Adverse neonatal and maternal outcome following vacuum-assisted vaginal delivery: does indication matter?

PURPOSE

To estimate the impact of indication for vacuum-assisted vaginal delivery on neonatal and maternal adverse outcome.

METHODS

Retrospective analysis of women carrying singleton-term pregnancies undergoing vacuum-assisted vaginal delivery in a tertiary hospital (2007-2014). Cohort was stratified by indication: non-reassuring fetal heart rate or prolonged second stage. Primary outcome was adverse neonatal outcome and secondary outcome was maternal morbidity. Logistic regression analysis was utilized to adjust for potential confounders.

RESULT

Overall, 4931 women met inclusion criteria. Delivery indication was prolonged second stage in 3143 (64%) cases and non-reassuring fetal heart rate in 1788 (36%). In the non-reassuring fetal heart rate group, there were higher rates of cephalohematoma, low 5-min Apgar-score, and asphyxia. In the prolonged second-stage group, there were higher rates of sepsis and post-partum hemorrhage. Composite neonatal birth trauma and maternal morbidity were higher for vacuum-assisted vaginal delivery following prolonged second stage. Following adjustment for confounders cephalohematoma (aOR 1.21, 95% CI 1.04-1.41), low 5-min Apgar-score (aOR 2.91, 95% CI 1.26-4.67) and asphyxia (aOR 1.81 95% CI 1.35-2.44) remained significant in the non-reassuring fetal heart rate group and neonatal sepsis remained significant for the prolonged second-stage group (aOR 1.77, 95% CI 1.38-2.27), p < 0.05 for all. However, there was no longer difference in the composite birth trauma, other neonatal or maternal morbidity.

CONCLUSION

The indication for vacuum-assisted vaginal delivery has an impact on neonatal outcome. While cephalohematoma, low 5' Apgar score, and asphyxia were more common in the non-reassuring fetal heart rate group, neonatal sepsis was more common in cases of prolonged second stage of labor.

Nerve surgery in obstetric brachial plexus palsy, report of 68 cases

BACKGROUND

Obstetric brachial plexus palsy aredue to elongation of the brachial plexus during delivery by increasing thedistance between the head and shoulder. The majority of paralysis recoverspontaneously, but in some cases, nerve repair is necessary. The timing of thisnerve surgery and criteria for its indication are topics of discussion in theworld literature.The aim of this study is to askdirections and to evaluate the contribution of nerve surgery in improving theprognosis of this disease.

METHODS

This is a retrospective study thathas interested 68 cases of obstetric brachial plexus palsy who needs a nerverepair, collected over a 8 year-period (2004 - 2011). We analyzed the musclequotes and evaluate the functions of the shoulder, elbow and hand pre and postoperative. A minimum 12 months'follow-up was observed.

RESULTS

Seventy-eight patients werecollected, 33 boys and 35 girls with a 62 days mean age at first consultationand a mean birth weight of 4187 grams . The presentation was cephalic in 66 cases. Theright side was interested in 66%. Clinically, we reported 50% of total brachialplexus palsy and 50% of C5-C6 palsy.The mean age at time of surgery was 9 months 10 days. Preoperatively, the shoulder was listed 0 or 1 according to Gilbert classification in 70% of cases in the C5-C6 plasy and 90% of the total brachial palsy. After a mean follow up of 30 months, the rate was respectively 9% and 15%. In 75% of cases of total brachial palsy, the hand was listed 0 according to Raimondi scale, while in postoperative, 65% of cases, the hand was listed 2 and 3 according to Raimondi scale. Nerve rupture was the predominant lesion on the C5 and C6 root while fibrosis was predominant on C7, C8 and T1 roots. We noted 6 complications including respiratory distress.

CONCLUSIONS

The nerve repair should not beperformed too early or too late. Too soon, we may operate those who can have aspontaneous recovery. Too late, the installation of the degeneration of motorendplates and muscle atrophy render unnecessary nerve repair. The absence ofbiceps clinical recovery in the 6th month of life and the presence of root-wrenching signs represented the absolute surgical indications. Its results areencouraging and improve functional outcome.

Decreased rates of shoulder dystocia and brachial plexus injury via an evidence-based practice bundle

OBJECTIVE

To evaluate whether a standardized approach to identify pregnant women at risk for shoulder dystocia (SD) is associated with reduced incidence of SD and brachial plexus injury (BPI).

METHODS

Between 2011 and 2015, prospective data were collected from 29 community-based hospitals in the USA during implementation of an evidence-based practice bundle, including an admission risk assessment, required "timeout" before operative vaginal delivery (OVD), and low-fidelity SD drills. All women with singleton vertex pregnancies admitted for vaginal delivery were included. Rates of SD, BPI, OVD, and cesarean delivery were compared between a baseline period (January 2011-September 2013) and an intervention period (October 2013-June 2015), during which there was a system-wide average bundle compliance of 90%.

