Singleton Vaginal Deliveries Research Articles

802: The effect of epidural analgesia on second stage length and delivery mode.

To examine the effect of epidural analgesia on the length of the second stage in a contemporary cohort of parturients and to establish risk factors for a prolonged second stage. A retrospective cohort study of all live singleton vaginal deliveries in a single tertiary center between 2011 and 2016. The 5%, 50% and 95% percentiles of second stage length were calculated stratified by parity and epidural analgesia during labor. Multivariate logistic regression analysis was used to assess risk factors for a prolonged second stage. During the 6-year study period, 46,638 deliveries met inclusion criteria. The 95th percentile of second stage length for primiparous women and multiparous women without epidural was 162 minutes and 40 minutes, respectively. Epidural use increased the 95th percentile of second stage length by 59 and 87 minutes in primiparous and multiparous women, respectively. It was associated with more than a two-fold increase in rates of a prolonged second stage (p<0.001, OR 2.03, CI 1.83-2.26), and more than a three-fold increase in instrumental delivery rates (p<0.001, OR 3.36, CI 2.89-3.91) regardless of parity, but did not increase rates of cesarean delivery. Primiparity was an independent risk factor for a prolonged second stage (OR 4.45, CI 4.10-4.85). Epidural use prolongs the length of the second stage of labor and increases rates of instrumental delivery in both primiparous and multiparous women.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Efficacy of Music Therapy on Immediate Postpartum Episiotomy Pain: A randomized controlled trial

Objectives: To evaluate the effectiveness of music therapy in alleviating immediate postpartum episiotomy wound pain. Material and Methods: A randomized controlled trial was conducted to evaluate the efficacy of music therapy in alleviating immediate pain from an episiotomy wound. Uncomplicated singleton vaginal delivery women with the second degree or less episiotomy wound at Delivery and Postpartum Inpatient Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Srinakharinwirot University, Thailand were enrolled into the study. Visual analog scale (VAS) scoring was used for comparing pain levels. Results: One hundred postpartum women were enrolled in our study. Baseline characteristics such as age, degree of episiotomy wound tear were similar between both groups. The median pain VAS score was statistically significantly lower in the music group than in the control group at the end of the 2nd hour after finish of episiotomy wound repairing process [24.0 millimeters (8.3-41.5) and 36.5 millimeters (20.0-53.3), p < 0.001]. The median pain VAS score was statistically significantly lower in the music group than in the control group at the end of 6th hour after finish of episiotomy wound repairing process [12.0 millimeters (3.0-21.0) and 22.0 millimeters (15.0-38.0), p < 0.001] Conclusion: Music therapy is effective for reducing the perceived immediate postpartum pain of an episiotomy wound. Keywords: episiotomy pain, music therapy, singleton pregnancy

Risk factors for episiotomy during vaginal childbirth: A retrospective cohort study in Western China.

To assess the incidence rates and risk factors for episiotomy during vaginal childbirth in a Western China context. A retrospective hospital-based cohort study was conducted using computerized data of 3721 singleton vaginal deliveries after 28weeks of gestation. Women who underwent episiotomy were compared with those who did not. The overall prevalence of episiotomy was 44.0% (1636/3721); 52.9% (1458/2756) among primiparas and 18.4% (178/965) among multiparas (P<0.001). Adjusted risk factors significantly associated with episiotomy included primiparity, prolonged second stage of labor, and labor-management personnel. Risk factors specific to primiparas were increasing maternal age (per year) (OR=1.04, 95% CI 1.01 to 1.07, P=0.035), increasing biparietal diameter (per centimeter) (OR=1.40, 95% CI 1.06 to 1.84, P=0.017), first stage of labor beyond 10-hour (OR=1.36, 95% CI 1.10 to 1.68, P=0.005), and birth weight (per 100g) (OR=1.06, 95% CI 1.03 to 1.09, P<0.001). Birth weight resulted in an adjusted risk increase of 6.1% among primiparas for every 100 additional grams of birth weight. For the analysis stratified by labor-management personnel, moderately experienced midwifery was a risk factor of episiotomy (OR=1.76, 95% CI 1.21 to 2.56, P=0.003); midwives with bachelor's degree (OR=1.47, 95% CI 1.15 to 1.88, P=0.002), and obstetricians with doctor's degree (OR=2.00, 95% CI 1.18 to 3.39, P=0.010) were most likely to perform episiotomy. Episiotomy is still commonly performed in Western China. A survey of maternity care professionals' knowledge of and attitudes towards episiotomy is urgently required to explore the complex reasons for conducting episiotomy.

