Operative Vaginal Delivery Rates Research Articles

291 Neonatal and maternal outcomes in laboring nulliparas by cesarean and operative vaginal delivery rates

To evaluate the association between cesarean delivery (CD) rates and neonatal and maternal outcomes, and whether operative delivery (OVD) rate modifies this association. Secondary analysis of a randomized trial of labor induction versus expectant management in low-risk nulliparous participants with a vertex fetus. We excluded those delivered in hospitals with <100 participants. The centers were categorized into CD and OVD tertiles (low, medium and high) according to their CD and OVD rates in the trial participants. The primary outcome was a composite of adverse neonatal outcomes (defined in Figure); the secondary outcome was a maternal composite (defined in Table). Multivariable regression was used to estimate the association between CD tertiles and outcomes, as well as test for interaction between CD and OVD tertiles. Of 6,106 participants, 4,973 (81%) met inclusion criteria. The mean respective CD rates in the low, medium and high tertiles were 15.0%, 18.7% and 23.9%, and 5.0%, 7.5%, and 11.9% for OVD. The rates of OVD were similar across CD tertiles (8.1%,8.3%,8.0%). For the adverse neonatal composite, there was significant interaction between CD and OVD. If OVD was infrequent (lowest tertile), the adverse neonatal composite was more common in the mid- (aRR 2.87;95%CI 1.88,4.38) or high CD tertiles (aRR 2.93;95%CI 2.04, 4.22). Conversely, if OVD were frequent (highest tertile), the neonatal composite was less common in middle tertile CD group (aRR 0.78; 95%CI 0.62,0.99). The adverse maternal outcome composite was more frequent with a higher rate of CD (medium and high CD tertiles) compared with the lowest tertile (aRR 1.21;95%CI 1.05, 1.39, aRR 1.18;95% CI 1.03, 1.36 respectively, table and figure). Among low-risk nulliparous subjects, the frequency of CD did not vary by OVD rates. While adverse maternal outcomes were lowest in centers with lowest CD rates, the risk of the neonatal composite was lower in the medium CD group among those in the highest OVD tertile. Optimizing maternal and neonatal outcomes requires balancing CD and OVD rates.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

738 Sex-specific differences in electronic fetal monitoring patterns

Fetal male sex is associated with worse neonatal outcomes, but etiology of this phenomenon is not well elucidated. It has been hypothesized that males have an increased cytokine response and decreased catecholamine response to traumatic events, which could suggest a decreased tolerance of labor and therefore be detected in electronic fetal monitoring (EFM) patterns. We sought to determine if there were differences in EFM features in the 60 minutes prior to delivery. We performed a secondary analysis of a prospective cohort study of low risk women (excluding those with hypertensive disorder or diabetes) with a singleton fetus admitted for labor at term between 2010 to 2014 in a single institution. Baseline characteristics were compared between mothers of male and female infants. The primary outcome was EFM characteristics in the 60 minutes before delivery. Multivariable logistic regression was performed to determine the relationship between fetal sex and EFM characteristic while adjusting for confounders. Of the 4,055 low risk patients, 2,074 (51%) delivered a male infant. Mothers of male fetuses were more likely to go into spontaneous labor (p=0.02), but rates of operative vaginal (5.6 vs 4.1%, p=0.04) and cesarean delivery (CD) (18.1 vs 14.0%, p<0.01) and non-reassuring fetal status as indication for delivery (18.1vs 14.0%, p<0.01) were higher among males. Males were more likely to have bradycardia, recurrent variable decelerations, and higher total deceleration area and were less likely to have tachycardia compared to females. Males had higher odds of decelerations and bradycardia, but females had higher odds of tachycardia, possibly due to improved ability to generate a catecholamine response. Cesarean deliveries for non-reassuring fetal status are more common in pregnancies with male fetuses. These data suggest males are less likely to tolerate stresses of labor, which may drive the difference in mode of delivery and at least partially explain the increased morbidity male neonates experience.

Do obstetrics trainees working hours affect caesarean section rates in normal risk women?

