Singleton Fetus In Vertex Presentation Research Articles

Time matters: Cervical ripening balloon for 6 versus 12 h-Retrospective comparison between two protocols.

Recently, two randomized controlled trials compared removal of cervical ripening balloon (CRB) after 6 versus 12 h. Their results showed similar Bishop score changes in both groups and a shorter time to delivery in the 6-h group. Neither of the studies was powered to show difference in mode of delivery. The aim of this study was to compare mode of delivery when the CRB was removed after 6 versus 12 h. A historical control study comparing induction of labor with a CRB between two time periods, one in which the CRB was removed after 12 h (12-h group), and the other in which it was removed after 6 h (6-h group). We included term pregnancies with a singleton fetus in vertex presentation. We excluded patients with a previous cesarean delivery, failed ripening with prostaglandins prior to CRB insertion, and any contraindication for vaginal delivery. The primary outcome was mode of delivery. Secondary outcomes included delivery within 24 h and other maternal and neonatal outcomes. We included 1704 patients, 914 in the 12-h group, and 717 in the 6-h group. Removal after 6 h was associated with a lower rate of cesarean and instrumental deliveries (28.6% vs 22.5%, and 12% vs 6.2%, respectively) and a higher rate of vaginal delivery within 24 h. All differences were statistically significant. Removing a cervical ripening balloon after 6 rather than 12 h is associated with reduced cesarean and instrumental delivery rates, and should be considered as a reasonable, and potentially superior alternative in labor induction protocols with intracervical ripening balloon.

Outpatient balloon catheter vs inpatient prostaglandin for induction of labor: a randomized trial

Approximately 1 in 4 pregnant women undergo induction of labor. Meta-analyses have shown that mechanical methods of induction of labor are safe and effective, as is starting induction in an outpatient setting. However, few studies have evaluated outpatient balloon catheter induction in comparison with pharmacologic methods. This study aimed to determine whether women who underwent outpatient induction of labor with a balloon catheter would have a lower cesarean delivery rate than women who underwent inpatient induction of labor with vaginal prostaglandin E2 without an increase in adverse maternal or neonatal events. This was a superiority randomized controlled trial. The eligibility criteria were pregnant women (nullipara and multipara) with a live singleton fetus in vertex presentation with any medical comorbidity who underwent planned induction of labor at term and who had an initial modified Bishop Score of 0 to 6 at 1 of 11 public maternity hospitals in New Zealand. The intervention groups were outpatient single balloon catheter induction in comparison with inpatient vaginal prostaglandin E2 induction. The primary hypothesis was that participants who started their induction at home with a balloon catheter would have a lower risk for cesarean delivery than participants who started their induction with prostaglandins and remained in hospital throughout. The primary outcome was cesarean delivery rate. Participants were randomized using a centralized secure online randomization website in a 1:1 ratio, stratified by parity and hospital. The participants and outcome assessors were not blinded to group allocation. An intention-to-treat analysis with adjustment for stratification variables was used. A total of 539 participants were randomized to outpatient balloon catheter induction, and 548 participants were randomized to inpatient prostaglandin induction; the mode of birth was reported for all participants. The cesarean delivery rate was 41.0% among participants allocated to outpatient balloon induction and 35.2% among those allocated to inpatient prostaglandin induction (adjusted odds ratio, 1.27; 95% confidence interval, 0.98-1.65). Women in the outpatient balloon catheter group were more likely to have artificial rupture of membranes and to received oxytocin and an epidural. No differences were found in the rates of adverse maternal or neonatal events. Outpatient balloon catheter induction was not found to reduce the cesarean delivery rate when compared with inpatient vaginal prostaglandin E2 induction. However, the use of balloon catheters in an outpatient setting does not seem to increase the rate of adverse events for mothers or babies and can be offered routinely.

Oxytocin versus prostaglandins for labour Induction of women with an unfavourable cervix after 24 hours of cervical ripening (OPIC): protocol for an open multicentre randomised non-inferiority trial

IntroductionIt remains uncertain whether the most appropriate management for women with an unfavourable cervix after 24 hours of cervical ripening is repeating the ripening procedure or proceeding directly to induction...

Grand multiparity, is it a help or a hindrance in a trial of labor after cesarean section (TOLAC)?