Birth outcomes of singleton vaginal deliveries to ART-treated, subfertile, and fertile primiparous women.

To determine whether differences in birth outcomes among assisted reproductive technology (ART)-treated, subfertile, and fertile women exist in primiparous women with, singleton, vaginal deliveries. Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) data were linked to Massachusetts vital records and hospital discharges for deliveries between July 2004 and December 2010. Primiparous women with in-state vaginal deliveries, adequate prenatal care, and singleton birth at ≥ 20weeks (n = 117,779) were classified as ART-treated (linked to ART data from SART CORS, n = 3138); subfertile (not ART-treated but with indicators of subfertility, n = 1507); or fertile (neither ART-treated nor subfertile, n = 113,134). Outcomes of prematurity (< 37weeks), low birthweight (< 2500g), perinatal death (death at ≥ 20weeks to ≤ 7days), and maternal prolonged length of hospital stay (LOS > 3days) were compared using multivariable logistic regression. Compared to fertile, higher odds were found for prematurity among ART-treated (adjusted odds ratio [AOR] 1.40, 95% confidence interval [CI] 1.25-1.50) and subfertile (AOR 1.25, 95% CI 1.03-1.50) women, low birthweight among ART-treated (AOR 1.41, 95% CI 1.23-1.62) and subfertile (AOR 1.40, 95% CI 1.15-1.71) women, perinatal death among subfertile (AOR 2.64, 95% CI 1.72-4.05), and prolonged LOS among ART-treated (AOR 1.33, 95% CI 1.19-1.48) women. Differences remained despite stratification by young age and absence of pregnancy/delivery complications. Greater odds of prematurity and low birthweight in ART-treated and subfertile, and perinatal death in subfertile deliveries are evident among singleton vaginal deliveries. The data suggest that even low-risk pregnancies to ART-treated and subfertile women be managed for adverse outcomes.

The association between neonatal head circumference and second stage duration

Purpose: To determine if head circumference (HC) is an independent factor influencing second stage duration stratified by parity and epidural use. Materials and methods: A retrospective cohort analysis of all live, singleton, term (37–42 weeks) vaginal deliveries in one university affiliated medical center (2012–2014). Exclusion criteria included operative deliveries due to fetal distress, major fetal anomalies/chromosomal abnormalities or cases with missing anthropometric data. Maternal demographics, labor characteristics and neonatal anthropometrics including birth weight and HC were retrieved. Multivariate linear regression was utilized to evaluate the association between HC and second stage duration. Analysis was stratified into four groups by parity and epidural use. Results: Of the 16 240 singleton vaginal deliveries during study period, 12 428 deliveries met inclusion criteria. Stratification by parity and epidural analgesia yielded four groups: 3337 (26.9%), 735 (5.9%), 5099 (41.0%) and 3257 (26.2%) deliveries – nullipara with/without epidural and multipara with/without epidural, respectively. In all groups, a large neonatal HC was significantly and independently associated with longer second stage duration: nullipara with epidural (beta 10.06, 95% CI 7.75–12.37), nullipara without epidural (beta 7.58, 95% CI 4.73–10.43), multipara with epidural (beta 4.64, 95%CI 3.47–5.8) and multipara without epidural (beta 1.35, 95% CI 0.76–1.94), p < .001 for all. Birth weight was not associated with second stage duration in any of the groups (p > .05). Conclusion: Large neonatal HC is significantly associated with longer second stage duration.

