Safe prevention of the primary cesarean delivery

Outcomes in low-risk patients before and after an institutional policy offering 39-week elective induction of labor

OBJECTIVE

Elective induction of labor versus expectant management at 39 weeks gestation in low-risk nulliparous patients was shown in the ARRIVE randomized trial of over 6000 patients to decrease risks of cesarean delivery without significant change in the composite perinatal outcome. We aimed to pragmatically analyze the effect of offering elective induction of labor (eIOL) to all low-risk patients.

METHODS

Retrospective cohort study of low-risk nulliparous and multiparous patients delivering live, non-anomalous singletons at a single center at greater than or equal to 39 0/7 weeks gestational age. Those with prior or planned cesarean delivery, ruptured membranes, medical comorbidities, or contraindications to vaginal delivery were excluded. Patients were categorized as before (pre-eIOL; 1/2012-3/2014) or after (post-eIOL; 3/2019-12/2021) an institution-wide policy offering eIOL at 39 0/7 weeks. Births occurring April 2014 to December 2018 were allocated to a separate cohort (during-eIOL) given increased exposure to eIOL as our center recruited participants for the ARRIVE trial. The primary outcome was cesarean birth. Secondary outcomes included select maternal (e.g. chorioamnionitis, operative delivery, postpartum hemorrhage) and neonatal morbidities (e.g. birthweight, small- and large-for gestational age, hypoglycemia). Characteristics and outcomes were compared between the pre and during-eIOL, and pre and post-eIOL groups; adjusted OR (95% CI) were calculated using multivariable regression. Subgroup analysis by parity was planned.

RESULTS

Of 10,758 patients analyzed, 2521 (23.4%) were pre-eIOL, 5410 (50.3%) during-eIOL, and 2827 (26.3%) post-eIOL. Groups differed with respect to labor type, age, race/ethnicity, marital and payor status, and gestational age at care entry. Post-eIOL was associated with lower odds of cesarean compared to pre-eIOL (aOR 0.83 [95% CI 0.72-0.96]), which was even lower among those specifically undergoing labor induction (aOR 0.58 [0.48-0.70]. During-eIOL was also associated with lower odds of cesarean compared to pre-eIOL (aOR 0.79 [0.69-0.90]). Both during and post-eIOL groups were associated with higher odds of chorioamnionitis, operative delivery, and hemorrhage compared to pre-eIOL. However, only among post-eIOL were there fewer neonates weighing ≥4000 g, large-for-gestational age infants, and neonatal hypoglycemia compared to pre-IOL.

CONCLUSION

An institutional policy offering eIOL at 39 0/7 to low-risk patients was associated with a lower cesarean birth rate, lower birthweights and lower neonatal hypoglycemia, and an increased risk of chorioamnionitis and hemorrhage.

Transcutaneous Discrimination of Fetal Heart Rate from Maternal Heart Rate: A Fetal Oximetry Proof-of-Concept

Intrapartum care uses electronic fetal heart rate monitoring (EFHRM) for over 50 years to indirectly assess fetal oxygenation. However, this approach has been associated with an increase in cesarean delivery rates and limited improvements in neonatal hypoxic outcome. To address these shortcomings, a novel transabdominal fetal pulse oximeter (TFO) is being developed to provide an objective measurement of fetal oxygenation. Previous studies have evaluated the performance of TFO on pregnant ewe. Building on the animal model, this study aims to determine whether TFO can successfully capture human fetal heart rate (FHR) signals during non-stress testing (NST) as a proof-of-concept. Eight ongoing pregnancies meeting specific inclusion criteria (18-40 years old, singleton, and at least 36 weeks' gestation) were enrolled with consent. Each study session was 15 to 20 min long. Reference maternal heart rate (MHR) and FHR were obtained using finger pulse oximetry and cardiotocography for subsequent comparison. The overall root-mean-square error was 9.7BPM for FHR and 4.4 for MHR, while the overall mean-absolute error was 7.6BPM for FHR and 1.8 for MHR. Bland-Altman analysis displayed a mean bias ± standard deviation between TFO and reference of -3.9 ± 8.9BPM, with limits of agreement ranging from -21.4 to 13.6 BPM. Both maternal and fetal heart rate measurements obtained from TFO exhibited a p-value < 0.001, showing significant correlation with the reference. This proof-of-concept study successfully demonstrates that TFO can accurately differentiate maternal and fetal heart signals in human subjects. This achievement marks the initial step towards enabling fetal oxygen saturation measurement in humans using TFO.

Understanding Obstetrical Surgical Planning for the Pediatrician

Cesarean deliveries are common in the United States, occurring in approximately one-third of deliveries in 2021. Given this high rate of cesarean deliveries, it is important for all clinicians caring for the pregnant person-infant dyad to be educated about cesarean deliveries. In this review, we describe the indications for cesarean delivery, the evidence-based practices of preoperative planning to ensure safe deliveries, and the clinical decision-making behind various cesarean incisions. In addition, we discuss the most common complications of cesarean deliveries for the pregnant person-infant dyad.

When Life Is Expected to Be Brief: A Case-Based Guide to Prenatal Collaborative Care

Advances in fetal health detection and neonatal care have improved outcome predictions but have outpaced the development of treatments, leaving some families facing the heartbreaking reality of their baby's short life expectancy. Families with a fetus that has a life-limiting condition must make tough decisions, including the possibility of termination, perinatal palliative care options, and the extent of newborn resuscitation. Access to abortion services is crucial in decision-making, underscoring the significance of palliative care as an option. Perinatal palliative care programs offer vital support, honoring the baby and family throughout pregnancy, birth, and death. They provide compassionate care for pregnant individuals, partners, and newborns, integrating seamlessly into standard pregnancy and birth care. Successful programs prioritize families' desires, goals, and personal priorities, whether through a dedicated team or an organized system. "Regardless of the length of a baby's life or duration of illness, it is their lifetime. The infant and family deserve skilled and compassionate attention to their plight; a safety net throughout the experience; a palliative care approach emphasizing living fully those days, hours, and even moments." (1).

Regional disparities in primary cesarean delivery rates in Japan: the role of obstetrician availability

Background

The prevalence of cesarean section procedures is on the rise worldwide, necessitating a deeper understanding of the factors driving this trend to mitigate potential adverse consequences associated with unnecessary cesarean section deliveries.

Objectives

This study aims to investigate the rate of primary cesarean deliveries (PCD), a potential key indicator of obstetric care quality.

Study Design

A national retrospective cohort study was conducted utilizing extensive data from the National Database of Health Insurance Claims and Specific Health Checkups of Japan spanning the years 2012 to 2018. The study examined the temporal trends in PCD rates and the indications for these procedures across different prefectures. Additionally, the study employed the obstetrician disproportionality index, as published by the Ministry of Health, Labour, and Welfare, to assess the influence of obstetrician availability on PCD rates.

Results

Throughout the study period from 2012 to 2018, the rate of PCD in Japan remained relatively stable at approximately 14%. The primary indications for PCD in 2018 included labor arrest (18.3%), malpresentation (16.5%), nonreassuring fetal status (6.5%), and macrosomia (6.0%). Substantial regional disparities in PCD rates were observed, ranging from 8.9% to 20.4% among prefectures in 2018. Notably, prefectures categorized in the bottom 10 of the obstetrician disproportionality index exhibited significantly higher PCD rates compared to the top 10 prefectures (P=.0232), with a similar trend noted for PCD due to labor arrest (P=.0288). Furthermore, a negative correlation was identified between the obstetrician disproportionality index and PCD rates at the prefectural level (r=-0.3119, P=.0328).

Conclusions

Our study presents a comprehensive analysis of PCD rates in Japan, shedding light on regional disparities and highlighting the notable influence of obstetrician availability on clinical decision-making. This study contributes to the ongoing discourse on the escalating global trend in cesarean sections and the importance of healthcare resource allocation in maternal care.

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

OBJECTIVE

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.

METHOD AND MATERIALS

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.

RESULTS

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).

CONCLUSION

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.

Pelvic floor dysfunction after intervention, compared with expectant management, in prolonged second stage of labour: A population-based questionnaire and cohort study

OBJECTIVE

To investigate the effect of vacuum extraction (VE) or caesarean section (CS), compared with expectant management, on pelvic floor dysfunction (PFD) 1-2 years postpartum in primiparous women with a prolonged second stage of labour.

DESIGN

A population-based questionnaire and cohort study.

SETTING

Stockholm, Sweden.

POPULATION

A cohort of 1302 primiparous women with a second stage duration of ≥3 h, delivering from December 2017 to November 2018.

METHODS

The 1-year follow-up questionnaire from the Swedish National Perineal Laceration Register was distributed 12-24 months postpartum. Exposure was VE or CS at 3-4 h or 4-5 h, compared with expectant management.

MAIN OUTCOME MEASURES

Pelvic floor dysfunction was defined as at least weekly symptoms of urinary incontinence, pelvic organ prolapse or a Wexner score of ≥4. The risk of PFD was calculated using Poisson regression with robust variance estimation, presented as crude and adjusted relative risks (RRs and aRRs) with 95% confidence intervals (95% CIs). The implication of obstetric anal sphincter injury (OASI) on pelvic floor disorders was investigated through mediation analysis.

RESULTS

In total, 35.1% of women reported PFD. Compared with expectant management, the risk of PFD was increased after VE at 3-4 h (aRR 1.33, 95% CI 1.06-1.65) and 4-5 h (aRR 1.34, 95% CI 1.05-1.70), but remained unchanged after CS. The increased risk after VE was not mediated by OASI.

CONCLUSIONS

Pelvic floor dysfunction was common in primiparous women after a prolonged second stage, and the risk of PFD increased after VE but was unaffected by CS, compared with expectant management. If a spontaneous vaginal delivery eventually occurred, allowing an extended duration of labour did not increase the risk of PFD.

New definitions, old complications: The association between duration of transition from latent to active labor and adverse obstetrical outcomes

OBJECTIVE

To explore the relationship between the duration of transition from latent to active labor and various obstetric, maternal, fetal, and neonatal outcomes.

METHODS

A retrospective cohort study was conducted on term, singleton deliveries at Soroka University Medical Center from 2013 to 2018. Data were extracted from electronic medical records. The exposure variable was defined as prolonged transition, which was itself defined as the upper 10th centile of dilation duration from 4 to 6 cm. Clinical and demographic characteristics were compared using χ2 test. Multivariate logistic regression was used to estimate the contribution of a prolonged transition with each adverse outcome adjusting for potential confounders.

RESULTS

In all, 12 104 deliveries met the inclusion criteria. The mean ± standard deviation of duration of dilation from 4 to 6 cm was 03:07:58 ± 03:03:42 (hours:minutes:seconds). Progress curves varied significantly among patients with different obstetrical and demographic characteristics. Prolonged transition was significantly linked to an increased risk of cesarean delivery (adjusted odds raito 2.607, 95% confidence interval 2.171-3.130, area under the curve 0.689) and higher rates of maternal and neonatal morbidity.

