Vaginal Delivery Research Articles

Cervicovaginal foetal fibronectin in predicting success of induced labour among nulliparous women: a systematic review

Background The global rates of labor induction continue to exhibit a surge, attributed to a range of medical, obstetric, and non-medical factors. Although the Bishop score is often used to assess cervical preparation, its ability to accurately predict outcomes, particularly in nulliparous women with an unfavorable cervix, is still unknown. Method A complete review of the literature was undertaken, including PubMed, EMBASE, Cochrane Library, and Google Scholar databases, with the search period extending until April 2023. The studies included in this analysis focused on investigating the predictive value of fFN concerning induced labor outcomes in nulliparous women. The process of data extraction primarily concentrated on the features of the study, interventions, controls, criteria for inclusion and exclusion, and the outcomes that were evaluated. The quality of the included studies was assessed using the Newcastle-Ottawa Scale. Results The review synthesized findings from five studies, revealing varied predictive values of fFN. Sciscione et al. (2005) reported no significant difference in vaginal delivery rates between positive and negative fFN groups (Positive fFN: 55.8% vs. Negative fFN: 53.3%; P > .70). Uygur et al. (2016) found a higher cesarean section rate in patients with negative fFN results (P = 0.002). Reis et al. (2003) highlighted that higher parity and Bishop scores were more predictive than fFN alone (P = .021 for funneling; P = .157 for fFN presence). Grab et al. (2022) and Khalaf et al. (2023) further corroborated fFN's role in predicting labor outcomes, with the latter study demonstrating high sensitivity (85%), specificity (80%), and accuracy (82.6%) in predicting successful labor induction (P < .05 for Bishop score relation with fFN; P = 0.029 for positive vs. negative fFN). Conclusion This systematic review validated that fFN is a significant biomarker for predicting labor induction outcomes, especially in nulliparous women. The combination of additional clinical factors with fFN has been shown to boost its prediction accuracy, indicating the need for a personalized strategy to labor induction.

Awareness and Attitude regarding Modes of Delivery among Pregnant Women Visiting Antenatal Clinic of University Hospital of Nepal: Cross-sectional Study

BACKGROUND The ultimate outcome of a nine-month pregnancy is considered delivery. There are two types of delivery: natural and artificial, also known as spontaneous vaginal delivery and cesarean section (CS), respectively. The purpose of this study was to determine pregnant women's awareness and attitudes toward modes of delivery when they visited the ANC clinic. METHODS The quantitative descriptive cross-sectional study was conducted among 369 pregnant women visiting the ANC clinic of a university hospital. Non-probability sampling was used for sample determination. An interview technique was used for data collection. RESULTS Among 369 participants' with an average age of 28.3 ± 4.9 years. The majority (90.2%) agreed with the statement that vaginal delivery is a natural procedure .Moreover, 22.6% agreed that CS is preferable to vaginal delivery, and 37.7% strongly agreed that the mother should have the freedom to perform a caesarean section in her choice. Only about one fifth of the respondent had moderate level of knowledge regarding modes of delivery. The level of knowledge is associated with the level of education (p = 0.020) and the decision-making role of the respondent (p = 0.002) but the attitude is found associated with type of the family (p = 0.037) and no. of ANC visits (p = 0.001) CONCLUSION The participants demonstrated moderate level of knowledge regarding modes of delivery and positive attitude towards normal delivery. Women having the right to make decisions regarding their preferred modes of delivery, including the freedom to choose CS.

Neonatal head circumference to maternal mid-transverse pelvic distance ratio as a key anatomical predictor for dystocia: Retrospective case-control study.

