Section Delivery Research Articles

Outcomes After Internal Versus External Tocodynamometry for Monitoring Labor

Professional societies in obstetrics and gynecology have recommended the use of internal tocodynamometry to monitor uterine contractions during induction or augmentation of labor. This recommendation is based on the hypothesis that internal tocodynamometry in comparison to external monitoring provides a more accurate assessment of contractions and may quantify the frequency, duration, and magnitude of uterine activity more accurately. Monitoring with internal tocodynamometry may improve maternal and fetal outcomes by allowing better adjustment of oxytocin, thereby preventing uterine hyperstimulation and fetal hypoxia. Because limited clinical data support such hypotheses, the recommendations are based on expert opinion. This randomized, multicenter, controlled clinical trial was designed to evaluate whether the use of internal tocodynamometry during labor, in a population of women with an indication for induced or augmented labor, provides superior outcomes compared to use of external monitoring. The study subjects were 1456 singleton women at >36 weeks' gestation, who required either induction or augmented labor with intravenous oxytocin. The women were randomly assigned to either an internal tocodynamometry group (n = 734) or an external monitoring group (n = 722). The trial was performed at 6 hospitals in the Netherlands between 2004 and 2007. The composite primary outcome was the rate of operative delivery, including cesarean section or instrumented vaginal delivery. Secondary outcomes evaluated were the use of antibiotics during labor, time from randomization to delivery, and adverse neonatal outcomes defined as a 5-minute Apgar score below 7, an umbilical artery pH below 7.05, or a neonatal admission longer than 48 hours. Operative delivery was performed in 230 (31.3%) of the women in the internal-tocodynamometry group and in 214 (29.6%) of those in the external-monitoring group (relative risk with internal monitoring = 1.1; 95% confidence interval = 0.91-1.2). No significant difference was found between the 2 groups in the frequencies of secondary outcomes. The rate of adverse neonatal outcomes was also similar (14.3% with internal monitoring vs. 15.0% with external monitoring; relative risk = 0.95, 95% confidence interval = 0.74-1.2). The use of the intrauterine pressure catheter was not associated with serious adverse events. These findings show no significant difference in the rates of operative delivery or adverse neonatal outcomes between internal tocodynamometry and external monitoring of uterine contractions in a population of women with an indication for induction or labor augmentation with oxytocin. The data do not support the routine use of internal tocodynamometry for monitoring contractions in women with induced or augmented labor.