RESULTS

There was a significant reduction in the incidence of SD (17.6%; P=0.028), BPI (28.6%; P=0.018), and OVD (18.0%; P<0.001) after implementation of the evidence-based practice bundle. There was a nonsignificant reduction in primary (P=0.823) and total (P=0.396) cesarean rates, but no association between SD drills and incidence of BPI.

CONCLUSION

Implementation of a standard evidence-based practice bundle was found to be associated with a significant reduction in the incidence of SD and BPI. Utilization of low-fidelity drills was not associated with a reduction in BPI.

LABOR, DELIVERY AND POSTPARTUM COMPLICATIONS IN NULLIPAROUS WOMEN WITH FEMALE GENITAL MUTILATION ADMITTED TO KARAMARA HOSPITAL

OBJECTIVES

To assess labor, delivery and postpartum complications in nulliparous women with FGM/C and evaluate the attitude of mothers towards elimination of FGM.

METHODS

A prospective hospital based study using structured questionnaire was conducted between January to March 2015 at Karamara hospital, Jijiga, Ethiopia. All nulliparous women admitted for labor and delivery were included. Data were collected regarding circumcision status, events of labor, delivery; postpartum and neonatal outcomes as well as attitude of mothers towards elimination of FGM/C.

RESULTS

Two hundred sixty four (92.0%) of the women had FGM/C with most (93.0%) undergoing Type III FGM. The mean age of the women was 22 yr. Failure to progress in 1st stage and prolonged 2nd stage of labor occurred in 165 (57.0%) and189 (65.6%) of the cases respectively. Caesarean section was performed in 17.0% and instrumental delivery in 23.0%. 64.5% required episiotomies, 83.3% had an anterior episiotomy, 29 % had perineal tears, 25.7%% experienced post-partum hemorrhage and 24% postpartum infection. Among the newborns, there were 6.4% perinatal deaths; 18.8 % low birth weight and 1.5% birth injuries. Almost all complications were more frequently seen in circumcised compared to non-circumcised women.

CONCLUSIONS

The prevalence of FGM is high and it substantially increases the risk of many maternal complications. Health professionals should be aware of these complications and support/care of women with FGM should be integrated at all levels of reproductive health care provision. Capacity building of responsible health professional should be initiated in the area with intensification of FGM eradication activities.

Neonatal outcomes of macrosomic infants of diabetic and non-diabetic mothers

OBJECTIVE

To compare neonatal outcomes (including breastfeeding (BF) initiation) of 170 macrosomic IDM with that of 739 macrosomic nIDM.

DESIGN/METHODS

Retrospective cohort investigation of all macrosomic infants born consecutively over a four-year period (2008-2011). Macrosomic (birth weight ≥4000 g) IDM included 100 infants whose mothers had gestational diabetes and 70 whose mothers had pregestational diabetes.

RESULTS

IDM were more likely to be delivered by cesarean to obese women while nIDM were more likely to be delivered vaginally to younger women with a higher level of education. Ethnic distribution (60% white, 20% black, 10% Hispanic and 10% Asian or African) was similar in each group. Forty-nine percent of IDM and 7% of nIDM required NICU admission. Respiratory disorders (mainly TTNB) affected 21% of IDM and 3% of nIDM while hypoglycemia was observed in 36% of IDM and 15% of nIDM. Of the 35 IDM delivered vaginally, 10 were complicated by shoulder dystocia without injury. Conversely, 70 of the 458 nIDM delivered vaginally experienced shoulder dystocia that resulted in 6 limb fractures and 3 brachial plexus injuries. On arrival to labor and delivery, 75% of all women intended to BF; however, at the time of discharge, 65% of women with diabetes and 92% of those without diabetes who intended to BF had initiated BF.

CONCLUSIONS

Both macrosomic IDM and macrosomic nIDM are at risk for significant morbidities. Macrosomic IDM carry a higher risk for NICU admissions, leading to maternal-infant separation, and lower BF initiation rates.

Pregnancy Outcomes in Women with 1-Hour Glucose Challenge Test ≥ 200 mg/dL

OBJECTIVE

Many protocols diagnose gestational diabetes mellitus (GDM) solely on a 1-hour glucose challenge test (GCT) ≥ 200 mg/dL. However, pregnancy outcomes in these women compared with women diagnosed with a 3-hour glucose tolerance test (GTT) has not been adequately evaluated. We hypothesize that a 1-hour GCT ≥ 200 mg/dL is associated with worse pregnancy outcomes as compared with a GCT 135 to 199 mg/dL with positive GTT.

STUDY DESIGN

A retrospective cohort of singleton pregnancies complicated by GDM. Maternal outcomes included A2DM, preeclampsia, primary cesarean, and failed trial of labor after cesarean. Perinatal outcomes were large/small for gestational age, shoulder dystocia, and birth injury. Groups were compared with t-test and chi-square test, and logistic regression to adjust for confounders.

