Fetal Injury Associated With Cesarean Delivery

The French Ambulatory Cesarean Section: Safety and Recovery Characteristics

OBJECTIVES

The French AmbUlatory Extraperitoneal Cesarean Section (FAUCS) is aimed at improving patients' birth experience and recovery. However, data are scarce regarding its maternal and neonatal safety. This study seeks to compare maternal and neonatal outcomes between FAUCS and conventional cesarean deliveries at term.

METHODS

This was a retrospective cohort study involving women who underwent scheduled cesarean deliveries at term. We compared a total of 810 cases using the FAUCS technique with 217 cases using conventional cesarean deliveries. Surgical complications, adverse neonatal events, and maternal recovery parameters were compared.

RESULTS

The incidence of overall surgical complications was comparable between the 2 groups, with rates of 1.97% for FAUCS and 1.85% for the conventional cesarean deliveries. The rates of specific complications such as bladder injury (0.1%), bowel injury (0.1%), blood transfusion (1.35%), and postpartum hemorrhage (1%) were consistent with existing literature. Neonatal outcomes, including neonatal acidemia and admission rates to the neonatal intensive care unit, were comparable between the groups and demonstrated favourable comparisons with previously reported data. Notably, women in the FAUCS group required less analgesia, with only 0.8% receiving morphine, as opposed to 38% in the control group. Furthermore, the FAUCS group demonstrated significantly quicker recovery, with 86% achieving autonomy and early discharge at their discretion within 48 hours after operation, in contrast to only 17% in the control group.

CONCLUSIONS

When performed by experienced practitioners, FAUCS proves to be a safe procedure, with no increased risk for maternal or neonatal complications. Its significant benefits in terms of enhancing maternal recovery are noteworthy.

Youngest hand injury during cesarean delivery: A case report

An emergency cesarean surgery resulted in extensor tendon lacerations in a 27-week-old preterm fetus. This injury is unique because fetal hand lacerations rarely occur, and to the best of our knowledge, this is the youngest case of hand injury during cesarean delivery reported in the literature. This case report sets the framework for a more in-depth investigation of the incidence and treatment options for fetal lacerations, with an emphasis on the less common but clinically important hand lacerations that can occur during cesarean section. LEVEL OF EVIDENCE: Therapeutic IV.

A systematic review of brachial plexus injuries after caesarean birth: challenging delivery?

BACKGROUND

Caesarean section (CS) is widely perceived as protective against obstetric brachial plexus injury (BPI), but few studies acknowledge the factors associated with such injury. The objectives of this study were therefore to aggregate cases of BPI after CS, and to illuminate risk factors for BPI.

METHODS

Pubmed Central, EMBASE and MEDLINE databases were searched using free text: ("brachial plexus injury" or "brachial plexus injuries" or "brachial plexus palsy" or "brachial plexus palsies" or "Erb's palsy" or "Erb's palsies" or "brachial plexus birth injury" or "brachial plexus birth palsy") and ("caesarean" or "cesarean" or "Zavanelli" or "cesarian" or "caesarian" or "shoulder dystocia"). Studies with clinical details of BPI after CS were included. Studies were assessed using the National Institutes for Healthy Study Quality Assessment Tool for Case Series, Cohort and Case-Control Studies.

MAIN RESULTS

39 studies were eligible. 299 infants sustained BPI after CS. 53% of cases with BPI after CS had risk factors for likely challenging handling/manipulation of the fetus prior to delivery, in the presence of considerable maternal or fetal concerns, and/or in the presence of poor access due to obesity or adhesions.

CONCLUSIONS

In the presence of factors that would predispose to a challenging delivery, it is difficult to justify that BPI could occur due to in-utero, antepartum events alone. Surgeons should exercise care when operating on women with these risk factors.

Can Intrapartum Ultrasonography Improve the Placement of the Vacuum Cup in Operative Vaginal Deliveries?

