Persistent Occiput Research Articles

The association between unintended hysterotomy extensions with cesarean delivery and subsequent preterm birth

BackgroundAn increased risk of preterm birth has been observed among individuals with a previous second stage cesarean delivery compared with a previous vaginal delivery. One mechanism that may contribute to the increased risk of preterm birth following second stage cesarean delivery is the increased risk of cervical injury due to extension of the uterine incision (hysterotomy) into the cervix. Investigating the contribution of hysterotomy extension to the rate of preterm birth has not been well-studied and may shed light on the mechanisms underlying the observed relationship between mode of delivery and subsequent preterm birth. ObjectiveWe aimed to quantify the association between unintended hysterotomy extension and preterm birth in a subsequent delivery. Study designWe performed a retrospective cohort study using electronic perinatal data collected in two university-affiliated obstetrical centers. The study included patients with a primary cesarean delivery of a term, singleton live birth and a subsequent singleton birth in the same catchment (2005-2021). The primary outcome was subsequent preterm birth <37 weeks; secondary outcomes included subsequent preterm birth <34, <32 and <28 weeks. We assessed crude and adjusted associations between unintended hysterotomy extensions and subsequent preterm birth with log binomial regression models using rate ratios (RRs) and 95% confidence intervals (CIs). Adjusted models included several characteristics of the primary cesarean delivery such as maternal age, length of active labour, indication for cesarean delivery, chorioamnionitis, and maternal comorbidity. ResultsA total 4,797 patients met the study inclusion criteria. The overall rate of unintended hysterotomy extension in the primary cesarean delivery was 6.0% and the total rate of preterm birth in the subsequent pregnancy was 4.8%. Patients with an unintended hysterotomy extension were more likely to have a longer duration of active labour, chorioamnionitis, failed vacuum delivery attempt, second stage cesarean delivery, and persistent occiput posterior position of the fetal head in the primary cesarean delivery and higher rates of smoking in the subsequent pregnancy. Multivariable analyses controlling for several confounders showed that a history of hysterotomy extension is not associated with a higher risk of preterm birth <37 weeks gestation (adjusted RR 1.55, 95% CI 0.98-2.47), but is associated with preterm birth <34 weeks gestation (adjusted RR 2.49, 95% CI 1.06-5.42). ConclusionPatients with a uterine incision extension have a 2.5 times higher rate of preterm birth <34 weeks compared with patients who do not sustain this injury. This association was not observed for preterm birth <37 weeks. Future research should aim to replicate our analyses while incorporating additional data to minimize the potential for residual confounding.

Perinatal outcomes in persistent occiput posterior fetal position: a systematic review and meta-analysis

Background/Aims Persistent occiput posterior fetal position is the most common fetal malposition during labour. The aim of this study was to measure the magnitude of the effects of this labour dystocia on perinatal outcomes, as compared to anterior position. Methods A systematic review of the literature included prospective and retrospective cohort studies of singleton term pregnancies, comparing the effect of occiput posterior fetal position with occiput anterior fetal position. Random-effect meta-analysis was performed. Results Overall, eight studies were included, for a total of 140 590 participants. Women with fetuses in occiput posterior position were more likely to give birth via caesarean section (odds ratio: 6.74, P&lt;0.001), based on data from all eight studies. Newborns experienced an increased risk of admission to a neonatal intensive care unit (odds ratio: 1.60, P&lt;0.001), based on data from five of the included studies. Conclusions Persistent occiput posterior fetal position negatively affects maternal and neonatal outcomes. Future studies should reduce potential bias, include adjusted analysis and investigate the best clinical management for this labour dystocia.

Knowledge and experience of midwives and gynecologists about manual rotation of persistent occiput posterior position

Backgroundmanagement of persistent occiput posterior position has always been controversial. Manual rotation by a delivery operator can reduce instrumental delivery and cesarean section.AimThis study aims to determine the knowledge and experience of midwives and gynecologists about manual rotation of persistent occiput posterior position.MethodsThis descriptive cross-sectional study was performed in 2022. The questionnaire link was sent to 300 participating midwives and gynecologists via WhatsApp Messenger. Two hundred sixty-two participants completed the questionnaire. Data analysis was performed using SPSS22 statistical software and descriptive statistics.Results189 people (73.3%) had limited information about this technique, and 240 (93%) had never performed it. If this technique is recognized as a safe intervention and is included in the national protocol, 239 people (92.6%) want to learn, and 212 (82.2%) are willing to do it.ConclusionAccording to the results, the knowledge and skills of midwives and gynecologists need to be trained and improved for manual rotation of persistent occiput posterior position.