Postpartum stress urinary incontinence and associated obstetric factors

To evaluate the effect of cesarean section (CS) and vaginal delivery (VD) on postpartum stress urinary incontinence (SUI) and pelvic floor muscles strength and to find out the correlated obstetric factors and prevention for postpartum SUI. Totally, 788 women, who visited the antenatal clinics, delivered and had the follow-up at 6-8 weeks after delivery in Beijing Obstetrics and Gynecology Hospital in the year of 2008, were enrolled in this study and were divided into 3 groups: CS group (n = 212); normal vaginal delivery (NVD) group (n = 534) and forceps delivery (FD) group (n = 42). Women in the NVD and FD group were merged into one VD group and then divided into SUI and non-SUI group. Information of delivery mode and the correlated obstetric factors were obtained through questionnaires and medical records. Femiscan pelvic floor muscle examine system was applied to measure the pelvic floor muscle strength to understand the relationship between postpartum SUI and pelvic floor muscle strength. (1) Incidence of SUI: the overall proportion of women who complained of urinary incontinence (UI) during pregnancy was 15.4% (121/788), and it was 15.9% (85/534), 11.9% (5/42) and 14.6% (31/212) in the NVD, FD and CS group, respectively (P > 0.05). The overall incidence of postpartum SUI was 17.1% (135/788), and it was 19.1% (102/534), 26.2% (11/42) and 10.4% (22/212) in the NVD, FD and CS group, respectively, with significant difference between the NVD and FD group, and between the CS and NVD group (all P < 0.01). (2) The associated obstetric factors of postpartum SUI: among the VD group, 113 women were in the postpartum SUI group and 463 in the non-SUI group. Univariate analysis and logistic multivariate analysis showed that delivery mode, neonatal birth weight and UI during pregnancy were risk factors of postpartum SUI. CS decreased and higher neonatal birth weight and UI during pregnancy increased the risk of postpartum SUI. In the VD group, neonatal birth weight, forceps delivery and UI during pregnancy increased the incidence of postpartum SUI (P < 0.01), but no correlation was found with labor analgesia, duration of labor, episiotomy, breast feeding, volume of postpartum bleeding, gestational weeks at delivery, induction and pre-pregnant BMI, etc (all P > 0.05). (3) Pelvic floor electromyogram: pelvic floor muscles strength in the CS group was significantly higher than that of the VD group [activity value: (19.7 +/- 9.9) microv vs (14.8 +/- 8.4) microv; work value: (84.5 +/- 37.2) microv vs (78.8 +/- 28.2) microv; peak value: (25.5 +/- 12.5) microv vs (19.7 +/- 11.8) microv, all P < 0.01]. Among women in the VD group, the relaxation value and the ratio of relaxation value over activity value (r/a) in the postpartum SUI group were significantly lower than those in the non-SUI group [relaxation value: (1.7 +/- 1.8) microv vs (3.0 +/- 3.9) microv; r/a ratio: 0.2 +/- 0.2 vs 0.3 +/- 0.5, all P < 0.01]. The r/a ratio in the VD group showed no difference compared to that in the CS group (0.2 +/- 3.5 vs 0.2 +/- 0.2, P > 0.05). Women experienced vaginal delivery, either NVD or FD, have a higher incidence of postpartum SUI than those delivered through CS. UI during pregnancy, forceps delivery and neonatal birth weight are risk factors of postpartum SUI.

Can the special care neonatal unit admission cut-off be lowered down to 1500g babies?

The study was conducted to find out whether there is any significant difference in outcome if low birth weight babies weighing between 1500g and 1800g are managed by keeping them with their mothers, i.e., without special care neonatal unit (SCNU) admission. It was a retrospective study for which data was collected from past medical record section of 6 months duration from 01.07.06 to 31.12.06, Medical College, Kolkata. The subject of the study was babies born with weight between 1500g and 2000g, divided into 2 groups. Group A representing babies born between weight 1500g and 1800g, groups B representing babies born between 1801g and 2000g. The groups were compared with regard to four variable namely average material age, sex of the babies, singleton or twin pregnancy, mode of delivery and gestational maturity. Test of one proportion was used for statistical analysis of outcome. Total number of live born babies in group A were 198 and in group B 223. Two group were comparable with respect to average maternal age (23.7 yr), sex distribution, singleton or twin pregnancy and number of cesarian section or vaginal delivery and proportion of small for gestational age (SGA) babies. In both the group 13 babies required SCNU admission after being given to their mothers in the postnatal ward. No significant difference in outcome was observed between the groups. We conclude that the recommended guidelines for giving institutional care to babies below 1800g may be lowered down to 1500g. However, more babies should be evaluated prospectively, over a longer duration of time, before changing the standard guidelines.

Clinic analysis on 2611 cases with continuous central fetal monito-ring during total labor course

Objective To discuss the role of continuous central fetal monitoring in early detection of fe-tal distress and prevention from neonatal asphyxia, and its effect upon delivery outcome. Methods 2 611 puerp-erants who had a delivery in our hospital during Jan. to Dec. 2008 were chosen as the observation group, while 2 671 puerporants who had a delivery in our hospital during Jan. to Dec. 2004 as the control group. The incidences of fetal distress, neonatal asphyxia, cesarean section, and virginal surgical delivery were compared between the two groups. Results The incidence of fetal distress was 4.83% in observation group and 5.02% in control group, neonatal asphyxia 0. 92% and 1.34%, cesarean section 54.92% and 51.63%, and virginal surgical delivery 0.94% and 0.94%. Conclusions Continuous fetal monitoring significantly reduces the incidence of severe neo-natal asphyxia, however, the incidence of cesarean section is increased correspondingly. Key words: Labor course; Continuous fetal monitoring; Neonatal asphyxia; Delivery pattern