Although the fetal head position has traditionally been evaluated by digital examination (DE), it has a failure rate ranging between 20 and 70%; hence, intrapartum transabdominal ultrasonography (TUS) has become relevant. We aimed to evaluate the utility of the TUS to identify the fetal head positions in vacuum-assisted deliveries. We performed a prospective observational study including 101 pregnant patients in active labor who required a vacuum-assisted delivery. The fetal head position was assessed by a DE and a TUS prior to vacuum cup placement. After delivery, the optimal vacuum cup placement was evaluated as the distance between the chignon and the flexion point ≤2 cm. The general concordance rate between the DE and TUS was 72.2%, with the poorest concordance rate for occiput posterior positions at 46.1%. In five cases (4.9%), it was not possible to determine the fetal head position through the DE. The correlation was higher in low and medium planes, with 77% and 68.1% concordance rates, respectively, while it was lower in high planes (60%). In 90.1% of cases, the vacuum cup placement was optimal. Our findings show that intrapartum transabdominal ultrasonography is a useful technique to identify the fetal head position allowing optimal placement of the vacuum cup necessary for correct vacuum-assisted delivery.

Risk factors associated with accidental fetal skin lacerations during cesarean delivery

OBJECTIVE

To identify risk factors associated with accidental fetal skin lacerations (AFL) during cesarean section (CS).

METHODS

This retrospective cohort study was obtained from the registry of two large medical centers between 2014 and 2019. The study group comprised all newborns identified with AFL. The rates of various potential risk factors were compared between the study group and a group of CS at which no AFL had occurred (the control group).

RESULTS

Of the 14 666 CS deliveries, 48 cases of AFL (0.33%) were documented, 52% of these following urgent CS. Compared with the control group (n = 14 618), the only risk factors associated with AFL were premature rupture of membranes (PROM) (odds ratio [OR] 5.38, 95% convidence interval [CI] 2.97-9.74) and meconium-stained amniotic fluid (OR 6.50, 95% CI 2.55-16.54). In subgroup analysis by CS urgency, no significance for these factors was noted in elective CS group; but higher rates of both PROM and meconium-stained amniotic fluid were noted in the AFL during urgent CS (OR 14.23, 95% CI 6.30-32.16 and OR 15.36, (95% CI 5.65-41.75, respectively).

CONCLUSIONS

During urgent CS, the surgeon should bear in mind that the presence of PROM or meconium-stained amniotic fluid should prompt extra care and application of preventive measures to decrease the rates of AFL.

Prediction model for prolonged hospitalization following cesarean delivery

INTRODUCTION

A rise in the rate of cesarean delivery (CD) has been found to be associated with a higher length of hospital stay, making it a public health concern. We aimed to evaluate risk factors for prolonged hospitalization following CD.

METHODS

A retrospective cohort study, in a single tertiary medical center, was conducted (2011-2019). Cesarean deliveries were categorized into three groups according to the postpartum length of stay (a) up to 3 days (the routine post cesarean hospital stay in our center, reference group) (b) 4-9 days, and (c) 10 days or above (prolonged hospitalization). Risk factors were examined using univariate analysis as well as multivariate logistic regression. A specific risk prediction score was developed to predict the need for prolonged hospitalization and ROC curve was assessed utilizing the performance of our model.

RESULTS

Overall, 87,424 deliveries occurred during the study period. Of them, 19,732 (22.5%) were cesarean deliveries. Hospitalization period was distributed as follows: 10,971 (55.6%) women were hospitalized for up to 3 days, 7,576 (38.4%) stayed for 4-9 days and 1,185 (6%) had a prolonged hospitalization period (≥10 days). Using multivariate analysis, multiple pregnancy (OR = 1.29, 95%CI 1.05-1.58), preterm delivery < 37 weeks (OR = 8.32, 95%CI 6.7-10.2), Apgar score < 7 (OR = 1.41, 95%CI 1.11-1.78) and non-elective CD (OR = 1.44, 95%CI 1.15-1.8) were identified as independent risk factors for prolonged hospitalization. Antenatal thrombocytopenia (PLT < 100 K) was found to be a protective factor (OR = 0.51, 95%CI 0.28-0.92). Our score model included antenatal risk factors and was found to be predicting the outcome, with an AUC of 0.845 (95%CI 0.83-0.86, p-value < 0.001).

