Singleton Vaginal Deliveries Research Articles

Racial/Ethnic Impact on Obstetric Anal Sphincter Injuries: A Multicentric Retrospective Study.

Obstetric anal sphincter injuries (OASIs), third- and fourth-degree lacerations, represent a severe obstetric complication. Previous studies reported a higher incidence of OASIs in Asian women in non-Asian countries. This study was aimed at establishing a different OASIs prevalence among the racial/ethnic groups in Southern European centers. A multicenter retrospective study that included pregnant women who had vaginal singleton delivery between January 2019 and September 2022 in two Italian University hospitals, Naples and Novara, was conducted. We excluded cesarean sections, nonvertex presentation, preterm delivery, multiple pregnancies, congenital malformations, or stillbirths. Statistical analysis with an independent association of ethnicity to the risk of OASIs using clinical characteristics-adjusted multivariate logistic regression was performed. A total of 3,049 pregnant women were included. 2.33% (71 patients) had an OASI. The median age was 31years (IQR 7.00) and median gestational age was 39weeks (IQR 1.40). Mean birth weight was 3,300g (IQR 580.00). 1' and 5' Apgar scores were 9 and 9. The univariate logistic regression was not statistically significant. Multivariate logistic regression model adjusted for baseline clinical characteristics showed an OR 2.540 (p value 0.01) for OASIs in Asian women. Primiparous andsecondiparous were protective factors for OASIs with OR 0.224 (p value < 0.001) and OR 0.209 (p value 0.01). Our results confirm racial/ethnic disparities regarding OASIs, with an elevated risk for Asian women in Southern Europe. Prevention strategies and obstetric care in developed countries should be modulated to offset the risk of OASIs in this population. Additional research is needed to explain the specific mechanisms of these disparities.

Construction and validation of a line chart for gestational diabetes mellitus based on clinical indicators

BackgroundGestational diabetes mellitus (GDM) is a common complication of mid–to-late pregnancy. Here, we constructed a predictive model for GDM based on a combination of clinical characteristics and relevant serum markers.MethodsData from full-term singleton vaginal deliveries from January 2022 to January 2023 were retrospectively collected from the obstetrics department. The data collected were segregated and assigned to training, validation, and external test sets. Maternal demographic characteristics, living and working habits, and haematological indicators, such as liver function and lipids were collected using a questionnaire designed for the study. The “rms” package in R was used to explore GDM-associated factors through stepwise regression at P < 0.05. A predictive model was developed based on the results of multifactorial logistic regression analysis. We then evaluated the differentiation of the column-line graphical model and performed internal and external validation. To assess the accuracy of the bar graphical model, we plotted calibration and decision curves.ResultsData from 265 pregnant women were included in the training and internal validation sets, and data from 113 pregnant women were included in the external validation set. The logistic regression algorithm screened 8 indicators as predictors. A prediction model was constructed with ALT, TBA, TC, and TG levels while considering whether GDM affects appetite, the husband– wife relationship, family history, and parental relationships as predictors. The Hosmer–Lemeshow goodness-of-fit test revealed that the chi-square values for the modelling, internal validation, and external validation groups (χ2 = 5.964, 3.249, and 12.182, respectively) were all P > 0.05. The ROC curve AUCs for the three groups were 0.93 (95% CI: 0.89–0.97), 0.72 (95% CI: 0.62–0.81), and 0.68 (95% CI: 0.53–0.83), respectively.ConclusionIn this study, a GDM prediction model was constructed to achieve high performance in GDM risk prediction based on routine obstetric tests and information.

Does infection with COVID-2019 during labor increase the risk for obstetric anal sphincter injuries?

