Vaginal Vertex Delivery Research Articles

External cephalic version in nonvertex second twin-Success rate, mode of delivery, and safety: A systematic review.

One of the key challenges regarding the management of twins involves choosing the optimal mode of delivery, which is strongly influenced by the final presentation of both fetuses. In cases of vertex-nonvertex pregnancies attempting the trial of vaginal delivery, external cephalic version (ECV) is one of possible management options. The main objective of this review was to collect and summarize available data in terms of the application of ECV in the population of nonvertex second twins. Using the PRISMA guidelines, we searched for original, English-language studies investigating ECV in nonvertex second twins. The PubMed/MEDLINE, SCOPUS, and COCHRANE databases were searched until May 2024. Reviews, case reports, editorials, and conference papers were excluded from further analysis. Out of 260 papers retrieved, 10 were subjected to the final analysis in terms of success rates, modes of delivery, and adverse outcomes. The total number of ECVs was 289, with an overall success rate of 64.4%. In the group of successful versions, vertex vaginal delivery was achieved in 171 cases (91.9%). The incidence of adverse maternal and neonatal outcomes was low. The purpose of this review was to consolidate and update the current knowledge regarding ECV in nonvertex second twins. Based on the results of this series of studies, ECV appears to be a reasonable management option. However, it is important to highlight several significant limitations. The primary concern is the lack of recent research in this field over the past three decades, with the most recent study in our review being published in 1998. Furthermore, the actual number of studies addressing this topic is relatively low, characterized by a retrospective nature and questionable methodologies. These limitations make it challenging to draw definitive conclusions for clinical practice. This is an important message for our community, emphasizing the need for further studies in this area, particularly randomized controlled trials, to evaluate the safety and success rate of vaginal twin delivery after ECV when the second twin presents in a nonvertex position.

External cephalic version success rate and associated factors: Experience from a tertiary center in Sub-Saharan Africa: A cross-sectional study.

To determine the success rate of external cephalic version (ECV) and its associated factors in an Ethiopian setting. A total of 152 ECVs performed at the St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia from June 1, 2018, up to March 30, 2019, were analyzed, using a prospective cross-sectional study design. Data were analyzed using SPSS version 21. Chi-square test of association was applied for categorical data analysis. Multivariate logistic regression analysis was used to determine predictors of success of ECV. Odds ratio, 95% CI, and P-value<0.05 were used to describe findings' significance. The success rate of ECV was 71.7%. ECV success rate did not differ between multiparous and nulliparous (AOR = 1.4, 95% CI 0.07-2.35), according to abdominal wall thickness status (AOR = 3.5, 95% Cl 0.29-42.40), and between unengaged and engaged presenting part (AOR = 1.1, 95% CI 0.26-4.74). A posterior placenta was associated with ECV success compared to anterior placenta (AOR = 1.14, 95% CI 1.03-2.60). Likewise, cases that experience no pain was associated with a higher ECV success rate (AOR 14.68, 95% CI 1.65-34.97). Soft uterine tone was also associated with a higher success rate compared to tense uterine tone (AOR = 3.89, 95% CI 0.02-0.39). Eighty-four percent of those mothers who had successful ECV had spontaneous vertex vaginal delivery. The success rate of ECV in this study is found to be 71.7%, which is higher than reports from previous studies. Absence of pain during the procedure, posterior placenta, and soft uterine tone were associated with successful ECV.

Neonatal admission rate after vaginal breech delivery.