This study aimed to examine maternal and neonatal factors in cesarean deliveries due to dystocia, including cephalopelvic disproportion, latent-phase prolongation, and fetal malposition or malpresentation. Additionally, we sought to compare the differences between the dystocia subgroups. This retrospective case-control study included women who delivered between January 2010 and June 2021 after 37 weeks of pregnancy and underwent abdominal-pelvic CT scans within 5 years before and after delivery. Neonatal factors were extracted from medical charts immediately after delivery. Among the 292 women studied, those with cesarean deliveries for dystocia were older (mean ± SD, 34.2 ± 4.27 vs. 32.2 ± 3.8, p-value = 0.002), had higher pre-pregnancy BMI (22.7 ± 3.67 vs. 21.4 ± 3.48, p-value = 0.012) and term-BMI (27.4 ± 3.72 vs. 25.9 ± 3.66, p-value = 0.010), shorter interspinous distance (ISD, the distance between ischial spine) (10.8 ± 0.76 vs. 11.2 ± 0.85 cm, p-value = 0.003), and longer head circumference (HC) (35 ± 1.47 vs. 34.4 ± 1.36 cm, p-value = 0.003) compared to those who had vaginal deliveries. Univariate logistic regression for dystocia revealed associations between HC/maternal height and HC/ISD ratios (OR, 2.02 [95% confidence interval, CI, 1.4 ~ 2.92], 12.13 [3.2 ~ 46.04], respectively). Multivariate logistic analysis indicated that maternal age, ISD, and HC were significant factors for dystocia (OR, 1.11 [95% CI, 1.01 ~ 1.21], 0.49 [0.26 ~ 0.91], 1.53 [1.07 ~ 2.19], respectively). The subgroup with latent-phase prolongation exhibited the lowest birthweight/term-BMI ratio (124 ± 18.8 vs. 113 ± 10.3 vs. 134 ± 19.1, p-value = 0.013). The HC/ISD ratio emerged as a crucial predictor of dystocia, suggesting that reducing term-BMI could potentially mitigate latent-phase prolongation. Further research assessing the maternal mid-pelvis during pregnancy and labor is warranted, along with efforts to reduce BMI during pregnancy.

Place de la chirurgie fœtale dans le cadre d’un dysraphisme ouvert

Open dysraphisms, including myelomeningocele and myeloschisis, are among the most common central nervous system anomalies prenatally diagnosed. These malformations lead to complex disabilities, including lower-limb sensory-motor disorders, sphincter disorders and cerebral complications. In most cases, open dysraphism are diagnosed prenatally, usually during the second-trimester ultrasound scan. The benefits of fetal surgery for open dysraphism were demonstrated in the early 2010s. Fetal surgery improves motor function and halves the risk of hydrocephalus requiring ventricular shunt. This surgery is performed before 26 weeks of gestation and is indicated for couples whose fetus has an isolated open dysraphism, and who wish to continue the pregnancy. Two techniques of fetal surgery are described: open surgery and fetoscopic surgery. Open surgery was the first to be developed. It requires a hysterotomy, which implies delivery by Caesarean section for the current pregnancy and all subsequent pregnancies. Fetoscopy is a more recent, less invasive technique, which allows vaginal delivery. The main complication of fetal surgery, whatever the technique, is the risk of premature delivery and potential neonatal complications related to prematurity.

Comparison and analysis of maternal and neonatal outcomes between vaginal delivery and cesarean section.

Comparison and analysis of maternal and neonatal outcomes between vaginal delivery and cesarean section.

A quality improvement initiative to augment success rate of labour analgesia: interrupted time series analysis

BACKGROUND Standard operating procedures (SOP) for abour analgesia for parturients in Nepal are lacking. Labour analgesia programme was being conducted without a SOP in our institution. We identified that the success rate of epidural labour analgesia (ELA) was low. We developed standard operating procedures for labour analgesia services with the combined effort of the department of anesthesia and pain management with the department of obstetrics and gynaecology in Nepal Mediciti in 2019 January. SOP and troubleshooting protocol was implemented in 2019 February and this study was conducted to investigate the impact of programmed protocol for labour analgesia. METHODS An interrupted time-series analysis was performed as a process improvement project for all cases who demanded labour analgesia from November 2017 to December 2019 with retrospective data collection. The success of epidural labour analgesia was defined as vaginal delivery with Numerical Rating Scale for labour pain of 3 or less. The time series analysis intended to identify the change in the level of success rate (increase or decrease) and change in the slope of success rate over time. RESULTS The major problems identified by the team included lack of patient counselling, inadequate followup after the first dose of epidural, delay in attending call for labour analgesia by the anesthesiologist and undefined clinical pathways for the usage of drugs and troubleshooting. After implementation of the protocol, the interrupted time series showed a 24.77% relative increase in success rate with p value <0.001. CONCLUSION Interdepartmental group discussions, interviews with the patients and development of a team that worked on formulating SOP was done after problem identification. Patient counselling after 28 weeks of gestation gave patients time for psychological preparation and have realistic expectations regarding ELA than labouring parturients. Clear protocol regarding drug dosing and troubleshooting disposed interpersonal variation among the anesthesiologists. Continuous patient follow-up by the nurse-led team helped to identify any additional problems and address it and add on to the protocol. In conclusion, standard operating procedures guided epidural labour analgesia programme enhanced the success rate of epidural labour analgesia.