Maternal Morbidity Following a Trial of Labor after Cesarean Section versus Elective Repeat Cesarean Delivery: A Systematic Review with Meta-analysis

Maternal Morbidity Following a Trial of Labor after Cesarean Section versus Elective Repeat Cesarean Delivery: A Systematic Review with Meta-analysis

Outcome of Planned Home Births Compared to Hospital Births in Sweden Between 1992 and 2004

OBJECTIVE: The aim of this population-based study was to measure the risk of adverse outcome for mother and child in planned home births in a Swedish population irrespective of where the birth actually occurred, at home or in hospital after transfer. DESIGN: A population-based study using data from the Swedish Medical Birth Register. SETTING: Sweden 1992-2004. PARTICIPANTS: A total of 897 planned home births were compared with a randomly selected group of 11,341 planned hospital births. MAIN OUTCOME MEASURES: Prevalence of mortality and morbidity among mothers and children, emergency conditions, instrumental and operative delivery and perineal lacerations were compared. RESULTS: During this period in Sweden the neonatal mortality rate was 2.2 per thousand in the home birth group and 0.7 in the hospital group (RR 3.6, 95% CI 0.2-14.7). No cases of emergency complications were found in the home birth group. The risk of having a sphincter rupture was lower in the planned home birth group (RR 0.2, 95% CI 0.0-0.7). The risk of having a cesarean section (RR 0.4, 95% CI 0.2-0.7) or instrumental delivery (RR 0.3, 95% CI 0.2-0.5) was significantly lower in the planned home birth group. CONCLUSION: In Sweden, between 1992 and 2004, the intrapartum and neonatal mortality in planned home births was 2.2 per thousand. The proportion is higher compared to hospital births but no statistically significant difference was found. Women in the home birth group more often experienced a spontaneous birth without medical intervention and were less likely to sustain pelvic floor injuries.

Social induction of labour: experience in an urban teaching hospital in Nigeria

To document the experience with social induction of labour (IOL) and compare its outcome with electively induced labour for prolonged pregnancy. A prospective matched case-control study. Social IOL was significantly common in women of high social class (78.3 vs. 45.6%, P=0.03) and the commonest indication was because the parturient was 'tired of pregnancy' (60.9%). There was no significant difference between both groups in the mean induction to delivery interval, caesarean section and instrumental delivery rates, 5-minute Apgar score <7 and early neonatal death. Social IOL in well-selected cases has comparable outcomes to elective IOL for prolonged pregnancy. There is still the need for evaluating the determinants of maternal request for social IOL and the development of guidelines to regulate its practice.

Abstract 1747: Therapeutic Potential of Mesenchymal Stem Cells Derived from Three Different Layers of Human Fetal Membrane in Hindlimb Ischemia Model

The fetal membrane (FM), which is reported to contain mesenchymal stam cells (MSC), has been regarded as an ideal source for regenerative medicine, although it is normally discarded after birth. Little information is available regarding the biological difference and therapeutic potential of MSC obtained from different layers of FM including amnion and chorion. We assessed the hypothesis that human FM-derived MSC (FM-MSC) might have therapeutic effects on hindlimb ischemia. FM was obtained following cesarean section and vaginal delivery of healthy donor mothers after obtaining informed consent. We mechanically and enzymatically separated human FM into three layers; amnion and inner and outer layers of chorion, and isolated dish-adherent cells from each layer of FM. These FM-derived cells showed similar surface antigen expression and pluripotency compared to bone marrow (BM)-derived MSC. Because cultured inner chorion-derived MSC (IC-MSC) secreted large amounts of growth factors including IGF-1(13.6 ± 0.08 ng/106cells/24hrs, p &lt; 0.001 vs. amnion or outer chorion-derived MSC (AM-MSC or OC-MSC)) and HGF (7.94 ± 0.67 ng/106cells/24hrs, p &lt; 0.001 vs. AM-MSC or OC-MSC) compared to AM-MSC or OC-MSC, we chose to use IC-MSC for further in vivo experiment. Hindlimb ischemia was induced in 6-week-old male NOD/SCID mice, which were divided into two groups: IC-MSC transplanted group (1 × 10 6 cells/50 μl PBS, n = 9), and control group (50 μl PBS, n = 10). IC-MSC was injected into ischemic hindlimb muscle at five different points. Laser Doppler perfusion analyses showed that the ischemic/nonischemic blood flow ratio was significantly increased in IC-MSC group compared to control group (0.468 ± 0.093 vs. 0.227 ± 0.045 respectively, p &lt; 0.01). Transplantation of FM-MSC showed significant neovascularization in murine hindlimb ischemia model. FM-MSC might have a potential to be an ideal source for treatment of ischemic cardiovascular disease.

