Singleton Cephalic Presentation Research Articles

Intra Cervical Foley’s Versus Combination Of Intra Cervical Foley’s And Extra Amniotic Saline Infusion As Cervical Ripening Agent For Induction Of Labor

Objective: To compare IntraCervical Foleys (ICF) and intracervical Foleys along with Extra Amniotic Saline Infusion (EASI) as a cervical ripening agent for Induction Of Labour(IOL). Methods: It was carried out at the Department of Obstetrics and Gynecology Holy Family Hospital, Rawalpindi. In this comparative study, we included 100 patients with singleton cephalic presentation, intact membranes and a BISHOP score ≤ 6. These were further subdivided into two groups, Group A (ICF) and Group B (ICF with EASI),50 in each group. In Group A, Foley’s catheter was placed cervically while in Group B extraamniotic saline infusion was also administered in the urine drainage port at midnight. PGE2/ Augmentation with syntocinon was considered according to the bishop score at 6 am. Improvement in BISHOP score, induction to delivery interval, and feto-maternal outcomes were noted in both groups. Results: Data analysis showed that the mean improvement in the BISHOP score of the patients in Group A was 3.78 ± 1.75 while that of Group B was 3.56 ± 1.79(pvalue = 0.508). The induction to delivery interval in group A patients was 14.6 ± 4.75 hours while that of group B was 13.22 ± 4.54 hours (p =0.103). Only 14/100 patients had failed IOL and underwent C- C-sections and 8/100 neonates had NICU admissions and were discharged later on. Conclusion: Both Intra Cervical Foley’s and a Combination Of Intra Cervical Foley’s And Extra Amniotic Saline Infusion are equally effective as cervical ripening agents for induction Of labour with high chances of successful vaginal delivery and good feto-maternal outcome. Keywords: Induction of labour, Intracervical folleys, Extra-amniotic saline infusion, BISHOP score.

Trends in Apgar scores and umbilical artery pH: a population-based cohort study on 10,696,831 live births in Germany, 2008–2022

Low Apgar scores and low umbilical arterial (UA) blood pH are considered indicators of adverse perinatal events. This study investigated trends of these perinatal health indicators in Germany. Perinatal data on 10,696,831 in-hospital live births from 2008 to 2022 were obtained from quality assurance institutes. Joinpoint regression analysis was used to quantify trends of low Apgar score and UA pH. Additional analyses stratified by mode of delivery were performed on term singletons with cephalic presentation. Robustness against unmeasured confounding was analyzed using the E-value sensitivity analysis. The overall rates of 5-min Apgar scores < 7 and UA pH < 7.10 in liveborn infants were 1.17% and 1.98%, respectively. For low Apgar scores, joinpoint analysis revealed an increase from 2008 to 2011 (annual percent change (APC) 5.19; 95% CI 3.66–9.00) followed by a slower increase from 2011 to 2019 (APC 2.56; 95% CI 2.00–3.03) and a stabilization from 2019 onwards (APC − 0.64; 95% CI − 3.60 to 0.62). The rate of UA blood pH < 7.10 increased significantly between 2011 and 2017 (APC 5.90; 95% CI 5.15–7.42). For term singletons in cephalic presentation, the risk amplification of low Apgar scores was highest after instrumental delivery (risk ratio 1.623, 95% CI 1.509–1.745), whereas those born spontaneous had the highest increase in pH < 7.10 (risk ratio 1.648, 95% CI 1.615–1.682). Conclusion: Rates of low 5-min Apgar scores and UA pH in liveborn infants increased from 2008 to 2022 in Germany.What is Known:• Low Apgar scores at 5 min after birth and umbilical arterial blood pH are associated with adverse perinatal outcomes.• Prospective collection of Apgar scores and arterial blood pH data allows for nationwide quality assurance.What is New:• The rates of liveborn infants with 5-min Apgar scores < 7 rose from 0.97 to 1.30% and that of umbilical arterial blood pH < 7.10 from 1.55 to 2.30% between 2008–2010 and 2020–2022. • In spontaneously born term singletons in cephalic presentation, the rate of metabolic acidosis with pH < 7.10 and BE < −5 mmol/L in umbilical arterial blood roughly doubled between the periods 2008–2010 and 2020–2022.

Variations over time in mode of birth and perinatal outcomes in women with one previous cesarean in the Netherlands: A 20-year population-based study.