Objective Parity is a prognostic variable when considering trial of labor after cesarean section (TOLAC). This study aimed to determine whether grandmultiparous patients are at increased risk of poor TOLAC outcomes such as uterine rupture. Study design A retrospective cohort was conducted at a single university-affiliated medical center with approximately 10,000 deliveries per year. The study group included women post one cesarean section who attempted TOLAC carrying a singleton fetus in vertex presentation. We divided the cohort into three groups: group 1 – women who had a parity of 1; group 2 – parity of 2–4; group 3 – parity of 5 and above. The primary outcome was successful VBAC. Secondary outcomes included mode of delivery, uterine rupture, and combined maternal and neonatal adverse outcomes. Data were analyzed using Fisher’s exact test, Chi-square test, ANOVA, and paired t-test. Results Five thousand four hundred and forty-seven women comprised the study group: group 1 – 879 patients, group 2 – 2374 patients, and group 3 − 2194 patients. No significant between-group differences were found in gestational age at delivery. Rates of a successful VBAC were 80.6%, 95.4%, and 95.5%, respectively. Group 1 were more likely to have a failed TOLAC compared to group 2 (OR 5.02, 95% CI 3.9–6.5, p<.001) and group 3 (OR 5.17, 95% CI 4.0–6.7, p<.001). There was no increased risk of failed TOLAC when comparing groups 2 and 3 (OR 1.03; 95% CI 0.8–1.4, p=.89). Operative delivery rate differed significantly between all three groups; 25.1%, 6.2%, and 3.6%, for groups 1, 2, and 3, respectively (p<.001). The rate of uterine rupture was significantly higher in group 1 compared to group 2 (1.02% vs. 0.29% p=.02) and group 3 (1.02% vs. 0.2%, p=.01, respectively). There were no differences between group 2 and group 3 (0.29% vs. 0.2% p=.78). Conclusions Grandmultiparity is not associated with an increased risk of uterine rupture during TOLAC.

Contextualizing disparities in NTSV cesarean rates with county-level data

The rate of cesarean births among nulliparous women with a term singleton fetus in vertex presentation (NTSV) is a quality indicator for perinatal care. Black women are disproportionately affected by high rates of unplanned cesarean birth and are at increased risk for the associated complications. We sought to describe disparities in the county-level NTSV cesarean birth rate in the United States to understand how cesarean disparities vary by place.

Preterm Birth and Small-for-Gestational Age Neonates among Prepregnancy Underweight Women: A Case-Controlled Study.

The aim of our study was to investigate whether prepregnancy underweight body mass index (BMI) is associated with preterm birth (PTB) and small-for-gestational age (SGA). This retrospective case-control study included 814 women with live singleton fetuses in vertex presentation that gave birth between January 2016 and November 2016 in two tertiary care hospitals. The study group (n = 407) comprised all women whose prepregnancy BMI was underweight (<18.5 kg/m2) and who delivered during the study period. A control group (n = 407) was established with women whose prepregnancy BMI was normal (18.5–24.9 kg/m2) by matching age and parity. Univariate and multivariate analyses were performed to compare PTB and SGA associated with prepregnancy underweight BMI. Compared with the control group, the study group had higher rates of overall PTB (10.1% vs. 5.7%, p = 0.02), iatrogenic PTB (4.2% vs. 1.5%, p = 0.02), and SGA (22.1% vs. 11.1%, p < 0.001). In a multivariable analysis, prepregnancy underweight BMI was associated with PTB (aOR 2.32, 95% CI 1.12–4.81) and with SGA (aOR 2.38, 95% CI 1.58–3.58). In singleton pregnancies, women’s prepregnancy underweight compared with normal BMI was associated with an increase in PTB and in SGA neonates. Identifying this specific high-risk group is pragmatic and practical for all physicians, and they should be aware about perinatal outcome among underweight women.

