Instrumental Delivery Rate Research Articles

Comparitive study of 0.1% ropivacaine with fentanyl versus 0.125% bupivacaine with fentanyl in epidural labour analgesia

Background: Analgesic adequacy during labor along with the avoidance of adverse effects is vital for obstetric conditions. Painful labor can have negative impacts on maternal and fetal physiology. Aim: The aim of the study was to compare the efficacy of ropivacaine with fentanyl and bupivacaine with fentanyl in epidural labour analgesia. Methodology: Seventy ASA I&II parturients with singleton pregnancies who presented in active labour with cervical dilatation of 3-5cm were studied in a prospective, randomized control manner. Patients were randomized into Group A (ropivacaine)-35 patients and Group B (bupivacaine) - 35 patients. Epidural analgesia was performed and various parameters (heart rate, blood pressure, respiratory rate, oxygen saturation, pain score) and complications if any were recorded every 15 minutes in the 1st hour, every 30 minutes in the 2nd hour and every hour later on. Results: The fluctuations in pain were not clinically or statistically significant between the two study groups. The number of patients who required bolus were 7(20%) in both the groups. The spontaneous deliveries were more, 62.9% in Group-A as compared to 54.3% in Group-B. The instrumental delivery rates were less, 25.7% in Group-A as compared to 37.1% in Group-B.

Effect of Epidural Bolus Levobupivacaine and Lignocaine in Late Second Stage of Parturition in Combined Spinal Epidural Labor Analgesia

Background: Use of minimum local analgesic concentration in the epidural component of combined spinal epidural (CSE) effectively maintains analgesia in the first stage of labor. However, local anesthetic concentration needs to increase to achieve effective analgesia in the second stage as there are more recruitment of A-δ fiber occurs. This study compared the effect of epidural bolus of Levobupivacaine and Lignocaine in the late second stage of parturition in combined spinal epidural labor analgesia.Methods: This multicenterd, open-label, randomized controlled trial was conducted under supervision of Department of Anesthesia, Analgesia, and Intensive Care Medicine of Bangabandhu Sheikh Mujib Medical University from July 2019 to June 2020 including 80 parturients of 18-35 years old, ASA status I and II, full-term, primiparous, who were randomized into two groups to receive either 10ml bolus of 0.0625% levobupivacaine with fentanyl 2μg/ml or 10ml bolus of 0.5% lignocaine with fentanyl 2μg/ml after CSE analgesia at first stage of labor. Level of analgesia, duration of second stage of labor, quality of pain relief, maternal satisfaction, mode of delivery and APGAR score of neonate were evaluated.Results: During delivery, levobupivacaine group had a lower intensity of pain compared to lignocaine group (VAS score 1.89±0.67 vs 2.64±0.92, p = 0.001). Duration of second stage of labor in levobupivacaine group was significantly shorter compared to lignocaine group (48.4±16 minutes vs 63.5±28.4, p-value 0.007). Besides, quality of pain relief and maternal satisfaction were better in levobupivacaine group compared to lignocaine group. Moreover, instrumental delivery rate was high in lignocaine group. Fetal outcome measured as APGAR score was similar in both groups.Conclusion: Epidural bolus of levobupivacaine-fentanyl produces more adequate analgesia than lignocaine-fentanyl in late second stage of labor and does not increase instrumental delivery rate with similar fetal outcome.

Chorioamnionitis and its association with neonatal and maternal adverse outcomes in women with and without epidural analgesia administration