ObjectivesThe rate of caesarean section (CS) is increasing globally. The nulliparous, term, singleton, vertex presentation, spontaneously labouring woman (Robson Group 1/RG1) is considered low risk for CS. It has been hypothesized that more CS occur at nighttime or at weekends due to doctor fatigue. The European Working Time Directive (EWTD) was implemented in our institution in 2013 to limit doctor working hours, which aimed at reducing fatigue but arguably fractures continuity of care. This study aimed to determine the effect of nocturnal hours and weekend on-call as well as the implementation of EWTD on our RG1 CS rates. Study designThis was a population-based study in a tertiary referral centre from 2008−2017. The inclusion criteria for our study were limited to RG1. Data were analysed from an established clinical database, including mode and time of delivery. Descriptive statistics are presented as number and percent for categorical variables. Relative frequencies were tested using chi-squared test. All statistical analyses were performed using SPSS Version 26. Statistical significance was defined as p < .05. ResultsThere were 86,473 deliveries over the 10-year study period. There were 18,761 women in RG1. Overall the RG1 CS rate was 12.9 % (n = 2415). Rates of CS in the RG1 were not statistically different between those delivering on weekdays (12.9 %, n = 1726/13,430) and weekends (12.9 %, n = 689/5,331, OR 0.99, 95 % CI = 0.90–1.09, p = .89). During daytime hours the CS rate was 12.1 % (n = 777/6411) and at nighttime was 13.3 % (n = 1638/12,350, OR 1.10, 95 % CI = 1.01–1.21, p = .03). Comparing the time periods pre and post EWTD implementation, there was a significant increase in CS rates (12.1 % n = 1319/10,873 V 13.9 % n = 1096/7,888, OR 1.17, 95 % CI = 1.07–1.27 p < .001). With respect to other modes of delivery in RG1 pre and post EWTD, there was a statistically significant decrease in operative vaginal delivery (OVD) rates (40.1%, n=4,360 V 37.7%, n=2,973, OR 0.90, 95% CI = 0.85-0.95, p = .001) ConclusionThis study shows an association between obstetric trainee working practices, RG1 CS and OVD rates; this is most pronounced at night and after the introduction of the EWTD. It is unlikely that obstetric trainee working practices are the only factor related to the increasing CS rate and reduced OVD rate. Consideration should be giving to addressing the needs of obstetric trainees in relation to achieving their competencies with now reduced labour ward exposure. Further study is required to see if alternate arrangements in relation to simulation training could increase the OVD rate and reduce the CS rate.

ASSOCIATION OF UMBILICAL CORD LENGTH WITH MODE OF DELIVERY

OBJECTIVE: To find out the average length of umbilical cord, variation in umbilical cord length in our antenatal women and to see the the association of umbilical cord length with mode of delivery. METHODS: This cross-sectional study was carried out at Lady Reading Hospital, Peshawar Pakistan, from Jan 2018 to Dec 2018. Using non-probability convenience sampling technique, 3300 pregnant women with singleton fetus between 37-42 weeks of gestation were included in the study. Umbilical cord length was measured by standard measuring tape. Umbilical cord length was divided into three groups and its association with mode of delivery was noted in each group. RESULTS: Umbilical cord length in our study varied from 31-100 cm. The mean umbilical cord length was 56±9.01 cm among 3,300 participants. Short umbilical cord length (≥40 cm) was found in 62 (1.8%) cases, out of which 36 (58.06%) normal vaginal delivery (NVD) while 21 (33.87%) had Caesarean section (CS). Normal umbilical cord length (41-70 cm) was found in n=3,079 (93%) participants, out of which 2,188 (71.06%) had NVD while CS rate was 17.1% (n=526/3079). Long umbilical cord (>70 cm) was found in 159 (4.8%) cases, where 96 (60.4%) had NVD and 31 (19.5%) had CS. Nuchal cords were more common in long umbilical cord group (n=136/159; 85.53%) as compared to normal (n=371/3079; 12.04%) & short cord length (n=3/62; 4.83%). CONCLUSION: Both long and short umbilical cords are associated with higher rate of operative vaginal delivery and caesarean section. Nchal cords were more in long umbilical cord group.