Outcomes of Expectant Management of Term Prelabor Rupture of Membranes

ObjectiveTo assess rates of induction/augmentation of labor, maternal infection, neonatal outcomes, and time to birth when women were expectantly managed after term prelabor rupture of membranes (PROM) at home or in the hospital. DesignRetrospective, descriptive study based on a review of data from a hospital midwifery service database and chart review. SettingA large Midwest hospital with 4,700 births annually. ParticipantsWe used the cases of women who received midwifery care, experienced term PROM, and had singleton fetuses in the vertex position. MethodsWe conducted an analysis of maternal and neonatal outcomes with term PROM using data from a midwifery service quality improvement database. We compared characteristics and outcomes between management plans (immediate induction, expectant hospital, and expectant home) using chi-square, analysis of variance, and independent t-tests. ResultsPROM occurred in 281 (12%) of the 2,357 women cared for by the midwifery service between January 2016 and December 2018. One hundred fifty women (53.3%) opted to wait for labor onset at home, 102 (36.3%) were expectantly managed in the hospital, 21 (7.5%) were admitted for immediate induction of labor, and 8 (2.8%) were admitted for immediate cesarean birth. The rate of spontaneous labor onset was not significantly different between the two expectant management groups or between nulliparous and multiparous women. A total of 88 (34.9%) women who were expectantly managed ultimately had their labors induced. Rates of chorioamnionitis and endometritis were not significantly different between the expectant management groups in this study or compared with national averages. There was no difference in NICU admissions or Apgar scores below 7. The mean time from PROM to birth was significantly shorter in the expectant management in hospital group (27.3 hours) than in the expectant management at home group (33.5 hours). ConclusionExpectant management at home or in the hospital is appropriate for low-risk pregnant women with term PROM. Women for whom this option is appropriate include those with term singleton fetuses in vertex presentation with reassuring fetal heart rates and confirmed clear amniotic fluid. Acceptable time frames for home management include up to 24 hours for women with negative group B streptococcus cultures and up to 12 hours for those with positive cultures.

Postpartum Hemorrhage and Very Advanced Maternal Age [28M

INTRODUCTION: Postpartum hemorrhage (PPH) is an important cause of maternal morbidity. Identifying women at increased risk for PPH can help reduce morbidity. The aim of this study was to determine if women over 45 years (very advanced maternal age, VAMA) are at increased risk for PPH. METHODS: Retrospective study of term, nulliparous women with singleton fetuses in vertex presentation who delivered at Kaiser Permanente Northern California Hospitals from 2010-2017 with complete data recorded. Incidence of PPH (estimated blood loss &gt;500 cc for vaginal delivery, &gt;1,000 cc for cesarean delivery, or other definitive chart evidence) among women over 45 years was compared to incidence of PPH among younger women. Logistic regression was used to adjust for confounders. RESULTS: There were 98,922 women included, including 177 women over 45 years. PPH occurred in 33.3% of women &gt;45 years as compared to 15.6% of women 45 years had significantly increased odds of PPH as compared to women &lt;35 years (OR 1.88, 95% CI 1.35–2.61). CONCLUSION: These data demonstrate that VAMA is an independent risk factor for PPH. This knowledge provides physicians with an opportunity to counsel patients over 45 years regarding the risk for PPH and to prepare for delivery with strategies including optimization of blood count, planning for delivery location and procurement of appropriate blood products before delivery.

Efficacy of transcutaneous electrical acupoint stimulation combined with epidural block for labor analgesia in parturients with preeclampsia

Objective To evaluate the efficacy of transcutaneous electrical acupoint stimulation (TEAS) combined with epidural block for labor analgesia in parturients with preeclampsia. Methods One hundred and twenty parturients with preeclampsia who were at full term with a singleton fetus in vertex presentation, aged 24-37 yr, weighing 66-105 kg, with height between 157-171 cm, of American Society of Anesthesiologists physical status Ⅲ, were divided into 3 groups (n=40 each) using a random number table method: epidural labor analgesia in active phase of labor group (group A), epidural labor analgesia in latent phase of labor group (group B) and TEAS combined with epidural labor analgesia in active phase of labor group (group C). Epidural labor analgesia was performed in active phase of labor (cervical dilatation≥3 cm) in group A and in latent phase of labor (cervical dilatation≥1 cm) in group B. In group C, TEAS was carried out in latent phase of labor, bilateral Hegu and Sanyinjiao acupoints were selected as the main acupoints and Zusanli as the auxiliary acupoints, patients received TEAS with a frequency 2/100 HZ, disperse dense waves, intensity (starting at a voltage of 15 mA) increasing to the maximum current that could be tolerated until delivery of fetus, and epidural labor analgesia was performed when parturients were in active phase of labor.Epidural labor analgesia solution contained the mixture (100 ml) of 0.08% ropivacaine and sufentanil 0.4 μg/ml, and the analgesia pump was set up to deliver a 5 ml bolus dose with a 30-min lockout interval and background infusion at 8 ml/h and then turned off after delivery of fetus.Mean arterial pressure and visual analogue scale (VAS) scores were recorded when the cervical dilation was 1, 2, 3, 4 and 10 cm and immediately after delivery.The labor time, volume of postpartum hemorrhage, requirement for oxytocin, cesarean section, adverse reactions and Apgar score of the newborn were recorded.Maternal venous blood samples were collected when the cervical dilation was 1 and 10 cm for determination of the concentrations of dynorphin (DYN) and cortisol in serum and adrenocorticotropic hormone, norepinephrine and epinephrine in plasma (by enzyme-linked immunosorbent assay) and serum glucose concentration (by glucose oxidase method). Results Compared with group C, the VAS scores and mean arterial pressure were significantly increased when the cervical dilation was 2 and 3 cm, the concentrations of DYN, cortisol and blood sugar in serum and adrenocorticotropic hormone, norepinephrine and epinephrine in plasma were increased when the cervical dilation was 10 cm(P 0.05), and the duration of the first stage of labor was significantly prolonged, the requirement for oxytocin was increased, the serum concentration of DYN was decreased when the cervical dilation was 10 cm (P 0.05). Conclusion Compared with epidural labor analgesia performed in the latent and active phases of labor, TEAS combined with epidural block provides better efficacy for labor analgesia in parturients with preeclampsia. Key words: Electric stimulation therapy; Analgesia, epidural; Labor pain; Pre-eclampsia