ObjectiveTo evaluate neonatal fever and adverse maternal and neonatal outcomes in febrile laboring women and assess whether the time interval between epidural analgesia (EA) administration and chorioamnionitis is associated with these complications. MethodsA retrospective cohort study at a university affiliated medical center between 2003 and 2015. Included were women who underwent term vaginal delivery attempt and diagnosed with chorioamnionitis. The primary outcomes compared between febrile women with and without EA were neonatal fever and adverse neonatal and maternal outcomes. The association between time from EA to fever (<6, 6–12, >12 h) and maternal and neonatal complications was also assessed. ResultsDuring the study period, 1,933 women with chorioamnionitis were assessed. Of them, 1,810 (93.6%) received EA prior to fever and 123 (6.4%) febrile parturients did not receive EA. Neonatal fever and other neonatal adverse outcomes were similar in the EA vs. non-EA group (2.2% vs. 0.8% and 2.7% vs. 4.9% (NS)), except for transient tachypnea of the newborn rates which were lower in the EA group (1.4% vs. 4.1%, p = 0.043). Maternal complications were similar, besides for higher rates of instrumental deliveries found in the EA group (24.0% vs. 5.7%, p < 0.001). Time between EA and fever onset was not associated with neonatal complications in logistic regression analysis. ConclusionNeonatal and maternal outcomes are similar in febrile laboring women with and without EA. The time interval between EA and onset of fever is not associated with increased rates of neonatal fever or adverse outcomes and should not affect the management of labor.

Impact of suspected late-onset fetal growth restriction on obstetrical interventions and perinatal outcomes at term; a retrospective cohort study

ObjectivesFirst, assess accuracy of late third trimester universal fetal growth screening in high risk nulliparous women with a singleton in vertex presentation at term. Second, assess instrumental delivery rates and perinatal outcomes in this population. Study designSingle centre retrospective cohort study in a teaching hospital, The Netherlands. ResultsIn a cohort of 1902 pregnancies, growth ultrasound after 33 weeks was moderately accurate in detecting children with a birthweight below the 10th centile with a sensitivity of 46.2% and a false positive rate of 4.7%. Induction of labour followed an antenatal suspicion of FGR more often than in the group with normal expected fetal weight (73.4% vs 52.6% OR 2.49 (1.88–3.3)) as could be expected from application of guidelines. The caesarean section rates was lowest in the group with suspected FGR compared to the group with expected normal fetal weight (15.2% vs 22.1% OR 0.63 (0.45–0.9)). There were no differences between both groups in rates of composite severe adverse perinatal outcome (0.7% vs 0.8% OR 0.87 (0.2–3.93)). ConclusionsThe detection of growth restriction using universal screening in term high risk nulliparous women with a singleton in vertex position is moderate. Despite this, caesarean section rates were not increased and perinatal outcomes were similar when compared to that found in the randomized controlled trial on which the recommendation for induction of labour for suspected term FGR is based. This supports universal late third trimester fetal growth screening in pregnancies under consultant-led care in the two tiers Dutch obstetrical system.

The Effect of Epidural Analgesia on the Maternal and Fetal Outcomes in Mothers Undergoing Induction of Labour.

Elective labour induction is associated with more pain, intrapartum interventions, cesarean deliveries, as compared with spontaneous labour, necessitating the use of labour analgesia. Epidural analgesia is one popular method for control of pain. This study was to determine the effect of epidural analgesia on the maternal and fetal outcomes in women undergoing induction of labour, as adequate data in this specific population is relatively sparse. This was a cross-sectional study conducted over a period of 18months which included mothers with singleton term gestation with cephalic presentation admitted for induction of labour. A sample of 238 mothers were included in the study. Among the study population, 52.7% opted for epidural analgesia. The pain score was less than 3/10 (VAS) in 81% of mothers who opted for epidural analgesia. The cesarean section rate was 20.5% and 34.3% in the epidural and non-epidural groups, respectively. After adjusting the confounding factors, there was a positive effect noted in the caesarean section rate among the epidural group, which was lesser than the non-epidural group. However, a higher instrumental delivery rate (18.8% vs. 10.5%, p-value < 0.05) was noted in the epidural group. There was no significant difference in the duration of labour and fetal outcome in the two groups. Epidural analgesia providing good pain relief in the majority of the mothers was reinforced. In our study, epidural analgesia was associated with a reduction of caesarean section rate after adjusting the confounding factor. Epidural analgesia did not affect the duration of labour, cesarean section rate and fetal outcome independently, however, it was associated with increased risk of instrumental delivery. The outcomes mainly depend on the confounding factors. Therefore, mothers can be provided with an evidence-based information regarding the effect of epidural analgesia in induced labour and help those seeking epidural analgesia to make an informed choice. The online version contains supplementary material available at 10.1007/s13224-022-01622-1.