Internal fetal and uterine monitoring in obese patients and maternal obstetrical outcomes

The maternal habitus in the setting of obesity makes external monitoring of the fetal heart rate and contractions suboptimal, and internal monitors may be utilized more often in this population. Obesity is a risk factor for obstetrical infectious complications, but it is unknown whether the use of internal monitors in this population is associated with additional risks. This study aimed to investigate the association between the use of an intrauterine pressure catheter and a fetal scalp electrode and maternal infectious morbidity among women with obesity. This secondary analysis of a prospective cohort study included women with singleton gestations admitted for labor at ≥37 weeks' gestation at a tertiary care institution from 2010 to 2014. Obesity was defined as a body mass index of ≥30 kg/m2. The primary outcome was a composite maternal infectious morbidity, which included peripartum maternal fever, chorioamnionitis, and endomyometritis. Secondary outcomes were cesarean delivery and individual components of the maternal infectious composite. Multivariable logistic regression was used to compare the rates of infectious maternal morbidity, cesarean delivery, or operative vaginal delivery between patients with and without internal monitors, while adjusting for the confounders. An interaction term was included in the logistic regression models to test whether the relationship between the internal monitors and cesarean delivery or infectious morbidity was modified by the presence or absence of obesity. Of the 8482 women who met the inclusion criteria for the study, 4727 (55.7%) had obesity and 3755 (44.3%) did not have obesity. The women with obesity were more likely to have internal monitors placed during labor than those without obesity (65.4% vs 50.5%; P<.001). The use of internal monitors was associated with an increased risk for the composite maternal infectious morbidity (9.9% vs 4.1%; P<.01 and adjusted odds ratio, 2.08; 95% confidence interval, 1.70-2.55). Women with obesity had a weaker association between the use of internal monitors and maternal infectious morbidity than women without obesity (P value for interaction of .02). The incidence of cesarean delivery was also significantly higher among women who had internal monitors placed during their labor course (adjusted odds ratio, 2.84; 95% confidence interval, 2.46-3.28), and this interaction was not modified by obesity. Although a higher proportion of women with obesity have internal monitors placed during their labor course, they are not more susceptible to maternal infectious morbidity as a result of internal monitor use. Providers should not limit the necessary internal monitor use in women with obesity on the basis of concerns for maternal infectious morbidity.

Comparison of Spontaneous Versus Operative Vaginal Delivery Using Obstetric Quality of Recovery-10 (ObsQoR-10): An Observational Cohort Study

(J Clin Anesth. 2020;63:109781) Within the UK, operative vaginal delivery rates are estimated at between 10% and 13% of deliveries, which accounts for an ∼85,000 births in 2018 within England and Wales. The US, by contrast, estimates a 3% rate, which is ∼115,000 births in 2018. The primary goal of this study was to investigate the patient recovery for both types of vaginal deliveries, to determine whether postpartum treatment of these patients ought to be individualized due to labor type or remain more universal for all deliveries as it currently exists. Authors hypothesized that a spontaneous vaginal delivery would yield a better recovery when compared with an operative vaginal delivery.

Against medical advice for induction of labor due to post-term pregnancies – the impact on pregnancy outcome

Objective To determine the impact of deciding against medical advice and refusing labor induction in post-term pregnancies on pregnancy outcome. Methods Maternal and neonatal outcomes of women who refused induction of labor due to post term pregnancy (study group) were retrospectively compared to a control group of women who agreed labor induction (1:2 ratio) in a university-affiliated tertiary single medical center. Results A total of 83 women who refused labor induction were identified and compared to 166 womenwho consented to labor induction. Women who refused labor induction had higher rates of cesarean deliveries (21.7 vs. 10.2% p = .04), longer post-delivery hospitalization (2.9 vs. 2.4 days p < .05) and more advanced gestational age at delivery (41 + 6 vs. 41 + 4 days, p < .05). No significant differences were found in the rate of operative vaginal deliveries, need for antibiotics treatment or blood transfusion between the studied groups. Adverse neonatal outcomes among women who refused labor induction were significantly higher with higher rates of meconium (44.6 vs. 15.7%, p < .01), admission to NICU (9.6 vs. 5%, p < .01) and need for mechanical ventilation (4.8 vs. 0.6%, p < .01). Conclusion Refusing induction of labor due to post- term pregnancy is associated with higher rate of adverse maternal and neonatal outcomes, with a significant higher risk for cesarean section.