Risk factors for postpartum urinary retention after vaginal delivery at term without epidural anesthesia

Objective: We performed a retrospective case-control study of vaginal delivery at term without epidural anesthesia to identify clinical predictions of postpartum urinary retention (PUR).Methods: We reviewed the obstetric records of all singleton vaginal deliveries at Japanese Red Cross, Katsushika Maternity Hospital form January 2016 through December 2017.Results: There were 58 women (2.4%) complicated by PUR and 2391 women without PUR. A multivariate analysis revealed nulliparity, instrumental delivery, and episiotomy as independent risk factors for PUR (nulliparity: adjusted OR 2.39, 95%CI 1.2–4.8, p = 0.01; instrumental delivery: 3.53, 95%CI 1.9–6.7, p < .01, episiotomy: adjusted OR 1.96, 95%CI 1.0–3.8, p = .04). While, urination (or urethral catheterization) within 1 hour before delivery revealed as independent prevention factor for PUR (adjusted OR 0.54, 95%CI 0.30–0.99, p = .048).Conclusions: The risk factors identified in our institute seemed to approximately similar to those observed in the institutes capable of performing epidural anesthesia. In addition, urination just before delivery seemed to be an independent prevention factor for PUR.

Prevalence of Post-Traumatic Stress Disorder after Vaginal Delivery and in Particular after Postpartum Hemorrhage [18H

INTRODUCTION: Post traumatic stress disorder (PTSD) involves intrusive thoughts, nightmares and flashbacks of traumatic events that interfere with daily activities. PTSD has been described most commonly after combat and assault, but is also described after medical intervention, particularly admission to the intensive care unit. The goal of this study was to assess prevalence of PTSD after vaginal delivery and compare women who did and did not experience postpartum hemorrhage (PPH). METHODS: Patients who had a singleton vaginal delivery who were English speaking and greater than 18 years old were identified between 1/1/2013 and 12/31/2014. Of these 4,738 patients, 339 had a PPH defined as an estimated blood loss greater than 500 ml. Surveys were sent to all PPH patients and 2000 of the non-PPH patients. Total response rate was 442, or 19.6%. The survey included questions regarding the delivery as well as the PCL-C, a validated PTSD questionnaire. Multivariate logistic regression models were used to compare those with clinically significant PTSD symptoms in those with and without PPH. RESULTS: Patients who experienced PPH were more likely to have fear of extra bleeding again (P&lt;.0001) and fear of becoming pregnant again (P=.001). Those who had PPH were more than two times more likely to have a moderate or severe PCL-C score (OR 2.85). CONCLUSION: Understanding the prevalence of PTSD both after vaginal delivery and PPH will create awareness for providers to diagnose and treat these patients in the postpartum setting.

351: The association between head circumference and second stage duration

Large neonatal head circumference (HC) is suggested to be associated with cesarean and instrumental delivery. We aimed to determine if HC is an independent factor influencing the second stage duration stratified by parity and epidural use. A retrospective cohort analysis of all live, singleton, term (37-42 weeks) vaginal deliveries in one university affiliated medical center (2012-2014). Exclusion criteria included operative deliveries due to fetal distress, major fetal anomalies/ chromosomal abnormalities or cases with missing anthropometric data. Maternal demographics, labor characteristics and neonatal anthropometrics including birth weight and HC were retrieved. Multivariate linear regression was utilized to evaluate the association of HC to second stage duration. Analysis was stratified to 4 groups by parity and epidural use. Of the 16,240 singleton vaginal deliveries during study period, 12,428 deliveries met inclusion criteria. Stratification by parity and epidural use yielded 4 groups: 3,337(26.9%), 735 (5.9%), 5,099(41.0%) and 3257 (26.2%) deliveries for nullipara with/without epidural and multipara with/without epidural, respectively. Rates of labor induction, oxytocin use, prolonged second stage and vacuum extraction due to prolonged second stage were significantly higher in nullipara with epidural compared to the other groups, p<0.001 for all. (Table 1). After adjusting for maternal age, induction of labor, neonatal gender, birth-weight and HC - multivariate linear regression demonstrated significant association between neonatal HC and second stage duration for all groups (p<0.05). For nulliparas with epidural- HC, maternal age and induction of labor entered the final equation; for nullipara without epidural- HC and maternal age entered the final equation and for both multiparas groups, HC was the single significant variable associated with second stage duration. In all groups and from all variables that entered the regression- HC had the largest B value suggesting its high impact on second stage duration. (Table 2) Large neonatal head circumference is significantly associated with longer second stage duration. Our study suggests it is the third most important determinant influencing the second stage duration after parity and epidural use.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

849: The association between Maternal GroupB Streptococcus colonization and offspring Gastro-Intestinal morbidity

