investigating the implementation of a Trial of Labour After Caesarean (TOLAC) delivery bundle with respect to decreasing caesarean delivery rates: a multisite quality improvement initiative

ObjectivesTo study the effect of implementing a Trial of Labour After Caesarean (TOLAC) delivery bundle with respect to decreasing caesarean delivery rates across five hospitals.DesignProspective quality improvement study.SettingFive Canadian hospital...

FETO-MATERNAL OUTCOMES OF INDUCTION OF LABOUR IN WOMEN WITH POST-TERM PREGNANCIES

Post-term pregnancies are associated with increased risks for both maternal and neonatal complications. Labor induction is a common intervention to reduce these risks; however, its outcomes remain variable. Understanding the fetomaternal outcomes of labor induction in post-term pregnancies is crucial for optimizing clinical management and decision-making. Objective: To evaluate the fetomaternal outcomes of labor induction in women with post-term pregnancies presenting at a tertiary care facility. Methods: This descriptive cross-sectional study was conducted in the Department of Obstetrics and Gynecology from March 2024 to September 2024. A total of 115 women aged 18 to 40 years with postdated pregnancies, regular menstrual cycles, and singleton vertex presentations were enrolled. High-risk pregnancies and those with prior cesarean sections or congenital fetal anomalies were excluded. Labor was induced using sublingual misoprostol (25 μg every four hours for up to four doses). Outcomes, including postpartum hemorrhage (PPH), cesarean delivery, prolonged hospital stay, birth asphyxia, neonatal intensive care unit (NICU) admissions, and meconium aspiration, were assessed. Results: Cesarean sections occurred in 20.9% of cases, and 17.4% experienced PPH. Prolonged hospital stays were recorded in 15.7% of participants. Birth asphyxia was observed in 11.3% of neonates, while 16.5% required NICU admission. Meconium aspiration was noted in 12.2% of cases. No notable associations were found between maternal age or parity and the assessed outcomes (p &gt; 0.05). Conclusion: Labor induction in post-term pregnancies is associated with a higher prevalence of cesarean delivery, PPH, and neonatal complications, including NICU admissions and meconium aspiration. These findings highlight the importance of timely interventions and vigilant monitoring to optimize outcomes in post-term pregnancies.

Safety of vaginal breech delivery following an unsuccessful external cephalic version: a comparative study.

To determine whether patients undergoing a trial of labor with a breech presentation following a failed attempt of external cephalic version (ECV) are at increased risk of adverse maternal and neonatal outcomes. This retrospective cohort study was conducted at a single university-affiliated medical center. The study group comprised women with singleton pregnancies at term, categorized into three groups: those who underwent a failed external cephalic version (ECV) and subsequently attempted a trial of breech delivery (Breech-failed-ECV group), those who attempted an assisted vaginal breech delivery without a prior ECV attempt (Breech-no-ECV group), and those with vertex presentation following a successful ECV (Vertex-ECV). The primary outcome measured was the mode of delivery. Secondary outcomes included adverse maternal and neonatal outcomes. The study group consisted of 229 patients who attempted a vaginal delivery during the study period following a diagnosis of non-cephalic presentation at term.There were 42 women in the Breech failed-ECV group, 102 in the Breech-no-ECV group, and 85 in the Vertex-ECV group. Among patients undergoing a trial of labor with a breech presentation, there were no significant differences in successful vaginal delivery rates between those who had an attempted ECV and those who did not (80.39% vs. 80.95%, p > 0.05), nor in the rate of adverse maternal or neonatal outcomes between the groups. However, the Vertex-ECV were more likely to have a vaginal delivery (91.78 vs 80.56%, p = 0.03) and less likely to experience adverse neonatal outcomes, including meconium-stained amniotic fluid, non-reassuring fetal heart rate (NRFHR), compared to those who underwent labor with a breech presentation (p < 0.05). A failed external cephalic version does not adversely affect maternal or neonatal outcomes in patients undergoing a trial of labor with a breech presentation and meet the criteria of our study.