To investigate the association between coronavirus disease 2019 (COVID-19) infection during the peripartum period and obstetric anal sphincter injuries (OASIS). A retrospective cohort study was conducted, including all singleton vaginal deliveries and cesarean deliveries due to failed vacuum extraction, between June 2020 and January 2022 at a large tertiary medical center. OASIS complication during childbirth was compared between women with and without peripartum diagnosis of COVID-19, defined as a positive polymerase chain reaction test obtained within 1 week before delivery or up to 3 days after delivery. Universal screening for COVID-19 was implemented. A logistic regression model was used to adjust for confounding variables. The study included 22 911 women, among whom 468 (2.0%) tested positive for COVID-19 and 22 443 women had no COVID-19 diagnosis. After adjusting for confounding variables, peripartum infection with COVID-19 was found to be independently associated with OASIS (adjusted odds ratio 4.38, 95% confidence interval 2.00-9.61; P < 0.001). Infection with COVID-19 during the peripartum period significantly increases the risk for OASIS by more than fourfold. These findings emphasize the importance of understanding the impact of COVID-19 on birth complications, such as OASIS, to improve public health measures and enhance obstetric outcomes during pandemics.

Risk of short-term cardiovascular disease in relation to the mode of delivery in singleton pregnancies: a retrospective cohort study

Cardiovascular disease (CVD) is increasing in prevalence and affects up to 4% of pregnancies in otherwise healthy persons. The specific factors that drive the development of CVD in pregnant people are poorly characterised. This study aimed to determine whether the mode of delivery in singletons affects the risk of cardiovascular morbidity and mortality within one year in patients without prior CVD. We designed a retrospective cohort study utilising the Nationwide Readmissions Database (NRD) to identify singleton delivery hospitalisations in the United States from Jan 1, 2010 to Nov 30, 2018. International Classification of Disease (ICD) versions 9 and 10 codes were used to identify patients with readmission for CVD within the calendar year of index delivery. Patients aged 15-54 who underwent a singleton vaginal or caesarean delivery were included. Patients with pre-existing CVD hospitalisations before or during delivery, ectopic pregnancies, or abortive outcomes were excluded. Participant data was retrieved from the NRD database. The primary outcome was hospital readmission, defined by ICD 9 and 10 codes for fatal or non-fatal CVD in the same calendar year as delivery. Cox proportional hazard regression models were used to adjust for confounders. These included maternal age, hospital bed size, hospital type, hospital teaching status, income quartile, insurance, and year of delivery. Additional sub-analyses were performed adjusting for hypertensive disorders of pregnancy and diabetes mellitus. Of the 14,179,299 singleton deliveries, 32% (n=4,553,492) underwent a caesarean. CVD readmissions occurred in 255.2 per 100,000 (n=11,710) caesarean deliveries compared with 133.9 per 100,000 (n=12,507) vaginal deliveries (rate difference [RD], 121.4, 95% confidence interval [CI], 114.8-127.9; hazard ratio [HR] adjusted for all confounders including hypertensive disorders of pregnancy and diabetes mellitus was 1.42, 95% CI 1.35-1.50). This association was highest in the first 0-29 days following delivery (HR 1.68, 95% CI 1.59-1.78). The risk of readmission for CVD persisted for one year. These findings suggest that caesarean delivery of singletons is associated with a higher risk of cardiovascular morbidity in patients without pre-existing CVD. This risk was highest in the first month but remained elevated for one year after delivery. These findings add to the accumulating evidence that undergoing caesarean delivery may have long-standing health implications and support the extension of the post-partum surveillance period. Limitations of this study include the lack of adjustment for body mass index, race, and parity. We were also unable to determine the reason for the caesarean delivery. None.

The association of insertion methods on immediate postpartum intrauterine device expulsion rates: A retrospective cohort study

ObjectiveTo evaluate the method of immediate postpartum IUD (ppIUD) insertion (manual versus ring forceps) and expulsion rate within 6-week postpartum. Study designWe performed a retrospective cohort study of patients who had a singleton vaginal delivery and an immediate ppIUD inserted at Rush University from January 2014 to September 2023. The primary outcome was rate of expulsion within 6-week postpartum. We compared the rate of expulsion by method of insertion, either using a manual technique versus using ring forceps. We performed univariable analysis for the association between baseline maternal characteristics and the primary outcome and we performed multivariable logistic regression to determine the independent association of the method of insertion and the primary outcome. ResultsTwo hundred nineteen patients met eligibility with 117 immediate ppIUDs inserted manually and 102 inserted with ring forceps. Baseline maternal demographics were similar across study groups. After adjusting for factors selected a priori (estimated blood loss, body mass index, gestational age at delivery, nulliparity, type of IUD), use of ring forceps was more likely to result in expulsion compared to manual insertion (30.4% vs 16.2% respectively; adjusted OR 2.49, 95% confidence interval 1.28–4.90). ConclusionIn this retrospective analysis, insertion of immediate ppIUD with ring forceps was independently associated with an increased rate of expulsion within 6 weeks postpartum when compared to manual insertion. ImplicationsIn this setting, ring forceps was associated with high rates of immediate postpartum IUD expulsion compared to manual technique. Studies disagree, suggesting need for additional work.