The safest mode of delivery for fetuses in breech presentations is still an ongoing debate. The aim of this study was to analyze neonatal admission rates after vaginal breech delivery and compare it to other modes of delivery in order to counsel pregnant women with breech presentation adequately. We performed a retrospective monocentric analysis of all deliveries with singleton pregnancies in breech presentation > 36.0weeks of gestation between 01/2018-12/2019. Short-term neonatal morbidity data was collected for vaginal delivery and primary as well as secondary cesarean sections from breech presentations. A total of n=41/482 (8.5%) neonates had to be admitted to NICU: vaginal breech delivery n=18/153 (11.8%), primary cesarean section n=9/101 (8.9%, OR 0.73; CI 0.32-1.70; p=0.47), secondary cesarean section n=10/76 (13.2%, OR 1.14; CI 0.50-2.60, p=0.76) and vaginal vertex delivery n=4/152 (2.6%, OR 0.20; CI 0.06-0.51; p=0.005). There was no significant difference in transfer to NICU between all breech position delivery modes. Despite significantly lower pH and 5' APGAR values after vaginal delivery, neonates delivered by primary cesarean section and NICU admission had to be treated there significantly longer (mean 80.9 vs. 174.0h). No significant difference in terms of ventilation parameters and infections were found between the vaginal delivery, primary and secondary cesarean section from breech presentation. Vaginal breech delivery does not result in a higher neonatal admission rate in comparison to primary and secondary section. In contrast, there is a shorter NICU duration in case of neonatal admission after vaginal delivery.

Nipple/Areola Dimensions in Early Breastfeeding.

Background: Nipple dimensions may be an important factor in breastfeeding (BF) initiation success. Objective: To establish standards of nipple/areola dimensions in early BF and to determine whether maternal age, gestational age (GA), parity, cup size, previous BF experience, and early (<2 hours) BF affect nipple dimensions (assessed on the second day of BF). Design/Methods: A total of 205 consecutive BF women were enrolled. They were all Caucasians, and had uncomplicated pregnancies, labors, and vertex vaginal deliveries. Measurements (immediately before and after BF) of nipple length and diameter and of prefeeding areolas were by sliding calipers. Results: In average, there were no significant differences between right (R) and left (L) side dimensions, except for post-BF nipple length, and post-BF horizontal nipple diameter (significantly higher on the L side). Both R and L nipple length correlated positively with maternal age, gravidity, parity, number of previously breastfed infants, and cumulative number of BF months. Early (<2 hours) first BF did not correlate with increased nipple length. Pre-BF nipple length correlated significantly with post-BF nipple length on both sides. There were significant differences between pre- and post- BF values in terms of nipple length (longer length post-BF), but not in terms of nipple diameter. In stepwise regression analysis, where pre-BF nipple length was the dependent variable, and parity (or maternal age, or previous BF), early first BF, and GA were independent variables, parity, maternal age, gravidity, or previous BF experience were positively and significantly associated with nipple length (p < 0.001). The correlation maternal age-nipple length remained significant in primigravida mothers. Conclusions: This study provided a set of standards for nipple and areola dimensions on day 2 of BF in Caucasian women. The only areola/nipple dimension significantly affected by BF is the nipple length. Increasing parity, maternal age, or previous BF experience is significantly associated with increased nipple length.

Circumferential shoulder laceration after posterior axilla sling traction: a case report of severe shoulder dystocia

BackgroundShoulder dystocia is an unpredictable and potentially catastrophic complication of vertex vaginal delivery. Posterior axilla sling traction (PAST) has recently been proposed as a method to resolve severe shoulder dystocia when commonly used techniques have failed.Case presentationA 33-year-old woman (gravida 5, para 0) at 35 weeks, 1 day gestation underwent induction of labor for poorly controlled type 2 diabetes mellitus. Delivery of the large-for-gestational-age infant (4,060 g) was complicated by intractable shoulder dystocia, relieved at 3 minutes with PAST, resulting in a deep, circumferential laceration of the fetal posterior shoulder and contralateral phrenic nerve palsy.ConclusionsPAST provides a potentially lifesaving option during intractable shoulder dystocia. Simulation or education about the technique facilitates its use when standard maneuvers fail. It is important to disseminate information about potential complications associated with these novel maneuvers.

Association between Shoulder Dystocia Maneuvers and Cervical Laceration Requiring Repair

Objective: To determine if there is an association between shoulder dystocia maneuvers (SDM) and cervical laceration requiring repair (CLRR). Study design: Retrospective cohort study in a single university-affiliated community hospital for term singleton vertex vaginal deliveries from 7/1/05-7/24/13. Data were analyzed by two-tailed exact mid-p test and risk ratio. Results: A total of 391 from 7,153 (5.5%) term singleton vertex vaginal deliveries required SDM. A total of 27 (0.38%) cervical lacerations were identified, 22 (81%) of which were repaired. Four of 391 patients (1.0%) with SDM had CLRR compared to 18 of 6,757 patients (0.3%) without SDM (p=0.035). The RR for CLRR with SDM was 3.84 (95% CI:1.3-11.5). There was no statistical difference (p=0.36) in delivery of the posterior arm with the incidence of cervical laceration requiring repair. Conclusion: SDM were significantly associated with CLRR. Cervical laceration may be an infrequent, but unavoidable consequence of SDM; however, this association may also reflect common risk factors between shoulder dystocia and cervical laceration.

