Choosing between bad, worse and worst: what is the preferred mode of delivery for failure of the second stage of labor?

Deep neural network (DNN) modelling for prediction of the mode of delivery

One of the factors that worry obstetricians the most is the method of delivery. In recent years, the rate of caesarean sections has steadily climbed and now exceeds the threshold advised by medical organizations. Obstetricians typically lack the tools they need to assess whether vaginal delivery or a caesarean delivery is more appropriate. In this work, we suggested a computerized decision-making process for deciding on the best birthing style. The data was collected from 101 pregnant subjects who were admitted to hospital in eastern India for delivery from January 2021 to September 2021.The data set had 101 instances & 11 variables. The response was a binary variable with "caesarean" & "vaginal" as the outputs. A deep neural network model (DNN) was developed by using train set with h2o package. The model was selected on the basis of AUC (Area under the Curve) & KS (Kolmogorov-Smirnov) score. The AUC, KS score for train set were 0.99, 0.98 respectively. The prediction error rates for caeseraen & vaginal classes in train data are 0.02 & 0.00 respectively. The results support the use of these algorithms in the creation of a clinical decision system to help gynaecologists choose the most appropriate delivery method.

A new classification allowing assessment of instrumental vaginal-birth practices

BACKGROUND

Instrumental vaginal birth, a very common intervention in obstetrics, concerns nearly one in eight women in France. Instrumentally assisted vaginal childbirth can be for maternal and/or fetal indications. Although it reduces recourse to caesarean section, it is subject to risks. Practices concerning instrumental birth are disparate, varying among different practitioners, maternity units and countries, and it is essential to be able to evaluate them. Our objective was to create a classification tool of women requiring instrumental birth to facilitate the analysis of practices within our maternity unit as well as to enable temporal and geographical comparisons.

MATERIALS AND METHODS

We propose a simple and robust classification based on the same principles as Robson's classification. It is made up of seven totally inclusive and mutually exclusive groups. Our classification was refined and validated using the Delphi method by a panel of 14 experts from throughout France, and tested in our maternity unit using data from throughout 2021.

RESULTS

The seven clinically relevant groups are based on five obstetric criteria (multiplicity, presentation, gestational age, previous type of birth, induction of labor). To classify each woman in a group, five successive questions are posed in a predefined order. The classification has been validated by the experts with highly satisfactory overall agreement.

CONCLUSION

In order to improve the quality of care, we propose a tool to standardize the evaluation of instrumental vaginal birth practice (called the "Isère classification", after the county where we work in south-eastern France). It will also facilitate the comparison the practices among different maternity units in a network, a country or even among different countries.

Association of the Kiwi OmniCup system with maternal and neonatal morbidity: A retrospective cohort study

OBJECTIVE

To discuss the effect of the Kiwi OmniCup system on reducing adverse maternal and neonatal outcomes and provide a reference for assisted vaginal delivery methods.

METHODS

Women who gave birth to singleton term neonates in a cephalic presentation and underwent assisted vaginal delivery from 2017 to 2021 were eligible for inclusion in the study; they were divided into a Kiwi OmniCup system group and a forceps group. Binary logistic regression analysis was used to observe and compare maternal and neonatal outcomes. The primary outcomes were severe maternal and neonatal morbidity. Severe maternal morbidity was defined as the occurrence of at least one of the following outcomes: third- or fourth-degree perineal lacerations, refractory postpartum hemorrhage, thrombotic events, amniotic fluid embolism, admission to the intensive care unit, and maternal death. Severe neonatal morbidity was defined as the occurrence of at least one of the following outcomes: neonatal asphyxia requiring resuscitation or intubation, neonatal head and face injuries, neonatal fracture, and admission to the neonatal intensive care unit for longer than 24 h.

RESULTS

The rate of severe neonatal morbidity in the forceps group was significantly higher than that in the Kiwi OmniCup system group, the differences between the two groups were significant (27.2% vs. 42.3%, P < 0.001), and there was no significant difference in the rate of severe maternal morbidity between the two groups (30% vs. 30%, P > 0.05). Binary logistic regression analysis showed that Kiwi OmniCup system-assisted delivery reduced severe neonatal morbidity (adjusted odds ratio 0.49; 95% confidence interval 0.33-0.73) and did not increase severe maternal morbidity compared with forceps-assisted delivery.