Prevalence and associated factors of maternal birth trauma following vaginal delivery at University of Gondar Comprehensive Specialized Hospital, North-West Ethiopia, 2022

BackgroundMaternal injury with any form of perineal trauma following vaginal delivery is very common which ranges globally from 16.2 to 90.4%. The frequency of Obstetric anal sphincter Injuries and the incidence of cervical laceration increases rapidly. However, in Ethiopia, there is limited evidence on the prevalence of maternal birth trauma and its determinant factors after vaginal delivery.ObjectiveTo assess the magnitude and associated factors of Maternal Birth Trauma after vaginal delivery at University of Gondar Comprehensive Specialized Hospital, Gondar, North-West Ethiopia, 2022.MethodsAn Institution based cross-sectional study was conducted among mothers with singleton vaginal delivery at University of Gondar Comprehensive Specialized Hospital from 9th May to 9th August 2022 among 424 study participants. Pre-tested semi-structured questioner was utilized. Epi-Data version 4.6 was used for data entry and exported to SPSS version 25 for data management and analysis. To identify the determinant factors, binary logistic regression model was fitted and variables with p-value < 0.2 were considered for the multivariable binary logistic regression analysis. In the multivariable binary logistic regression analysis, Variables with P-value < 0.05 were considered to have statistical significant association with the outcome variable. The Adjusted Odds Ratio (AOR) with 95% CI was reported to declare the statistical significance and strength of association between Maternal Birth Trauma and independent variables.ResultsA total of 424 mothers who delivered vaginally were included. The mean age of participants was 26.83 years (± 5.220 years). The proportion of birth trauma among mothers after vaginal delivery was47.4% (95%CI: 43.1, 51.7). Of different forms of perineal trauma, First degree tear in 42.8%, OASIs in 1.5% and Cervical laceration in 2.5% study participants. In the multivariable binary logistic regression analysis being primiparous (AOR = 3.00; 95%CI: 1.68, 5.38), Gestational age ≥ 39 weeks at delivery (AOR = 2.96; 95%CI: 1.57, 5.57), heavier birth weight (AOR = 12.3; 95%CI: 7.21, 40.1), bigger head circumference (AOR = 5.45; 95%CI: 2.62, 11.31), operative vaginal delivery (AOR = 6.59; 95%CI: 1.44, 30.03) and delivery without perineum and/or fetal head support (AOR = 6.30; 95%CI: 2.21, 17.94) were significantly associated with the presence of maternal birth trauma.Conclusion and recommendationMaternal birth trauma following vaginal delivery was relatively high in this study. Prim parity, gestational age beyond 39 weeks at delivery, heavier birth weight, bigger head circumference, operative vaginal delivery and delivery without perineum and/or fetal head supported were factors affecting perineal outcome. The Ministry of Health of Ethiopia should provide regular interventional training as to reduce maternal birth trauma.

Effect of feeding time on womens satisfaction after caesarean section a randomized control study.

Trail design A quazi randomizedd controlled trial Methods Particpaints A total of 226 parous women with singleton vaginal delivery at term pregnancy 37 to 42 weeks of gestation with cephalic presentation. Study participants who had undergone the use of tocolytics drugs for delivery, or caesarian section performed under general anaesthesia were excluded from the study. Moreover, participants with intra-operative complications bowel injury, bowel adhesions, post-partum haemorrhage and anaesthetic complications and postoperative complications postpartum haemorrhage, shock, fever, eclampsia, and use of MgSo4 were excluded from the study. The participants with pre-existing medical conditions like hypertension, diabetes and gastrointestinal diseases were screened off and removed from the study. Additionally, obstructed labour and the use of butrophanone as labour analgesia or postoperative analgesia were excluded. Intervention The study participants were divided into two groups based on the intervention considered. After the participants were selected as per inclusion criteria, an informed consent was taken from all the respondents. The early feeding group was allowed for intake of food after 6 hours of delivery starting with liquid diet followed by solid diet. Similarly delayed feeding group was allowed for intake of food after complete reversal of anaesthesia i.e. 12 hours of delivery starting with liquid diet followed by solid diet.