Is Operative Delivery Associated With Postnatal Back Pain at Eight Weeks and Eight Months? A Cohort Study

Background. Back pain is very common during pregnancy and postnatally, and is a serious cause of morbidity. This research investigates the prevalence of antenatal back pain and the associations between mode of delivery and postnatal back pain at 8 weeks and 8 months. Methods. A prospective population-based cohort based in Avon, UK. Some 14,663 women were recruited antenatally, due between 1 April 1991 and 31 December 1992. Of these, 12,944 women with singleton, liveborn, term fetuses were included. Self-reported postal questionnaires were used to assess back pain antenatally and postnatally. The main outcome measures were postnatal back pain at 8 weeks and 8 months. Results. Back pain was very common with a prevalence of 80% at 32 weeks antenatally. Postnatally, back pain affected 68% of women at 8 weeks, and 60% at 8 months. Postnatal back pain was not associated with elective or emergency caesarean section (e.g. adjusted 8 weeks OR: 1.23, 95% CI: 0.89, 1.70, and OR: 0.89, 95% CI: 0.65, 1.22, respectively) nor with assisted versus spontaneous vaginal delivery (OR: 0.99, 95% CI: 0.82, 1.20). Very similar patterns were observed at 8 months. Conclusions. Antenatal and postnatal back pain are common. Elective caesarean section does not protect against postnatal back pain. Neither emergency caesarean section nor assisted vaginal delivery increases the risk of postnatal back pain compared with spontaneous delivery.

Symptoms of Anal and Urinary Incontinence Following Cesarean Section or Spontaneous Vaginal Delivery

Evidence is accumulating that vaginal delivery has adverse effects on the integrity of the pelvic floor, and many women today request elective cesarean delivery in the hope of avoiding postpartum pelvic floor dysfunction. It is not, however, certain that operative delivery does protect against pelvic floor dysfunction in the long term. This study compared the prevalence of urinary and anal incontinence in 200 women having only spontaneous vaginal deliveries and 195 having only cesarean deliveries for 10 years after the index delivery. A self-administered questionnaire provided information on lower urinary tract and anorectal symptoms. At the time of the study, women in the vaginal delivery and cesarean section groups had average ages of 40 and 41.5 years, respectively. Episodes of stress urinary incontinence and the use of protective pads both were more frequent in the vaginal delivery group. There were, however, no significant group differences in symptoms of urinary urgency or urge incontinence. Fecal urgency, but not stool incontinence, was significantly increased in the vaginal delivery group. A majority of women in both groups with severe stress and urge urinary incontinence, who had symptoms at least once a week, also had flatus incontinence. Apart from an increased risk of flatus incontinence in women with a history of obstetrical injury to the anal sphincter, multivariate regression analysis disclosed no significant association between mode of delivery and symptoms of incontinence. The investigators conclude that, at least for 10 years after initial delivery, cesarean section is not associated with a major reduction in urinary or anal incontinence compared with vaginal delivery.

