Spontaneous Vaginal Delivery Group Research Articles

Trends in obstetric anal sphincter injury in spontaneous vaginal delivery versus operative vaginal delivery over a 10-year period: Lessons learned.

To evaluate trends in the incidence of women with obstetric anal sphincter injuries (OASIS) over a 10-year period comparing spontaneous vaginal delivery (SVD) and operative vaginal delivery (OVD). A retrospective study was performed in which all women who underwent vaginal delivery over a 10-year period (n = 86 242, 2009-2018) at the Rotunda Hospital were reviewed. The overall incidence of OASIS was compared with incidence rates stratified by parity and type of vaginal birth. The 10-year vaginal delivery rate was 69% (n = 59 187) where 24 580 women (42%) were primiparous and 34 607 women (58%) were multiparous. SVD rate was 74% and OVD rate was 26%. The overall incidence of OASIS was 2.9%. The incidence of OASIS in OVD was 5.5% and the incidence in SVD was 2%. Of 498 multipara who sustained OASIS, 366 (73%) had an SVD without episiotomy compared with 14 (3%) who had an episiotomy. There was a significant reduction of OASIS over the 10-year period in primipara who had an OVD but no reduction in the other groups. The primiparous OVD group had a significant reduction of OASIS. Continued education around perineal protection and episiotomy at SVD could positively impact further reduction in OASIS, particularly in the SVD groups.

Postpartum recovery of nulliparous women following scheduled cesarean delivery and spontaneous vaginal delivery: a prospective observational study

Inpatient postpartum recovery trajectories following cesarean delivery and spontaneous vaginal delivery are underexplored. This study primarily aimed to compare recovery following cesarean delivery and spontaneous vaginal delivery in the first postpartum week, and secondarily to evaluate psychometrically the Japanese version of the Obstetric Quality of Recovery-10 scoring tool. Following institutional review board approval, the EQ-5D-3L (EuroQoL 5-Dimension 3-Level) questionnaire and a Japanese version of the Obstetric Quality of Recovery-10 measure were used to evaluate inpatient postpartum recovery in uncomplicated nulliparous parturients delivering via scheduled cesarean delivery or spontaneous vaginal delivery. A total of 48 and 50 women who delivered via cesarean delivery and spontaneous vaginal delivery, respectively, were recruited. Women delivering via scheduled cesarean delivery experienced significantly worse quality of recovery on days 1 and 2 compared with those who had spontaneous vaginal delivery. Quality of recovery significantly improved daily, plateauing at days 4 and 3 for cesarean delivery and spontaneous vaginal delivery groups, respectively. Compared with cesarean delivery, spontaneous vaginal delivery was associated with prolonged time to analgesia requirement, decreased opioid consumption, reduced antiemetic requirement, and reduced times to liquid/solid intake, ambulation, and discharge. Obstetric Quality of Recovery-10-Japanese is a valid (correlates with the EQ-5D-3L including a global health visual analog scale, gestational age, blood loss, opioid consumption, time until first analgesic request, liquid/solid intake, ambulation, catheter removal, and discharge), reliable (Cronbach alpha=0.88; Spearman-Brown reliability estimate=0.94; and intraclass correlation coefficient=0.89), and clinically feasible (98% 24-hour response rate) measure. Inpatient postpartum recovery is significantly better in the first 2 postpartum days following spontaneous vaginal delivery compared with scheduled cesarean delivery. Inpatient recovery is largely achieved within 4 and 3 days following scheduled cesarean delivery and spontaneous vaginal delivery, respectively. Obstetric Quality of Recovery-10-Japanese is a valid, reliable, and feasible measure of inpatient postpartum recovery.

