Singleton Vaginal Births Research Articles

Obstetric anal sphincter injury in the second birth after perineal wound complication in the first birth: A nationwide register cohort study.

To investigate whether perineal wound complications in the first birth, alone or in conjunction with obstetric anal sphincter injury (OASI), is associated with an increased risk of OASI in the second birth. Nationwide population-based cohort study. Sweden. Women (n = 411 317) with first and second singleton vaginal births in Sweden, 2001-2019. Data on diagnostic codes and surgical procedures were retrieved from the Swedish Medical Birth Register and the Swedish Patient Register. A perineal wound complication was defined as wound infection, dehiscence or perineal haematoma within 2 months of childbirth. Associations between wound complications in the first birth and OASI in the second birth were investigated with logistic regression and presented as adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs). In total, 2619 (0.6%) women had a wound complication in the first birth, and 5318 (1.3%) had an OASI in the second birth. Women with a wound complication but no OASI in the first birth had more than doubled odds of OASI in the second birth (aOR 2.73, 95% CI 2.11-3.53). Women with OASI and a wound complication in the first birth had almost tenfold odds (aOR 9.97, 95% CI 6.53-15.24) of recurrent OASI. Perineal wound complication in the first birth increases the likelihood of OASI in a subsequent birth.

Relationship between the natural cessation time of umbilical cord pulsation in full-term newborns delivered vaginally and maternal-neonatal outcomes: a prospective cohort study

BackgroundTo analyze the impact of the time of natural cessation of the umbilical cord on maternal and infant outcomes in order to explore the time of clamping that would be beneficial to maternal and infant outcomes.MethodsThe study was a cohort study and pregnant women who met the inclusion and exclusion criteria at the Obstetrics and Gynecology Department of Qilu Hospital of Shandong University from September 2020 to September 2021. Analysis using Kruskal-Wallis rank sum test, Pearson’s Chi-squared test, generalized linear mixed model (GLMM) and repeated measures ANOVA. If the difference between groups was statistically significant, the Bonferroni test was then performed. A two-sided test of P < 0.05 was considered statistically significant.ResultsA total of 345 pregnants were included in this study. The subjects were divided into the ≤60 seconds group (n = 134), the 61–89 seconds group (n = 106) and the ≥90 seconds group (n = 105) according to the time of natural arrest of the umbilical cord. There was no statistically significant difference in the amount of postpartum hemorrhage and the need for iron, medication, or supplements in the postpartum period between the different cord spontaneous arrest time groups for mothers (P > 0.05). The weight of the newborns in the three groups was (3316.27 ± 356.70) g, (3387.26 ± 379.20) g, and (3455.52 ± 363.78) g, respectively, and the number of days of cord detachment was 12.00 (8.00, 15.75) days, 10.00 (7.00, 15.00) days and 9.00 (7.00, 13.00) days, respectively, as the time of natural cessation of the cord increased. The neonatal lymphocyte ratio, erythrocyte pressure, and hemoglobin reached a maximum in the 61–89 s group at (7.41 ± 2.16) %, (61.77 ± 8.17) % and (194.52 ± 25.84) g/L, respectively. Lower incidence of neonatal hyperbilirubinemia in the 61–89 s group compared to the ≥90s group 0 vs 4.8 (P < 0.05).ConclusionsIn full-term singleton vaginal births, maternal and infant outcomes are better when waiting for 61–89 s after birth for the cord to stop pulsating naturally, suggesting that we can wait up to 90s for the cord to stop pulsating naturally, and if the cord does not stop pulsating after 90s, artificial weaning may be more beneficial to maternal and infant outcomes.

Mechanics of vaginal breech birth: Factors influencing obstetric maneuver rate, duration of active second stage of labor, and neonatal outcome.

We investigated possible parameters that could predict the need for obstetric maneuvers, the duration of the active second stage of labor (i.e., the duration of active pushing), and short-term neonatal outcome in vaginal breech births. We performed a retrospective analysis of 268 successful singleton vaginal breech births in women without previous vaginal births from January 2015 to August 2022. Multivariable regression was used to investigate associations between maternal and fetal characteristics (including antepartum magnetic resonance (MR) pelvimetry) with obstetric maneuvers, the duration of active second stage of labor, pH values, and admission to the neonatal unit. Models for the prediction of obstetric maneuvers were built and internally validated. Obstetric maneuvers were performed in a total of 130 women (48.5%). A total of 32 neonates (11.9%) had to be admitted to the neonatal unit. The intertuberous distance (ITD) (p < 0.001), epidural analgesia (p < 0.001), and birthweight (p = 0.026) were associated with the duration of active second stage of labor. ITD (p = 0.028) and birthweight (p = 0.011) were also independently associated with admission to the neonatal unit, while pH values below 7.10 dropped significantly (p = 0.0034) if ITD was ≥13 cm. Furthermore, ITD (p < 0.001) and biparietal diameter (p = 0.002) were independent predictors for obstetric maneuvers. ITD is independently associated with the duration of active second stage of labor. Thus, it can predict suboptimal birth mechanics in the last stage of birth, which may lead to the need for obstetric maneuvers, lower arterial pH values, and admission to the neonatal unit. Consequently, MR pelvimetry gives additional information for practitioners and birthing people preferring a vaginal breech birth.