CONCLUSION

A prediction score model for prolonged hospitalization after CD may be beneficial for risk assessment and post-partum management.

Head Injury during Childbirth

Head injuries are the most common type of birth injuries. Among them, most of the injuries is limited to the scalp. and the prognosis is good enough to be unnoticed in some cases. Intracranial injuries caused by excessive forces during delivery are rare. However, since some of them can be fatal, it is necessary to suspect it at an early stage and evaluate thoroughly if there are abnormal findings in the patient.

OUP accepted manuscript

Infected cephalhaematomas are rare and can lead to complications such as sepsis, meningitis and osteomyelitis. We present an infected cephalhaematoma in a neonate with resultant underlying osteomyelitis and a review of the literature. Our patient presented 6 days following birth with a fever and a swelling consistent with cephalhaematoma. He was managed with intravenous antibiotics and early surgical intervention. Imaging demonstrated underlying osteomyelitis. The patient made a full recovery and was discharged home on completing his antibiotic course. On reviewing the literature, it is clear that early diagnosis and treatment with surgical intervention and antibiotic therapy are associated with improved outcome and can reduce the possibility of osteomyelitis developing.

Prevalence and associated factors of birth injury among neonates admitted at neonatal intensive care unit (NICU) in governmental hospitals of Southwest Ethiopian people regional state, Ethiopia: A multicenteric cross-sectional study

INTRODUCTION

Neonatal birth injury is the functional or structural damage of the new-born during child birth. Fetal related factors such as macrosomia, fetal height, fetal weight, and prematurity; maternal related factors such as overly young and old maternal age, parity, poor maternal health, and pelvic anomalies contribute to neonatal birth injury. Labor and delivery related factors including prolonged labor, fetal mal-presentation and mal-position, cesarean and instrumental deliveries also predispose the neonate to birth injury. This study was conducted to assess the prevalence and associated factors of birth injury among neonates admitted to the neonatal intensive care unit (NICU) in Governmental Hospitals of Southwest Ethiopia.

OBJECTIVE

To assess the prevalence and associated factors of birth injury among neonates admitted to the neonatal intensive care unit (NICU) in governmental hospitals in Southwest Ethiopia.

METHOD

Hospital-based cross-sectional study design was implemented at Mizan-Tepi University Teaching Hospital, Bonga Gebretsadik Shawo General Hospital, and Tepi General Hospital. A total of 1,315 neonates were included in the study using systematic random sampling techniques. Data was entered using Epi-Data version 4.2 and exported to SPSS version 21 for analysis. Logistic regression analysis was conducted to see the association between the dependent and independent variable.

RESULTS

The prevalence of neonatal birth injury was 16.7%. Predictors such as primipara, no formal education, mothers with no antenatal care, and mothers whose occupational status were unemployed were 12.27, 2.52, 2.40, and 4.26 times more likely to develop neonatal birth injuries than their counterparts, respectively. Whereas, maternal age within the age range of 25-34 years, and neonates delivered via instrumental delivery were 6.68, and 2.81 times more likely to develop neonatal birth injury compared to those whose age was greater than 34 years and neonates delivered through Cesarean section, respectively.

CONCLUSION

The magnitude of birth injury in the current study was significantly high. Primiparity, mothers with no history of antenatal care follow up, uneducated women, unemployed women, mode of delivery, and maternal age between 25 and 34 years were strong predictors associated with neonatal birth injury. Therefore, comprehensive maternal health care such as antenatal care follow up and health institution delivery should be promoted and well addressed to all reproductive age women and special attention should be given particularly to pregnant women in order to mitigate problems related to childbirth.