Association between Endometriosis and Delivery Outcomes: A Systematic Review and Meta-Analysis.

Endometriosis is a common benign gynecological disorder; however, delivery outcomes concerning pregnancies with endometriosis remain understudied. This study aimed to assess the effect of endometriosis on delivery outcomes, including the rate of instrumental delivery, cesarean delivery (CD), postpartum hemorrhage (PPH), and perioperative complications during CD. A systematic literature review was conducted using multiple computerized databases, and 28 studies met the inclusion criteria. Pooled analysis showed that histologically diagnosed endometriosis was associated with an increased rate of instrumental delivery (odds ratio [OR] 1.26, 95% confidence interval [CI] 1.02–1.56) and an increased risk of CD (adjusted OR 2.59, 95%CI 1.32–5.07). In our analysis, histologically diagnosed endometriosis was not associated with an increased rate of PPH; however, one retrospective study reported that endometriosis increased the rate of PPH during CD (adjusted OR 1.7, 95%CI 1.5–2.0). Two studies examined perioperative complications during CD, and women with deep endometriosis had a higher rate of bowel resection or bladder injury than those without endometriosis. Our findings suggest that endometriosis is a significant risk factor for instrumental delivery and CD and may be associated with a higher rate of PPH and intraoperative complications during CD.

Association of high Body Mass Index and postdates pregnancy.

Background and Objective:Obesity with its growing prevalence is a major public health problem influencing gestational age at delivery. Raised Body Mass Index (BMI) has been shown to be associated with significantly increased risk of prolonged pregnancy; which is an important contributor to perinatal morbidity and mortality. Obesity needs modified antenatal, intrapartum and postpartum care by obstetrician. Limited data is found regarding association of obesity with prolonged pregnancy and the same fact led us to search for this association.Methods:This cohort study was carried out in Gynecology and Obstetrics department, MTI Lady Reading Hospital Peshawar from March 2020 to April 2021. Patients were enrolled in third trimester at 37 weeks of gestation with primary exposures of interest being either self-reported pre-pregnancy weight or obtained from first trimester antenatal record. Patients were divided into two classes based on BMI i.e., one with BMI <25 and other with BMI ≥ 25. Patients in both classes were followed till their delivery to determine outcome of gestational age at delivery.Results:Statistically significant difference between the two groups was seen at lower age range of 18-21 years(p-0.04) and higher age range of 39-42 years (p-0.0001). Statistically significant association was found between high pre pregnancy BMI and postdates pregnancy (OR: 4.93 ;95% CI: 1.98-12.26, p-0.001). Association of induction of labor with high pre pregnancy BMI was not significant. (OR 0.56, 95% CI: 0.21-1.48, P < 0.001). Higher rates of Instrumental deliveries(p-0.0005) and cesarean sections (p-0.0001) were seen in higher BMI group.Conclusion:Higher pre-pregnancy BMI is associated with increased risk of postdates pregnancy.

A Comparison Between Dexmedetomidine and Clonidine as Adjuvants to Levobupivacaine in Labour Analgesia.