Multicenter Remote-Access Simulation of Vaginal Delivery for High-Flexibility Medical Education during the Coronavirus Pandemic.

During the coronavirus pandemic, face-to-face simulation education became impossible. Therefore, we aimed to develop remote-access simulation education with a sense of realism through Information and Communication Technology (ICT) using a perinatal whole-body management and delivery simulator. In September 2021, we administered a multi-center simultaneous remote simulation based on our developed model. Ten universities in the Chugoku-Shikoku region were connected via a web-conferencing system to a live broadcast of a virtual vaginal birth in which a fictional hospitalized pregnant woman experienced accelerated labor and gave birth through vacuum delivery for fetal distress. A Video on Demand (VOD) was made beforehand using a new simulator that allowed for a visual understanding of the process of the inter-vaginal examination. We provided a participatory program that enhanced the sense of realism by combining VOD and real-time lectures on each scenario, with two-way communication between participants and trainee doctors using a chat function. Most participants answered "satisfied" or "very satisfied" with the content, level of difficulty, and level of understanding. From November 2021, we have used the videos of all processes in face-to-face classes. Our construction of a high-flexibility education system using remote simulation in the field of obstetrics and gynecology, especially in the vaginal delivery module, is unique, creative, and sustainable.

Prevalence and Determinants of Exclusive Breastfeeding Among Mothers of Children Aged 6-24 Months in the Aseer Region.

Background Exclusive breastfeeding (EBF) is crucial for infant and maternal health, providing optimal nutrition and immune protection for infants while reducing maternal postpartum depression and cancer risk. However, global trends show an early cessation of breastfeeding and the introduction of other foods. This study aims to determine the prevalence and factors influencing EBF among mothers in the Aseer region of Saudi Arabia. Methodology A cross-sectional study using a multistage cluster sampling approach was conducted from January to March 2024 in primary healthcare centers across the Aseer region. Participants included mothers of children aged 6-24 months attending primary healthcare centers for immunizations or routine check-ups. A pretested structured questionnaire, developed after an extensive literature review and expert consultation, was used to interview consenting participants. The questionnaire covered sociodemographic data, obstetric and medical history, child data, EBF practices, maternal knowledge and perception of breastfeeding, counseling about breastfeeding, antenatal care, breastfeeding support, and barriers and motivators of EBF. Results A total of 1,008 eligible mothers were included. Only 131 (13%) fulfilled the World Health Organization criteria for EBF. Moreover, 257 (25.5%) mothers initiated breastfeeding within the first hour after delivery, and 387 (38.4%) exclusively breastfed for six months or more. EBF was less frequent among mothers with higher education (8%, n = 2) compared to those with lower education (23%, n = 23, p = 0.017). EBF was also less frequent among mothers who delivered via cesarean section (7.9%, n = 28) compared to those who had a vaginal delivery (15.8%, n = 103, p = 0.001). Conversely, EBF was more common among mothers with more than five pregnancies (15.8%, n = 45) compared to those with one to two pregnancies (9.4%, n = 37, p = 0.023). EBF was also more common among mothers who had breastfed more than four children (16.7%, n = 39) compared to those who had not (12.1%, n = 49, p = 0.048). Finally, EBF was more common among mothers without postpartum complications (13.4%, n = 131) or whose infants had no birth complications (13.4%, n = 128) compared to their respective counterparts (p = 0.029 and p = 0.048, respectively). Conclusions This study found a low prevalence of EBF in the Aseer region, despite high maternal knowledge and positive perceptions. Factors such as low education, medical barriers, unemployment, and high parity were associated with increased EBF rates. Interventions should focus on improving workplace support and increasing maternal awareness of EBF recommendations.