CONCLUSION

The Kiwi OmniCup system, which can reduce the incidence of severe neonatal morbidity without increasing the incidence of serious adverse maternal outcomes, is worthy of clinical promotion.

Association of maternal body mass index with success and outcomes of attempted operative vaginal delivery

BACKGROUND

Increasing maternal body mass index is associated with increased morbidity at cesarean delivery in a dose-dependent manner. In some clinical scenarios, operative vaginal delivery is a strategy to prevent the morbidity associated with second-stage cesarean delivery, but the relationship between maternal body mass index and outcomes of attempted operative vaginal delivery is not well characterized.

OBJECTIVE

This study aimed to assess whether the success of and adverse outcomes after attempted operative vaginal delivery are associated with maternal body mass index at delivery among nulliparous individuals.

STUDY DESIGN

This was a secondary analysis from the prospective cohort Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be study. This analysis included cephalic live-born nonanomalous singleton pregnancies ≥34 weeks at delivery with an attempted operative vaginal delivery (either forceps or vacuum). The primary exposure was maternal body mass index at delivery (≥30 vs <30 kg/m2 [referent]). The primary outcome was an unsuccessful operative vaginal delivery attempt, defined as a cesarean delivery after an attempted operative vaginal delivery. The secondary outcomes included maternal and neonatal adverse outcomes. Multivariable logistic regression was used, and statistical interaction between operative instrument type (vacuum vs forceps) and body mass index was assessed.

RESULTS

Of 10,038 assessed individuals, 791 (7.9%) had an attempted operative vaginal delivery and were included in this analysis. Of note, 325 individuals (41%) had a body mass index ≥30 kg/m2 at delivery. Overall, 42 of 791 participants (5%) experienced an unsuccessful operative vaginal delivery. Individuals with a body mass index ≥30 kg/m2 at delivery were more than twice as likely to have an unsuccessful operative vaginal delivery than those with a body mass index <30 kg/m2 (8.0% vs 3.4%; adjusted odds ratio, 2.23; 95% confidence interval, 1.16-4.28; P=.005). Composite maternal morbidity and composite neonatal morbidity did not vary by body mass index group. There was no evidence of interaction or effect modification by operative instrument type for the rate of unsuccessful operative vaginal delivery attempt, composite maternal morbidity, or composite neonatal morbidity.

CONCLUSION

Among nulliparous individuals who underwent an attempted operative vaginal delivery, those with a body mass index ≥30 kg/m2 at delivery were more likely to have an unsuccessful operative vaginal delivery attempt than those with a body mass index <30 kg/m2. There was no difference in composite maternal or neonatal morbidity after attempted operative vaginal delivery by body mass index category.

Nomogram based on the final antepartum ultrasound features before delivery for predicting failed spontaneous vaginal delivery in nulliparous women

Background

Accurate identification of nulliparous women with failed spontaneous vaginal delivery (SVD) is crucial to minimize the hazards associated with obstetrical intervention (OI). While abnormal labor progression can be identified with intrapartum ultrasonography, labor-related complications may be unavoidable due to the limited time window left to the obstetrician. Antepartum ultrasound enables sufficient obstetric planning. However, there is typically a longer gap between ultrasound assessment and delivery that often lowers the prediction accuracy compared to intrapartum ultrasonography.

Objective

In this study, antepartum ultrasound assessment was included to each fetal ultrasound examination after 36 weeks of gestation until the onset of labor. We aim to establish a nomogram to predict the likelihood of failed SVD in nulliparous women using the last antepartum ultrasound findings before labor beginning.

Methods

Of the 2,143 nulliparous women recruited, 1,373 were included in a training cohort and 770 in a validation cohort, based on their delivery date. Maternal and perinatal characteristics, as well as perinatal ultrasound parameters were collected. In the training cohort, the screened correlates of SVD failure were used to develop a nomogram for determining whether a nulliparous woman would experience SVD failure. This model was validated in both training and validation cohorts.