Placenta Previa: Case Report

Placenta previa is a significant obstetric complication that occurs during pregnancy, characterized by abnormal implantation of the placenta in the lower uterine segment. Risk factors for having had a previous caesarean section, multiple pregnancies, advanced maternal age, or having a history of uterine surgery at higher risk, a history of previous uterine curettage, may increase the likelihood of placenta previa. woman aged 29 years G3P2A0 38 weeks pregnant came with complaints of fresh blood coming out of the birth canal since 3 hours before entering the hospital about half of the pads. Previous history to an obstetrician with malpositioned ultrasound results and a history of 2 previous deliveries by cesarean section. Physical examination, blood pressure 110/70, pulse 78 times/minute, respiration 18 times/minute, temperature 360C, there was no clinical anemia, obstetric examination of the height of the uterine fundus (TFU) 33 cm with an estimated fetal weight (TBJ) 3100 gr, FHR 152 times/minute regularly, positive His 1-2 times/10 minutes 10-15 seconds each. From vaginal positive spots, no active bleeding, vaginal touch was not done. Ultrasound of the fetus in cephalic presentation, positive FHB, EFW 3100 gr, placenta corpus posterior closing OUI grade 3 SDP 6 cm PAI score 2 positive hypoechoic zone, negative lacuna, KTG category 1. From investigations, Hb was 10.2 gr/dl. Ht 30%, leukocytes 12,950 uL, platelets 322,000 uL, bleeding time and clotting time within normal limits. management carried out strict vital signs monitoring, planned sectio caesaria cito and given premedication injection of ceftriaxone 2gr and 250cc PRC blood supply. Placenta previa is a complex obstetric condition that requires careful diagnosis, monitoring and management. Prompt recognition of the condition, close monitoring of maternal and fetal safety, and timely intervention, such as cesarean section when indicated, are critical to reducing the risks associated with placenta previa.

Comparison of balloon catheter, oral misoprostol, or combination of both for cervical ripening in late-term and post-term nulliparous women: A Finnish randomized controlled multicenter pilot trial.

Nulliparous women beyond term have high rates of induction failure. The aim of this study was to compare delivery outcomes for balloon catheter, misoprostol, and combination of both in nulliparous late- and post-term women with unfavorable cervices. We intended to explore whether the combination strategy has lower cesarean section rate and is as safe as either method alone. The randomized multicenter pilot trial was carried out in the five university hospitals and the largest secondary care hospital of Finland March 1, 2018-March 31, 2022. A total of 273 nulliparous women with viable singleton fetus in cephalic presentation, intact amniotic membranes, and an unfavorable cervix at 41 + 0 gestational weeks were included. The study protocol was registered in the ISCTN registry (ISRCTN83219789). The women were randomized into cervical ripening by balloon catheter, oral misoprostol 50 μg every 4 h, or the combination use of both. The primary outcomes of the study were the rates of cesarean section and composite of adverse neonatal outcomes (5-min Apgar score <7, umbilical artery pH ≤7.05, or NICU admission). Ninety-seven women (35.5%) were allocated in the balloon catheter arm, 94 (34.4%) in the oral misoprostol arm, and 82 (30.0%) in the combination treatment arm. The rates of cesarean section (balloon catheter 23.7%, n = 23/97, vs. oral misoprostol 24.5%, n = 23/94, vs. combination 17.1%, n = 14/82) or composite adverse neonatal outcome (7.2% vs. 7.4% vs. 7.3%, respectively) were not statistically significantly different between the groups. The median (interquartile range) induction to delivery interval was the shortest in the combination treatment, 21.7 (15.1-33.2) h compared to balloon catheter 31.7 (21.9-44.5) h; p < 0.01 or oral misoprostol 37.0 (26.7-60.3) h; p < 0.01. The proportion of women with induction to delivery interval ≤24 h was significantly higher in the combination arm compared to balloon catheter (54.4% vs. 31.1%; p < 0.01) or oral misoprostol (54.4% vs. 21.1%; p < 0.001). Our findings confirm the effectiveness of combining balloon catheter and oral misoprostol for cervical ripening, showing shorter induction to delivery interval and comparable rates of cesarean section and neonatal outcomes compared to either method alone. These results advocate for a shift toward adopting combination strategy in the induction of nulliparous late- and post-term women.