706: Outcomes of routine shoulder dystocia screening using a commercially available screening tool

A sensitive prediction model to aid the identification of women at risk of shoulder dystocia has remained elusive thus far. A proprietary tool known as the PeriCALM Shoulder Screen (PeriGen, Princeton, NJ) has been suggested in observational data to identify at-risk patients through a composite of historical, demographic, and medical factors. This study sought to investigate the effects of routine use of the Shoulder Screen in a community hospital. This was a retrospective review of all deliveries from January 2012 through December 2012 at a residency-affiliated community hospital. The Shoulder Screen has been routinely performed by nearly half of the providers delivering at this hospital since 2011. Analysis was limited to pregnancies of at least 36 weeks' gestation and eligible for vertex vaginal delivery. Of 1,793 eligible pregnancies, 738 (41%) underwent the screening process. Those screened were younger, be of non-white race, and have a higher BMI. The odds of shoulder dystocia were similar between women in the screened and unscreened groups (2.57% vs 2.56%; odds ratio, 0.96; 95% CI: 0.52-1.77). The rates of cesarean delivery (23.3% vs 24.5%, P = 0.38), operative vaginal delivery (4.3% vs 5.6%, P = 0.23), brachial-plexus injury (0.27% vs 0%, P = 0.09), admission to the neonatal intensive-care unit (8.7% vs 8.8%, P = 0.92), and low five-minute Apgar scores (0.41% vs 0.28%, P = 0.66) were also similar. There were statistically significantly decreased incidences of episiotomy (4.5% vs 8.1%, P = 0.003) and severe perineal laceration (1.1% vs 2.6%, P = 0.026) in the unscreened group as well as an increased risk of neonatal clavicular or humeral fracture (0.41% vs 0%, P = 0.038). Use of the Shoulder Screen, while not affecting the cesarean rate, did not reduce the incidence of shoulder dystocia. The differences in maternal and neonatal outcomes may be attributed to the effect of screening or variations in provider practice.

Outcomes of non-vertex second twins, following vertex vaginal delivery of first twin: a secondary analysis of the WHO Global Survey on maternal and perinatal health.

BackgroundMode of delivery remains a topic of debate in vertex/non-vertex twin pregnancies. We used the WHO Global Survey dataset to determine the risk of adverse maternal/perinatal outcomes associated with presentation of the second twin, following vaginal delivery of a vertex first twin.MethodsWe analysed a derived dataset of twin pregnancies ≥ 32 weeks gestation where the first twin was vertex and delivered vaginally. Maternal, delivery and neonatal characteristics and adverse outcomes were reported by presentation of the second twin. Logistic regression models (adjusted for maternal and perinatal confounders, mode of delivery and region) were developed to determine odds of adverse outcomes associated with presentation.Results1,424 twin pregnancies were included, 25.9% of these had a non-vertex second twin and Caesarean was more common in non-vertex presentations (6.2% vs 0.9%, p < 0.001). While the odds of Apgar < 7 at 5 minutes were higher in non-vertex presenting second twins (16.0% vs 11.4%, AOR 1.42 95% CI 1.01-2.00), the odds of maternal ICU admission (4.6% vs 1.7%, AOR 1.30, 95% CI 0.88-1.94), blood transfusion (6.0% vs 3.4%, AOR 1.23, 95% CI 0.67-2.25), stillbirth (7.6% vs 4.7%, AOR 1.15, 95% CI 0.72-1.73), early neonatal death (3.8% vs 2.1%, AOR 1.68, 95% CI 0.96-2.94), and NICU admission (26.6% vs 23.2%, AOR 0.93, 95% CI 0.62-1.39) were not.ConclusionAfter a vaginal delivery of a vertex first twin, non-vertex presentation of the second twin is associated with increased odds of Apgar <7 at 5 minutes, but not of other maternal/perinatal outcomes. Presentation of the second twin is not as important a consideration in planning twin vaginal birth as previously considered.