Persistent occiput posterior position: predictive factors of spontaneous rotation of the fetal head

Objectives To assess factors associated with spontaneous rotation in the occiput anterior position for fetuses in persistent occiput posterior (OP) during the second stage of labor. To evaluate maternal and fetal outcomes after spontaneous rotation of persistent OP. Methods This is a prospective cohort of 495 women with fetuses in persistent OP position, confirmed with ultrasonography during the second stage of labor. We performed simple logistic regressions, followed by multiple logistic regressions. Results Among 495 women with fetuses in persistent OP position, 78 fetuses (16%) underwent a spontaneous rotation during the second stage of labor. The multivariate analysis found that a short duration of the first stage of labor (<7 h) was associated with a spontaneous rotation of the fetal head in the second stage of labor (OR 0.43 [0.23; 0.76. There were fewer episiotomies (25.6% vs 52.3%, p < .01), cesarean sections (0% v. 5.4%, p = .03), and instrumental deliveries (8.9% vs. 50%, p < .01) in the "spontaneous rotation” group, and the two groups were similar regarding post-partum hemorrhage. The newborns in the “spontaneous rotation” group had a higher Apgar score at 1 min (10 v. 9, p = .02). The two groups did not differ for other neonatal parameters, such as arterial pH value, Apgar score at 5 min, birth trauma, or transfer into the pediatric unit. Conclusion A shorter duration of the first stage of labor (< 7 h) is a predictive factor of spontaneous rotation in the occiput anterior position for fetuses in persistent OP position. A spontaneous rotation in case of an OP position is associated with better maternal and fetal outcomes.

Prolonged Dystocic Labor in Neuraxial Analgesia and the Role of Enkephalin Neurotransmitters: An Experimental Study

The investigation studied the enkephalinergic neuro fibers (En) contained in the Lower Uterine Segment (LUS) during the prolonged dystocic labor (PDL) with Labor Neuraxial Analgesia (LNA). PDL is generally caused by fetal head malpositions in the Occiput Posterior Position (OPP), Persistent Occiput Posterior Position (POPP), in a transverse position (OTP), and asynclitism (A), and it is detected by Intrapartum Ultrasonography (IU). The En were detected in the LUS samples picked up during cesarean section (CS) of 38 patients undergoing urgent CS in PDL, compared to 37 patients submitted to elective CS. Results were statistically evaluated to understand the differences in En morphological analysis by scanning electron microscopy (SEM) and by fluorescence microscopy (FM). The LUS samples analysis showed an important reduction in En in LUS of CS for the PDL group, in comparison with the elective CS group. The LUS overdistension, by fetal head malpositions (OPP, OTP, A) and malrotations, lead to dystocia, modification of vascularization, and En reduction. The En reduction in PDL suggests that drugs used during the LNA, usually local anesthetics and opioids, cannot control the "dystocic pain", that differs from normal labor pain. The IU administration in labor and the consequent diagnosis of dystocia suggest stopping the numerous and ineffective top-up drug administration during LNA, and to shift the labor to operative vaginal delivery or CS.

Labor and delivery outcomes by delivery method in term deliveries in occiput posterior position: a population-based retrospective cohort study