Neuraxial analgesia interfered with the circadian rhythm of labor: a propensity score matched cohort study

ObjectivesTo investigate whether neuraxial analgesia and other medical interventions have effects on the circadian rhythm of labor.MethodsIt was a retrospective propensity score matched cohort study. Parturients were recruited, who delivered term singletons in cephalic position, from seven hospitals in Harvard University Partners Healthcare Systems, 2016–2018. The parturients were divided into two groups, neuraxial analgesia delivery and spontaneous vaginal delivery, the stratification was performed according to labor induction, oxytocin, operative delivery. The parturients in each group were divided into 12 periods in every 2 h based on the birth time of babies. Cosine function fitting was used to verify whether the birth time had the characteristic of circadian rhythm.ResultsIn spontaneous vaginal deliveries, the peak of birth time was at 2:00–4:00, and the nadir was at 14:00–16:00, this showed a circadian rhythm presented by a cosine curve fitting with the formula (y = 0.0847 + 0.01711 × cos(− 0.2138 × x + 0.4471). The labor rhythm of NAD (Neuraxial Analgesia Delivery) group changed completely, inconsistent with the cosine curve fitting of the circadian rhythm. The intervention of induction and oxytocin blurred the circadian rhythm of SVD (Spontaneous Vaginal Delivery) group and increased the amplitude of the fluctuation in NAD (Neuraxial Analgesia Delivery) group. The intervention of operative delivery had changed the distribution curve completely both in the SVD (Spontaneous Vaginal Delivery) group and the NAD (Neuraxial Analgesia Delivery) group.ConclusionsNeuraxial analgesia did affect on circadian rhythm of labor, changed the cosine rhythm of labor with spontaneous vaginal delivery, and this trend was aggravated by the use of induction, oxytocin and operative delivery.

Prediction of labor outcome by measuring the angle of progression using two dimensional trans-perineal Ultrasound: A prospective cohort study

Background: Failure of descent due to fetal malposition is one of the most common indications for performing surgical deliveries. It has recently been suggested that trans-perineal intra-partum ultrasonography may be useful in assessing fetal head engagement, position and station as well as it’s reliable, cheap, painless and effective tool. Measuring the ‘angle of progression’ could assist in the obstetrician’s decision regarding mode of delivery. Objectives: The primary outcome is to use the AOP to develop a predictive model for the probability of successful vaginal delivery. Secondary outcomes including assessment of possibly successful VBAC in previous one CS women. Methods: We recruited 500 women in labor. For each woman, a (TPU) was performed to measure the AOP in late first and second stages of labor. We compared AOP between women who delivered fetuses through vaginal route to those who delivered by CS. Results: Through 467 women included in the study, AOP was significantly Higher in spontaneous vaginal delivery group (with cut off 123°±8.5°) as compared with women delivered by vacuum or by CS (113°±10.5°) (P=0.003). The VBAC as another secodary outcome seems to be insignificant. Conclusions: TPU is safe, non-invasive and easily preformed technique which is useful to predict labor outcomes.

Surface electromyography of the pelvic floor at 6-8 weeks following delivery: a comparison of different modes of delivery.

The objective of this study was to compare the impact of different modes of delivery, especially forceps delivery (FD), on pelvic floor muscles (PFMs) through vaginal surface electromyography (sEMG) in primiparous women at early (6-8weeks) postpartum. A total of 1259 primiparous women with full-term singleton births were included in this cross-sectional study. Of these, 98 were delivered by forceps, 865 underwent spontaneous vaginal delivery (SD) and 296 underwent elective cesarean delivery (CD). Clinical demographic characteristics and vaginal sEMG variables of parturients 6-8weeks after birth were collected and analyzed using SPSS software. One-way ANOVA with Bonferroni correction, Chi-square test or Student's t-test was used according to the variable type. Spearman correlation and binary logistic regression analyses were also used. P/α ≤ 0.05 was considered statistically significant. Amplitude of fast and sustained contractions on sEMG in the FD group was significantly lower compared with the CD and SD groups. The sEMG amplitude of all contractions was significantly higher in the CD group compared with the FD and SD groups (P < 0.01). According to binary logistic regression analysis, mode of delivery was a major influencing factor in sEMG. An early postpartum sEMG test appears to be helpful for the assessment of PFM activity. Mode of delivery was a major influencing factor on sEMG. Forceps delivery significantly inversely influenced PFM activity.

Human Milk Virome Analysis: Changing Pattern Regarding Mode of Delivery, Birth Weight, and Lactational Stage.

