Operative Delivery Rates Research Articles

Peripartum disease activity in moderately and severely disabled women with multiple sclerosis.

BackgroundThe effects of pregnancy on multiple sclerosis (MS) inflammatory activity are not well described in women with moderate to severe disabilities.ObjectiveTo quantify the peripartum annualized relapse rate (ARR) in women with MS with an Expanded Disability Status Scale (EDSS) ≥ 3.MethodsWe performed a retrospective cohort study of 85 pregnancies in 74 subjects with preconception EDSS ≥ 3. We quantified peripartum ARR and tested for risk factors predictive of peripartum relapses, postpartum brain magnetic resonance imaging activity (new T2 or gadolinium-enhancing lesions), and disability worsening.ResultsThere were 74 live births, with a 56% operative delivery rate. In subjects with relapsing-remitting MS, ARR decreased to 0.11 during the third trimester of pregnancy compared to 0.59 in the year preconception and increased to 1.22 in the 3 months postpartum. Women with a higher preconception EDSS had higher odds of postpartum relapses and clinically significant worsening of disability as compared to subjects with a lower EDSS.ConclusionsModerately to severely disabled women with MS have a lower risk of relapse during pregnancy as compared to preconception, followed by a marked increase postpartum. Further studies are needed to identify ways to reduce peripartum inflammatory activity and disability progression in women with MS with moderate to severe disability.

A step towards better audit: The Robson Ten Group classification system for outcomes other than cesarean section.

The Robson Ten Group Classification System is widely used for the audit of cesarean section (CS) rates. However, CS rate alone is a poor quality indicator and should be balanced with other obstetric endpoints. The aim of this study was to evaluate whether Swedish national data on obstetric outcomes other than CS, stratified by the Robson classification, could be analyzed in a useful way. All births in Sweden from 2017 through 2020 recorded in the nationwide Swedish Pregnancy Register were categorized using the Robson classification with subdivision of some groups. Five outcomes were explored: CS, operative vaginal delivery, postpartum hemorrhage, obstetric anal sphincter injury (OASIS) and Apgar score<7 at 5 minuteutes. Rates of each outcome and contribution of each group to the total outcome rate were calculated. The largest Robson groups were nulliparous and multiparous women with single-term cephalic pregnancies, unscarred uterus and spontaneous labor. Intrapartum CS rates were highest for multiple pregnancies, women with induced labor after previous CS, and nulliparous women with induced labor. Nulliparous women and multiparous women with a previous CS with attempted vaginal birth had the highest operative vaginal delivery and OASIS rates. The postpartum hemorrhage rate was highest for multiple pregnancies and transverse lie, followed by prelabor CS in nulliparous and multiparous women with single-term cephalic pregnancies and unscarred uterus. The highest rates of Apgar score<7 at 5 minute were observed in preterm deliveries, multiple pregnancies, transverse lie and breech presentation. The largest contribution to the total CS rate was made by women with previous CS delivered by prelabor CS, and nulliparous women with induced or spontaneous labor. The largest contribution to all other outcomes was made by nulliparous women with spontaneous or induced labor and, notably, multiparous women with spontaneous labor and unscarred uterus. The Robson classification provides a useful framework for analyzing CS rates alongwith rates of operative vaginal delivery, OASIS, postpartum hemorrhage and low Apgar score. Parallel interpretation of several outcomes allows a systematic and multidimensional audit, helpful for families and healthcare professionals, and can be used for comparisons, assessment of trends and subpopulations.

Implementation of a revised classification for intrapartum fetal heart rate monitoring and association to birth outcome: Anational cohort study.