Association of maternal SARS-CoV-2 infection at the time of admission for delivery with labor process and outcomes of vaginal birth: A cohort study.

This study aimed to investigate the impact of maternal SARS-CoV-2 infection at the time of admission for delivery on labor process and outcomes of vaginal birth. A cohort study was carried out at the Obstetrics Department of Anhui Provincial Hospital, China, where universal reverse transcriptase polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 infection was introduced for all women admitted for labor and delivery from December 1-31, 2022. Women were divided into positive and negative groups based on the test result. All women having a singleton vaginal birth were included in final analysis. The effect of SARS-CoV-2 positivity on labor process and outcomes of vaginal birth was estimated by regression analyses. Among a total of 360 women included, 87 had a positive SARS-CoV-2 test and 273 a negative test. Women in the positive group had an increased likelihood of having longer labor (median 9.3 vs 8.3 hours; sB [log-transformed] 0.19; 95% confidence interval [CI] 0.09-0.28), episiotomy (39.1% vs 23.8%; adjusted odds ratio [aOR] 2.31; 95% CI 1.27-4.21), grade III meconium-stained amniotic fluid (19.5% vs 7.0%; aOR 2.52; 95% CI 1.15-5.54) and postpartum hospital stay exceeding 37 hours (58.6% vs 46.5%; aOR 1.71; 95% CI 1.00-2.91). They had reduced rates exclusive breastfeeding (26.7% vs 39%; aOR 0.21; 95% CI 0.09-0.46) as well as mixed feeding (46.5% vs 52.2%; aOR 0.28; 95% CI 0.13-0.60) at 1 week postpartum. No significant differences were observed in other aspects of labor process and birth outcomes, including the uptake of labor analgesia, postpartum hemorrhage (>500 mL) or neonatal outcomes. A positive maternal SARS-CoV-2 test in labor among women having vaginal birth was associated with a slightly longer duration of labor, increased likelihood of episiotomy, increased incidence of grade III meconium-stained amniotic fluid, a longer postpartum hospital stay and a lower rate of breastfeeding 1 week postpartum. However, it did not have an adverse impact on other birth outcomes.

Closed- or open-glottis pushing for vaginal delivery: a planned secondary analysis of the TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery study

The effect on obstetrical outcomes of closed- or open-glottis pushing is uncertain among both nulliparous and parous women. This study aimed to assess the association between open- or closed-glottis pushing and mode of delivery after an attempted singleton vaginal birth at or near term. This was an ancillary planned cohort study of the TRAAP (TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery) randomized controlled trial, conducted in 15 French maternity units from 2015 to 2016 that enrolled women with an attempted singleton vaginal delivery after 35 weeks' gestation. After randomization, characteristics of labor and delivery were prospectively collected, with special attention to active second-stage pushing and a specific planned questionnaire completed immediately after birth by the attending care provider. The exposure was the mode of pushing, classified into 2 groups: closed- or open-glottis. The main endpoint was operative vaginal delivery. Secondary endpoints were items of maternal morbidity, including severe perineal laceration, episiotomy, postpartum hemorrhage, duration of the second stage of labor, and a composite severe neonatal morbidity outcome. We also assessed immediate maternal satisfaction, experience of delivery, and psychological status 2 months after delivery. The associations between mode of pushing and outcome were analyzed by multivariate logistic regression to control for confounding bias, with multilevel mixed-effects analysis, and a random intercept for center. Among 3041 women included in our main analysis, 2463 (81.0%) used closed-glottis pushing and 578 (19.0%) open-glottis pushing; their respective operative vaginal delivery rates were 19.1% (n=471; 95% confidence interval, 17.6-20.7) and 12.5% (n=72; 95% confidence interval, 9.9-15.4; P<.001). In an analysis stratified according to parity and after controlling for available confounders, the rate of operative vaginal delivery did not differ between the groups among nulliparous women: 28.7% (n=399) for the closed-glottis and 27.5% (n=64) for the open-glottis group (adjusted odds ratio, 0.93; 95% confidence interval, 0.65-1.33; P=.7). The operative vaginal delivery rate was significantly lower for women using open- compared with closed-glottis pushing in the parous population: 2.3% (n=8) for the open- and 6.7% (n=72) for the closed-glottis groups (adjusted odds ratio, 0.43; 95% confidence interval, 0.19-0.90; P=.03). Other maternal and neonatal outcomes did not differ between the 2 modes of pushing among either the nulliparous or parous groups. Among nulliparous women with singleton pregnancies at term, the risk of operative vaginal birth did not differ according to mode of pushing. These results will inform shared decision-making about the mode of pushing during the second stage of labor.