RESULTS

A total of 602 women diagnosed with GDM by 1-hour GCT 135 to 199 mg/dL and confirmatory 3-hour GTT (< 200 group) and 225 women diagnosed with 1-hour GCT ≥ 200 alone (≥ 200) were included. The ≥ 200 group had a higher incidence of preeclampsia (16.4 vs. 10.6%) and shoulder dystocia (3.1 vs. 1.0%). Adjusted odds ratio and 95% confidence interval were 1.80 (1.10-2.94) and 5.10 (1.25-20.76), respectively.

CONCLUSION

Preeclampsia and shoulder dystocia are more frequent in women with GCT ≥ 200 mg/dL than those with a positive GTT following a GCT of 135 to 199 mg/dL.

Influence of ultrasound determination of fetal head position on mode of delivery: a pragmatic randomized trial

OBJECTIVE

To evaluate the influence of ultrasound determination of fetal head position on mode of delivery.

METHODS

This was a pragmatic open-label randomized controlled trial that included women with a singleton pregnancy in the vertex presentation at ≥ 37 weeks' gestation, cervical dilation ≥ 8 cm and who received epidural anesthesia. Women were assigned randomly to undergo either digital vaginal examination (VE group) or both digital vaginal and ultrasound examinations (VE+US group) to determine fetal head position. When the ultrasound and digital vaginal findings were inconsistent in the VE+US group, the ultrasound result was used for clinical management. The primary outcome assessed was operative delivery (Cesarean or instrumental vaginal delivery), and maternal and fetal morbidity were also assessed.

RESULTS

The VE and VE+US groups included 959 and 944 women, respectively. The overall rate of operative delivery was significantly higher in the VE+US group than in the VE group: 33.7% vs 27.1%, respectively (relative risk (RR), 1.24 (95% CI, 1.08-1.43)), as was the rate of Cesarean delivery: 7.8% vs 4.9%, respectively (RR, 1.60 (95% CI, 1.12-2.28)). The rate of instrumental vaginal delivery was also higher, albeit not significantly: 25.8% in the VE+US group vs 22.2% in the VE group (RR, 1.16 (95% CI, 0.99-1.37)). Neonatal outcomes did not differ between the two groups. When analysis was restricted to instrumental vaginal deliveries only, maternal and neonatal morbidity outcomes were similar in both groups.

CONCLUSION

Correction of fetal occiput position, determined initially by digital vaginal examination, using systematic ultrasound examination did not improve management of labor and increased the rate of operative delivery without decreasing maternal and neonatal morbidity.

[Neonatal complications related to shoulder dystocia]

OBJECTIVE

To describe neonatal complications related to shoulder dystocia.

METHODS

This systematic evidence review is based on PubMed search, Cochrane library and experts' recommendations.

RESULTS

The risks of brachial plexus birth injury, clavicle and humeral fracture, perinatal asphyxia, hypoxic-ischemic encephalopathy and perinatal mortality are increased after shoulder dystocia. The medical team should be able to provide neonatal resuscitation in the delivery room in case of perinatal asphyxia following shoulder dystocia, according to national and international guidelines. The initial clinical examination should search for complications such as brachial plexus birth injury or clavicle fracture.

CONCLUSION

The risk of perinatal complications is increased in newborn after shoulder dystocia. The medical team should be able to manage these complications.

Extra-Pituitary Birth Defects May Predict Diagnosis of Congenital Hypopituitarism in a Short Child

BACKGROUND

Extra-pituitary birth defect (EPBD) in children with congenital hypopituitarism is largely unknown.

OBJECTIVE

The study aims to evaluate the incidence and pattern of EPBD in children with congenital hypopituitarism and to evaluate whether it can serve as a clue to diagnose this condition.

PATIENTS AND METHODS

Retrospective analysis of hospital record of patients of short stature due to various etiology from which patients with congenital hypopituitarism with age ≥18 years were recruited for the analysis. Clinical, hormonal, radiological and ocular electrophysiological studies were done in all patients and all EPBD were noted.

RESULTS

Twenty seven patients (79%) had multiple pituitary hormone deficiency (MPHD) of which growth hormone was universal followed by gonadotropin (62%), TSH (59%), ACTH (44%) and prolactin (12%). Nineteen patients (56%) had multiple EPBD in various combinations. Twenty three ocular abnormalities were present in 12 patients (35%). Nine patients (26%) had other associated EPBD along with ocular abnormalities while 3 had ocular abnormalities without any other associated birth defect. Skeletal defects were present in 10 patients (29.5%). On the contrary, 5 patients in the EPBD group had total 15 visual defects. The most common abnormality of the visual system were abnormal visual evoke response (VER, 18%), followed by strabismus (15%), visual acuity (VA, 12%), electroretinogram (ERG) and electrooculogram (EOG) 8% each and visual field defect 6%. There was a trend towards early age at presentation with EPBD.

CONCLUSIONS

Presence of EPBD in a short child is a sensitive marker to diagnose congenital hypopituitarism. Subtle abnormalities of visual pathway without absent septum pellucidum or midline brain defects were common.

Frequency, causes and outcome of neonates with respiratory distress admitted to Neonatal Intensive Care Unit, National Institute of Child Health, Karachi

OBJECTIVE

To determine the frequency, aetiology and outcome of respiratory distress in neonates in intensive care unit.