1410 The Relationship of Maternal Ethnicity with Incidence of Shoulder Dystocia in Newborns: Study From a London University Hospital

AimsTo evaluate maternal ethnicity as a factor reported to increase the risk of shoulder dystocia, and to evaluate its predictive value at a population level.MethodsWe conducted a retrospective cohort study...

Selective vaginal breech delivery at term – still an option

To compare the neonatal outcome between planned vaginal or planned cesarean section (CS) breech delivery and planned vaginal vertex delivery at term with singleton fetuses. A cohort study. Delivery Unit, Tampere University Hospital, Finland, with 5200 annual deliveries. The term breech deliveries over a period of five years (January 2004 to January 2009), a total of 751 breech deliveries, and 257 vertex controls. The data were collected from the mother's medical records, including a summary of the newborn. In the case of neonatal health problems, the pediatric records were also examined. Maternal and neonatal mortality and morbidity as defined in the Term Breech Trial. Low Apgar scores or umbilical cord pH as secondary end-points. There was no neonatal mortality. Severe morbidity was rare in all groups, with no differences between groups. The Apgar scores at one minute were lower in the planned vaginal delivery group compared with the other groups, but there was no difference at the age of five minutes. Significantly more infants in the vaginal delivery group had a cord pH < 7.05. There was one maternal death due to a complicated CS in the planned CS group and none in the other groups. Mothers in the planned CS group suffered significantly more often from massive bleeding and needed transfusions. Vaginal delivery remains an acceptable option for breech delivery in selected cases.

Twin-to-Twin Delivery Time: Neonatal Outcome of the Second Twin

To examine the effect of twin-to-twin delivery time (TTDT) on neonatal outcome. We evaluated twin deliveries >34 weeks of gestation. Twin pregnancies with both twins delivered by cesarean section and pregnancies with antenatal complications were excluded. We analyzed TTDT and neonatal outcomes of the second twin (umbilical arterial pH value (pH(art)), Apgar scores at 1, 5 and 10 minutes, need for intensive care). The study population was divided into two homogenous groups based on the mode of delivery: (A) vertex presentation and vaginal delivery of both twins, (B) vertex presentation and vaginal or vaginal operative delivery of twin I, breech or transverse presentation and vaginal breech delivery or cesarean section (CS) of twin II. A total of 207 twin pairs were included in our study. In Group A (n = 151) there were no significant correlations between TTDT and pH(art) or Apgar scores at 1,5 and 10 minutes of twin II (p = .156; 0.861; 0.151 and 0.384, respectively). In Group B (n = 56), the mean pH(art) of twin II was inversely correlated to TTDT, but not significantly (p = .417). TTDT was inversely related to 1-min and 5-min Apgar scores, but not significantly (p = .330; p = .138, respectively). The 10-min Apgar score showed no correlation with TTDT (p = .638). Increasing TTDT was not associated with adverse fetal outcome. Expectant management of the second twin appears possible and elapsed time alone does not appear to be an indication for intervention.

Legal Briefs

A 3,545-g, 35–3/7 weeks', large for gestational age (LGA) male is delivered to an insulin-dependent diabetic mother who became pregnant with the help of a fertility specialist. After conception, a general obstetrician managed her pregnancy. The antenatal course was uneventful except for a history of herpes simplex virus (HSV) infection. A cesarean section was planned at 38 weeks' gestation because of a relatively large fetus and a small pelvic outlet. The mother developed premature rupture of membranes (PROM) at 35 weeks' gestation, and 48 hours later, labor began. The obstetrician was out of town, and the mother was triaged to a midwife for the delivery. The mother's last HSV outbreak was 2 weeks before delivery, with lesions healing 4 days before delivery. The mother claimed in her deposition that she told the midwife about her history of herpes. The medical records from the fertility specialist and the obstetrician documented the history of HSV. The medical records reflecting the herpes were computerized and available to the midwife and the nurses who managed labor and delivery. The infant was delivered by a spontaneous vaginal vertex delivery. The Apgar scores were 8 at 1 minute and 9 at 5 minutes. The infant was asymptomatic and observed for 6 hours before rooming-in with his mother. Multiple bedside glucose evaluations were read as normal. A complete blood count (CBC) yielded unremarkable results. A blood culture was reported as negative on the final reading. Vital signs were stable. The infant was sleepy at the breast, but the mother fed him formula. The discharge examination was performed at 41 hours, and the only notable finding besides the LGA and late preterm gestation was that an ophthalmic examination could not be performed because the eyes were closed. The grandmother stated in her deposition that the baby's eyes were …