Globally, cesarean birth rates are rising, and while it can be a lifesaving procedure, cesarean birth is also associated with increased maternal and perinatal risks. This study aims to describe changes over time about the mode of birth and perinatal outcomes in second-pregnancy women with one previous cesarean birth in the Netherlands over the past 20 years. We conducted a nationwide, population-based study using the Dutch perinatal registry. The mode of birth (intended vaginal birth after cesarean (VBAC) compared with planned cesarean birth) was assessed in all women with one previous cesarean birth and no prior vaginal birth who gave birth to a term singleton in cephalic presentation between 2000 and 2019 in the Netherlands (n = 143,146). The reported outcomes include the trend of intended VBAC, VBAC success rate, and adverse perinatal outcomes (perinatal mortality up to 7 days, low Apgar score at 5 min, asphyxia, and neonatal intensive care unit admission ≥24 h). Intended VBAC decreased by 21.5% in women with one previous cesarean birth and no prior vaginal birth, from 77.2% in 2000 to 55.7% in 2019, with a marked deceleration from 2009 onwards. The VBAC success rate dropped gradually, from 71.0% to 65.3%, across the same time period. Overall, the cesarean birth rate (planned and unplanned) increased from 45.2% to 63.6%. Adverse perinatal outcomes were higher in women intending VBAC compared with those planning a cesarean birth. Perinatal mortality initially decreased but remained stable from 2009 onwards, with only minimal differences between both modes of birth. In the Netherlands, the proportion of women intending VBAC after one previous cesarean birth and no prior vaginal birth has decreased markedly. Particularly from 2009 onwards, this decrease was not accompanied by a synchronous reduction in perinatal mortality.

Intrapartum ultrasound and mother acceptance: A study with informed consent and questionnaire

IntroductionIntrapartum ultrasound (IU) is used in the delivery ward; even if IU monitors the labouring women, it could be perceived as a discomfort and even as an“ obstetric violence”, because it is a young technique, not often well "accepted". A group of clinicians aimed at obtain an informed consent from patients, prior to perform a translabial ultrasound (TU). The aim of this study was to evaluate the acceptance of both translabial and transabdominal IU. MethodsIn this study, performed at the University Hospital of Bari (Unit of Obstetrics and Gynecology), were enrolled 103 patients in the first or second stage of labor in singleton cephalic presentation. A statistical frequency and an association analysis were performed. As a significant result, we consider the peace of mind/satisfaction and the” obstetric violence”. IU was performed both transabdominal and translabial to determine the presentation, head positions, angle of progression and head perineum distance. During the first and second stage of labor, the ASIUG questionnaires (Apulia study intrapartum ultrasonography group) were administered. Results74 (71, 84%) patients underwent IU and 29 had a vaginal examination (28, 15%). Significant less “violence” has been experienced with a IU (73 out 74/98, 65%) and only one person (1 /1, 35%) recorded that. On the contrary, 10 patients (10/29) perceived that “violence” (34, 48%) while 19 (65, 52%) did not respond on a similar way, after a vaginal examination (VE). More patients felt satisfaction (71 out 74/95, 95%) with the use of IU and only 3 (3/4, 05%) felt unease. A different picture was evident in the vaginal examination group. Only 17 patients (17 out 29/58, 62%) felt comfort while 12 (41, 38%) felt unease. ConclusionsIn our study, IU use is well accepted by most of patients, because it could reassure women about their fetal condition. Moreover, they can see the fetus on the screen, while the obstetrician is performing the US and this is important for a visual feedback, in comparison with the classical VE.

Misoprostol with balloon vs oxytocin with balloon in high-risk pregnancy induction: a randomized controlled trial