Effective Epidural Analgesia during Labor: A Feasible Method to Decrease Unnecessary Cesarean Deliveries in Thailand

Thailand has reported a high rate of cesarean delivery (45%–55%), prompting global concern about an increase in cesarean delivery rates. Fear of labor pains is one of the most common reasons pregnant women opt for cesarean delivery. Labor pain is associated with cervix dilation and fetal descent into the birth canal, which is exacerbated by ischemic pain caused by uterine contraction. Modern medical and non-medical techniques have demonstrated efficacy in reducing pain and ensuring safety during labor and delivery. Neuraxial labor analgesia is a highly effective medical pain relief method but has no effect on the rate of cesarean or assisted vaginal delivery. Medication administration for pain relief during labor, using a combination of a local anesthetic and an opioid, was observed to be transmitted across the placenta to the fetus, but had no significant effects on fetal outcomes in mothers who chose epidural analgesia. There are several techniques for administering neuraxial labor analgesia that can be customized for each pregnant woman. To achieve the most wonderful feasible labor and delivery experience, effective epidural labor analgesia is a crucial technique for reducing anxiety and suffering about labor pain. It is safe, widely used world-wide, and effective. Implementing a policy to increase public and medical providers awareness and acceptance of labor pain relief, as well as establishing a safe obstetric anesthesia service provided by obstetric anesthesiologists, could improve maternal and neonatal safety while significantly lowering the rate of unnecessary cesarean deliveries.

Exploring maternal and neonatal outcomes in women with Type-1 Diabetes: A study from Pakistan.

Pregnancy in women diagnosed with Type-1 diabetes mellitus poses a higher risk of experiencing complications related to the health of the fetus, the mother, and the newborn, along with potential obstetric issues. The objective of this study was to examine the maternal and fetal outcomes, as well as complications faced by pregnant women with type-1 diabetes, and to identify potential preventable factors. This retrospective cohort study, conducted at Baqai Institute of Diabetology and Endocrinology (BIDE), Baqai Medical University, Karachi, Pakistan (January 2022 - January 2023), focused on registered pregnancies of women with Type-1 diabetes. A predesigned questionnaire recorded demographic information, diabetes and obstetric history, clinical details, treatment specifics, maternal, perinatal, and neonatal outcomes. This study included 100 women with pre-existing Type-1 diabetes (mean age: 15.11 ± 5.64 years at diabetes diagnosis). Of these, 72% reported unplanned pregnancies, with a mean HbA1C at conception 8.29%. Median gestational age at delivery was 32.15 ± 10.82 weeks. Delivery outcomes included 40% normal vaginal deliveries and 60% C-sections (9% emergency, 51% elective). Stillbirths occurred in 14 cases, while 16 women experienced one miscarriage, seven had two, and 10 had three miscarriages. Glycemic targets (fasting) were achieved in 55 women, and post-meal targets only in 29, whereas, neonatal complications included hypoglycemia in 13 and low birth weight in 12 neonates. The high frequency of unplanned pregnancies and cesarean sections along with poor management of pre-pregnancy care and poor glycemic control results in compromised maternal and perinatal outcomes in this high-risk group.

ART conceptions: timing of delivery and the risk of hypertensive disorders of pregnancy

Research questionAre there differences in the rates of hypertensive disorders of pregnancy among in vitro fertilization (IVF) patients who underwent induction of labor at 39 weeks compared to those who were managed expectantly? DesignThis is a retrospective cohort study of 1,176 low-risk singleton pregnancies conceived following IVF with no contraindications to vaginal delivery. Two groups were constructed: elective induction of labor from 39 weeks 0 days to 39 weeks 6 days (n=234) versus expectant management (n=942). Main outcome measure was the incidence of hypertensive disorders of pregnancy. Secondary outcome was the rate of cesarean delivery. Sub-analyses were performed within fresh and frozen embryo transfer groups. ResultsHypertensive disorders of pregnancy developed in 8.1% of patients in the induction of labor group and in 12.4% in the expectant management group (P=.06). This difference was attenuated after controlling for potential confounders (P=.28). For frozen embryo transfers, the unadjusted odds of hypertensive disorders of pregnancy were significantly lower with induction of labor compared to expectant management (P=.02) and after adjusting for confounders, the odds ratio neared significance (P=.09). For fresh transfers, there was no difference in the odds of hypertensive disorders of pregnancy between the two groups. The odds of delivering via cesarean section were higher in the induction of labor group, in the total population and in sub-analyses. ConclusionOverall, in IVF conceived pregnancies, induction of labor when compared to expectant management was not associated with a lower incidence of hypertensive disorders of pregnancy, it was however, associated with a higher rate of cesarean delivery.