The human milk (HM) microbiota is a significant source of microbes that colonize the infant gut early in life. The aim of this study was to compare transient and mature HM virome compositions, and also possible changes related to the mode of delivery, gestational age, and weight for gestational age. Overall, in the 81 samples analyzed in this study, reads matching bacteriophages accounted for 79.5% (mainly Podoviridae, Myoviridae, and Siphoviridae) of the reads, far more abundant than those classified as eukaryotic viruses (20.5%, mainly Herpesviridae). In the whole study group of transient human milk, the most abundant families were Podoviridae and Myoviridae. In mature human milk, Podoviridae decreased, and Siphoviridae became the most abundant family. Bacteriophages were predominant in transient HM samples (98.4% in the normal spontaneous vaginal delivery group, 92.1% in the premature group, 89.9% in the C-section group, and 68.3% in the large for gestational age group), except in the small for gestational age group (only ~45% bacteriophages in transient HM samples). Bacteriophages were also predominant in mature HM; however, they were lower in mature HM than in transient HM (71.7% in the normal spontaneous vaginal delivery group, 60.8% in the C-section group, 56% in the premature group, and 80.6% in the large for gestational age group). Bacteriophages still represented 45% of mature HM in the small for gestational age group. In the transient HM of the normal spontaneous vaginal delivery group, the most abundant family was Podoviridae; however, in mature HM, Podoviridae became less prominent than Siphoviridae. Myoviridae was predominant in both transient and mature HM in the premature group (all C-section), and Podoviridae was predominant in transient HM, while Siphoviridae and Herpesviridae were predominant in mature HM. In the small for gestational age group, the most abundant taxa in transient HM were the family Herpesviridae and a species of the genus Roseolovirus. Bacteriophages constituted the major component of the HM virome, and we showed changes regarding the lactation period, preterm birth, delivery mode, and birth weight. Early in life, the HM virome may influence the composition of an infant’s gut microbiome, which could have short- and long-term health implications. Further longitudinal mother–newborn pair studies are required to understand the effects of these variations on the composition of the HM and the infant gut virome.

Association of cesarean delivery on maternal request with neonatal iron stores at birth.

Cesarean has been suggested to decrease neonatal iron stores at birth. However, few studies have differentiated the effect induced by cesarean operation from that related to medical indications. We aimed to estimate the association of cesarean delivery on maternal request (CDMR), a subtype of cesarean without any medical indications, with a spectrum of indicators reflecting iron stores at birth. This prospective cohort study involved 288 term singleton neonates born to women without any complications by CDMR or spontaneous vaginal delivery (SVD). Measured hematological iron-related indicators in cord blood included serum ferritin (SF), hemoglobin (Hb), red blood cell (RBC), and hematocrit (Hct). Blood flow volume (BFV) of cord vein when clamping was measured to reflect placental transfusion status during birth. Quantile regression was used to assess the association between delivery mode and the iron store indicators. CDMR (n = 154) versus SVD group (n = 134) had lower conditional median cord blood SF (-34.80; 95% CI -64.70, -4.90 μg/L; P = 0.02), Hb (-10.67; 95% CI -18.87, -2.47 g/L; P = 0.01), RBC (-0.30; 95% CI -0.48, -0.12 ×1012/L; P = 0.002), and Hct (-3.06; 95% CI -6.08, -0.04 %; P = 0.047). The BFV was higher in CDMR than SVD group at the 25th centile (0.51; 95% CI 0.19, 0.82 ml/cm3; P = 0.002), median (0.49; 95% CI 0.04, 0.95 ml/cm3; P = 0.03) and the 75th centile (0.54; 95% CI 0.06, 1.03 ml/cm3; P = 0.03). The cesarean operation per se likely hampered placental transfusion from mother to neonate and decreased iron stores at birth.