Pregnancies at high risk for maternal, fetal, or placental complications often necessitate induction of labor in the late preterm or early term period for delivery. Limited data exist on the safest method of induction to use in this specific patient population. This study aimed to compare the combination of oxytocin plus a Cook balloon vs misoprostol plus a Cook balloon for induction of labor in high-risk pregnancies. We conducted an open-label, randomized controlled trial at a single institution from July 2020 to May 2022. The study was approved by the institutional review board and registered with ClinicalTrials.gov (NCT04492072). Individuals with a high-risk pregnancy, at least ≥22 weeks' gestation, with a singleton in cephalic presentation, Bishop score ≤6, and intact membranes were offered enrollment. A high-risk pregnancy was defined as a pregnancy with any of the following complications: hypertensive disease of pregnancy, fetal growth restriction, oligohydramnios, suspected placental abruption requiring delivery, uncontrolled pregestational diabetes, or abnormal biophysical profile or nonstress test requiring delivery. The primary outcome was the rate of cesarean delivery. Secondary maternal outcomes included induction to delivery interval, number of vaginal deliveries within 24 hours, rates of uterine tachysystole, intraamniotic infection, operative vaginal delivery, and postpartum hemorrhage. Secondary fetal outcomes included fetal heart rate abnormalities, stillbirth, Apgar scores <7 at 5 minutes, admission to the neonatal intensive care unit, arterial umbilical blood pH <7.1, sepsis, and neonatal death. A subgroup analysis was planned for the primary outcome to assess the different indications for cesarean delivery. An intent-to-treat analysis was performed. During the 22 months of the trial, a total of 150 patients were randomized, and 73 (49%) of those were induced with oxytocin and a Cook balloon and 77 (51%) were induced with misoprostol and a Cook balloon. There was no significant difference in the overall rate of cesarean delivery between the study groups, (21.9% vs 31.1%; relative risk, 0.70; 95% confidence interval, 0.41-1.21), nor among those for which the cesarean delivery was performed for a specific indication. There were no differences in the secondary maternal and fetal or neonatal adverse outcomes. In high-risk pregnancies, the rate of cesarean delivery and adverse maternal and fetal outcomes were similar for induction of labor with oxytocin and a Cook balloon and for induction with misoprostol and a Cook balloon.

Can the Day of the Week and the Time of Birth Predict the Mode of Delivery According to Robson Classification?

Worldwide, the cesarean section rate has steadily increased from 6.7% in 1990 to 21.1% in 2018 and is expected to rise even more. The World Health Organization propose the adoption of the Robson classification system as a global standard for monitoring, evaluating, and comparing delivery rates. The purpose of the current study is to use the Robson classification system to investigate how, independently of medical factors, the day of the week and time of delivery may be related to the mode of birth. In the sample analysis, we included the records of 8572 women giving birth in one private health facility in Greece. Over 60% of deliveries during the study period were performed by cesarean section, 30.6% by vaginal delivery, and 8.5% of deliveries were performed by operative vaginal delivery. The results of this study indicate that the lowest birth rates are observed on Monday, Saturday, and Sunday. Nulliparous women with no previous cesarean delivery, with a singleton in cephalic presentation ≥37 weeks with spontaneous labor (group 1) are 73% more likely to deliver by cesarean section between 08:00 A.M. and 03:59 P.M. compared to those who give birth between 12:00 A.M. and 07:59 A.M. Also, multiparous women with a single cephalic term pregnancy and one previous cesarean section (group 5.1) are 16.7 times more likely to deliver by cesarean section in the morning compared to overnight deliveries. These results point out two non-clinical variables that influences the CS rate. The Robson classification system was a useful tool for the above comparisons.

Hand Forceps for Delivery of Floating Fetal Head at Cesarean Section: A Randomized Pilot Study [ID: 1375984

INTRODUCTION: On occasion, obstetricians encounter difficulty delivering the floating fetal head at cesarean section; additional techniques may need to be employed beyond the traditional one-handed delivery technique. We propose a modified two-handed manual delivery method or “hand forceps,” with surgeon’s both hands shaped like a pair of forceps, as an alternative technique for fetal head delivery. The purpose of this study is to compare the efficacy and safety of two-handed technique by comparing with the traditional one-handed technique. METHODS: We conducted a randomized pilot study of women undergoing cesarean section (NCT04159857, ClinicalTrials.gov). Inclusion criteria included a singleton in cephalic presentation, at gestational age of 37 weeks or greater, with planned low transverse uterine incision, cervical dilation of 6 cm or lower and station less than −3. Patients were randomized to either the one-handed or two-handed delivery group. The primary outcome was “U-D interval,” defined as the time from entry of the hands into the uterus to the delivery of the fetal head. The secondary outcome was incidence of hysterotomy extension. Neonatal safety data were also collected. RESULTS: A total of 40 patients participated in the study; 16 randomized to the one-handed group, 19 randomized to the two-handed group, and 5 patients excluded because of protocol deviation. U-D interval (mean±SD) was significantly shorter in the two-handed group (6.0±7.4 seconds) than in the one-handed group (14.3±9.9 seconds), P&lt;.001. There was no significant difference in incidence of hysterotomy extension, maternal and neonatal outcomes between the two groups. CONCLUSION: The two-handed method for fetal head delivery has a significantly decreased U-D interval compared to the one-handed method, without increasing the incidence of hysterotomy extension. A large-scale multicenter randomized controlled study is needed to further determine whether the “hand forceps” can be considered a safe alternative technique for delivery of the floating fetal head in cesarean sections.

Relation between perinatal outcome and gestational duration in term primiparous pregnancies stratified by body mass index.