Pregnancy and delivery outcomes after abdominal vs. laparoscopic myomectomy: an evaluation of an American population database

ObjectiveTo evaluate population characteristics and obstetrical complications after abdominal myomectomy vs. laparoscopic myomectomy. DesignRetrospective cohort study, using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, with hospital discharge between 2004 and 2014. SettingsPopulation-based. Subject(s)13868 and 338 pregnancies following abdominal or laparoscopic myomectomy, respectively. ExposureObstetrics outcomes following abdominal and laparoscopic myomectomy were collected. MethodsMultiple and Binomial logistic regression were used and adjusted in different models for age, obesity, chronic hypertension, and pre-gestational diabetes mellitus. Main Outcome Measure(s)Pregnancy, delivery, and neonatal outcomes were analyzed. Result(s)Abdominal myomectomy were characterized by younger patients, lower rates of Caucasian, chronic hypertension, pregestational diabetes, active smoking, illicit drug use, and higher rates of previous cesarean delivery, and multiple gestations when compared to laparoscopic myomectomy. Pregnant women with laparoscopic myomectomy had decreased rates of pregnancy-induced hypertension [adjusted risk ratios (aRR) 0.12, 95% confidence intervals (CI) 0.006-0.24)], gestational hypertension (aRR 0.24, 95%CI 0.08-0.76), preeclampsia (aRR 0.18, 95%CI 0.07-0.48), and preeclampsia or eclampsia superimposed on chronic hypertension (aRR 0.03, 95%CI 0.005-0.3), gestational diabetes mellitus (aRR 0.14, 95%CI 0.06-0.34), preterm premature rupture of membranes (aRR 0.14, 95%CI 0.02-0.96), preterm delivery (aRR 0.36, 95%CI 0.23-0.55), and cesarean delivery (CD) (aRR 0.01, 95%CI 0.007-0.01) and small for gestational age (aRR 0.15, 95%CI 0.005-0.04), compared to abdominal myomectomy group. Laparoscopic myomectomy group had a higher rate of spontaneous aRR 35.57, 95%CI 22.53-62.66), and operative vaginal delivery (aRR 10.2, 95%CI 8.3-12.56), uterine rupture (aRR 6.1. 95%CI 3.2-11.63), postpartum hemorrhage (aRR 3.54, 95%CI 2.62-4.8), hysterectomy (aRR 7.74, 95%CI 5.27-11.4), transfusion (aRR 3.34, 95%CI 2.54-4.4), pulmonary embolism (aRR 7.44, 95%CI 2.44-22.71), disseminated intravascular coagulation (aRR 2.77, 95% CI 1.47-5.21), maternal infection (aRR 1.66, 95%CI 1.1-2.5) and death (aRR 2.04 95%CI 1.31-3.2)) and intra-uterine fetal death (aRR 2.99, 95%CI 1.72-5.2) compared to the abdominal myomectomy group. ConclusionsWomen who had a previous abdominal myomectomy have underlying risk factors for hypertension disorders of pregnancy and gestational diabetes. Women who underwent laparoscopic myomectomies have higher risks of bleeding, uterine rupture, resultant complications, and death, and should be monitored as high-risk patients, like abdominal myomectomies.

Empowering Expecting Mothers: The Impact of Antenatal Classes on Child Birth Experience.