Occiput posterior is the most common malposition in labor. Deliveries in occiput posterior position have been shown to have higher rates of adverse short-term maternal and neonatal outcomes compared with deliveries in occiput anterior position. There are no guidelines providing recommendations nor summarizing risks of adverse outcomes by delivery method to inform the decision-making process in occiput posterior delivery management. Population-based studies examining the outcomes associated with various management processes of occiput posterior position at the time of labor or delivery are lacking. This study aimed to describe the current management of term singleton occiput posterior deliveries in British Columbia, Canada and to examine the association between different management strategies and adverse outcomes by describing the rates of: occiput posterior malposition; and spontaneous vaginal delivery, operative vaginal delivery, and cesarean delivery from occiput posterior malposition. We also analyzed the rates of adverse labor and delivery outcomes stratified by fetal position and delivery mode, and the interaction effect of occiput posterior position and delivery mode on the rates of adverse outcomes. This was a retrospective cohort study of cephalic term singleton deliveries in British Columbia from 2004 to 2020, using the British Columbia Perinatal Data Registry. The obstetrical adverse outcome index (a composite of 10 adverse maternal or neonatal events), adverse outcome index subcomponent rates, and adverse outcome index-derived weighted scores were compared between deliveries stratified by fetal position at delivery (occiput posterior or occiput anterior) and occiput posterior deliveries stratified by delivery method. Multivariable log-binomial logistic regression was used to model the adverse outcome index score. Of 306,237 term births, 19% had occiput posterior position during labor, 37% of which persisted in occiput posterior position at delivery. Among occiput posterior deliveries, 27% were spontaneous vaginal deliveries, 8% vacuum, 5% forceps, 1% mixed vacuum-forceps, and 59% were cesarean delivery; this distribution differed from that of occiput anterior deliveries (P<.0001). Overall, adverse outcome index scores were significantly higher in persistent occiput posterior deliveries (8.8% had ≥1 adverse outcomes; adjusted rate ratio, 1.07 [1.01-1.14]) than in occiput posterior labors that rotated to occiput anterior deliveries; the most frequent adverse outcome was third- or fourth-degree lacerations. Neonatal adverse outcomes were also more frequent in occiput posterior delivery (4.3% vs 3.3%; adjusted rate ratio, 1.21 [1.10-1.35]), whereas maternal outcomes were similar between groups (4.8% vs 6.0%; adjusted rate ratio, 1.04 [0.96-1.13]). Among persistent occiput posterior deliveries, spontaneous vaginal delivery and cesarean delivery had the lowest proportion of deliveries with ≥1 adverse outcomes (6.1% and 6.2%), whereas forceps deliveries had the highest (38.1%); the largest contributor to the adverse outcomes were third- or fourth-degree lacerations. Among occiput posterior deliveries with any adverse outcome, cesarean delivery had the highest Severity Index score, due in part to the inclusion of third- or fourth-degree tears (which are assigned a comparatively low score) as the most common adverse event in the other vaginal delivery modes, and because of outcomes with a higher severity score being associated with cesarean delivery, such as uterine rupture (a reason for cesarean delivery) and intensive care unit admission (an outcome following cesarean delivery). Overall, in a multivariable regression model, delivery mode and the interaction between delivery mode and occiput posterior position were significant predictors of a delivery with ≥1 adverse outcomes, whereas occiput posterior position itself was not. One in five singleton deliveries at term gestation had occiput posterior position in labor; most of these rotated to occiput anterior by delivery, which had better outcomes than persistent occiput posterior deliveries. Among the latter, spontaneous vaginal delivery and cesarean delivery had the lowest frequency of adverse outcomes, whereas forceps deliveries had the highest. This study provides a robust updated analysis of birth outcomes following different occiput posterior management strategies, which can inform provider decision-making and counseling. Its observational design may limit its use for direct recommendations for management of occiput posterior malposition, yet the study helps to define the risks associated with different modes of delivery in the setting of occiput posterior malposition. With additional studies examining success rates of intermediate occiput posterior-occiput anterior rotation, other delivery management steps, and long-term outcomes, this study helps to define safe management of occiput posterior delivery.

Safety of vaginal delivery in women with placental chorioangiomas diagnosed by prenatal ultrasound: A retrospective cohort study.

This study aimed to examine the maternal and neonatal outcomes in different mode of delivery in pregnant women with placental chorioangiomas, in order to determine the safety of vaginal delivery.We conducted a retrospective study of 54 women with placental chorioangioma diagnosed by prenatal ultrasound and subsequently proven histologically, excluding those who underwent cesarean section for obstetric indications. The mode of delivery was divided into a vaginal delivery group (23 women) and a cesarean section group (31 women). The indication of cesarean section group was only for placental chorioangioma, no other obstetric indications. The maternal characteristics, pregnancy outcomes and the color doppler imaging characteristics of placental chorioangioma of the 2 groups were compared, and the clinical characteristics of women in the vaginal delivery group were described in detail.The incidence of placental chorioangioma was nearly 0.43‰ in our study. There was no significant difference in the maternal characteristics and pregnancy outcomes between the 2 groups. 82.6% (19/23) of the women successfully delivered vaginally and 4 failed who turned to cesarean section in the vaginal delivery group; among them, 17 women had giant chorioangiomas (>4 cm in diameter). The direct cause of vaginal delivery failure was fetal distress, persistent occiput posterior fetal position and cephalopelvic disproportion.Pregnant women with placental chorioangiomas and no other obstetric indications for cesarean section may attempt a vaginal delivery, even with giant chorioangiomas. If there are risk factors of vaginal delivery failure, the progress of labor needs to be closely monitored.