BackgroundThe epidural analgesia technique is effective for labor analgesia and combinations of various local anesthetics with lipophilic opioids like fentanyl are used. However, fentanyl can cause an increased incidence of pruritus, urinary retention, nausea, vomiting, giddiness, shivering, and respiratory depression. Dexmedetomidine and clonidine are selective alpha 2 agonists with analgesic properties and have been used via the neuraxial route with local anesthetics for the same without the side effects of fentanyl. Thus, the primary objective was to assess and compare the analgesic efficacy of the two-drug combinations by the visual analog scale (VAS) score.MethodsFifty-four primigravida women were randomly allocated in two groups of 27 each and were given an initial bolus of 10 mL of 0.125% levobupivacaine with dexmedetomidine 0.5 ug/kg in Group A and with clonidine 1 μg/kg in Group B. Subsequently, each patient received a background infusion rate of 10 mL/h, a bolus dose of 5 ml, and a lock-out interval of 10 min via a patient-controlled-analgesia (PCA) pump. The blood pressure, heart rate, and severity of pain using VAS were assessed. Durations of the stages of labor, rate of instrumental delivery, and cesarean section, side effects, maternal sedation, and neonatal Apgar scores were also recorded.ResultsVAS scores in both the groups progressively decreased to <3 by 15 min with significant differences at five, 10, 15, and 120 min being lower in group A. Onset of analgesia and time for maximum analgesia was significantly shorter in group A. There was a significant decrease in hemodynamic parameters from baseline in both groups. The fall in heart rate was significantly greater in Group A and at almost all the time intervals after baseline, diastolic blood pressure (DBP) was also lower in group A. Maternal motor blockade scores, the intensity of maternal sedation, the incidence of maternal complications, the duration of the first and second stage of labor, the rate of instrumental delivery and cesarean section, total analgesic dose and PCA bolus requirement, and neonatal Apgar scores did not show a significant difference between the two groups.ConclusionBoth dexmedetomidine and clonidine provide hemodynamically stable labor with a fall in heart rate and maternal blood pressure in the initial hours. Dexmedetomidine has the advantage of faster onset of analgesia and time for maximum analgesia.

Reduced Growth in Non-Small for Gestational Age Fetuses from 35 Weeks of Gestation to Birth and Perinatal Outcomes

Objective: This study aimed to assess reduced fetal growth between 35 weeks of gestation and birth in non-small for gestational age fetuses associated with adverse perinatal outcomes (APOs). Material and Method: It is a retrospective cohort study of 9,164 non-small for gestational age fetuses estimated by ultrasound at 35 weeks. The difference between the birth weight percentile and the estimated percentile weight (EPW) at 35 weeks of gestation was calculated, and we studied the relationship of this difference with the appearance of APO. APOs were defined as cesarean or instrumental delivery rates for nonreassuring fetal status, 5-min Apgar score <7, arterial cord blood pH <7.10, and stillbirth. Fetuses that exhibited a percentile decrease between both moments were classified into 6 categories according to the amount of percentile decrease (0.01–10.0, 10.01–20.0, 20.01–30.0, 30.01–40.0, 40.01–50.0, and >50.0 percentiles). It was evaluated whether the appearance of APO was related to the amount of this percentile decrease. Relative risk (RR) was calculated in these subgroups to predict APOs in general and for each APO in particular. Receiver operating characteristic and area under curves (AUC) for the difference in the percentile was calculated, used as a continuous parameter in the entire study population. Results: The median gestational age at delivery in uncomplicated pregnancies was 40.0 (39.1–40.7) and in pregnancies with APOs 40.3 (49.4–41.0), p < 0.001. The prevalence of APOs was greater in the group of fetuses with a decrease in percentile (7.6%) compared to those with increased percentile (4.8%) (p < 0.001). The RR was 1.63 (95% CI: 1.365–1.944, p < 0.001). Although the differences were significant in all decreased percentile groups, RRs were significantly higher when decreased growth values were >40 points (RR: 2.036, 95% CI: 1.581–2.623, p < 0.001). The estimated value of the AUC for percentile decrease was 0.58 (0.56–0.61, p < 0.001). Conclusion: Fetuses with a decrease in the EPW between the ultrasound at 35 weeks of gestation and birth have a higher risk of APOs, being double in fetuses with a decrease of >40 percentile points.

