Umbilical Artery pH Research Articles

Impaired glucolipid metabolism in gestational diabetes mellitus with T variation of TCF7L2 rs7903146: A case–control study

BackgroundTranscription factor 7-like 2 (TCF7L2) rs7903146 polymorphism has been shown to display a significant association with gestational diabetes mellitus (GDM). But the effects of TCF7L2 rs7903146 on glucose and lipid metabolism are not clear.ObjectiveThe purpose of this study was to assess the role of TCF7L2 rs7903146 genotypes on glycolipid metabolism in GDM.MethodsIn total, 484 individuals (239 in GDM group and 245 in control group) were included in the final analysis from January 2015 to February 2022. Their baseline demographics, plasma lipid concentration in the first trimester and third trimester, blood glucose values of the OGTT during gestational 24–28 weeks, glycosylated hemoglobin, fasting plasma glucose and fasting insulin in third trimester, 1 min Apgar scores, 5 min Apgar scores, glucose values of cord blood, and umbilical artery pH were collected. TCF7L2 rs7903146 genotypes were analyzed by polymerase chain reaction-Sanger sequencing.ResultsThe frequencies of TCF7L2 rs7903146 genotype were found to have no significant differences between the two groups; however, the plasma lipid concentrations during the first trimester were higher in GDM group than control group. In GDM group, women carried the risk allele (T) in TCF7L2 rs7903146 displayed the significantly higher glucose values at 1-h during OGTT, and the higher TG and lower fasting insulin levels than those in non-carriers.ConclusionOur results indicate that the risk allele (T) in TCF7L2 rs7903146 plays an important role in the abnormality of glucose and lipid metabolism in GDM women. For the risk allele(T) carriers of TCF7L2 rs7903146, low-fat and low-sugar diets, exercise interventions can be carried out at an early stage, and insulin therapy should be considered when their blood glucose were inadequately controlled.

Intrapartum Oxygen for Fetal Resuscitation: State of the Science.

This review aims to summarize the current evidence regarding maternal oxygen supplementation for Category II fetal heart tracings (FHT) in labor. We aim to evaluate the theoretical rationale for oxygen administration, the clinical efficacy of supplemental oxygen, and the potential risks. Maternal oxygen supplementation is an intrauterine resuscitation technique rooted in the theoretic rationale that hyperoxygenating the mother results in increased oxygen transfer to the fetus. However, recent data suggest otherwise. Randomized controlled trials on the efficacy of oxygen supplementation in labor suggest no improvement in umbilical cord gases or other adverse maternal and neonatal outcomes compared to room air. Two meta-analyses demonstrated that oxygen supplementation is not associated with an improvement in umbilical artery pH or reduction in cesarean delivery. Although we lack data on definitive clinical neonatal outcomes with this practice, there is some suggestion of adverse neonatal outcomes with excess in utero oxygen exposure, including lower umbilical artery pH. Despite historic data suggesting the benefit of maternal oxygen supplementation in increasing fetal oxygenation, recent randomized trials and meta-analyses have demonstrated a lack of efficacy of this practice and some suggestion of harm. This has led to conflicting national guidelines. Further research is needed on short- and long-term neonatal clinical outcomes following prolonged intrauterine oxygen exposure.

Real-time imaging as visual biofeedback in active second stage of labor among nulliparas: a randomized controlled trial

A prolonged second stage of labor increases the risk of severe perineal laceration, postpartum hemorrhage, operative delivery, and poor Apgar score. The second stage is longer in nulliparas. Maternal pushing during the second stage of labor is an important contributor to the involuntary expulsive force developed by uterine contraction to deliver the fetus. Preliminary data indicate that visual biofeedback during the active second stage hastens birth. This study aimed to evaluate if visual feedback focusing on the perineum reduced the length of the active second stage of labor in comparison with the control. A randomized controlled trial was conducted in the University Malaya Medical Centre from December 2021 to August 2022. Nulliparous women about to commence the active second stage, at term, with singleton gestation, reassuring fetal status, and no contraindication for vaginal delivery were randomized to live viewing of the maternal introitus (intervention) or maternal face (sham/placebo control) as visual biofeedback during their pushing. A video camera Bluetooth-linked to a tablet computer display screen was used; in the intervention arm, the camera was focused on the introitus, and in the control arm, on the maternal face. Participants were instructed to watch the display screen during their pushing. The primary outcomes were the intervention-to-delivery interval and maternal satisfaction with the pushing experience assessed using a 0-to-10 visual numerical rating scale. Secondary outcomes included mode of delivery, perineal injury, delivery blood loss, birthweight, umbilical cord arterial blood pH and base excess at birth, Apgar score at 1 and 5 minutes, and neonatal intensive care unit admission. Data were analyzed with the t test, Mann-Whitney U test, chi-square test, and Fisher exact test, as appropriate. A total of 230 women were randomized (115 to intervention and 115 to control arm). The active second stage duration (intervention-to-delivery interval) was a median (interquartile range) of 16 (11-23) and 17 (12-31) minutes (P=.289), and maternal satisfaction with the pushing experience was 9 (8-10) and 7 (6-7) (P<.001) for the intervention and control arm, respectively. Women randomized to the intervention arm were more likely to agree to recommend their management to a friend (88/115 [76.5%] vs 39/115 [33.9%]; relative risk, 2.26 [95% confidence interval, 1.72-2.97]; P<.001) and more likely to have less severe perineal injury (P=.018). Real-time viewing of the maternal introitus as visual biofeedback during pushing resulted in higher maternal satisfaction compared with the sham control of viewing the maternal face; however, the time to delivery was not significantly shortened.