CONCLUSIONS

Patients experiencing transition phases exceeding the 90th centile faced an elevated risk of cesarean delivery and postpartum complications. Future studies should focus on interventions during the transition phase to improve pregnancy outcomes and enhance patient safety.

Characteristics Associated with Trial of Labor among Patients with Twin Pregnancies

OBJECTIVE

This study aimed to identify patient and provider factors associated with undergoing trial of labor (TOL) among eligible patients with twin gestations.

STUDY DESIGN

This retrospective cohort study of patients with twin gestations who received care at a large tertiary care center from 2000 to 2016 included individuals with live pregnancies greater than 23 weeks of gestation and cephalic-presenting twin. Patients with a prior uterine scar or contraindication to vaginal delivery were excluded from analyses. Maternal and clinical characteristics were compared among patients who did and did not undergo TOL. Multivariable logistic regression models included characteristics chosen a priori and those with bivariable associations with p < 0.1. Interactions between parity and other significant variables in the primary models were also investigated.

RESULTS

Among 1,888 eligible patients, 80.7% (N = 1,524) underwent TOL. Those undergoing TOL were more likely to be younger, multiparous, and have a maternal-fetal medicine physician as the delivering provider (p < 0.01). Hypertensive disorders of pregnancy were less prevalent among patients undergoing TOL (20.2 vs. 27.8%, p < 0.01). In multivariable analysis, advanced maternal age (adjusted odds ratio [aOR]: 0.55, 95% confidence interval [CI]: 0.40-0.74) and nulliparity (aOR: 0.36, 95% CI: 0.25-0.52) conferred a lower odds of TOL, while having a maternal-fetal medicine provider (aOR: 2.74, 95% CI: 1.55-4.83) was associated with higher odds. Interaction analyses demonstrated no significant interaction effects between parity and other characteristics. Among those undergoing a TOL, 76.0% (1,158/1,524) had a successful vaginal delivery of both twins, with 48.1% (557/1,158) having breech extraction of the second twin.

CONCLUSION

In this cohort of twin gestations with a high frequency of TOL, patient and provider characteristics are associated with attempting vaginal delivery. Variation in provider practices suggests differing skills and comfort with twin vaginal delivery may influence route of delivery decision-making in patients with twins.

KEYPOINTS

· Most patients with twin pregnancies undergoing TOL had successful vaginal deliveries.. · Having an MFM delivering provider was associated with higher odds of attempting twin TOL.. · Nulliparity and advanced maternal age were associated with lower odds of twin TOL..

Fetal and Maternal Factors Predictive of Primary Cesarean Delivery at Term in a Low-Risk Population: NICHD Fetal Growth Studies-Singletons

OBJECTIVE

 This study aimed to examine associations of fetal biometric and amniotic fluid measures with intrapartum primary cesarean delivery (PCD) and develop prediction models for PCD based on ultrasound parameters and maternal factors.

STUDY DESIGN

 Secondary analysis of the National Institute of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Fetal Growth Studies-singleton cohort (2009-2013) including patients with uncomplicated pregnancies and intent to deliver vaginally at ≥370/7 weeks. The estimated fetal weight, individual biometric parameters, fetal asymmetry measurements, and amniotic fluid single deepest vertical pocket assessed at the final scan (mean 37.5 ± 1.9 weeks) were categorized as <10th, 10th to 90th (reference), and >90th percentiles. Logistic regression analyses examined the association between the ultrasound measures and PCD. Fetal and maternal SuperLearner prediction algorithms were constructed for the full and nulliparous cohorts.

RESULTS

 Of the 1,668 patients analyzed, 249 (14.9%) had PCD. The fetal head circumference, occipital-frontal diameter, and transverse abdominal diameter >90th percentile (adjusted odds ratio [aOR] = 2.50, 95% confidence interval [95% CI]: 1.39, 4.51; aOR = 1.86, 95% CI: 1.02, 3.40; and aOR = 2.13, 95% CI: 1.16, 3.89, respectively) were associated with PCD. The fetal model demonstrated poor ability to predict PCD in the full cohort and in nulliparous patients (area under the receiver-operating characteristic curve [AUC] = 0.56, 95% CI: 0.52, 0.61; and AUC = 0.54, 95% CI: 0.49, 0.60, respectively). Conversely, the maternal model had better predictive capability overall (AUC = 0.79, 95% CI: 0.75, 0.82) and in the nulliparous subgroup (AUC = 0.72, 95% CI: 0.67, 0.77). Models combining maternal/fetal factors performed similarly to the maternal model (AUC = 0.78, 95% CI: 0.75, 0.82 in full cohort, and AUC = 0.71, 95% CI: 0.66, 0.76 in nulliparas).

CONCLUSION

 Although a few fetal biometric parameters were associated with PCD, the fetal prediction model had low performance. In contrast, the maternal model had a fair-to-good ability to predict PCD.

KEY POINTS

· Fetal HC >90th percentile was associated with cesarean delivery.. · Fetal parameters did not effectively predict PCD.. · Maternal factors were more predictive of PCD.. · Maternal/fetal and maternal models performed similarly.. · Prediction models had lower performance in nulliparas..

Utilizing Fetal Echocardiography to Risk Stratify and Predict Neonatal Outcomes in Fetuses Diagnosed with Congenital Heart Disease

OBJECTIVE

 Risk stratification of fetuses diagnosed with congenital heart disease (CHD) helps provide a delivery plan and prepare families and medical teams on expected course in the delivery room. Our aim was to assess the accuracy of echocardiographically determined risk-stratification assignments in predicting postnatal cardiac outcomes beyond the delivery room.

STUDY DESIGN

 This was a retrospective study at a single center evaluating all fetuses with CHD who were risk-stratified by echocardiographically determined level of care (LOC) assignment, ranging from 1a (lowest risk) to 4 (highest risk). All data were collected from January 1, 2017, to November 1, 2021. Outcomes included any unexpected cardiac interventions and neonatal clinical outcomes including in-hospital mortality, the need for prostaglandins or inotropes, and defined critical illness. These outcomes were assessed for each LOC assignment by Fisher's exact test.

RESULTS

 Out of 817 patients assigned a LOC, a total of 747 fetuses were included in our final cohort with a separate subanalysis of 70 fetuses diagnosed with coarctation of the aorta. The sensitivity and specificity were high for all LOC levels in predicting delivery room needs (93-100%). Higher LOC levels (3-4) had a lower positive predictive value (66-67%) indicating a high false-positive rate. Subjects with higher LOC assignments had a greater frequency of critical illness, hospital mortality, need for inotropes, need for neonatal surgical or catheterization interventions, and need for prostaglandins (p < 0.001 for all outcomes). A post-hoc analysis reviewing LOC assignments revealed a greater tendency to over-assign LOC at higher assignments (19% for LOC 3 and 4) compared to lower assignments (4% for LOC 1 and 2).

CONCLUSION

 Risk stratification based on fetal echocardiography can predict neonatal clinical outcomes and acuity of postnatal management needs. However, there is greater variability in expected clinical events and an expected degree of false positives for those with higher LOC assignments.

KEY POINTS

· Risk stratification utilizing fetal echocardiography can be used to predict neonatal needs.. · Complex heart disease has lower positive predictive value in predicting postnatal clinical needs.. · There is a tendency to over-assign risk of acute hemodynamic instability for complex heart disease.. · False positives are expected when planning high-risk deliveries to avoid compromising situations..

Effects of epidural analgesia at 1 cm cervical dilatation on multiparae: A retrospective cohort study using propensity score-matching

OBJECTIVE

The aim of the present study was to investigate the effects of epidural analgesia (EA) administered at cervical dilatation of 1 cm on multiparae who underwent vaginal delivery.

METHODS

This propensity score-matched retrospective cohort research was conducted between 2021 and 2022. All the singleton multiparae who had previous successful vaginal deliveries and epidural analgesia during this delivery were screened for eligibility. The primary outcome was the effect of EA on the duration of labor. The main secondary outcomes included the incidence of cesarean delivery and umbilical arterial pH.

RESULTS

This study incorporated 686 multiparae who were divided into two cohorts: EA 1 (cervical dilatation = 1 cm, n = 166) and EA 2 (cervical dilatation >1 cm, n = 520). In the propensity score-matched cohort (including 164 women in each group), there were no statistically significant differences in the incidence of cesarean delivery (4 [2.4%] vs 4 [2.4%], P = 1.000), umbilical arterial pH (7.28 ± 0.06 vs 7.28 ± 0.07, P = 0.550) and other secondary outcomes between the two groups. Based on a comparative assessment of the women who delivered vaginally to the Kaplan-Meier curves and propensity score-matching (including 160 women in each group), there was no statistical significance in the duration of the first, second and third stages of labor (log rank P, P = 0.811; P = 0.413; P = 0.773, respectively).

CONCLUSION

Initiation of epidural analgesia at cervical dilatation of 1 cm in multiparae did not cause adverse effects with regard to the duration of labor, increased cesarean deliveries, and bad neonatal outcomes.

Ensemble learning for fetal ultrasound and maternal-fetal data to predict mode of delivery after labor induction

Providing adequate counseling on mode of delivery after induction of labor (IOL) is of utmost importance. Various AI algorithms have been developed for this purpose, but rely on maternal-fetal data, not including ultrasound (US) imaging. We used retrospectively collected clinical data from 808 subjects submitted to IOL, totaling 2024 US images, to train AI models to predict vaginal delivery (VD) and cesarean section (CS) outcomes after IOL. The best overall model used only clinical data (F1-score: 0.736; positive predictive value (PPV): 0.734). The imaging models employed fetal head, abdomen and femur US images, showing limited discriminative results. The best model used femur images (F1-score: 0.594; PPV: 0.580). Consequently, we constructed ensemble models to test whether US imaging could enhance the clinical data model. The best ensemble model included clinical data and US femur images (F1-score: 0.689; PPV: 0.693), presenting a false positive and false negative interesting trade-off. The model accurately predicted CS on 4 additional cases, despite misclassifying 20 additional VD, resulting in a 6.0% decrease in average accuracy compared to the clinical data model. Hence, integrating US imaging into the latter model can be a new development in assisting mode of delivery counseling.

Labor patterns of spontaneous first-stage labor in Chinese women with normal neonatal outcomes

BACKGROUND

Friedman's standards, developed almost 50 years ago, may no longer align with the needs of today's obstetric population and current pregnancy management practices. This study aims to analyze contemporary labor patterns and estimate labor duration in China, focusing on first-stage labor data from Chinese parturients with a spontaneous onset of labor.

METHODS

This retrospective observational study utilized data from electronic medical records of a tertiary hospital in Changsha, Hunan. Out of a total of 2,689 parturients, exclusions were made for multiple gestations, preterm, post-term, or stillbirth, cesarean delivery, non-vertex presentation, and neonatal intensive care unit admission. Average labor curves were constructed by parity using repeated-measure analysis, and labor duration was estimated through interval-censored regression, stratified by cervical dilation at admission. We performed an analysis to assess the impact of oxytocin augmentation and amniotomy on labor progression and conducted a sensitivity analysis using women with complicated outcomes.