Tatalaksana Penggunaan Forceps pada Posisi Oksiput Posterior Persisten

Maternal health is the health of women during pregnancy, childbirth and the postnatal period. World Health Organization (WHO) record every day in 2017 about 810 women died from preventable causes related to pregnancy and childbirth. Between 2000-2017, the maternal mortality ratio dropped by about 38% worldwide, but 4% of all maternal deaths occur in low and lower middle-income countries. Persistent occiput posterior (OP) is associated with increased rates of maternal and newborn morbidity. Cesarean delivery is higher (3 times greater risk of death) maternal morbidity and mortality than vaginal delivery and also costs more than normal childbirth. Forceps extraction is one of the operative obstetric actions that aims to help childbirth through normal childbirth. This is done for all conditions that threaten the mother and fetus that have indications to undergo childbirth. the use of forceps techniques, will assure successful, safe, and steady performance of forced delivery. Therefore, obstetric forceps should be inherited of skills to the trainee at this time. Therefore, it is reasonable for the standards establishing the proper position for forceps delivery to vary between experienced and inexperienced operators. The first priority is safe and secure implementation of the procedure.

Management of persistent occiput posterior position: The added value of manual rotation.

To evaluate the delivery rate in the occiput posterior position according to the result of manual rotation performed in the case of persistent occiput posterior position. Secondary objectives were perinatal outcomes. This was a prospective cohort study conducted in two French tertiary care units. All women with a singleton pregnancy after 37weeks of gestation with a fetus in persistent occiput posterior position and an attempt of manual rotation were included. The main outcome was the occiput position at delivery. The secondary outcomes were duration of labor, mode of delivery, and perineal tears. Two groups were compared according to the result of manual rotation. In total, 460 women were included, with a manual rotation success of 62.4%. The success was significantly associated with a decrease in occiput posterior position at vaginal delivery (1.4% vs 57.2%, P<0.0001), cesarean (0.7% vs 17.9%, P<0.0001), operative vaginal delivery (40.1% vs 78%, P<0.0001), episiotomy (40.1% vs 54.9%, P<0.0001), and obstetric anal sphincter injury (3.1% vs 8.7%, P=0.008) compared with a failure. An attempt of manual rotation in the case of persistent occiput posterior position is associated with decreased rates of occiput posterior position at delivery, operative delivery, and anal sphincter injuries.

Prolongation of active second stage of labor: Associated factors and perinatal outcomes

BackgroundCurrent data does not allow to define a reasonable threshold of duration of active second stage (ASS) of labor beyond which a medical intervention should be considered. Primary objective was to analyse perinatal outcomes associated with prolonged ASS beyond 45 min. Secondarily, we analysed associated maternal, gestational, labor and delivery characteristics associated with prolonged ASS. MethodsWe performed a monocentric retrospective study among women with vaginal delivery, a term singleton cephalic fetus, without history of cesarean section. We compared women with active second stage of labor longer than 45 min (ASS ≥45 min, group A) and women with instrumental vaginal delivery (IVD) only for failure to progress (FtP) before 45 min of pushing (group B). Primary outcome was postpartum hemorrhage (PPH). Maternal and neonatal outcomes associated with ASS ≥ 45 min were assessed with multivariable logistic regression models. ResultsProlonged ASS ≥45 min (group A, N=177) was associated with lower rate of persistent occiput posterior position (1.7 vs 9.5%, p<0.01) and of non-engaged presentation when expulsive efforts started (10.7 vs 27.4%, p<0.01), compared to IVD for FtP <45 min (group B, N=84). In group A, 52% of women had instrumental delivery. Prolonged active second stage was independently associated with lower odds of episiotomy (38.4 vs 61.9%, AOR(95%CI)=0.43[0.24-0.78]) and was not associated with PPH (5.1 vs 5.9%, AOR=1.01[0.28-3.68]), pH<7.20, 5-min Apgar score < 7 (20.2 vs 15.9%, AOR=2.00[0.89-4.48]), lactates > 6 (23.0 vs 24.3, AOR=1.45[0.68-3.07]) or transfer to neonatal intensive care unit (6.2 vs 2.4%, AOR=4.71[0.76-29.08]. DiscussionExtending the duration of active second stage of labor beyond 45 min seems reasonable under rigorous surveillance of maternal and fetal wellbeing.