Prevention of spinal hypotension during cesarean section: A systematic review and Bayesian network meta-analysis based on ephedrine, phenylephrine, and norepinephrine.

The aim of this study is to perform a Bayesian network meta-analysis to evaluate the safety and efficacy of prophylactic bolus of different doses of ephedrine, phenylephrine, and norepinephrine for the prevention of spinal hypotension during cesarean section. The Web of Science, PubMed, EMBASE, Cochrane Library were searched until to May 20, 2022. The indicators included incidence of hypotension, reactive hypertension, bradycardia, nausea and vomiting, umbilical artery pH, and Apgar scores. About 3125 related records were obtained and 17 RCTs met our eligibility criteria. Based on the results, prophylactic bolus injection of 21-30 mg ephedrine (82%) was the best efficacious option for preventing hypotension, followed by 13-16 μg norepinephrine and 81-120 mg phenylephrine; 121-150 μg phenylephrine had the highest probability (62%) caused reactive hypertension, followed by 11-30 mg ephedrine; phenylephrine was most likely to cause bradycardia in a dose-dependent manner; 81-120 μg phenylephrine had the highest probability (37%) which associated with IONV; 6-12 μg norepinephrine (31%) had the lowest influence on IONV and had highest probability (34%) associated with improving umbilical arterial pH; 13-16 μg norepinephrine had highest probability (67% at 1 min, 49% at 5 min) which associated with improving Apgar scores. Based on this study, 5-10 mg ephedrine and 13-16 μg norepinephrine prophylactic bolus injection may be the optimum dosage of three drugs prevent spinal-induced hypotension, which has the least impact on maternal and neonatal outcomes.

Prior History of Cholestasis Is Not Associated With Worsening Outcomes in Subsequent Pregnancy With Cholestasis [ID: 1363296

INTRODUCTION: Intrahepatic cholestasis of pregnancy (IHCP) is associated with adverse pregnancy outcomes including intrauterine fetal demise, spontaneous preterm labor, and meconium-stained amniotic fluid. Studies have yet to determine whether a prior pregnancy complicated by cholestasis is associated with more severe adverse outcomes in a subsequent pregnancy complicated by cholestasis. METHODS: This was a retrospective cohort study of multiparous, singleton, nonanomalous live gestations complicated by IHCP at Elmhurst Hospital Center from 2005 to 2019. We compared rates of adverse outcomes in multiparous pregnancies complicated by IHCP with or without history of prior IHCP. Our primary outcome of interest was rates of spontaneous preterm labor. Our secondary outcomes included rates of iatrogenic preterm birth, meconium-stained amniotic fluid, cesarean delivery (CD) for nonreassuring fetal heart tracing, umbilical artery pH less than 7.20, and neonatal intensive care unit (NICU) admission. Chi-square and multivariate regression tests were used to determine the strength of association. In all analyses, a P value less than 0.05 and 95% CI not crossing 1.00 indicated statistical significance. Mount Sinai Icahn School of Medicine IRB approval was obtained for this project. RESULTS: Of the 795 multiparous pregnancies complicated by IHCP, 618 (77.7%) had no prior history of IHCP and 177 (23.3%) had prior history of IHCP. Multiparous pregnancies with prior history of IHCP had higher rates of prior preterm birth, had earlier gestational age at diagnosis and delivery, and were more likely to receive ursodeoxycholic acid therapy. In subsequent pregnancies with IHCP, history of IHCP was associated with iatrogenic preterm birth and NICU admission. After adjusting for confounders, the association with iatrogenic preterm birth and NICU admission were no longer statistically significant. There was no significant association between history of prior IHCP and other adverse obstetric outcomes. CONCLUSION: Findings suggest that history of prior IHCP is not associated with worsening outcomes in subsequent pregnancies complicated by cholestasis.

