Operative Delivery Research Articles

Evaluation of the Ei SMART training programme in the UK

IntroductionEarly intervention (Ei) is recommended for infants at high risk of neurodevelopmental challenges. Ei SMART is an evidence-based clinical reasoning framework supporting infant development by integrating Sensory, Motor, Attention and regulation, and Relational development through healthcare professionals (HCPs) and parents working Together. Aim: To evaluate learning outcomes following Ei SMART training. Methods34 staff members from one UK neonatal operational delivery network participated in face-to-face training, co-produced and co-presented by parents and HCPs via online modules/tutorials. Participants completed pre/post-training surveys. Questions quantified self-perceived understanding of Infant Development & Well-Being, Parent/Family Support and Engagement, and Staff Engagement & Well-Being. Total and Domain scores were compared pre/post-training. Results33/34(97%) respondents completed both pre-and post-training surveys; one respondent was excluded (incomplete data). Median (IQR) post-training score was significantly increased (152(22) v 108(26) (p < 0.001), as were domain scores. ConclusionEi SMART training provided measurable improvements in perceived learning for HCPs.

Temporal trends and regional variations in operative vaginal deliveries in Japan: A national representative cohort study.

To analyze temporal trends and regional variations in operative vaginal delivery (OVD) in Japan. Using the National Database of Health Insurance Claims and Specific Health Checkups of Japan from 2014 to 2021, we identified the numbers of vacuum and forceps deliveries. We analyzed annual totals and proportions of OVDs and calculated the mean age of women undergoing these deliveries. We also predicted trends in OVD for the next 20 years and compared geographical differences in the proportions of forceps deliveries among OVDs. During the observation period, out of 7 368 814 total births, 8.4% were through OVD, including 7.6% by vacuum and 0.8% by forceps. Both delivery methods showed an increasing trend from 2014 to 2021: vacuum deliveries rose from 7.0% to 8.7%, and forceps deliveries increased from 0.6% to 1.0%. Notably, the proportion of forceps deliveries in OVD increased from 8.1% to 10.5%. The mean age was higher for forceps deliveries than vacuum deliveries. According to our predictions, vacuum deliveries may continue to increase, but forceps deliveries may stabilize. The proportion of forceps deliveries among OVDs ranged from 0% to 38% across Japanese prefectures. This study shows an increase in the use of OVD in Japan from 2014 to 2021. There are large regional differences in the choice between vacuum and forceps deliveries. These findings can help us understand the practice of OVD in Japan.

Incidence of neonatal respiratory morbidity after vaginal and caesarean delivery in the late-preterm and term period - a retrospective cohort study.

Respiratory distress syndrome is a leading cause of neonatal intensive care unit admissions for late preterm (34-36 weeks gestational age) and term infants (37-41 weeks). The risk for respiratory morbidity appears to increase after an elective caesarean delivery and might be reduced after antenatal corticosteroids. However, before considering antenatal corticosteroids for women at high risk of preterm birth after 34 weeks, the incidence of respiratory distress syndrome and the effect of delivery mode on this incidence requires further evaluation. Therefore, this study aimed to investigate the relationship between respiratory distress syndrome incidence and delivery mode in late preterm and term infants. In this retrospective cohort study, the clinical databases of the University Hospitals of Zurich and Basel were queried regarding all live births between 34 + 0 and 41 + 6 weeks. Neonatal intensive care unit admissions due to respiratory distress syndrome were determined and analysed in regard to the following delivery modes: spontaneous vaginal, operative vaginal, elective caesarean, secondary caesarean and emergency caesarean. After excluding malformations (n = 889) and incomplete or inconclusive data (n = 383), 37,110 infants out of 38,382 were evaluated. Of these, 5.34% (n = 1980) were admitted to a neonatal intensive care unit for respiratory distress syndrome. Regardless of gestational age, respiratory distress syndrome in infants after spontaneous vaginal delivery was 2.92%; for operative vaginal delivery, it was 4.02%; after elective caesarean delivery it was 8.98%; following secondary caesarean delivery, it was 8.45%, and after an emergency caesarean it was 13.3%. The risk of respiratory distress syndrome was higher after an elective caesarean compared to spontaneous vaginal delivery, with an odds ratio (OR), adjusted for gestational age, of 2.31 (95% CI 1.49-3.56) at 34 weeks, OR 5.61 (95% CI 3.39-9.3) at 35 weeks, OR 1.5 (95% CI 0.95-2.38) at 36 weeks, OR 3.28 (95% CI 1.95-5.54) at 37 weeks and OR 2.51 (95% CI 1.65-3.81) at 38 weeks. At 39 weeks, there was no significant difference between the risk of respiratory distress syndrome after an elective caesarean vs. spontaneous vaginal delivery. Over the study period, gestational age at elective caesarean delivery remained stable at 39.3 ± 1.65 weeks. The incidence of respiratory distress syndrome following an elective caesarean is up to threefold higher in infants born with less than 39 weeks gestational age compared to those born by spontaneous vaginal delivery. Therefore - and whenever possible - an elective caesarean delivery should be planned after 38 completed weeks to minimise the risk of respiratory morbidity in neonates.

Associations between fetal position at delivery and duration of active phase of labor: A historical cohort study.