Effect of psychosocial nursing intervention on analgesic efficacy of labour analgesia in parturients

Objective To evaluate the effect of psychosocial nursing intervention on the analgesic efficacy of labour analgesia in parturients. Methods A total of 160 parturients, aged 18-35 yr, with a singleton fetus in vertex presentation at 38-41 week gestation, who required labor analgesia voluntarily, were divided into 2 groups (n=80 each) using a random number table: control group (group C) and psychosocial nursing intervention group (group I). The epidural catheter was placed at L2, 3 interspace when the cervical dilation was 3 cm, and 0.1% ropivacaine 12 ml was injected.And then patient-controlled epidural analgesia (PCEA) was performed.The solution for PCEA contained 0.1% ropivacaine and hydromorphone hydrochlorid 2.5 μg/ml(diluted to 160 ml in 0.9% normal saline). The catheter was connected to a PCEA pump programmed to deliver 6 ml with a lockout interval of 12 min, background infusion at 0.1 ml/h and limit dose of 30 ml/h.After the initial administration of ropivacaine, parturients were only informed of the usages and notice items of the PCEA pump in group C, and in addition psychological nursing intervention was carried out, and the peak effect of drugs and principle of PCEA pump were also introduced in group I. The intensity of pain was assessed using visual analogue scale score before labour analgesia and at 15, 30, 60, 120, 180 and 240 min after labour analgesia.The development of adverse reactions such as lower extremity numbness, motor nerve block, nausea and vomiting, pruritus, urinary retention and hypotension after labour analgesia was recorded.Parturient′s satisfaction with labour analgesia was evaluated at 24 h after the end of delivery, and the rate of satisfactory analgesia was calculated. Results Compared with group C, visual analogue scale scores were significantly decreased at 60, 120, 180 and 240 min after labour analgesia, and the rate of satisfactory analgesia was increased in group I (P<0.05). One patient developed motor nerve block at 30 min after labour analgesia in group C, and no patient developed motor nerve block after labour analgesia in group I. No adverse reactions such as lower extremity numbness, nausea and vomiting, pruritus, urinary retention or hypotension were found in the two groups. Conclusion Psychosocial nursing intervention can raise the analgesic efficacy of labour analgesia in parturients. Key words: Labor pain; Analgesia, epidural; Propaganda and education

Variation in Cesarean Birth Rates by Labor and Delivery Nurses

ObjectiveTo examine variation in the cesarean birth rates of women cared for by labor and delivery nurses. DesignRetrospective cohort study. SettingOne high-volume labor and delivery unit at an academic medical center in a major metropolitan area. ParticipantsLabor and delivery nurses who cared for nulliparous women who gave birth to term, singleton fetuses in vertex presentation. MethodsData were extracted from electronic hospital birth records from January 1, 2013 through June 30, 2015. Cesarean rates for individual nurses were calculated based on the number of women they attended who gave birth by cesarean. Nurses were grouped into quartiles by their cesarean rates, and the effect of these rates on the likelihood of cesarean birth was estimated by a logit regression model adjusting for patient-level characteristics and clustering of births within nurses. ResultsSeventy-two nurses attended 3,031 births. The mean nurse cesarean rate was 26% (95% confidence interval [23.9, 28.1]) and ranged from 8.3% to 48%. The adjusted odds of cesarean for births attended by nurses in the highest quartile was nearly 3 times (odds ratio = 2.73, 95% confidence interval [2.3, 3.3]) greater than for births attended by nurses in the lowest quartile. ConclusionThe labor and delivery nurse assigned to a woman may influence the likelihood of cesarean birth. Nurse-level cesarean birth data could be used to design practice improvement initiatives to improve nurse performance. More precise measurement of the relative influence of nurses on mode of birth is needed.