Maternal Group B Streptococcus (GBS) colonization is associated with peripartum complications. We sought to evaluate the association between maternal GBS colonization and long-term gastrointestinal (GI) morbidity in the offspring. A population based retrospective cohort study was conducted in a tertiary medical center, serving a population of one million inhabitants. The risk for pediatric GI morbidity of offspring (up to the age of 18 years) was compared among two study groups: exposed and unexposed to maternal rectovaginal GBS colonized mothers, based on perinatal hospitalization databases. All singleton vaginal deliveries occurring between the years 1991-2014 were included. Offspring with congenital malformations were excluded. GI morbidities were based on a pre defined set of ICD-9 codes, as recorded in the hospital computerized files. Kaplan Meier survival curves were used to compare the cumulative risks among the two study groups, and Cox multivariable survival models were used to adjusted for confounding variables. During the study period, 195,457 newborns met the inclusion criteria; 4820 parturient had a proven diagnosis of GBS colonization. Selected categories of GI morbidity are presented in the Table. Total GI morbidity rate was higher in the GBS positive group as compared with the comparison group (7.69 vs. 5.03/ 1000-person years; Table). Offspring of GBS positive mothers had significantly higher rates of gastroduodenal diseases (0.69 vs. 0.51/1000-person years, p=0.005; Table) and of inflammatory bowel diseases (IBD), 3.03 vs. 1.26/1000 person years, p=0.023). The Kaplan-Meier survival curve demonstrated GBS positive offspring to have a significantly higher cumulative incidence of total GI morbidity (log rank, p=0.002; Figure). The association between maternal GBS and offspring GI morbidity remained significant in the Cox model, which adjusted for maternal age, diabetes, hypertensive disorders and gestational age (adjusted HR=1.2; 95% CI 1.1- 1.2). Maternal GBS colonization is an independent risk factor for long-term GI morbidity in the offspring, and specifically for gastroduodenal diseases and IBD. The exact mechanism leading to these findings, whether fetal microbiome changes or immunological alterations due to peripartum antibiotic exposure, awaits further investigations.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Impact of shoulder dystocia, stratified by type of manoeuvre, on severe neonatal outcome and maternal morbidity.

Shoulder dystocia is an uncommon and unpredictable obstetric emergency. It is associated with significant neonatal, maternal and medico-legal consequences. To ascertain the impact shoulder dystocia has on severe neonatal and maternal outcomes specific to the type of manoeuvre. This was a retrospective study of 48021 term singleton vaginal deliveries the Mater Mothers' Hospital in Brisbane between 2007 and 2015. Maternal and neonatal outcomes were compared between deliveries complicated by shoulder dystocia and those uncomplicated. Deliveries complicated by shoulder dystocia are associated with low Apgar scores (≤3) at five minutes (odds ratio (OR) 5.25, 95% CI 3.23-8.56, P<0.001), acidosis (OR 3.10, 95% CI 2.76-3.50, P<0.001), postpartum haemorrhage (OR 2.28, 95% CI 1.90-2.75, P<0.001) and perineal trauma (OR 1.92, 95% CI 1.54-2.39, P<0.001). Compared to McRoberts' manoeuvre and suprapubic pressure alone, the odds of serious neonatal outcome are increased with internal rotational manoeuvres (OR 3.82, 95% CI 2.54-5.74, P<0.001) and delivery of the posterior arm (OR 4.49, 95% CI 3.54-5.69, P<0.001). The OR of maternal injury is 2.07 (95% CI 1.77-2.45, P<0.001), 2.26 (95% CI 1.21-4.21, P<0.001) and 2.29 (95% CI 1.58-3.32, P<0.001) with McRoberts'/suprapubic pressure, internal rotation and posterior arm delivery, respectively. Brachial plexus injuries and fractures complicate 1.4 and 0.9% of deliveries, with the risk of injury increasing when greater than one manoeuvre is required. The risk of neonatal and maternal trauma is strongly associated with the number and types of manoeuvres. Given the associated implications, adequate antenatal counselling, simulation training and enhanced labour surveillance are essential.