Knowledge Awareness and Attitude of Women toward Epidural Anesthesia during Labor

Background: Epidural analgesia is a central nerve block technique achieved by injection of a local anesthetic close to the nerves that transmit pain, and is widely used as a form of pain relief in labor. However, it is likely that epidural blocks lengthen labor and result in increased rates of operative vaginal delivery. Although, questions have been raised about its side effects.&#x0D; Objectives: The aims of this research study are; to predict the common use of epidural analgesia in Palestinian women, to assess its effectiveness on pain relief, and to determine its adverse effects. However, the study designed to measure the knowledge awareness, and attitude of Palestinian women toward epidural anesthesia during labor.&#x0D; Methods: A cross-sectional study was conducted using an online questionnaire. The study included females (age &lt; 20 - &gt; 40 years old) from all governorates in Palestine. The survey was designed to measure the knowledge awareness and attitude of Palestinian women toward epidural anesthesia during labor. A total of 2685 females participated in the study. SPSS version 22 was used to analyze the data collected.&#x0D; Results: About 893 women (33%) participated in the research study didn’t use the epidural analgesia and 1792 (67%) women used it, out of 2685 women completed the questionnaire. The research study included Palestinian women in different Governorates in Palestine. 43.2 % (800) of women who participated in this research study mentioned that the epidural injection is painless, 29.3% (543) said that it is painful and others filled it may be painful. In women used epidural injection, the expending of uterus was 1-2 cm in 355 women (20.5%), 2-3 cm in 325 women (18.7%), 3-4 cm in 482 women (27.8 %), 4-5 cm in 355 women (20.5%) and more than 5 cm in 218 women (12.6 %). The percentage of birth pain which anesthetized by epidural analgesia; 621 women (35%) mentioned that the epidural injection anesthetized about 80-100% , 24.5% (434) is 60-80% ,13% (230) is 40-60% , 9.4 (166) is 20-40% and 18.2% (322) is 0-20% . &#x0D;

Vacuum Deliveries: A Retrospective Study on Immediate Maternal and Neonatal Outcomes in Western Regional Hospital, Pokhara

Introduction: The overall rate of operative vaginal delivery is diminishing, but the proportion of operative vaginal deliveries conducted by vacuum is increasing. As forceps assisted delivery requires more skill and has more complications on maternal genital tract, this procedure is being less frequently practiced. By the 1970s, the vacuum extractor virtually replaced forceps for assisted deliveries in most of the countries. Vacuum assisted vaginal delivery reduces maternal as well as neonatal morbidity and mortality in prolonged second stage of labor, non reassuring fetal status and maternal conditions requiring a shortened second stage. &#x0D; Materials and Methods: This was a record based retrospective study of 217 vacuum assisted vaginal deliveries conducted at Western Regional Hospital, Pokhara for a period of one year. Patient’s discharge charts were studied and details of indications for vacuum application, maternal genital tract status, amount of blood loss, postpartum hemorrhage (PPH), birth weight, APGAR score at 1 and 5 minute, Neonatal Intensive Care Unit (NICU) admission and neonatal death (NND) were collected. Descriptive data analysis was done using SPSS program. &#x0D; Results: Out of the 8778 deliveries conducted during the study period, 217 (2.47%) cases were vacuum assisted vaginal deliveries. No significant adverse obstetrics outcomes were noted. Most frequent indication was fetal distress which accounted for 53.9%. Though 3rd/4th degree perineal tears were less, episiotomy rate was higher (69.1%). Regarding neonatal outcomes, mean APGAR score at 5 minute was 7.42 ± 1.11 SD and 12.4% neonates had APGAR score of less than 7 at 5 minute. &#x0D; Conclusion: When standard criteria for vacuum application are met and standard norms are followed, there is no evidence of adverse obstetrics outcomes in vacuum assisted vaginal delivery. Prompt delivery by a skilled clinician in non reassuring fetal cardiac status reduces neonatal morbidity and mortality.

Association between maternal height and mode of delivery in nulliparous Japanese women.

The primary aim of this study was to examine the association between maternal height and mode of delivery in nulliparous Japanese women. The secondary aim was to examine the association between maternal height and maternal and neonatal morbidities. This retrospective cohort study included women who gave birth at Osaka Women's and Children's Hospital, a tertiary perinatal center in Japan, from January 2015 to December 2017. Nulliparous Japanese women with singleton gestation, who went into labor at term were included in the study. The primary outcome was mode of delivery, and the secondary outcomes were maternal and neonatal morbidities. The relationships between maternal height and the outcomes were evaluated using multivariate logistic regression analysis adjusted for potential confounders. Maternal height was categorized into five groups with 5-cm increments for the analysis. A total of 1593 women were analyzed in this study. Shorter women had higher rate of cesarean delivery (CD) than taller women. There were no significant differences in the rates of operative vaginal delivery, maternal morbidity and neonatal morbidity among the maternal-height groups. The adjusted odds ratios (95% confidential interval) of maternal heights of <150 cm, 150-154 cm, 160-164 cm and ≥165 cm for CD, compared with a maternal height of 155-159 cm, were 3.56 (1.79-7.09), 1.68 (1.06-2.64), 0.63 (0.40-1.00) and 0.57 (0.30-1.01), respectively. Shorter nulliparous Japanese women were more likely to undergo intrapartum CD. However, the rates of maternal and neonatal morbidities in shorter women were similar to those in taller women.