Prophylactic manual rotation of occiput posterior and transverse positions to decrease operative delivery: the PROPOP randomized clinical trial

Persistent occiput posterior and occiput transverse positions are the most common malpositions of the fetal head during labor and are associated with prolonged second stage of labor, cesarean deliveries, instrumental deliveries, severe perineal tears, postpartum hemorrhage, and chorioamnionitis. Manual rotation is one of several strategies described to deal with these malpositions. This study aimed to determine if the trial of prophylactic manual rotation at the early second stage of labor is associated with a decrease in operative deliveries (instrumental and/or cesarean deliveries). We conducted a multicenter, open-label, randomized controlled trial in 4 French hospitals. Women with singleton term pregnancy and occiput posterior or occiput transverse position confirmed by ultrasound at the early second stage of labor and with epidural analgesia were eligible. Women were randomly assigned (1:1) to either undergo a trial of prophylactic manual rotation of occiput posterior or occiput transverse position (intervention group) or no trial of prophylactic manual rotation (standard group). The primary outcome was operative delivery (instrumental and/or cesarean deliveries). The secondary outcomes were length of the second stage of labor, maternal complications (postpartum hemorrhage, operative complications during cesarean delivery, episiotomy and perineal tears), and neonatal complications (Apgar score of <5 at 10 minutes, arterial umbilical pH of <7.10, neonatal injuries, neonatal intensive care unit admission). The main analysis was focused on intention-to-treat analysis. From December 2015 to December 2019, a total of 257 women (mean age, 30.4 years; mean gestational age, 40.1 weeks) were randomized: 126 were assigned to the intervention group and 131 were assigned to the standard group. Operative delivery was significantly less frequent in the intervention group compared with the standard group (29.4% [37 of 126] vs 41.2% [54 of 131]; P=.047; differential [intervention-standard] [95% confidence interval]=-11.8 [-15.7 to-7.9]; unadjusted odds ratio [95% confidence interval]= 0.593 [0.353-0.995]). Women in the intervention group were more likely to have a significantly shorter second stage of labor. Trial of prophylactic manual rotation of occiput posterior or occiput transverse positions during the early second stage of labor was statistically associated with a reduced risk of operative delivery. This maneuver could be a safe strategy to prevention operative delivery.

3 Prophylactic Manual Rotation of Persistent Occiput Posterior to decrease operative Delivery: a Multicentric Randomized Trial

Persistent occiput posterior (POP) positions are the commonest malpresentations of the fetal head during labor and are associated with prolonged second stage of labor, cesarean, instrumental deliveries, obstetrical anal sphincter injuries, postpartum hemorrhage and chorioamnionitis. Manual rotation is one of several strategies described to deal with POP. The literature suggests that manual rotation of POP could decrease operative deliveries but no randomized study has confirmed these findings. The aim of this study was to determine if the trial of prophylactic manual rotation during the early second stage of labor is associated with a decrease risk of operative deliveries (instrumental and/or cesarean deliveries). This study was a prospective, randomized, controlled trial conducted in four French hospitals. Women with singleton term pregnancy and POP position confirmed by ultrasound at early second stage of labor and with epidural analgesia were eligible and randomized (1:1) to either receive the trial of prophylactic manual rotation of POP position (intervention group) or no trial of prophylactic manual rotation (standard group). The primary outcome was operative deliveries (instrumental and/or cesarean deliveries). From December 2015 to December 2019, 257 women were randomized: 126 assigned to the intervention group and 131 to the standard group. The groups did not differ in baseline characteristics. Operative delivery was significantly less frequent in the intervention (I) group compared to the standard (S) group (29.4 vs. 41.2%, p=.047, Differentiel (I-S) [95% confidence interval, CI] = -11.8 [-15.7;-7.9]; relative risk [95% CI] = 0.71 [0.51-1.00]). Women in the intervention group were more likely to have a significant shorter second stage of labor and have a neonate with a significant higher Apgar score at 5 minutes. The were no differences in other secondary outcomes. Trial of prophylactic manual rotation of persistent POP positions during the early second stage of labor is associated with a decrease risk of operative delivery.