The impact of obesity on maternal-fetal prognosis through a comparative study

Abstract Objectives To clarify the impact of obesity on the course of pregnancy and childbirth by specifying maternal and fetal complications. Materials and Methods This is a comparative case-control study, conducted over a period of two months from February 1 to March 31, 2019, which included patients who gave birth in the Farhat Hached Sousse University Hospital and the Maternity and Neonatology Hospital of Monastir. Patients meeting the inclusion criteria were divided into two groups according to body mass index (BMI) at the end of pregnancy: group I: normal weight 18,5≤ BMI &amp;lt;25 and group II BMI greater than or equal to 30. Results Pregnancies of women in Group II were more frequently complicated by gravidic hypertension 8% against 1%, 3% pre-eclampsia against 0% and gestational diabetes 14% against 3%, as well as infections. In obese patients, there were more labor abnormalities with a 17% vs. 3% cesarean section rate and higher instrumental delivery rate 15% vs. 7%. Post-partum follow-up was marked by the occurrence of infectious maternal complications, anemia with breastfeeding difficulties. The newborns of group II women were born with a lower Apgar score and had more neonatal complications such as trauma 6% versus 0% meconium inhalation 6% versus 2% and hypoglycemia 4% versus 0%. Conclusions Obesity is a serious problem in obstetrics, with adverse effects on the health of the mother and her baby throughout pregnancy, childbirth and post-partum. The management of obese or overweight pregnant women must be early and adapted to each case with close obstetrical surveillance. Key messages Obesity is a serious problem in obstetrics, with adverse effects on the health of the mother and baby. The management of obese or overweight pregnant women must be early.

Maternal Hypotension and Tachysystole Following Neuraxial Anesthesia: Effect on Fetus in Labor.

Maternal Hypotension and Tachysystole Following Neuraxial Anesthesia: Effect on Fetus in Labor.

Pain management during labor: use of intermittent drug delivery devices for improvement of obstetric and neonatal outcome and reduction of healthcare burden: A large non-inferiority randomized clinical trial

BackgroundAutomated continuous epidural administration of local anesthetics provides a more stable analgesic block with decreasing of healthcare staff compared to manual boluses administration (TOP-UP) but is associated to high rate of operative vaginal delivery. We hypothesized that the use of programmed intermittent automated boluses (PIEB) is able to provide a good quality of analgesia and decreasing of anesthesiologic workload without increasing the rate of instrumental vaginal birth in comparison with TOP-UP technique. Laboring nulliparous woman aged between 18 and 46 years were randomized to epidural analgesia with 0.0625% levobupivacaine and sufentanil administered by PIEB or by TOP-UP techniques. Primary outcome was instrumental vaginal delivery rate and secondary outcomes were quality of analgesia, total and time-related drugs doses used, motor block, newborn outcome, and anesthesiologic workload.ResultsSix hundred twenty-nine were randomized, and 628 were included in the intention-to-treat analysis. The rate of instrumental vaginal delivery was similar in the PIEB and TOP-UP groups (13.2% vs 9.7%, OR 1.4 95% CI 0.8 to 2.5; p 0.21). There was no difference between groups regarding mode of delivery (cesarean section vs vaginal birth), newborn outcome, and motor block. Patients in the PIEB group received more total and time-related drugs doses and a better quality of analgesia. Anesthesiological workload was significantly reduced in the PIEB group.ConclusionsOur study demonstrated that epidural anesthesia with programmed intermittent epidural boluses by an automated device provides an effective and safe management of labor analgesia with improvement of pain control and sparing of man workload compared to manual top-up protocols.

English

Participants was 35.3 (standard deviation: 7.1) years. The demographics (98%), foetal heart rate (80.5%), temperature, pulse and respiratory (74.5%) and maternal blood pressure (73.2%) section of the partograph were the most charted. The least charted sections were foetal descent (19.5%), cervical dilatation (21.5%) and uterine contractions (24.8%). Use of the partograph was associated with the female gender with a 58% (aOR: 0.42. 95% CI: 0.19-0.91) lower odds compared to male nurses. The findings highlight a persistent gap in the use of the partograph in Kenya despite the recent countrywide BEmONC training. There is a need for enhanced on-job training for nurses and midwives on the use of the partograph but also a need to explore the possibility of using the electronic partograph that are effective in reducing adverse foetal outcomes and improve adherence to labour care and strengthen routine support supervision to review nurses-midwives in the use of the partograph. In low resource setting, the completion rate of partograph is low despite heavy investment in training of healthcare workers on Basic Emergency Obstetric and Neonatal Care (BEmONC), which promotes the use of partographs to monitor the progress of labour. In Kenya, the rate of caesarean section, instrumental delivery and APGAR score less than 7 at 1 min has increased. Therefore, this study determined the extent of use of partograph as a tool for monitoring the progress of the mother and the foetus during labour in selected Western counties in Kenya. This cross-sectional study was conducted in Kisumu and Vihiga counties in Western Kenya between May and June 2019. Validated self-administered questionnaires and checklists were used to collect data from participants and randomly chosen participant-filled partograph. Sample characteristic and extent of use of partograph were described using frequencies and percentages while factors associated with partograph use were assessed using multivariable logistic regression. Statistical significance was set at p&lt;0.05. Out of 149 participants, 104 (69.8%) were female, 144 (96.6%) were nurses, 52% worked in health centres, 37% had worked for seven or more years and trained on BEmONC within 1 to 2 years. Key words: Partograph, labour, antenatal care, skilled birth attendance, Kenya.