Diabetes and Hypertensive Disorders of Pregnancy and the Risk of Third- and Fourth-Degree Perineal Lacerations: A Large United States Cohort 2016–2020 [ID: 1377605

INTRODUCTION: The objective of this study was to assess the effect diabetes and hypertensive disorders of pregnancy have on the rate of third- and fourth-degree perineal laceration (3/4 PL). METHODS: This represents a retrospective cohort based on the Centers for Disease Control and Prevention Natality Live Birth database (2016–2020). We compared the rates of 3/4 PL in term, singleton vaginal births across the United States based on maternal gestational hypertension, preeclampsia, pregestational diabetes, and gestational diabetes. We used Pearson χ2 and multivariate logistic regression to control for confounding variables. Statistical significance was determined as P&lt;.05, and results were displayed as adjusted odds ratios (aORs) with 95% CI. RESULTS: Of the 11,677,671 who met inclusion criteria, 139,174 (1.2%) women experienced 3/4 PL. Gestational hypertension and preeclampsia were associated with increased rates of 3/4 PL (1.53% with aOR 1.28, 95% CI 1.25–1.30, and 1.61% with aOR 1.31, 95% CI 1.06–1.17, respectively). Additionally, both pregestational diabetes and gestational diabetes were associated with higher rates (1.44% with aOR 1.45, 95% CI 1.35–1.56, and 1.44% with aOR 1.27, 95% CI 1.25–1.30, respectively). CONCLUSION: Based on this current U.S. database, we identified several medical complications of pregnancy that are associated with an increased risk for 3/4 PL. Specifically, hypertensive disorders of pregnancy (gestational hypertension and preeclampsia), pregestational as well as gestational diabetes were all associated with significantly increased risks. Understanding these associations may contribute to reduction in the rates of 3/4 PL in gravidas with these conditions.

Chorioamnionitis Is an Independent Risk Factor for Third- and Fourth-Degree Perineal Lacerations in the United States [ID: 1377609

INTRODUCTION: The objective was to determine the effect chorioamnionitis has on the risk of third- and fourth-degree perineal lacerations (3/4 PL). METHODS: This represents a retrospective cohort based on the Centers for Disease Control and Prevention Natality Live Birth database (2016–2020). We compared the rates of 3/4 PL in term, singleton vaginal births across the United States based on diagnosed intrapartum chorioamnionitis. We used Pearson chi-square and multivariate logistic regression to control for confounding variables. Statistical significance was determined as P&lt;.05, and results were displayed as adjusted odds ratios (aORs) with 95% CI. RESULTS: Of the 11,677,671 who met inclusion criteria, 139,174 (1.2%) women experienced 3/4 PL. Intrapartum chorioamnionitis was associated with a staggering 3.96% rate of 3/4 PL compared to a 1.15% rate in women without chorioamnionitis (aOR 1.85, 95% CI 1.80–1.90). CONCLUSION: Based on this current U.S. database we identified chorioamnionitis as a major risk factor for 3/4 PL. The potential explanation may be due to dysfunctional labor, increased perineal edema secondary to protracted labor, or increased friability of tissue. Understanding this association may assist in better counseling and potentially reduce the rates of 3/4 PL in gravidas with chorioamnionitis.

Antibiotic administration and wound complications after obstetric anal sphincter injuries.