Postplacental intrauterine device expulsion by 12 weeks: a prospective cohort study

An intrauterine device placed immediately following a delivery can serve as an effective and safe contraceptive strategy in the postpartum period. There is limited evidence that the levonorgestrel intrauterine system may have a higher rate of expulsion compared to the copper intrauterine device; however, rates of expulsion for these 2 intrauterine device types have not been compared directly. We sought to compare expulsion rates by 12 weeks' postpartum for the levonorgestrel intrauterine system and copper intrauterine device. We enrolled women who received postplacental intrauterine devices at 2 urban hospitals. Eligible women were ≥18 years old, English- or Spanish-speaking, with singleton vaginal delivery at ≥35 weeks' gestation. Intrauterine devices were inserted within 10 minutes of placental delivery by trained providers using ring forceps or the operator's hand. Intrauterine device location was evaluated via abdominal ultrasound at 24-48 hours' postpartum, and via transvaginal ultrasound 6 and 12 weeks later, categorizing position of the intrauterine device at the fundus, below the fundus but above the internal os, any part of the intrauterine device below the internal os (partial expulsion), or no intrauterine device visualized. Outcomes included intrauterine device expulsion and method continuation. We used multivariable logistic regression to identify factors associated with expulsion. We enrolled 123 women ages 18-40 years. Of these, 68 (55%) initiated levonorgestrel intrauterine system and 55 (45%) initiated copper intrauterine device. Groups were similar except more copper intrauterine device users were Hispanic (66% vs 38%) and fewer were primiparous (16% vs 31%). Among the 96 (78%) with 12-week follow-up, expulsion was higher for levonorgestrel intrauterine system users (21/55 or 38%) than for copper intrauterine device users (8/41 or 20%) (odds ratio, 2.55; 95% confidence interval, 0.99-6.55; P= .05). At 24 hours' postpartum, there was no significant difference in median distance from the intrauterine device to the fundus between intrauterine device types or between those who did or did not experience expulsion. Of expulsions, 86% occurred ≤6 weeks' postpartum. All complete expulsions were clinically identified, but of the partial expulsions, only 4/10 (40%) were clinically suspected prior to ultrasound. The only independent predictor of expulsion was intrauterine device type. Including reinsertions, intrauterine device use at 12 weeks was not significantly different for levonorgestrel intrauterine system and copper intrauterine device users (80% vs 93%; P= .14). Women initiating postplacental levonorgestrel intrauterine system are more likely to experience complete expulsion than those initiating copper intrauterine device. Using sonographic criteria results in higher expulsion rates than previously reported. It is unclear if such high expulsion rates would be identified following standard clinical practice.

The Great Divide: Country of birth as a risk factor for obstetric anal sphincter injuries.

Obstetric anal sphincter injuries (OASIS) can complicate up to 6% of births and are a major contributor to preventable maternal morbidity. Asian women have a risk of third and fourth degree perineal tears up to four times greater than women of other ethnicities in the same community, but the lack of differentiation of Asian women into regional groups has limited insight into the reasons behind their increased risk. To investigate risk of OASIS associated with country of birth. This was a retrospective cohort study of all women with a singleton, nulliparous pregnancy who delivered vaginally by spontaneous vaginal birth or an instrumental delivery between 1 January 2009 and 31 December 2015. The demographics of women who experienced OASIS were compared with those women who had minor perineal trauma. From January 2009 to December 2015 there were 10750 singleton, nulliparous and natural vaginal birth (NVB), forceps or vacuum deliveries. Of these deliveries, 581 (5.4%) werehad third degree tears and 36 (0.3%) fourth degree tears. Women born in South Asia were at a much higher risk of OASIS than other groups, including women born in other Asian countries, compared to the Australian/New Zealand cohort. One in every 10 nulliparous South Asian women having a singleton vaginal or instrumental delivery will sustain an OASIS. Our study further confirms the role of Asian ethnicity in the risk of OASIS, and is the second to confirm that South Asian women are at a dramatically increased risk.