BMI Had a Negative Effect on Decision-to-Incision Times for Urgent Cesarean Deliveries [ID: 1377147

INTRODUCTION: Greater maternal body mass index (BMI) is associated with worse maternal and fetal outcomes. Intrapartum care of patients may be more difficult with higher BMIs. We studied the effect of BMI on decision-to-incision times less than 30 minutes for urgent cesarean sections. METHODS: After IRB approval, a retrospective chart review of 186 consecutive urgent cesarean deliveries during 2020 at an academic medical center were examined. Data were abstracted from patient and neonate charts. Statistical analysis was performed using χ2, t test, and Pearson’s r test. RESULTS: Seventy-one percent of patients with BMI greater than 30 had decision-to-incision times of more than 30 minutes, compared to 46% with BMI less than 30 (P=.03). The mean time from decision-to-incision with BMI greater than 30 was 44 minutes, and 36 minutes with BMI less than 30 (P=.005). When BMI was greater than 40, the mean time was 50 minutes (P=.03). 16% of patients with BMI greater than 30 had decision-to-incision times of more than 60 minutes, compared to 2% with BMI less than 30 (P=.007). BMIs greater than 30 had longer decision-to-operating room (OR) entry (22 versus 17 minutes, P=.02) and OR entry-to-incision times (22 versus 19 minutes, P=.053). Body mass indexes of greater than 40 had both longer decision-to-OR entry (24 versus 19 minutes) and OR entry-to-incision times (25 versus 19 minutes, P=.005). Mothers with BMI greater than 50 had the longest times from OR entry-to-incision and had babies most likely to go to the neonatal intensive care unit (NICU) (50% versus 16%). CONCLUSION: Greater maternal BMIs had longer times for urgent cesarean sections for decision to incision, decision to OR entry, and OR entry to incision. There was a lengthening of decision-to-incision times with increasing BMI. The highest maternal BMIs were most likely to result in NICU admissions. Decision-to-incision time of greater than 30 minutes did not affect umbilical cord arterial pH or NICU admission.

The Majority of Urgent Cesarean Sections Had a Decision-to-Incision Time of Greater Than 30 Minutes [ID: 1377172

INTRODUCTION: The American College of Obstetricians and Gynecologists has recommended that hospitals providing obstetrical care should have the capability to begin cesarean deliveries within 30 minutes. This has been taken out of context in that failure to meet a 30-minute decision-to-incision time for urgent cesarean sections may be criticized litigiously if a poor neonatal outcome occurs. METHODS: After IRB approval, a retrospective chart review of 186 consecutive urgent cesarean deliveries during 2020 at an urban academic medical center was performed. Data were abstracted from patient and neonate charts. Statistical analysis was performed using χ2, t test, and Pearson’s r test. RESULTS: Sixty-seven percent of urgent cesarean section had a decision-to-incision time greater than 30 minutes. Mean time was 42 minutes and median time was 36 minutes (8–194 minutes). Seventy-one percent of patients with body mass index (BMI) greater than 30 had decision-to-incision times greater than 30 minutes, compared to 46% with BMI less than 30 (P=.03). Seventy-eight percent of patients without an epidural took more than 30 minutes, compared to 64% with an epidural (P=.09). Sixty-four percent of urgent cesarean sections occurring between 7 am and 5 pm had decision-to-incision times of greater than 30 minutes, compared to 69% between 5 pm and 7 am (P=.54). CONCLUSION: Sixty-seven percent of urgent cesarean sections had a decision-to-incision time greater than 30 minutes at an academic medical center. Deliveries with BMI greater than 30 were associated with failure to meet a 30-minute threshold. Not having an epidural trended towards failure to meet a 30-minute threshold. Whether delivering during the daytime or nighttime, race, and insurance status did not affect decision-to-incision times. Decision-to-incision time greater than 30 minutes did not affect umbilical cord arterial pH or neonatal intensive care unit admission.

Neonatal condition at birth of twins conceived by medically assisted reproductive technology compared to those conceived spontaneously: A retrospective study.

To examine neonatal outcomes at birth among twins conceived spontaneously or by medically assisted reproduction (MAR). A retrospective study was conducted at a single university teaching hospital on data collected between January 1995 and September 2019. Live twin deliveries at more than 24 weeks of pregnancy were included. The study group consisted of women who conceived by MAR and the controls were spontaneously conceived twins. The study group was further divided into two groups: in vitro fertilization (IVF) and ovulation induction (OI) groups. The primary outcomes were umbilical artery pH less than 7.1 and/or Apgar score less than 7 of any twin 5 min after birth. Overall, 2235 eligible twin gestations were included, corresponding to a total of 4470 live neonates; 1009 (45.1%) conceived by MAR (762 [75.5%] IVF and 247 [24.5%] OI) and 1226 (54.9%) conceived spontaneously. Incidence of the primary outcome was 5.3% and 5.1% in the study and control groups, respectively (P = 0.71). The primary outcome was comparable among the IVF (5%), OI (6.2%), and control (5.1%) groups. The results did not change even after adjusting for demographic and obstetric variables, including mode of delivery, which differed between the groups. Neonatal condition of twin pregnancies at birth among MAR subgroups is similar to spontaneously conceived twins.