Obstetric anal sphincter injuries (OASIS) are associated with both short-term and long-term maternal morbidity. Antibiotic administration has been shown to decrease wound complications after OASIS. However, the rate of antibiotic administration in a contemporary obstetric population is not known. To describe the rate of antibiotic administration with OASIS, to characterize factors associated with antibiotic administration on the day of delivery among women with OASIS, and to determine whether there was an association with reduced wound complications. Retrospective cohort study of women with a singleton vaginal birth complicated by OASIS between 2016 and 2021 in a single healthcare system. Any antibiotic administration on the day of delivery was collected. Wound complications (determined by ICD-10 codes) occurring within the first six months postpartum were available for patients delivering at tertiary care centers. Multivariable logistic regression analysis was used to identify factors associated with antibiotic administration and the association between antibiotics and wound complications. During the study period, 1,550 women met inclusion criteria, of whom 855 (55.2%) received antibiotics. Antibiotic administration was higher at tertiary care vs community-based hospitals (68.7 vs 26.8%, p<0.001). In the adjusted analysis, antibiotic administration was higher among women with a fourth-degree laceration (adjusted odds ratio 2.72, 95% CI 1.69-4.37) and lower among women of Asian or Pacific Islander heritage (aOR 0.88, 95% CI 0.80-0.97). At tertiary care hospitals, forty-three women (4.1%) had a wound complication, with more than 80% presenting within the first two weeks postpartum. Antibiotic use was associated with reduced rates of wound complications (aOR 0.34, 95% CI 0.13-0.91). All patients received a regimen with gram positive coverage; there was no association between type of antibiotic regimen administered and wound complication. Any antibiotic administration on the day of delivery is associated with a decreased rate of wound complications after OASIS. However, only about half of women with OASIS received antibiotics. Optimizing antibiotic administration may help to reduce the risk of complications in this population.

Understanding risk factors for shoulder dystocia using interpretable machine learning

To use interpretable machine learning to identify the most important risk factors for shoulder dystocia (SD). This retrospective study used clinical data from 82,889 singleton vaginal births (24-43 weeks’ gestation) from 20 U.S. hospitals (01/2016 - 12/2021) to train and externally validate a predictive model for SD using 57 features available at the time of delivery plus birthweight (which can be estimated prenatally but is not known until birth). Using bootstrap analysis, an Explainable Boosting Machine (EBM) was trained using data from 59,665 births at 13 hospitals and externally validated using 23,224 births at 7 different hospitals. A logistic regression (LR) model was also trained for comparison. SD occurred in 3.4% of births. An AUC of 0.74 (95% CI 0.73 – 0.75) was obtained for the EBM. Sensitivity for SD was 62%, for a false positive rate (FPR) of 25%. LR yielded an AUC of 0.74 (95% CI 0.73 – 0.75). The most important features for predicting SD were birthweight, maternal height, BMI, cervical dilation at initial exam, and time from admission to full dilation. SD risk increased dramatically and linearly with birthweight and decreased as maternal height increased (Figure 1). Surprisingly, length of 2nd stage was not a strong predictor. Using only the top 5 features gave a slightly higher AUC of 0.75 (95% CI 0.74 – 0.76) and a 65% sensitivity for a 25% FPR, suggesting that eliminating some features might yield a small model with clinically useful SD prediction. AI models trained on these data yielded modest accuracy for predicting shoulder dystocia risk and EBM intelligibility highlighted that consideration of factors in addition to fetal weight, may add to the assessment of risk. EBMs also reinforced the need to accurately estimate fetal weight, as evident through birthweight’s exceptionally large contribution to risk. Our results suggest that a novel, clinically useful model for predicting SD at the time of delivery might be achievable using only a small number of features.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Association between maternal antibiotic exposure during pregnancy and childhood obesity in the Japan Environment and Children's Study.

The association between maternal antibiotic exposure during pregnancy and childhood obesity is still unclear. The study aimed to evaluate the association between prenatal exposure to antibiotics and obesity at age 3 years using data from a large Japanese birth cohort. The Japan Environment and Children's Study is a nationwide birth cohort study. In this study, singleton vaginal full-term births were included. Obesity was defined as body mass index ≥95th percentile according to child growth standards. Prenatal antibiotic exposure was defined as antimicrobial agent use during pregnancy and was collected from maternal interviews and medical record transcripts. Logistic regression analysis was performed to evaluate the association of prenatal antibiotic exposure with child obesity at 3 years. In the crude and adjusted models with all children, maternal antibiotic exposure during pregnancy showed a marginal relationship with child obesity at 3 years. In the analyses according to exposure period and sex, exposure to antibiotics during the second/third trimester was significantly associated with obesity at the age of 3 years in female infants, but not in male infants, although the exposure during the first trimester was not in both sexes. Maternal antibiotic exposure during mid/late pregnancy may result in child obesity.

Modifiable and non-modifiable risk factors for obstetric anal sphincter injury in a Norwegian Region: a case\u2013control study