Potential Risk Factors for Predicting Fetal Shoulder Dystocia

Objective: The aim of this study was to assess maternal, obstetric, and fetal risk factors, as well as shoulder dystocia (SD) maneuvers and perinatal outcomes, in the management of SD. Materials and Methods: This descriptive retrospective cross-sectional study analyzed 66 documented patient cases of SD from a pool of 36 390 singleton vaginal deliveries. This review was based on hospital deliveries that occurred between 2017 and 2022. In addition, 201 control cases were selected from a computer-assisted randomization program, which were based pregnancy, delivery, fetal, and newborn outcome data. Regression analysis was used to elucidate the relationship between SD and associated risk factors. Results: The SD group exhibited a significantly higher mean age ( P &lt; .05) compared with control group. Notably, the abdominal circumference (AC) measurement (sensitivity = 81.8% and specificity = 91.0%) and birth weight (sensitivity = 62.4% and specificity = 91.5%) emerged as the most significant risk factors for SD. Conclusion: These retrospective findings may suggest that aside from birth weight and AC measurements, other risk factors for SD demonstrate low sensitivity. This work also underscored the unpredictable nature of this obstetric complication.

The association between BMI, episiotomy, and obstetric anal sphincter injuries (OASIS) in singleton vaginal deliveries

ObjectivePrevalence of obesity in reproductive age and pregnant women has been on the rise during the past several decades. The relationship between body mass index (BMI) and obstetric anal sphincter injuries (OASIS) or episiotomy has not yet been thoroughly investigated. The objective of this study was to shed light on this issue. MethodsThis retrospective cohort study was performed using electronic database of an obstetrics department at a university-affiliated tertiary medical center. All spontaneous singleton vaginal deliveries at term between January 2015 and December 2021 were included. The primary outcome was the incidence of OASIS (third- and fourth-degree perineal tears) and obesity. These were compared across three BMI categories: normal (BMI below 25 kg/m2), overweight (BMI 25.0–29.9 kg/m2), and obesity (BMI of 30 kg/m2 and over). ResultsOf the overall 13,932 spontaneous vaginal deliveries identified, 34.7 % had BMI in the normal range, 43.1 % were overweight, and 25.4 % were obese. Multivariate analysis demonstrated lower rates of OASIS in obese (OR 0.2, 95 %CI 0.04–0.9) and in overweight (OR 0.3, 95 %CI 0.1–0.99) women, as compared to the normal-weight cohort. In addition, lower rates of episiotomy were noted in the obese cohort (OR 0.7, 95 %CI 0.6–0.8). ConclusionsDecreased incidence of OASIS was noted in women with obesity, in conjunction with lower use of episiotomy. These findings imply that obstetrics clinics might consider a more conservative approach to episiotomy in obese patients.

Risk Factors for Intrapartum Anorectal Mucosal Lacerations and Rectovaginal Fistula: A Retrospective Comparative Study.