Decreasing incidence and changing aetiological factors of vesico-vaginal fistula in south-east Nigeria

SummaryThis study retrospectively reviewed 476 cases of vesico-vaginal fistula (VVF) in the University of Nigeria Teaching Hospital Enugu, south-east Nigeria from 1981 to 2005. The majority (86.6%) of the VVFs were of obstetric origin, resulting from vaginal delivery (n = 330), caesarean section (n = 35), caesarean hysterectomy (n = 26) and instrumental delivery (n = 21). The remaining 13.4% (n = 64) resulted from pelvic surgery, malignancy and radiotherapy treatment. The contribution of obstetrics to VVF development showed a downward trend from 95% in 1981 to 60% in 2005. A success rate of 83% was recorded in the repair with large sized fistula and extensive fibrosis at the fistula site contributing mostly to failure. There is a need to increase access to trained delivery attendants to sustain the downward trend in the incidence of VVF.

Anti-Aging Effects of Nanpao®, a Kampo Medicine, on Reproductive Functions in Female Rats

The improvement effect of nanpao, a kampo medicine, on the age-related decline in reproductive function was evaluated in female rats given the test drug for a long-term period. Young rats were allocated to the cesarean section and natural delivery groups to examine reproductive performance (young rat groups). Five-month-old rats were allocated to the 3 groups (aged rat groups): 1--control and 2--nanpao-treated groups. They were given orally in a dose of 0, 30 or 100mg/kg/day of the test drug, respectively. In aged rats, the first mating experiment was initiated at week 21 of dosing to evaluate reproductive performance by natural delivery and the second mating experiment at week 31 of dosing was evaluated by cesarean section. In the first and second mating experiments, various reproductive functions decreased in aged rats as compared to the young rats. On the other hand, loss of regular estrous cycles, decreases in delivery and pregnancy rates and mean fetal weights were inhibited in the treated groups as compared to the control group. In addition, decreases in the numbers of mean live offspring and fetuses were inhibited in the 100 mg/kg/day group. In conclusion, nanpao maintained normal embryo-foetal development in female rats.

Anthropomorphic characteristics as obstetric risk determinants

An essential element in achieving a successful birth process is the size of the infant and its relationship to the birth canal. The maternal anthropomorphic characteristics of height and weight are determinant in establishing birth canal adequacy and infant size. The present study assesses the risk element of these two factors on obstetric performance in a Mediterranean population characterised by a relatively short stature and a high prevalence of the Metabolic Syndrome. Obese women have been shown to have pregnancies which are more likely to be complicated by hypertension and diabetes when compared to their leaner counterparts. They were more likely to be delivered by Caesarean section and vaginal delivery was more likely to be complicated by shoulder dystocia. The infants born to these mothers were heavier and were more likely to suffer from respiratory distress in the neonatal period. The short stature woman similarly had a greater likelihood of requiring Caesarean delivery in spite of having a tendency to infants with smaller birth weights than their taller counterparts. The study confirms that the maternal body habitus remains an obstetric risk consideration that needs to be addressed when deciding on management of delivery.

Twinning rate in a rural mission tertiary hospital in the Niger delta, Nigeria

SummaryTwin pregnancy is associated with an increased risk of pre-term deliveries, perinatal morbidity, mortality and maternal complications, especially in developing countries. A descriptive study of all women who had twin pregnancies in a rural mission tertiary hospital over a 7-year period was undertaken. There were a total of 3,351 deliveries and 99 cases of twin deliveries during the study period giving an incidence of 29.5/1,000 or one in 33.8 deliveries. Some 60% of the twins were delivered by caesarean section, while 36.4% had vaginal delivery. A total of 4% had vacuum delivery and a combination of vacuum and caesarean delivery. Twinning rate increased with increasing age and parity. The majority of the patients were unbooked (65.7%). The study could not detect any differences in the birth weights of twin 1 compared to twin 2. There were more females (52%) than males (48%). Low birth weight babies constituted 57.1% of twins. There were 26 perinatal deaths giving rise to a perinatal mortality rate of 131/1,000 and there was no difference in the perinatal mortality rate in the unbooked (131/1,000) and the booked (132/1,000). ). Booking status had no significant effect on perinatal mortality of twins and singletons, p value = 0.65. Singletons had significantly more caesarean section and vaginal delivery than twins, p value < 0.0001. Prematurity was the chief cause of perinatal death (65.4%). The most common mode of presentation was cephalic/cephalic (58.6%), followed by cephalic/breech (29.2%), breech/cephalic (7.1%) and breech/breech (5.1%). There was no maternal death.