In clinical experience, occiput posterior (OP) position is associated with longer labor duration than occiput anterior (OA) position, but few studies have investigated the association between labor duration and fetal position. We aimed to compare duration of the active phase of labor in OP deliveries with OA deliveries in a contemporary population using survival methods. Secondary aims were to compare the frequencies of operative interventions, obstetric anal sphincter injuries (OASIS), postpartum hemorrhage, and newborn outcomes in OP with OA deliveries. We did a historical cohort study in three university hospitals in Norway from 2012 to 2022. Women with a single fetus in cephalic presentation, no previous cesarean section and gestational age ≥37 weeks were eligible and stratified into the first four groups of the Robson ten-group classification system (TGCS). We estimated the mean duration and calculated the hazard ratio (HR) for delivery using survival analyses. Cesarean sections and instrumental vaginal deliveries were censored. The study population comprised 112 019 women, 105 571 (94.2%) were delivered in OA and 6448 (5.8%) in OP position. The estimated mean duration of the active phase of labor was longer in women with the fetus in OP position in all four TGCS groups. The estimated duration was longer in the OP groups in analyses stratified with respect to epidural analgesia and oxytocin augmentation. The graphical abstract illustrates the probability of delivery in OP compared with OA position in merged TGCS groups 1 and 2a, as a function of time. The unadjusted HR was 0.33 (95% CI 0.31-0.36) for fetuses delivered in OP position compared with OA position in TGCS group 1, 0.25 (95% CI 0.21-0.27) in group 2a, 0.70 (95% CI 0.67-0.73) in group 3, and 0.61 (95% CI 0.55-0.67) in group 4a, respectively. Neither maternal age, gestational age, BMI nor birthweight had confounding effect. Operative delivery rates and OASIS rates were higher in OP position in all four groups. We found longer duration of the active phase of labor in women with the fetus delivered in OP position in all four TGCS groups.

Peculiarities of anesthesia for caesarean section in patients with gestational diabetes mellitus

BACKGROUND: Women with gestational diabetes mellitus are at high risk of operative delivery. Meanwhile, hyperglycemia affects the metabolism of narcotic analgesics, while increasing their need. Thus, the anesthesiologist is faced with the question of what method of anesthesia to choose for a particular cesarean section. AIM: The aim of this study was to estimate the features of the perioperative period of cesarean section in patients with gestational diabetes mellitus. MATERIALS AND METHODS: This prospective, controlled, single-center study enrolled 101 patients who were delivered by planned cesarean sections from April to November 2023. Group 1 included patients with gestational diabetes mellitus on diet therapy (n = 28), group 2 comprised patients with gestational diabetes mellitus on insulin therapy (n = 29), and group 3 (control) included women with a normal pregnancy without carbohydrate metabolism disturbances (n = 44). RESULTS: The highest initial values of mean arterial pressure were in group 2 and amounted to 91.8 ± 7.0 mmHg. In group 1, the mean arterial pressure was within 89.1 ± 6.4 mmHg, and in group 3, that was 85.9 ± 9.1 mmHg, which was significant (p 0.05). The sympathetic block developed longer in patients of group 2. In group 1, the sensory block was recorded at the ThIV–ThV level after 10.1 minutes and the motor block (Bromage score 3) after 12.2 minutes compared to 7.8 and 8.6 minutes, respectively, in group 2, and 4.5 and 5.1 minutes, respectively, in group 3. In group 2, authors observed the most rapid regression of the block (79.4 minutes after the injection of local anesthetic), which required an earlier start of the transversus abdominis plane block (after 65.3 minutes). The sympathetic block regressed after 86.2 and 138.1 minutes in patients of groups 1 and 3, respectively (p 0.05), when the transversus abdominis plane block was performed. Thus, immediately after cesarean section, women with gestational diabetes mellitus (especially on insulin therapy) had a higher need for analgesics than those without gestational diabetes mellitus. CONCLUSIONS: During cesarean section under spinal anesthesia in patients with gestational diabetes mellitus, the rate of development of the sympathetic block is reduced (especially in women who received insulin therapy). At the same time, block regression in these patients occurs much faster, which requires an earlier start of postoperative anesthesia. An increased need for systemic analgesics has been demonstrated during the postoperative period in women with gestational diabetes mellitus, mainly with insulin therapy.

Upright Versus Recumbent Position in the Second Stage of Labor for Women With Epidural Analgesia: A Randomized Clinical Trial

Epidural analgesia (EA) is an effective and common method of pain relief during labor. However, EA may also have some adverse effects like prolonged labor, increased risk of operative delivery, and some unwanted complications. It's unclear how maternal position affects the outcomes of natural birth with EA. This study aimed to compare mode of delivery and maternal and neonatal outcomes between recumbent and upright positions in nulliparous women with EA. This randomized clinical trial involved 540 women who received EA at cervical dilatation of 4 to 6 cm. During the second stage of labor, they were instructed to adopt upright or recumbent position. The main outcome was the mode of delivery. The secondary outcomes included duration of labor, pain intensity, the Apgar score, and other maternal and neonatal complications. Finally, 528 women were included in the final analysis. The upright group had a higher rate of cesarean section than the recumbent group. The duration of the labor stages did not differ between the groups. The pain intensity in the second stage was higher in the upright position. The Apgar score at 1 and 5 minutes was higher in the recumbent group. There was no difference in terms of other outcomes between the groups. Recumbent positions are beneficial in the case of rate of cesarean, mother’s pain, and Apgar score in women with EA. So, adopting a recumbent position during the second stage of labor may be preferable for women with EA.

A Study on Challenges and Optimization of Last Mile Delivery and its Impact on Customer Satisfaction.

The last mile delivery, the final stage of the delivery process from a distribution center to the end user, plays a critical role in the supply chain, significantly influencing customer satisfaction. Against the backdrop of a rapidly growing e-commerce sector, the demand for swift and flexible delivery options has made last-mile delivery a vital determinant of overall customer satisfaction. This study analyzes the impact of optimizing last-mile delivery on customer satisfaction and loyalty, highlighting that efficient last-mile operations can lead to continued use of the delivery service. Key areas contributing to last-mile delivery challenges include timeliness, condition of delivered items, communication during delivery, flexibility of delivery options, and overall customer experience. The study concludes that addressing these challenges and implementing effective strategies is essential for meeting customer expectations and enhancing satisfaction in the competitive e-commerce landscape. The findings and recommendations provide a comprehensive roadmap for businesses aiming to improve their last-mile delivery operations and boost customer satisfaction.

Improving healthcare transition for young people with cancer: factors fundamental to the quality improvement journey.