Affiliation of Postpartum Depression with Mode of Delivery; A Disregarded Domain

Background: Postpartum Depression is a serious issue that can lead to irreversible disasters if not timely recognized and diagnosed. There are various modes of delivery; which may contribute towards physical and mental trauma. Methods: It was a prospective descriptive cross- sectional study carried out to evaluate the alliance of postnatal depression with different modes of delivery i.e. vaginal or lower segment caesarean section. The study was conducted at Ziauddin University Hospital. A sample size of 200 was taken. It was carried out from June 2019 to December 2019. A Performa was designed that questioned about different socio-demographic characteristics and risk factors for post-natal depression (PND). Edinburg Post-Natal Depression Scale (EPNDS) was used for authenticated identification of women with depression in purpeurium. Results: Out of the total sample of 200 women, 100 were taken from the spontaneous vaginal delivery group and 100 from cesarean section group. Mean age was 21-34 years. It was noticed that 60% women who underwent cesarean section became a victim of depression and 40% women who had a normal vaginal delivery were identified to have post natal depression. Conclusion: The study identifies cesarean section to be one of the culprits of postnatal depression as compared to woman undergoing spontaneous vaginal delivery. There is an exponential rise in the frequency of performing unexplained cesarean sections that would also boost up the graphs of postnatal depression; hence there is a dire need to instruct women to follow up postnatal so that they can be evaluated for post partum depression.

High mobility group box 1 and markers of oxidative stress in human cord blood.

Parturition induces considerable oxidative stress and many inflammatory mediators, such as high mobility group box 1 (HMGB1), are involved from the beginning of the pregnancy to birth. The aim of the present study was to evaluate serum cord blood concentration of diacron-reactive oxygen metabolites (d-ROM), biological antioxidant potential (BAP), and HMGB1 to investigate the perinatal oxidative status of neonates and correlation with mode of delivery, as well as the influence of labor. The subjects consisted of 214 neonates delivered at University Hospital "G. Martino", Messina, in a 6months period. Venous blood samples were collected from the umbilical cord after cord separation. Umbilical cord venous blood HMGB1 was significantly higher in the spontaneous vaginal delivery (SVD) group than in the elective or emergency cesarean section (CS) group (P = 0.018). Regarding labor, there was no significant difference in HMGB1 concentration in umbilical vein blood between the spontaneous and induced labor groups (P = 0.250). Furthermore, d-ROM was significantly different between the SVD group and the elective or emergency CS group (P = 0.044). BAP concentration, however, was not significantly different, not even with regard to mode of labor. Oxidation is higher in newborns delivered by SVD than in those delivered by CS, and HMGB1 may be involved in the mechanisms of birth, and responsible for decidual modifications that lead to birth.

Contraction of the levator ani muscle during Valsalva maneuver (coactivation) is associated with a longer active second stage of labor in nulliparous women undergoing induction of labor

The Valsalva maneuver is normally accompanied by relaxation of the levator ani muscle, which stretches around the presenting part, but in some women the maneuver is accompanied by levator ani muscle contraction, which is referred to as levator ani muscle coactivation. The effect of such coactivation on labor outcome in women undergoing induction of labor has not been previously assessed. The aim of the study was to assess the effect of levator ani muscle coactivation on labor outcome, in particular on the duration of the second and active second stage of labor, in nulliparous women undergoing induction of labor. Transperineal ultrasound was used to measure the anteroposterior diameter of the levator hiatus, both at rest and at maximum Valsalva maneuver, in a group of nulliparous women undergoing induction of labor in 2 tertiary-level university hospitals. The correlation between anteroposterior diameter of the levator hiatus values and levator ani muscle coactivation with the mode of delivery and various labor durations was assessed. In total, 138 women were included in the analysis. Larger anteroposterior diameter of the levator hiatus at Valsalva was associated with a shorter second stage (r= -0.230, P= .021) and active second stage (r= -0.338, P= .001) of labor. Women with levator ani muscle coactivation had a significantly longer active second stage duration (60 ± 56 vs 28 ± 16 minutes, P < .001). Cox regression analysis, adjusted for maternal age and epidural analgesia, demonstrated an independent significant correlation between levator ani muscle coactivation and a longer active second stage of labor (hazard ratio, 2.085; 95% confidence interval, 1.158-3.752; P= .014). There was no significant difference between women who underwent operative delivery (n= 46) when compared with the spontaneous vaginal delivery group (n= 92) as regards anteroposterior diameter of the levator hiatus at rest and at Valsalva maneuver, nor in the prevalence of levator ani muscle coactivation (10/46 vs 15/92; P= .49). Levator ani coactivation is associated with a longer active second stage of labor.