Risk factors associated with adverse perinatal outcome in planned vaginal breech labors at term: a retrospective population-based case-control study

BackgroundVaginal breech delivery is associated with adverse perinatal outcome. The aim of this study was to identify factors associated with adverse perinatal outcome in term breech pregnancies, and to provide clinicians an aid in selecting women for a trial of vaginal labor with the fetus in breech position.MethodsWe conducted a retrospective, nationwide, Finnish population-based case-control study. All planned singleton vaginal deliveries at term with the fetus in breech position between the years 2005 and 2014 were analyzed. The study’s end point was a composite set of adverse perinatal outcomes. All infants with an adverse outcome were compared to the infants with normal outcomes. A multivariate logistic regression model was used to analyze the data.ResultsAn adverse perinatal outcome was recorded for 73 (1.5%) infants. According to the study results fetal growth restriction (adjusted odds ratio, 2.94; 95% CI, 1.30–6.67), oligohydramnios (adjusted odds ratio, 2.94; 95% CI, 1.15–7.18), a history of cesarean section (adjusted odds ratio, 2.94; 95% CI, 1.28–6.77, gestational diabetes (adjusted odds ratio, 2.89; 95% CI, 1.54–5.40), epidural anesthesia (adjusted odds ratio, 2.20; 95% CI, 1.29–3.75) and nulliparity (adjusted odds ratio, 1.84; 95% CI, 1.10–3.08) were associated with adverse perinatal outcome.ConclusionsAdverse perinatal outcome in planned vaginal breech labor at term is associated with fetal growth restriction, oligohydramnios, previous cesarean delivery, gestational diabetes, nulliparity and epidural anesthesia.

Are Asian American women at higher risk of severe perineal lacerations?

Objective: To evaluate whether Asian race is an independent risk factor for severe perineal lacerations.Methods: We performed a nationwide population-based retrospective cohort study examining the relationship between Asian race and severe perineal lacerations (third and fourth degree). The data were collected from the 2012 Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS). Characteristics of Asian American women were compared with those of non-Asian women. The primary outcome of interest was severe perineal lacerations. Multivariable logistic regression was used to refine the associations between Asian race and severe perineal lacerations while adjusting for confounding effects. Results were compared with previously published data using a pooled odds ratio.Results: 2,270,044 Women with singleton vaginal deliveries were identified, and 120,452 (5.3%) were Asian. After adjusting for confounders, Asian women were more likely to experience severe perineal lacerations than any other racial group (3.5% versus 6.3%, adjusted odds ratio [aOR] 1.50, 99% CI 1.29–1.74, p < 0.0001). Analysis of literature indicated that Asian American women are 74% more likely to experience severe perineal lacerations (aOR 1.74, 99% CI 1.72–1.76, p < 0.0001) than non-Asians.Conclusion: Asian race is an independent risk factor for severe perineal lacerations in the United States.

The association between maternal age at first delivery and risk of obstetric trauma

There are a number of poor birth outcomes with advancing maternal age. Although there is some evidence of a higher risk of trauma to obstetric anal sphincter and the levator ani muscle with advancing age, findings to date are inconclusive. The aim of this study was to assess the risk of pelvic floor injury using translabial 3- and 4-dimensional ultrasound relative to advancing maternal age in primiparous women after a singleton vaginal delivery at term and to determine any association between maternal age and obstetric trauma, including obstetric anal sphincter injuries, levator avulsion, and irreversible overdistension of the levator hiatus. This is a subanalysis of a perinatal intervention trial conducted in a specialist urogynecology referral unit at 2 tertiary units. All primiparous women with singleton birth at term underwent 3- and 4-dimensional translabial pelvic floor ultrasound both ante- and postnatally for the assessment of the obstetric trauma including levator ani muscle avulsion, hiatal overdistension to 25 cm(2) or more, and obstetric anal sphincter injuries. A multivariate logistic regression analysis was performed to examine the association between maternal age and obstetric trauma diagnosed on 3- and 4-dimensional translabial ultrasound. Multiple confounders were included, and the most significant (forceps and vacuum delivery) were used for probability modeling. Of 660 women recruited for the original study, a total of 375 women who had a vaginal delivery with complete data sets were analyzed. A total of 174 women (46.4%) showed evidence of at least 1 form of major pelvic floor trauma. Advancing maternal age at first delivery carries with it a significant incremental risk of major pelvic floor trauma with an odds ratio of 1.064 for overall risk of injury for each increasing year of age past age 18 years (P= .003). The probability of any type of trauma appears to besubstantially higher for forceps delivery. Vacuum delivery appears to increase the risk of obstetric anal sphincter injuries but not of levator avulsion. There is a significant association between the risk of major pelvic floor injury and increasing maternal age at first delivery.

Risk factors and outcomes in "well-selected" vaginal breech deliveries: a retrospective observational study.