A revised intrapartum cardiotocography (CTG) classification was introduced in Sweden in 2017. The aims of the revision were to adapt to the international guideline published in 2015 and to adjust the classification of CTG patterns to current evidence regarding intrapartum fetal physiology. This study aimed to investigate adverse neonatal outcomes before and after implementation of the revised CTG classification. A before-and-after design was used. Cohort I (n=160210) included births from June 1, 2014 through May 31, 2016 using the former CTG classification, and cohort II (n=166558) included births from June 1, 2018 through May 31, 2020 with the revised classification. Data were collected from the Swedish Pregnancy and Neonatal Registers. The primary outcome was moderate to severe neonatal hypoxic ischemic encephalopathy (HIE 2-3). Secondary outcomes were birth acidemia (umbilical artery pH <7.05 and base excess < -12mmol/L or pH <7.00), A-criteria for neonatal hypothermia treatment, 5-min Apgar scores <4 and <7, neonatal seizures, meconium aspiration, neonatal mortality and delivery mode. Logistic regression was used (period II vs period I), and results are presented as adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs). There were no statistically significant differences in HIE 2-3 (aOR 1.27; 95% CI 0.97-1.66), proportion of neonates meeting A-criteria for hypothermia treatment (aOR 0.96; 95% CI 0.89-1.04) or neonatal mortality (aOR 0.68; 95% CI 0.39-1.18) between the cohorts. Birth acidemia (aOR 1.36; 95% CI 1.25-1.48), 5-min Apgar scores <7 (aOR 1.27; 95% CI 1.18-1.36) and <4 (aOR 1.40; 95% CI 1.17-1.66) occurred more often in cohort II. The absolute risk difference for HIE 2-3 was 0.02% (95% CI 0.00-0.04). Operative delivery (vacuum or cesarean) rates were lower in cohort II (aOR 0.82; 95% CI 0.80-0.85 and aOR 0.94; 95% CI 0.91-0.97, respectively). Although not statistically significant, a small increase in the incidence of HIE 2-3 after implementation of the revised CTG classification cannot be excluded. Operative deliveries were fewer but incidences of acidemia and low Apgar scores were higher in the latter cohort. This warrants further in-depth analyses before a full re-evaluation of the revised classification can be made.

Operative vaginal delivery: practice patterns and outcomes at a tertiary general hospital.

There has been a global decrease in operative vaginal deliveries, with a marked shift towards the vacuum extractor. However, little is known about the trends in operative vaginal delivery in Singapore. A retrospective study was conducted on all operative vaginal deliveries performed from 2012 to 2017 at Singapore General Hospital (SGH). Maternal outcomes in terms of postpartum haemorrhage and obstetric anal sphincter injuries were compared between forceps- and vacuum-assisted deliveries. Neonatal outcomes in terms of neonatal intensive care unit (NICU) admission and clinically significant neonatal events were compared. The instrument preference of obstetricians was analysed. A total of 906 consecutive operative vaginal deliveries were included in the study, comprising 461 forceps- and 445 vacuum-assisted deliveries. The rate of operative vaginal delivery was maintained at approximately 10% from 2012 to 2017. Neonatal cephalohematomas were more common after vacuum-assisted deliveries. Other maternal and neonatal outcomes did not differ significantly between the two groups. Clinically significant neonatal events were mostly due to shoulder dystocia, whereas all cases of NICU admissions were not directly related to the mode of delivery. Obstetricians' choice of instrument appeared to reflect personal preference and was not affected by the year of graduation. The rates of neonatal and maternal morbidity were low at SGH. Overall instrument use of forceps and vacuum was balanced, and proficiency in both was demonstrated by all operators. Operative vaginal delivery remains an essential skill in facilitating safe vaginal delivery, which should be maintained to keep Caesarean section rates in check.

Vacuum assisted delivery outcomes. Does advanced maternal age matter?

This study evaluated whether advanced maternal age during vacuum-assisted delivery (VAD) leads to a higher rate of adverse maternal and neonatal outcomes. This retrospective cohort study included all nulliparous women who underwent a singleton, VAD in our institution, from 2014 through 2019. The women were grouped according to maternal age ≥ 35 in the study group and < 35 in the control group. Power analysis calculation determined that a sample size of at least 225 women in each group was sufficient to detect significant differences between groups in the rate of third- and fourth-degree perineal tears and umbilical cord pH < 7.15. primary maternal outcomes were third- and fourth-degree perineal tears. primary neonatal outcomes were umbilical cord pH < 7.15. Secondary outcomes were maternal blood loss, Apgar scores, cup detachment, and subgaleal hematoma. Outcomes were compared between the two groups. During the study period, 13,967 nulliparous women delivered in our institution, including 8,810 (63.1%) spontaneous vaginal deliveries, 2,432 (17.4%) instrumental deliveries and 2,725 (19.5%) cesarean sections. The rate of operative vaginal delivery was higher in the advanced maternal age group. Among the vaginal deliveries, 10,116 (90%) were to women < 35, with 2,067 (20.5%) successful vacuum-assisted delivery VAD, and 1,126 (10%) were to women ≥35 years, with 348 (30.9%) successful VAD. There were no significant differences in the rates of third and fourth-grade perineal lacerations or lower cord pH between the study groups. Although there was no difference in the indications for the procedure between the groups, advanced maternal age was associated with a higher head station during the pre-procedure assessment (p=0.002). Vacuum-assisted delivery is not associated with a higher risk for adverse maternal or neonatal outcomes among women with advanced maternal age.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The impact on obstetric and perinatal outcomes in term infants following the introduction of a colour-coded, hierarchical cardiotocography classification system: A retrospective non-inferiority study.