Young people receiving cancer treatment in the South Thames Children's, Teenagers' and Young Adults' Cancer Operational Delivery Network usually receive care across two or more NHS trusts, meaning transition into adult services can be challenging. To develop a planned, co-ordinated approach to transition across the network that meets National Institute for Health and Care Excellence guidance recommendations for transition and the cancer service specifications. A 2-year, nurse-led quality improvement (QI) project, using the principles of experience-based co-design. The QI project resulted in the development of six key principles of practice; refining and testing of a benchmarking tool; initiatives to facilitate first transition conversations; and the launch of an information hub. Robust QI processes, cross-network collaboration and wide stakeholder involvement required significant resource, but enabled deeper understanding of existing pathways and processes, facilitated the establishment of meaningful objectives, and enabled the testing of interventions to ensure the project outcomes met the needs of all stakeholders.

P-752 Association between obesity in women with multiple gestations and adverse obstetric outcomes: a study of an American population database with over 136,000 unique deliveries

Abstract Study question The purpose of this study is to compare obese and non-obese women with multiple pregnancies to determine the effects on pregnancy, delivery, and neonatal outcomes. Summary answer Obesity and multiple gestations are independent risk factors for adverse obstetric outcomes. Combined, obesity in multiple gestation increases risk of maternal, delivery, and neonatal complications. What is known already Obesity is a pandemic and multiple pregnancies are a known consequence of assisted reproductive technologies. Obese women (body mass index [BMI] &amp;gt;30kg/m2) are at higher risk of hypertensive disorders, gestational diabetes, fetal growth complications, stillbirth, preterm birth, labour complications, caesarean deliveries, wound infection, venous thromboembolism, and adverse neonatal outcomes. Multiple gestation is associated with greater obstetric risks, including miscarriage, preterm birth, gestational diabetes, hypertensive disorders, operative delivery, postpartum hemorrhage, congenital anomalies, and fetal growth restriction. The combined effects are not well-established. Study design, size, duration We conducted a retrospective population-based study utilizing data collected between 2004 and 2014 inclusively, from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample. We evaluated deliveries using the international classification of diseases [ICD], ninth edition, clinical modification codes for delivery-related discharge diagnosis and birth-related procedural diagnosis. All women with a diagnosis of multiple pregnancies were selected. They were subsequently divided based on the ICD-9 code for obesity. A total of 137,303 multiple pregnancies were analyzed. Participants/materials, setting, methods Within the 137,303 multiple pregnancies, 130,542 (95%) were non-obese, while 6,761 (5%) were obese. An initial analysis was performed to identify the prevalence of obesity in women with multiple pregnancies. We then compared baseline clinical and demographic characteristics between women with obesity to those without obesity using chi-squared tests. Subsequently, binary logistic regression analyses were conducted to explore comparisons between the obese and non-obese groups while adjusting for the potential confounding effects. Main results and the role of chance Over the 11-year study period, there was a statistically significant increase in prevalence of obesity for women with multiple gestations (p &amp;lt; 0.0001). The obese group was at higher risk of pregnancy-induced hypertension (adjusted odd’s ratio [aOR]=1.89, 95% confidence interval [CI]=1.77-2.02), gestational hypertension (aOR=1.84, CI = 1.65-2.05), preeclampsia (aOR=1.68, CI = 1.55-1.81), preeclampsia or eclampsia superimposed on pre-existing hypertension (aOR=1.86, CI = 1.58-2.20), gestational diabetes mellitus (aOR=2.65, CI = 2.44-2.87), and placenta previa (aOR=0.57, CI = 0.39-0.85). They were more likely to have preterm premature rupture of membranes (aOR=1.19, CI = 1.06-1.34), chorioamnionitis (aOR=1.24, CI = 1.03-1.51), caesarean sections (aOR=1.28, CI = 1.18-1.38), wound complications (aOR=1.65, CI = 1.31-2.08), and transfusions (aOR=0.77, CI = 0.67-0.89). They were less likely to have small for gestational age neonates (aOR=0.88, CI = 0.79-0.97), though more likely to have neonates with congenital anomalies (aOR=1.56, CI = 1.16-2.10). Conversely, for certain factors, the outcomes were similar between obese and non-obese women with multiple gestation including rates of eclampsia (p = 0.07), abruptio placenta (p = 0.82), hysterectomy (p = 0.36), postpartum hemorrhage (p = 0.08), maternal death (p = 0.98), maternal infection (p = 0.10), deep vein thrombosis (p = 0.17), pulmonary embolism (p = 0.75), venous thromboembolism (p = 0.15), disseminated intravascular coagulation (p = 0.85) and intrauterine fetal demise (p = 0.52). Limitations, reasons for caution The database is retrospective and relies on hospitals reporting elevated body mass index, which may not always be consistently recognized, potentially resulting in an underestimation of the total number of obese women. However, this only stands to support the increased risks detected in this study as being legitimate. Wider implications of the findings We addresses a significant gap in the literature by simultaneously exploring the impacts of multiple pregnancies and maternal obesity on obstetric complications. This can guide clinical practice, encouraging single embryo transfer in obese women undergoing in-vitro fertilization and tailored care for obese patients with multiple pregnancies, anticipating the associated risks. Trial registration number not applicable

P-288 How do pregnancy complications, intrapartum, and neonatal risks differ in bicornuate and didelphys uteri. A population-based study