Effect of maternal age on maternal and perinatal outcomes including cesarean delivery following induction of labor in uncomplicated elderly primigravidae.

Age above 35 years at the time of birth is generally referred to as advanced maternal age (AMA), and it could be a risk factor for various complications besides genetic changes in the fetus. The primary outcome of this study was to determine if AMA is associated with emergent cesarean delivery (CD) following induction of labor (IOL). The secondary outcomes were a composite of adverse maternal and perinatal outcomes following IOL.This retrospective observational study included women with singleton, live-born, cephalic, non-anomalous pregnancies undergoing IOL from 38 0/7 to 41 6/7 weeks of gestation. Mode of delivery and other maternal and neonatal outcomes were compared between women aged ≥35 (AMA) and <35 years. Multivariate logistic regression analyses were performed.A total of 307 nulliparous women underwent IOL (≥35 years n = 73, 23.8%; <35 years n = 234, 76.2%) and among them, 252 (82.1%) delivered vaginally. The rate of CD was significantly higher in women of AMA (31.5% vs 13.7%, P = .001). Multivariable analysis showed that AMA was independently associated with CD (odds ratio 3.04, 95% confidence interval 1.55-5.96, P = .001). The rate of instrumental deliveries was higher in the AMA group (19.6% vs 8.2%, P = .043) and hemoglobin decrease during delivery was similar between the 2 groups (1.90 ± 1.25 vs 2.02 ± 1.27 mg/dL, all P > .05). Regarding neonatal outcomes, there was no difference between the 2 groups in the neonatal intensive care unit admission rate and Apgar score <7 at 5 minutes (30.3% vs 30.1% and 6.0% vs 8.2%, respectively, all P > .05). Neonatal intubation rate and severe respiratory problems were non-significantly higher in AMA (3.8% vs 2.7% and 3.4% vs 1.4%, respectively, all P > .05).AMA was associated with an approximately three-fold increased likelihood of birth by CD and operative vaginal delivery in uncomplicated nulliparous women following IOL. However, we found no evidence that IOL in primigravid women of AMA increases adverse maternal and perinatal outcomes as compared with women aged <35 years except the high prevalence of CD and operative vaginal delivery.

Inequalities in maternal health and pregnancy outcome among Nigerian women migrated to Italy.

Among migrant women, unfavourable health conditions and adverse obstetric events are observed more often than in native-born parturients. This observational retrospective study evaluated selected pregnancy outcomes in a Nigerian population giving birth at the University Hospital of Verona. Compared to national controls, being Nigerian was associated with preterm birth (aOR 1.6, 95% CI 1.1-2.2) and Cesarean section (aOR 2.2, 95% CI 1.5-2.7). No differences were found in rates of instrumental delivery and the immigrant group had half the risk of genital tears (aOR 0.6, 95% CI 1.1-2.2) with a higher likelihood of undamaged genitals (aOR 1.5, 95% CI 1.3-2.1). Perinatal indicators of neonatal distress were increased among Nigerians, namely a low Apgar score (aOR 2.6, 95% CI 1.4-4.9), NICU admission (aOR 1.7, 95% CI 1.1-2.8), and stillbirth (aOR 4.0, 95% CI 1.3-12.8). In conclusion, sub-Saharan African women of Nigerian origin appeared more vulnerable and exposed to several adverse pregnancy outcomes. These disparities call for the improvement of obstetric care in this immigrant group.