Queensland introduced a colour-coded cardiotocograph (CTG) classification system (green, blue, yellow and red) to complement the Royal Australian and New Zealand College of Obstetricians and Gynaecologists prose-based classification system of 'low, unlikely, maybe or likely' fetal compromise. The aim of the study was to determine the clinical impact of the introduction of the colour-coded CTG classification system compared to the prose-based system. We hypothesised there would be no change in the rate of operative delivery for intrapartum fetal compromise (OD-IFC). This retrospective non-inferiority study from November 2014 to May 2018 used routinely collected data from the Mater Mother's Hospital. Non-insured women with a singleton, non-anomalous, cephalic fetus at term, attempting a vaginal birth with continuous intrapartum CTG were included. The primary outcome was OD-IFC. Secondary outcomes included various obstetric and perinatal outcomes. Non-inferiority analysis was performed with a pre-specified non-inferiority margin of 2% risk difference. Eleven thousand seven hundred and twenty-seven participants were included. The OD-IFC rate was similar across the study groups (prose-based 15.1% vs colour-coded 15.3%, adjusted odds ratio (aOR) 1.02, 95% CI 0.93-1.13) with the adjusted risk difference of 0.29% (95% CI -0.98 to 1.56), which did not exceed the inferiority margin. There were more spontaneous (aOR 1.11, 95% CI 1.04-1.19) and fewer instrumental (aOR 0.87, 95% CI 0.80-0.95) vaginal births in the colour-coded cohort. There were no differences in neonatal outcomes. Reassuringly, the colour-coded CTG classification system was non-inferior to the prose-based system, did not influence OD-IFC but was associated with more spontaneous vaginal deliveries.

Trends in Operative Delivery in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia: A 5 years' Retrospective Review.

Operative vaginal delivery refers to the use of measures to accomplish vaginal delivery through the use of instruments, mainly obstetric forceps and vacuum cups. In developed countries, the rate of cesarean section is increasing for fear of vaginal delivery complications, including instrumental delivery. This study was done to explore trends of operative vaginal deliveries and their characteristics. A cross-sectional, facility-based retrospective study was conducted over a period of five years July 1, 2011, to June 30, 2016, using data collected from the labor ward logbook, patient charts. Data were coded, entered, using SPSS version 20 statistical software. Descriptive statistical analysis was used to describe and analyze the data into graphs and tables. The rates of operative vaginal delivery and cesarean section over the five-year study period were 11.9% and 30.4%, respectively. The trend in the operative vaginal delivery rate declined from 15.8% in July 2011 to 9.9% in June 2016, while it shows a noticeable rise in cesarean section rate 25.4% to 33.8%. The trend in the use of vacuum has shown a sharp decrease from 58% in the 1st year to 10.5% in the fifth year of the study period. There is a rise in the use of forceps from 42% of all operative vaginal delivery in the first year to 89.5% in the fifth year. This study shows that the rate of operative vaginal delivery has declined. The use of vacuum-assisted delivery has especially decreased compared to that of forceps-assisted delivery.

The history of labour induction: How did we get here?

The mean duration of human pregnancy is 280 days but the range is wide, and "term" has been defined to range from 37 to 42 weeks. In the 18th and 19th centuries, labour induction was used mainly in cases of pelvic deformity, before the foetus grew too large to be delivered. Induction methods were unreliable until the 20th century, when pituitary extract, and then synthetic oxytocin and prostaglandins, became available. "Disproportion" was the leading indication for induction until the 1950s, when it became clear that prolonged pregnancy was associated with increased perinatal mortality. Pregnancy dating was improved by ultrasound, which also showed that foetal growth slows at term. Induction rates rose during the 1970s, causing public concern about obstetric intervention. In the 21st century, large-scale randomised trials showed that perinatal mortality is lowest at 39-40 weeks, and that induction at that time does not increase the rate of operative delivery.