512 Hands-and-knees position and incidence of occiput anterior position at birth: a systematic review and meta-analysis

Persistent occiput posterior (OP) and occiput transverse (OT) positions are associated with adverse maternal and neonatal outcomes. Our objective was to assess the efficacy of hands-and-knees to increase occiput anterior (OA) position in the second stage of labor or at time of delivery. An electronic search of five databases was performed. We included all randomized controlled trials of singleton gestations at ≥37 weeks that were randomized to either hands-and-knees position or control (i.e., any position other than hands-and-knees). The primary outcome was OA position in second stage of labor or at time of delivery. Secondary outcomes were change to OA position after initial intervention, as well as delivery and neonatal outcomes. A prespecified subgroup analysis for patients in labor was planned for the primary outcome. Meta-analysis was performed using the random-effects model expressed as relative risk (RR) or mean difference with 95% confidence intervals (CI). Heterogeneity was assessed using the I2 statistic. Of 1,079 studies screened, five met inclusion criteria (N=1,727 hands-and-knees position and N=1,641 controls). Duration of intervention varied from 10-60 minutes. Participants using hands-and-knees position did not have an increased rate of OA position during second stage of labor or at time of delivery (RR 1.03, 95% CI 0.92-1.14, 4 studies, 3,178 patients) or after initial intervention (RR 1.60, 95% CI 0.88-2.90, 4 studies, 788 patients). No difference was found on subgroup analysis of patients in labor (RR 1.06, 95% CI 0.87-1.29, 3 studies, 631 patients). Regional anesthesia use, duration of labor, rate of operative or cesarean deliveries, risk of perineal laceration, neonatal birth weight, and low Apgar scores did not differ between groups. Hands-and-knees position does not increase the incidence of OA position in labor or at time of delivery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The role of the angle of progression in the prediction of the outcome of occiput posterior position in the second stage of labor

Occiput posterior position is the most frequent cephalic malposition, and its persistence at delivery is associated with a higher risk of maternal and perinatal morbidity. Diagnosis and management of occiput posterior position remain a clinical challenge. This is partly caused by our inability to predict fetuses who will spontaneously rotate into occiput anterior from those who will have persistent occiput posterior position. The angle of progression, measured with transperineal ultrasound, represents a reliable tool for the evaluation of fetal head station during labor. The relationship between the persistence of occiput posterior position and fetal head station in the second stage of labor has not been previously assessed. This study aimed to evaluate the role of fetal head station, as measured by the angle of progression, in the prediction of persistent occiput posterior position and the mode of delivery in the second stage of labor. We recruited a nonconsecutive series of women with posterior occiput position diagnosed by transabdominal ultrasound in the second stage of labor. For each woman, a transperineal ultrasound was performed to measure the angle of progression at rest. We compared the angle of progression between women who delivered fetuses in occiput anterior position and those with persistent occiput posterior position at delivery. Receiver operating characteristics curves were performed to evaluate the accuracy of the angle of progression in the prediction of persistent occiput posterior position. Finally, we performed a multivariate logistic regression to determine independent predictors of persistent occiput posterior position. Overall, 63 women were included in the analysis. Among these, 39 women (62%) delivered in occiput anterior position, whereas 24 (38%) delivered in occiput posterior position (persistent occiput posterior position). The angle of progression was significantly narrower in the persistent occiput posterior position group than in women who delivered fetuses in occiput anterior position (118.3°±12.2° vs 127.5°±10.5°; P=.003). The area under the receiver operating characteristics curve was 0.731 (95% confidence interval, 0.594-0.869) with an estimated best cutoff range of 121.5° (sensitivity of 72% and specificity of 67%). On logistic regression analysis, the angle of progression was found to be independently associated with persistence of occiput posterior position (odds ratio, 0.942; 95% confidence interval, 0.889-0.998; P=.04). Finally, women who underwent cesarean delivery had significantly narrower angle of progression than women who had a vaginal delivery (113.5°±8.1 vs 128.0°±10.7; P<.001). The area under the receiver operating characteristics curve for the prediction of cesarean delivery was 0.866 (95% confidence interval, 0.761-0.972). At multivariable logistic regression analysis including the angle of progression, parity, and gestational age at delivery, the angle of progression was found to be the only independent predictor associated with cesarean delivery (odds ratio, 0.849; 95% confidence interval, 0.775-0.0930; P<.001). In fetuses with occiput posterior at the beginning of the second stage of labor, narrower values of the angle of progression are associated with higher rates of persistent occiput posterior position at delivery and a higher risk of cesarean delivery.