There is growing evidence that induction of labor at 41 completed weeks improves neonatal outcome, at least among primiparous women. This study was performed to investigate whether maternal body mass index (BMI) should be considered when deciding on timing of intervention in term pregnancies. The study design was a historical cohort study using data from the Swedish Medical Birth Register, singletons in cephalic presentation with births 39+0 to 41+6 weeks, with available information on maternal BMI 2005-2017 (n= 352 567). Modified Poisson regression analyses were used to investigate the association between gestational duration and stillbirth or death before 45 postmenstrual weeks (primary outcome) and Apgar score <7 at 5 minutes (secondary outcome) by BMI, respectively. Adjustments were made for maternal age, smoking, country of birth and educational level. The adjusted relative risk (ARR) of stillbirth or death before 45 weeks among infants born at 41+0 to 41+6 vs 40+0 to 40+6 weeks, was 1.26 with a 95% confidence interval (CI) of 1.07-1.48. Among women with BMI≥30, the offspring mortality risk in pregnancies lasting 39+0 to 39+2 weeks was significantly above the corresponding risk among women of normal BMI who delivered at 41+0 to 41+2 weeks (ARR=1.95; 95% CI 1.07-3.56) but no statistically significant heterogeneity was found regarding the magnitude of the association between gestational duration and offspring mortality. The ARR, for Apgar <7 at 5minutes (41+0 to 41+6 vs 40+0 to 40+6 weeks, regardless of BMI), was 1.36 (95% CI 1.27-1.45). The risk for low Apgar score at 41+0 weeks was 1.5% among all children regardless of maternal BMI. Among children to women with BMI≥30, this magnitude of risk was found already at 39+3 weeks. In primiparous women with obesity the risk of stillbirth or death before 45 postmenstrual weeks were increased throughout all full-term gestational age categories, compared with women with overweight or normal BMI. Children to obese women had the same risk for Apgar scores <7 at 5minutes compared with women overall at earlier gestational age. The results suggest that maternal BMI needs to be considered when discussing timing of elective induction in term healthy pregnancies of primiparous women.

Optimal Gestational Weight Gain for Women With Obesity

ObjectiveTo determine the optimal gestational weight gain interval for women with obesity in order to minimize neonatal and maternal adverse events. MethodsSecondary analysis of the QUARISMA trial, including women with obesity who delivered a full-term singleton in cephalic presentation from 2008 to 2011 in Québec. The primary outcome was a composite risk of major neonatal morbidity. Secondary outcomes were composite risks of major maternal morbidity, minor neonatal and maternal morbidity, and cesarean delivery. Various ranges of weight gain were compared with the current recommendations (reference group) using logistic regression to identify an optimal gestational weight gain interval. In a secondary analysis, women with obesity were stratified by obesity class (I–III). ResultsAmong 16 808 eligible women with obesity, 3270 gained less weight than recommended, 4355 gained weight as recommended (5–9.09 kg), and 9183 gained more weight than recommended. Optimal gestational weight change for all women with obesity was –1 to +4 kg and was associated with reduced risk of major neonatal morbidity (aOR 0.49; 95%CI 0.33–0.73, P < 0.001) compared with the reference group. Analysis by class of obesity showed a reduced risk of major neonatal morbidity with a weight change of –1 to +4 kg for class I, –2 to +2 for class II), and –2 to +3 kg for class III. ConclusionCompared with the current guidelines, a gestational weight change of –1 to +4 kg is associated with reduced risk of adverse perinatal outcomes. While similar findings were seen among women with class I obesity, women with class II or III obesity could benefit from a lower weight gain.

Impact of Gestational Weight Gain Recommendations for Obese Women on Neonatal Morbidity.