Maternal and neonatal outcomes in prolonged second stage deliveries in nulliparous

Introduction: The prolongation of the second stage of labor in pregnant women, in order to reduce the rate of cesarean sections, constitutes a scientific and clinical dilemma. This controversy is generated because the increase in the prolonged second stage time can increase the maternal and neonatal risks. Objective: To analyze differences in maternal and neonatal outcomes between pregnant women who have a prolonged vs non-prolonged delivery. To study those pregnant women who have prolonged second stage (&gt;180 minutes) and identify differences between them according to mode of delivery (non-operative, operative or cesarean delivery). Material and methods: Prospective cohort study of all nulliparous pregnant women treated at the Hospital Universitario de Fuenlabrada between January 1, 2018 and December 31, 2019. Differences in pregnant women with prolonged versus non-prolonged delivery are analyzed. Those cases in which the prolonged second stage period was equal to or greater than 180 minutes were selected and differences according to the mode of delivery were studied. During the study period, 944 women met the inclusion criteria, of which 445 (47.1%) had prolonged second stage periods equal to or greater than 180 minutes. Results: Prolonged second stage is associated with a higher rate of operative delivery 44.5% vs. 28.1% and a higher rate of cesarean section 6.7% vs. 2% (p: 0.000), a higher rate of shoulder dystocia 3.8% vs. 1.6%, greater weight at birth of the newborn 3279 g vs 3119 g and greater perinatal trauma 13.3 vs 6.6% compared with non-prolonged second stage delivery. By selecting only pregnant women with prolonged delivery, we observed a higher rate of complications of surgical wound in caesarean sections 13.3%, vs 1.5% in operative delivery and 0% in spontaneous vaginal delivery and a higher rate of grade III-IV degree perineal lacerations in deliveries eutocic and instrumental. With respect to the neonate, a greater weight of the newborn is observed in caesarean sections 3445 grams compared to eutocic deliveries 3230 grams and operative delivery 3275 grams (p: 0.001), a higher rate of type III resuscitation in those neonates born by caesarean section 26, 7% vs 4.2% in spontaneous vaginal delivery and 5.6% in operative delivery and a higher rate of admission to the neonatal ICU in caesarean sections 26.7% vs 6.9% spontaneous vaginal delivery and 9.1% operative delivery (p: 0.002) . Conclusion: A higher rate of operative delivery and cesarean sections has been observed in pregnant women with prolonged second stage, as well as a higher rate of shoulder dystocia, newborn weight, and perinatal trauma compared with non-prolonged delivery. When studying the cohort of pregnant women with prolonged second stage, there is a higher rate of cesarean section in pregnant women with a previous suspicion of fetal macrosomia, a higher weight of the newborn at birth, a higher rate of type III neonatal resuscitation and admission of the newborn to the neonatal ICU in pregnant women. that end in caesarean section with respect to spontaneous vaginal delivery or operative delivery.

Transverse position. Using rotation to aid normal birth—OUTcomes following manual rotation (the TURN-OUT trial): a randomized controlled trial