Results

SVD failure affected 217 nulliparous women (10.13%). In the training cohort, SVD failure was independently associated with BMI [odds ratio (OR) = 1.636], FHC (OR = 1.194), CL (OR = 1.398), and PCA (OR = 0.824) (all P < 0.05). They constituted a nomogram to estimate the individual risk of SVD failure. The model obtained clinical net benefits in both the training and validation cohorts and was validated to present strong discrimination and calibration.

Conclusion

The developed nomogram based on the last antepartum ultrasound findings may be helpful in avoiding OI and its related complications by assessing the likelihood of a failed SVD in nulliparous women.

Second stage expedite delivery of low birth weight neonates: Emergent cesarean delivery versus vacuum assisted delivery

OBJECTIVE

To determine maternal and neonatal outcomes among women undergoing second stage emergent cesarean delivery (ECD) versus vacuum-assisted delivery (VAD) of low birthweight neonates.

MATERIALS AND METHODS

A retrospective cohort study from two tertiary medical centers. We included women who underwent either ECD or VAD during the second stage of labor, and delivered neonates with a birthweight of <2500 g during 2011-2019. Characteristics and outcomes were compared between the groups. The primary outcome was the rate of a composite adverse neonatal outcome, defined as the presence of ≥1 of the following: Apgar 5 min < 7, respiratory distress syndrome, neonatal intensive care unit admission, mechanical ventilation and intrapartum fetal death.

RESULTS

The study cohort included 611 patients, of whom 46 had ECD and 565 had VAD. Baseline characteristics did not differ between the groups. The rate of Apgar score < 7 at 1 min was higher among the ECD group]10 (22%) vs. 29 (5%), OR (95% CI) 5.1 (2.3-11.3), p < 0.001[. Other neonatal and maternal outcomes were similar in both groups.

CONCLUSIONS

Neonatal and maternal outcomes do not differ substantially between ECD and VAD of neonates weighing <2500 g. This information may be useful when contemplating the preferred mode of delivery in this setting.

Neonatal outcome of second-stage cesarean delivery versus vacuum extraction among neonates <34 weeks

OBJECTIVE

Among deliveries <34 weeks, there is inconclusive evidence regarding the preferred route of delivery when there is a need to expedite delivery during the second stage of labor. As it is unreasonable that future randomized controlled trials will be conducted to settle this query, every clinical data concerning this topic, may be helpful. We aim to compare neonatal outcomes among women undergoing emergent cesarean delivery (ECD) versus vacuum-assisted delivery (VAD) during the second stage of labor among singleton gestations <34 weeks.

METHODS

A retrospective cohort study including all women who underwent either ECD or VAD at the second stage of labor between 30°^/7 and 33^6/7weeks, during 2011-2019. The primary outcome was the rate of adverse neonatal outcomes, defined as intrapartum death, mechanical ventilation, asphyxia, respiratory distress syndrome, subgaleal hemorrhage, intraventricular hemorrhage, necrotizing enterocolitis, and phototherapy.

RESULTS

Of the 153,672 live singleton deliveries during the study period, 2871 (1.9%) delivered before 34°^/7. Of those 1674 (58.3%) delivered vaginally unassisted and 1137 (39.6%) delivered by a CD during the first stage of labor. A total of 60 deliveries were analyzed, with a median gestational age of 32 weeks, interquartile range (IQR) 31-33. Median birth weight at delivery was 1845 g, IQR 1574-2095. Overall 25 (42%) of women were delivered by VAD and 35 by CD (58%). Indications for expeditious delivery did not differ between the study groups. Neonates delivered by VAD had a higher median birth weight (1940 vs. 1620 g, p = .02). Second stage of labor was longer in the ECD group as compared to the VAD group (median 200 vs. 52 min, p = .01). The rate of Apgar score at 1 min <7 was higher among the CD group (10 (40%) vs. 5 (14%), OR [95% CI]: 4.0 (1.1-13.8), p = .03). Longer length of stay was evident in the CD group as compared to the VAD group (median 30 vs. 21 days, p = .001). The rate of composite neonatal adverse outcome was comparable between the study groups. Adverse outcomes were associated with lower body mass index (median 27.7 vs. 34.9, p = .04), higher rate of premature preterm rupture of membranes (40 (91%) vs. 5 (31%), OR [95% CI]: 22.0 (5.0-91.1), p < .001) and labor dystocia as the indication for expedited delivery (38 (86%) vs. 7 (44%), OR [95% CI]: 8.1 (2.1-30.1), p = .001).