Sexual dysfunction and mode of delivery in Chinese primiparous women: a systematic review and meta-analysis

BackgroundUp to now, there is controversy over the effect of delivery mode cesarean delivery and spontaneous vaginal delivery on sexual function. Therefore, we did a systematic review and meta-analysis in postpartum women to explore the mode of delivery, cesarean delivery, and spontaneous vaginal delivery and differences in postpartum sexual function (short- and long-term) in Chinese primiparous women.MethodsComprehensive electronic searches of PubMed, EMBASE, Web of Science, Elsevier Science Direct, Cochrane Library, the Chinese Biological Medical Literature database and the Chinese National Knowledge Infrastructure database were conducted to identify any study in each database published to August 31, 2017. The primary outcome was the sexual satisfaction and the secondary outcomes were resumed intercourse and sexual pain in the postpartum.ResultsWe identified 10 studies with a total population of 2851 in the present meta-analysis. Five and six eligible articles were respectively included for sexual satisfaction in postpartum at 3- and 6 months. Compared with vaginal delivery group, two time points were all not found statistically significance (OR 1.53, 95%CI 0.93–2.49; OR 1.15, 95%CI 0.95–1.39, respectively) in cesarean and spontaneous vaginal delivery group; in resumed intercourse and sexual pain domains, they were all significantly, with an overall OR of 2.05 (95%CI 1.36–3.11) at 3 months, 1.50 (95%CI 1.04–2.16) at 6 months and 0.29 (95%CI 0.24, 0.36) at 3 months, 0.73 (95%CI 0.58, 0.93) at 6 months, respectively. With the passage of time, the gap was closing. Sensitivity analysis was indicated a good stability of the meta-analysis in each domain.ConclusionsIn conclusion, this meta-analysis indicated that the mode of delivery, cesarean and spontaneous vaginal delivery did not affect postpartum sexual satisfaction (short- and long-term) and appeared to have minimal effect on the long-term resumed intercourse and sexual pain in Chinese primiparous women. Primiparous women should be more cautious to choose cesarean section in order to preserve sexual function.

Perinatal impact of cesarean delivery on maternal request compared with vaginal delivery among low-risk pregnancies in a university hospital: a prospective observational study in Bogotá, Colombia

Objetivo: existe evidencia insuficiente sobre el impacto de la cesárea por solicitud materna (CSM); este estudio evalúa el efecto de la CSM en los múltiples desenlaces maternos y neonatales comparando CSM con parto vaginal entre embarazos de bajo riesgo. Materiales y métodos: estudio observacional prospectivo que incluyó mujeres entre 18 y 45 años de edad, con un embarazo a término y de bajo riesgo, que tuvieron parto entre junio de 2008 y abril de 2012 en un hospital universitario en Bogotá, Colombia. Se comparó la ocurrencia de cualquiera de 5 eventos adversos maternos preespecificados, y de cualquiera de 17 eventos neonatales preespecificados, entre CSM y partos vaginales. Los partos vaginales inducidos fueron analizados separadamente. Todas las mujeres recibieron el mismo cuidado estandarizado. El efecto de variables confusoras se ajustó mediante regresión logística múltiple.Resultados: se incluyeron 214 mujeres con CSM, 341 con parto vaginal espontáneo (PVE) y 376 con parto vaginal inducido (PVI). Respecto al grupo PVE, el OR ajustado del desenlace materno fue 0,21 (IC 95 %: 0,05-0,97) en el grupo CSM y 0,93 (IC 95%: 0,42-2,06) en el grupo PVI. Los OR del desenlace neonatal fueron 0,59 (IC95%: 0,36-0,93) para CSM y 0,84 (IC95%: 0,59-1,21) para PVI. La frecuencia de hospitalización del neonato más baja fue en el grupo de CSM (10,3 % frente a 15,8 % para PVE, 16,2 % para PVI).Conclusiones: en pacientes con embarazo de bajo riesgo que ingresaron a un protocolo estándar de cuidado obstétrico, CSM se acompañó de una menor tasa de eventos adversos perinatales respecto al parto vaginal espontáneo. Sin embargo, se requieren estudios que evalúen la seguridad de CSM en el largo plazo.