RESULTS

Nulliparous women take over 180 minutes for cervical dilation from 3 to 4 cm, and the duration from 5 to 6 cm exceeds 145 minutes. Multiparous women experience shorter labor durations than nulliparous. Labor acceleration is observed after 5 cm in nulliparous, but no distinct inflection point is evident in the average labor curve. In the second stage of labor, the 95th percentile for nulliparous, with and without epidural analgesia, is 142 minutes and 127 minutes, respectively.

CONCLUSIONS

These findings provide valuable insights for the reassessment of labor and delivery processes in contemporary obstetric populations, including current Chinese obstetric practice.

How Much is too Much? High Utilization of Prenatal Care and Its Impact on Primary Cesarean Birth Among Women in the United States

INTRODUCTION

Nationally, cesarean birth is one of the most performed surgical procedures, yet cesarean births have been linked to an increased risk of delivery complications. Prenatal care (PNC) and education are possible strategies to reduce the number of cesarean births. However, there is scant research assessing the impact of these strategies on safely reducing primary cesarean births. This study evaluates the association between the adequacy of PNC utilization and primary cesarean birth.

METHODS

The analysis used 2018 birth certificate data, and the sample included nulliparous women with no reported pregnancy or delivery complications (N = 729,140). Logistic regression was used to model the association between the adequacy of PNC utilization and delivery method, as well as identify other factors associated with the delivery method.

RESULTS

Among women with a primary cesarean birth, 36.2% had received adequate plus PNC. After adjustment, there was no significant association between women receiving inadequate, intermediate, or adequate PNC and primary cesarean birth. However, women who received adequate plus PNC had an increased odds of having a primary cesarean birth compared to women with no PNC (OR, 1.23; 95% CI, 1.18-1.28).

DISCUSSION

Findings from this study highlight the need to further understand the role of PNC and its potential impact on the delivery method. Within the patient-provider relationship, healthcare providers have the unique opportunity to provide education and inform patients of the risks and benefits of all delivery options. Thus, there is an increased opportunity to safely reduce primary cesarean births.

Does delayed vacuum-assisted delivery harbor greater maternal or neonatal complications?

OBJECTIVE

To compare maternal and fetal outcomes between early (<2 h) and delayed (>2 h) vacuum extraction (VE) deliveries.

METHODS

We performed a retrospective cohort study in a single, university-affiliated medical center (2014-2021). We included term singleton pregnancies delivered by VE, allocated into one of two groups according to second stage duration: <2 h or >2 h. Primary outcome was maternal composite adverse outcome (included chorioamnionitis, 3-4 degree lacerations, and postpartum hemorrhage [PPH]).

RESULTS

We included 2521 deliveries: 2261 (89.6%) with early VE and 260 (10.4%) with delayed VE. Study groups' characteristics were not different, except of parity. Maternal composite outcome almost reached a significance (P = 0.054) comparing between the groups. Comparing second stage length up to 2 h versus more, there was similar rate of advance maternal lacerations. However, extending the second stage to more than 3 h was associated with third degree lacerations compared to 2-3 h (9.8% vs 3%, P = 0.011). There were significantly more PPH events in the later VE group (P = 0.004), but the need for blood transfusions was similar. The rates of 5 min Apgar score ≤7 (P = 0.001) and umbilical artery pH <7.0 were significantly higher in group 2 compared with group 1. The effect was much more pronounced when second stage was >3 h. After conducting multiregression analysis, the results became insignificant.

CONCLUSION

Our study suggests that VE performed in the late second stage of labor, up to 3 h, is safe as VE performed in the early stages regarding maternal and neonatal outcomes. Extra caution is needed with extended second stage to more than 3 h.

New labor curves of dilation and station to improve the accuracy of predicting labor progress

BACKGROUND

The diagnosis of failure to progress, the most common indication for intrapartum cesarean delivery, is based on the assessment of cervical dilation and station over time. Labor curves serve as references for expected changes in dilation and fetal descent. The labor curves of Friedman, Zhang et al, and others are based on time alone and derived from mothers with spontaneous labor onset. However, labor induction is now common, and clinicians also consider other factors when assessing labor progress. Labor curves that consider the use of labor induction and other factors that influence labor progress have the potential to be more accurate and closer to clinical decision-making.

OBJECTIVE

This study aimed to compare the prediction errors of labor curves based on a single factor (time) or multiple clinically relevant factors using two modeling methods: mixed-effects regression, a standard statistical method, and Gaussian processes, a machine learning method.

STUDY DESIGN

This was a longitudinal cohort study of changes in dilation and station based on data from 8022 births in nulliparous women with a live, singleton, vertex-presenting fetus ≥35 weeks of gestation with a vaginal delivery. New labor curves of dilation and station were generated with 10-fold cross-validation. External validation was performed using a geographically independent group. Model variables included time from the first examination in the 20 hours before delivery; dilation, effacement, and station recorded at the previous examination; cumulative contraction counts; and use of epidural anesthesia and labor induction. To assess model accuracy, differences between each model's predicted value and its corresponding observed value were calculated. These prediction errors were summarized using mean absolute error and root mean squared error statistics.

RESULTS

Dilation curves based on multiple parameters were more accurate than those derived from time alone. The mean absolute error of the multifactor methods was better (lower) than those of the single-factor methods (0.826 cm [95% confidence interval, 0.820-0.832] for the multifactor machine learning and 0.893 cm [95% confidence interval, 0.885-0.901] for the multifactor mixed-effects method and 2.122 cm [95% confidence interval, 2.108-2.136] for the single-factor methods; P<.0001 for both comparisons). The root mean squared errors of the multifactor methods were also better (lower) than those of the single-factor methods (1.126 cm [95% confidence interval, 1.118-1.133] for the machine learning [P<.0001] and 1.172 cm [95% confidence interval, 1.164-1.181] for the mixed-effects methods and 2.504 cm [95% confidence interval, 2.487-2.521] for the single-factor [P<.0001 for both comparisons]). The multifactor machine learning dilation models showed small but statistically significant improvements in accuracy compared to the mixed-effects regression models (P<.0001). The multifactor machine learning method produced a curve of descent with a mean absolute error of 0.512 cm (95% confidence interval, 0.509-0.515) and a root mean squared error of 0.660 cm (95% confidence interval, 0.655-0.666). External validation using independent data produced similar findings.

CONCLUSION

Cervical dilation models based on multiple clinically relevant parameters showed improved (lower) prediction errors compared to models based on time alone. The mean prediction errors were reduced by more than 50%. A more accurate assessment of departure from expected dilation and station may help clinicians optimize intrapartum management.

Pregnancy-associated fulminant type 1 diabetes: a case report and review of the literature

Pregnancy-associated fulminant type 1 diabetes (PF) has received high clinical attention because of its low incidence and poor prognosis. It poses a great threat to the lives of mothers and infants; therefore, it is imperative to understand its characteristics and approach methods. However, no studies have described whether a cesarean section or conservative treatment should be considered at the onset of PF. We report a case of PF, review the published literature and consider a cesarean section at the onset of PF. A 39-year-old woman was admitted to our hospital with dyspnea and nausea. The patient was diagnosed with PF. Insulin Lispro and Glargine were administered to control the blood glucose levels. Six hours later, the fetus died. The fetal status due to PF probably worsened during the conservative treatment. No perioperative complications have been reported for cesarean sections under diabetic ketoacidosis due to PF and there have been cases of live birth by emergency cesarean section. Identifying the features of PF and considering and performing cesarean sections early after diagnosis is essential to save fetal life.

The Role of Passive Descent and Epidural Analgesia in Outcomes Associated With Prolonged Pushing Among Nulliparous Individuals in Midwifery Care

INTRODUCTION

Efforts to reduce primary cesarean birth may include supporting longer second stages of labor. Although midwifery-led care is associated with lower cesarean use, little has been published on associated outcomes of prolonged second stage (≥3 hours of pushing) for nulliparous individuals in US hospital-based midwifery care. Epidural analgesia and the role of passive descent in midwifery-led care are also underexplored in relation to the second stage. In this study, we report the incidence of prolonged second stage stratified by epidural analgesia and/or passive descent. Secondary aims included calculating the odds of cesarean birth, obstetric anal sphincter injury (OASI), postpartum hemorrhage (PPH), and neonatal complications.

METHODS

Data were collected prospectively from a single academic center in the United States from 2012 through 2019. Our cohort analysis of labors attended by midwives for nulliparous, term, singleton, and vertex pregnancies included both descriptive and inferential statistics comparing outcomes between prolonged versus nonprolonged pushing groups. We stratified the sample and quantified second stage outcomes by epidural analgesia and by use of passive descent.

RESULTS

Of the 1465 births, 17% (n = 247) included prolonged pushing. Cesarean ranged from 2.2% without prolonged pushing to 26.7% with prolonged pushing. Fetal malposition, epidural analgesia, and longer passive descent were more common among those with prolonged active pushing. Despite these factors, neither odds for PPH nor poor neonatal outcomes were associated with prolonged pushing. Those with more than one hour of passive descent in the second stage who also had prolonged active pushing had lower odds for cesarean but higher odds for OASI relative to those who had little passive descent before pushing for more than 3 hours.

DISCUSSION

Prolonged pushing occurred in nearly 2 of 10 nulliparous labors. Fetal malposition, epidural analgesia, and prolonged pushing were commonly observed with longer passive descent, cesarean, and OASI. Passive descent in these data likely reflects individualized midwifery care strategies when pushing was complicated by fetal malposition or other complexities.

Factors influencing midwives' intentions to facilitate normal physiological birth: A qualitative study

BACKGROUND

Whilst most women desire to birth vaginally, research highlights reducing rates of normal physiological birth worldwide. Previous studies have focussed largely on clinical practices associated with vaginal birth however health care professionals' intentions are also known to effect behaviour; a factor not well understood within the context of midwifery and normal physiological birth.

QUESTION/AIM

To explore factors influencing midwives' intentions to facilitate normal physiological birth.

METHODS

A qualitative study using individual interviews was conducted. The Theory of Planned Behaviour was used to develop a semi-structured interview guide to gather perceptions, thoughts, knowledge, and experience of normal physiological birth from participants. Data were analysed thematically within the theoretical constructs: attitudes, subjective norms, and perceived behavioural control.

FINDINGS

Fourteen midwives from various practice settings, models, and locations in Australia were interviewed. Major factors influencing midwives' intentions to facilitate normal physiological birth were influenced by workplace culture, values and influence of leaders, the need to prioritise collaborative interdisciplinary relationships and support autonomy in midwifery.

DISCUSSION

Factors influencing the midwives' intentions of facilitating normal physiological birth were multifaceted. Some influences are more obvious and observable through practice, while others were rooted in underlying beliefs and attitudes that were hidden in the subconscious of those involved. However, all contributing influences ultimately shape midwives' intentions and the way in which they facilitate normal physiological birth.

CONCLUSIONS

Midwives intend to support normal physiological birth; however multiple factors influence their intentions over time. Prioritising collaborative interdisciplinary relationships and supporting autonomy in midwifery could address known barriers.