CONCLUSIONS

Cesarean delivery during the second stage of labor of gestations <34 weeks was associated with a higher rate of lower Apgar scores and longer length of stay.

SYNOPSIS

Delivery by second stage CD of premature neonates <34 weeks is associated with a higher rate of lower Apgar score.

Risks associated with cesarean delivery during prolonged second stage of labor

BACKGROUND

Data regarding maternal and fetal morbidities are limited to surgical morbidity per each additional hour in the second stage of labor.

OBJECTIVE

This study aimed to quantify perinatal morbidities associated with cesarean delivery by duration of the second stage of labor.

STUDY DESIGN

Our work is a retrospective cohort study of cesarean deliveries during the second stage of labor using the Consortium on Safe Labor database. All term, singleton pregnancies in cephalic presentation were included. Women with stillbirth or contraindications to vaginal delivery were excluded. Groups were divided by duration of the second stage of labor: ≤3 hours, 3-4 hours, 4-5 hours, 5-6 hours, and >6 hours. The primary outcome was a composite of maternal morbidities. The secondary outcomes were a composite of neonatal morbidities and individual maternal and neonatal morbidities. Baseline demographic and clinical characteristics were compared among groups. Univariate and multivariate analyses were performed.

RESULTS

We included 6273 women in total. In addition, 3652 women (58.2%) went through the second stage for ≤3 hours, 854 (13.6%) for 3 to 4 hours, 618 (9.9%) for 4 to 5 hours, 397 (6.3%) for 5 to 6 hours, and 752 (12.0%) for >6 hours. Neither the maternal nor neonatal morbidity composite outcomes were statistically different among the groups. Extended maternal length of stay (>5 days), increased birthweight, and lower rates of general anesthesia were associated with an increased duration of the second stage of labor. Chorioamnionitis, wound complications, postpartum hemorrhage, and thrombosis did not increase over time.

CONCLUSION

Women should be counseled regarding the duration of the second stage of labor, which should include a discussion of the risks associated with a cesarean delivery with a prolonged second stage of labor. However, these risks may not be as high as anticipated.

A comparison of maternal and neonatal outcomes with forceps delivery versus cesarean delivery

Objective: To compare maternal and neonatal outcomes by forceps vaginal delivery versus cesarean delivery during the second stage of labor.Methods: We conducted a retrospective cohort study in a large tertiary maternity center in Shanghai, China through 2007-2016. A total of 7046 women carrying a singleton term nonanomalous fetus with vertex presentation who underwent forceps vaginal delivery, or cesarean delivery from a low station in the second stage of labor were included.Results: Of the 7046 women, 6265 underwent forceps and 781 underwent second stage cesarean delivery. Forceps were associated with lower frequency of maternal infection (2.2 versus 4.7%), but higher incidence of mild postpartum hemorrhage (PPH) (4.3 versus 0.6%). When the procedures were performed for fetal indication, forceps were associated with lower frequency of the composite of perinatal mortality and/or hypoxic ischemic encephalopathy (HIE) (0.5 versus 1.9%; adjusted odds ratio (aOR), 0.24; 95% CI: 0.08-0.75), and also shorter decision to delivery interval (12.3 ± 3.5 versus 19.1 ± 5.0 min). The neonatal infection rate was higher in the forceps group (3.9 versus 2.0%). There were no differences in other neonatal outcomes including birth trauma.Conclusions: In women who had a need for intervention during the second stage with a station of +2 or below, forceps were associated with a lower frequency of maternal infection but a higher rate of PPH. Deliveries performed for nonreassuring status were accomplished faster by forceps and were associated with a lower frequency of the composite of perinatal mortality and HIE.