Introduction Antenatal education is one of the ways to increase a woman's knowledge about pregnancy and childbirth, which could improve self-efficacy during labor, making the expecting mothers well-prepared for labor and nursing. One of the ways for its delivery could be via well-structured antenatal classes. Such classes are part of many countries' healthcare systems and have proven to decline maternal anxiety, shorten labor, increase partner involvement, and overall improve labor experience. However, at the same time, such classes can augment more interventions in labor, induction of labor, and epidural usage. Despite the heterogeneous results of their effect, the high demands of antenatal education amongpregnant women can justify its incorporation into antenatal care. By allowing the women to identify labor correctly and preventing admission in false labor, shortening the labor, and teaching women non-pharmacologic ways to manage labor pains, it can reduce the patient and fiscal burden on the already overwhelmed maternity units of Pakistan, hence proving to be an inexpensive health promotion tool. Methods This cross-sectional study was conducted in the Department of Obstetrics and Gynecologyof Aga Khan University Hospital Karachi, Pakistan, between December 2020 and June 2021. All pregnant women, aged 18 to 45 years, between gestational ages of 37 to 42 weeks, with singleton, cephalic pregnancy, booked during the first or second trimester, and who attended at least one antenatal class, were invited to participate. Women who had any contraindication to vaginal delivery, whose labor was induced, or who suffered from medical, psychological, or obstetric comorbidities were excused. The participants were observed for labor outcomes in terms of stage of labor on arrival, use of epidural analgesia, mode of delivery, and childbirth experience, using a validated research tool, known as the Questionnaire for Assessing the Childbirth Experience (QACE)to identify women with a positive or negative childbirth experience. A higher score representing on the questionnaire represented a more negative birth experience. A score of less than 19 was considereda positive birth experience. Data was analyzed using IBMStatistical Package for Social Sciences (SPSS) Statistics for Windows, Version 19. Results The mean QACE score was reported as 18.2±3.00, reflecting that on average the mothers had a positive childbirth experience. Modes of delivery revealed 57.6% of the women delivering spontaneously, with 60.4% of them arriving in the labor room in active labor. Demand for labor analgesia in the form of epidural was 64%. Majorly the participants attended only one antenatal class, with 66.91% of women reporting a positive childbirth experience. Conclusion Antenatal education classes are a low-input, high-yielding resourcethat can be used to empower mothers with pertinent information and support for a pleasant childbirth experience while simultaneously taking the edge off the overburdened maternity wards of low resources, in densely populated countries like Pakistan. Hence it is the need of the hour to devise plans to invest in these classes to make them available to the masses.

EFEKTIFITAS OPERASI SC ERACS TERHADAP MOBILISASI PASIEN DAN LAMA PERAWATAN

Background: Sectio Caesarea is a birth operation that has been proven to reduce maternal mortality when vaginal delivery is indicated to be risky. Wound healing in Sectio Caesarea surgery patients requires good blood circulation for cell growth or repair. Mobilization will improve blood circulation and you may soon experience recovery or healing. Method: A literature search was carried out based on articles published between 2018-2023 according to the inclusion and exclusion criteria that had been determined using 1 data base, namely Google Schoolar. This literature search uses the PRISMA guideline in carrying out the screening process. From the search results, 200 articles were obtained. After carrying out the screening process, there were 8 articles that met the criteria and will be analyzed. Results: Based on a review of 8 literature, it was found that SC ERACS was effective in speeding up patient mobilization and shortening the length of treatment Conclusion: From the results of a literature review of 8 journals, it was found that SC ERACS was effective in speeding up patient mobilization and shortening the length of treatment.

Temporal trends and regional variations in operative vaginal deliveries in Japan: A national representative cohort study.

To analyze temporal trends and regional variations in operative vaginal delivery (OVD) in Japan. Using the National Database of Health Insurance Claims and Specific Health Checkups of Japan from 2014 to 2021, we identified the numbers of vacuum and forceps deliveries. We analyzed annual totals and proportions of OVDs and calculated the mean age of women undergoing these deliveries. We also predicted trends in OVD for the next 20 years and compared geographical differences in the proportions of forceps deliveries among OVDs. During the observation period, out of 7 368 814 total births, 8.4% were through OVD, including 7.6% by vacuum and 0.8% by forceps. Both delivery methods showed an increasing trend from 2014 to 2021: vacuum deliveries rose from 7.0% to 8.7%, and forceps deliveries increased from 0.6% to 1.0%. Notably, the proportion of forceps deliveries in OVD increased from 8.1% to 10.5%. The mean age was higher for forceps deliveries than vacuum deliveries. According to our predictions, vacuum deliveries may continue to increase, but forceps deliveries may stabilize. The proportion of forceps deliveries among OVDs ranged from 0% to 38% across Japanese prefectures. This study shows an increase in the use of OVD in Japan from 2014 to 2021. There are large regional differences in the choice between vacuum and forceps deliveries. These findings can help us understand the practice of OVD in Japan.

