Uncomplicated Term Vaginal Deliveries Research Articles

Primary Posterior Uterine Rupture in Labor: Case Report and Literature Review

Purpose: To report a rare case of primary posterior uterine rupture in a healthy term multigravida. Methods: Case report. Results: We present the case of an otherwise healthy 35-year-old gravida 4 para 3 with no reported medical or surgical history and three prior uncomplicated term vaginal deliveries who presented in labor at 39 weeks gestation. After four hours of oxytocin augmentation, the fetus was noted to have recurrent late decelerations and then became bradycardic with a baseline of 60 bpm. The patient’s cervix was found to be 7 cm dilated, 90% effaced, and -1 station. Standard resuscitative measures were undertaken at which point the patient’s cervix was rechecked and found to be 9 cm dilated, 90% effaced, and -1 station. Attempts at manually reducing the cervix while the patient pushed were unsuccessful. With the fetus still bradycardic with a baseline of 60 bpm, the patient was taken for an emergency Cesarean delivery. Within seven minutes of calling the emergency Cesarean delivery, surgery had started. However, there was difficulty with delivering the fetus, who had flipped to transverse back down. The fetus was rotated to breech before being delivered through a “T” incision made on the uterus to facilitate delivery of the head. Three tight nuchal cords were reduced at time of delivery. Examination of the uterus after delivery of the fetus revealed a full thickness, cruciate-shaped laceration in the posterior lower uterine segment extending ~9 cm in the vertical plane, involving the vagina, and ~5 cm in the transverse plane. The rupture was repaired, and the remainder of the surgery proceeded without further complication. Blood loss was estimated at 2500 mL, and she required transfusion of 4 units of packed red cells, 2 units cryoprecipitate, 1 unit fresh frozen plasma, and 1 unit of platelets. The infant was atonic upon delivery with a weight of 3785g and APGARs of 1/5/7. Umbilical artery blood gas analysis was normal with a pH of 7.19 and a base deficit of 7.9 mmol/L. The infant initially required intubation, but quickly improved and was extubated to room air at 1 hour of life. Imaging and neurological exams indicated possible moderate encephalopathy, and the infant underwent therapeutic hypothermia for four days at which point cooling was discontinued after improvement was noted. The remainder of his NICU stay was unremarkable and he was discharged on day nine of life. The mother required 2 additional units of packed red cells during the remainder of her postpartum course, but otherwise did well and she was discharged on post-op day five. Conclusion(s): Uterine rupture is the complete separation of all three layers of the uterus. It is a life-threatening event for both the fetus and the mother. Most uterine ruptures occur in a previously scarred uterus. Uterine rupture in a previously unscarred uterus (primary uterine rupture) is rare and estimated to occur in ~1:20,000 pregnancies. Over 90% of primary uterine ruptures occur in the anterior lower uterine segment. Although this patient did not have any reported medical or surgical history, her status as a multipara and being of advanced maternal age did pose a higher risk of primary rupture. This patient also underwent 3 ½ hours of oxytocin infusion at the time the Cesarean was called. Although she was not on oxytocin for long, its use is associated with primary uterine rupture more so than secondary rupture. Normal indicators of uterine rupture include non-reassuring fetal heart rate tracing, sudden unexplained abdominal pain, unexplained vaginal bleeding, and loss of fetal station. In this patient, fetal bradycardia was the only sign that her uterus was compromised. Although the uterine arteries were not involved in this patient’s rupture, blood loss was still profound due to the extensive uterine defect. This case highlights that, while rare, uterine rupture can occur in any patient, regardless of uterine surgical history and physicians must be prepared to intervene quickly.

Maternal height, and ethnicity and birth weight: A retrospective cohort study of uncomplicated term vaginal deliveries in Malaysia.