A randomized trial of Foley balloon induction of labor trial in nulliparas (FIAT-N)

With an increasing rate of induction of labor, it is important to choose induction methods that are safe and efficient in achieving a vaginal delivery. The optimal method for inducing nulliparous women with an unfavorable cervix is not known. We sought to determine if induction of labor with simultaneous use of oxytocin and Foley balloon vs sequential use of Foley balloon followed by oxytocin decreases the time to delivery in nulliparous women. We conducted a randomized controlled trial of nulliparous women presenting for induction at a single institution from December 2013 through March 2015. After decision for induction was made by their primary provider, women with gestational age ≥24 weeks with a nonanomalous, singleton fetus in vertex presentation with intactmembranes were offered participation. Exclusion criteria included history of uterine surgery, unexplained vaginal bleeding, latex allergy, or contraindication to vaginal delivery. Participants were randomized to either simultaneous (oxytocin and Foley balloon) or sequential (oxytocin after expulsion of Foley balloon) induction group. The primary outcome was time from induction to delivery. Secondary outcomes included mode of delivery, estimated blood loss, postpartum hemorrhage, chorioamnionitis, and composite neonatal outcome. Maternal and neonatal outcomes were collected via chart review. Analyses were done on an intention-to-treat basis. A total of 166 patients were enrolled; 82 in the simultaneous and 84 in the sequential group. There were no differences in baseline characteristics in the 2 groups. Patients who received simultaneous oxytocin with insertion of a Foley balloon delivered significantly earlier (15.92 vs 18.87 hours, P= .004) than those in the sequential group. There was no difference in rate of cesarean delivery, estimated blood loss,postpartum hemorrhage, chorioamnionitis, or composite neonatal outcome. Simultaneous use of oxytocin and Foley balloon for induction of labor results in a significantly shorter interval to delivery in nulliparas.

Effect of labor analgesia on development of postpartum depression

Objective To evaluate the effect of labor analgesia on the development of postpartum depression. Methods Seventy nulliparous parturients who were at full term with a singleton fetus in vertex presentation, aged 20-35 yr, with body mass index<27 kg/m2, at 38-41 weeks of gestation, of ASA physical statusⅠ, were enrolled and divided into 2 groups(n=35 each)using a random number table: vaginal delivery group(group VD)and labor analgesia group(group LA). In LA group, the epidural catheter was placed at L2, 3 interspace for combined spinal-epidural analgesia when their cervical dilations were in 2-3 cm.VAS score was maintained below 3 after the analgesia.Parturients completed Edinburgh Postnatal Depression Scale questionnaires 42 days after the labor.The development of depression was recorded. Results The incidence of postnatal depression was significantly lower in LA group(17%)than in VD group(40%). Conclusion Labor analgesia can decrease the development of postpartum depression. Key words: Analgesia, obstetrical; Depression, postpartum

Spontaneous hemoperitoneum with intrahepatic cholestasis during the third trimester of pregnancy