Effect of anesthesia on the success rate of external cephalic version: GRADE- assessed systematic review and meta-analysis of randomized controlled trials

BackgroundExternal cephalic version (ECV) is a medical procedure in which an extracorporeal manipulation is performed to render the breech presentation (BP) fetus in the cephalic position. The use of anesthesia to facilitate repositioning has been evaluated in various randomized clinical trials (RCTs), but its potential effectiveness remains controversial.MethodsA systematic literature search was carried out in 8 electronic databases. In the meta-analysis, a random effects model was used to calculate the pooled relative risk (RR) and its 95% confidence interval (CI), and the pooled standardized mean difference (SMD) and its 95% CI, in order to systematically assess the effect of anesthesia on the success rates of ECV, vaginal delivery, cesarean delivery as well as other outcomes. Relevant subgroup analyses, publication bias test and sensitivity analyses were also conducted.ResultsThis review included 17 RCTs. Women who received anesthesia had a significantly higher incidence of successful ECV (RR: 1.37, 95% CIs: 1.19-1.58) and vaginal delivery (RR: 1.23, 95% CIs: 1.03-1.47), and a significantly lower incidence of cesarean delivery (RR: 0.69, 95% CIs: 0.53-0.91), compared with those who did not.ConclusionThe administration of anesthesia not only significantly reduces maternal pain but also significantly increases the success rate of ECV in women with malpresentation at term, leading to a significant rise in the incidence of vaginal delivery. However, it may increase the incidence of maternal hypotension.Systematic review registrationThe protocol was prospectively registered with PROSPERO, registration CRD42022381552.

In Vitro and Ex Vivo Evaluation of Novel Methacrylated Chitosan-PNIPAAm-Hyaluronic Acid Hydrogels Loaded with Progesterone for Applications in Vaginal Delivery.

Miscarriage is defined as the loss of a pregnancy before 24 weeks and administration of progesterone in pregnancy has considerably decreased the risk of premature birth. Progesterone (PGT) starting from the luteal phase stabilizes pregnancy, promotes differentiation of the endometrium, and facilitates the implantation of the embryo. Within the present study, novel hybrid hydrogels based on chitosan methacrylate (CHT), hyaluronic acid (HA), and poly(N-isopropylacrylamide) (PNIPAAm) for vaginal delivery of progesterone were evaluated. The hydrogels were characterized by Fourier transform infrared spectroscopy (FTIR) and scanning electron microscopy (SEM) for structural identity assessment and evaluation of their morphological aspects. The ability to swell, the release capacity, enzymatic degradation, cytotoxicity, and mucoadhesion were also reported. The characterized hydrogels demonstrated mucoadhesive properties in contact with the vaginal tissue of swine and bovine origin as substrates, and biodegradability and controlled release in a simulated vaginal environment. Cytocompatibility tests confirmed the ability of the hydrogels and progesterone to support cell viability and growth. The results showed pH-dependent behavior, controlled drug release, good cytocompatibility, and mucoadhesive properties. The hydrogels with higher chitosan amounts demonstrated better bioadhesive properties. This study provides insights into the potential of these hydrogels for the controlled vaginal delivery of progesterone, with promising therapeutic effects and no cytotoxicity observed. The experimental results indicated that a composition with a moderate content of PNIPAAm was suitable for the controlled delivery of progesterone.