Abstract Study question Are there differences between didelphys and bicornuate uteri regarding obstetrical and neonatal outcomes based on an analysis of a population database? Summary answer Didelphys uteri present higher risks of preeclampsia, preterm delivery, PPROM, and cesarean delivery; while bicornuate uteri present higher risks of placenta previa, and placental abruption. What is known already Didelphys and bicornuate uteri are similar congenital anomalies with duplication of the uterine corpus. It is thought that both defects are similar when it comes to pregnancy complications, with increased risks of preterm delivery (PTD), malpresentation, and cesarean delivery, when compared to women without uterine anomalies. The didelphys uterus has two cervixes and a double vagina while the bicornuate uterus has one cervix and a single vagina. This minor difference may or may not alter the risks of pregnancy complications in these groups. However, obstetric and perinatal outcomes for didelphys and bicornuate uteri have never been directly compared. Study design, size, duration This retrospective population-based cohort study utilized data from the Healthcare-Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) from 2010 to 2014, inclusively. There were 3,846,342 births between 2010 and 2014, 1146 women with didelphys uteri and 6327 women with bicornuate uteri were included in the database and the study. Women were included only once per pregnancy. Participants/materials, setting, methods HCUP-NIS is the largest inpatient database in the USA and is comprised of hospitalizations throughout the USA. It provides information relating to seven-million inpatient stays yearly, includes 20% of admissions, and represents over 96% of Americans. Multivariate logistic regression was conducted to explore associations between bicornuate uteri and delivery outcomes while controlling for confounding effects. According to the Tri-Council Policy Statement (2018), IRB approval was not required, given data was anonymous and publicly available. Main results and the role of chance No significant difference was seen between the groups in regard to age, income, medical insurance plan, rates of obesity, illicit drug use, chronic hypertension, diabetes, thyroid disease, HIV, tobacco smoking during pregnancy, previous cesareans, pregnancy from IVF, and multiple gestations (P &amp;gt; 0.05). The only difference was in racial distribution, which was controlled for in the subsequent analysis (p &amp;lt; 0.05).In comparison to pregnant women with bicornuate uteri, patients with didelphys uteri were more likely to experience preeclampsia (aOR 1.38 95%CI: 1.05-1.80 P = 0.020), preterm premature rupture of membranes (PPROM) (aOR 1.76 95%CI1.32-2.34 P = 0.000), preterm delivery (aOR 1.39 95% CI1.18-1.64P=0.000), and higher chances of cesarean delivery (aOR 1.41 95% CI1.20-1.64 P = 0.000), after controlling for confounding demographics. Additionally, women with didelphys uteri have less risks of developing placenta previa (aOR 0.26 95%CI: 0.08-0.84 P = 0.024) and Abruptio placenta (aOR 0.52 95%CI 0.31-0.87 P = 0.013). No significant difference was seen between the groups regarding pregnancy induced hypertension, eclampsia, gestational diabetes, chorioamnionitis, operative vaginal delivery, hysterectomy, post-partum hemorrhage, wound complications, blood transfusion, maternal death, maternal infection, venous thromboembolism, pulmonary embolism or DIC (P &amp;gt; 0.05). Moreover, there was no significant difference between the two groups when comparing neonatal outcomes, including small for gestational age fetuses and intrauterine fetal demise (P &amp;gt; 0.05). Limitations, reasons for caution The limitation of our study are related to its retrospective nature and use of administrative database, which relies on the accuracy, and consistency of the individual coding the data, and the masking of undetected bias. Wider implications of the findings The present study demonstrates that women with bicornuate and didelphys uteri have certain differences when it comes to pregnancy, and intrapartum complications, including rates of preeclampsia, placenta previa, placental abruption, cesarean section, PPROM, and preterm delivery. These findings emphasize the importance of individualized perinatal care in these two cases. Trial registration number not applicable

O-228 Do myomectomies decrease third trimester pregnancy complications when compared to women without myomectomies and uterine fibroids in situ? A study of an American population database

Abstract Study question Myomectomies are performed to decrease pregnancy complications, among other indications, however, do myomectomies decrease third trimester pregnancy complications? Summary answer Post-myomectomy, pregnancies experienced more complications including hypertensive disorders, premature-pre-term-rupture of membranes, preterm-delivery, placenta-previa, cesareans, uterine ruptures, wound complications, transfusions, and small for gestational age infants. What is known already Patients with fibroid uterus experience reduced fertility rates and increased in obstetrical complications compared to patients without fibroids. If the removal of fibroids improves fertility is controversial for intramural fibroids, it is recommended for submucosal fibroids by the American College Of Gynaecology guidelines. It is a common, untested belief that myomectomies may reduce the risks of certain obstetrics complications. While rates of mal-placentation and hypertensive disorders may increase post-myomectomy as shown by the literature comparing myomectomy vs. control groups without fibroids, other complications may be anticipated to decrease. However, no population-based studies have attempted to answer this question. Study design, size, duration Retrospective cohort study, using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample between 2004 and 2014, inclusively, based on International Classification of Diseases, 9th edition, diagnoses (ICD-9). Data collected from 48 states and the District of Columbia, representing 20% of annual hospital admissions in the United States. Population-based study, including 89,025 with uterine fibroids: 7508 pregnancies with previous abdominal myomectomy (AM) or laparoscopic myomectomy (LM), and 81,517 controls with uterine fibroids in-situ, without myomectomies. Participants/materials, setting, methods We included patients delivery discharge diagnoses or maternal deaths, and with either uterine fibroids (ICD-9 codes 218.0, 218.1, 218.2, 218.9) or AM or LM prior to the pregnancy, (ICD-9 codes 68.29 and 68.19 or CPT procedure code 58140, 58145, 58146, 58545 and 58546). Binomial logistic regression was used and adjusted for age, race, income quartiles, smoking, previous cesarean section, chronic and pregnancy-induced hypertension, obesity, multiple gestations, pre-gestational and gestational diabetes mellitus. Main results and the role of chance The myomectomy group was characterized by older patients, higher rates of Caucasian race, chronic hypertension, previous cesarean delivery, and multiple gestations, and lower, income quartiles, rates of obesity, compared to the fibroid in-situ group (P &amp;lt; 0.05). There was no difference for rates of medical insurance plan type, tobacco smoking, pregestational diabetes, illicit drug use, thyroid disease, or in vitro fertilization use (P &amp;gt; 0.05, all). The myomectomy group had increased rates of pregnancy-induced hypertension (adjusted odd ratios(aOR)-1.15, 95% confidence intervals(CI):1.06-1.26), preeclampsia (aOR:1.25 95%CI:1.12-1.41), preterm delivery (aOR:1.4, 95%CI:1.27-1.53), preterm premature rupture of membranes (aOR:1.29, 95%CI:1.05-1.58), placenta previa (aOR:1.59, 95%CI:1.32-1.92), cesarean delivery (aOR:37.1, 95%CI:27.35-50.4), uterine rupture (aOR:2.1, 95%CI:1.06-4.16), blood transfusion (aOR:1.21, 95%CI:1.68-2.24), wound complications (aOR:1.44, 95%CI:1.1-1.9), disseminated intravascular coagulation (aOR:1.58, 95%CI:1.1-2.27), and small for gestational age (SGA) infants (aOR:0,19, 95%CI:1.05-1.39) compared to the fibroid in-situ group. The myomectomy group had a lower rate of gestational diabetes mellitus (aOR:0,88, 95%CI:0,79-0,97), chorioamnionitis (aOR:0,74, 95%CI:0,6-0,93), maternal infection (aOR:0.79, 95%CI:0.65-0.95), spontaneous (aOR:0.03, 95%CI:0.02-0.04) and operative vaginal delivery (aOR:0.87, 95%CI:0.75-0.99), and postpartum hemorrhage (aOR:0.73, 95%CI:0.62-0.87). There was no significant differences for rates of gestational hypertension, eclampsia, preeclampsia or eclampsia superimposed on pre-existing hypertension, abruptio placenta, hysterectomy, maternal death, deep venous thrombosis, pulmonary embolism and venous thromboembolism events (P &amp;gt; 0.05, all). Limitations, reasons for caution The retrospective nature of the study may mask undetected bias. Moreover, although the rate of uterine rupture was increased in the myomectomy group, it was rare and requires confirmation. Further prospective studies are needed to evaluate the outcomes in pregnancy after myomectomy. Wider implications of the findings The complications seen after myomectomies were likely related to uterine-incisions and alteration of myometrial vascularization, impairing trophectoderm invasion and leading to hypertensive disorders, mal-placentation, and abnormalities of fetal growth. Patients should be counselled regarding these potential risks. Increased understanding of the role of myomectomies on reproductive outcomes needs further study. Trial registration number not applicable