In 2013, the American College of Obstetricians and Gynecologists (ACOGs) developed gestational weight gain guidelines to minimize the risks associated with obesity during pregnancy. However, a growing body of evidence suggests that current recommendations should be revised for obese women. The objective of this study is to assess the impact of gestational weight gain recommendations for obese women (body mass index ≥ 30 kg/m2) on neonatal and maternal outcomes in Quebec. Secondary analysis of the QUARISMA trial was performed including obese women who delivered a full-term singleton in cephalic presentation from 2008 to 2011 in Quebec. Outcomes assessed were composite risks of major neonatal and maternal complications, minor neonatal and maternal complications, as well as obstetrical interventions. Outcomes were compared between weight gain recommendations (reference group) and three weight gain/loss categories using logistic regressions. In second analysis, obese women were stratified by obesity class. Among the 16,808 eligible obese women, 605 lost weight during pregnancy, 2,665 gained between 0 and 4.9 kg, 4,355 gained weight within the recommendations (5-9.09 kg), and 9,183 gained at least 9.1 kg. Results showed a significant reduction in major neonatal morbidity (adjusted odds ratio [aOR] = 0.69, 95% confidence interval [CI] = 0.51-0.94), minor maternal morbidity (aOR = 0.79, 95%CI = 0.67-0.93), and assisted vaginal delivery (aOR = 0.82, 95%CI = 0.68-0.99) among women who gained 0 to 4.9 kg compared with the reference group. Cesarean delivery and preeclampsia/eclampsia were significantly reduced with weight loss (aOR = 0.76, 95%CI = 0.64-0.89 and 0.58, 95%CI = 0.42-0.78) compared with the reference group. Weight gain above recommendations was associated with an increased risk of minor neonatal morbidity, major and minor maternal morbidity, as well as cesarean delivery. Compared with a weight gain within the recommendations, a gestational weight gain/loss of less than 5 kg in obese women is associated with a reduced risk of major neonatal morbidity, minor maternal morbidity, preeclampsia/eclampsia, cesarean delivery, and assisted vaginal delivery. Guidelines on gestational weight gain for obese women should be updated. · Gestational weight gain/loss of less than 5 kg reduces the risk of perinatal complications.. · As suggested by ACOG recommendations, guidelines for obese women should be updated.. · Recommendations stratified by obesity class should be included in revised guidelines..

Term prelabor rupture of the membranes with unfavorable cervix: Frequency and factors associated with spontaneous onset of labor after two days of expectant management

IntroductionIn case of term prelabor rupture of membranes (PROM), expectant management is a reasonable option. We aimed at assessing the frequency of spontaneous onset of labor after two days of term PROM and its associated factors. Material and MethodsWomen delivering at a tertiary center of a singleton in cephalic presentation, after a term PROM with an unfavorable cervix and with an expectant management period of at least two days were included during a 2-year period. Women were excluded in case of induction of labor before or at day 2(D2) or of spontaneous labor before D2. The frequency of spontaneous labor was assessed, then maternal characteristics at admission and at D2 were compared between women with a spontaneous onset of labor before D3, and women with an induced labor at D3. The maternal and neonatal outcomes were compared between the two groups. The factors associated with spontaneous labor in univariate analysis were tested in multivariable analysis. ResultsAmong the 11 608 women delivering at term, 933(8.4%) had a term PROM. Among them, 191 had an unfavorable cervix after D2 including 86(45%) women with a spontaneous labor onset between D2 and D3 and 105(55%) induced at D3. Maternal age below 35 years (reference ≥35years) and Bishop score of 3,4 and 5,6 at D2 (reference score 0–2) were significantly associated with spontaneous onset of labor, respectively aOR 2.62; 95%CI[1.26–5.45], aOR 2.38; 95%CI[1.18–4.78] and aOR 10.16; 95%CI[3.67–28.15]. DiscussionIn women with a term PROM and an unfavorable cervix, spontaneous labor still occurs in nearly half of women undelivered after two days of expectant management.

Maternal body mass index and oxytocin in augmentation of labour in nulliparous women: a prospective observational study

ObjectiveTo evaluate oxytocin use for augmentation of labour in relation to body mass index (BMI) on admission to the labour ward, focusing on cumulative oxytocin dose and maximum rate of...

The Incidence of and Predictors for Severe Perineal Trauma and Intact Perineum in Women Having a Waterbirth in England: A Hospital-Based Study.

Background: To determine the incidence of and predictors for obstetric anal sphincter injuries (OASIS) and intact perineum in women giving birth in the water and compare with the general obstetric population. Materials and Methods: Data were retrospectively collected for women who had singleton cephalic presentation vaginal births in the water and the general obstetric population between August 2007 and December 2017. Results: We identified 1,007 women who had a waterbirth and 36,924 women from the general obstetric population. There was no significant difference in the incidence of OASIS between waterbirths and the general obstetric population (2.3% vs. 2.0%). Having a waterbirth was associated with a lower probability for an intact perineum (odds ratio [OR] = 0.83; confidence interval [95% CI]: 0.73-0.94) when compared with the general obstetric population (44.7% vs. 51.3%). Nulliparous women with a waterbirth when compared with multiparous women had an eightfold higher likelihood for the occurrence of OASIS (OR = 8.28; 95% CI: 2.64-25.86). The risk for a higher degree of OASIS was associated with increased maternal age in the total sample (OR = 1.08; 95% CI: 1.06-1.11) and with a lower body mass index (BMI) at booking in multiparous women (OR = 0.96; 95% CI: 0.92-0.99). The risk for any type of perineal trauma was associated with increased maternal age in the total sample (OR = 1.10; 95% CI: 1.07-1.13) and with a lower BMI at booking in multiparous women (OR = 0.95; 95% CI: 0.91-0.99). Conclusions: We found that giving birth in the water reduced the chance of having an intact perineum. We have also shown that nulliparity, increased maternal age in all women, and a lower BMI at booking in multiparous were associated with OASIS and lower rates of intact perineum in waterbirths.