METHODS

The descriptive cross-sectional study was conducted at the Neonatal Intensive Care Unit, National Institute of Child Health, Karachi, from October 2009 to March 2010. It comprised neonates aged day 0 to 28 who were admitted to Neonatal Intensive Care Unit. The neonates were screened first for respiratory distress and presence of one or more signs and symptoms. History, examination and investigations were carried out to find out various aetiologies of respiratory distress. Outcome was measured in terms of discharge and death. Data was analysed using SPSS12.

RESULTS

Of the 205 neonates in the study, 120(58.6%) were boys and 85(41.4%) were girls The overall mean age was 70.58±110.02 hours and the mean gestational age was 36.32±2.72 weeks while the mean weight was 2.41±2.4kg. Respiratory rate >60/min was found in all (100%) the neonates. In terms of signs and symptoms, 125(60.9%) had grunting, 205(100%) had subcostal retractions and nasal flaring, and 81(40%) had cyanosis. The aetiologies observed were birth asphyxia, sepsis, transient tachypnoea of the newborn, pneumonia, meconium aspiration syndrome and respiratory distress syndrome in 22(10.75%), 37(18.05%), 29(14.1%), 36(17.6%), 34(16.7%) and 47(23.0%) neonates respectively. The incidence of neonates with respiratory distress was 68(33.3%).

CONCLUSIONS

The frequency of respiratory distress among the neonates was high, while mortality was high in neonates with respiratory distress, especially in pre-term and low birthweight neonates. Early diagnosis and management is important for better outcome.

Cortical morphology and early adverse birth events in men with first-episode psychosis

BACKGROUND

Reduced cortical gray-matter volume is commonly observed in patients with psychosis. Cortical volume is a composite measure that includes surface area, thickness and gyrification. These three indices show distinct maturational patterns and may be differentially affected by early adverse events. The study goal was to determine the impact of two distinct obstetrical complications (OCs) on cortical morphology.

METHOD

A detailed birth history and MRI scans were obtained for 36 patients with first-episode psychosis and 16 healthy volunteers.

RESULTS

Perinatal hypoxia and slow fetal growth were associated with cortical volume (Cohen's d = 0.76 and d = 0.89, respectively) in patients. However, the pattern of associations differed across the three components of cortical volume. Both hypoxia and fetal growth were associated with cortical surface area (d = 0.88 and d = 0.72, respectively), neither of these two OCs was related to cortical thickness, and hypoxia but not fetal growth was associated with gyrification (d = 0.85). No significant associations were found within the control sample.

CONCLUSIONS

Cortical dysmorphology was associated with OCs. The use of a global measure of cortical morphology or a global measure of OCs obscured important relationships between these measures. Gyrification is complete before 2 years and its strong relationship with hypoxia suggests an early disruption to brain development. Cortical thickness matures later and, consistent with previous research, we found no association between thickness and OCs. Finally, cortical surface area is largely complete by puberty and the present results suggest that events during childhood do not fully compensate for the effects of early disruptive events.

Fetal Macrosomia at a Tertiary Care Centre in Lagos, Nigeria

BACKGROUND

Large babies have attracted immense attention as they present obstetric problems with associated increase in perinatal morbidity and mortality. The major risk of fetal macrosomia is trauma to the fetus and mother during vaginal delivery.

OBJECTIVE

To compare the outcome of macrosomic babies with babies of normal birth weights.

METHODS

This was a retrospective comparative study of deliveries over a period of two years from 1 "August 2005 to 31st July 2007.

RESULTS

There were 198 macrosomic babies (6.9%) out of a total of 2,879 deliveries that occurred within the study period. Majority of the mothers were multiparous; para 2 to 4 (47.5% in the study group and 33.7% in the control group). Emergency Caesarean Section (EMCS) rate in the study group was 44.4% while it was 25.3% in the control group and this was statistically significant (p value <0.001). In this study the maternal injuries in the study group were not significantly higher than the control group. The fetal morbidity and mortality in the study group was significantly higher than the control group both with p values <0.001.

CONCLUSION

Fetal macrosomia is associated with high morbidity and mortality in this centre, there is a need to identify pregnant women at risk as well as adequate counseling of possible interventions and outcomes.

[Multicenter analysis of risk factors and clinical characteristics of shoulder dystocia]

OBJECTIVE

To explore the risk factors and clinical characteristics of shoulder dystocia.

METHODS

The data of 44 580 single pregnancy and full-term head delivery were colleceted in the Third Affiliated Hospital of Guangzhou Medical University, Nanfang Hospital, Shenzhen Nanshan Hospital, Peking University Shenzhen Hospital and Yue Bei People's Hospital from January 2008 to September 2013. Totally 116 cases of shoulder dystocia were defined as the shoulder dystocia group, and the others were in the control group. The clinical data of the two groups were analyzed retrospectively, including the maternal age, maternal height, pre-gestational body mass index, weight gain during pregnancy, gestational weeks, gravidity, parity, fundal height, fetal abdominal perimeter, shoulder dystocia medical history, macrosomia, gestational diabetes mellitus, pre-gestational diabetes mellitus, post-term pregnancy and the condition of labor stages.