The fetal occiput transverse position in the second stage of labor is associated with adverse maternal and perinatal outcomes. Prophylactic manual rotation in the second stage of labor is considered a safe and easy to perform procedure that has been used to prevent operative deliveries. This study aimed to determine the efficacy of prophylactic manual rotation in the management of the occiput transverse position for preventing operative delivery. We hypothesized that among women who are at ≥37 weeks' gestation with a baby in the occiput transverse position early in the second stage of labor, manual rotation compared with a "sham" rotation will reduce the rate of operative delivery. A double-blinded, parallel, superiority, multicenter, randomized controlled clinical trial in 3 tertiary hospitals was conducted in Australia. The primary outcome was operative (cesarean, forceps, or vacuum) delivery. Secondary outcomes were cesarean delivery, serious maternal morbidity and mortality, and serious perinatal morbidity and mortality. Outcomes were analyzed by intention to treat. Proportions were compared using χ2 tests adjusted for stratification variables using the Mantel-Haenszel method or Fisher exact test. Planned subgroup analyses by operator experience and technique of manual rotation (digital or whole hand rotation) were performed. The planned sample size was 416 participants (trial registration: ACTRN12613000005752). Here, 160 women with a term pregnancy and a baby in the occiput transverse position in the second stage of labor, confirmed by ultrasound, were randomly assigned to receive either a prophylactic manual rotation (n=80) or a sham procedure (n=80), which was less than our original intended sample size. Operative delivery occurred in 41 of 80 women (51%) assigned to prophylactic manual rotation and 40 of 80 women (50%) assigned to a sham rotation (common risk difference, -4.2% [favors sham rotation]; 95% confidence interval, -21 to 13; P=.63). Among more experienced proceduralists, operative delivery occurred in 24 of 47 women (51%) assigned to manual rotation and 29 of 46 women (63%) assigned to a sham rotation (common risk difference, 11%; 95% confidence interval, -11 to 33; P=.33). Cesarean delivery occurred in 6 of 80 women (7.5%) in the manual rotation group and 7 of 80 women (8.7%) in the sham group. Instrumental (forceps or vacuum) delivery occurred in 35 of 80 women (44%) in the manual rotation group and 33 of 80 women (41%) in the sham group. There was no significant difference in the combined maternal and perinatal outcomes. The trial was terminated early because of limited resources. Planned prophylactic manual rotation did not result in fewer operative deliveries. More research is needed in the use of manual rotation from the occiput transverse position for preventing operative deliveries.

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.

The effect of Cushing's syndrome on pregnancy complication rates: analysis of more than 9 million deliveries

Purpose The purpose of this study to evaluate the risk of Cushing’s syndrome (CS) and maternal and fetal complications using the American Nationwide Inpatient Sample database. Materials and methods This is a retrospective study using the Health Care Cost and Utilization Project-Nationwide Inpatient Sample database from 2004 to 2014. We compared pregnancies with CS versus non-CS regarding pregnancy, delivery, and neonatal outcomes using multivariate logistic regression. Results We identified 9,096,788 pregnancies during the study period. Cushing’s syndrome complicated 135 pregnancies at a rate of 1–2 cases per 100,000 births. Cushing’s syndrome subjects were more likely to be older, obese, have private insurance, chronic hypertension, and pre-gestational diabetes (p<.001). The maternal mortality rate was 0.7 and 0.007% in Cushing’s syndrome and control groups, respectively, although due to small numbers of cases, this should be interpreted with caution. Preeclampsia was higher in CS compared to controls after controlling for confounding variables, aOR 2.20. Operative vaginal delivery and blood transfusion rates were higher in CS patients than controls after controlling for confounding factors, aOR 6.49 and 3.09, respectively. The rates of preterm delivery (8.9 versus 7.2%) and gestational diabetes (8.1 versus 5.8%) were not statistically different between CS and control groups. Conclusion Cushing’s syndrome patients begin pregnancies often with maladies making them more at risk for complications including, preeclampsia, blood transfusion, and operative vaginal delivery. These patients might benefit from prevention methods for preeclampsia, and increased surveillance to decrease maternal morbidity and mortality. However, the nature of the database and its limitations, including the lack of information about CS activity and treatments received by patients, warrant careful interpretation of these results.

Recurrent short interpregnancy interval: Maternal and neonatal outcomes

ObjectiveTo evaluate maternal and neonatal outcomes associated with recurrent short interpregnancy interval (IPI) in women in their third delivery. MethodsA retrospective computerized database study of all women who delivered their first three consecutive deliveries in a single tertiary medical center over 20 years (1999–2019). Maternal and neonatal outcomes of women with recurrent short IPI (<6 months between the 1st and 2nd pregnancy and the 2nd and 3rd pregnancy) were compared to women with recurrent optimal IPI (18–48 months), and to women with a single short IPI (<6 months between the 1st and 2nd pregnancy followed by an optimal IPI of 18–48 months between the 2nd and 3rd pregnancy). Additionally, in the recurrent short IPI groups, outcomes of the 2nd and 3rd pregnancies were compared in order to achieve an ideal adjustment to background characteristics. Univariate analysis was followed by multiple logistic regression models; adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated. ResultsDuring the study period 10,569 women had three consecutive deliveries at our medical center, of those 338 (3.2%) women had recurrent short IPIs, and 1,021 (9.7%) had recurrent optimal IPIs. Recurrent short IPI was associated with a significantly higher risk of maternal anemia (Hb < 10gr%) on admission to labor (aOR 3.4 [95% CI 1.09–10.65], p = 0.04) and higher risk of small for gestational age neonates (aOR 10.4 [95% CI 2.32–46.93], p < 0.01), as compared with women with recurrent optimal IPI and significantly higher rates of low neonatal birth weights (2500 gr) and anemia (Hb < 10gr%) alongside lower rates of operative vaginal deliveries as compared with women with single short IPI followed by an optimal IPI. In the recurrent short IPI groups, the 3rd deliveries had significantly higher rates of in-labor cesarean and anemia (Hb < 10gr%) on admission as compared to their 2nd deliveries. ConclusionRecurrent short IPI is associated with maternal anemia and small for gestational age neonates. Guiding patients towards prolongation of the IPI should include explanatory comments on these outcomes.