We examined the risk factors for fourth-degree perineal lacerations (intrapartum anorectal mucosal lacerations) and rectovaginal fistulas as one of the later complications. We reviewed the obstetric records of all singleton vaginal deliveries after 22 weeks of gestation at our institute between January 2006 and December 2018 (n = 19,370). Of the 19,370 deliveries, 61 had fourth-degree perineal lacerations (0.31%). Of the 61 women, 5 (8.2%) developed rectovaginal fistulas 2-3 weeks after their deliveries. Upon multivariate analysis, nulliparity (Adjusted odds ratios (OR) 3.58, 95% confidence interval (CI) 1.6-8.1, p < 0.01), midline episiotomy (Adjusted OR 2.10, 95% CI 1.0-4.2, p = 0.03), vacuum extraction (Adjusted OR 7.01, 95% CI 3.5-14, p < 0.01), and forceps delivery (Adjusted OR 22.0, 95% CI 7.8-61, p < 0.01) were independently associated with fourth-degree perineal lacerations, while mediolateral episiotomy (Adjusted OR infinity, 95% CI 2.1-infinity, p = 0.03) and forceps delivery (Adjusted OR infinity, 95% CI 14.5-infinity, p = 0.01) were independently associated with rectovaginal fistulas. In addition, in the women with fourth-degree perineal lacerations, mediolateral episiotomy was associated with rectovaginal fistulas (OR infinity, 95% CI 1.8-infinity, p = 0.04). Midline episiotomy and instrument-assisted delivery are independent risk factors for fourth-degree perineal lacerations after vaginal delivery. Mediolateral episiotomy and forceps delivery were independently associated with rectovaginal fistulas. Once fourth-degree perineal lacerations occurred, women with mediolateral episiotomies were more likely to develop rectovaginal fistulas.

Efficacy of Marham-e-Dakhilyun Ointment and Alum Perineal Wash for Perineal Wound Healing and Pain Intensity in Postpartum Women: A Self-control Clinical Trial

Background and Objective:: Episiotomy, worldwide, is the most frequently performed obstetric surgical procedure. Delayed wound healing potentially amplifies the risk of wound infection, structural muscular alterations, and ultimately contributes to the loss of muscle tone. In addition, rapid and complete repair of the episiotomy or perineal tear is very important as the pain and discomfort of episiotomy wounds may affect the quality of life of postnatal mothers. Therefore, we aimed to determine the efficacy of Marham-e-Dakhilyun ointment and alum perineal wash on perineal wound healing and pain intensity in postnatal mothers. Materials and Methods:: A single-arm self-controlled study was conducted on postnatal mothers aged 18 to 40 years, who underwent full-term normal cephalic singleton vaginal delivery with episiotomy and/or 1st, 2nd, or 3rd-degree perineal tears. The recommended external care regimen for a period of 10 days involved perineal wash with a solution of alum powder (2 gm/500ml), followed by the application of Marham-e Dakhilyun ointment twice daily to the perineal wound. For the primary evaluation of wound healing, the REEDA (redness, edema, ecchymosis, discharge, and approximation) scale has been utilized, while the secondary assessment involved the use of the VAS (visual analog scale) pain intensity scale. The therapeutic outcome was determined based on the grading of REEDA scores on days 10-14 and VAS scores. Results:: We observed our trial medicine showed complete wound healing in 86.4% on days 10- 14. The mean pain reduction percentage (PR %) was 96.85% on days 10-14 from baseline. The REEDA score was 2.41±0.81 and 0.23±0.61 at one hour and day 10-14, respectively, with significant differences (p &lt; 0.001). The VAS score was 2.86±1.08 and 0.09±0.29 at one hour and day 10-14, respectively, with significant differences (p &lt; 0.001). Therefore, the trial ointment and alum have demonstrated beneficial effects in promoting perineal wound healing and alleviating pain in postnatal mothers. Conclusion:: The potential efficacy of Marham-e-Dakhilyun can be attributed to its composition of various phytoconstituents, such as oleuropein, phenolic acids, flavonols, flavones, linoleic acid isovitexin, vitexin vanillic acid, salicylic acid, beta-D-glucopyranoside, olanigroside Y1, solasonine, gallic acid, aucubin, scopoletin, and lantamajoside. These constituents have been proven in research studies to possess anti-inflammatory, wound healing, antimicrobial, analgesic, and antioxidant properties. The investigators have optimized the use of these Unani medicines to provide clinical evidence supporting their effectiveness in the wound-healing process and in reducing pain intensity.

Migrant-Native Disparities in Obstetric Neuraxial Analgesia Use: The Role of Host-Country Language Proficiency

(Anesth Analg. 2023;137(4):870–881) Neuraxial analgesia (NA) is highly effective for labor pain relief, but its use varies among countries and is influenced by factors like ethnicity and region of origin. This study investigated how language proficiency affected NA utilization and satisfaction with labor pain management in migrant women compared to native women. Data came from the baMBINO study in Portuguese public hospitals, including migrant and native women. The study involved interviews conducted in various languages and excluded certain cases, resulting in a sample of 3697 women with singleton vaginal deliveries. This research aimed to explore the impact of language barriers on disparities in labor pain management.