Spontaneous hemoperitoneum in pregnancy is a rare but potentially life-threatening condition for the mother and fetus. A case of spontaneous hemoperitoneumwith intrahepatic cholestasis of pregnancy during the third trimester is presented. The bleeding site remained undiscovered after two exploratory laparotomies. A 33-year-old woman (G5, P1) at 32 weeks of pregnancy presented at the affiliated hospital of North Szechwan Medical College in January 2012 with acute pain in the right middle abdomen that had been ongoing for 6 hours. The patient reported no history of trauma or previous cesarean delivery, had no vaginal bleeding, no fever or vomiting, and had not received regular prenatal check-ups. Her vital signs were stable and there was severe abdominal tenderness on physical examination. Fundal height was 32 cm and the patient’s cervix was not effaced. A nonstress test was reactive and uterine contractions were not detected. The laboratory results indicated infection and mild anemia (Table 1). Sonographic examination showed a singleton fetus in vertex presentation and the patient’s liver, spleen, and gallbladder were normal; appendicitis was suspected. An exploratory laparotomy was performed under epidural anesthesia. The incision was made over the right lower quadrant and a profuse amount of blood and a blood clot were observed. The appendix was intact. A right paramedian incision was then performed under general anesthetic. After removing 1.5 liters of intraperitoneal clotted blood, the peritoneal cavity was palpated carefully to find the source of the bleeding. The explorationwas suboptimal owing to the enlarged uterus, and no obvious active bleeding was found. The patient’s condition was stable and preterm delivery was avoided. Surgical drainswere left in place postoperatively tomonitor the output. The daily output was 30–50 mL of exudative sanguineous fluid and there was no evidence of new active bleeding. The patient received dexamethasone, formula supplements including vitamin B complex, aminofusin, and potassium and magnesium aspartate, and a red blood cell suspension transfusion of 7 units. Laboratory results on the seventh day after the first laparotomy raised suspicion for intrahepatic cholestasis of pregnancy with associated hypoproteinemia (Table 1). A viable male neonate weighing 2390 g was delivered by emergency cesarean and treated in the intensive care unit. APGAR scores were 9 and 10 at 1 and 5 minutes, respectively. Following closure of the uterine incision, a second laparotomy was performed to check the abdominal and pelvic organs, but the origin of the hemorrhage could still not be located. The postoperative period was uneventful. The patient and neonate were discharged on the ninth day after delivery. No further hemoperitoneum or adverse outcomes occurred during the next six months of follow-up. Spontaneous hemoperitoneum during the second or third trimester of pregnancy is rare. Thepathogenesis of spontaneous hemoperitoneum is unclear because it may develop from the rupture of various abdominal or pelvic structures, including the liver, spleen, uterus, and blood vessels [1]. A review of the literature and 25 cases reported that endometriosis might be another risk factor for the condition [2]. Only one International Journal of Gynecology and Obstetrics 127 (2014) 297–300

The incidence and risk factors for retained placenta after vaginal delivery – a single center experience

Objective: We aimed to determine the incidence and risk factors for retained placenta immediately after vaginal delivery in a single, university-affiliated tertiary center.Methods: A case-control study. Women who delivered vaginally and diagnosed with suspected retained placenta were compared to control group of women with spontaneous vaginal delivery with spontaneous non-complicated placental separation between the years 2007 and 2012. Eligibility was limited to singleton fetuses in vertex presentation with no history of more than one cesarean section, stillbirth or major fetal anomaly.Results: Overall, 33 925 women delivered vaginally, of them, 491 (1.4%) underwent revision of uterine cavity due to suspected retained placenta. Women with retained placenta were characterized by a higher rate of previous cesarean section (OR 1.71, 95% CI 1.23–2.36), previous abortions, lower parity (OR 0.79, 95% CI 0.68–0.91), lower gestational age at delivery. Hypertensive disorders, oligohydramnios and labor and delivery interventions as induction of labor (OR 1.84, 95% CI 1.30–2.59), neuro-axial analgesia (OR 1.60, 95% CI 1.27–2.00) and vacuum delivery (OR 1.89, 95% CI 1.48–2.41) were independently associated with uterine revision for retained placenta.Conclusion: Risk factors for manual revision due to retained placenta can be recognized. This data should be taken into consideration in the assessment of women immediately after delivery.