Planned delivery route and outcomes of cephalic singletons born spontaneously at 24-31weeks' gestation: The EPIPAGE-2 cohort study.

The objective of this study was to investigate the association between planned mode of delivery and neonatal outcomes with spontaneous very preterm birth among singletons in cephalic presentation. Etude Epidémiologique sur les Petits Ages Gestationnels 2 is a French national, prospective, population-based cohort study of preterm infants. For this study, we included women with a singleton cephalic pregnancy and spontaneous preterm labor or preterm premature rupture of membranes at 24-31weeks' gestation. The main exposure was the planned mode of delivery (ie planned vaginal delivery or planned cesarean delivery at the initiation of labor). The primary outcome was survival at discharge and secondary outcome survival at discharge without severe morbidity. Propensity scores were used to minimize indication bias in estimating the association. The study population consisted of 1008 women: 206 (20.4%) had planned cesarean delivery and 802 (79.6%) planned vaginal delivery. In all, 723 (90.2%) finally had a vaginal delivery. Overall, 187 (92.0%) and 681 (87.0%) neonates in the planned cesarean delivery and planned vaginal delivery groups were discharged alive, and 156 (77.6%) and 590 (76.3%) were discharged alive without severe morbidity. After matching on propensity score, planned cesarean delivery was not associated with survival (adjusted odds ratio [aOR] 1.05, 95% confidence interval [CI] 0.48-2.28) or survival without severe morbidity (aOR 0.64, 95% CI 0.36-1.16). Planned cesarean delivery for cephalic presentation at 24-31weeks' gestation after preterm labor or preterm premature rupture of membranes does not improve neonatal outcomes.

Are there differences in pain intensity between two consecutive vaginal childbirths? A retrospective cohort study

BackgroundPain assessment is crucial for in-labour pain management. Even though women's self-rated pain intensity is the standard for pain relief or analgesic administration, multiparas appear to receive worse in-labour pain management than primiparas do. The discrepancy in pain perception between primiparas and multiparas remains unclear. Healthcare providers tend to think that multiparas endure the pain and report less pain because they have experienced childbirth. ObjectiveTo retrospectively analyse the intensity of in-labour pain during first and second vaginal childbirth within the same group of women and explore whether parity may be an influential factor in labour pain intensity. DesignRetrospective cohort study. SettingLabour and delivery in a large academic specialized hospital in Guangzhou, China. ParticipantsWomen were included if they had two consecutive vaginal childbirths with singleton cephalic presentations and cervical dilation ≤ 3 cm for the first childbirth and ≤ 2 cm for the second childbirth. The final study sample consisted of 417 women. MethodsAll childbirth case records between January 2015 and August 2018 were scanned using a structured electronic medical system. Maternal and neonatal demographics as well as obstetric and neonatal outcomes were extracted. The in-labour pain for each childbirth was compared between first and second births. Paired t-tests, McNemar's chi-square tests and mixed-effects modelling were applied to compare the differences in labour pain intensity between the two vaginal childbirths and explore the factors that influenced maximum labour pain scores during the second childbirth. ResultsFour hundred seventeen women were included, with an average birth interval of 1.7 years. The average maximum labour pain score during the latent phase was 6 (5,6) for the first childbirth and 5 (4,6) for the second childbirth (paired t =-6.13, P <0.001). Pain scores decreased in 28.1% (117/417) of women and increased in 13.7% (57/417) of women from the first to the second childbirth. More than half of the women in our study experienced the same maximum labour pain score during the first and second labour. Mixed-effects modelling revealed that parity, education and pregnancy complications were independently associated with maximum labour pain scores. ConclusionsFrom a clinical point of view, in-labour pain is not clinically different for women when comparing their first and second labours. Health care professionals may underestimate in-labour pain in primiparas when comparing them with nulliparas. More studies are warranted to explore options for achieving better pain management for women with more childbirths.

Risk factors for failed induction of labor among pregnant women with Class III obesity.