Prevalence and associated factors of caesarean section among mothers who gave birth across Eastern Africa countries: Systematic review and meta-analysis study

Background

Caesarean section (CS) rate increased dramatically worldwide, exceeding the World Health Organization's benchmark (10-15 %) in many countries. This rate varies in different regions of the continent. Using various study designs, researchers from across East African countries investigated the prevalence of caesarean section and the factor associated with it but no study shows a pooled prevalence of caesarean section in the Eastern African region. Therefore, this review aimed to systematically summarize and estimate the pooled prevalence of caesarean section and its associated factors in Eastern Africa, 2023.

Methods

PubMed, Web of Science, EMBASE, Scopus and CINAHL were rigorously searched to find relevant studies. All identified observational studies reporting the prevalence of CS and its associated factors in East Africa published till August 2023 were considered. Heterogeneity across the studies was evaluated using the I2 test. Publication bias was assessed by funnel plot and Egger's regression test. Finally, a random effect meta-analysis model was computed to estimate the pooled prevalence of CS and qualitative analysis was employed for associated factors. The study protocol was registered in PROSPERO.

Results

This review was assessed using twenty-six eligible studies from a total of 2223 articles with a total of 600,431 participants. In this meta-analysis, the pooled prevalence of caesarean section in Eastern Africa was 24.0 % (95%CI: 22-27 %). The highest pooled prevalence of caesarean section was in Ethiopia, 28.30 % (95%CI; 21.3-35.2 %), and the lowest was seen in Uganda, 11.9 % (95%CI; 7.9-15.9 %). Urban residency, having high level of wealth asset, education level college and above, advanced maternal age, big birth weight, history of previous caesarean section, private institution delivery, multiple pregnancies, pregnancy-induced hypertension, antepartum haemorrhage and fetal malpresentation were linked with a greater likelihood of having CS.

Conclusions

and recommendation: The overall pooled prevalence of CS in Eastern Africa was high compared to the WHO proposed recommended range. Therefore, the finding implies that each East African countries Ministry of Health and health care professionals shall be given particular emphasis made on strengthening antenatal care services and ensure more women have access to skilled healthcare professionals during childbirth. This can help in providing appropriate interventions, support to women and reducing the need for emergency and unnecessary CSs. The result of this research are a baseline data for future researchers to conduct further studies to better understand the reasons behind the high rates and identify potential interventions and solutions specific to the African context.PROSPERO protocol number: CRD42023440131.

Early vs. delayed amniotomy in individuals undergoing pre-induction cervical ripening with transcervical Foley balloon: a meta-analysis

OBJECTIVES

To systematically review randomized controlled trials (RCTs) and perform a meta-analysis comparing early amniotomy with delayed amniotomy in individuals undergoing pre-induction cervical ripening by Foley balloon. The primary outcome was the rate of cesarean delivery. Understanding the impact of the timing of amniotomy on the rate of cesarean delivery is crucial for obstetricians and healthcare providers when making decisions about the management of labor induction.

DATA SOURCES

Data were sourced from electronic databases, including PubMed, OVID, Cochrane Library, Web of Science, and ClinicalTrials.gov through February 2024. The review adhered to Preferred Reporting Item for Systematic Reviews guidelines and registered with PROSPERO (ID CRD42023454520).

STUDY ELIGIBILITY CRITERIA

Inclusion criteria comprised RCTs comparing early amniotomy with delayed amniotomy in individuals undergoing cervical ripening by Foley balloon. Early amniotomy was defined as amniotomy soon after cervical ripening. Delayed amniotomy was defined as withholding amniotomy until after the onset of the active phase of labor, until at least 4 hours from either initiation of oxytocin or Foley balloon removal/expulsion, or until achieving >4 cm of dilation. Participants included nulliparous or multiparous individuals with singleton pregnancies undergoing labor induction at 37 weeks or later.

STUDY APPRAISAL AND SYNTHESIS

A systematic literature search was conducted using defined search terms including "early amniotomy," "delayed amniotomy," "induction of labor," "cervical ripening," and "Foley balloon," and "Foley catheter." The quality of the included trials was assessed using the Cochrane Risk of Bias Tool for randomized controlled trials. The primary outcome was cesarean delivery. Secondary outcomes included outcomes related to labor duration and neonatal outcomes. Pooled relative risks (RR) and weighted mean differences (WMD) with 95% confidence intervals were calculated.

RESULTS

Five trials involving 849 participants undergoing induction and cervical ripening by Foley balloon were included. The rate of cesarean delivery did not differ between individuals randomly assigned to the early amniotomy group compared with those assigned to the delayed amniotomy group (22.9% vs. 23.3%; RR 1.00; 95% CI 0.65-1.55). Early amniotomy compared to delayed amniotomy was associated with a higher proportion of delivery within 24 hours (79.9% vs. 67.1%; RR 1.19; 95% CI 1.04-1.36). Early amniotomy compared with delayed amniotomy was associated with a shorter interval from oxytocin to delivery (WMD -1.5 hours; 95% CI -2.1 to -0.8), from Foley expulsion to vaginal delivery (WMD -2.5 hours; 95% CI -4.8 to -0.1), and from the start of oxytocin to vaginal delivery (WMD -1.8 hours; 95% CI -3.2 to -0.4). Other outcomes were not significantly different.

CONCLUSION

Early amniotomy following cervical ripening by Foley balloon in individuals with singleton pregnancies did not impact rates of cesarean delivery compared with delayed amniotomy but led to shorter duration for various labor progress outcomes.

Prediction of spontaneous vaginal delivery in the prolonged second stage using the delta angle of progression

BACKGROUND

It is clinically challenging to determine when to intervene in the prolonged second stage. Although individualized prediction of spontaneous vaginal delivery is crucial to avoid maternal and neonatal complications associated with operative deliveries, the approach has not been fully established.

OBJECTIVE

We aimed to evaluate the predictability of spontaneous vaginal delivery using the difference in angle of progression between pushing and rest, delta angle of progression, to establish a novel method to predict spontaneous vaginal delivery during the prolonged second stage in nulliparous women with epidural anesthesia.

STUDY DESIGN

We retrospectively analyzed deliveries of nulliparous women with epidural anesthesia between September 2018 and October 2023. Women were included if their delta angle of progression during the second stage was available. Operative deliveries were defined as the cases that required forceps, vacuum, and cesarean deliveries due to labor arrest. Women requiring operative deliveries due to fetal and maternal concerns, or women with fetal occiput posterior presentation were excluded. The second stage was stratified into the prolonged second stage, the period after 3 hours in the second stage, and the normal second stage, the period from the beginning until the third hour of the second stage. The association of the delta angle of the progression measured during each stage with spontaneous vaginal delivery and operative deliveries was investigated. Furthermore, the predictability of spontaneous vaginal delivery was evaluated by combining the delta and rest angle of progression.

RESULTS

A total of 129 women were eligible for analysis. The delta angle of progression measured during the prolonged second stage and normal second stage were significantly larger in women who achieved spontaneous vaginal delivery compared to operative deliveries (p<.001 and p<.05, respectively). During the prolonged second stage, a cutoff of 18.8 derived from the receiver operative characteristic curves in the context of the delta angle of progression predicted the possibility of spontaneous vaginal delivery (sensitivity, 81.8%; specificity, 60.0%; AUC, 0.76). Combining the rest angle of progression (>140) and delta angle of progression (>18.8) also provided quantitative prediction of spontaneous vaginal delivery (sensitivity, 86.7%; specificity, 70.0%; AUC, 0.80).

CONCLUSION

The delta angle of progression alone or in combination with the rest angle of progression can be used to predict spontaneous vaginal delivery in the second stage in nulliparous women with epidural anesthesia. Quantitative analysis of the effect of pushing using the delta angle of progression provides an objective guide to assist with an assessment of labor dystocia in the prolonged second stage on an individualized basis, which may optimize labor management in the prolonged second stage by reducing neonatal and maternal complications related to unnecessary operative deliveries and prolonged second stage of labor.

YouTube as a Source of Patient Information on External Cephalic Version: Cross-Sectional Study

BACKGROUND

With the global increase of cesarean deliveries, breech presentation is the third indication for elective cesarean delivery. Implementation of external cephalic version (ECV), in which the position of the baby is manipulated externally to prevent breech presentation at term, remains suboptimal. Increasing knowledge for caretakers and patients is beneficial in the uptake of ECV implementation. In recent decades, the internet has become the most important source of information for both patients and health care professionals. However, the use and availability of the internet also bring about concerns since the information is often not regulated or reviewed. Information needs to be understandable, correct, and easily obtainable for the patient. Owing to its global reach, YouTube has great potential to both hinder and support spreading medical information and can therefore be used as a tool for shared decision-making.

OBJECTIVE

The objective of this study was to investigate the available information on YouTube about ECV and assess the quality and usefulness of the information in the videos.

METHODS

A YouTube search was performed with five search terms and the first 35 results were selected for analysis. A quality assessment scale was developed to quantify the accuracy of medical information of each video. The main outcome measure was the usefulness score, dividing the videos into useful, slightly useful, and not useful categories. The source of upload was divided into five subcategories and two broad categories of medical or nonmedical. Secondary outcomes included audience engagement, misinformation, and encouraging or discouraging ECV.

RESULTS

Among the 70 videos, only 14% (n=10) were defined as useful. Every useful video was uploaded by educational channels or health care professionals and 80% (8/10) were derived from a medical source. Over half of the not useful videos were uploaded by birth attendants and vloggers. Videos uploaded by birth attendants scored the highest on audience engagement. The presence of misinformation was low across all groups. Two-thirds of the vloggers encouraged ECV to their viewers.

CONCLUSIONS

A minor percentage of videos about ECV on YouTube are considered useful. Vloggers often encourage their audience to opt for ECV. Videos with higher audience engagement had a lower usefulness score compared to videos with lower audience engagement. Sources from medically accurate videos should cooperate with sources with high audience engagement to contribute to the uptake of ECV by creating more awareness and a positive attitude of the procedure, thereby lowering the chance for a cesarean delivery due to breech presentation at term.

Delivery mode after cervical ripening among patients with no prior vaginal births

PURPOSE

To compare mode of delivery and maternal and neonatal outcomes using cervical ripening balloon (CRB) for induction of labor (IOL) in nulliparous patients vs. those undergoing first trial of labor after cesarean (TOLAC).

METHODS

Retrospective cohort study including data from two tertiary medical centers. Included were all patients with a singleton pregnancy and a gestational age > 37+0 weeks and no prior vaginal birth undergoing IOL with CRB. Nulliparous patients (nulliparous group) were compared to patients with one prior cesarean delivery (CD) and no prior vaginal delivery (TOLAC group). Patients who withdrew consent for trial of labor at any time in both groups were excluded. The primary outcome was mode of delivery.

RESULTS

Overall, 161 patients were included in the TOLAC group and 1577 in the nulliparous group. The rate of CD was similar in both groups and remained similar after adjusting for confounders (29.8 % vs. 28.9 %, p = 0.86, OR 1.1, 95 %, CI 0.76-1.58). CD due to fetal distress was more common in the TOLAC group (75 % vs. 56 %, p = 0.014). Other maternal outcomes and neonatal outcomes were similar in the two groups.