Small for gestational age (SGA) and large for gestational age (LGA) are designations given to neonates based solely on birthweight, with no distinction made for maternal height. However, there is a possibility that maternal height is significantly correlated with neonatal birthweight, and if so, SGA and LGA cutoffs specific to maternal height may be a more precise and useful tool for clinicians. To explore this possibility, we analyzed the association between maternal height and ethnicity and neonate birthweight in women with low-risk, 37- to 40-week gestation, singleton pregnancies who gave birth vaginally between 2010 and 2017 (n = 354,488). For this retrospective cohort study, we used electronic obstetric records obtained from the National Obstetrics Registry in Malaysia. National Obstetric Registry (NOR) data were used to calculate the 10th and 90th birthweight percentiles for each maternal height group by gestational age and neonatal sex. Multiple linear regression models, adjusted for maternal age, weight, parity, gestational age, and neonatal sex, were used to examine the association between neonate birthweight and maternal ethnicity and height. The following main outcome measures were assessed: small for gestational age (<10th percentile), large for gestational age (>90th percentile), and birthweight. The median height was 155 cm (IQR, 152-159), with mothers of Chinese descent being the tallest (median (IQR): 158 cm (154-162)) and mothers of Orang Asli (Indigenous) descent the shortest (median (IQR): 151 cm (147-155)). The median birthweight was 3000 g (IQR, 2740-3250), with mothers of Malay and Chinese ethnicity and Others having, on average, the heaviest babies, followed by other Bumiputeras (indigenous) mothers, mothers of Indian ethnicity, and lastly, mothers of Orang Asli ethnicity. For infants, maternal age, height, weight, parity, male sex, and gestational age were positively associated with birthweight. Maternal height had a positive association with neonate birthweight (B = 7.08, 95% CI: 6.85-7.31). For ethnicity, compared with neonates of Malay ethnicity, neonates of Chinese, Indian, Orang Asli, and other Bumiputera ethnicities had lower birthweights. Birthweight increases with maternal height among Malaysians of all ethnicities. SGA and LGA cutoffs specific to maternal height may be useful to guide pregnancy management.

Child Abuse, Misdiagnosed by an Expertise Center: Part I-Medico-Social Aspects.

Child abuse is a dangerous situation for an infant. Professionals need to weigh the risk of failing to act when children are seriously harmed against the serious harm done by carrying out safeguarding interventions. In severe cases, foster care might be advisable. The negative effects for the child's psychosocial development requires that such placement must be based on very solid evidence. Our aim is to identify why Dutch parents whose child may have a medical condition that could mimic symptoms of child abuse have a significant chance of being erroneously convicted and losing custody of their child. As a method, we describe and analyze the following case. An Armenian-Dutch newborn (uncomplicated term vaginal delivery), starting at two weeks after birth, developed small bruises on varying body locations. At two months, a Well-Baby Clinic physician referred the girl to a university hospital, mentioning that there were no reasons to suspect child abuse and that her Armenian grandmother easily bruised as well. However, before consultation by a pediatrician of the hospital-located Expertise Center for Child Abuse, the parents were suspected of child abuse. Based on the expertise center's protocols, skeletal X-rays were made, which showed three healed, asymptomatic rib fractures, while invalid statistics suggested, incorrectly, a 10-100 times more likely non-accidental than accidental cause of the symptoms (discussed in Part II of this series). The expertise enter physician ignored any argument that could show parental innocence, including the positive parent-child relationship reported by the Well-Baby Clinic and the general practitioner. The girl and her older brother were placed in a family foster home and then in a secret home. The case radically resolved when a large bruise also developed there, and an independent tissue disease specialist diagnosed a hereditary connective tissue disorder in the mother, implying that the girl's bruises and rib fractures could well be disease-related. In conclusion, if child abuse is suspected, and foster care placement considered, the patient and the parents should be thoroughly investigated by an independent experienced pediatrician together with an experienced pediatric clinical psychologist or psychotherapist to produce an independent opinion. Children deserve this extra safeguard before being separated from their parents.