Double-balloon catheter vs dinoprostone (PGE-2) insert for labour induction: A meta-analysis of 2493 pregnancies.

Induction of labor (IOL) is the stimulation of the uterus during pregnancy to begin the onset of labour. Nearly two of five pregnancies require IOL. We compared the effectiveness of double-balloon catheter (DBC) with dinoprostone (PGE-2) insert for labour induction from previous studies. We included randomized controlled trials (RCTs) that compared the safety and efficacy of DBC to PGE-2. To evaluate the studies, we utilized the Cochrane tool for risk of bias assessment. The rates of vaginal birth and cesarean section were the primary outcomes. We included ten RCTs in this meta-analysis with a total sample of 2493 singleton pregnancies. After 24 hours, there was no significant difference in the delivery rates between DBC and PGE-2 s [R.R=1.08, 95% CI, (0.77, 1.52), P.value=0.65], and the rate of cesarean delivery [R.R=1.03, 95% CI, (0.90; 1.18), P.value=0.65]. The DBC showed a significantly higher oxytocin use rate compared to the PGE-2 group [R.R=1.77, 95% CI, (1.41; 2.32), P.value<0.0001]. In the PGE-2 group, there was a significantly higher risk of uterine hyperstimulation, tachysystole, and umbilical artery PH levels below 7. There was no significant difference in the efficacy between the PGE-2 and DBC in terms of delivery rate in 24 hours and the rate of cesarean delivery except for a slight BISHOP score improvement with DBC. However, DBC showed a higher rate of oxytocin use compared to the PGE-2, the DBC seems to be safer with a lower risk of umbilical artery PH < 7, uterine hyperstimulation, and tachysystole incidence than PGE-2.

SEE Question

Article| April 2023 SEE Question ASA Monitor April 2023, Vol. 87, 13. https://doi.org/10.1097/01.ASM.0000924956.59857.11 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation SEE Question. ASA Monitor 2023; 87:13 doi: https://doi.org/10.1097/01.ASM.0000924956.59857.11 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: cesarean section, fetus, hypotension, mothers, norepinephrine, phenylephrine, spinal anesthesia, systolic blood pressure, heart rate You are administering spinal anesthesia during an urgent cesarean delivery for a nonreassuring fetal heart rate. According to a recent study, which of the following outcomes is MOST likely in this parturient if you administer norepinephrine for maternal hypotension, compared to a similar parturient receiving phenylephrine? Guidelines from ASA and the Society for Obstetric Anesthesia and Perinatology recommend ephedrine or phenylephrine for treating maternal hypotension following spinal anesthesia for cesarean delivery. However, the guidelines also cite evidence that phenylephrine may more effectively treat hypotension and improve umbilical artery pH compared to ephedrine. Thus, phenylephrine – via preemptive infusion or rescue bolus – has gained favor in this setting. More recently, norepinephrine, with both α- and β-adrenergic agonist properties, has been explored as a potential replacement for phenylephrine. However, outcomes in relatively uncomplicated cesarean deliveries have been equivocal, and essentially no studies have compared these agents in the setting of potential... You do not currently have access to this content.

Sonographic examination at the beginning of the second stage of labor predicts birth outcome in vaginally intended breech deliveries: a blinded prospective study

PurposeIn order to spread competence in vaginal breech deliveries, it is necessary to develop new and easily applicable tools for birth progression and safety evaluation. Ultrasound is a useful and ubiquitously available tool with already documented value for birth progression observation. In deliveries out of breech presentation, an established ultrasound examination is missing. We determined the descent of the fetal buttocks in relation to the maternal pelvic inlet using intrapartum ultrasound. We evaluated these results in comparison to the clinical vaginal examination with the aim to establish an easily applicable method for birth outcome prediction. Therefore, we analyzed the predictive value of our examinations on birth outcome parameters, such as cesarean section rate, as well as fetal and maternal outcome parameters.MethodsWe performed a prospective blinded study on 106 mothers with vaginally intended breech delivery. At beginning of stage two in labor, the descent of the fetal buttocks into the mother’s pelvic inlet was detected with transabdominal ultrasound and vaginal examination by different observers. Primary outcome variable: Cesarean section rate. Secondary outcome variables: rate of manual assistance in vaginal deliveries, birth duration, 5′ APGAR score, umbilical arterial pH, maternal blood loss, and perineal injury. For non-parametric values, Wilcoxon’s χ2 test was performed. In order to analyze the predictive value of our examination, lack-of-fit analysis was conducted. Reliability evaluation of the sonographic examination was done with a matched-pair analysis.ResultsWomen with positive intrapartum ultrasound breech engagement sign (+ IPUBES) had a significantly lower rate of cesarean section in comparison with those with negative IPUBES (5/67; 7.5% vs. 18/39; 46.2%; p < 0.0001). The area under the ROC curve for the prediction of CS for negative IPUBES was 0.765 with a sensitivity of 78.3% and a specificity of 74.7%. Sonographic examination showed an excellent reliability in a matched-pair analysis comparing vaginal and sonographic examinations with a mean difference of 0.012 (SD ± 0.027, 95% CI − 0.014 to 0.065). Mean birth duration was significantly longer in deliveries with negative IPUBES (533 min vs. 440 min; p = 0.0011). Fetal and maternal outcome parameters were not significantly different between deliveries with positive and negative IPUBES.ConclusionsSonographic evaluation of the fetal descent in relation to the mother’s pelvic inlet screens reliably for emergency cesarean section. This newly presented method for birth progression observation might be a powerful tool for distribution of expertise in vaginal breech delivery and is able to give reference for clinical vaginal examination by obstetricians in training.Trail registryClinical trial. Date of registration: 13.03.2019; Date of initial participant enrollment: 20.03.2019; DRKS00016885; https://www.drks.de; German clinical trials register.