Operative vaginal delivery and third grade educational outcomes

Operative vaginal delivery rates continue to drop nationally with many citing neonatal safety concerns as a primary driver of this decrease. Previous evidence on short-term neonatal outcomes does not support this concern. This study aimed to better understand the impact of delivery mode on childhood educational outcomes. A statewide retrospective cohort was created in which third grade Rhode Island Department of Education data for 2014 to 2017 were linked to Rhode Island Department of Health birth certificate data. Children's third grade reading and math proficiencies were compared by the mode of delivery listed in their birth certificates. The study population was limited to children who were term, singleton births without congenital anomalies. The mode of delivery was classified as operative vaginal (forceps or vacuum), primary cesarean, or spontaneous vaginal delivery. Children born via repeat cesarean delivery were excluded. Bivariate analyses were conducted to assess differences in demographic variables between mothers and children by mode of delivery and between reading and math proficiencies and mode of delivery. Bivariable and multivariable log-binomial regression was used to examine the association between subject proficiency and predictors including mode of delivery, gestational age, sex, race/ethnicity, and lunch subsidy. Of the 18,247 children who met the inclusion criteria, 6% were delivered by operative vaginal delivery, 19% by primary cesarean delivery, and the remaining 75% by spontaneous vaginal delivery. After adjustment for confounders including gestational age at delivery, child's race/ethnicity, sex, and socioeconomic factors, there was no difference in reading proficiency (adjusted risk ratio, 1.03; 95% confidence interval, 0.96-1.10) or math proficiency (adjusted risk ratio, 1.01; 95% confidence interval, 0.95-1.08) in those born by operative vaginal delivery compared with primary cesarean delivery, and no difference was found in either proficiency when spontaneous vaginal delivery was compared with primary cesarean delivery (reading, adjusted risk ratio, 0.97; 95% confidence interval, 0.93-1.01; math, adjusted risk ratio, 0.98; 95% confidence interval, 0.94-1.01). Operative vaginal delivery was not associated with differences in later childhood educational outcomes after adjusting for baseline differences. This should assuage previous concerns about long-term safety outcomes after operative vaginal delivery and may assist in shared decision making when operative vaginal or primary cesarean delivery is being considered.

Influence of Sonographic Fetal Weight Estimation Inaccuracies inMacrosomia on Perinatal Outcome.

To evaluate the influence of inaccurate sonographic fetal weight estimation in macrosomia on the mode of delivery and neonatal outcome (NO). In 14 633 pregnancies between 2002 and 2016, this retrospective study evaluated the association between sonographic fetal weight estimation, true birth weight (BW), mode of delivery (primary cesarean section [pCS], secondary cesarean section, vaginal delivery, and operative vaginal delivery rates) and NO parameters (5-min Apgar < 7, pH < 7.1, neonatal intensive care unit [NICU] admission, shoulder dystocia). Singleton pregnancies > 37 + 0 weeks with ultrasound-estimated fetal weight (EFW) within 7 days before delivery were included. The study population was divided into four groups: Group 1 (false-negative): EFW < 4000 g/BW ≥ 4000 g; Group 2 (true-positive): EFW ≥ 4000 g/BW ≥ 4000 g; Group 3 (false-positive): EFW ≥ 4000 g/BW < 4000 g; and Group 4 (true-negative): EFW < 4000 g/BW < 4000 g. As expected, the highest secondary cesarean section (sCS) rate was found in Group 2 (true-positive) (30.62 %), compared with only 17.68 % in Group 4 (true-negative). The sCS rate in the false-positive Group 3 was significantly higher (28.48 %) in comparison with the false-negative Group 1 (21.22 %; OR 1.48; 95 % CI, 1.16 to 1.89; P = 0.002). In comparison with the true-negative Group 4, univariate analyses showed significantly higher rates for sCS in all other groups: odds ratio (OR) 2.06 for Group 2 (95 % CI, 1.74 to 2.42; P < 0.001), 1.85 for Group 3 (95 % CI, 1.54 to 2.22, P < 0.001), and 1.25 for Group 1 (95 % CI, 1.05 to 1.49; P < 0.01). No significant differences were found for NO between Groups 1 and 3 for the parameters 5-min Apgar < 7 (P = 0.75), pH < 7.1 (P = 0.28), or NICU admission (P = 0.54). However, there was a significantly higher chance for shoulder dystocia in Group 1 compared with Group 3 (OR 4.58; 95 % CI, 1.34 to 24.30; P = 0.008). Sonographic EFW inaccuracies in fetal macrosomia appear to have a greater impact on the mode of delivery than birth weight itself. Underestimation of fetal weight may be associated with a higher probability of shoulder dystocia.