RESULTS

(1) The incidence of shoulder dystocia was 0.260% (116/44 580). The maternal age, pre-gestational body mass index and weight gain during pregnancy in the shoulder dystocia group were higher than those in the control group (all P < 0.01). While the maternal height, gestational weeks, gravidity, parity, fundal height, abdominal circumference in the two groups had no significant difference (all P > 0.05). (2) In the shoulder dystocia group, the incidence of shoulder dystocia medical history (11.21%, 13/116), macrosomia (13.79% , 16/116), pre-gestational diabetes mellitus (7.76% , 9/116), post-term pregnancy (10.34%, 12/116), prolongation of maximum acceleration phase (8.62%, 10/116) and prolongation of second labor stage (7.76%, 9/116) were different from those in the control group[1.43% ( 636/44 464), 1.48% (658/ 44 464), 0.57% ( 252/44 464), 1.15% (513/44 464),0.72% (322/44 464), 0.65% (289/44 464), respectively; all P < 0.05]. (3) Logistic regression analysis showed that the risk factors of shoulder dystocia were maternal age over thirty-five years (OR = 1.116, 95%CI: 1.022-2.445), pre-gestational body mass index more than 27 kg/m(2) (OR = 1.893, 95% CI: 1.358-2.228), weight gain more than 20 kg during pregnancy (OR = 2.031, 95% CI: 1.749-3.231), shoulder dystocia medical history (OR = 2.138, 95%CI:1.564-3.853), macrosomia (OR = 3.276, 95% CI:2.315- 4.638), pre-gestational diabetes mellitus (OR = 3.261, 95% CI:2.237- 4.943), post-term pregnancy (OR = 1.473, 95% CI:1.003-2.721), prolongation of the maximum acceleration phase (OR = 2.022, 95% CI:1.681- 3.732), prolongation of second labor stage(OR = 1.943, 95% CI:1.285- 3.215).

CONCLUSION

Maternal age over thirty-five years old, pre-gestational body mass index more than 27 kg/m(2), weight gain more than 20 kg during pregnancy, shoulder dystocia medical history, macrosomia, pre-gestational diabetes mellitus, post-term pregnancy, prolongation of the maximum acceleration phase, and prolongation of second labor stage are risk factors and clinical characteristics of shoulder dystocia.

[Risk factors and clinical prediction of shoulder dystocia in non-macrosomia]

OBJECTIVE

To investigate the risk factors, clinical prediction and intrapartum management of shoulder dystocia in non-macrosomia.

METHODS

Totally 7 811 cases of vaginal delivery were retrospectively reviewed from Juanary 2009 to December 2013 in Shengjing Hospital. Shoulder dystocia was found in 11 cases (0.14% , 11/7 811), including 1 case of macrosomia and 10 cases of non-macrosomia (shoulder dystocia group). Each non-macrosomia shoulder dystocia case was matched with 10 cases of normal delivery in the same week, which were selected randomly as the control group. The tendency and risk factors of shoulder dystocia in macrosomia and non-macrosomia were analyzed, and the following data between the two groups were compared, including the height of uterus fundus, abdominal circumference of the pregnant woman, the increasing of body mass index (BMI), fetal biparietal diameter (BPD), fetal femur length (FL), duration of every stage of labor, birth weight of the newborn, head circumference and chest circumference of the newborn, Apgar score.

RESULTS

(1) There were 213 macrosomias among the 7 811 vaginal deliveries, with the incidence of 2.73% (213/7 811). Only 1 shoulder dystocia was macrosomia (0.46%, 1/213); while the other 10 cases were non-macrosomia ( 0.13%, 10/7 598). (2) From 2009 to 2013, the macrosomia happened by 24 cases (2.32%, 24/1 034), 42 cases (3.61%, 42/1 164), 46 cases (2.60%, 46/1 772), 62 cases (3.01%, 62/2 060), 39 cases (2.19%, 39/1781), respectively. The incidence of macrosomia had no significant difference among these 5 years (P > 0.05). The shoulder dystosia occurrence without macrosia in these 5 years were 1 case ( 0.10% , 1/1 034), 3 cases (0.26%, 3/1 164), 2 cases ( 0.11%, 2/1 172), 2 cases (0.10%, 2/2 060), 2 cases ( 0.11%, 1/1 781), respectively. The incidence of shoulder dystocia without macrosomia had no significant difference among these 5 years (P > 0.05). (3) In the should dystocia group, 5 cases were complicated with premature rupture of membrane (5/10), 4 cases were mother≥ 35 years old (4/10), 3 cases were multipara(3/10), 3 cases had gestational diabetes mellitus(3/10), 3 cases were occiput posterior during the first stage of labor (3/10), 3 cases had prolonged second stage of labor (3/10) and 6 cases had routine lateral incision (6/10). In the control group, 3 cases were complicated with premature rupture of membrane(3/10); 1 case was mother≥35 years old (1/10); 2 cases were multipara(2/10), 3 cases had gestational diabetes mellitus (3/10), 1 case had prolonged second stage (1/10) and 7 cases had routine lateral incision (7/10). (4) There were no significant difference in the height of uterus fundus, BMI, BPD, FL, and duration of the first stage of labor between the shoulder dystocia group and the control group (P > 0.05). Compared with the control group, the increasing of BMI [(6.8±3.1) vs (4.8±1.4) kg/m(2)], the time of the second stage of labor[(86±65) vs (38±28) minutes ] and abdominal circumference[(108±8) vs (101±7) cm] were significantly higher in the shoulder dystosia group (P < 0.05). (5) There were significant difference in the chest circumference of the newborn [(34.0±1.6) vs (32.2±1.9) cm ] and the ratio of chest circumference to head circumference of the newborn [(0.99±0.03) vs (0.97±0.03) ] between the two groups (P < 0.05). The 1-minute Apgar score of the newborn (7.4±2.8) was significantly lower than the control group (10.0±0.0) (P < 0.01). Clavicular fracture occurred in 3 newborns and brachial plexus injury occurred in 4 newborns in the shoulder dystosia group.