P-625 Association between advanced maternal age in women with polycystic ovary syndrome and adverse obstetric outcomes

Abstract Study question What is the effect of advanced maternal on the likelihood of experiencing adverse pregnancy, delivery, and neonatal outcomes in pregnant women with PCOS? Summary answer Advanced maternal age in women with polycystic ovary syndrome confers an additional risk of pregnancy induced hypertension, preeclampsia, preterm delivery, c-section, and placenta previa. What is known already Women with PCOS have an increased risk of obstetric complications, including preterm delivery, PROM, hypertensive disorders, gestational diabetes, cesarean section, and placental abruption. Similarly, the impact of advanced maternal age on pregnancy outcomes has been widely studied. Studies have highlighted the association between advanced maternal age and increased risks of preeclampsia, gestational diabetes mellitus, preterm labor, cesarean section, stillbirth, and fetal growth restriction. The role of advanced maternal age on pregnancy complications in PCOS in a population database has not been thoroughly evaluated. Study design, size, duration A retrospective population-based study using data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) database was performed. All deliveries between 2004 to 2014, inclusively, were studied using ICD-9 codes. Within the study period, 14,846 women had a diagnosis of PCOS, of which 943 (6.35%) were of significant advanced maternal age (38-43 years/old). The study could not be extended since in 2015 ICD-10 codes were used which are not compatible with ICD-9 codes. Participants/materials, setting, methods Chi-squared tests were used for comparison of demographics. Multivariate logistic regression analysis was performed to calculate unadjusted and adjusted odds ratios (aORs) and corresponding 95% confidence intervals (CI), controlling for confounding effects. According to Tri-Council Policy statement (2018), IRB approval was not required, given data was anonymous and publicly available Main results and the role of chance Women with PCOS and advanced maternal age were more likely to develop pregnancy complications, including pregnancy induced hypertension (aOR 1.32; 95% CI: 1.09-1.59; p = 0.004), preeclampsia (aOR 1.51; 95% CI: 1.16-1.98; p = 0.003), and gestational diabetes mellitus (aOR 1.66; 95% CI: 1.40-1.97; p &amp;lt; 0.001), after controlling for confounding demographics. Women with PCOS of advanced maternal age were also at increased risk of delivery by cesarean section (aOR 1.20 95% CI: 1.10-1.43; p &amp;lt; 0.001). Women with PCOS and advanced maternal age were not at an increased risk of preterm delivery, PPROM, placental abruption, chorioamnionitis, operative vaginal delivery, post-partum hemorrhage, wound complications, transfusion, maternal infection, deep vein thrombosis, pulmonary embolism, venous thromboembolism, disseminated intravascular coagulation and eclampsia (p &amp;gt; 0.05 in all cases). Results demonstrated no difference in the rate of women who gave birth to SGA infants, the rate of IUFDs, and the rate of infants with congenital anomalies between the two groups. Limitations, reasons for caution The limitations of our study are its retrospective nature and use of an administrative database which relies on the accuracy and consistency of the individuals coding the data. There are known limitations in how accurately hospital coding is able to capture perinatal conditions and complications. Wider implications of the findings The impact of advanced maternal age on the relationship between PCOS and pregnancy outcomes should be considered when counseling and planning care for pregnant women affected by these conditions. This emphasizes the importance of optimal perinatal care in older women with PCOS as they have higher risks of obstetric complications. Trial registration number NA

The red hat — designating leadership using visual and verbal cues: a mixed-methods study

BackgroundDuring a critical event in the labor and delivery operating room, it is crucial for team members responding to the situation to be aware of the designated leaders. Visual and verbal cues have been utilized to designate leadership in various healthcare settings; however, previous research has indicated mixed results using visual cues for role designation.MethodsThe purpose of this study was to explore the use of the red surgical hat as a visual cue of leadership during obstetric emergency simulation training. We used a mixed-methods design to analyze simulation-based education video and debriefing transcripts.ResultsThere was a statistically significant difference in the proportion of participants who declared leadership vs. those who donned the red hat. Participants were more likely to visually declare leadership utilizing a red surgical bouffant hat than to verbally declare leadership. Most participants indicated that observing the red hat to detect leadership in the operating room was more effective than when leaders used a verbal declaration to inform others who was leading.ConclusionsOur findings suggest that utilizing a visual cue of leadership with the red surgical bouffant hat improves participant perceptions of communication of the surgical team during an obstetrical critical event in a simulation environment.