BackgroundObstetric anal sphincter injury (OASI) is a common and severe complication of vaginal delivery and may have short- and long-term consequences, including anal incontinence, sexual dysfunction and reduced quality of life. The rate of OASI varies substantially between studies and national birth statistics, and a recent meta-analysis concluded that there is a need to identify unrecognized risk factors. Our aim was therefore to explore both potential modifiable and non-modifiable risk factors for OASI.MethodsWe performed a case–control study in a single center maternity clinic in South-Eastern Norway. Data were extracted retrospectively from an institutional birth registry. The main outcome measure was the occurrence of the woman’s first-time 3rd or 4th degree perineal lesion (OASI) following singleton vaginal birth after 30 weeks’ gestation. For each woman with OASI the first subsequent vaginal singleton delivery matched for parity was elected as control. The study population included 421 women with OASI and 421 matched controls who gave birth during 1990–2002. Potential risk factors for OASI were assessed by conditional logistic regression analyses.ResultsThe mean incidence of OASI was 3.4% of vaginal deliveries, but it increased from 1.9% to 5.8% during the study period. In the final multivariate regression model, higher maternal age and birthweight for primiparous women, and higher birthweight for the multiparous women, were the only non-modifiable variables associated with OASI. Amniotomy was the strongest modifiable risk factor for OASI in both primi- (odds ratio [OR] 4.84; 95% confidence interval [CI] 2.60–9.02) and multiparous (OR 3.76; 95% CI 1.45–9.76) women, followed by augmentation with oxytocin (primiparous: OR 1.63; 95% CI 1.08–2.46, multiparous: OR 3.70; 95% CI 1.79–7.67). Vacuum extraction and forceps delivery were only significant risk factors in primiparous women (vacuum: OR 1.91; 95% CI 1.03–3.57, forceps: OR 2.37; 95% CI 1.14–4.92), and episiotomy in multiparous women (OR 2.64; 95% CI 1.36–5.14).ConclusionsAmniotomy may be an unrecognized independent modifiable risk factor for OASI and should be further investigated for its potential role in preventive strategies.

Physiological breech birth training: An evaluation of clinical practice changes after a one-day training program.

The "physiological breech birth" one-day training program is based on evidence about the physiology of breech births and how clinicians learn breech skills. Previous evaluations have demonstrated positive effects on confidence and knowledge, but the training's effect on clinical practice and outcomes is unknown. A mixed-methods evaluation was conducted in eight National Health Service hospitals in England and Northern Ireland. Changes in confidence and knowledge were assessed using pretraining and post-training surveys. Mode of birth and maternal birth positions were evaluated using audit data covering one year before the training and one year after, for all singleton vaginal breech births at term. A total of 263 participants completed the surveys. Confidence in managing breech births in both upright and supine positions significantly increased, as did participant knowledge. Audited data for 1402 women were collected. Overall vaginal birth rates remained similar in both periods. Among singleton vaginal breech births >37weeks, the use of upright birthing positions increased significantly (P = .002). The study was not powered to detect differences in other outcomes, but pilot data were collected to inform the design of future studies. Increase in use of upright birthing positions suggests that physiological breech birth training is likely to lead to clinical practice changes, which may help support maternal choice in line with current guidance. However, provision of a one-day training program did not change overall vaginal breech birth rates. Adequately powered research is needed to determine effects of clinical practice changes on clinical outcomes.

Predicting obstetrical anal sphincter injuries in patients who undergo vaginal birth after cesarean delivery

Women with a history of previous cesarean delivery must weigh the numerous potential risks and benefits of elective repeat cesarean delivery or trial of labor after cesarean delivery. Notably, 1 important risk of vaginal delivery is obstetrical anal sphincter injuries. Furthermore, the rate of obstetrical anal sphincter injuries is high among women undergoing vaginal birth after cesarean delivery. However, the risk of obstetrical anal sphincter injuries is not routinely included in the trial of labor after cesarean delivery counseling, and there is no tool available to risk stratify obstetrical anal sphincter injuries among women undergoing vaginal birth after cesarean delivery. This study aimed to develop and validate a predictive model to estimate the risk of obstetrical anal sphincter injuries in the setting of vaginal birth after cesarean delivery population to improve antenatal counseling of patients regarding risks of trial of labor after cesarean delivery. This study was a secondary subgroup analysis of the Maternal-Fetal Medicine Units Network Trial of Labor After Cesarean Delivery prospective cohort (1999-2002). We identified women within the Maternal-Fetal Medicine Units Network cohort with 1 previous cesarean delivery followed by a term vaginal birth after cesarean delivery. This Maternal-Fetal Medicine Units Network Vaginal Birth After Cesarean Delivery cohort was stratified into 2 groups based on the presence of obstetrical anal sphincter injuries, and baseline characteristics were compared with bivariate analysis. Significant covariates in bivariate testing were included in a backward stepwise logistic regression model to identify independent risk factors for obstetrical anal sphincter injuries and generate a predictive model for obstetrical anal sphincter injuries in the setting of vaginal birth after cesarean delivery. Internal validation was performed using bootstrapped bias-corrected estimates of model concordance indices, Brier scores, Hosmer-Lemeshow chi-squared values, and calibration plots. External validation was performed using data from a single-site retrospective cohort of women with a singleton vaginal birth after cesarean delivery from January 2011 to December2016. In this study, 10,697 women in the Maternal-Fetal Medicine Units Network Trial of Labor After Cesarean Delivery cohort met the inclusion criteria, and 669 women (6.3%) experienced obstetrical anal sphincter injuries. In the model, factors independently associated with obstetrical anal sphincter injuries included use of forceps (adjusted odds ratio, 5.08; 95% confidence interval, 4.10-6.31) and vacuum assistance (adjusted odds ratio, 2.64; 95% confidence interval, 2.02-3.44), along with increasing maternal age (adjusted odds ratio, 1.05; 95% confidence interval, 1.04-1.07 per year), body mass index (adjusted odds ratio, 0.99; 95% confidence interval, 0.97-1.00 per unit kg/m2), previous vaginal delivery (adjusted odds ratio, 0.19; 95% confidence interval, 0.15-0.23), and tobacco use during pregnancy (adjusted odds ratio, 0.59; 95% confidence interval, 0.43-0.82). Internal validation demonstrated appropriate discrimination (concordance index, 0.790; 95% confidence interval, 0.771-0.808) and calibration (Brier score, 0.047). External validation used data from 1266 women who delivered at a tertiary healthcare system, with appropriate model discrimination (concordance index, 0.791; 95% confidence interval, 0.735-0.846) and calibration (Brier score, 0.046). The model can be accessed at oasisriskscore.xyz. Our model provided a robust, validated estimate of the probability of obstetrical anal sphincter injuries during vaginal birth after cesarean delivery using known antenatal risk factors and 1 modifiable intrapartum risk factor and can be used to counsel patients regarding risks of trial of labor after cesarean delivery compared with risks of elective repeat cesarean delivery.