Persistent occiput posterior position outcomes following manual rotation: a randomized controlled trial

Persistent occiput posterior position in labor is associated with adverse maternal and perinatal outcomes. Prophylactic manual rotation from the occiput posterior position to the occiput anterior position in the second stage of labor is considered a safe and easy to perform procedure that in observational studies has shown promise as a method for preventing operative deliveries. This study aimed to determine the efficacy of prophylactic manual rotation in the management of occiput posterior position for preventing operative delivery. The hypothesis was that among women who are at least 37 weeks pregnant and whose baby is in the occiput posterior position early in the second stage of labor, manual rotation will reduce the rate of operative delivery compared with the "sham" rotation. A double-blinded, parallel, superiority, multicenter, randomized controlled clinical trial in 4 tertiary hospitals was conducted in Australia. A total of 254 nulliparous and parous women with a term pregnancy and a baby in the occiput posterior position in the second stage of labor were randomly assigned to receive either a prophylactic manual rotation (n=127) or a sham rotation (n=127). The primary outcome was operative delivery (cesarean, forceps, or vacuum delivery). Secondary outcomes were cesarean delivery, combined maternal mortality and serious morbidity, and combined perinatal mortality and serious morbidity. Analysis was by intention to treat. Proportions were compared using chi-square tests adjusted for stratification variables using the Mantel-Haenszel method or the Fisher exact test. Planned subgroup analyses by operator experience and by manual rotation technique (digital or whole-hand rotation) were performed. Operative delivery occurred in 79 of 127 women (62%) assigned to prophylactic manual rotation and 90 of 127 women (71%) assigned to sham rotation (common risk difference, 12; 95% confidence interval,-1.7 to 26; P=.09). Among more experienced operators or investigators, operative delivery occurred in 46 of 74 women (62%) assigned to manual rotation and 52 of 71 women (73%) assigned to a sham rotation (common risk difference, 18; 95% confidence interval,-0.5 to 36; P=.07). Cesarean delivery occurred in 22 of 127 women (17%) in both groups. Instrumental delivery (forceps or vacuum) occurred in 57 of 127 women (45%) assigned to prophylactic manual rotation and 68 of 127 women (54%) assigned to sham rotation (common risk difference, 10; 95% confidence interval,-3.1 to 22; P=.14). There was no significant difference in the combined maternal and perinatal outcomes. Prophylactic manual rotation did not result in a reduction in the rate of operative delivery. Given manual rotation was associated with a nonsignificant reduction in operative delivery, more randomized trials are needed, as our trial might have been underpowered. In addition, further research is required to further explore the potential impact of operator or investigator experience.

Risk factors for obstetric anal sphincter injuries during vaginal delivery: can we reduce the burden?

Background: Third- and fourth-degree perineal tears are associated with significant discomfort and impact on women’s quality of life after labor. We reviewed the literature on risk factors for obstetric anal sphincter injuries (OASIS), focusing on modifiable risk factors for OASIS to help obstetricians prevent them. Methods: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus using key search terms. We selected clinical studies, systematic reviews, and meta-analyses in English investigating antepartum and intrapartum factors associated with OASIS. Three researchers independently selected studies and documented outcomes. Results: We identified forty-two relevant articles for inclusion. Among antepartum factors, primiparity, neonatal birth weight, and ethnicity were associated with a higher risk of OASIS. Instrumental delivery, midline episiotomy, duration of the second stage of labor, persistent occiput posterior position, and labor augmentation were those intrapartum factors reported associated with OASIS. Conclusions: Multiple ante- and intrapartum factors are associated with a higher risk of OASIS. The actual modifiable factor is episiotomy during the second stage of labor. However, literature reporting episiotomy associated with a reduction in OASIS prevalence during instrumental delivery is limited. These results may help obstetricians recognize women at higher risk of developing severe perineal tears and recommend further investigation on the role of episiotomy in an operative delivery.