Use of the Robson Ten Group Classification System to categorise operative vaginal delivery.

Operative vaginal delivery (OVD), either vacuum or forceps, can be used to expedite vaginal delivery. While rates of OVD have been reducing worldwide, rates in Ireland remain high. The Robson Ten Group Classification System (TGCS) was originally created to compare rates of caesarean delivery between healthcare units, although no similar system exists for the analysis of OVD. We sought to examine rates of OVD using the TGCS in an effort to understand which patient groups make significant contributions to the overall rate of OVD. This is a retrospective cohort study of all women delivering in a tertiary-level university institution in Dublin, Ireland, from 2007 to 2016. Mode of delivery for all patients was extracted from contemporaneously recorded hospital records. Rates of OVD were analysed according to the TGCS, and the contribution of each group to the overall hospital population was calculated. There were 86191 deliveries of women in our institution, of which 19.3% (16673/86191) had an OVD. Women in Group 1 (singleton, cephalic, nulliparous women at term in spontaneous labour) contributed the most to the overall rate of OVD, accounting for almost half of all OVDs (46.1% (7679/16673)). Nulliparous women with a singleton, cephalic fetus at term who were induced (Group 2) were more likely to have an OVD than similar patients who laboured spontaneously (Group 1). OVD accounts for almost one in five deliveries in our population and is predominately performed in nulliparous women. These groups may be the subject of interventions to lower rates of OVD. The Robson TGCS is a freely available tool to hospitals and birthing centres to facilitate comparison of rates of OVD on local and national levels.

Sex-Specific Differences in Neonatal Morbidity at Term [34O

INTRODUCTION: Male sex is associated with worse outcomes among preterm neonates, but it is unclear if such sex discordant morbidity occurs in term infants. The aim of this study was to investigate the relationship between fetal sex and neonatal morbidity at term gestation. METHODS: This is a secondary analysis of a prospective cohort of women admitted for labor at term within a single institution from 2010 to 2015. The primary outcome was composite neonatal morbidity that included death, respiratory distress, mechanical ventilation, meconium aspiration syndrome, suspected sepsis, hypoxic-ischemic encephalopathy, therapeutic hypothermia, and seizure. Multivariable logistic regression was used to estimate the association between infant sex and neonatal morbidity. RESULTS: Of the 8578 participants, 51% delivered a male fetus. Birthweight was higher in male infants (3304 g vs 3177 g, P&lt;.01), as were the rates of prostaglandin administration (19.0 vs 11%, P&lt;.01), operative vaginal (4.0 vs 5.6%, P&lt;.01), and cesarean delivery (15.4 vs 18.6%, P&lt;.01). After adjusting for birthweight, male infants had a significantly higher risk of composite neonatal morbidity (aOR 1.21 [95% CI 1.04, 1.40]). This association was driven primarily by a higher rate of respiratory distress in male infants (1.34 [1.07, 1.68]). CONCLUSION: Term male infants appear to be at increased risk for neonatal morbidity compared to females even after adjustment for birthweight. This association was partly driven by a higher rate of respiratory morbidity in male infants. Our findings reinforce the current notion that neonatal outcomes can be sex-dependent, and call for further investigation into the physiologic mechanisms driving this association.