Effectiveness, reliability, and validity of new Japanese diagnostic criteria for obstetrical disseminated intravascular coagulation

Since July 2022, obstetrical disseminated intravascular coagulation (DIC) in Japan has been diagnosed based on the new criteria (tentative version), which assesses the main underlying disease, fibrinogen level, and fibrin/fibrinogen degradation products or D-dimer level. In June 2024, the tentative version underwent minor revision and the final version was released. The previous Japanese criteria assessed underlying disease, clinical symptoms, and various laboratory findings. This study aimed to prove the effectiveness, reliability, and validity of the new criteria (final version). We analyzed 212 women with singleton pregnancies who delivered after 22 gestational weeks and experienced blood loss ≥ 1000 mL during vaginal delivery or ≥ 2000 mL during cesarean section. Those with missing laboratory findings before receiving blood transfusion at delivery were excluded. In the obstetrical DIC group, the frequency of fibrinogen levels < 150 mg/dL was significantly higher than in the control group (90% vs. 5%, p < 0.0001), as was the frequency of scores ≥ 8 according to the previous Japanese criteria (100% vs. 10%, p < 0.0001). Cronbach alpha was 0.757 and Spearman’s rank-order correlation was 0.558 between the new and previous criteria. In conclusion, we proved the effectiveness, reliability, and validity of the Japanese new criteria (final version) to diagnose obstetrical DIC.

Biochemical analysis of catecholamine and cortisol for the evaluation of the fetal distress in third trimester stillbirths

BackgroundStress hormones like catecholamine and cortisol are thought to reflect the magnitude of physical stress in adults and were studied in relationship to the cause of death and agony time. Intrauterine distress, intrapartum events, and modes of delivery can affect the fetal endocrine stress response, as reflected by biochemical analyses. The aim of the present study was to evaluate the role of catecholamines and cortisol as markers of ante-mortem fetal distress. The role of cortisol as a marker of circadian timing of delivery was also assessed.MethodsA 2-year prospective cohort-comparison inclusion of stillbirths and newborns took place with collection of antemortem data, labor parameters, neonatal outcome, post-mortem data and blood samples. Stillbirths were classified as acute or chronic on the basis of a multidisciplinary evaluation. Heart blood of stillbirths and cord blood of newborns were analyzed by high pressure liquid chromatography (HPLC) for adrenaline and noradrenaline and by immunoassay for cortisol determination.ResultsFifteen stillbirths and 46 newborns, as a comparison group, delivered by spontaneous vaginal birth, elective, and emergency cesarean sections were included. Stillbirths’ main cause of death was cord thrombosis. Levels of adrenaline and noradrenaline (median: 14,188 pg/ml and 230.5 pg/ml, respectively) were significantly higher (p < 0.001) in stillbirths than in newborns and were also higher in acute compared to chronic distress. Cortisol levels were significantly higher (p < 0.05) in spontaneous vaginal delivery (median: 18.2 μg/dl) compared to elective cesarean sections (median: 3.8 μg/dl). No difference in cortisol concentrations was detected between newborns delivered at morning and at afternoon/evening.ConclusionOur results suggest that the biochemical measurement of adrenaline and noradrenaline levels might reflect a marked physical stress response during the process of death in stillbirths. On the contrary, the elevation of cortisol levels could mirror the elevation in maternal cortisol level during vaginal delivery. For the post-mortem evaluation of stillbirths, the analysis of CA levels could provide additional data on the duration of distress, useful to integrate the forensic diagnosis.

Preparing the Heart for a New Baby: Management of Pregnancy in Heart Transplant Recipients.

Heart transplant (HT) recipients are more frequently reaching childbearing age given improvement in median survival and outcomes after HT. Although most pregnancies in HT recipients have favorable outcomes, poor fetal outcomes and maternal complications such as hypertensive disorders of pregnancy are more common in HT recipients than in the general population. In this review, we summarize the current evidence to guide the management of pregnancy in HT recipients. Preconception counseling, focused on risk stratification and optimal timing of conception, is the first important step to optimize pregnancy outcomes. During pregnancy and in the postpartum period, frequent monitoring of graft function and immunosuppressive levels is recommended. Calcineurin inhibitors and corticosteroids should be the mainstay of treatment for both prevention and treatment of graft rejection. Delivery planning should follow usual obstetric indications, preferably with vaginal delivery at term using regional anesthesia. A multidisciplinary care team should be involved in management through all stages of pregnancy to ensure success.