To assess risk factors for adverse perinatal and neonatal outcomes in "well-selected" singleton vaginal breech deliveries at term. During the time span from January 2008 up to April 2015 a total of 786 singleton term breech deliveries with a planned vaginal delivery were identified in a retrospective observational study at Helsinki University Central Hospital, Finland. The study's end point was a composite of adverse perinatal and neonatal outcomes. Infants with an adverse outcome were compared to all spontaneous singleton vaginal breech deliveries with normal perinatal and neonatal outcomes. A multivariate logistic regression model was used to analyze associations between adverse neonatal outcomes and several variables. The secondary outcome was the severe morbidity rate according to the criteria of the term breech trial. An adverse neonatal outcome was recorded for 38 (4.8%) infants. According to the study the second delivery stage lasting <40 min [adjusted odds ratio (aOR): 0.34, 95% confidence interval (95% CI): 0.15-0.79] was associated with lower odds and had a protective effect against adverse outcomes. Epidural anesthesia (aOR: 2.88, 95% CI: 1.08-7.70) was associated with higher adverse outcomes. The incidence rate of severe morbidity was 1.3% (10/787). Adverse neonatal outcomes in well-selected breech deliveries are associated with a prolonged second delivery stage lasting >40 min and with epidural anesthesia.

Length of Stay After Childbirth in 92 Countries and Associated Factors in 30 Low- and Middle-Income Countries: Compilation of Reported Data and a Cross-sectional Analysis from Nationally Representative Surveys.

BackgroundFollowing childbirth, women need to stay sufficiently long in health facilities to receive adequate care. Little is known about length of stay following childbirth in low- and middle-income countries or its determinants.Methods and FindingsWe described length of stay after facility delivery in 92 countries. We then created a conceptual framework of the main drivers of length of stay, and explored factors associated with length of stay in 30 countries using multivariable linear regression. Finally, we used multivariable logistic regression to examine the factors associated with stays that were “too short” (<24 h for vaginal deliveries and <72 h for cesarean-section deliveries).Across countries, the mean length of stay ranged from 1.3 to 6.6 d: 0.5 to 6.2 d for singleton vaginal deliveries and 2.5 to 9.3 d for cesarean-section deliveries. The percentage of women staying too short ranged from 0.2% to 83% for vaginal deliveries and from 1% to 75% for cesarean-section deliveries.Our conceptual framework identified three broad categories of factors that influenced length of stay: need-related determinants that required an indicated extension of stay, and health-system and woman/family dimensions that were drivers of inappropriately short or long stays. The factors identified as independently important in our regression analyses included cesarean-section delivery, birthweight, multiple birth, and infant survival status. Older women and women whose infants were delivered by doctors had extended lengths of stay, as did poorer women. Reliance on factors captured in secondary data that were self-reported by women up to 5 y after a live birth was the main limitation.ConclusionsLength of stay after childbirth is very variable between countries. Substantial proportions of women stay too short to receive adequate postnatal care. We need to ensure that facilities have skilled birth attendants and effective elements of care, but also that women stay long enough to benefit from these. The challenge is to commit to achieving adequate lengths of stay in low- and middle-income countries, while ensuring any additional time is used to provide high-quality and respectful care.

Obstetric Anal Sphincter Injury as a Quality Metric: 16-Year Experience at a Single Institution.

To evaluate trends in annual rates of vaginal birth, cesarean delivery, and obstetric anal sphincter injury at a single institution before and after the designation of obstetric anal sphincter injury as a measure of obstetric quality and safety. This was a retrospective cohort study of women undergoing a singleton vaginal delivery and diagnosed with obstetric anal sphincter injury over a 16-year period. International Classification of Diseases, 9th Revision codes for perineal lacerations were used as identifiers. Trends in annual cesarean delivery, perineal laceration, and obstetric anal sphincter injury rates were assessed in a linear regression model. The data were divided into two time periods (1998-2005 and 2006-2013) based on the year (2006) in which obstetric anal sphincter injury was designated as a quality marker and compared. A total of 1,366 women had obstetric anal sphincter injury, and 1,360 were included for analysis. There was a 12.1% decline in annual vaginal delivery rates (from 77.1% to 67.8%) and a 40.6% increase in annual cesarean delivery rate (from 22.9% to 32.2%; P<.001). The rate of first-degree and second-degree laceration increased significantly (P=.009), and obstetric anal sphincter injury decreased significantly (P<.001). Operative vaginal birth and episiotomy were associated with obstetric anal sphincter injury in 2006-2013 compared with 1998-2005 (P<.001 and P=.018, respectively). After the designation of obstetric anal sphincter injury as an institutional quality measure, rates of obstetric anal sphincter injury decreased.