Maternal 3-Month Postpartum Physical Health Problems, Depression, and their Relations to the Mode of Delivery: A Cohort Study in Jeddah

Background: Postpartum physical and emotional health remains unaddressed by researchers, clinicians and women themselves. An important factor that affects postpartum recovery is the method of delivery. The objectives of this study were to estimate the incidence of postpartum physical health problems and depression in the first three months after delivery and to identify their relationship with mode of delivery along with other factors associated with the incidence of postpartum depression (PPD).Methods: In this prospective cohort study, women were recruited from three public hospitals within 24-48 hours after delivery. Edinburgh postpartum depression scale (EPDS) and structured validated questionnaires were used. Follow-ups were conducted at 1-week and 3-months after delivery.Results: The most prevalent 3-month physical health problems were insomnia (75%), fatigue (70%), and back pain (65%). There was a high incidence of nipple pain (73%) and vaginal itch (25%) in the spontaneous vaginal delivery (SVD) group during the immediate (1-week) postpartum period, whereas wound pain washigher in the cesarean section (CS) group during the immediate (94%) and 3-month follow-up (55%) postpartum period. The incidence of 3-month PPD (EPDS>=12) was 28% in SVD group and 24% in CS group. There was no effect of the delivery mode on EPDS scores (p=0.59). Wanted pregnancy (OR=0.507), higher number of living children (OR=0.631), gravidity (OR=1.36), and income (OR= 0.536) were protective factors for immediate PPD.Conclusions: Postpartum physical health problems and depression are common after delivery. Health care providers should be aware of these to perform early screening and interventions to alleviate them.

Episiotomy – risk factors and outcomes

Objective: To identify risk factors for mediolateral episiotomy, and evaluate the risk of obstetrical anal sphincter injury (OASI) among women with an episiotomy.Methods: A retrospective cohort study of all singletons vaginal deliveries at term between 2007 and 2014. Spontaneous and operative vaginal deliveries were compared separately, as well as nulliparous and multiparous women.Results: Overall, 41,347 women were included in the spontaneous vaginal delivery group: 12,585 (30.4%) nulliparous and 28,762 (69.6%) multiparous women. Risk factors for episiotomy (nulliparous) were maternal age (aOR 0.98), gestational age (GA, aOR 1.07), regional analgesia (RA, aOR 1.18), labor induction (aOR 1.17), meconium (aOR 1.37) and birth weight (BW, aOR 1.04). Episiotomy was associated with PPH (aOR 1.49). Among multiparous, risk factors were maternal age (aOR 1.04), previous vaginal delivery (aOR 0.38), GA (aOR 1.06), RA (aOR 1.22), meconium (aOR 1.22) and BW (aOR 1.05). Episiotomy was associated with 3rd degree perineal tear (aOR 2.26, 95% CI 1.03-4.97). Only birth weight (nulliparous) and previous vaginal deliveries (multiparous) were contributors for episiotomy in the OVD group.Conclusion: Several risk factors for mediolateral episiotomy exist. Episiotomy does not protect nulliparous women, and may be associated with an increased risk for multiparous, for OASI. Therefore, the practice of routine episiotomy should be abandoned, and the practice of selective episiotomy reconsidered.

Association of fetal biparietal diameter with mode of delivery and perinatal outcome.

To determine the association between sonographic assessment of fetal biparietal diameter (BPD) and pregnancy outcome. This was a retrospective cohort study of pregnancies at 37-42 weeks of gestation which had antepartum sonographic measurement of BPD within 7 days before delivery. Eligibility was limited to singleton pregnancies with neither known structural or chromosomal abnormalities nor prelabor Cesarean delivery (CD). The association of BPD with outcome was analyzed using multivariate logistic regression, receiver-operating characteristics curves and stratification according to BPD quartiles. In total, 3229 women were eligible for analysis, of whom 2483 (76.9%) had a spontaneous vaginal delivery (SVD), 418 (12.9%) underwent operative vaginal delivery (OVD) and 328 (10.2%) underwent CD. The mean BPD in the obstetric intervention groups (OVD and CD) was significantly higher than that in the SVD group (P < 0.001). After adjusting for confounders, increased BPD was an independent risk factor such that higher values of BPD were associated with progressively higher risk of obstetric intervention (adjusted odds ratio, 1.05 for each 1-mm increase in BPD (95% CI, 1.02-1.09)), but no clear cut-off value for obstetric intervention was found. The fourth quartile group (BPD ≥ 97 mm) was associated with a significantly lower SVD rate (P < 0.001) and higher OVD rate (P = 0.04), relative to the first (BPD 88-90 mm) and second (BPD 91-93 mm) quartile groups, with no apparent adverse impact on immediate neonatal outcome. Increased BPD within the week prior to delivery is an independent risk factor such that higher values of BPD are associated with progressively higher risk of obstetric intervention; however, in our experience, no adverse neonatal outcome resulted from such intervention. Thus, increased BPD should not discourage a trial of vaginal delivery.