Predicting risk of postpartum hemorrhage associated with vaginal delivery of twins: A retrospective study.

Many studies have only focused on the risk factors for postpartum hemorrhage (PPH) in singleton vaginal deliveries and twin cesarean deliveries. We analyzed the factors of influencing PPH occurrence in twin vaginal deliveries and developed a nomogram for clinical application. This retrospective study included 274 pregnant women with twin pregnancies who were hospitalized for delivery from January 2014 to December 2018. The patients opted for vaginal delivery and experienced spontaneous labor. Univariate analysis of PPH risk factors was performed. Multivariate analysis was performed using the least absolute shrinkage and selection operator (LASSO) to obtain relevant factors and build a prediction model, which was presented as a nomogram. The model was internally validated by bootstrap self-sampling method. Model accuracy was evaluated with the concordance index (C-index). There were 36 (13.14%) and 238 (86.9%) patients in the PPH and no PPH groups, respectively. Univariate analysis identified twin chorionicity, hypertensive disorders complicating pregnancy (HDCP), anemia in pregnancy, delivery mode of the second twin, oxytocin use during labor, postpartum curettage, cervical laceration, intrapartum fever, fibrinogen degradation products (FDP), and platelet count (PLT) as significant PPH factors. On multivariate analysis, HDCP, anemia in pregnancy, intrapartum fever, oxytocin use during labor, fetal distress, PLT, direct bilirubin, and FDP were noted as significant PPH factors and were included in the prediction model. A C-index of 0.816 was noted after internal validation, and the calibration curve showed good consistency. We developed a model to predict PPH risk in the vaginal delivery of twin pregnancies and visualized it with a nomogram that can be applied clinically to assess PPH risk and aid PPH prevention.

Predicting perineal trauma during childbirth using data from a general obstetric population.

Perineal trauma is a common complication of childbirth and can have serious impacts on long-term health. Few studies have examined the combined effect of multiple risk factors. We developed and internally validated a risk prediction model to predict third and fourth degree perineal tears using data from a general obstetric population. Risk prediction model using data from all singleton vaginal deliveries at Cork University Maternity Hospital (CUMH), Ireland during 2019 and 2020. Third/fourth degree tears were diagnosed by an obstetrician or midwife at time of birth and defined as tears that extended into the anal sphincter complex or involved both the anal sphincter complex and anorectal mucosa. We used univariable and multivariable logistic regression with backward stepwise selection to develop the models. Candidate predictors included infant sex, maternal age, maternal body mass index, parity, mode of delivery, birthweight, post-term delivery, induction of labour and public/private antenatal care. We used the receiver operating characteristic (ROC) curve C-statistic to assess discrimination, and bootstrapping techniques were used to assess internal validation. Of 8,403 singleton vaginal deliveries, 8,367 (99.54%) had complete data on predictors for model development. A total of 128 women (1.53%) had a third/fourth degree tear. Three variables remained in the final model: nulliparity, mode of delivery (specifically forceps delivery or ventouse delivery) and increasing birthweight (per 100 gram increase) (C-statistic: 0.75, 95% CI: 0.71, 0.79). We developed a nomogram to calculate individualised risk of third/fourth degree tears using these predictors. Bootstrapping indicated good internal performance. Use of our nomogram can provide an individualised risk assessment of third/fourth degree tears and potentially aid counselling of women on their potential risk.

Migrant-Native Disparities in Obstetric Neuraxial Analgesia Use: The Role of Host-Country Language Proficiency.