A Review Paper on the Crucial Factors that Influencing RMC Delivery Operation

The delivery process of ready-mix concrete (RMC) is a critical component in construction projects, influencing the quality, efficiency, and timeliness of concrete placement. This abstract explores the various factors that impact the RMC delivery process, ranging from logistical considerations to concrete properties and customer requirements. Key factors affecting RMC delivery include the distance to the construction site, traffic conditions, weather, regulatory constraints, batching plant operations, order volume, customer specifications, concrete mix design, truck capacity, and communication channels among stakeholders. Each of these factors can significantly influence the success of RMC delivery, posing challenges and opportunities for optimization.

Challenges in Obstetric Anesthesia for a Parturient With Asherson’s Syndrome

Abstract Ashersons’ syndrome is a rare and serious form of coagulation disorder with thrombo-embolic complications. The combination of a dysfunctional protein C and protein S along with anti-phospholipid antibody syndrome, is known as the catastrophic anti-phospholipid antibody syndrome (CAPS) or Asherson’s syndrome. Their deficiency predisposes the patient to thrombotic events involving multi-organ vasculature. Obstetric anaesthesia in a patient with Asherson’s syndrome can be quite challenging, as we are dealing with two lives simultaneously. We hereby describe an uneventful case of operative delivery for a pregnant women with Asherson’s syndrome under subarachnoid block, with no veto-maternal complications. Literature is sparse focusing on the peri-operative care of this rare syndrome.

Implementation of an Outpatient Cervical Ripening Program: Outcomes and Provider and Patient Perspectives

Purpose: The purpose of this study is to evaluate the implementation, outcomes, and patient/provider acceptance of an outpatient cervical ripening program for induction of labor (IOL) at a teaching hospital. Methods: In an effort to reduce patient risk resulting from congestion in the Labor and Delivery (L&amp;D) unit of a level III maternity hospital with 3400 annual births, our department promoted the use of outpatient cervical balloon ripening. Over the course of 5 months, educational materials were distributed, Grand Rounds were held, an appeal to use outpatient cervical ripening was issued, and providers received written personal requests to consider outpatient balloons for each of their upcoming eligible scheduled inductions. Despite these efforts, uptake was minimal, as determined by a manual review over a 1-month period. Beginning in September 2022, new workflows were mandated: all patients needing cervical ripening and not meeting a defined list of exclusions were required to have outpatient balloons placed 6-18 hours prior to IOL in L&amp;D, or to be scheduled for IOL over the weekend. Routine practice for inpatient balloons included planned removal after 6 hours and use of a ripening agent (vaginal misoprostol 25 ug every 3 hours for 1-2 doses or intravenous oxytocin). The institution’s Data Warehouse was queried to obtain clinical outcomes for all IOL requiring cervical ripening occurring over a 3-month period beginning one month after implementation of the new workflow (October-December 2022). A survey was distributed to all L&amp;D providers 1 month prior to and 5 months following initiation of the mandatory outpatient cervical ripening program. Providers were asked their perception on benefits, risks, barriers, and likeliness to recommend outpatient cervical ripening. Patients who delivered following IOL over the same 3-month period were contacted via telephone and/or email and consented to complete a survey regarding their delivery experience. Outcomes were compared using chi square and t-test Results: Outpatient cervical balloon utilization increased to 27.7% of eligible patients during the 3-month auditing period after implementation of mandatory outpatient cervical ripening from 7.2% at baseline. Among 141 subjects with inpatient and 54 with outpatient cervical balloons, there were no significant differences between groups in the rates of cesarean delivery (24.8% vs 18.5%, p=0.35), operative vaginal delivery (6.4% vs 11.1%, p=0.27), chorioamnionitis (12.1% vs 16.7%, p=0.40), postpartum hemorrhage (17.0% vs 13.0%, p=0.49), or NICU admission (12.1% vs 9.3%, p=0.58). Length of stay in L&amp;D was significantly less in the outpatient group (1606 minutes vs 1366, p=0.02). Fifty-three providers responded to the pre-implementation survey. Perceived benefits to outpatient ripening included less time in the hospital (94.3% of respondents), and patient comfort (37.7%). There were 34 respondents to the post-implementation survey. Decreased time in the hospital (94.3% pre vs 91.2% post, p=0.16) remained a perceived benefit, however patient comfort did not (37.7% pre vs 17.6% post, p=0.046). Concern over incorrect placement diminished significantly on post survey (50.9% pre vs 29.4% post, p=0.049). Respondents additionally reported concerns regarding delays in L&amp;D causing balloons to remain in situ for longer than scheduled and subsequent effect on patient anxiety. Barriers to outpatient ripening before and after implementation included office workflow (58.5% pre vs 52.9% post, p=0.65), and provider comfort with the procedure (32.1% pre vs 41.2% post, p=0.39). Over time, respondents were increasingly “somewhat” to “very likely” to recommend outpatient ripening to their patients (64.2% pre vs 91.7% post, p=0.004). On post survey, most respondents were “somewhat” to “very satisfied” with the current program (64.7%), and “somewhat” to “very likely” to recommend to their colleagues (82.4%). A total of 188 patients who underwent balloon cervical ripening were contacted, and 63 (33.5%) responded. Forty-five (71.4%) patients surveyed had a spontaneous vaginal delivery, 4 (6.35%) required operative vaginal delivery, and 14 (22.2%) underwent cesarean delivery. The majority (61.9%) were nulliparous. Seventeen (27%) patients had an outpatient balloon. Mean pain scores were not statistically significant between outpatient and inpatient groups (6.13 vs 5.28, p=0.25). There was no difference in patient self-perceived preparedness for balloon placement (41.2% outpatient vs 41.3% inpatient, p=0.99). There were no differences in delivery-related anxiety between groups (47.1% outpatient vs 60.9% inpatient, p=0.32) or in likelihood to recommend the experience (41.2% outpatient somewhat to very likely to recommend versus 32.6% inpatient, p=0.53). Conclusion: Adoption of outpatient cervical ripening required a mandatory program, as persuasion and education were insufficient to induce a change in practice. No differences were seen in delivery outcomes between inpatient and outpatient balloon ripening, though this analysis is not powered to assess outcomes. A 4-hour decreased length of stay on L&amp;D was observed in those who had an outpatient balloon. Providers are overall satisfied with outpatient cervical ripening. Patient satisfaction remains mixed regardless of cervical balloon placement location.