Failure of two different doses of ondansetron to prevent maternal hypotension in spinal anesthesia with ropivacaine 0.75% for cesarean section; a randomized, double blind trial.

Introduction: Ondansetron, a selective 5-hydroxytryptamine 3 (5-HT3) receptor antagonist, commonly used as an antiemetic has been proven in recent studies to be effective for the prevention of spinal-induced hypotension for elective cesarean section. &nbsp; Methods: One hundred and thirty-eight healthy primigravida parturients scheduled for elective cesarean section were randomly assigned to three groups. Participants in the ONDA4, ONDA8, and CONTROL groups received 4 mg of ondansetron,&nbsp;8&nbsp;mg&nbsp;of ondansetron and&nbsp;normal saline respectively, 10 minutes before spinal anesthesia. Spinal anesthesia was performed at L3-L4 interspinous space, with 1.7 ml ropivacaine 0.75% and 15 mcg of fentanyl, via a 27 G pencil point needle. Blood pressure and heart rate were recorded upon arrival at the operating room, after preloading with 500 ml of 6% hydroxyethylstarch, at the time of spinal injection, and at one-minute intervals for 10 minutes thereafter. Blood pressure and heart rate values, total phenylephrine (mcg) or/and ephedrine (mg) doses, the incidence of maternal nausea/vomiting/shivering, umbilical artery pH and Apgar scores at 1 and 5 min were recorded. Time for the sensory block to reach T4 and regress to T7 dermatome, and the time for the motor block to reach Bromage scale 3 and to regress to Bromage scale 1, were also noted. &nbsp; &nbsp; Results: There were no differences between groups in hemodynamic parameters or doses of vasoactive agents used, sensory or motor block characteristics, incidence of nausea/vomiting, umbilical artery pH or Apgar scores of the neonates. &nbsp; Conclusion: Our results failed to demonstrate the significance of ondansetron in preventing maternal hypotension following spinal anesthesia for cesarian section.

Incidence of bradycardia during noradrenaline or phenylephrine bolus treatment of postspinal hypotension in cesarean delivery: A randomized double-blinded controlled trial.

The treatment of choice for spinal anesthesia-induced hypotension during cesarean section is phenylephrine. As this vasopressor can cause reflex bradycardia, noradrenaline is a suggested alternative. This randomized double-blinded controlled trial included 76 parturients undergoing elective cesarean delivery under spinal anesthesia. Women received noradrenaline in bolus doses of 5mcg or phenylephrine in bolus doses of 100 mcg. These drugs were used intermittently and therapeutically to maintain systolic blood pressure ≥ 90% of its baseline value. The primary study outcome was bradycardia incidence (<60 bpm) with intermittent bolus administration of these drugs. Secondary outcomes included extreme bradycardia (<40 bpm), number of bradycardia episodes, hypertension (systolic blood pressure > 120% of baseline value), and hypotension (systolic blood pressure < 90% of baseline value and requiring vasopressor use). Neonatal outcomes per the Apgar scale and umbilical cord blood gas analysis were also compared. The incidence of bradycardia in both groups (51.4% and 70.3%, respectively; p=0.16) were not significantly different. No neonates had umbilical vein or artery pH values below 7.20. The noradrenaline group required more boluses than phenylephrine group (8 vs. 5; p=0.01). There was no significant intergroup difference in any of the other secondary outcomes. When administered in intermittent bolus doses for the treatment of postspinal hypotension in elective cesarean delivery, noradrenaline, and phenylephrine have a similar incidence of bradycardia. When treating hypotension related to spinal anesthesia in obstetric cases, strong vasopressors are commonly administered, thought these can also have side effects. This trial assessed bradycardia after bolus administration of noradrenaline or phenylephrine, and found no difference in risk for clinically meaningful bradycardia.