Improvement of Operative Vaginal Delivery Training in Residency: A Single Institution Experience [17G

INTRODUCTION: Operative vaginal delivery (OVD) rates are decreasing in the US, creating fewer opportunities for trainee participation. Residents, not adequately trained in OVD, are less likely to use this skill after training, contributing to a growing cesarean rate. We aimed to improve resident participation in OVD. METHODS: Retrospective analysis from July 2017 to December 2018 of an intervention bundle applied prospectively on all OVDs performed at Yale New Haven Hospital. Staff and clinicians were interviewed to assess barriers to resident participation. Interventions applied: 1) training of residents in didactics and simulations on OVD, 2) outreach to providers to create awareness and comfort with resident participation, and 3) change of workflow on the Labor &amp; Birth unit to improve notification to the resident team about OVD events through a mobile texting tool. Our goal was to achieve &gt;90%; resident participation in OVD, calculated to meet the ACGME minimum. Process control and run charts were used for analysis. RESULTS: There were 214 OVDs. Overall mean resident coverage was 83.6%. Prior to intervention, the median attendance rate of residents at OVD was 76%. After intervention, the median monthly coverage rate was 100%. Prior to intervention, process control chart analysis shows multiple points outside control limits (outside 3 standard deviations). After intervention, there were no points outside of control limits, and &gt;8 points were above the median consecutively, showing achievement of process control. Mean attendance rate after intervention was 98.7%. CONCLUSION: Resident participation in OVD increased to the target rate with implementation of low cost, low technology solutions.

The effect of meconium-stained amniotic fluid on perinatal outcome in pregnancies complicated by preterm premature rupture of membranes.

To determine whether meconium-stained amniotic fluid (MSAF) encountered in pregnancies complicated by preterm premature rupture of membranes (PPROM) is associated with adverse maternal and perinatal outcome. A retrospective cohort study of all singleton pregnancies with PPROM and MSAF who delivered in a tertiary hospital at 24 + 0-36 + 6weeks of gestation between 2007 and 2017. Women with PPROM-MSAF (study group) were compared to women with PPROM and clear amniotic fluid (control group). Controls were matched to cases according to age, gravidity, parity and gestational age at delivery in a 3:1 ratio. Primary outcome was defined as neonatal intensive care unit admission. Secondary outcomes were neonatal adverse outcomes, chorioamnionitis and placental abruption diagnosed clinically or by placental cultures and histology. Seventy-five women comprised the study group and were matched to 225 women representing the control group. A significantly higher rate of neonatal intensive care unit admissions was noted in the study group compared to controls (61.3% vs. 45.7%, p = 0.03). Multivariate analysis demonstrated that MSAF is an independent risk factor for neonatal intensive care unit admission (adjusted OR = 2.82, 95% CI 1.39-5.75, p = 0.004). MSAF was found to be associated to higher rates of cesarean and operative vaginal deliveries (30.7% vs. 24.4% and 5.3% vs. 2.7%, p = 0.057, respectively) as well as to chorioamnionitis and placental abruption (33.3% vs. 19.3%, p = 0.034 and 16.0% vs. 7.7%, p = 0.021, respectively). MSAF is associated with higher frequencies of adverse perinatal outcome when compared to clear amniotic fluid in pregnancies complicated by PPROM.

Physical exercise at term for enhancing the spontaneous onset of labor: a randomized clinical trial

Introduction Physical exercise at term is empirically used as a method of enhancing the spontaneous labor onset. The objective of this study was to evaluate the effect of controlled maternal physical exercise at term as a method of enhancing the spontaneous labor onset. Materials and methods At 38 weeks low-risk pregnant women, with a singleton cephalic fetus and no previous cesarean deliveries were randomly allocated to one of two arms: the experimental group performed 30 min of walking 3 times a week at 4 km/h, and the control group maintained their usual work and household activities. The primary outcome measure was the rate of labor induction. A sample size of 60 per group was planned to detect a 10% difference in labor induction rate, at a significance level of 0.05 and a power of 0.80. Results The exercise group had a lower rate of labor induction (17.5 versus 33.3%, adjusted odds ratio [OR] = 0.28, 95% confidence interval [CI]; 0.14–0.87) and fewer operative vaginal deliveries (20.6 versus 38.1%, adjusted OR = 0.42, 95% CI; 0.17–0.92). No differences were found in gestational age at onset of spontaneous labor, duration of the active phase of labor, interval between induction and the active phase of labor, cesarean section rates, birth weight, and Apgar scores. No maternal or fetal heart rate abnormalities were recorded during the exercise sessions. Conclusions For low-risk women at term walking for 30 min 3 times a week at 4 km/h from 38-week onwards is safe, enhances the spontaneous onset of labor and reduces operative vaginal delivery rates. Key Message Physical exercise at term is empirically used as a method of enhancing the spontaneous labor onset. In finding that for low-risk women walking for 30 min 3 times a week at 4 km/h from 38-week onwards enhances spontaneous labor onset of and reduces operative vaginal delivery. Clinical Trial Registration ClinicalTrials.gov. www.clinicaltrials.gov NCT02460185