Estimation of Blood Loss after Cesarean Section and Vaginal Delivery Has Low Validity with a Tendency to Exaggeration

Estimation of Blood Loss after Cesarean Section and Vaginal Delivery Has Low Validity with a Tendency to Exaggeration

The Influence of Timing of Elective Cesarean Section on Risk of Neonatal Pneumothorax

Some earlier reports identified neonatal pneumothorax in as many as a third of infants with iatrogenic respiratory distress syndrome. More recently, pneumothorax and/or severe, persistent pulmonary hypertension have been observed in infants delivered by elective cesarean section. These studies, however, were limited to infants admitted to intensive care. The lethality of iatrogenic pneumothorax necessitates prompt diagnosis and specialized care. This study enrolled 66,961 term infants born during a 2-year study period in an attempt to learn whether the timing of elective cesarean delivery influences the risk of neonatal pneumothorax. Just over one-fourth of infants were delivered by cesarean section: electively in 56% of instances and by emergency section in 44%. In 5408 instances, elective cesarean section was carried out before 39 completed weeks of gestation. Pneumothorax was diagnosed in 59 newborn infants, representing 0.8 per 1000 births. All of them were managed by thoracostomy. The incidence of pneumothorax was increased at 2.9 per 1000 births in those infants who were delivered by elective cesarean section, compared with both infants delivered by emergency section and those delivered vaginally. The odds ratio (OR) for pneumothorax following elective cesarean delivery, compared to emergency cesarean delivery, was 4.21 (95% confidence interval [CI], 2.04-8.74), and compared to vaginal delivery, 7.95 (95% CI, 4.41-14.32). In elective cesarean deliveries, the incidence of pneumothorax declined progressively and significantly from the 37th gestational week onward. There was a similar but less significant trend for vaginal delivery but not for emergency cesarean delivery. None of the infants with pneumothorax died, but 14% of those born by elective cesarean section developed pulmonary hypertension, necessitating high-frequency oscillatory ventilation and nitric oxide inhalation. Elective cesarean delivery at term carries an increased risk of neonatal pneumothorax compared to either emergency section or vaginal delivery. Performing elective cesarean deliveries after 39 completed weeks of gestation would be expected to lower the risk of iatrogenic neonatal pneumothorax.

Maternal and neonatal outcome after failed ventouse delivery: Comparison of forceps versus cesarean section

Objectives. To compare the immediate maternal and neonatal morbidity in women delivered by forceps or cesarean section after failed ventouse delivery.Methods. Case notes of 400 consecutive successful ventouse deliveries compared with 342 failed ventouse deliveries, where delivery was subsequently achieved with either forceps (N = 247) or cesarean section (N = 95), which took place between October 1999 and May 2003, were reviewed.Results. Failed ventouse delivery was associated with an increased chance for fetal malposition (OR 3.7, 95% CI 2.6 – 5.3) and postpartum hemorrhage (OR 3.5, 95% CI 1.8 – 6.8). Compared to forceps after failed ventouse, cesarean section was associated with a higher prevalence of postpartum hemorrhage (OR 7.8, 95% CI 3.6 – 16.9) and fewer third degree perineal tears (p < 0.05). There were no significant differences between cesarean section and forceps delivery after failed ventouse for neonatal morbidity.Conclusions. Failure of ventouse delivery is 3 – 4 times more likely with a fetal malposition and is associated with an increased risk of postpartum hemorrhage. While cesarean section increases the postpartum hemorrhage rate, forceps delivery is associated with increased likelihood of third degree perineal tears. The neonatal morbidity was comparable regardless of whether forceps or cesarean was used after failed ventouse.