Is epidural analgesia during labor related to retained placenta?

To explore the influence of epidural analgesia on the course of the third stage of labor and on the incidence of the complete retained placenta as well as retained parts of the placenta. This is a population-based cohort study in a tertiary medical center. We collected data from all 4227 spontaneous singleton vaginal deliveries during 6 months and compared the incidence of retained placenta in deliveries with epidural analgesia with those without analgesia. Multivariable logistic regression was used to control for possible confounders. More than two-thirds of the women (69.25%) used epidural analgesia during their delivery. A need for intervention due to placental disorder during the third stage of labor was noted in 4.2% of all deliveries. Epidural analgesia appeared to be significantly (P=0.028) related to placental disorders compared with no analgesia: 4.8% vs. 3%, respectively. Deliveries with manual interventions during the third stage, for either complete retained placenta or suspected retained parts of the placenta, were associated with the use of epidural analgesia (P=0.008), oxytocin (P=0.002) and older age at delivery (P=0.000), but when including all factors in a multivariable analysis, using a stepwise logistic regression, the factors that were independently associated with interventions for placental disruption during the third stage of delivery were previous cesarean section, oxytocin use and, marginally, older age. Complete retained placenta and retained parts of the placenta share the same risk factors. Epidural analgesia does not directly influence the incidence of complete retained placenta or retained parts, though clinically linked through increased oxytocin use. The factors that were independently associated with interventions for placental disruption during the third stage of delivery were previous cesarean section, oxytocin use and older age.

Outcomes of singleton and twin breech deliveries in a ten year (2005 to 2014) retrospective audit at two rural hospitals in Papua New Guinea’s Gulf Province

&lt;p&gt;&lt;span style="text-decoration: underline;"&gt;Introduction&lt;/span&gt;&lt;em&gt; &lt;/em&gt;The aim of this audit was to investigate the rates of breech-related perinatal death and maternal and neo-natal morbidity in a resource-poor setting where caesarean sections are difficult to perform. &lt;span style="text-decoration: underline;"&gt;Method&lt;/span&gt;&lt;em&gt;. &lt;/em&gt;An audit of 5,102 babies born at two rural Papua New Guinean hospitals, Kapuna and Kikori, from 2005 to 2014 inclusive was performed. Information was gathered from the facility obstetric registers and supplemented by Kikori Hospital’s surgical register. During the period there were 179 breech presentations (103 singletons, 76 twins). The primary outcome was defined as perinatal death. Secondary outcomes were neonatal morbidity and maternal post-partum haemorrhage. Exclusion criteria were applied prior to analysis. These included: Likely pre-labour intrauterine death; mother presenting to hospital in second or third stage; baby born before arrival at hospital; prematurity recorded in the notes or birth weight less than 1500g as a surrogate marker; significant fetal abnormality; and significant maternal medical condition. &lt;span style="text-decoration: underline;"&gt;Findings&lt;/span&gt;&lt;em&gt;. &lt;/em&gt;The adjusted incidence of the outcomes were: Perinatal death for vaginal breech singletons 235/1,000 (95% CI 158-336/1,000) and vaginal breech twins 31/1,000 (95% CI 9-107/1,000); neonatal morbidity for vaginal breech singletons 141/1,000 (95% CI 82-231/1,000) and vaginal breech twins 31/1,000 (95% CI 9-107/1,000); post-partum haemorrhage for vaginal breech singletons 129/1,000 (95% CI 74-217/1,000) and vaginal breech twins 230/1,000 (95% CI 137-361/1,000). &lt;span style="text-decoration: underline;"&gt;Conclusions&lt;/span&gt;&lt;em&gt;. &lt;/em&gt;Poor outcomes for singleton vaginal breech delivery at the two hospitals were common. The potential in the rural setting for increased education on safe trial of vaginal breach delivery as well as increasing access to caesarean sections deserves consideration. &lt;/p&gt;