Unplanned Cesarean Delivery in the Second Stage of Labor Holds Higher Odds of Complications than in the First Stage, while Similar in Primiparas and Multiparas

Background: While endeavors to reduce cesarean delivery (CD) rates are given priority worldwide, it is important to evaluate if these efforts place parturients and neonates at risk. CD performed in the second stage of labor carries higher risks of maternal and fetal complications and is a more challenging surgical procedure than that performed in the first stage or before labor. In a population with a low CD rate, we sought to evaluate the rate of maternal and fetal complications associated with unplanned CD (UCD) performed in the second vs. the first stage of labor, in primiparas and multiparas, as well as the risk factors leading to and the complications associated with UCD in the second stage of labor in this low-CD rate setting. Methods: This was a retrospective, electronic medical record-based study of 7,635 term and preterm singletons born via UCD in the period 2003–2015. Maternal and neonatal background and outcome parameters were compared between groups. Logistic regression modeling was applied to adjust for clinically and statistically significant risk factors. Results: UCD was more likely to be performed in the second stage of labor in mothers delivering larger fetuses (head circumference and body weight ≥90 centile) and those with persistent occiput posterior (POP) presentation. UCD in the second stage was strongly associated with serious maternal complications (excessive hemorrhage and fever) compared to UCD performed in the first stage, in both primiparas and multiparas. Conclusions: UCD performed in the second stage of labor, while less frequent than first-stage UCD, is more likely with larger neonates and POP presentation, and is associated with a higher rate of maternal complications in primiparas and multiparas. Complication rates in our low-CD-rate population did not exceed those reported in the literature from high-CD-rate areas.

Intrapartum Care

Intrapartum care encompasses the treatment of pregnancy during labor and delivery. Knowledge of the normal labor process is essential to effectively recognize and treat abnormalities, and thus optimize maternal and fetal health. This review aims to outline the physiology of labor and discuss contemporary features of spontaneous labor, prolonged labor, and arrest of labor. It addresses management of group B streptoccocous colonization and electronic fetal monitoring practices. Additionally, issues associated with term labor such as prelabor rupture of membranes, abruption, intrapartum intraamniotic infection, and persistent occiput posterior position are discussed. The review concludes with a brief overview of delivery methods. This review contains 7 figures, 14 tables, and 49 references. Keywords: term labor, intrapartum monitoring, induction of labor, Group B Streptococcous prophylaxis, prelabor rupture of membranes, intraamniotic infection, mode of delivery

Successful management of a supralevator intraperitoneal puerperal hematoma with angiographic embolization

Puerperal hematomas are rare, yet often life threatening, complications following vaginal deliveries. The etiology remains broad; however, early recognition is vital in preventing postpartum hemorrhage and maternal death. Our case illustrates treatment of a supralevator hematoma with angiographic embolization following a spontaneous vaginal delivery in a young woman. Her labor course was complicated by persistent occiput posterior presentation that failed spontaneous and manual rotation.

Persistent occiput posterior position and stress distribution in levator ani muscle during vaginal delivery computed by a finite element model

Introduction and hypothesisObjective of this study was to develop an MRI-based finite element model and simulate a childbirth considering the fetal head position in a persistent occiput posterior position.MethodsThe model involves the pelvis, fetal head and soft tissues including the levator ani and obturator muscles simulated by the hyperelastic nonlinear Ogden material model. The uniaxial test was measured using pig samples of the levator to determine the material constants. Vaginal deliveries considering two positions of the fetal head were simulated: persistent occiput posterior position and uncomplicated occiput anterior position. The von Mises stress distribution was analyzed.ResultsThe material constants of the hyperelastic Ogden model were measured for the samples of pig levator ani. The mean values of Ogden parameters were calculated as: μ1 = 8.2 ± 8.9 GPa; μ2 = 21.6 ± 17.3 GPa; α1 = 0.1803 ± 0.1299; α2 = 15.112 ± 3.1704. The results show the significant increase of the von Mises stress in the levator muscle for the case of a persistent occiput posterior position. For the optimal head position, the maximum stress was found in the anteromedial levator portion at station +8 (mean: 44.53 MPa). For the persistent occiput posterior position, the maximum was detected in the distal posteromedial levator portion at station +6 (mean: 120.28 MPa).ConclusionsThe fetal head position during vaginal delivery significantly affects the stress distribution in the levator muscle. Considering the persistent occiput posterior position, the stress increases evenly 3.6 times compared with the optimal head position.