Comparison of obstetric anal sphincter injuries in nulliparous women before and after introduction of the EPISCISSORS-60(®) at two hospitals in the United Kingdom.

AimTo assess whether the introduction of episiotomy scissors specially designed to achieve a cutting angle of 60°, EPISCISSORS-60®, in two hospitals in the UK would result in a reduction in obstetric anal sphincter injuries (OASIS) in nulliparous women.MethodsA structured training program for all doctors and midwives provided a theoretical framework around OASIS including risk factors and the role of episiotomies and a practical hands-on training element to use EPISCISSORS-60® correctly and to measure perineal body length and post-suturing angles. Data for perineal body length, post-suturing angles, user feedback, episiotomy use, and incidence of OASIS were collected through specifically designed forms and the general hospital data collection system.ResultsData were available for 838 nulliparous vaginal deliveries. Mean perineal body length was 37 mm in spontaneous vaginal delivery group (standard deviation [SD] =8.3, 95% confidence interval [CI] =34–39) and 38 mm in the operative vaginal delivery group (SD=8, 95% CI=35–40). Post-suturing episiotomy angles were 53° (SD=6.5, 95% CI=50.7–55.8) in spontaneous vaginal deliveries and 52° (SD=9.6, 95% CI=49–54) in operative vaginal deliveries. EPISCISSORS-60® were rated as “good” to “very good” by 84% of users. There was a 47% increase in the number of episiotomies in nulliparous spontaneous vaginal deliveries at Poole (P=0.007) and a 16.5% increase in the number of episiotomies in nulliparous operative vaginal deliveries in Hinchingbrooke (P=0.003). There was an overall 11% increase in episiotomy numbers in nulliparous vaginal deliveries (P=0.08). There was a statistically significant OASIS reduction of 84% in nulliparous spontaneous vaginal deliveries in women who received an episiotomy (P=0.003).ConclusionInitial results after introduction of EPISCISSORS-60® show that the majority of health care professionals achieve post-suturing episiotomy angles between 40° and 60°. The results also show a significant increase in the use of episiotomies in the delivery of nulliparous women. There has been a statistically significant reduction in OASIS in nulliparous spontaneous vaginal deliveries.

Randomized trial of cesarean vs vaginal delivery for effects on the pelvic floor in squirrel monkeys

Vaginal delivery is a risk factor in pelvic floor disorders. We previously described changes in the pelvic floor associated with pregnancy and parturition in the squirrel monkey, a species with a humanlike pattern of spontaneous age- and parity-associated pelvic organ prolapse. The potential to prevent or diminish these changes with scheduled cesarean delivery (CD) has not been evaluated. In a randomized, controlled trial, we compared female squirrel monkeys undergoing spontaneous vaginal delivery with those undergoing scheduled primary CD for pelvic floor muscle volumes, muscle contrast changes, and dynamic effects on bladder neck position. Levator ani, obturator internus, and coccygeus (COC) muscle volumes and contrast uptake were assessed by magnetic resonance imaging in 20 nulliparous females examined prior to pregnancy, a few days after delivery, and 3 months postpartum. The position of bladder neck relative to bony reference line also was assessed with abdominal pressure using dynamic magnetic resonance imaging. Baseline measurements of 10 females randomly assigned to scheduled primary CD were not different from those of 10 females assigned to spontaneous vaginal delivery. Levator ani and obturator internus muscle volumes did not differ between groups, while volumes were reduced (P < .05) in the observation immediately after pregnancy. The COC muscles increased (P < .05) immediately after delivery for females in the spontaneous vaginal delivery group, but not for females in the scheduled CD group. Position of the bladder neck descended (P < .05) by 3 months postpartum in both groups. Scheduled CD diminishes changes in COC muscle volume and contrast reported to be associated with spontaneous vaginal delivery in squirrel monkeys. However, pelvic support of the bladder was not protected by this intervention suggesting that effects of pregnancy and delivery are not uniformly prevented by this procedure.