Caesarean sections in the second stage of labour – a risk evaluation

Objective: To retrospectively analyse the relative rate of complications of caesarean sections performed in the second stage, in comparison to those done in the first stage of labour, in singleton uncomplicated pregnancies. A secondary objective was to see whether a conscious attempt had been made for an instrumental delivery where it seemed feasible to avert a caesarean in the second stage of labour. Method: A retrospective cohort study of 2440 caesarean sections out of a total of 5349 procedures done in 2019 and 2020, at ward 10, at a shocking rate reaching 49% and 60% (university, health ministry units) at the Teaching Hospital, Peradeniya. The instrumental delivery rate was a mere 1.63% in 2020. There were only 1220 caesareans performed in the second stage of labour. Hence, only a similar number (1220) of cases were selected from first stage procedures for the purpose of comparison of complications. Results: Requirement of blood transfusions; intraoperative or within 24 hours of delivery were 6 against 36 instances for first and second stage respectively. There were 16 recorded instances of extensions of angles or tears, and 3 cases of broad ligament haematomas in the second stage procedures. There was one instance of even a vaginal tear dislodging a jammed fetal head following failed forceps. Only 3 records of angle extensions were recorded when attempting to deliver high floating heads during the first stage. Uterine scar dehiscence was found in 36 instances in second stage procedures against 12 in the first but this was not a result of the procedure but the longer duration of labour in the former situation. There were two recorded instances of bladder injury in the first stage against 7 in the second. The mean duration of hospital stay was markedly different at 2.2 and 4.6 days. 6 against 17 patients ended in the high dependency unit or the ICU due to procedure-related complications. There were no mortalities. The mean operating times from the sample drawn from operating theatre records (300 of each stage) drawn was 28.6 min against 46.5 min. Failed forceps and ventouse were recorded in only 2 instances. Conclusions: Second stage caesareans seemed more technically difficult as judged by the longer time taken and were more likely to be complicated and result in a longer hospital stay and a higher risk of admission to Intensive care. We cannot conclude that they were any safer than AVD, as a comparison with complications of AVD were not audited in this study. Better training in instrumental delivery may improve an unacceptable situation where half the women (49%) had caesarean deliveries in 2019. Failed trial of instrumental delivery and any resultant injury should not result in automatic reprimand of the operator as this leads to performing caesareans as defensive medicine. Senior-most obstetricians on site must be called in for second stage caesareans with higher morbidity. This is more so when a trial of AVD has failed.

Epidural Analgesia for Labour: Comparing the Effects of Continuous Epidural Infusion (CEI) and Programmed Intermittent Epidural Bolus (PIEB) on Obstetric Outcomes.

In the last few years there is a trend of transiting from the continuous epidural infusion (CEI) method for epidural analgesia to a new method - programmed intermittent epidural analgesia (PIEB). This change improves the quality of epidural analgesia, thanks to an increased spread of the anaesthetic in the epidural space and higher maternal satisfaction. Nevertheless, we must make sure that such change of method does not lead to worse obstetric and neonatal outcomes. This is a retrospective observational case control study. We compared several obstetrical outcomes between the CEI and PIEB groups, such as the rates of instrumental delivery, rates of caesarean section, duration of first and second stages of labour well as APGAR scores. We further segmented the subjects and examined them in groups of nulliparous and multiparous parturients. 2696 parturients were included in this study: 1387 (51.4%) parturients in the CEI group and 1309 (48.6%) parturients in the PIEB group. No significant difference was found in instrumental or caesarean section delivery rates between groups. This result held even when the groups were differentiated between nulliparous and multiparous. No differences were revealed regarding first and second stage duration or APGAR scores. Our study demonstrates transition from the CEI to the PIEB method does not lead to any statistically significant effects on either obstetric or neonatal outcomes.