CONCLUSION

Comparable vaginal delivery rates may be achieved in patients with or without a previous CD attempting their first trial of labor, with a cervical ripening balloon for labor induction, without increasing adverse maternal or neonatal outcomes.

Epidemiology of Opioid Prescribing After Discharge From Surgical Procedures Among Adults

Importance

Opioid medications are commonly prescribed for the management of acute postoperative pain. In light of increasing awareness of the potential risks of opioid prescribing, data are needed to define the procedures and populations for which most opioid prescribing occurs.

Objective

To identify the surgical procedures accounting for the highest proportion of opioids dispensed to adults after surgery in the United States.

Design, Setting, and Participants

This cross-sectional analysis of the 2020-2021 Merative MarketScan Commercial and Multi-State Databases, which capture medical and pharmacy claims for 23 million and 14 million annual privately insured patients and Medicaid beneficiaries, respectively, included surgical procedures for individuals aged 18 to 64 years with a discharge date between December 1, 2020, and November 30, 2021. Procedures were identified using a novel crosswalk between 3664 Current Procedural Terminology codes and 1082 procedure types. Data analysis was conducted from November to December 2023.

Main Outcomes and Measures

The total amount of opioids dispensed within 3 days of discharge from surgery across all procedures in the sample, as measured in morphine milligram equivalents (MMEs), was calculated. The primary outcome was the proportion of total MMEs attributable to each procedure type, calculated separately among procedures for individuals aged 18 to 44 years and those aged 45 to 64 years.

Results

Among 1 040 934 surgical procedures performed (mean [SD] age of patients, 45.5 [13.3] years; 663 609 [63.7%] female patients), 457 016 (43.9%) occurred among individuals aged 18 to 44 years and 583 918 (56.1%) among individuals aged 45 to 64 years. Opioid prescriptions were dispensed for 503 058 procedures (48.3%). Among individuals aged 18 to 44 years, cesarean delivery accounted for the highest proportion of total MMEs dispensed after surgery (19.4% [11 418 658 of 58 825 364 MMEs]). Among individuals aged 45 to 64 years, 4 of the top 5 procedures were common orthopedic procedures (eg, arthroplasty of knee, 9.7% of total MMEs [5 885 305 of 60 591 564 MMEs]; arthroscopy of knee, 6.5% [3 912 616 MMEs]).

Conclusions and Relevance

In this cross-sectional study of the distribution of postoperative opioid prescribing in the United States, a small number of common procedures accounted for a large proportion of MMEs dispensed after surgery. These findings suggest that the optimal design and targeting of surgical opioid stewardship initiatives in adults undergoing surgery should focus on the procedures that account for the most opioid dispensed following surgery over the life span, such as childbirth and orthopedic procedures. Going forward, systems that provide periodic surveillance of opioid prescribing and associated harms can direct quality improvement initiatives to reduce opioid-related morbidity and mortality.

Effects of perineal massage at different stages on perineal and postpartum pelvic floor function in primiparous women: a systematic review and meta-analysis

BACKGROUND

Perineal massage, as a preventive intervention, has been shown to reduce the risk of perineal injuries and may have a positive impact on pelvic floor function in the early postpartum period. However, there is still debate concerning the best period to apply perineal massage, which is either antenatal or in the second stage of labor, as well as its safety and effectiveness. Meta-analysis was used to evaluate the effect of implementing perineal massage in antenatal versus the second stage of labor on the prevention of perineal injuries during labor and early postpartum pelvic floor function in primiparous women.

METHODS

We searched nine different electronic databases from inception to April 16, 2024. The randomized controlled trials (RCTs) we included assessed the effects of antenatal and second-stage labor perineal massage in primiparous women. All data were analyzed with Revman 5.3, Stata Statistical Software, and Risk of Bias 2 was used to assess the risk of bias. Subgroup analyses were performed based on the different periods of perineal massage. The primary outcomes were the incidence of perineal integrity and perineal injury. Secondary outcomes were perineal pain, duration of the second stage of labor, postpartum hemorrhage, urinary incontinence, fecal incontinence, and flatus incontinence.

RESULTS

This review comprised a total of 10 studies that covered 1057 primigravid women. The results of the analysis showed that perineal massage during the second stage of labor reduced the perineal pain of primigravid women in the immediate postpartum period compared to the antenatal period, with a statistical value of (MD = -2.29, 95% CI [-2.53, -2.05], P < 0.001). Additionally, only the antenatal stage reported that perineal massage reduced fecal incontinence (P = 0.04) and flatus incontinence (P = 0.01) in primiparous women at three months postpartum, but had no significant effect on urinary incontinence in primiparous women at three months postpartum (P = 0.80).

CONCLUSIONS

Reducing perineal injuries in primiparous women can be achieved by providing perineal massage both antenatally and during the second stage of labor. Pelvic floor function is improved in the postnatal phase by perineal massage during the antenatal stage.

TRIAL REGISTRATION

CRD42023415996 (PROSPERO).

Basic psychological needs: A framework for understanding childbirth satisfaction

Women often report being dissatisfied with their childbirth experience, which in turn predicts negative outcomes for themselves and their children. Currently, there is no consensus as to what constitutes a satisfying or positive birth experience. We posit that a useful framework for addressing this question already exists in the form of Basic Psychological Needs Theory, a subtheory of Self-Determination Theory (Deci & Ryan, Can. Psychol., 49, 2008, 182). Specifically, we argue that the degree to which maternity care practitioners support or frustrate women's needs for relatedness, competence, and autonomy predicts their childbirth satisfaction. Using this framework provides a potentially powerful lens to better understand and improve the well-being of new mothers and their infants.

Optimizing Management of the Second Stage of Labor: A Multicenter Randomized Controlled Trial

To review the findings of the Optimizing Management of the Second Stage of Labor randomized controlled trial in the context of prior and subsequent obstetric literature. A multi-database search was performed in addition to a review of the parent trial and secondary studies. Nulliparous patients with neuraxial anesthesia randomized to either immediate or delayed pushing showed no difference in vaginal delivery rates. However, delayed pushing is associated with an increased duration of the second stage and perinatal morbidity. Patients should be appropriately counseled on the timing of second-stage pushing and the risks of prolonged second-stage labor.

Characterizing uterine responsiveness to oxytocin augmentation across four labor patterns in maternal obesity

BACKGROUND

Optimizing care during labor protraction is a key strategy for reducing cesareans, especially among people with obesity. The pathophysiology of labor dystocia remains poorly understood, limiting precise interventions targeting the cause of protraction.

METHODS

In this secondary analysis of nulliparas (n = 92) with obesity (BMI ≥ 30 kg/m2) and spontaneous labor onset, we classified labor into four phenotypes based on duration of protraction and birth route: (1) no protraction, (2) short protraction and vaginal birth, (3) extended protraction meeting criteria for labor arrest, but with eventual progression and vaginal birth, and (4) extended protraction meeting criteria for labor arrest and cesarean birth. Across these phenotypes, we compared MVU, oxytocin dose, and novel measures of uterine responsiveness to oxytocin augmentation (MVU to oxytocin dose ratios).

RESULTS

In our sample, phenotype group 1 comprised 14.1% (n = 13); group 2 comprised 30.4% (n = 28); group 3 comprised 34.8% (n = 32); and group 4 comprised 20.7% (n = 19). Uterine responsiveness to oxytocin, but not MVU, decreased with each labor phenotype. Participants with cesarean birth had the lowest uterine responsiveness to oxytocin.

CONCLUSION

Labor and birth outcomes were associated with measures of uterine responsiveness to oxytocin rather than MVU alone, and thus these may be more clinically appropriate measures for guiding clinical decision-making. Current criteria for labor arrest are likely too stringent for nulliparas with obesity, many of whom appear to progress to safe vaginal birth after longer labor durations. Differences in uterine responsiveness to oxytocin augmentation across the groups suggests underlying physiologic differences in the labor phenotypes, which should drive future research targeting pathophysiology.

Engaging women to set the research agenda for assisted vaginal birth

INTRODUCTION

Public and patient involvement can provide crucial insights to optimise research by enhancing relevance and appropriateness of studies. The World Health Organization (WHO) engaged in an inclusive process to ensure that both technical experts and women had a voice in defining the research gaps and needs to increase or reintroduce the use of assisted vaginal birth (AVB) in settings where this intervention is needed but unavailable or underused.

METHODS

We describe the methods and outcomes of online workshops led by WHO to obtain women representatives' perspectives about AVB research gaps and needs.

RESULTS

After technical experts created a list of research questions based on various evidence syntheses, WHO organised four online workshops with 31 women's representatives from 27 mostly low- and middle-income (LMIC) countries. Women rated the importance and priority of the research questions proposed by the technical experts, improving and broadening some of them, added new questions, and voiced their main concerns and views about AVB. Women helped to put the research questions into context in their communities, highlighted neglected factors/dimensions that influence practices and affect women's experience during labour and childbirth, underscored less salient consequences of AVB, and highlighted the main concerns of women about research on AVB. The consolidated vision of technical experts and women's representatives resulted in a technical brief published by WHO. The technical brief is expected to stimulate global research and action closely aligned with women's priorities.

CONCLUSIONS

We describe a successful experience of engaging women, mostly from LMICs, in the identification of research gaps and needs to reintroduce AVB use. This process contributed to better aligning research questions with women's views, concerns, and priorities. Given the scarcity of reports about engaging women from LMICs to optimise research, this successful experience can serve as an inspiration for future work.

PATIENT OR PUBLIC CONTRIBUTION

Women representatives were involved at every stage of the workshops described in full in this manuscript.

Intrapartum exposure to synthetic oxytocin, maternal BMI, and neurodevelopmental outcomes in children within the ECHO consortium

BACKGROUND

Synthetic oxytocin (sOT) is frequently administered during parturition. Studies have raised concerns that fetal exposure to sOT may be associated with altered brain development and risk of neurodevelopmental disorders. In a large and diverse sample of children with data about intrapartum sOT exposure and subsequent diagnoses of two prevalent neurodevelopmental disorders, i.e., attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), we tested the following hypotheses: (1) Intrapartum sOT exposure is associated with increased odds of child ADHD or ASD; (2) associations differ across sex; (3) associations between intrapartum sOT exposure and ADHD or ASD are accentuated in offspring of mothers with pre-pregnancy obesity.

METHODS

The study sample comprised 12,503 participants from 44 cohort sites included in the Environmental Influences on Child Health Outcomes (ECHO) consortium. Mixed-effects logistic regression analyses were used to estimate the association between intrapartum sOT exposure and offspring ADHD or ASD (in separate models). Maternal obesity (pre-pregnancy BMI ≥ 30 kg/m2) and child sex were evaluated for effect modification.

RESULTS

Intrapartum sOT exposure was present in 48% of participants. sOT exposure was not associated with increased odds of ASD (adjusted odds ratio [aOR] 0.86; 95% confidence interval [CI], 0.71-1.03) or ADHD (aOR 0.89; 95% CI, 0.76-1.04). Associations did not differ by child sex. Among mothers with pre-pregnancy obesity, sOT exposure was associated with lower odds of offspring ADHD (aOR 0.72; 95% CI, 0.55-0.96). No association was found among mothers without obesity (aOR 0.97; 95% CI, 0.80-1.18).