Stillbirths at the mater Misericordiae hospital, Afikpo, southeast Nigeria – a review.

Background: Stillbirths contribute significantly to fetal loss in poor sub-Saharan African countries. In Nigeria, affected parents often experience long-lasting grief. Objective: To determine the incidence of stillbirths at Afikpo, Southeast Nigeria. Methodology: A three-year retrospective review of all cases of stillbirths delivered at the Mater the Misericordiae Hospital, Afikpo, was conducted. Results: Of 1859 babies, 199 stillbirths were delivered by 190 mothers, giving a stillbirth rate of 107 per 1000 total deliveries. The mean maternal age and parity were 27.6 years and 1.8 respectively. The major complications encountered by mothers in pregnancy were unexplained intrauterine death (31 or 16.3%), malaria and twin pregnancy, and in labour, unexplained intrauterine death (21.5%), obstructed labour, and ruptured uterus. One hundred and thirty-two stillbirths (66.3%) were delivered by spontaneous vaginal (vertex) delivery, 18.7% by caesarean section and 8.9% through laparotomy for ruptured uterus. Thirty (15.8%) of the mothers had severe morbidities and four died, giving a case fatality rate of 2.1%. The mean gestational age of the stillbirths was 37.3 weeks, and birthweight 2.5 kg. Fresh (67.3%) and male stllbirths (52.3%) dominated. The probable cause of stillbirth was documented in 61.3% of cases. Fetal distress (14.6%), obstructed labour and ruptured uterus were the major culprits. No stillborn underwent post-mortem confirmation of cause of death. Conclusion: Stillbirth rates reflect the standard of available obstetric services. Improving obstetric care could reduce it. Proper classification of stillbirths with autopsy confirmation of causes of death, will improve practice. A stillbirth programme incorporating community education will facilitate these. Key words : stillbirths, pregnancy, labour, complications, Afikpo, Nigeria

Mutations in LTBP4 Cause a Syndrome of Impaired Pulmonary, Gastrointestinal, Genitourinary, Musculoskeletal, and Dermal Development

We report recessive mutations in the gene for the latent transforming growth factor-beta binding protein 4 (LTBP4) in four unrelated patients with a human syndrome disrupting pulmonary, gastrointestinal, urinary, musculoskeletal, craniofacial, and dermal development. All patients had severe respiratory distress, with cystic and atelectatic changes in the lungs complicated by tracheomalacia and diaphragmatic hernia. Three of the four patients died of respiratory failure. Cardiovascular lesions were mild, limited to pulmonary artery stenosis and patent foramen ovale. Gastrointestinal malformations included diverticulosis, enlargement, tortuosity, and stenosis at various levels of the intestinal tract. The urinary tract was affected by diverticulosis and hydronephrosis. Joint laxity and low muscle tone contributed to musculoskeletal problems compounded by postnatal growth delay. Craniofacial features included microretrognathia, flat midface, receding forehead, and wide fontanelles. All patients had cutis laxa. Four of the five identified LTBP4 mutations led to premature termination of translation and destabilization of the LTBP4 mRNA. Impaired synthesis and lack of deposition of LTBP4 into the extracellular matrix (ECM) caused increased transforming growth factor-beta (TGF-beta) activity in cultured fibroblasts and defective elastic fiber assembly in all tissues affected by the disease. These molecular defects were associated with blocked alveolarization and airway collapse in the lung. Our results show that coupling of TGF-beta signaling and ECM assembly is essential for proper development and is achieved in multiple human organ systems by multifunctional proteins such as LTBP4.