A case of uterine rupture in second term delivery after septum resection

Introduction: The decision to resect a uterine septum remains individualized. Hysteroscopic approach is the gold standard for uterine septum resection. Uterine rupture in subsequent pregnancy is a known but rare complication without identified methods of prevention. Case Report: A 32-year-old woman underwent uncomplicated hysteroscopic uterine septum resection followed by uncomplicated term vaginal delivery, with uterine rupture and intrauterine fetal demise at 38 weeks gestational age in the subsequent pregnancy. Conclusion: Term uterine rupture is possible when the only history of uterine surgery is hysteroscopic septum resection, even with an intervening delivery. Providers should have a low threshold to initiate diagnostic evaluation with fetal or maternal distress in pregnancy after any uterine surgery. Modifiable risk factors for uterine rupture after septum resection may include residual septa, short interval between surgery and pregnancy, and labor induction methodology. Providers should consider these factors when counseling regarding the risks and benefits of resection.

The effects of placental transfusion on mothers

Objective While there is ample evidence supporting delayed cord clamping (DCC) in neonates, the data on the maternal outcomes related to DCC are relatively sparse. Moreover, the outcomes, such as postpartum hemorrhage (PPH), were mostly reported for uncomplicated term vaginal deliveries. The objective of this study was to present the two primary maternal outcomes, incidence of PPH and change in hematocrit pre- and post-delivery in complex situations of preterm deliveries and term cesarean sections. Study design Maternal data were collected prospectively since the placental transfusion process was implemented in a step-wise fashion in our delivery hospitals, starting August, 2013. These data on very preterm singleton, moderate preterm, very preterm twin gestation, late preterm deliveries and term cesarean sections with DCC or umbilical cord milking (UCM) were compared with respective retrospective cohorts of deliveries in which immediate cord clamping (ICC) was performed. Results Comparing very preterm singleton deliveries, the incidence of PPH was similar between the ICC and DCC groups (2.3% vs. 1.7%). There was no significant difference in mean hematocrit change pre- and postdelivery (3.06 ± 1.32 vs. 3.47 ± 1.52). When 45 s DCC cohort was compared with 60 s DCC cohort, there were no significant differences in the incidence of PPH (1.7% vs. 4.8%) or the hematocrit change pre- and postdelivery (3.47 ± 1.52 vs. 4.32 ± 1.88). PPH was not observed in either group when comparing retrospective ICC cohort with prospective DCC cohort with 60 s delay in very preterm twin gestation deliveries. There was no significant difference between the mean hematocrit change pre- and postdelivery (5.5 ± 3.3 vs. 5.8 ± 3.9). When moderate and early late preterm deliveries between 32° to 346 weeks of gestation were compared, there were no differences between the incidence of PPH (0.9% vs. 0%) or hematocrit change pre- and postdelivery (4.2 ± 2.3 vs. 4.8 ± 2.9). Comparing late preterm deliveries between 35° and 366 weeks of gestation, there was no significant difference in the incidence of PPH (13% vs. 11.4%) or the mean hematocrit change pre- and postdelivery (5.0 ± 3.0 vs. 5.1 ± 2.8). In term cesarean deliveries, the incidence of PPH was 2.2% in the retrospective ICC group and 1.4% in the prospective UCM group. There was no difference in mean hematocrit change pre- and postdelivery (5.9 ± 3.7 vs. 6.2 ± 2.8). Conclusion DCC or UCM was not associated with the increased risk for PPH or significant change in maternal hematocrit pre- and postdelivery in very preterm singleton, moderate preterm, very preterm twin gestation, late preterm deliveries and term cesarean sections.

Umbilical blood flow patterns directly after birth before delayed cord clamping

BackgroundDelayed umbilical cord clamping (DCC) affects the cardiopulmonary transition and blood volume in neonates immediately after birth. However, little is known of blood flow in the umbilical vessels immediately after...