Clinical use of PGE2 (dinoprostone) and cervical ripening balloon catheter during delivery induction in patients with a Bishop score of ≤4 with vertex presentation

Purpose: We aimed to compare the clinical use of PGE2 (dinoprostone) and cervical ripening balloon catheter for delivery induction in patients with a Bishop score of ≤4 with vertex presentation. Material and Methods: This study was retrospectively conducted and included the induction of labor between January 2014 and January 2017 at Eskisehir Osmangazi University, Department of Obstetrics and Gynecology. There was a total of 60 patients in the study and 30 patients were given dinoprostone and 30 patients were given birth by double balloon catheter. We compared the clinical results of the patients. Multivariable regressions were used to identify odds of induction success. Results: There was no significant difference between the demographic characteristics of the patients. When the clinical results of the patients were compared, there was no difference between the vaginal delivery rate and the delivery time between the two groups. The duration of active labor in the balloon catheter group was statistically significantly longer (p = 0.036). The amount of postpartum hemorrhage in the balloon catheter group was also significantly higher (p = 0.008). Conclusion: The ideal agent to be used in cervical pregnancy is still a controversial issue. In this regard, more work needs to be done with the patient.

Routine 36-week scan: diagnosis and outcome of abnormal fetal presentation.

First, to report the incidence of non-cephalic presentation at a routine 36-week ultrasound scan, the uptake and success of external cephalic version (ECV) and the incidence of spontaneous rotation from non-cephalic to cephalic presentation. Second, to determine the maternal and pregnancy characteristics that provide a significant contribution to the prediction of non-cephalic presentation at the 36-week scan, successful ECV from non-cephalic to cephalic presentation and spontaneous rotation from non-cephalic to cephalic presentation. This was a retrospective analysis of prospectively collected data from 107 875 women with a singleton pregnancy who had undergone a routine ultrasound scan at 35 + 0 to 36 + 6 weeks' gestation. Patients with breech or transverse/oblique presentation were divided into two groups: those scheduled for elective Cesarean section for a fetal or maternal indication other than abnormal presentation, and those that would potentially require ECV. The latter group was reassessed after 1-2 weeks and, if the abnormal presentation persisted, the parents were offered ECV or elective Cesarean section at 38-40 weeks' gestation. Multivariable logistic regression analysis was carried out to determine which maternal and pregnancy characteristics provided a significant contribution in the prediction of non-cephalic presentation at the 36-week scan, successful ECV from non-cephalic to cephalic presentation and spontaneous rotation from non-cephalic to cephalic presentation. At the 36-week scan, fetal presentation was cephalic in 101 664 (94.2%) pregnancies and either breech, transverse or oblique in 6211 (5.8%). In 0.3% of cases with cephalic presentation at the 36-week scan, there was subsequent spontaneous rotation to non-cephalic presentation, and in half of these, the diagnosis was made during labor or at birth. ECV was attempted in 1584/6211 (25.5%) pregnancies with non-cephalic presentation at the 36-week scan and was successful in only 44.1% of cases. In the remaining 74.5% of cases, ECV was not attempted because of any of the following reasons: ECV was declined; Cesarean section was planned for a reason other than abnormal presentation; ECV was planned for the subsequent 1-2 weeks but, in the meantime, there was spontaneous rotation to cephalic presentation; or there was spontaneous onset of labor or rupture of membranes before planned ECV. In 5513/6211 (88.8%) pregnancies with non-cephalic presentation at the 36-week scan, ECV was not attempted or was unsuccessful, and in 37.7% of these, there was subsequent spontaneous rotation to cephalic presentation. Among the 6211 pregnancies with non-cephalic presentation at the 36-week scan, the presentation at birth was cephalic in 43.8%; in 74.8%, this was due to spontaneous rotation, and in 25.2%, it was due to successful ECV. Multivariable analysis demonstrated that the likelihood of non-cephalic presentation at the 36-week scan, that of successful ECV and that of spontaneous rotation from non-cephalic to cephalic presentation was affected by several maternal and pregnancy characteristics, but the predictive performance for these events was poor, with the area under the receiver-operating-characteristics curve ranging from 0.608 to 0.717 and the detection rate at a 10% false-positive rate ranging from 19.0% to 33.7%. Routine ultrasound examination at 35 + 0 to 36 + 6 weeks' gestation could improve pregnancy outcome by substantially reducing the risk of unexpected abnormal presentation in labor. However, an additional ultrasound scan for fetal presentation should be considered in all women when they present in labor. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.