Intramuscular oxytocin versus Syntometrine® versus carbetocin for prevention of primary postpartum haemorrhage after vaginal birth: a randomised double-blinded clinical trial of effectiveness, side effects and quality of life.

To compare intramuscular oxytocin, Syntometrine® and carbetocin for prevention of postpartum haemorrhage after vaginal birth. Randomised double-blinded clinical trial. Six hospitals in England. A total of 5929 normotensive women having a singleton vaginal birth. Randomisation when birth was imminent. Primary: use of additional uterotonic agents. Secondary: weighed blood loss, transfusion, manual removal of placenta, adverse effects, quality of life. Participants receiving additional uterotonics: 368 (19.5%) oxytocin, 298 (15.6%) Syntometrine and 364 (19.1%) carbetocin. When pairwise comparisons were made: women receiving carbetocin were significantly more likely to receive additional uterotonics than those receiving Syntometrine (odds ratio [OR] 1.28, 95% CI 1.08-1.51, P=0.004); the difference between carbetocin and oxytocin was non-significant (P=0.78); Participants receiving Syntometrine were significantly less likely to receive additional uterotonics than those receiving oxytocin (OR 0.75, 95% CI 0.65-0.91, P=0.002). Non-inferiority between carbetocin and Syntometrine was not shown. Use of Syntometrine reduced non-drug PPH treatments compared with oxytocin (OR 0.64, 95% CI 0.42-0.97) but not carbetocin (P=0.64). Rates of PPH and blood transfusion were not different. Syntometrine was associated with an increase in maternal adverse effects and reduced ability of the mother to bond with her baby. Non-inferiority of carbetocin to Syntometrine was not shown. Carbetocin is not significantly different to oxytocin for use of additional uterotonics. Use of Syntometrine reduced use of additional uterotonics and need for non-drug PPH treatments compared with oxytocin. Increased maternal adverse effects are a disadvantage of Syntometrine. IM carbetocin does not reduce additional uterotonic use compared with IM Syntometrine or oxytocin.

Poor uterine contractility and postpartum hemorrhage among low-risk women: A case-control study of a large-scale database from Japan.

To examine the association between the risk of postpartum hemorrhage (PPH) and poor uterine contractility, which is suggested by the characteristics of labor. This case-control study used cases recorded in the Japan Perinatal Registry database during the period 2013-2016. After exclusion of women with specified known risk factors for PPH, we enrolled 174082 primiparas who had a full-term live singleton vaginal birth. Participants were classified into four classes according to the diagnosis of abnormal labor patterns and use of uterotonics. χ2 tests were used to compare PPH cases with controls, and odds ratios (OR) were calculated by univariate and multivariate analyses. Among the enrolled women, 10508 (6.0%) had PPH. Abnormal labor patterns were significantly associated with an increased risk of PPH. Compared with women without any abnormal labor patterns who had not used uterotonics, women with abnormal labor patterns were at a significantly increased risk for PPH regardless of whether they had used uterotonics (adjusted OR 1.23, 95% confidence interval [CI] 1.10-1.37) or not (adjusted OR 1.30, 95% CI 1.23-1.37). Our study suggests that among low-risk women with PPH, poor uterine contractility in labor could be a significant predisposing risk factor for PPH.