Trends in major modifiable risk factors for severe perineal trauma, 1996–2006

Objective: To examine what effect the major modifiable risk factors for severe perineal trauma have had on the rates of this trauma over time. Methods: A retrospective observational cohort study of singleton vaginal deliveries taken from a perinatal database for the period 1996 through 2006. Results: A total of 46 239 singleton vertex vaginal deliveries met the inclusion criteria. Major risk factors for severe perineal trauma were increased maternal age (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.1–1.5), non-African American ethnicity (OR 1.5, 95% CI 1.3–1.7), nulliparity (OR 4.8, 95% CI 4.11–5.6), fetal birth weight (OR 2.2, 95% CI 1.9–2.4), forceps (OR 8.3, 95% CI 5.4–10.8), vacuum (OR 2.9, 95% CI 1.9–4.4), and midline episiotomy (OR 5.7, 95% CI 5.0–6.4). Evaluation of the changes in rates of these factors over the study period revealed that the decline in the rates of episiotomy and the use of forceps accounted for a reduction in severe lacerations of more than 50%. Conclusion: Reduction of severe perineal trauma by restricted use of the 2 modifiable clinical variables, episiotomy and forceps, is evident over time.

Impact of parity on obstetric and neonatal outcome of external cephalic version

SummaryThis study sought to investigate the impact of parity on the outcome of external cephalic version (ECV) over a 3-year period. In the study, 163 women with singleton uncomplicated breech pregnancy at term were offered ECV and 103 (63%) underwent the procedure. In 42 women, ECV was successful and 74% had a vaginal vertex delivery; whereas 61 women had a failed ECV and none had a vaginal vertex delivery. The probability of vaginal vertex delivery after ECV increased five-fold in nulliparous women (OR 5.2, 95% CI 1 – 42.8) and four-fold (OR 3.8, 95% CI 1.3 – 11.5) in multiparous women. After successful ECV, 50% of nulliparous women and 88.5% of multiparous women had a vaginal vertex delivery (p = 0.006). Neonatal outcome was favourable in all patients. We conclude that parity has little impact on efficacy of ECV, but significantly influences the overall chance of vaginal vertex delivery in women with an uncomplicated breech presentation at term.

The relationship of fetal position and ethnicity with shoulder dystocia and birth injury

The objective of this study was to examine factors associated with the occurrence of shoulder dystocia and subsequent perinatal outcomes. We conducted a retrospective cohort study of 29,612 consecutive term, singleton, vertex vaginal deliveries. The primary outcome was reported shoulder dystocia. Fetal position, ethnicity, and their interaction terms were examined along with maternal characteristics, induction and length of labor, operative vaginal delivery, epidural, and birth weight in both bivariate and multivariate analyses. Among women who met study criteria, 524 (1.8%) experienced a shoulder dystocia. African American women had the highest risk of shoulder dystocia (2.6%), compared with other races/ethnicities (P = .001). Women who delivered in occiput posterior position were noted to have a lower risk for shoulder dystocia (1.1%) as compared with occiput anterior position (1.8%, P = .046). However, in the setting of a shoulder dystocia, a higher risk of brachial plexus injury was observed in neonates delivered in occiput posterior position (adjusted odds ratio 10.4, 95% confidence interval 3.03 to 35.88) by vacuum-assisted vaginal delivery (adjusted odds ratio 3.24, 95% confidence interval 1.37 to 7.67) and neonates weighing 4000 g or more (adjusted odds ratio 2.53, 95% confidence interval 1.09 to 5.85). Overall African American women have an increased risk of shoulder dystocia, but their neonates are not more likely to experience birth injury. Although occiput posterior position has a protective effect for shoulder dystocia, the risk of brachial plexus injury is increased in the setting of a persistent occiput posterior delivery. These factors should be used to consider a patient's prospective risk for shoulder dystocia and associated outcomes.