Selective Vaginal Breech Delivery at Term—Still an Option

The mode of delivery for breech presentation has long been a subject of debate. Planned cesarean delivery (CD) has become the favored method, but planned vaginal delivery (VD) is still considered an acceptable option in some settings. This study was undertaken to assess the neonatal and maternal outcomes of planned vaginal breech delivery (planned VD), planned breech CD (planned CD), or planned VD in vertex presentation. Only patients with live singleton fetuses at gestation of 37 weeks or more were included. Deliveries planned to be by CD were classified as planned CD, and those planned to be vaginal deliveries were classified as planned VD, regardless of the actual delivery mode. For every planned breech VD, a term, singleton fetus in vertex presentation was selected as an additional control. The final population totaled 1008 deliveries, of which 497 (66.2% of breech deliveries) were in the planned CD group, 254 (33.8% of breech deliveries) were in the planned VD group, and 257 were in the vertex group. From a total of 24,850 deliveries, the incidence of term, singleton breech delivery was 3.1%. The most common indication for planned CD was either the mother’s fear of VD or her expressed desire for an elective CD. The primary end point was neonatal mortality or serious morbidity and serious maternal morbidity. Low Apgar scores (≤6 at 1 or 5 minutes) and an umbilical artery pH less than 7.05 were secondary end points. All statistical analyses were done using SPSS for Windows 14.0. The mode of delivery changed significantly more often and was more often emergency CD in the planned VD group compared with the other 2 groups. Newborns in both the planned CD group and vertex group had Apgar scores of equal to or greater than 7 more often and lower scores less often than in the planned VD group at 1 minute, but no significant differences were noted at 5 minutes. No neonates died. Infants in the planned VD group had an umbilical cord pH of less than 7.05 significantly more often than those in either of the other groups. Infants in the planned VD group had significantly more infections compared with the planned CD group, but the rates for the planned VD and vertex groups were similar. The groups did not differ in the frequency of admission to the neonatal intensive care unit. Rates of severe morbidity were low. One breech infant in the planned CD group, 2 in the planned VD group, and 3 in the vertex group had serious neonatal morbidity, but the groups did not statistically differ in overall morbidity. Two birth traumas occurred in the planned VD group, one in the vertex group, and none in the planned CD group. One mother in the planned CD group died of pulmonary embolism 12 days after an elective CD. Women in the planned CD group had significantly more frequent massive bleeding that required transfusions. The groups did not differ in the frequency of puerperal infections or surgical complications. Severe bleeding (>1500 mL) occurred in 1.1% of vaginal deliveries, 8.0% of elective CDs, and 6.4% of emergency CDs. When nulliparous and multiparous women who actually gave birth vaginally were compared, breech infants of nulliparous mothers had Apgar scores of less than 4 at 1 minute significantly more often (9.3% vs 0%; P = 0.010) than breech infants of multiparous women, but at 5 minutes, no significant differences were noted. Median pH values were 7.22 and 7.31 in the breech infants of nulliparous and multiparous women, respectively. No differences in neonatal intensive care unit admittance or infant morbidity were noted between nulliparous and multiparous breech delivery groups. Based on these results, the dilemma and uncertainty regarding breech delivery are still present. With proper selection of patients for a trial of VD and a low trigger point for change in mode of delivery if signs of asphyxia or poor progress of labor are present, vaginal breech delivery is still an acceptable option.

Fetal macrosomia in African women: a study of 249 cases

To determine the incidence and risk factors of macrosomia in a Nigerian centre, and to assess the relation of maternal body mass index (BMI) at birth and of the total weight gain during pregnancy to macrosomia and adverse pregnancy outcome. A retrospective review of fetal macrosomia over a 5-year period. Abia State University Teaching Hospital, Aba in Southeast Nigeria. A total of 9,970 parturients managed from 1 January 1999 to 31 December 2003. Out of 249 documented cases of infants with birth weights > or =4,500 g, 240 (96.4%) maternal and neonatal records of macrosomia were available for review. Maternal and neonatal characteristics of the 240 cases were compared with 8,800 other parturients with singleton fetuses in vertex presentation. Macrosomic babies represented 2.5% of the infants delivered (249 of 9,970). Most of the mothers (92.5%) were multiparous. Maternal median weight gain was 11 kg (7-15), while the mean weight gain was 12.5 kg. Maternal median BMI was 28.1 kg/m(2) at delivery, while the mean BMI was 30.3 kg/m(2) (range 23-40) at delivery. Macrosomia was suspected in 80% on the basis of clinical examination, sonography, and the presence of the following risk factors in association: previous delivery of an infant weighing >4,000 g (62.5%), maternal weight at booking of more than 80 kg (90%), maternal BMI before delivery of > or =28 kg/m(2) (50%), gestational diabetes mellitus (2.5%), and weight increase of more than 13 kg during pregnancy (5%). The mean birth weight of the babies was 4,750 g (4,500-5,000). The overall CS rate was 15%. The difference in the CS rate between these mothers and the control was not significant (P = 0.41). Only 9 (3.8%) mothers were successfully delivered with the aid of ventouse due to delayed second stage of labor. There was a significant difference in the complication rates between the mothers of large infants and the control (P < 0.001). Four maternal deaths were associated with macrosomia for a maternal mortality rate of 1667/100,000. Four infants had shoulder dystocia and associated injuries. The perinatal mortality rate was 112.5/1,000 births. The higher the total body weight at birth, the higher the rate of macrosomia. Macrosomia had implications for high morbidity and mortality in the mothers and their infants. Delivery methods need to be evaluated. Caesarean section should be more readily used.