Neuraxial analgesia (NA) is the most effective modality in managing labor pain with widespread availability in high-income countries. Previous research has reported a differential obstetric NA use among migrant and native women, but the contribution of language barriers is not well understood. We aimed to investigate whether host-country language proficiency among migrant women influences NA use and satisfaction with pain management during labor, when compared to natives. We conducted a secondary analysis of data collected from 1024 native and 1111 migrant women who had singleton vaginal deliveries between 2017 and 2019 and were enrolled in the nationwide Portuguese baMBINO prospective cohort study. Obstetric NA use, satisfaction with labor pain management, and migrants' Portuguese language proficiency were self-reported. Data were analyzed using robust multilevel Poisson regression, adjusted for maternal region of birth (characterized by the Human Development Index), age, and education. Overall, 84.4% of native women gave birth with NA, compared to 81.6%, 71.3%, and 56.9% of migrant women with full, intermediate, and limited language proficiency, respectively. Compared to native women, migrants with intermediate (adjusted risk ratio [aRR] = 0.91 [95% confidence interval {CI}, 0.82-0.99]) and limited (aRR = 0.73 [95% CI, 0.56-0.94]) proficiency were less likely to receive NA. However, no significant differences were observed in pain management satisfaction by language proficiency level. Compared to native women, we observed a differential obstetric NA use across migrant women with different host-country language proficiency levels in Portugal, without affecting satisfaction with labor pain management. Although defining the mechanisms underlying NA use discrepancies requires further research, our findings support systematically evaluating pregnant migrant women's linguistic skills and ensuring their access to adequate obstetric analgesia-related information and interpretation services.

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.

Re-evaluation of modifiable risk factors for obstetric anal sphincter injury in a real-world setting.

The objective was to identify modifiable risk factors for obstetric anal sphincter injury (OASI) in primiparous women. This was a retrospective cohort study of primiparous women with a singleton vaginal delivery. Main outcome measures were incidence of OASI and odds ratios for possible risk factors: maternal age, body mass index and height, fetal birthweight and head circumference, gestational age, epidural analgesia, mediolateral episiotomy, and instrumental deliveries. Univariate and multivariate logistic regressions were performed using forward methods for variable selection. Of 19,786 primiparous women with a singleton vaginal delivery, 369 sustained an OASI (1.9%). Risk factors were identified: vacuum extraction (adjusted OR 2.06, 95% CI, 1.59-2.65, p < 0.001), increased fetal weight (aOR 1.06, 95% CI, 1.02-1.11, p = 0.002, per 100-g increments); head circumference (aOR 1.24, 95% CI, 1.13-1.35, p < 0.001, per 1-cm increments); gestational week (aOR 1.11, 95% CI, 1.02-1.2, p = 0.012, per week). Protective factors: mediolateral episiotomy (aOR 0.75, 95% CI, 0.59-0.94, p = 0.013) particularly in vacuum deliveries (aOR 0.50, 95% CI, 0.29-0.97, p = 0.040); epidural analgesia (aOR 0.64, 95% CI, 0.48-0.84, p = 0.001); maternal height ≥157 cm (aOR 0.97, 95% CI, 0.96-0.98, p = 0.006, risk decreases by 2.6% per 1 cm increase in height). Mediolateral episiotomy was protective against OASI in both spontaneous and instrumental deliveries of primiparae. Increased fetal weight and large fetal head circumference, particularly in short women, were significant risk factors. These findings support the performance of ultrasound to acquire updated fetal measures before admission to the labor ward.

Risk factors associated with third- and fourth-degree perineal lacerations in singleton vaginal deliveries: a comprehensive United States population analysis 2016-2020.

Perineal lacerations are a common complication of vaginal birth, affecting approximately 85 % of patients. Third-and fourth-degree perineal lacerations (3/4PL) remain a significant cause of physical and emotional distress. We aimed to perform an extensive assessment of potential risk factors for 3/4PL based on a comprehensive and current US population database. Retrospective population-based cohort analysis based on the US Centers for Disease Control and Prevention Natality Live Birth online database between 2016-2020. Baseline characteristics were compared between women with 3/4PL and without 3/4PL by using Pearson's Chi-squared test with statistical significance set at p<0.05. Bonferroni correction was used to account for multiple comparisons. Multivariable logistic regression was performed to evaluate the association between a variety of potential risk factors and the risk of 3/4P. Asians/Pacific Islanders had the highest risk of 3/4PL (2.6 %, aOR 1.74). Gestational hypertension and preeclampsia were associated with increased risk of 3/4PL (aOR1.28 and 1.34, respectively), as were both pre-gestational and gestational diabetes (aOR 1.28 and 1.46, respectively). Chorioamnionitis was associated almost double the risk (aOR 1.86). Birth weight was a major risk factor (aOR 7.42 for greater than 4,000 g), as was nulliparity (aOR 9.89). We identified several maternal, fetal, and pregnancy conditions that are associated with an increased risk for 3/4PL. As expected, nulliparity and increased birth weight were associated with the highest risk. Moreover, pregestational and gestational diabetes, hypertensive disorders of pregnancy, Asian/Pacific Islander race, and chorioamnionitis were identified as novel risk factors.