Does gestational age at term play a role in the association between cerebroplacental ratio and operative delivery for intrapartum fetal compromise?

To assess the impact of gestational age at term on the association between cerebroplacental ratio (CPR) and operative delivery for intrapartum fetal compromise (IFC) and prognostic performance of CPR to predict operative delivery for IFC. This was a retrospective cohort study including 2052 singleton pregnancies delivered between 37+0 and 41+6 weeks of gestation in a single tertiary referral center over an 8-year period. CPR was measured within 1week of delivery. IFC was defined as the presence of persistent pathological cardiotocography pattern or the combination of pathological cardiotocography pattern and fetal scalp pH<7.20. Operative delivery included instrumental vaginal delivery and cesarean section. Pregnancies were grouped according to birthweight (small for gestational age [SGA, birthweight <10th centile] and appropriate for gestational age [AGA, birthweight 10th-90th centile]) and gestational age by week at delivery. Rates of operative delivery were compared between the subgroups. Prognostic value of CPR was assessed using receiver operating characteristic curve. Of the study cohort, 308 (15%) had a CPR <10th centile, 374 (18%) operative delivery for IFC, and 298 (15%) were SGA at birth. Overall, the rates of operative delivery for IFC were higher in the low CPR group both in SGA (35% vs. 22%; p=0.023) and in AGA (23% vs. 16%; p=0.007). According to gestational age by week at delivery, fetuses with low CPR showed higher rates of operative delivery for IFC with advancing gestational age, mainly in pregnancies delivered at 40weeks (54% vs. 23%; p=0.004) and at 41weeks (60% vs. 19%; p=0.010) for SGA and at 41weeks (39% vs. 20%; p=0.001) for AGA. The predictive value of CPR remained stable throughout term and was poor both in SGA and in AGA. Both SGA and AGA fetuses with low CPR showed higher rates of operative delivery for IFC at term with advancing gestational age. Prognostic value of CPR throughout term was poor.

The effects of smoking on pregnancy risks in women with polycystic ovary syndrome: a population-based study.

Is there is an association between smoking and pregnancy complications in pregnant women with polycystic ovarian syndrome (PCOS)? There is an increased risk of developing gestational diabetes mellitus (GDM) among women with PCOS who smoke. Smokers are at increased risk of developing Type 2 Diabetes Mellitus (DM). Given the common pathophysiology and shared risk factors between type 2 DM and GDM, we sought to assess whether an association between smoking and the development of GDM exists. This is a retrospective population-based study utilizing data from the HCUP-NIS over 11 years from 2004 to 2014. Pregnant women with PCOS who did smoke were compared to pregnant women with PCOS who did not smoke. A second comparison was made between pregnant smokers with and without PCOS. Of the 443 590 women who smoked during pregnancy and the 14 882 women with PCOS, 631 women were both smokers and diagnosed with PCOS. The Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) is the largest inpatient sample database in the USA and is composed of hospital inpatient stays submitted by hospitals throughout the entire country. Each year, the database provides information relating to 7 million inpatient stays, including patient characteristics, diagnosis and procedures. The data are representative of ∼20% of admissions to US hospitals across 48 states and the District of Columbia. There were no differences in the risks of preterm delivery (aOR1.2; CI 0.8-1.9), placental abruption (aOR1.1; CI 0.4-3.2), pregnancy induced hypertension (aOR1.0; CI 0.7-1.5), rate of operative vaginal delivery (aOR1.5; CI 0.9-2.5) and rates of cesarean section (C/S) (aOR1.0; CI 0.7-1.3) between smoking and non-smoking women with PCOS. A significant association between smoking and GDM was observed in women with PCOS (aOR1.5; CI1.01-2.1). The limitations of our study are its retrospective nature and the fact that it relies on an administrative database. Data regarding smoking and PCOS diagnosis could be skewed due to patients' underreporting, lack of documentation and documentation differences. The public health implications of confirming smoking as a risk for GDM among women with PCOS are many. This can lead to earlier screening in pregnancy of smokers for GDM. Earlier initiation of interventions could decrease fetal complications and possibly have an impact on the life and long-term health of the offspring. Future studies are needed in order to assess whether smoking cessation during pregnancy decreases the risk of GDM in that gestation. No external funding was used. The authors report no competing interests. N/A.