CONCLUSIONS

In a large, diverse sample, we found no evidence of an association between intrapartum exposure to sOT and odds of ADHD or ASD in either male or female offspring. Contrary to our hypothesis, among mothers with pre-pregnancy obesity, sOT exposure was associated with lower odds of child ADHD diagnosis.

Relationships Among Mode of Birth, Onset of Labor, and Bishop Score

OBJECTIVE

To investigate mode of birth in relation to onset of labor and Bishop score.

DESIGN

Retrospective observational cohort design.

SETTING

A 434-bed Magnet redesignated community hospital.

PARTICIPANTS

Nulliparous women, 18 years of age or older, who gave birth at 37 to 41 weeks gestation to live, singleton fetuses in the vertex presentation (N = 701).

METHODS

We conducted a retrospective chart review and used chi-square analysis to measure the associations among mode of birth, onset of labor, and Bishop score. We used logistic regression to test the probability of cesarean birth for women undergoing elective induction of labor.

RESULTS

Most participants (n = 531, 75.7%) gave birth vaginally. Significant findings included the following relationships: spontaneous onset of labor and vaginal birth (χ2 = 22.2, Ø = 0.18, p < .001) and Bishop score of greater than or equal to 8 and vaginal birth (χ2 = 4.9, Ø = .14, p = .028). Induction of labor was a significant predictor in cesarean birth when controlling for age and body mass index (OR = 2.1, 95% confidence interval [1.5, 3.1], p < .001).

CONCLUSION

Reducing elective induction of labor in women with low-risk pregnancies may help lower the risk of cesarean birth. Clinically, Bishop score and mode of birth have a weak association, particularly when induction includes cervical ripening.

Rate of Primary Cesarean Delivery by Language Preference among Nulliparas

OBJECTIVE

Sociodemographic factors such as race/ethnicity and socioeconomic status affect primary cesarean delivery rates. Language is associated with disparate health care outcomes but has not been well studied in obstetrics. We examined the association between primary unscheduled cesarean delivery rate and preferred patient language.

STUDY DESIGN

A retrospective cohort study was conducted at an urban medical center between January 2017 and January 2020. Nulliparous women with early or full-term gestation and having no obstetric or medical contraindication to vaginal delivery were included. We used multivariable linear and logistic regressions to evaluate language differences in cesarean delivery odds and indication for cesarean.

RESULTS

Of the 1,314 eligible women, 76.8% of patients preferred English, 17.8% Spanish, and 5.4% other languages. Overall cesarean delivery rate was 27.6%. Controlling for age, race/ethnicity, body mass index, insurance, gravidity, pregnancy comorbidities, labor induction, and infant birth weight, Spanish- and other language-speaking women had significantly higher odds of undergoing cesarean compared with English-speaking women (adjusted odds ratio [OR]: 1.75; 95% confidence interval [CI]: 1.25, 2.46). Relative proportions of indications for cesarean did not differ by language group. Documented interpreter use was an effect modifier on the relationship between language preference and cesarean (OR with interpreter use: 2.89, 95% CI: 1.90, 4.39).

CONCLUSION

Primary cesarean delivery rates were significantly higher among nulliparous women who prefer languages other than English. This difference may reflect lack of communication, provider bias or discrimination, or other factors, and should be further studied. Interpreter services should be routinely utilized and documented effectively.

KEY POINTS

· Women who prefer languages other than English had higher odds of cesarean.. · Indication for cesarean did not differ by language.. · Interpreter use did not reduce risk for cesarean..

Maternal Morbidity in the Second Stage of Labor: Analysis to Simulate the Clinical Choice

OBJECTIVE

The aim of the study is to analyze maternal morbidity in the second stage of labor in a manner that approximates clinical choice.

STUDY DESIGN

The study design comprises secondary analysis of the Consortium for Safe Labor, which included 228,688 deliveries at 19 hospitals between 2002 and 2008. We included the 107,675 women who were undergoing a trial of labor without a prior uterine scar or history of substance abuse, who reached the second stage, with a liveborn, nonanomalous, vertex, singleton, at term of at least 2,500 g. Maternal complications included postpartum fever, hemorrhage, blood transfusion, thrombosis, intensive care unit (ICU) admission, hysterectomy, and death. For maternal complications, we simulated the clinical choice by comparing operative vaginal or cesarean deliveries to continued expectant management at every hour in the second stage. For neonatal complications, we modeled the risk of severe neonatal complication by second stage duration for spontaneous vaginal deliveries only, adjusting for maternal demographics, comorbidities, and delivery hospital. Severe neonatal complications included death, asphyxia, hypoxic-ischemic encephalopathy (HIE), seizure, sepsis with prolonged stay, need for mechanical ventilation, and 5-minute Apgar score <4.

RESULTS

Maternal morbidity was higher with operative vaginal/cesarean delivery versus continued expectant management for every hour in the second stage, a difference that was statistically significant at hour 2 (18.4 vs. 14.7%; p <0.01). Overall, 951 (0.88%) deliveries were complicated by a severe neonatal complication. A second stage over 4 hours was associated with an adjusted odds of severe neonatal complication of 2.10 (95% confidence interval [CI]: 1.32-3.34) as compared with women who delivered in the first hour.

CONCLUSION

There is a trade-off between maternal and neonatal morbidity in the second stage of labor. Serious neonatal complications rise throughout, however, there is no time at which maternal morbidity is improved with a cesarean or operative vaginal delivery. Strategies are needed to identify neonates at highest risk of complication for targeted intervention.

KEY POINTS

· Severe neonatal complications increase with every hour in the second stage.. · Shortening the second stage is associated with higher maternal complications at every hour.. · There is a trade-off between maternal and neonatal morbidity in the second stage..

Effect of Calcium Channel Blocker on Labor Curve in Pregnant Individuals with Chronic Hypertension

OBJECTIVE

This study aimed to compare the labor progress between individuals who received calcium channel blocker (CCB) and those who did not receive CCB during labor.

STUDY DESIGN

This was a secondary analysis of a retrospective cohort study of individuals with chronic hypertension who underwent vaginal delivery at a tertiary care center from January 2010 to December 2020. We excluded individuals with prior uterine surgeries and a 5-minute Apgar score of less than 5. We used a repeated-measures regression with a third-order polynomial function to compare the average labor curves according to antihypertensive medication. Estimates of the median (5th-95th percentile) traverse times between two dilations were computed using interval-censored regression.

RESULTS

Of 285 individuals with chronic hypertension, 88 (30.9%) received CCB. Individuals who received CCB during labor compared with those who did not were more likely to deliver at earlier gestational age and to have pregestational diabetes and superimposed preeclampsia (p  < 0.01). The progress of labor in the latent phase was not found to be significantly different between both groups (median: 11.51 vs. 8.74 hours; p = 0.08). However, after stratification by parity, nulliparous individuals who received CCB during labor were more likely to have a longer latent phase of labor (median: 14.4 vs. 8.5 hours; p  = 0.03) CONCLUSION:  A calcium channel blocker may slow the latent phase of labor in individuals with chronic hypertension. Aiming to minimize intrapartum iatrogenic interventions, allowing adequate time for pregnant individuals during the latent phase of labor is especially important if individuals are on a calcium channel blocker.

KEY POINTS

· Calcium channel blockers seem to be associated with a longer latent phase of labor.. · The effect of calcium channel blocker on labor was not observed in multiparous individuals.. · Allowing adequate labor time for individuals taking calcium channel blocker is important..

Contemporary Trends in Cesarean Delivery Rates and Indications

OBJECTIVE

This study aimed to describe cesarean delivery rates and indications at a single center in order to assess the impact of the guidelines published by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine on trends in labor management.

STUDY DESIGN

This is a retrospective cohort study of patients ≥23 weeks' gestation delivering at a single tertiary care referral center from 2013 to 2018. Demographic characteristics, mode of delivery, and main indication for cesarean delivery were ascertained by individual chart review. Cesarean delivery indications (mutually exclusive) were the following: repeat cesarean delivery, nonreassuring fetal status, malpresentation, maternal indications (e.g., placenta previa or genital herpes simplex virus), failed labor (any stage labor arrest), or other (i.e., fetal anomaly and elective). Polynomial (cubic) regression models were used to model rates of cesarean delivery and indications over time. Subgroup analyses further examined trends in nulliparous women.

RESULTS

Of the 24,637 patients delivered during the study period, 24,050 were included in the analysis; 7,835 (32.6%) had a cesarean delivery. The rates of overall cesarean delivery were significantly different over time (p < 0.001), declining to a minimum of 30.9% in 2014 and peaking at 34.6% in 2018. With regard to the overall cesarean delivery indications, there were no significant differences over time. When limited to nulliparous patients, the rates of cesarean delivery were also noted to be significantly different over time (p = 0.02) nadiring at 30% in 2015 from 35.4% in 2013 and then rising up to 33.9% in 2018. As for nulliparous patients, there was no significant difference in primary cesarean delivery indications over time except for nonreassuring fetal status (p = 0.049).

CONCLUSION

Despite changes in labor management definitions and guidelines encouraging vaginal birth, the rates of overall cesarean delivery did not decrease over time. The indications for delivery, particularly failed labor, repeat cesarean delivery, and malpresentation have not significantly changed over time.

KEY POINTS

· The rates of overall cesarean deliveries did not decrease despite the 2014 published recommendations for the reduction in cesarean deliveries.. · There were no significant differences in the indications of cesarean deliveries among nulliparous or multiparous women.. · Despite the adoption of strategies to reduce the overall and primary cesarean delivery rates, these trends remain unchanged.. · Indications for delivery, particularly failed labor, repeat cesarean delivery, and malpresentation have also not significantly changed over time.. · Additional strategies to encourage and increase vaginal delivery rates must be adopted..

Fetoscopic Laser Ablation of Type II Vasa Previa: A Cost Benefit Analysis

OBJECTIVE

We aimed to compare costs of two strategies for third-trimester type II vasa previa management: (1) fetoscopic laser ablation surgery (FLS) referral and (2) standard management (SM).

STUDY DESIGN

A decision analytic model and cost-benefit analysis from a health care perspective were performed. The population included patients with type II vasa previa at approximately 32 weeks. SM entailed 32-week antepartum admission and cesarean at approximately 35 weeks. FLS referral included consultation and possible laser surgery at 32 weeks for willing/eligible candidates. Successful laser surgery allowed the possibility of term vaginal delivery. Outcomes included antepartum admission, preterm birth, cesarean, neonatal transfusion, and death. Sensitivity analyses were performed.

RESULTS

In base case analysis, FLS referral was cost saving compared with SM (total cost per patient $65,717.10 vs. 71,628.16). FLS referrals yielded fewer antepartum admissions, cesareans, premature births, neonatal transfusions, and deaths. Eligible referred patients choosing FLS incurred a total cost of $41,702.46, a >40% decrease compared with SM. FLS referral was cost saving in all one-way sensitivity analyses except when antepartum admission costs were low. In threshold analyses, FLS referral was cost saving unless laser surgery cost was >$39,892 (2.75x expected cost), antepartum admission cost for monitoring of vasa previa or ruptured membranes was <$7,455, <11% patients were eligible for laser surgery, and when <12% of eligible patients chose laser surgery. In two-way sensitivity analysis, FLS referral was cost saving except at very high laser surgery costs and extremely low antepartum admission costs.