Healing at Home: Impacting Postpartum Outcomes Utilizing Clinical Practice Changes and Augmented Intelligence [ID: 1379350

INTRODUCTION: The fourth trimester is a time of great physical and emotional challenge. To help patients navigate this period, we created the Healing at Home (H@H) program, which combined expedited discharge with a 24/7 bidirectional postpartum support chatbot. METHODS: Clinical outcomes, abstracted from medical record and patient report via text message, were evaluated for patients enrolled in H@H (March 2020 to September 2021) compared to patients delivering prior to program implementation (July to December 2019). Enrolled patients had a full-term singleton vaginal delivery of a non-small-for-gestational-age infant without postpartum hemorrhage (&gt;1,000 cc), a low-risk sepsis risk score, a low- to intermediate-risk bilirubin, and lack of significant maternal comorbidities (eg, preeclampsia, preexisting diabetes). Institutional review board waiver for this quality improvement study was obtained. RESULTS: There were 490 patients enrolled in H@H versus 309 in preintervention group. The groups were similar in parity, race, ethnicity, and insurance status. There was no difference in the primary outcome, postpartum visit attendance (76.9% versus 76.1%, P=.77). H@H patients had a shorter postpartum length of stay (33.3 versus 46.7 hours, P&lt;.001), higher rates of exclusive breastfeeding at 1 week (59.2% versus 57.0%, P=.02), and a higher rate of contraceptive use (55% versus 44%, P=.01), with no difference in maternal unscheduled visits or hospital readmissions. CONCLUSION: This innovative postpartum program was associated with a shorter length of stay and improvement in contraceptive acceptance and breastfeeding without increasing unscheduled visits. Future studies should evaluate the cost-effectiveness of this program and expansion to higher-risk patients including those with cesarean delivery and medical comorbidities.

Correlation of anorectal symptoms and endoanal ultrasound findings after obstetric anal sphincter injuries (OASIS).

Obstetric anal sphincter injuries (OASIS) predispose to development of anorectal symptoms that affect women's quality of life. A retrospective cohort study was conducted for all women with singleton vaginal deliveries who had a primary OASIS repair and attended the Postpartum Perineal Clinic between July 1st 2017 and December 31st 2020. This study was approved by the Research Ethics Board. The purpose of this study was (1) to determine correlation between endoanal ultrasound (EAUS) findings and anorectal symptoms quantified by the St. Mark's Incontinence Score (SMIS), (2) to determine the incidence of residual anal sphincter defects, and (3) to determine the rate of clinical overdiagnosis of OASIS. Pearson correlation coefficient was used to assess correlation between anorectal symptoms and EAUS findings. A total of 247 participants with clinical diagnosis of OASIS met the inclusion criteria. A 3rd-degree tear was identified in 126 (51.0%) and 4th-degree tear was identified in 30 (12.1%) participants. In participants with sonographic evidence of OASIS, there was a statistically significant weak positive correlation between the size of residual defect and SMIS for both external anal sphincter (EAS) (r= .3723, p<.0001) and internal anal sphincter (IAS) (r= .3122, p=.0180). Residual defect in the anorectal sphincter of greater than 1 hour (>30°) in width was present in 64.3% participants with 3rd-degree tear and 86.7% participants with 4th-degree tear. The rate of overdiagnosis was 36.8%. The size of residual defect of EAS and IAS has a weak positive correlation with anorectal symptoms, emphasizing the importance of EAUS for counselling regarding mode of subsequent delivery.