Femur Shaft Fracture in Newborns: A Report of Two Cases

Birth injuries caused by trauma during the childbirth process are very rare. They are a cause of significant neonatal morbidity despite improved obstetric and perinatal care, particularly in developing countries. Our current research, consisting of two newborns with a femur fracture, aims to shed light on their treatment strategy.

A demand-smoothing incentive for cesarean deliveries

We study the demand-smoothing incentives for private hospitals to perform c-sections. First, we show that a policy change in Chile that increased delivery at private hospitals by reducing the out-of-pocket cost for women with public insurance increased the probability of a c-section by 8.6 percentage points despite private hospitals receiving the same price for a vaginal or cesarean delivery. Second, to understand hospitals' incentives to perform c-sections, we present a model of hospital decisions about the mode of delivery without price incentives. The model predicts that, because c-sections can be scheduled, a higher c-section rate increases total deliveries, compensating the forgone higher margin of vaginal deliveries. Finally, we provide evidence consistent with the demand-smoothing mechanism: hospitals with higher c-section rates are more likely to reschedule deliveries when they expect a high-demand week.

A retrospective analysis of risk factors for clavicle fractures in newborns with shoulder dystocia and brachial plexus injury: A single-center experience

OBJECTIVE

We aimed to analyze the risk factors for clavicle fractures in newborns with shoulder dystocia and brachial plexus injury and to determine whether their incidence is associated with local characteristics.

METHODS

This study was conducted as a retrospective trial between January 2017 and December 2018. Patients with clavicular fracture who were hospitalized in the neonatal intensive care unit of a community hospital were retrospectively analyzed. The clavicular fracture cohort was first divided into two groups and then two subgroups: patients with/without shoulder dystocia and patients with/without a brachial plexus injury. Peripartum and neonatal risk factors of these patients were reviewed using the patient information system. Any additional neurological or musculoskeletal trauma was noted. A multivariate logistic regression analysis was performed to determine independent predictors of shoulder dystocia and brachial plexus injury.

RESULTS

A total of 46 patients with shoulder dystocia in 25 (54%) and brachial plexus injury in 12 (26%) were included in the study. The birth weight of patients with shoulder dystocia was 4,164.2±412.7 g, and that of patients without was 3,535.8±865.2 g (p=0.003). In 11 of 14 patients (44%) in whom labor was induced and whose infant had a fractured clavicle, the infant also had shoulder dystocia (p=0.029). Brachial plexus injury was found in 8 (66.7%) of 14 infants who were born by induced labor and who had a clavicular fracture (p=0.002). The regression analysis revealed that age and induction of labor were independent risk factors for brachial plexus injury (odds ratio=1.599 and 81.862, respectively). Gestational weight gain (p=0.003) and neonatal birth weight (p=0.047) were also found as independent risk factors for shoulder dystocia.

CONCLUSION

Evidence from this study has shown that not only birth age or birth weight but also excessive weight gain by mother and induction of labor may increase the risk of clavicula fracture with brachial plexus palsy. Advanced maternal age, multiparity, and deliveries after 39 weeks seem to be risk factors for a clavicular fracture with a brachial plexus injury.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Delivery mode and future infectious morbidity of the offspring: a sibling analysis

PURPOSE

Cesarean delivery (CD) has been recently suggested to be associated with offspring's long-term health implications. We aimed to investigate the association between delivery mode and long-term infectious morbidity of the offspring while employing sibling matched analysis to maximize confounder control.

METHODS

A retrospective population-based cohort study was performed, which included all sibling deliveries occurring between 1991 and 2014 at a regional tertiary medical center. Offsprings were followed up until the age of 18 years. The study included 13,516 individuals (6758 sibling pairs): the first born was via vaginal delivery and the second via CD. Each siblings pair was considered a matched set, with the aim to perform a within-family analysis. A Kaplan-Meier survival curve was used to compare the cumulative infectious morbidity incidence and a multivariable Cox survival hazards regression model to control for confounders.