Is there an Association between Vaginal Birth after Cesarean Prediction and Obstetric Anal Sphincter Injury?

This study aimed to estimate whether there is an association between the predicted probability of vaginal birth after cesarean delivery (VBAC) and the occurrence of obstetric anal sphincter injuries (OASIS). This was a single-site retrospective cohort study of all women with a singleton vaginal birth after a previous cesarean section between January 2011 and December 2016. Women were divided into four ordinal groupings by the predicted probability of achieving vaginal birth after cesarean using the Maternal-Fetal Medicine Units Network VBAC calculator (less than 41%, 40.1-60%, 60.1-80%, and greater than 80%). The primary outcome was OASIS, defined as a 3rd or 4th degree perineal laceration. Bivariable and multivariable analyses were used to examine the association between predicted VBAC probability and OASIS. In total, 1,411 women met inclusion criteria and 73 (5.2%) sustained OASIS. The median predicted probability of VBAC was lower in women with OASIS compared with those without OASIS (60% [interquartile range {IQR}: 48-70%] vs. 66% (IQR: 52-80%), p = 0.02]. On bivariable and multivariable logistic regression, predicted probability of VBAC was associated with increased odds of OASIS (less than 41% probability: adjusted odds ratio [aOR]: 3.18, 95% confidence interval [CI]: 0.90-11.21; 41-60% probability: aOR: 3.76, 95% CI: 1.34-10.57; 61-80% probability aOR: 3.47, 95% CI: 1.25-9.69) relative to women with a predicted probability of VBAC of greater than 80%. Having a lower predicted probability of VBAC is associated with an increased risk of OASIS at the time of a VBAC relative to those with greater than 80% predicted probability. Incorporation of this aspect of maternal morbidity may inform risk-stratification at the time of trial of labor after cesarean, as well as the choice of performing an operative vaginal delivery. · Predicted probability of VBAC is associated with OASIS.. · Low predicted probability of VBAC is associated with increased odds of OASIS.. · Forceps delivery was associated with the highest odds of OASIS..

Symptoms of fecal incontinence two decades after no, one, or two obstetrical anal sphincter injuries

The long-term effects of 1 or 2 consecutive obstetrical anal sphincter injuries on bowel continence are still inadequately investigated, and published results remain contradictory. This study aimed to present detailed descriptive measures of the current bowel incontinence 20 years after the first birth in women who had 2 vaginal deliveries with and without sphincter injuries. Birth register data were used prospectively and linked to information from a questionnaire survey about current symptoms. Women with 2 singleton vaginal births, from 1992 to 1998, and no further births were retrieved and surveyed by the Swedish Medical Birth Register and Statistics Sweden in 2015. A simple random sample of 11,000 women was drawn from a source cohort of 64,687 women. The cumulative effect was studied in all women with a repeat sphincter injury from 1987 to 2000. Postal and web-based questionnaires were used. The study population consisted of 6760 women with no sphincter injury, 357 with 1 sphincter injury, and 324 women with 2 sphincter injuries. Women with 2 deliveries without sphincter injuries aged 40 to 60 years as reference, were compared with those of women that sustained 1 or 2 consecutive sphincter injuries. Here, third- and fourth-degree perineal tears were presented as 1 group. Fecal incontinence was defined as current involuntary leakage of solid or liquid stool, with and without concomitant leakage of gas. The Fisher exact test and the Mann-Whitney U test were used to compare the results of the 2 groups. The trend was analyzed using the Mantel-Haenszel statistics. Logistic regression models obtained the estimated age-related probability of fecal incontinence components. The risk of sphincter injury at first delivery was 3.9%, and the risk of a repeat sphincter injury was 10.0% (odds ratio, 2.70; 95% confidence interval, 1.80-4.07). The overall prevalence of fecal incontinence in women without sphincter injuries was 11.7%, which doubled to 23.8% (odds ratio, 2.27; 95% confidence interval, 1.75-2.94) in those with 1 sphincter injury and more than tripled to 36.1% (odds ratio, 3.97; 95% confidence interval, 3.11-5.07) after 2 sphincter injuries (trend P<.0001). The proportion of women with severe fecal incontinence increased 3-fold and 5-fold from 1.8% after no obstetrical anal sphincter injury to 5.4% (95% confidence interval, 3.3-8.2) and 9.0% (95% confidence interval, 6.1-12.6) after 1 or 2 obstetrical anal sphincter injuries, respectively (trend P<.0001). In women without sphincter injuries, the estimated probability of fecal incontinence increased from 7.0% at the age of 40 years to 19.8% at the age of 60 years. In contrast, in women with 1 or 2 sphincter injuries, the estimated probability of fecal incontinence increased from 26.1% and 33.3%, respectively, at the age of 40 years to 36.8% and 48.8% at the age of 60 years. The prevalence of fecal incontinence increased after 52 years of age in women with 1 or 2 sphincter injuries. The dominant types of leakage in women with fecal incontinence were the combination of liquid stool and gas, and the triple combination consisting of solid and liquid stools and gas. The triple combination increased from 18.9% in those without sphincter injury to 28.2% in women with 2 injuries (trend P=.0204). The risk of sustaining a repeat sphincter injury at the second delivery was almost tripled compared with the risk at the first delivery. Furthermore, 1 or 2 sphincter injuries brought severe long-term consequences for bowel continence. Accidental leakage of stool and gas increased with each sphincter injury, and the effect was proportionally cumulative. After the age of 52 years, the prevalence of fecal incontinence seemed to accelerate.