CONCLUSION

It is difficult to predict shoulder dystocia in non-macrosomia. Shoulder dystocia of non-macrosomia could be predicted by measurement of the head circumference, chest circumference, the ratio of chest circumference to head circumference by using prenatal ultrasound. The risk factors may complicated with premature rupture of membrane, abnormal occiput position during the first stage of labor and prolonged second stage of labor.

A prospective cohort study of the morbidity associated with operative vaginal deliveries performed by day and at night

OBJECTIVE

To evaluate maternal and neonatal outcomes associated with operative vaginal deliveries (OVDs) performed by day and at night.

DESIGN

Prospective cohort study.

SETTING

Urban maternity unit in Ireland with off-site consultant staff at night.

POPULATION

All nulliparous women requiring an OVD with a term singleton fetus in a cephalic presentation from February to November 2013.

METHODS

Delivery outcomes were compared for women who delivered by day (08:00-19:59) or at night (20:00-07:59).

MAIN OUTCOME MEASURES

The main outcomes included postpartum haemorrhage (PPH), anal sphincter tear and neonatal unit admission. Procedural factors included operator grade, sequential use of instruments and caesarean section.

RESULTS

Of the 597 women who required an OVD, 296 (50%) delivered at night. Choice of instrument, place of delivery, sequential use of instruments and caesarean section did not differ significantly in relation to time of birth. Mid-grade operators performed less OVDs by day than at night, OR 0.60 (95% CI 0.43 to 0.83), and a consultant supervisor was more frequently present by day, OR 2.26 (95% CI 1.05 to 4.83). Shoulder dystocia occurred more commonly by day, OR 2.57 (95% CI 1.05 to 6.28). The incidence of PPH, anal sphincter tears, neonatal unit admission, fetal acidosis and neonatal trauma was similar by day and at night. The mean decision to delivery intervals were 12.0 and 12.6 min, respectively.

CONCLUSIONS

There was no evidence of an association between time of OVD and adverse perinatal outcomes despite off-site consultant obstetric support at night.

Preterm birth by vacuum extraction and neonatal outcome: a population-based cohort study

BACKGROUND

Very few studies have investigated the neonatal outcomes after vacuum extraction delivery (VE) in the preterm period and the results of these studies are inconclusive. The objective of this study was to describe the use of VE for preterm delivery in Sweden and to compare rates of neonatal complications after preterm delivery by VE to those found after cesarean section during labor (CS) or unassisted vaginal delivery (VD).

METHODS

Data was obtained from Swedish national registers. In a population-based cohort from 1999 to 2010, all live-born, singleton preterm infants in a non-breech presentation at birth, born after onset of labor (either spontaneously, by induction, or by rupture of membranes) by VD, CS, or VE were included, leaving a study population of 40,764 infants. Logistic regression analyses were used to calculate adjusted odds ratios (AOR), using unassisted vaginal delivery as reference group.

RESULTS

VE was used in 5.7% of the preterm deliveries, with lower rates in earlier gestations. Overall, intracranial hemorrhage (ICH) occurred in 1.51%, extracranial hemorrhage (ECH) in 0.64%, and brachial plexus injury in 0.13% of infants. Infants delivered by VE had higher risks for ICH (AOR = 1.84 (95% CI: 1.09-3.12)), ECH (AOR = 4.48 (95% CI: 2.84-7.07)) and brachial plexus injury (AOR = 6.21 (95% CI: 2.22-17.4)), while infants delivered by CS during labor had no increased risk for these complications, as compared to VD.

CONCLUSION

While rates of neonatal complications after VE are generally low, higher odds ratios for intra- and extracranial hemorrhages and brachial plexus injuries after VE, compared with other modes of delivery, support a continued cautious use of VE for preterm delivery.