The future of electronic fetal monitoring.

Continuous electronic fetal monitoring (EFM) was first introduced commercially over 50 years ago with the hope of improving perinatal outcomes during labor. However, despite the increased use of EFM, definitive improvements in perinatal outcomes have not been demonstrated. Variance in tracing interpretation and intervention has led to increased rates of cesarean and operative vaginal deliveries and perhaps increased maternal and neonatal morbidity. Since its inception, several strategies have been developed in hopes of optimizing EFM and improving these outcomes. We discuss the current standards of intrapartum fetal monitoring and review optimization strategies and technologies in development to improve intrapartum fetal monitoring.

Perineal Laceration and Episiotomy Repair Using a Beef Tongue Model.

Declining rates of operative vaginal deliveries and routine episiotomy in obstetric practice, along with rising cesarean section rates, have decreased OB/GYN resident experience with episiotomy repair and obstetric anal sphincter injuries (OASIS). Simulation models are valuable educational tools in procedural training. Several models have been reported, each with its own limitations and benefits. We developed a 1-hour workshop to teach novice OB/GYN residents perineal laceration repair skills on a modified beef tongue model. The model required 5-10 minutes to assemble following written and video instruction, and learners had 30-50 minutes to practice using learner instructions. Learners were evaluated using a procedure checklist and global objective structured assessment of technical skills. To evaluate the session, we surveyed current faculty and residents, as well as residency graduates. Between 2008 and 2017, an estimated 82 OB/GYN residents participated in this activity, and 95 participants and facilitators received the survey. Forty-one (59%) respondents agreed that this model was similar to repairing OASIS in clinical practice. Our trainees reported that the optimal time for simulated OASIS repair was the R2 and R3 years; however, 90% of respondents felt residents should be offered this simulation yearly. Based on our survey of trainees, graduates, and faculty, we created a realistic simulated OASIS repair training, despite the limitation that the model lacked a rectum. Learners reported an interest in repeating the simulation frequently during residency to augment their clinical experience and increase perceived competence in third- and fourth-degree laceration repair by their graduation.

Solving the Obstetrical Paradox: The FETAL Technique-A Step toward Noninvasive Evaluation of Fetal pH.

Every year, about 85 percent of the approximately 5 million births in North America are evaluated with the electronic fetal monitoring (EFM). Clinicians use the EFM as a proxy to assess fetal oxygenation status, fetal well-being, and potential compromise. Despite the widespread use of this technology, neonatal hypoxia and acidosis continue to make up a high proportion of neonatal morbidity at term. Indeed, though the fetal heart rhythm is inextricably linked to fetal acid-base status, EFM has not been shown to reliably predict neonatal pH status nor has it reduced adverse maternal or neonatal outcomes. As a consequence, the high false-positive rate of EFM for predicting adverse neonatal outcomes has led to an increase in the rate of operative vaginal and cesarean delivery, with elevated rates of associated maternal and neonatal morbidity. This fact invariably leads to a paradox we have henceforth defined as the “obstetrical paradox.” Herein, we explore the potential solutions to this paradox and introduce a novel noninvasive technique to assess fetal acid-base status in utero known as the “FETAL technique” (Fourier Evaluation of Tracings and Acidosis in Labour). The FETAL technique, currently under investigation, applies the discrete Fourier transformation to EFM tracings to determine the spectral frequency distribution of the fetal heart rate. These specific frequency distributions correlate with specific umbilical pH values and may provide the missing link between fetal heat rate patterns and acid-base status at birth. As we work toward realizing the full potential benefits of EFM, finding the best assessment strategies to evaluate fetal pH in real time remains a key goal in obstetrics.