Randomized clinical trial of active induction versus expectant management in premature rupture of the membranes at term

Immediate induction of labour in cases of pregnancy with PROM used to be a standard practice to avoid potential complications but induced labour is likely to be associated with increased risks of fetal and maternal complications due to oligohydramnios like cord compression and high rate of operative delivery. Purpose of this study is to determine in case the practice of actively inducing labour in women with PROM at term is preferable than expectant management for 12 hours and also to study the maternal and neonatal outcome. A total of 150 pregnant women were randomized into two groups who are between 18-35 years, at term gestation (37-40 weeks) having PROM irrespective of gravida. Women were immediately induced by Tab. Misoprostol(25microgrmas) in immediate induction group. Women who presented with PROM were observed for 12hrs from time of PROM without any intervention to accelerate the labour in conservative management group. An observation between the two groups of patients would be made with respect to maternal and fetal outcome. We observed that there was statistically insignificant increase in duration of labour and increased rate of caesarean section in expectant group. Maternal complications in both groups were found to be insignificant. However, women who were managed expectantly developed more puerperal pyrexia, wound infection and prolonged hospitalization than women who were managed with induction method. There was no statistically significant difference in the perinatal complications.

Perinatal Outcome and its Prediction Using Longitudinal Feto-Maternal Doppler Follow-Up in Late Onset Small for GestationalAge Fetuses - A Prospective Cohort Study.

To describe the perinatal outcome of a prospective cohort of late-onset small-for-gestational-age (SGA) fetuses and to test adverse perinatal outcome (APO) prediction using Doppler measurements. Singleton pregnancies from 32 weeks with suspicion of SGA (followed-up each 2 weeks) and randomly selected healthy controls at a university hospital were included. The whole SGA group was divided into the FGR subgroup or SGA percentile 3-10 subgroup. The following Doppler measurements were evaluated prospectively: umbilical artery (UA) pulsatility index (PI), middle cerebral artery (MCA) PI, cerebro-placental ratio (CPR), and mean uterine artery (mUtA) PI. APO was defined as arterial cord blood pH ≤ 7.15 and/or 5-minute Apgar ≤ 7 and/or emergency operative delivery and/or admission to the neonatal unit. Induction of labor was indicated according to a stage-based protocol. A total of 149 SGA and 143 control fetuses were included. The number of operative deliveries was similar between both groups (control: 29 %, SGA: 28 %), especially the cesarean delivery rate after the onset of labor (11 % vs. 10 %). Most SGA cases ended up in induction of labor (61 % vs. 31 %, p < 0.001). The areas under the curve (AUC) for APO prediction were similar using the last UA PI, MCA PI, CPR, and mUtA PI and barely reached 0.60. The AUC was best for the FGR subgroup, using the minimal CPR or maximum mUtA PI z-score of all longitudinal measurements (AUC = 0.63). SGA fetuses do not have a higher rate of operative delivery if managed according to a risk stratification protocol. Prediction of APO is best for SGA and FGR using the "worst" CPR or mUtA PI but it remains moderate.

Prognostic Value of Cerebroplacental Ratio in Appropriate-for-Gestational-Age Fetuses Before Induction of Labor in Late-Term Pregnancies.