Our aim was to identify risk factors for failed induction in morbidly obese patients undergoing the induction of labor at term. This was a retrospective multicenter study on a cohort of 235 patients with a body mass index greater than 40kg/m2 and giving birth to a singleton in cephalic presentation, who had an induction of labor from 38weeks of amenorrhea. Scheduled cesareans and spontaneous vaginal deliveries were excluded. Maternal, peri-partum and neonatal characteristics were analyzed according to the delivery route. In all, 235 patients were included. Of these, 62.5% patients delivered vaginally and 37.5% by cesarean section. The frequency of nulliparity was greater in patients who had a cesarean section (56 [interquartile range, IQR, 38.1] vs 56 [IQR 63.6], P<.001). In multivariate analysis, nulliparity (odds ratio [OR] 2.81, 95% confidence interval [CI] 1.58-4.97], P<.001), low Bishop's score (OR .794, 95% CI .70-.90, P<.001) and weight gain (OR 1.04, 95% CI 1.01-1.08, P=.033) were independent risk factors for failed induction. Umbilical cord pH at birth lower than 7 (0 vs 7 [IQR 8.0], P<.001) and lower than 7.20 (36 [IQR 24.5] vs 35 [IQR 39.8], P=.014) as well as the Apgar at 1minute (14 [IQR 9.5] vs 17 [IQR 19.3], P=.032) was significantly higher in infants born by cesarean section. In this cohort, 63% of women with Class III obesity had successful inductions of labor; risk factors for failed induction include nulliparity and unfavorable Bishop score.

The effect of the use of a decision aid with individual risk estimation on the mode of delivery after a caesarean section: A prospective cohort study.

ObjectiveAfter one previous caesarean section (CS), pregnant women can deliver by elective repeat CS or have a trial of labor which can end in a vaginal birth after caesarean (VBAC) or an unplanned CS. Despite guidelines describing women’s rights to make an informed choice, trial of labor and VBAC rates vary greatly worldwide. Many women are inadequately informed due to caregivers’ fear of an increase in CS rates in a high VBAC rate setting. We compared counseling with a decision aid (DA) including a prediction model on VBAC to care as usual. We hypothesize that counselling with the DA does not decrease VBAC rates. In addition, we aimed to study the effects on unplanned CS rate, patient involvement in decision-making and elective repeat CS rates.MethodsWe performed a prospective cohort study. From 2012 to 2014, 483 women in six hospitals, where the DA was used (intervention group), were compared with 441 women in six matched hospitals (control group). Women with one previous CS, pregnant of a singleton in cephalic presentation, delivering after 37 weeks 0 days were eligible for inclusion.ResultsThere was no significant difference in VBAC rates between the intervention (45%) and control group (46%) (adjusted odds ratio 0,92 (95% Confidence interval 0.69–1.23)). In the intervention group more women (42%) chose an elective repeat CS compared to the control group (31%) (adjusted odds ratio 1.6 (95% Confidence interval 1.18–2.17)). Of women choosing trial of labor, in the intervention group 77% delivered vaginally compared to 67% in the control group, resulting in an unplanned CS adjusted odds ratio of 0,57 (0.40–0.82) in the intervention group. In the intervention group, more women reported to be involved in decision-making (98% vs. 68%, P< 0.001).ConclusionsImplementing a decision aid with a prediction model for risk selection suggests unchanged VBAC rates, but 40% reduction in unplanned CS rates, increase in elective repeat CS and improved patient involvement in decision-making.

Effect of simulation-based training on the accuracy of fetal head position determination in labor

ObjectivesThe objective of this study was to evaluate the effect of simulation-based training on the accuracy of fetal head position determination by junior residents during the second stage of labour. Study DesignThis prospective study was conducted in a tertiary care university hospital. During an initial period of 12 weeks, 13 junior residents were asked to routinely evaluate fetal head position by digital examination during the second stage of labour, in women with term singletons in cephalic presentation. Digital examination was followed immediately by transabdominal ultrasound to confirm fetal head position, performed by an experienced physician. Following this initial period, all participants attended a workshop where simulation-based training of fetal head position determination was provided. A second 12-week period was subsequently completed, with similar characteristics to the initial one. The accuracy of clinical evaluations was assessed by the percentage of exact evaluations, the percentage of correct evaluations within a 45° error margin, and by Cohen’s kappa coefficient of agreement. ResultsA total of 83 observations were performed in the initial period of the study and 74 observations were performed in the second period. The accuracy of fetal head position determination during the first period of the study was 59.0% (95% CI 47.7–69.7), k = 0.517 (95%CI 0.391 - 0.635), corresponding to a moderate agreement. Considering a 45° margin of error, accuracy was 71.1% (95% CI 60.1–80.5), k = 0.656 (95% CI 0.538 – 0.763), corresponding to substantial agreement. Following simulation-based training, the accuracy of fetal head position determination was 70.3% (95% CI 58.5–80.3), k = 0.651 (95% CI 0.526 - 0.785), corresponding to a substantial agreement. Considering a 45° margin of error, accuracy was 78.4% (95% CI 67.3–87.1), k = 0.745 (95% CI 0.631 – 0.854), corresponding to a substantial agreement. ConclusionsAlthough a trend towards increased accuracy in fetal head position determination was observed after simulation-based training, the difference was not statistically significant. Further studies are needed to clarify the role of simulation-based training for fetal head position determination during residency.