PS-316 Umbilical Blood Flow Patterns Directly After Birth Before Delayed Cord Clamping

<h3>Background</h3> Delayed cord clamping (DCC) effects both cardio-pulmonary transition and blood volume in neonates. Understanding the circulation through the umbilical vessels immediately after birth, with cord and placenta intact, is important. <h3>Objective</h3> To describe the duration and patterns of blood flow through the umbilical vessels during DCC. <h3>Methods</h3> Arterial and venous umbilical blood flow was measured during DCC using Doppler ultrasound in a prospective, observational, study of uncomplicated term vaginal deliveries. Immediately after birth, the probe was placed in the middle of the umbilical cord and the pattern and duration of flow in the vein and arteries evaluated until cord clamping. <h3>Results</h3> Thirty infants were studied. Venous: In 10% there was no flow, in 57% flow stopped at a median (IQR) min:sec of 4:34(3:03–7:31) after birth before cord was clamped, and in 33% flow continued until cord clamping at 5:13 (2:56–9:15). Venous flow was initially intermittent (100% increase during large breaths, stopped/reversed during crying), but became continuous. Arterial: In 17% there was no flow, in 40%, flow stopped at 4:22(2:29–7:17), while cord pulsations were still palpable. In 43% flow continued until cord was clamped at 5:16(3:32–10:20). Arterial flow was pulsatile, unidirectional towards placenta or bidirectional to/from placenta. In 40% flow became almost continuous (non pulsatile) later after birth. <h3>Conclusion</h3> During DDC venous and arterial umbilical flow occurs for longer than previously described. Net placental transfusion is probably the result of several factors of which breathing could play a major role. Umbilical flow is unrelated to cessation of pulsations.

Autophagy and Human Parturition: Evaluation of LC3 Expression in Placenta from Spontaneous or Medically Induced Onset of Labor

Induction of labor is one of the most used procedures in obstetrics, performed to achieve vaginal delivery through cervical ripening and stimulation of uterine contractions. We investigated the impact of induction of labor upon placental autophagy, a catabolic pathway activated in response to alteration of the physiological intracellular conditions. We collected 28 singleton placentas at the time of uncomplicated term vaginal delivery (7 spontaneous onset of labor, 21 induced labor). Autophagy was evaluated by immunohistochemistry, immunofluorescence, and immunoblotting. No significant difference in the autophagy expression was found between spontaneous or induced onset of labor. We found an inverse relationship between autophagy expression and the maternal prepregnancy body mass index, irrespective of the mode of labor onset. This result could be related to the nutritional maternal habits before and throughout pregnancy rather than rapid metabolic changes during labor.

A Rare Case of Congenital Cytomegalovirus Infection in Pregnancy

Mrs. SC, 30-years old in her third pregnancy, had two previous pregnancies 7 and 2 years ago which ended in uncomplicated term vaginal deliveries. She was booked for antenatal care at about 13 weeks. The mother’s blood group was A Rhesus positive. She had triple test for trisomy 21 and neural tube defects at 16 weeks gestation and was found to be low risk for both. At 30 weeks gestation she reported reduced fetal movements. The Cardiotocography (CTG) (Fig. 1) showed diminished variability with a few shallow decelerations suggesting fetal hypoxia. Considering the suboptimal CTG an ultrasound scan was performed which showed significant ventriculomegaly (Fig. 2), pericardial effusion, ascites, splenomegaly and oligohydramnios. The couple was counselled regarding significant risk of handicap. Since the underlying cause was uncertain at that point, she had further investigations for hydrops including maternal serology for viral screening and fetal cordocentesis which subsequently confirmed maternal and fetal Cytomegalovirus (CMV) infection (Table 1). She did not want any active intervention. A couple of days later the mother reported no fetal movements and an ultrasound scan confirmed intrauterine fetal death. A stillborn female baby (Fig. 3) weighing 1,455 g was delivered 2 days later following induction of labour. In the post-mortem report, it was commented that the lung showed numerous enlarged cells with nuclear and cytoplasmic inclusions characteristic of active CMV infection. The macroscopic feature of hepatosplenomegaly was consistent with this finding and that no other internal anatomical abnormalities were found.