The Association of Anesthesia Type and Neonatal Outcomes Following Category-1 Cesarean Delivery: A Retrospective Cohort Study.

Objectives Neuraxial anesthesia is the preferred anesthesia technique for cesarean delivery due to a decreased risk of adverse events. However, general anesthesia is often employed during emergent cesarean deliveries to achieve a shorter decision-to-delivery interval. The objective of this study was to determine if the conversion of epidural labor analgesia to surgical anesthesia for a category-1 cesarean delivery is associated with significant neonatal morbidity. Study design This was a retrospective cohort study of all intrapartum category-1 cesarean deliveries performed at an academic tertiary care institution between August 2016 and July 2021. The primary outcome was neonatal morbidity, defined as a composite of neonatal umbilical artery pH < 7.10 and/or 5-min Apgar score < 7, and/or neonatal intensive care unit admission. A multivariate regression analysis was performed to control for the presence of covariates and examine the degree to which they influenced the outcome. Results A total of 185 mother-neonate pairs qualified for inclusion, of which 23 had cesarean delivery under general anesthesia and 162 under epidural anesthesia. There was no significant difference in adverse neonatal outcomes between category-1 cesarean deliveries done under general anesthesia compared to epidural anesthesia (47% vs 35%,p = 0.3). The incidence of umbilical arterial pH < 7.10 was higher in the general anesthesia group compared to the epidural anesthesia group (35% vs 12%,p = 0.018). The multivariate regression model showed that gestational age (OR = 0.63; 95% CI = 0.51-0.75, p = <0.001) and non-reassuring fetal heart trace (OR = 0.18; 95% CI = 0.05-0.58, p = 0.005) were significant predictors of adverse neonatal outcome. Conclusion Our results suggest that the conversion of epidural analgesia to surgical anesthesia for category-1 cesarean delivery in women with a functional labor epidural catheter is not associated with poorer neonatal outcomes.

Induction of Labor in Twins—Double Trouble?

To determine and compare the safety and efficacy of different methods of induction of labor in twin gestations and their effect on maternal and neonatal outcomes. A retrospective observational cohort study was conducted at a single university-affiliated medical center. Patients with a twin gestation undergoing induction of labor at >32 + 0 weeks comprised the study group. Outcomes were compared to patients with a twin gestation at >32 + 0 weeks who went into labor spontaneously. The primary outcome was cesarean delivery. Secondary outcomes included operative vaginal delivery, postpartum hemorrhage, uterine rupture, 5 min APGAR < 7, and umbilical artery pH < 7.1. A subgroup analysis comparing outcomes for the induction of labor with oral prostaglandin E1 (PGE1), IV Oxytocin ± artificial rupture of membranes (AROM), and extra-amniotic balloon (EAB)+ IV Oxytocin was performed. Data were analyzed using Fisher's exact test, ANOVA, and chi-square tests. 268 patients who underwent induction of labor with a twin gestation comprised the study group. 450 patients with a twin gestation who went into labor spontaneously comprised the control group. There were no clinically significant differences between the groups for maternal age, gestational age, neonatal birthweight, birthweight discordancy, and non-vertex second twin. There were significantly more nulliparas in the study group compared to the control group (23.9% vs. 13.8% p < 0.001). The study group was significantly more likely to undergo a cesarean delivery of at least one twin (12.3% vs. 7.5% OR, 1.7 95% CI 1.04-2.85 p = 0.03). However, there was no significant difference in the rate of operative vaginal delivery (15.3% vs. 19.6% OR, 0.74, 95% CI 0.5-1.1 p = 0.16), PPH (5.2% vs. 6.9% OR, 0.75 95% CI 0.39-1.42 p = 0.37), 5-min APGAR scores < 7 (0% vs. 0.2% OR, 0.99 95%CI 0.99-1.00 p = 0.27), umbilical artery pH < 7.1 (1.5% vs. 1.3% OR, 1.12 95% CI 0.3-4.0), or combined adverse outcome (7.8% vs. 8.7% OR, 0.93 95% CI 0.6-1.4 p = 0.85). Furthermore, there were no significant differences in the rates of cesarean delivery or combined adverse outcomes in patients undergoing induction with oral PGE1 compared to IV Oxytocin ± AROM (13.3% vs. 12.5% OR, 1.1 95% CI 0.4-2.0 p = 1.0) (7% vs. 9.3% OR, 0.77 95% CI 0.5-3.5 p = 0.63 ) or EAB+ IV Oxytocin (13.3% vs. 6.9% OR, 2.1 95% CI 0.1-2.1 p = 0.53) (7% vs. 6.9% OR, 1.4 95% CI 0.15-3.5 p = 0.5) or between patients undergoing induction of labor with IV Oxytocin ± AROM and EAB+ IV Oxytocin (12.5% vs. 6.9% OR, 2.1 95% CI 0.1-2.4 p = 0.52) (9.3% vs. 6.9% OR, 0.98 95% CI 0.2-4.7 p = 0.54). There were no cases of uterine rupture in our study. Induction of labor in twin gestations is associated with a two-fold increased risk of cesarean delivery, although this is not associated with adverse maternal or neonatal outcomes. Furthermore, the method of induction of labor used does not affect the chances of success nor the rate of adverse maternal or neonatal outcomes.