Predicting Obstetric Anal Sphincter Injury (OASIS) in Women Undergoing Trial of Labor After Cesarean (TOLAC) [25L

INTRODUCTION: We aimed to evaluate the relationship between predicted success of trial of labor after cesarean (TOLAC) and obstetric anal sphincter injury (OASI) to develop a predictive model. METHODS: We performed a secondary analysis of the Maternal Fetal Medicine Units Network (MFMU) TOLAC prospective cohort (1999–2002) and a single-site retrospective analysis of a cohort of women with a singleton vaginal birth after cesarean (VBAC) between 2011 and 2016 (modern population [MP]) (IRB approval STU00204149). Women were stratified by the presence of OASI and characteristics were compared with bivariate analysis, including the predicted probability of achieving VBAC using the MFMU calculator. Significant risk factors were included in a backward stepwise multivariable logistic regression model to identify independent risk factors for OASI and generate a predictive model. Model performance was evaluated using concordance indices, brier scores and calibration plots. Internal validity was assessed with bootstrapping and external validation performed using MP data. RESULTS: 12,108 women met inclusion criteria and 739 (6.1%) sustained OASI. Factors independently associated with OASI included forceps (OR 5.0 CI 4.1-6.2) and vacuum (OR 2.8 CI 2.2-3.6), along with predicted likelihood of VBAC (aOR 0.5 CI 0.4-0.6), race and smoking. The concordance index of the model and MP validation cohort was 0.79 (CI 0.77-0.81) and 0.77 (CI 0.71-0.83). The model demonstrates internal validity, but slight overcalibration within the MP cohort. CONCLUSION: Predicted likelihood of VBAC is inversely proportional to the likelihood of sustaining OASI. Our model provides a robust estimate of OASI risk during VBAC that can be easily utilized in counseling.

Incidence and risk factors for obstetric anal sphincter ruptures, OASIS, following the introduction of preventive interventions. A retrospective cohort study from a Norwegian hospital 2012–2017

ObjectiveA decrease of obstetric anal sphincter injuries (OASIS) was observed after preventive interventions were implemented at a Norwegian university hospital. The aim was to investigate whether the improvement had sustained over the following years. Materials and methodsWe performed a retrospective cohort study of 18 258 singleton vaginal cephalic births, ≥37 + 0 weeks of gestation during 2012–2017, examining data from the hospital’s birth journals and separate registration forms. Interventions to prevent OASIS were implemented in 2011, and training in practical skills was repeated each year. Main outcome measuresThe main outcome was OASIS (n = 377). ResultsFrequency of OASIS overall decreased from 3.6% prior to 2011 to 2.1% after the intervention and sustained at that level throughout the study period. A trend of fewer OASIS among spontaneous deliveries, decreasing from 2.1% to 1.2% (p = 0.01) was observed, but no trend was seen for instrumental deliveries (p = 0.37), where the incidence fluctuated between 4.0% and 9.3% with an average of 6.5%. Primiparity, increased maternal age and increased fetal head circumference were associated with more OASIS in spontaneous deliveries. In instrumental deliveries, primiparity, occiput posterior position and increased fetal head circumference were associated with more OASIS, whilst episiotomy was associated with fewer OASIS. ConclusionThe incidence of obstetric anal sphincter injuries maintained at a similar level of around 2.1% during the six following years after introducing preventive interventions. Regularly repetition and practical training seemed to be effective.

Episiotomy practice in six Palestinian hospitals: a population-based cohort study among singleton vaginal births

ObjectiveTo explore the rates, characteristics and indications for episiotomy among women delivering vaginally for the first time, as well as parous women.Study designA prospective, population-based birth cohort study.SettingObstetric departments in...