CONCLUSION

Referral for FLS for type II vasa previa was cost saving and improved outcomes compared with SM, despite upfront costs, fetoscopy-related risks, and many patients being ineligible or not opting for surgery after referral.

KEY POINTS

· Vasa previa rupture may lead to fetal exsanguination and death.. · Late preterm cesarean is common practice for prenatally diagnosed vasa previa.. · Successful fetoscopic laser ablation for type II vasa previa has been described.. · Laser ablation of vasa previa allows for a safe-term vaginal delivery.. · Referral for laser surgery is cost saving and is associated with improved outcomes..

Clinical Factors Associated with Intrapartum Presentation Change after Mechanical Cervical Ripening

OBJECTIVE

The use of mechanical cervical ripening with balloon devices is common during induction of labor; however, there is risk for displacement of the fetal presenting part during its insertion. This study sought to investigate the clinical risk factors associated with an intrapartum presentation change from cephalic to noncephalic presentation after mechanical cervical ripening.

STUDY DESIGN

Data were obtained from the Consortium on Safe Labor, a multicenter retrospective study that abstracted detailed labor and delivery information from electronic medical records in 19 hospitals across the United States. All women with fetal cephalic confirmed position on admission undergoing induction of labor with mechanical cervical ripening were included. Women who had a cesarean delivery for noncephalic presentation were compared with women who had a vaginal delivery or cesarean delivery for other indications. Models were adjusted for nulliparity, multiple gestation, and gestational age.

RESULTS

A total of 3,462 women met inclusion criteria, with 1.3% (n = 46) having an intrapartum presentation change from cephalic to noncephalic presentation after mechanical cervical ripening. Those who had a cesarean delivery for an intrapartum presentation change were more likely to be nulliparous (82.6 vs. 65.4%, p = 0.01), less than 34 weeks' gestation (6.5 vs. 1.3%, p = 0.02), and have twins (6.5 vs. 1.2%, p = 0.02). In adjusted analysis, twins were associated with an increased odds of cesarean delivery for intrapartum presentation change (adjusted odds ratio [aOR]: 4.43; 95% confidence interval [CI]: 1.25-15.77), whereas multiparity reduced the odds (aOR: 0.38; 95% CI: 0.17-0.82).

CONCLUSION

Nulliparity and multifetal gestation are associated with a cesarean delivery for an intrapartum presentation change after mechanical cervical ripening.

KEY POINTS

· Intrapartum presentation change after mechanical cervical ripening is low at 1.3%.. · Nulliparity and multifetal gestation are associated with a cesarean delivery for presentation change.. · There were no significant differences in neonatal morbidity by delivery status to delivery type..

Applying Automated Machine Learning to Predict Mode of Delivery Using Ongoing Intrapartum Data in Laboring Patients

OBJECTIVE

This study aimed to develop and validate a machine learning (ML) model to predict the probability of a vaginal delivery (Partometer) using data iteratively obtained during labor from the electronic health record.

STUDY DESIGN

A retrospective cohort study of deliveries at an academic, tertiary care hospital was conducted from 2013 to 2019 who had at least two cervical examinations. The population was divided into those delivered by physicians with nulliparous term singleton vertex (NTSV) cesarean delivery rates <23.9% (Partometer cohort) and the remainder (control cohort). The cesarean rate among this population of lower risk patients is a standard metric by which to compare provider rates; <23.9% was the Healthy People 2020 goal. A supervised automated ML approach was applied to generate a model for each population. The primary outcome was accuracy of the model developed on the Partometer cohort at 4 hours from admission to labor and delivery. Secondary outcomes included discrimination ability (receiver operating characteristics-area under the curve [ROC-AUC]), precision-recall AUC, and calibration of the Partometer. To assess generalizability, we compared the performance and clinical predictors identified by the Partometer to the control model.

RESULTS

There were 37,932 deliveries during the study period; after exclusions, 9,385 deliveries were included in the Partometer cohort and 19,683 in the control cohort. Accuracy of predicting vaginal delivery at 4 hours was 87.1% for the Partometer (ROC-AUC: 0.82). Clinical predictors of greatest importance in the stacked Intrapartum Partometer Model included the Admission Model prediction and ongoing measures of dilatation and station which mirrored those found in the control population.

CONCLUSION

Using automated ML and intrapartum factors improved the accuracy of prediction of probability of a vaginal delivery over both previously published models based on logistic regression. Harnessing real-time data and ML could represent the bridge to generating a truly prescriptive tool to augment clinical decision-making, predict labor outcomes, and reduce maternal and neonatal morbidity.

KEY POINTS

· Our ML-based model yielded accurate predictions of mode of delivery early in labor.. · Predictors for models created on populations with high and low cesarean rates were the same.. · A ML-based model may provide meaningful guidance to clinicians managing labor..

Cesarean Sections and Family Planning Among Ultra-Orthodox Israeli Jews

The elevated frequency of Cesarean sections (C-sections) in OECD countries not only burdens health systems financially but also heightens the risks for mothers and infants. This study explores the feasibility of reducing C-section rates by examining the Israeli ultra-Orthodox population, noted for its large families and low C-section rates. We analyze birth data from an Israeli hospital, focusing on ultra-Orthodox mothers with husbands who are yeshiva students compared to other mothers. Our findings reveal that all else being equal, mothers married to yeshiva students exhibit a lower likelihood of undergoing a C-section and a higher propensity to seek private medical services to avoid this procedure. This behavior is attributed to their preference for large families and the desire to minimize C-sections, which may restrict the number of possible future pregnancies. These insights underscore the potential effectiveness of initiatives encouraging mothers to opt for vaginal deliveries, thereby reducing healthcare costs and maternal-infant risks.

Impact of time interval from cesarean delivery to frozen embryo transfer on reproductive and neonatal outcomes

OBJECTIVE

To evaluate differences in reproductive and neonatal outcomes on the basis of the time interval from cesarean delivery to subsequent frozen embryo transfer (FET).

DESIGN

Retrospective cohort.

SETTING

Multicenter fertility practice.

PATIENTS

Women undergoing autologous elective single embryo transfer FET after prior cesarean delivery.

INTERVENTION

Time from prior cesarean delivery to subsequent FET.

MAIN OUTCOME MEASURES

live birth (LB).

RESULTS

A total of 6,556 autologous elective single embryo transfer FET cycles were included. Frozen embryo transfer cycles were divided into eight groups on the basis of the time interval from prior cesarean delivery to subsequent FET in months. A secondary analysis was then performed with time as a continuous variable. The proportion of LBs did not differ significantly across all time interval groups and over continuous time (range: 40.0%-45.6%). The mean gestational age at the time of delivery did not significantly differ as the time between prior cesarean delivery and subsequent FET increased (range: 37.3-38.4). When time was evaluated continuously, the proportion of preterm births was higher with a shorter time between cesarean delivery and subsequent FET. The mean birth weight ranged from 3,181-3,470g, with a statistically significant increase over time. However, the proportions of extremely low birth weight, very low birth weight, and low birth weight did not significantly differ.

CONCLUSION

There were no significant differences in reproductive outcomes on the basis of the time interval from cesarean delivery to FET, including LB. The proportion of preterm deliveries decreased with a longer time between cesarean delivery and FET. Differences in mean neonatal birth weight were not clinically significant because the proportion of low birth weight neonates was not significantly different over time. Although large, this sample cannot address all outcomes associated with short interpregnancy intervals, particularly rarer outcomes such as uterine rupture. When counseling patients, the timing of FET after cesarean delivery must be balanced against the risks of increasing maternal age on reproductive and neonatal outcomes.

Risk of intrapartum cesarean delivery in twin pregnancies: A retrospective cohort study

OBJECTIVE

To compare the risk of intrapartum cesarean delivery (CD) between patients with twin and singleton pregnancies undergoing a trial of labor and identify risk factors for intrapartum CD in twin pregnancies.

METHODS

The present study was a retrospective cohort study of patients with a twin or singleton pregnancy who underwent a trial of labor at ≥340/7 weeks in a single center (2015-2022). The primary outcome was the rate of intrapartum CD. In twin pregnancies, this outcome was limited to CD of both twins. The association of plurality with intrapartum CD was estimated using multivariable Poisson regression.

RESULTS

A total of 20 754 patients met the study criteria, 669 of whom had a twin pregnancy. Patients with twins had a greater risk of intrapartum CD (of both twins) than those with singleton pregnancies (22.1% vs 15.9%, respectively; aRR 1.38 [95% CI: 1.15-1.66]), primarily due to a greater risk of failure to progress. In addition, 4.1% of the twin pregnancies had a CD for the second twin, resulting in an overall CD rate in twin pregnancies of 26.2%. Variables associated with intrapartum CD in twin pregnancies included nulliparity (aOR 3.50, 95% CI: 2.34-5.25), birthweight discordance >20% (aOR 2.47, 95% CI: 1.27-4.78), and labor induction (aOR 1.64, 95% CI: 1.07-2.53). The rate of intrapartum CD was highest when all three risk factors were present (67% [95% CI: 41%-87%]).

CONCLUSION

Twin pregnancies are associated with a greater risk of intrapartum CD than singleton pregnancies. Information on the individualized risk of intrapartum CD may be valuable when counseling patients with twins regarding mode of delivery.

Pre-pregnancy body mass index and caesarean section in Andean women in Peru: a prospective cohort study

BACKGROUND

During the last two decades, Caesarean section rates (C-sections), overweight and obesity rates increased in rural Peru. We examined the association between pre-pregnancy body mass index (BMI) and C-section in the province of San Marcos, Northern Andes-Peru.

METHODS

This is a prospective cohort study. Participants were women receiving antenatal care in public health establishments from February 2020 to January 2022, who were recruited and interviewed during pregnancy or shortly after childbirth. They answered a questionnaire, underwent a physical examination and gave access to their antenatal care card information. BMI was calculated using maternal height, measured by the study team and self-reported pre-pregnancy weight measured at the first antenatal care visit. For 348/965 (36%) women, weight information was completed using self-reported data collected during the cohort baseline. Information about birth was obtained from the health centre's pregnancy surveillance system. Regression models were used to assess associations between C-section and BMI. Covariates that changed BMI estimates by at least 5% were included in the multivariable model.

RESULTS

This study found that 121/965 (12.5%) women gave birth by C-section. Out of 495 women with pre-pregnancy normal weight, 46 (9.3%) had C-sections. Among the 335 women with pre-pregnancy overweight, 53 (15.5%) underwent C-sections, while 23 (18.5%) of the 124 with pre-pregnancy obesity had C-sections. After adjusting for age, parity, altitude, food and participation in a cash transfer programme pre-pregnancy overweight and obesity increased the odds of C-section by more than 80% (aOR 1.82; 95% CI 1.16-2.87 and aOR 1.85; 95% CI 1.02-3.38) compared to women with a normal BMI.