Vacuum assisted birth and risk for cerebral complications in term newborn infants: a population-based cohort study

BACKGROUND

Few studies have focused on cerebral complications among newborn infants delivered by vacuum extraction (VE). The aim of this study was to determine the risk for intracranial haemorrhage and/or cerebral dysfunction in newborn infants delivered by VE and to compare this risk with that after cesarean section in labour (CS) and spontaneous vaginal delivery, respectively.

METHODS

Data was obtained from Swedish national registers. In a population-based cohort from 1999 to 2010 including all singleton newborn infants delivered at term after onset of labour by VE (n = 87,150), CS (75,216) or spontaneous vaginal delivery (n = 851,347), we compared the odds for neonatal intracranial haemorrhage, traumatic or non-traumatic, convulsions or encephalopathy. Logistic regressions were used to calculate adjusted (for major risk factors and indication) odds ratios (AOR), using spontaneous vaginal delivery as reference group.

RESULTS

The rates of traumatic and non-traumatic intracranial hemorrhages were 0.8/10,000 and 3.8/1,000. VE deliveries provided 58% and 31.5% of the traumatic and non-traumatic cases, giving a ten-fold risk [AOR 10.05 (4.67-21.65)] and double risk [AOR 2.23 (1.57-3.16)], respectively. High birth weight and short mother were associated with the highest risks. Infants delivered by CS had no increased risk for intracranial hemorrhages. The risks for convulsions or encephalopathy were similar among infants delivered by VE and CS, exceeding the OR after non-assisted spontaneous vaginal delivery by two-to-three times.

CONCLUSION

Vacuum assisted delivery is associated with increased risk for neonatal intracranial hemorrhages. Although causality could not be established in this observational study, it is important to be aware of the increased risk of intracranial hemorrhages in VE deliveries, particularly in short women and large infants. The results warrant further studies in decision making and conduct of assisted vaginal delivery.

Neonatal head injury unrelated to birth trauma in South-East Nigeria

BACKGROUND

Neonatal head trauma resulting from causes other than birth trauma has rarely been the focus of many a research theme in the literature.

AIM/OBJECTIVE

To highlight the occurrence of non-birth trauma related neonatal head injury, and evaluate the causes and outcome of treatment.

METHODS

A 3 year retrospective review of neonatal patients with head injury from two tertiary hospitals in South-East Nigeria between July 2009 and June 2012 (n-37). Data was collected from patients' birth and medical records. Data was analyzed using the SPSS version 15.

RESULT

Among the one hundred and seventy-six cases (11.78)% pediatric head injury cases seen, thirty seven (2.48)% occurred in neonatal patients. The most common cause of head injury was fall 22 cases [59.5%]. Children of mothers with low educational qualification were more likely to sustain falls 22 cases (59.5%). Road traffic accident (n = 15) was associated with more severe injuries and poorer outcome. Operative treatment was associated with increased mortality (two of three cases). The mortality rate in our series is 8.10%.

CONCLUSION

Reduction of neonatal head trauma could be achieved through improved maternal education.

Increasing rates of operative vaginal delivery across two decades: accompanying outcomes and instrument preferences

OBJECTIVE

To examine rates and outcomes of operative vaginal delivery over a 20-year study period and the changing preference for various instruments during this period.

STUDY DESIGN

This retrospective analysis of prospectively gathered data was carried out at a large tertiary referral center from 1991 to 2010. All cases of operative vaginal delivery during the study period were recorded. The rates of instrumental delivery, as well as neonatal outcomes and instrument preference, were compared for individual 5-year epochs.

RESULTS

During the study period there were 156,130 deliveries of which 17,841 were operative vaginal deliveries, an incidence of 11.4/100 deliveries and 13.6/100 vaginal deliveries. There was an increase in the rate of operative vaginal delivery across the 20-year period (P < 0.0001; R(2) = 0.85; Slope = 0.42). When individual 5-year epochs were compared, the incidence of instrumental delivery increased from 7.3% (2340/31,937) in the first five years, 1991-1995, to 13.7% (6179/45,177) in the final five years, 2006-2010 (P < 0.0001; OR 2.34, 95% CI = 2.23-2.47). The perinatal mortality rate in cases of instrumental delivery was decreased when these time periods were compared (7.3/1000 (17/2340) vs. 1.8/1000 (11/6179); P = 0.003, OR 0.24, 95% CI = 0.11-0.52). The choice of instrument also varied, with 68.2% (1596/2340) of instrumental deliveries in 1991-1995 being carried out with forceps compared to 32.9% (2033/6179) in 2006-2010 (P < 0.001).

CONCLUSION

Rates of operative vaginal delivery have increased over the 20-year study period. The rate of perinatal mortality in infants who had an assisted vaginal delivery was decreased in the 5-year epoch at the end of the study compared with the period at the beginning. The rate of forceps delivery has fallen significantly, with vacuum delivery now being the choice of the majority of clinicians.