The impact of a national cardiotocography education program on neonatal and maternal outcomes: A historical cohort study.

Studies indicate an association between errors in cardiotocography (CTG) management and hypoxic brain injuries among newborns. Continuing professional education is recommended. We aimed to examine whether the implementation of a national interprofessional CTG education program in Denmark was associated with a decrease in risk of fetal hypoxia measured by umbilical cord pH<7.00, 5-minute Apgar score<7 or neonatal therapeutic hypothermia. As a secondary aim, we assessed whether the educational intervention was associated with an increase in operative deliveries. We conducted a historical cohort study from 2009 to 2015 including all intended vaginal deliveries with liveborn singletons in cephalic presentation and gestational age≥37weeks. Data were retrieved from the Medical Birth Register and the National Patient Register. The study period was divided in three: pre-implementation (2009-2012), implementation (2013) and post-implementation (2014-2015). Using logistic regression we estimated odds ratios (OR) of fetal hypoxia outcomes using the pre-implementation period as reference. Analyses were adjusted for potential maternal, neonatal and delivery-associated confounders. Missing data were accounted for by multiple imputation. In all, 331282 deliveries were included. Overall risks of pH<7.00, Apgar score<7 and therapeutic hypothermia were respectively 0.45%, 0.58% and 0.06%. Adjusted OR in the post-implementation period were 1.12 (95% confidence interval [CI] 1.00-1.26), 0.99 (95% CI 0.90-1.10) and 1.34 (95% CI 0.99-1.82) for the three outcomes, respectively. The pH missingness equaled 12.4%. Odds of emergency cesarean section was unaltered, whereas the odds of assisted vaginal delivery decreased by 14% (0.86, 95% CI 0.84-0.89). Healthcare professionals are considered the weakest link of CTG technology. We did not find that increasing healthcare professionals' CTG interpretation skills affected the risk of fetal hypoxia. Missing data for pH values were substantial and represent a limitation of the study. We cannot with certainty rule out that missingness masked a true effect of the intervention. Our study indicates that assisted vaginal deliveries can be decreased without an increased risk of fetal hypoxia. Dilution of effect in a complex clinical setting, rare outcomes, insufficient intervention and a possible overestimation of the impact of errors in CTG management might explain the lack of effect.

Value-based health care in obstetrics.

We strive to maximize outcomes that are relevant to the women who deliver in our hospital. We demonstrate a practical method of using value-based health care (VBHC) concepts to analyse how care can be improved. Using International Consortium of Health Outcome Measurements (ICHOM) set, a practical outcome set was constructed for women who go into spontaneous labour at term of a singleton in cephalic presentation and used for benchmarking. We included data on interventions that are major drivers of outcomes. Data from two hospitals in Amsterdam and for The Netherlands for 2011 to 2015 were collected. Benchmarking of readily available data helped identify a number of statistically significant and clinically relevant differences in obstetric outcomes. Caesarean section rate was significantly different at 13.7% in hospital 2 compared with 11.5% in hospital 1 with similar neonatal outcomes. Third and fourth degree tearing rates were significantly higher for hospital 1 at 5.5% compared with 3.6% for hospital 2 and the national average of 3.5%. On the basis of the guidelines, literature, and discussion, initiatives on how to improve these outcomes were then identified. These include caesarean section audit and guidelines regarding caesarean section decision making. In order to reduce the rate of third and fourth degree tearing, routine episiotomy on vaginal operative deliveries was introduced, and a training programme was set up to make care providers more aware of risk factors and potential preventive measures. Defining, measuring, and comparing relevant outcomes enable care providers to identify improvements. Collection and comparison of readily available data can provide insights in where care can be improved. Insights from literature and comparison of care practices and processes can lead to how care can be improved. Continuous monitoring of outcomes and expanding the set of outcomes that is readily available are key in the process towards value-based care provision.