Uncomplicated term vaginal delivery following magnetic resonance-guided focused ultrasound surgery for uterine fibroids

A 35 year-old para 1+0 underwent MRgFUS per study protocol for multiple uterine fibroids, the largest of which measured 5 cm. She conceived 10 months following the procedure. The patient was induced at 41+6 weeks and underwent a normal vaginal delivery.

Preoperative Magnetic Resonance Imaging and Antepartum Myomectomy of a Giant Pedunculated Leiomyoma

Antepartum myomectomy is reserved for severe pain and prevention of fetal complications. Magnetic resonance imaging has been useful in nonpregnant women for preoperative management and patient counseling. A primigravida was admitted at 12 weeks of gestation in severe acute abdominal pain with a large abdominal mass, confirmed by magnetic resonance imaging to be a pedunculated 30x27x19-cm uterine leiomyoma. An uncomplicated abdominal myomectomy was performed, incorporating a flat cup vacuum device to mobilize the mass without disturbing the gravid uterus. The patient later had an uncomplicated term vaginal delivery and healthy newborn. Magnetic resonance imaging and a flat cup vacuum device were helpful in preoperative planning and performing an uncomplicated abdominal myomectomy during pregnancy, respectively.

Third Trimester Uterine Torsion: Case Report

BackgroundRotation of the gravid uterus is a normal finding in the third trimester of pregnancy. However, a pathologic rotation of the uterus beyond 45 degrees—torsion of the entire uterus—is rarely seen in obstetrical practice. We report here a case of uterine torsion from our obstetrical practice and a review of reported cases. CaseThe patient, a 36-year-old gravida 3 para 2 at 36 weeks’ gestation with a singleton pregnancy, was admitted to the obstetrical unit with uterine cramping and decreased fetal movement. Her prior obstetrical history included two uncomplicated term vaginal deliveries, and the current pregnancy had been uncomplicated until the date of presentation. After 3 hours’ observation, uterine cramping and tenderness increased, and fetal tachycardia developed. The presumptive diagnosis was a concealed placental abruption. The patient was not in labour, so an emergency Caesarean section (CS) was carried out. At the time of CS, the diagnosis of uterine torsion was made. The patient recovered and was discharged home with her baby on the third postoperative day. ConclusionUterine torsion is an infrequently reported and potentially dangerous complication of pregnancy that occurs mainly in the third trimester with adverse maternal and neonatal consequences.

A randomized trial of active versus expectant management of the third stage of labor

STAGE OF LABOR MATTHEW HOFFMAN, FATIMA NAQVI, ANTHONY SCISCIONE, Christiana Hospital, Newark, Delaware, Christiana Care Health Services, Obstetrics and Gynecology, Newark, Delaware, Drexel University College of Medicine, Obstetrics and Gynecology, Philadelphia, Pennsylvania OBJECTIVE: We sought to compare active management of the third stage of labor to the more traditional expectant management. STUDY DESIGN: We conducted a randomized controlled trial of women who had an uncomplicated term vaginal delivery. Women were randomized to either expectant or active management of the third stage of labor before delivery. Active management consisted of a standardized oxytocin infusion immediately following delivery of the fetus coupled with cord traction and fundal massage. The expectant group had cord traction and fundal massage upon signs of placental separation coupled with a standardized oxytocin infusion following placental delivery. Our primary outcome variable was the mean change in hematocrit pre and post delivery. Univariate analysis was performed using Student’s t test with unequal variance, Wilcoxon rank sum, c and Fisher exact test when appropriate. A P value of ! .05 was statistically significant. RESULTS: One hundred and fifty women were randomized between August 2002 and November 2003 (72 active management and 78 expectant management). Active management of the third stage of labor was associated with a shorter duration of the third stage of labor (7.3 minutes vs. 9.8 minutes; P value ! .0001). Although there was no difference in incidence of postpartum hemorrhage (EBL >500 mL) in the expectant versus the actively managed groups (17.39% vs. 11.11%; P = .302), the mean change in hct was significantly less in women who were in the actively managed group (2.5 vs. 3.35 P = .0475). There was no significant difference in the need for placental extraction or retained placentas between the groups. CONCLUSION: Active management of the third stage of labor was associated with faster delivery of the placenta and a smaller decrease in the mean pre and post-delivery hematocrit. S82 SMFM Abstracts