CONCLUSIONS

High pre-pregnancy BMI is associated with an increased odds of having a C-section. Furthermore, our results suggest that high BMI is a major risk factor for C-section in this population. The effect of obesity on C-section was partially mediated by the development of preeclampsia, suggesting that C-sections are being performed due to medical reasons.

Impact of prior use of topical hemostatic agents on trial of labor after cesarean: Insights from a multicenter cohort study

OBJECTIVE

To evaluate the association between a topical hemostatic agent used at the time of cesarean delivery and uterine scar disruption (rupture or dehiscence) at the subsequent trial of labor after cesarean (TOLAC).

METHODS

A multicenter retrospective cohort study was conducted (2005-2021). Parturients with a singleton pregnancy in whom a topical hemostatic agent was placed during the primary cesarean delivery were compared with patients in whom no such agent was placed. We assessed the uterine scar disruption rate after the subsequent TOLAC and the rate of adverse maternal outcomes. Univariate analyses were followed by multivariate analysis (adjusted odds ratio [aOR]; 95% confidence interval [CI]).

RESULTS

During the study period, 7199 women underwent a trial of labor and were eligible for the study; 430 (6.0%) had prior use of a hemostatic agent, 6769 (94.0%) did not. In univariate analysis, a history of topical hemostatic agent use was not found to be significantly associated with uterine scar rupture, dehiscence, or failed trial of labor. This was also confirmed on multivariate analysis for uterine rupture (aOR 1.91, 95% CI 0.66-5.54; P = 0.23), dehiscence of uterine scar (aOR 1.62, 95% CI 0.56-4.68; P = 0.37), and TOLAC failure (aOR 1.08, 95% CI 0.79-1.48; P = 0.61).

CONCLUSION

A history of hemostatic agent use is not associated with an increased risk for uterine scar disruption after subsequent TOLAC. Further prospective studies in other settings are needed to strengthen these findings.

Adherence to Definitions of Labor Arrest Influence on Primary Cesarean Delivery Rate

OBJECTIVE

The cesarean delivery rate in the United States is 31.9%. One of the leading indications for primary cesarean delivery is labor arrest. A modern understanding of the labor curve supports more time prior to the diagnosis of labor arrest. We conducted this study to examine the impact of adherence to the modern criteria for labor arrest and failed induction on rates of primary cesarean delivery and to identify predictors of meeting these criteria.

STUDY DESIGN

We analyzed rates of primary cesarean deliveries overall and primary cesarean deliveries occurring due to arrest of dilation, arrest of descent, and failed induction among the 17,877 live births at a large academic center from 2010 through 2013. Multiple logistic regression modeling identified predictors of meeting the new criteria for these indications based on guidelines published by the 2012 National Institute of Child Health and Human Development.

RESULTS

The primary cesarean delivery rate decreased from 23.5 to 21.1% (p = 0.026) from 2010 to 2013. Primary cesarean delivery rate for labor arrest and failed induction decreased from 8.5 to 6.7% (p = 0.005). The percentage of primary cesarean deliveries meeting the 2012 criteria for labor arrest increased from 18.8 to 34.9% (p = 0.002), and the rate of primary cesarean deliveries due to arrest of dilation decreased from 5.1 to 3.4% (p < 0.0005). The percentage of cases meeting the 2012 criteria for arrest of descent increased from 57.8 to 71.0% (p < 0.007), while primary cesarean delivery rate due to arrest of descent remained relatively unchanged, 3.1 to 2.6% (p = 0.330).

CONCLUSION

A decrease in the primary cesarean rate was attributable to a decrease in cesarean for arrest of dilation in the setting of a significant increase in meeting the 2012 criteria for arrest of dilation. At the end of the study period, 65.2% of cesareans still did not meet the criteria for arrest of dilation. Greater rates of adherence to these guidelines may yield further reductions in the cesarean rate.

KEY POINTS

· Primary cesarean delivery for labor arrest was decreased.. · Meeting criteria for labor arrest increased.. · A hospitalist provider increased odds of meeting criteria..

The Relationship between Gestational Weight Gain and Cesarean Delivery among Patients undergoing Induction of Labor

OBJECTIVE

This study aimed to determine the impact of pregnancy weight gain above National Academy of Medicine (NAM) guidelines on cesarean delivery rates following induction.

STUDY DESIGN

This is a secondary analysis of a prospective cohort study of patients who underwent induction at a single tertiary care center between July 2017 and July 2019. Included in the primary study were patients undergoing term (≥37 weeks) labor induction with a singleton gestation, intact membranes, and unfavorable cervical examination (Bishop score of ≤6 and cervical dilation ≤ 2 cm). Eligibility for this analysis was limited to patients with a documented prenatal body mass index (BMI) < 20 weeks' gestation. The primary exposure was gestational weight gain greater than NAM guidelines (WGGG) for a patient's initial BMI category. The primary outcome was cesarean delivery for any indication.

RESULTS

Of 1,610 patients included in the original cohort, 1,174 (72.9%) met inclusion criteria for this analysis and 517 (44.0%) of these had weight gain above NAM guidelines. Of the entire cohort, 60.0% were Black and 52.7% had private insurance. In total, 160 patients (31%) with WGGG underwent cesarean compared with 127 patients (19.3%) without WGGG (p < 0.001), which equates to a 59% increased odds of cesarean when controlling for initial BMI category, parity, gestational diabetes, and indication for induction (Adjusted Odds Ratio [aOR] 1.58, 95% confidence interval [CI] 1.17-2.12). Among only nulliparous patients, WGGG was associated with an increased odds of cesarean (26.4 vs. 38.2%, aOR 1.50, 95% CI 1.07-2.10). In multiparous patients, however, there was no difference in cesarean between those with and without WGGG (8.8 vs. 14.1%, aOR 1.85, 95% CI 0.96-3.58).

CONCLUSION

This study demonstrates that weight gain above NAM guidelines is associated with more than a 50% increased odds of cesarean. Patients should be informed of this association as gestational weight gain may be a modifiable risk factor for cesarean delivery.

KEY POINTS

· Weight gain above NAM guidelines was associated with a 59% increased odds of cesarean delivery.. · Nulliparous patients with weight gain above NAM guidelines are at higher risk of cesarean delivery.. · No difference in cesarean delivery among multiparous patients regardless of gestational weight gain..

Routine vaginal examination to assess labor progress at 8 compared to 4 hours after early amniotomy following Foley balloon ripening in the labor induction of multiparas: a randomized trial

BACKGROUND

Vaginal examination to monitor labor progress is recommended at least every 4 hours, but it can cause pain and embarrassment to women. Trial data are limited on the best intensity for vaginal examination. Vaginal examination is not needed for oxytocin dose titration after an amniotomy has been performed and oxytocin infusion started. The Foley balloon commonly ripens the cervix without strong contractions. Amniotomy and oxytocin infusion are usually required to drive labor.

OBJECTIVE

This study aimed to evaluate the first vaginal examination at 8 vs 4 hours after amniotomy-oxytocin after Foley ripening in multiparous labor induction.

STUDY DESIGN

A randomized controlled trial was conducted from October 2021 to September 2022 at the University Malaya Medical Center, Kuala Lumpur, Malaysia. Multiparas at term were recruited at admission for labor induction. Participants were randomized to a first routine vaginal examination at 8 or 4 hours after Foley balloon ripening and amniotomy. Titrated oxytocin infusion was routinely commenced after amniotomy to initiate contractions. The 2 primary outcomes were the time from amniotomy to delivery (noninferiority hypothesis) and maternal satisfaction (superiority hypothesis). Data were analyzed using the Student t test, Mann-Whitney U test, and chi-square test (or Fisher exact test), as suitable for the data.

RESULTS

A total of 204 women were randomized, 102 to each arm. Amniotomy to birth intervals were 4.97±2.47 hours in the 8-hour arm and 5.79±3.17 hours in the 4-hour arm (mean difference, -0.82; 97.5% confidence interval, -1.72 to 0.08; P=.041; Bonferroni correction), which were noninferior within the prespecified 2-hour upper margin, and the maternal satisfaction scores (11-point 0-10 numerical rating scale) with allocated labor care were 9 (interquartile range, 8-9) in the 8-hour arm and 8 (interquartile range, 7-9) in the 4-hour arm (P=.814). In addition, oxytocin infusion to birth interval difference was noninferior within the 97.5% confidence interval (-1.59 to 0.23) margin of 1.3 hours. Of the maternal outcomes, the amniotomy to first vaginal examination intervals were 3.9±1.8 hours in the 8-hour arm and 3.4±1.3 hours in the 4-hour arm (P=.026), and the numbers of vaginal examinations were 2.00 (interquartile range, 2.00-3.00) in the 8-hour arm and 3.00 (interquratile range, 2.00-3.25) in the 4-hour arm (P<.001). For the 8-hour arm, the first vaginal examination was less likely to be as scheduled and more likely to be indicated by sensation to bear down (P<.001), and the epidural analgesia rates were lower (13/102 participants [12.7%] in the 8-hour arm vs 28/102 participants [27.5%] in the 4-hour arm; relative risk, 0.46; 95% confidence interval, 0.26-0.84; P=.009). Other outcomes of the mode of delivery, indications for cesarean delivery, and delivery blood loss were not different. Neonatal outcomes were not different.

CONCLUSION

Routine first vaginal examination at 8 hours compared with that at 4 hours was noninferior for the time to birth but did not improve maternal satisfaction.

Trends in vacuum and forceps delivery in teaching hospitals and academic health systems in West Java, Indonesia: A retrospective study

Objectives

Recently, there has been a decline in the use of vacuums and forceps. This is due to complications that occur in the mother and baby as well as the operator's ability to operate the instruments. Concerning Professional Education Standards for Obstetrics and Gynecology Specialists, the minimum skill that must be achieved by vacuum extraction and forceps is a minimum of five cases. This is difficult to achieve with the number of obstetrics and gynecology residents in West Java.

Methods

A retrospective study was conducted using medical records based on the International Classification of Disease 10th Revision from 1 to 28 February 2023 at teaching hospitals and Academic Health System in West Java, namely Hasan Sadikin Hospital, Al-Ihsan Hospital Bandung, and Cikalong Wetan Hospital West Bandung, in the period 1 January 2018 to 31 December 2022. The main outcome was vacuum and forceps extraction with consecutive sampling. The relationship between maternal characteristics such as maternal age, parity, gestational age, and indication for delivery with vaginal operative delivery was descriptive statistics analyzed using IBM SPSS Statistics 26.

Results

Trends indicate that the percentage of vaginal operative deliveries tends to be low, below 5%. Vacuum deliveries decreased from 0.75% in 2018 to 0.68% in 2022, while forceps deliveries decreased from 2.77% to 0.98% over the same period.

Conclusion

This study concludes that there was an insufficiency of vacuum extraction and forceps delivery cases at the teaching hospital and Academic Health System in West Java to achieve a minimum case of vacuum and forceps. Further research studying how educational interventions improve operative delivery skills might be considered.