[Risk factors of birth obstetric trauma]

BACKGROUND

The proper prenatal care for pregnant women is crucial to quickly identify risk factors for birth trauma.

OBJECTIVE

To identify risk factors for neonatal birth trauma.

PATIENTS AND METHOD

Case-control study that included a patient in the case group for every two controls. The following risk factors were identified: cephalopelvic disproportion, macrosomia, use of forceps, precipitated or prolonged labor, malpresentation, and the most common types of birth trauma. We used descriptive statistics and odds ratios.

RESULTS

Statistically significant risk factors for birth trauma were: maternal age < or = 20 years (OR = 16) and > or = 30 years (OR = 2.5), first pregnancy (OR = 4.0), cephalopelvic disproportion (OR = 8.3), forceps delivery (OR = 9.4), birth weight greater than 3,800 g (OR = 6.6), and non-cephalic presentation (OR = 8.3). Found birth trauma types were: ecchymosis (40.4%), caput succedaneum (25%), erosion (15.4%), clavicle fracture (5.9%), brachial plexus paralysis (4.7%), inter alia. The perinatal outcome of 79 infants with birth trauma were compared to 158 healthy newborns.

CONCLUSION

Risk factors associated with birth injuries were: Maternal (age, pregnancy), newborn (weight), and birth care (presentation, instrumentation and pelvic sufficiency).

Emergency caesarean delivery in prolonged obstructed labour as risk factor for obstetric fractures--a case series

Birth fractures predominantly affect the clavicle, humerus or femur. Brachial plexus injury may co-exist with humeral or clavicular fractures. From January 2002 to December 2010, 8 neonates with fractures after caesarean section were treated under the supervision of the first author following obstructed labour and caesarean delivery. The most classical of the cases is a vertex-presenting neonate who was delivered by caesarean section for obstructed labour in a primipara in whom ipsilateral klumpke's palsy and fractures of the clavicle and humerus were confirmed. Literature review did not consider emergency caesarean delivery as one of the predisposing factors for such birth injuries. This case series, in addition to presenting emergency caesarean section as a predisposing factor for birth injuries, offers to suggest a manoeuvre that may reduce severity and rate of birth injuries in caesarean section for obstructed labour in our environment where obstructed labour is still rife.

Maternal obesity and pregnancy outcome: a prospective analysis

OBJECTIVE

To analyze whether the obese women have an increased risk of pregnancy complications and adverse fetal outcome.

METHODS

The longitudinal prospective study was carried out in the Obst and Gynae department, IPGME and R, Kolkata. The study enrolled 422 pre-pregnant obese women with pregnancy as study population and equal number of non obese pregnant mothers as controls. Body mass index (BMI) was > or = 30.0 kg/m2 and 20-22 kg/m2 in obese and control group respectively.

RESULTS

In comparison to average weight pregnant women, obese pregnant women were at increased risk of gestational diabetes mellitus (19.43 vs 3.79%; p < 0.001), pregnancy induced hypertension (12.32 vs 2.36%; p < 0.001), pre-eclampsia (8.76 vs 3.31%; p < 0.001), preterm labor in less than 34 week gestation (7.58 vs 3.55%; p < 0.001), cesarean section (36.72 vs 17.53%; p < 0.001), instrumental deliveries (12.32 vs 5.21%; p < 0.001) and postpartum infection morbidities (9.95 vs 3.79%; p < 0.001). These women were more prone to develop overt diabetes (2.36% vs 0) and chronic hypertension (5.21 vs .47% ) in future as well. Neonates of obese women were mostly large for gestational age, macrosomic and they had high incidences of birth injuries, shoulder dystocia, premature deliveries, late fetal deaths and congenital malformations particularly spina bifida, cleft lip, cleft palate and heart defect.

CONCLUSION

As obesity is considered to be a modifiable risk factor, preconception counseling and creating awareness regarding health risks associated with over weight and obesity should be encouraged.

Neonatal brachial plexus injury: comparison of incidence and antecedents between 2 decades

OBJECTIVE

We sought to compare the incidence and antecedents of neonatal brachial plexus injury (BPI) in 2 different 5-year epochs a decade apart following the introduction of specific staff training in the management of shoulder dystocia.

STUDY DESIGN

All infants with BPI were prospectively identified during 2004 through 2008. Injuries were correlated with maternal details and intrapartum events and compared with the earlier series.

RESULTS

Of 41,828 deliveries during 2004 through 2008, 72 infants with BPI were identified (1.7/1000), compared to 54 cases (1.5/1000) from 1994 through 1998 (P = .4); 9 injuries (12.5%) were persistent from 2004 through 2008, compared with 10 (18.5%) earlier (P = .4). There were no significant differences between the 2 time periods with respect to maternal parity, obesity, or prolonged pregnancy, although the cesarean section rate had increased from 10.7 to 18.4%.

CONCLUSION

Despite training in the management of shoulder dystocia and a rising institutional cesarean section rate, the incidence of BPI has remained unchanged compared with 10 years earlier.