A Term Infant Who Has Severe Respiratory Distress

A term infant with severe respiratory failure. ### Prenatal History: ### Birth History and Presentation: The infant was born by vaginal vertex delivery at 38 weeks gestational age. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. He developed respiratory distress shortly after delivery and was placed under an oxygen hood with 35% O2. A chest radiograph revealed ground glass appearance, consistent with respiratory distress syndrome. ### Subsequent Course: The infant was intubated and received three doses of surfactant via endotracheal tube. He was treated for 10 days with both conventional ventilation and high-frequency oscillatory …

Attendance of paediatricians at elective Caesarean sections performed under regional anaesthesia: Is it warranted?

Whether or not a paediatric registrar or consultant paediatrician trained in advanced neonatal resuscitation is needed at elective Caesarean section (CS) deliveries remains controversial. The objective of this study was to provide recent population-based data comparing the need for resuscitation of babies born at >or=37 weeks gestation by elective CS under regional anaesthesia with those born by spontaneous, unassisted vertex vaginal delivery. We performed a population-based cohort study in Tasmania using data collected between January 1998 and December 2003 inclusive. Data on all singleton births>or=37 weeks gestation was analysed from the Tasmanian Obstetric and Neonatal Audit database to determine the number and type of resuscitations, and the number of low 1-min Apgar scores for each mode of delivery. There were 31 820 singleton deliveries born at >or=37 weeks gestation over the 6-year period. Of these 21 733 (68.3%) were spontaneous unassisted vertex vaginal deliveries and 2918 (9.2%) were elective CSs performed under regional anaesthesia (2620 spinal and 298 epidural). The incidence of a 1-min Apgar score of <4 and a 1-min Apgar score of >or=4 and <7 for elective sections under spinal was significantly lower when compared with unassisted, spontaneous, vertex vaginal delivery at 0.57% and 11.8% respectively. The relative risks when compared with unassisted, spontaneous, vertex vaginal delivery were 0.36 (95% confidence interval (CI) 0.21-0.60, P<0.05) and 0.73 (95% CI 0.65-0.81, P<0.05), respectively. There was a small but statistically significant difference between unassisted, spontaneous, vertex vaginal delivery and elective CSs performed under regional anaesthesia in the requirement for resuscitation in the form of bag and mask ventilation. The relative risk for the need for bag and mask ventilation was 1.33 (95% CI 1.11-1.58, P<0.05) for spinal anaesthesia and 1.99 (95% CI 1.33-2.96, P<0.05) for epidural anaesthesia. There was no difference in the need for bag and mask ventilation or low 1-min Apgar scores between non-cephalic and cephalic presentation at elective CS under regional anaesthesia. Elective CSs performed under regional anaesthesia are low-risk deliveries. The slight increased requirement for bag and mask ventilation is not practically significant. Such deliveries do not require the routine attendance of experienced paediatric medical staff.

Incidence and risk factors for severe perineal laceration after vaginal delivery in Japanese patients

The aim of this study was to assess the frequency of severe perineal lacerations defined as either third- or fourth-degree lacerations during normal spontaneous vaginal delivery and to evaluate potential risk factors in Japanese patients. An electronic audit of the perinatal database at the Tama-Nagayama Hospital of Nippon Medical School and Yamaguchi Hospital from 1997 through 2004 was completed. Singleton vaginal vertex deliveries were analyzed for potential risk factors using univariate and multivariate logistic regression analysis. From the database, 7,946 deliveries were identified, with 135 deliveries resulting in severe lacerations (1.7%). In the multivariate logistic regression analysis, severe lacerations were associated significantly with primiparous (odds ratio, 4.36; 95% CI, 2.17-9.57), oxytocin use (odds ratio, 2.19; 95% CI, 1.27-3.73), midline episiotomy (odds ratio, 4.68; 95% CI, 2.09-11.55), forceps-assisted delivery (odds ratio, 7.11; 95% CI, 1.95-20.59), vacuum-assisted delivery (odds ratio, 5.93; 95% CI, 3.38-10.36), and shorter attendant experience (odds ratio, 2.88; 95% CI, 1.12-9.81). The present study demonstrated that operator factors, such as midline episiotomy, oxytocin use, assisted delivery and attendant experience, are independent risk for severe perineal lacerations after vaginal delivery in Japanese patients. The results suggest that midline episiotomy and assisted vaginal delivery, especially forceps-assisted delivery should be avoided in patients who are being delivered of a first child whenever possible.