To evaluate the relationship between cerebroplacental ratio (CPR) and the need for operative delivery due to intrapartum fetal compromise (IFC) and adverse perinatal outcome (APO) in appropriate-for-gestational-age (AGA) late-term pregnancies undergoing induction of labor. The predictive performance of CPR was also assessed. Retrospective study including singleton AGA pregnancies that underwent elective induction of labor between 41 + 0 and 41 + 6 weeks and were delivered before 42 + 0 weeks. IFC was defined as persistent pathological CTG or pathological CTG and fetal scalp pH < 7.20. Operative delivery included instrumental vaginal delivery (IVD) and cesarean section (CS). APO was defined as a composite of umbilical artery pH < 7.20, Apgar score < 7 at 5 minutes, and admission to the neonatal intensive care unit for > 24 hours. The study included 314 women with 32 (10 %) IVDs and 49 (16 %) CSs due to IFC and 85 (27 %) APO cases. Fetuses with CPR < 10th percentile showed a significantly higher rate ofoperative delivery for IFC (40 % (21/52) vs. 23 % (60/262); p = 0.008) yet not a significantly higher rate of APO (31 % (16/52) vs. 26 % (69/262); p = 0.511). The predictive values ofCPR for operative delivery due to IFC and APO showed sensitivities of 26 % and 19 %, specificities of 87 % and 84 %, positive LRs of 2.0 and 1.2, and negative LRs of 0.85 and 0.96, respectively. Low CPR in AGA late-term pregnancies undergoing elective induction of labor was associated with a higher risk of operative delivery for IFC without increasing the APO rate. However, the predictive value of CPR was poor.

The continuum of a prolonged labor and a second stage cesarean delivery

Objective To investigate the association of the timing of primary cesarean delivery with the progress of labor and the operative delivery rate at the subsequent successful trial of labor. Methods A retrospective study of women with a primary cesarean and subsequent term cephalic vaginal delivery in two medical centers. Cesarean deliveries were classified as planned, intrapartum first stage or intrapartum second stage. The second stage duration and the operative delivery rate, adjusted to epidural analgesia and oxytocin use, were compared between the groups. χ2 and Kruskal–Wallis tests were used for analysis of categorical and continuous variables, respectively. Results The study population included 1166 women. The second stage of labor was longer when the previous cesarean delivery occurred during the second stage compared to planned or first stage (1.7 h vs 1.3 h vs 1.3 h, p = 0.005). The proportion of operative deliveries was greater among women with previous cesarean in the second stage of labor (39.6%), compared to planned (26.9%) or first stage (28.8%), p = 0.006. Conclusion Cesarean delivery at the second stage of labor is associated with a longer second stage and an increased operative delivery rate at the subsequent vaginal birth. Our findings attest to the delicate passenger-passage relations that can exist in some parent-couples.

Measuring the impact of cardiotocograph decision support software on neonatal outcomes: A propensity score-matched observational study.

This study follows the 2017 UK INFANT Collaborative Group RCT, which compared neonatal outcomes with and without the use of the INFANT cardiotocograph decision support system for over 46000 patients in labour. The original trial failed to demonstrate a significant improvement to neonatal outcomes; however, the study design was subject to methodological critique. This Australian retrospective cohort study aimed to report perinatal outcomes before and after the introduction of INFANT decision support software for cardiotocograph use in labour. The study cohort was divided into two equivalent 18-month epochs, before and after the introduction of INFANT-Guardian® CTG decision support system. Propensity score matching analysis was undertaken to balance pre- and post-implementation groups by baseline covariates. The matched cohort included 11154 public-funded women between November 2016 and 2019, with a singleton live fetus ≥34+0weeks, being induced or in spontaneous labour. The main outcome measures were: a composite measure of serious adverse neonatal outcome comprising of one or more of: admission to intensive care nursery >48h, Apgar <4 at 5min, cord arterial pH <7.0, hypoxic ischaemic encephalopathy grade 2 or 3, therapeutic hypothermia, neonatal death. The incidence of the composite primary outcome was significantly lower following implementation of INFANT (0.57% vs. 1.00%; OR 0.57, 95%CI 0.37-0.88; P=0.01). A significant reduction in nursery admission >48h was also observed (0.05% vs. 0.30%; OR 0.18, 95%CI 0.05-0.60; P=0.002). INFANT software is associated with a reduction in serious adverse neonatal outcomes, without increasing the rate of operative delivery.