Cervical Dilation at the Time of Epidural Catheter Insertion Is Not Associated With the Degree of Prolongation of the First or Second Stages of Labor, or the Rate of Instrumental Vaginal Delivery

(Acta Obstet Gynecol Scand. 2020;99:1039–1049) Although epidural analgesia (EA) is used in over 60% of deliveries in Western countries with high patient satisfaction, it has been associated with risk of prolonged second stage of labor and instrumental vaginal delivery. The optimal time to administer EA based on cervical dilation is unknown, and whether the timing of its administration affects the duration of the first and second stages of labor or maternal or fetal outcomes. The aim of this study was to determine if the cervical dilation at the time of epidural placement impacts the duration of the first and/or second stage of labor and correlates with the rate of instrumental vaginal delivery.

Metabolomic Biomarkers in Gestational Diabetes Mellitus: A Review of the Evidence.

Gestational diabetes mellitus (GDM) is the fastest growing type of diabetes, affecting between 2 to 38% of pregnancies worldwide, varying considerably depending on diagnostic criteria used and sample population studied. Adverse obstetric outcomes include an increased risk of macrosomia, and higher rates of stillbirth, instrumental delivery, and birth trauma. Metabolomics, which is a platform used to analyse and characterise a large number of metabolites, is increasingly used to explore the pathophysiology of cardiometabolic conditions such as GDM. This review aims to summarise metabolomics studies in GDM (from inception to January 2021) in order to highlight prospective biomarkers for diagnosis, and to better understand the dysfunctional metabolic pathways underlying the condition. We found that the most commonly deranged pathways in GDM include amino acids (glutathione, alanine, valine, and serine), carbohydrates (2-hydroxybutyrate and 1,5-anhydroglucitol), and lipids (phosphatidylcholines and lysophosphatidylcholines). We also highlight the possibility of using certain metabolites as predictive markers for developing GDM, with the use of highly stratified modelling techniques. Limitations for metabolomic research are evaluated, and future directions for the field are suggested to aid in the integration of these findings into clinical practice.

A STUDY OF VAGINAL MISOPROSTOL TABLET VERSUS INTRACERVICAL DINOPROSTONE FOR INDUCTION OF LABOUR

Background:Induction of labour is the process of initiating the labour by articial means post 24 weeks of gestation. This study was undertaken to compare the efcacy and safety of vaginal Misoprostol [25-50ug] with intracervical Dinoprostone gel (0.5mg) for induction of labour at term in terms of efcacy of drug, feto-maternal outcome, side effects and complications of drugs. Methods: 400 nulliparas at term admitted in the OBG ward were included in this study. They were randomly allocated to two groups A&amp; B. Group A (200 women) received tablet Misoprostol 25 micrograms vaginally 4 hrly to a maximum of 3 doses and Group B (200 women) received Dinoprostone gel 0.5mg intracervically 6 hrly to a maximum of 3 doses. Comparison was done in terms of induction to delivery interval, rates of instrumental and LSCS delivery, need for NICU care and cost-effectiveness. ADRs, if any were documented and proper care taken. Results: The mean induction to delivery interval was less in the Misoprostol group than Dinoprostone group (12 hrs vs. 22 hrs). 82% patients delivered in the rst 24 hrs in Misoprostol group compared to 54 % patients in Dinoprostone group. Group A had a higher success rate (80% vs.75%) and also required less augmentation of labor ( 35% vs. 65%) compared to group B. Need for LSCS was also lower in Misoprostol group (13% vs. 18%). Need for instrumentation and incidence of NICU admission was similar in both groups. Misoprostol was more cost effective compared to Dinoprostone. Conclusions: The Misoprostol group had a shorter induction to delivery interval, more number of deliveries in the rst 24 hrs of induction and a reduced need of augmentation of labor with oxytocin. There was no signicant difference in the rate of caesarean section, hyper-stimulation syndrome, neonatal and maternal morbidity between the two groups. Thus, Misoprostol appears to be safer, cheaper and more efcacious alternative for induction of labor especially for non-fetal indications as compared to Dinoprostone gel.