Does maternal oxygen administration during non-reassuring fetal status affect the umbilical artery gas measures and neonatal outcomes?

To clarify whether maternal oxygen administration during vaginal delivery improves umbilical artery (UA) gas measurements and neonatal outcomes. Singleton pregnancies requiring operative vaginal delivery or emergency cesarean section (CS) due to non-reassuring fetal status (NRFS) during vaginal delivery at our hospital from 2018 to 2021 were retrospectively investigated. Intrapartum fetal wellbeing was evaluated based on the 5-tier fetal heart rate (FHR) pattern which is a delivery management method widely used in Japan. Operative vaginal deliveries or emergency CS was performed under integrated judgment in NRFS. Patients were divided into the oxygen group to whom oxygen (10 L/min) was supplied by a facemask and the room air group. The UAgas measurements and neonatal outcomes were compared. The oxygen administration was classified by conditions before and after the coronavirus disease 2019 pandemic. As a secondary evaluation, stratification of FHR pattern levels and factors associated with UA pH < 7.15 were examined. A total of 250 patients required obstetric surgical delivery due to NRFS, including 140 (56%) and 110 (44%) in the oxygen and room air groups, respectively. No differences in maternal background factors were found between both groups, except for maternal age. UA gas measurements and neonatal outcomes also showed no significant differences. No significant factors were extracted in the multivariate analysis for UA pH < 7.15. Trans-maternal oxygen administration for intrapartum NRFS did not affect neonatal cord blood gasses or neonatal outcomes. Thus, routine oxygen administration for intrapartum NRFS may not always be necessary.

Association between Elevated Intrauterine Resting Tone during Labor and Neonatal Morbidity.

Internal contraction monitoring provides a quantitative assessment of intrauterine resting tone. During the course of labor, elevated intrauterine resting tone may be identified. We hypothesized that elevated intrauterine resting tone could lead to compression of the spiral arteries, thus limiting uterine blood flow and resulting in neonatal compromise. Therefore, our objective was to assess the association between elevated resting tone during labor and neonatal morbidity. This was a secondary analysis of a prospective cohort study of singleton deliveries at ≥37 weeks of gestation. Patients with ruptured membranes and an intrauterine pressure catheter in place for at least 30 minutes prior to delivery were included. Intrauterine resting tone was calculated as the average baseline pressure between contractions during the 30 minutes prior to delivery. The study group had elevated intrauterine resting tone, defined as intrauterine resting tone ≥75th percentile (≥12.3 mm Hg). Primary outcome was composite neonatal morbidity: hypoxic-ischemic encephalopathy, hypothermia treatment, intubation, seizures, umbilical arterial pH ≤7.1, oxygen requirement, or death. Secondary outcomes included umbilical artery pH <7.2, lactate ≥4 mmol/L, and rates of neonatal intensive care unit admission. Of the 8,580 patients in the cohort, 2,210 (25.8%) met the inclusion criteria. The median intrauterine resting tone was 9.7 mm Hg (interquartile range: 7.3-12.3 mm Hg). Elevated resting tone was associated with a shorter median duration of the first stage of labor (10.0 vs. 11.0 hours, p < 0.01) and lower rates of labor induction and oxytocin augmentation (p < 0.01). Neonatal composite morbidity was higher among patients with elevated intrauterine resting tone (5.1 vs. 2.9%, p = 0.01). After adjusting for chorioamnionitis and amnioinfusion, elevated intrauterine resting tone was associated with increased risk of neonatal morbidity (adjusted odds ratio: 1.70, 95% confidence interval: 1.06-2.74). Our findings suggest that elevated intrauterine resting tone is associated with increased risk of neonatal composite morbidity. · Higher intrauterine resting tone is associated with increased risk of neonatal morbidity.. · Elevated intrauterine tone can negatively impact umbilical artery pH and lactate levels.. · If elevated intrauterine pressure is noted, we recommend close monitoring of fetal status..