Extravasated Pudendal Artery Pseudoaneurysm Presenting as a Large Vaginal Hematoma Following Uncomplicated Delivery

Body of Abstract: (1) To report a case of an extravasated pudendal pseudoaneurysm presenting as vaginal hematoma following an uncomplicated delivery. (2) To discuss alternatives of management of vulvar hematomas. Introduction: Postpartum hemorrhage is a leading cause of maternal mortality and can infrequently (1/300-1/1500 deliveries) be caused by vulvar hematomas. Vulvar hematomas are typically small and resolve with conservative treatment. Rarely, they can develop rapidly, posing a significant risk to the patient. Risks for vulvar hematomas include a prolonged second stage of labor, multiple gestation, operative vaginal delivery, episiotomy, and vaginal laceration. Extravasation from a pseudoaneurysm in the pelvic arteries is a rare cause of vulvar hematomas (&lt; 5% of cases) with &gt;75% involving the uterine artery. Pseudoaneurysms typically result from damage to vasculature during a traumatic delivery. Spread into the retroperitoneal space can lead to shock and eventual demise if improperly managed. This case illustrates the exceptionally rare occurrence of a pudendal artery pseudoaneurysm with rapidly expanding potentially catastrophic hematoma formation. Case Summary: Presented is a 21-year-old G2P1011 patient at 39w5d with a large vaginal hematoma diagnosed shortly following spontaneous vaginal delivery. The case initially presented to the hospital one hour after spontaneous rupture of membranes with an unremarkable pregnancy. Normal labor ensued and stage II of labor lasted one hour with an uncomplicated nonoperative vaginal delivery. Postpartum a significant increase in fundal height was noted. Cytotec was given and bladder catheterization removed 800 ml urine. Abdominal pain increased. Vital signs were normal. Exam revealed a large posterior vaginal wall swelling extending upward, but without active bleeding. A computerized tomography (CT) scan of the abdomen/pelvis revealed a 9.7 X 10.5 X 13.2 cm pelvic hematoma arising from the posterior vaginal wall with extension cephalad into the perirectal space and right adnexa. Evidence of active bleeding and bilateral hydronephrosis were reported. Hemoglobin was 10.1, down from admission 12.5. Symptoms included worsening abdominal pain and dizziness. Based on the active bleeding noted on CT scan and the progressive symptoms, the patient was transferred to a tertiary care center. Upon tertiary center admission the patient was tachycardic and hypotensive (P 153 and BP 101/61). Hemoglobin was 9.3. Physical exam was unchanged. Interventional radiology recommended and patient underwent embolization of bilateral uterine arteries for treatment of a diagnosed pseudoaneurysm with extravasation of the right pudendal artery. Postpartum day 1, mild right lower quadrant pain was felt to be consistent with the embolization. Hemoglobin decreased to 6.5, and the patient received one unit of packed red blood cells (PRBCs). Clinically, ambulation was tolerated, but tachycardia and hypotension remained and there was decreased swelling. Hemoglobin remained low at 6.8, and another unit of PRBCs was given. Hospital course thereafter was uneventful and discharge was on day 3. Discussion: This case describes a vaginal hematoma and pudendal artery pseudoaneurysm as a very rare but potentially life-threatening postpartum hemorrhage following vaginal delivery. Association with an uncomplicated pregnancy and delivery, involvement of the pudendal artery with an expanding large hematoma dissecting the retroperitoneal space creating a hemodynamically unstable situation are only rarely seen concurrently. Hematoma treatment starts conservatively, utilizing ice, rest, and pain control if patient is hemodynamically stable and the hematoma is small. When large, rapidly expanding, or the patient is hemodynamically unstable, surgical intervention or artery embolization should be considered when imaging identifies the source of bleeding. Imaging may include ultrasound, CT, CT angiography, and magnetic resonance imaging as options for localization of hematoma. No superior mode of evaluation is identified. Pseudoaneurysms following delivery have most commonly been described in the uterine arteries with only a handful of case reports documenting other sources including the obturator, labial, vaginal, and internal pudendal arteries. Our case demonstrates that extravasated pelvic artery pseudoaneurysms can present in benign appearing nonoperative deliveries and should be considered in the differential diagnosis as a source of post-partum hemorrhage. Recently, pseudo-aneurysms have more commonly been treated with IR artery embolization as it is a less invasive and better tolerated procedure by patients. Tsumagari et al suggested an algorithm proposing vulvovaginal hematomas should be observed versus surgically evacuated, whereas upper vaginal hematomas should undergo CT angiography for assessment for selective arterial embolization. Conclusion: Pseudoaneurysms of the pudendal artery with hematoma formation occurring in an uncomplicated delivery are an extremely rare cause of potentially life-threatening hemorrhage as reported in only a handful of cases. Because of their potential for catastrophic sequelae, they should be considered in the differential diagnosis of expanding upper vaginal hematomas. This case depicts the importance and success of rapid identification and embolization of pudendal artery pseudoaneurysm to prevent mortality.