Prospective Randomized Trial of Cesarean Delivery versus Vaginal Delivery for Effects on the Pelvic Floor in Squirrel Monkeys

Objectives: Vaginal delivery is a risk factor in pelvic floor disorders. We previously described changes in the pelvic floor associated with pregnancy and parturition in the squirrel monkey, a species with a humanlike pattern of spontaneous age and parity associated pelvic organ prolapse. The potential to prevent or diminish these changes with scheduled cesarean section has not been evaluated in a randomized, controlled trial. Therefore, this trial compares female squirrel monkeys undergoing spontaneous vaginal delivery with those undergoing scheduled primary cesarean section for pelvic floor muscle volumes, muscle contrast changes, and dynamic effects on bladder neck position. Materials and Methods: In a prospective randomized trial Levator ani (LA), obturator internus (OI), and coccygeus (COC) muscle volumes and contrast uptake were assessed by MR imaging in 20 nulliparous females examined prior to pregnancy, a few days after delivery, and 3 months post-partum. The position of bladder neck relative to boney reference line was also assessed with abdominal pressure using a dynamic MRI. Results: Baseline measurements of 10 females randomly assigned to scheduled primary cesarean sections were not different from those of 10 females assigned to spontaneous vaginal delivery. LA and OI muscle volume did not differ between the two groups. However, the volume was reduced (p 0.05) in the observation immediately after pregnancy for both muscles. The COC muscles increased (p 0.05) immediately after delivery for females in the spontaneous vaginal delivery group, but did not change in females in the scheduled cesarean section group. Position of the bladder neck descended (p\0.05) by 3 months post-partum in both groups. Conclusion: This study provides the first observations in a randomized, controlled trial that scheduled cesarean section diminishes changes in COC muscle volume and contrast reported to be associated with spontaneous vaginal delivery. However, pelvic support of the bladder was not protected by this intervention suggesting that effects of pregnancy and delivery are not uniformly prevented by this procedure.

Comparison of Blood Loss in Induced vs. Spontaneous Vaginal Delivery Using Specialized Blood Collection Bag.

To compare third stage blood loss in induced vs. spontaneous vaginal deliveries and to correlate the amount of blood loss with the decrease in haemoglobin following deliveries. Department of Obstetrics and Gynaecology, Kasturba Hospital Manipal, Karnataka, India. Blood loss following placental deliveries was measured by using special collection bags in 150 pregnant ladies who delivered vaginally by labour induction and it was compared with that of another 50 women who had spontaneous vaginal deliveries. Haemoglobin values were recorded for each patient prior to labour and after delivery of child. The mean blood loss in induced group was 30 mL more than that in spontaneous group (202 ± 117 mL vs. 172 ± 114 mL), but this was not statistically significant (p=0.12). However, when different methods of induction were compared, oxytocin group was found to have significantly higher blood loss (327 ± 140 mL) as compared to that in other types of labour inductions as well as spontaneous deliveries. Labour induction using prostaglandins did not produce more blood loss as compared that produced by spontaneous deliveries. Both induced and spontaneous delivery groups showed statistically significant drops in post-delivery haemoglobin values, but the drop was relatively more in induced group as compared to that in spontaneous vaginal delivery group (0.96gm/dL vs. 0.56gm/dL), which appeared to be statistically significant (p=0.002). Labour induction using prostaglandins is safe as compared to oxytocin usage. Accurate estimation of blood loss is important in all types of deliveries, in order to detect postpartum haemorrhage early, so that appropriate measures can be undertaken.

PL.79 A Clinical Audit; Risk of Subsequent Perineal Trauma After Previous Obstetric Anal Sphincter Injury

IntroductionObstetric anal sphincter injuries (OASIS) are a serious complication of vaginal deliveries and can lead to faecal and urinary incontinence. Women, who have sustained OASIS in a previous pregnancy, undergo...