Correlation of umbilical cord arterial blood pH with meconium stained liquor

Intrauterine passage of meconium may be due to fetal hypoxia, or it may simply indicate a normal gastrointestinal tract maturation. Umbilical cord blood pH is the best available criterion for detecting fetal hypoxia and making appropriate decisions about care after birth.To determine the correlation of umbilical cord arterial blood pH with meconium stained liquor and neonatal outcome. To determine whether the mode of delivery had any influence on the occurrence of acidemia in the neonate complicated with meconium stained liquor. A prospective observational study was conducted for a period of 6 months. Immediately following delivery in pregnancies complicated with meconium stained liquor, blood was drawn from the umbilical artery and sent for arterial blood gas (ABG) analysis. Neonatal outcome parameters and mode of delivery were then recorded in a pre-designed proforma. There was a statistically significant correlation between abnormal pH (acidosis) and thick meconium stained liquor. Neonatal outcome parameters like Apgar scores at 1 minute and 5 minutes, intravenous antibiotic administration, NICU admission and oxygen supplementation were statistically significant when correlated with the pH level.The degree of meconium thickness independently correlates with the composite adverse neonatal outcome. Cases with meconium stained liquor should be monitored vigorously with timely interventions and proper neonatal resuscitation, especially the ones with thick meconium stained liquor, in order to prevent adverse neonatal outcome.

Comparison of Four Intrapartum Cardiotocography Classifications for Predicting Neonatal Acidemia at Birth.

To compare diagnostic values of four intrapartum cardiotocography (CTG) classifications in predicting neonatal acidemia at birth. Retrospective case-control study. Forty-three CTG traces with an umbilical artery pH < 7.00 (study group) and 43 traces with a pH ≥ 7.00 (control group) were analyzed. Inclusion criteria were singleton pregnancy, cephalic presentation, admission to labour ward during active phase of first stage of labour, and gestational age 37+0 to 41+6 weeks. Exclusion criteria were suspected intrauterine growth restriction, oligohydramnios, polyhydramnios, pregestational or gestational insulin-dependent diabetes mellitus, and preeclampsia. Last 30-60 minutes before delivery of CTG traces was classified retrospectively according to four classification systems-International Federation of Gynecology and Obstetrics (FIGO), Royal College of Obstetricians and Gynaecologists (RCOG), National Institute of Child Health and Human Development (NICHD), and the 5-tier system by Parer and Ikeda. Predictive value of each classification for neonatal acidemia was assessed using receiver operating characteristics (ROC) analysis. FIGO, RCOG, and NICHD classifications predicted neonatal acidemia with areas under the ROC curves (AUC) of 0.73, 95% confidence interval (CI) 0.63-0.84; 0.72, 95% CI 0.60-0.83; and 0.69, 95% CI 0.57-0.80, respectively. The five-tier system by Parer and Ikeda had significantly better predictive value with an AUC of 0.96, 95% CI 0.91-1.00. The 5-tier classification system proposed by Parer and Ikeda for assessing CTG in labour was superior to FIGO, RCOG, and NICHD intrapartum CTG classifications in predicting severe neonatal acidemia at birth.

Rate of decline of fetal base excess after neuraxial anesthesia for scheduled cesarean delivery

In scheduled cesarean deliveries, the rate of decrease in the umbilical artery pH is related to the severity of maternal hypotension and the interval from spinal placement to delivery. Base excess values have greater use than umbilical artery pH values to time the duration of fetal acidemia because they demonstrate a linear rather than logarithmic correlation with the degree of acidosis. This study aimed to evaluate the rate of decline in the fetal base excess in scheduled cesarean deliveries that were converted to emergency cesarean delivery owing to fetal bradycardia following spinal anesthesia. All cases of scheduled cesarean deliveries in gestations at >34 weeks' gestation under spinal anesthesia that were converted to emergency cesarean deliveries owing to fetal bradycardia in the period May 2019 to May 2021 were reviewed. Included were those with (1) a preoperative reactive nonstress test and (2) fetal acidemia (umbilical artery pH <7.20). Excluded were those with anesthesia other than spinal and a birthweight below the 10th percentile for gestational age. Time intervals between the completion of spinal anesthesia and delivery were calculated and related to umbilical cord gas analytes. From a cohort of 1064 scheduled cesarean deliveries, 7 fulfilled the study criteria yielding 8 neonates. Mean ± standard error of the mean interval of spinal anesthesia to delivery was 15.0±1.9 minutes, and the decrease in mean blood pressure after spinal anesthesia was 39.1±3.0 mm Hg. Umbilical artery base excess ranged from -5.2 to -16.6 mmol/L (median, -8.0). Based on published normative data of prelabor fetal umbilical artery base excess (-2±0.6 mmol/L), the mean rate of base excess decrease was 0.38±0.25 mmol/minute. The rate of decrease in base excess when scheduled cesarean deliveries are converted to emergency cesarean deliveries owing to fetal bradycardia related to spinal anesthesia (1 mmol/2.6 min) matches the estimated rate of loss of base excess (1 mmol/2-3 minutes) reported in cases of severe bradycardia or sentinel events during labor.