Umbilical Artery Blood Acid-Base and Blood Gas Status Following Uncomplicated Term Vaginal Deliveries in Japanese Newborn Infants.

The objective of this study is to define normal values for umbilical artery blood acid-base and blood gas analysis in Japanese newborn infants. Subjects were 236 newborns, who were born after uncomplicated vaginal deliveries at 37 to 42 weeks' gestation. All had a normal finding of fetal heart rate monitoring and were born to women without pregnancy complications such as preeclampsia, fetal growth retardation, diabetes mellitus, twins and meconium-stained amniotic fluid. Specimens were obtained from the umbilical artery as soon after delivery as possible. One to two millilitres of blood were collected. Blood acid-base and gas determinations were performed within five minutes of delivery using a Corning 238 analyzer (Corning Medical, USA). The results of the study for the parameters were : pH, 7.31±0.05 ; pCO2, 39.7±8.0mmHg ; pO2, 21.0±5.8mmHg ; bicarbonate, 20.1±3.1mmol/L ; BE, -5.2±2.8mmol/L(mean value ± 1SD). In conclusion, normal values for umbilical artery blood analysis in a sizable group of Japanese newborns were defined. Umbilical cord blood analysis could provide the most accurate method of quantifying the newborn's acid-base status at delivery and of evaluating obstetric techniques for the management of labour. However, the cut-off value for pathologic fetal acidemia remains to be defined.

Real-time ultrasonographic analysis of the normal postpartum uterus: technique, variability, and measurements.

We evaluated normal uterine involution prospectively with real-time ultrasonography in 100 women after uncomplicated term vaginal delivery. Transducers easily distorted the spongy uterus during early postpartum scanning, an effect minimized with sector transducers that are superior to linear or convex probes for accurate early postpartum uterine measurement. Long-axis measurements correcting for uterine angulation were the most reproducible and accurate, irrespective of bladder distention. Uterine contractions caused instability of particularly the transverse dimension. Increasing maternal parity was associated with slightly but significantly larger uterine dimensions up to 4 weeks post partum. The uterus reassumed nongravid dimensions by 6 to 8 postpartum weeks. Uterine involution was unrelated to infant birth weight or breast feeding.

Umbilical cord pH, Pco2, and bicarbonate following uncomplicated term vaginal deliveries

Normal values for umbilical arterial and venous pH, Pco2, Po2, and bicarbonate must be known before these parameters can be used for assistance in clinical decisions. We evaluated the cord blood from 146 infants born after uncomplicated labor and vaginal deliveries at 37 to 42 weeks' gestation. All infants had a normal baseline fetal heart rate and normal beat-to-beat variability for at least 10 minutes preceding expulsion. The cord blood of infants born to women with pregnancy complications such as diabetes mellitus, preeclampsia, twins, meconium-stained amniotic fluid, or fetal growth retardation was not included. Mean umbilical arterial values ± 1 SD for the parameters studied were: pH, 7.28 ± 0.05; Pco2, 49.2 ± 8.4 mm Hg: Po2, 18.0 ± 6.2 mm Hg; bicarbonate, 22.3 ± 2.5 mEq/L. Umbilical venous values were: pH, 7.35 ± 0.05; Pco2, 38.2 ± 5.6 mm Hg; Po2, 29.2 ± 5.9 mm Hg; bicarbonate, 20.4 ± 4.1 mEq/L.