Prediction of Duration of Active Labor in Nulliparous Women at Term

We have assessed the independent predictors of duration of active labor in nulliparous women at term. Using a cohort of 1067 nulliparae in spontaneous labor at > 37.0 weeks with singleton fetuses in vertex presentation, multivariate analysis was used to identify independent predictors of duration of active labor. Duration of active labor was 4.1 +/- 2.4 hours. Stepwise linear regression selected 10 independent predictors of duration of active labor: gestational age at delivery ( P < 0.001), race ( P = 0.014), obstetric risk factors ( P = 0.022), amniotomy ( P < 0.001), fundal height ( P = 0.005), cervical dilation on admission ( P < 0.001), frequency of contractions ( P < 0.001), station of presenting part ( P < 0.001), oxytocin ( P < 0.001), and epidural use ( P < 0.001). A prediction formula incorporating the 10 predictors accounted for 51% of the total variance of the observed duration of active labor. Ten variables are independent predictors of duration of active labor; when incorporated in a prediction formula they account for > 50% of the variability of duration of labor in nulliparous women.

Trends in obstetric interventions in the Dutch obstetrical care system in the period 1993–2002

Objective To determine trends in induction of labour-, instrumental vaginal delivery- and caesarean section rates in the Netherlands in the period 1993–2002. Study design Data derived from The Netherlands Perinatal Registry and Statistics Netherlands were used to calculate annual rates for induction of labour, instrumental vaginal delivery and caesarean section. Regarding caesarean section, rates were also calculated for different subgroups with respect to parity, presentation of the fetus, gestational age and multiple pregnancies. In the subgroup of women with a singleton fetus in vertex presentation between 37 and 42 weeks of gestation instrumental delivery rates were compared for women with induced labours and women in spontaneous labour. Results The overall CS rate rose from 8.1 to 13.6%. Proportionally the rise was greatest for breech presentation (+37.7%), multiple gestations (+12.7%) and women delivering between 24 and 28 weeks (+9.5%). However, in absolute numbers the rise was most impressive in the group of women with a singleton fetus in vertex presentation between 37 and 42 weeks of gestation. Rate of induction of labour and instrumental vaginal delivery remained constant (approximately 15% respectively 10% of all deliveries). In nulliparous term women with singletons in vertex presentation the CS rate increased with 8.0% to a rate of 20.7% when labour was induced versus an increase of 3.4% to a rate of 7.5% in spontaneous labour. Conclusion In absolute numbers the rise in CS was most extensive in the group of women with a singleton fetus in vertex presentation between 37 and 42 weeks of gestation. Induction of labour rates and instrumental vaginal delivery rates remained constant during the past decade.

The Effect of Fundal Pressure Manoeuvre on Intrauterine Pressure in the Second Stage of Labour

Fundal pressure is the application of external force to the uppermost part of the uterus in the caudal direction in an attempt to shorten the duration of the second stage of labor. Although a large majority of US centersuse fundal pressure, many fail to document the practice in medical records. Studies of how fundal pressure might speed delivery are lacking. The authors report a prospective study in 40 healthy, full-term women in spontaneous labor who had intrauterine pressure recorded during the second stage. The authors' hypothesis was that fundal pressure might act in part through increasing intrauterine pressure. All participants were in active labor at term (defined as a gestational age >37 weeks) and had a singleton fetus in vertex presentation. Epidural or combined spinal-epidural analgesia was used in all cases; the women remained alert and responsive throughout. The median oxytocin dose was 6 mU/min. Intrauterine pressure was monitored using a sensor-tip catheter introduced into the uterine cavity. Fundal pressure was applied at a 30- to 40-degree angle to the spine in the direction of the pelvis, using a semi-inflated pressure cuff interposed between the clinician's hand and the abdominal wall. Applied pressure was maintained at 80 to 90 mm Hg. All but 4 of the 40 women delivered vaginally without intervention. A Valsalva maneuver during contraction increased the expulsive force by 55% of the spontaneous contraction. Adding fundal pressure to the Valsalva led to an 86% increase over baseline intrauterine pressure (which represents expulsive force). Fundal pressure alone increased the active contraction area 28% over baseline. When measured between contractions, both fundal pressure and the Valsalva increased uterine pressure, but significantly less than during baseline uterine contractions. Analyzing the peak expulsive force achieved showed that 53% of overall performance reflected uterine contraction. The Valsalva added another 30%, and fundal pressure, an additional 17%. In certain patients, fundal pressure contributed significantly to overall expulsive force, but in others it added nothing. On multivariate linear regression analysis, fundal pressure and the Valsalva were most effective when the myometrium was relatively thin and gestational age was greater. Parity was not a factor in how efficiently either fundal pressure or the Valsalva increased expulsive uterine force. Fundal pressure can substantially augment intrauterine pressure in some parturients, and they can be identified in the labor room. Excessive force may be avoided by monitoring intrauterine pressure as fundal pressure is applied.