Admission cardiotocography versus intermittent auscultation of fetal heart rate: Effects on neonatal Apgar score, on the rate of caesarean sections and on the rate of instrumental delivery—A systematic review

Objective The aim of this review was to determine whether intrapartum admission cardiotocography (CTG) in women at low obstetric risk can improve neonatal outcome (in terms of Apgar score) and whether it is associated with an increase in the incidence of instrumental delivery and caesarean section. Review methods The Cochrane Library, Medline (1966–November 2005), Embase (1980–November 2005) and the PubMed were searched for randomized control trials and systematic reviews of randomized control trials. Studies were assessed for quality. Outcomes considered the neonatal Apgar score at 5 min after delivery, caesarean section and instrumental delivery. A meta-analysis of the results of the randomized controlled trials was performed. Results The pooled relative risk for having an Apgar score less than 7 points at 5 min after delivery was higher in the admission CTG group (RR 1.35, 95% CI 0.85–2.13) but it was not statistically significant. The pooled relative risks for having a caesarean section-delivery (RR 1.2 95% CI 1.00–1.41) and an instrumental delivery (RR 1.1 95% CI 1.00–1.18) were both higher in the admission CTG group. Both these were statistically significant. Conclusion Intrapartum admission cardiotocography in women at low obstetric risk increases the risk of caesarean section and instrumental delivery. In addition, there is no evidence for neonatal benefit in terms of Apgar score at 5 min after delivery. A larger sample size would be needed in order to answer this important question.

Understanding operative intervention in childbirth: A patient perspective

SummaryA study was undertaken to ascertain patients' understanding of the operative interventions in labour and to assess follow-up by the operator. A total of 200 consecutive women who had undergone caesarean section or instrumental delivery were selected. These women were questioned postoperatively. Questions were asked to ascertain the patients' understanding of the procedure and to assess follow-up by the operator. Seven patients had a forceps delivery, 64 had a ventouse delivery and 129 had a caesarean section. The majority of patients felt that the reason for the operative delivery had been explained to them at delivery and that they fully understood the need for this intervention. A total of 26 women were not seen postoperatively by the doctor who delivered them. Women who underwent forceps or ventouse delivery were less likely to be seen post-delivery, although this difference did not reach statistical significance.

The Safety of Low-Molecular-Weight Heparin Therapy During Labor

For some years, low-molecular-weight heparin (LMWH) has been widely used to prevent thromboembolic complications in pregnancies at risk. Its safety has been well established in previous studies. This study was designed to determine the safety of discontinuing LMWH for 12 to 24 hours before vaginal delivery or an invasive procedure. Hemorrhagic and other complications were surveyed in 284 women given enoxaparin during pregnancy and in 16,132 others not given this treatment. Enoxaparin was self-administered by subcutaneous injection, as a preventive measure (0.5–1 mg/kg daily) in 84% of women, and therapeutically (1.5–2 mg/kg daily) in the remaining 16%. Postpartum hemorrhage was defined as an estimated loss of more than 500 mL of blood after vaginal delivery, more than 1000 mL after cesarean section, or a drop of at least 2 gram% of hemoglobin or 10% in hematocrit 24 to 72 hours after giving birth. The duration of treatment averaged 251 days and included at least 6 postpartum weeks. Nearly one fourth of treated women had previously experienced thromboembolism. The treated and untreated women were similar in age and pregestational body mass index. Postpartum hemorrhage was rare in both groups, occurring in 2.1% of treated women and 1.9% of those not treated. Three of 6 hemorrhages in LMWH-treated women were ascribed to uterine atony after prolonged labor with oxytocin. Four of the 6 treated women with postpartum hemorrhage had their last treatment more than 24 hours earlier. In only one case did the dose of enoxaparin exceed 0.5 mg/kg daily. Just over three fourths of treated women had an epidural catheter placed. The last injection of LMWH generally was given 12 to 24 hours before delivery, cesarean section, or catheter placement. No spinal hematomas were diagnosed. Discontinuing LMWH 12 to 24 hours or longer before vaginal or section delivery did not influence the 5-minute Apgar score, umbilical arterial blood pH, or admission to neonatal intensive care. None of the infants born to LMWH-treated mothers had hemorrhagic complications. LMWH in the form of enoxaparin may be safely discontinued 12 hours before labor is induced whether vaginal or operative delivery is carried out. It also appears that epidural anesthesia is safe if 12 or more hours have elapsed since the last dose of enoxaparin.