Optimization of merchandise delivery logistics: case studies at Bejaia port

The object of the study is the logistics of goods delivery by ports. This study presents a methodology designed to improve the efficiency of goods delivery logistics at the Bejaia port (Algeria). It prioritizes the optimization of empty container allocation to the ZEP zone, taking into account the geographical accessibility of the Tixter area, aiming to reduce the high costs linked with goods transportation. At the core of this strategy lies the use of simulation techniques to optimize truck fleets, ensuring maximum utilization rates and effective management of delivery operations by the Bejaia Mediterranean Terminal (BMT) for its clients. Addressing this challenge, the study offers an exhaustive analysis, integrating truck assignment models and accessibility assessments of logistic zones. The results highlight the paramount significance of optimal resource allocation and synchronized client coordination for achieving streamlined goods delivery. It becomes apparent that employing these methodologies can yield substantial productivity improvements, emphasizing their pivotal role in strengthening the port's logistical infrastructure. Via rigorous analysis and insights derived from data, this study elucidates avenues towards achieving operational excellence within the logistical infrastructure of the port. By harnessing innovative strategies to confront persistent challenges, such as optimizing truck fleets and strategically allocating resources, the research anticipates a profound transformation in the efficiency and cost-effectiveness of goods delivery operations. Ultimately, the integration of these methodologies holds the potential to propel the port of Bejaia towards enduring success and a competitive edge in the ever-evolving landscape of global trade. Through extensive efforts, this strategy can be extended to other national and international ports operating under similar conditions, as it provides valuable information and methodologies to optimize logistics and transportation operations.

Prevalence and associated factors of maternal birth trauma following vaginal delivery at University of Gondar Comprehensive Specialized Hospital, North-West Ethiopia, 2022

BackgroundMaternal injury with any form of perineal trauma following vaginal delivery is very common which ranges globally from 16.2 to 90.4%. The frequency of Obstetric anal sphincter Injuries and the incidence of cervical laceration increases rapidly. However, in Ethiopia, there is limited evidence on the prevalence of maternal birth trauma and its determinant factors after vaginal delivery.ObjectiveTo assess the magnitude and associated factors of Maternal Birth Trauma after vaginal delivery at University of Gondar Comprehensive Specialized Hospital, Gondar, North-West Ethiopia, 2022.MethodsAn Institution based cross-sectional study was conducted among mothers with singleton vaginal delivery at University of Gondar Comprehensive Specialized Hospital from 9th May to 9th August 2022 among 424 study participants. Pre-tested semi-structured questioner was utilized. Epi-Data version 4.6 was used for data entry and exported to SPSS version 25 for data management and analysis. To identify the determinant factors, binary logistic regression model was fitted and variables with p-value < 0.2 were considered for the multivariable binary logistic regression analysis. In the multivariable binary logistic regression analysis, Variables with P-value < 0.05 were considered to have statistical significant association with the outcome variable. The Adjusted Odds Ratio (AOR) with 95% CI was reported to declare the statistical significance and strength of association between Maternal Birth Trauma and independent variables.ResultsA total of 424 mothers who delivered vaginally were included. The mean age of participants was 26.83 years (± 5.220 years). The proportion of birth trauma among mothers after vaginal delivery was47.4% (95%CI: 43.1, 51.7). Of different forms of perineal trauma, First degree tear in 42.8%, OASIs in 1.5% and Cervical laceration in 2.5% study participants. In the multivariable binary logistic regression analysis being primiparous (AOR = 3.00; 95%CI: 1.68, 5.38), Gestational age ≥ 39 weeks at delivery (AOR = 2.96; 95%CI: 1.57, 5.57), heavier birth weight (AOR = 12.3; 95%CI: 7.21, 40.1), bigger head circumference (AOR = 5.45; 95%CI: 2.62, 11.31), operative vaginal delivery (AOR = 6.59; 95%CI: 1.44, 30.03) and delivery without perineum and/or fetal head support (AOR = 6.30; 95%CI: 2.21, 17.94) were significantly associated with the presence of maternal birth trauma.Conclusion and recommendationMaternal birth trauma following vaginal delivery was relatively high in this study. Prim parity, gestational age beyond 39 weeks at delivery, heavier birth weight, bigger head circumference, operative vaginal delivery and delivery without perineum and/or fetal head supported were factors affecting perineal outcome. The Ministry of Health of Ethiopia should provide regular interventional training as to reduce maternal birth trauma.

Third-Stage Complications Among In Vitro Fertilization Pregnancies: An Observational Study.

This study aimed to determine the third-stage complications and their risk factors in in vitro fertilization (IVF) pregnancies. This prospective observational study was conducted from March 2022 to November 2023 at a tertiary care university hospital in South India. We included a total of 217 women following IVF conception, and details of the third-stage labor complications were documented and expressed as the frequency with percentage. The risk factors were analyzed using a logistic regression model. Among 217 participants, 51 (23.5%) had third-stage complications. Postpartum hemorrhage (PPH) was the most common, complicating 20% of the deliveries. Multiple gestations (adjusted odds ratio (aOR) 2.7, 95% confidence interval (CI) 1.03-7.46, p = 0.04), operative vaginal delivery (aOR 57, 95% CI 4.2-770, p = 0.002), and emergency cesarean section (aOR 14.8, 95% CI 1.3-160.5, p = 0.026) were the risk factors for PPH. Intrapartum infection was found to be associated with a risk for the retained placenta (aOR 8, 95% CI 1.37-46.4, p = 0.02) and adherent placenta (aOR 6.06, 95% CI 1.07-34.3, p = 0.04). Assisted reproductive technology (ART)-related factors were not found to be significantly associated with third-stage complications. There is a risk of third-stage complications, especially postpartum hemorrhage, among IVF pregnancies. The type of embryo transfer was not associated with third-stage complications.