RESULTS

Crude rates of total infectious hospitalizations were found to be significantly higher in the CD group (OR 1.25; 95% CI 1.12-1.40). Specifically, bronchiolitis (OR 2.02, 95% CI 1.56-2.63), otitis (OR 1.52, 95% CI 1.21-1.9), and gastroenteritis (OR 1.41, 95% CI 1.05-1.9) were all found to be significantly more common in the CD group. The survival curve demonstrated significantly higher cumulative infection-related hospitalization rates in the CD group (log-rank p < 0.001). The Cox model, adjusted for several confounders, confirmed the significant association between CD and offspring's infection-related morbidity (adjusted HR 1.25; 95% CI 1.02-1.53).

CONCLUSION

CD appears to be independently associated with later offspring infection-related morbidity, even while rigorously adjusting for confounders.

Bilateral Cephalohematoma With Sagittal Synostosis and Scaphocephaly

Inappropriate fusion of the cranial sutures leads to craniosynostosis and the subsequent skull rigidity can cause many developmental and structural problems. Cephalohematoma is a subperiosteal collection of blood commonly associated with birth trauma or instrument-assisted delivery and is one of the most frequently reported fetal injuries in Caesarian section procedures. There have been very few cases reported of patients with both scaphocephaly due to sagittal craniosynostosis and cephalohematoma and no reports of scaphocephaly with bilateral cephalohematoma as of the date of this report. The current literature suggests that the two conditions are potentially associated, either through mechanical pathways involving trauma or through a complex interplay of growth factors. The authors present a case of bilateral cephalohematoma with scaphocephaly secondary to progressive sagittal craniosynostosis.

Eye lid and canalicular laceration due to obstetric trauma. Case report

Ocular injuries associated with birth trauma are rare. Their incidence increases in cases of instrument-assisted delivery, emergency cesarean section, and abnormal presentation of the fetus. We present the clinical case of a premature Asian male baby, aged 33+2 weeks and weighing 1,500g. The infant was born out of a twin pregnancy and was delivered by emergency cesarean section. Following delivery, a 5mm long lower eyelid laceration was observed in the inner corner of the left eye, with injury to the inferior canaliculus. A Mini-Monoka® (FCI, Issy-Les Moulineaux, France) monocanalicular intubation stent was inserted on the seventh day with anastomosis of the proximal and distal ends of the canaliculus laceration. The skin was then sutured with a polyglactin 8/0 (Vicryl 8/0, Ethicon, Johnson & Johnson S. A., Madrid, Spain) suture. The postoperative treatment consisted of tobramycin and dexamethasone eye drops four times per day for 10 days. A good progression was observed, the position of the inferior lacrimal punctum was adequate, and syringation was normal. The Mini-Monoka® was removed after 14 weeks.

Delivery room emergencies due to birth injuries

Delivery room emergencies due to birth injuries are serious, usually unexpected, and can be distressing situations that necessitate immediate action to reduce neonatal morbidity and prevent neonatal mortality. Birth injuries requiring immediate, urgent care in the delivery room are uncommon, hence knowledge of obstetric risk factors and prenatal conditions linked to birth injury is an important first step in the management of affected neonates. Furthermore, immediate recognition of injury and quick action upon delivery is essential in order to achieve the best possible outcomes. This chapter briefly reviews the known risk factors associated with birth injury, and then discusses the identification and management of specific injuries that may require immediate treatment in the delivery room, or hasty management within hours after birth.

External Cephalic Version in Cases of Imminent Delivery at Preterm Gestational Ages: A Prospective Series

Objective  When delivery of a breech fetus is required at a preterm gestational age, Cesarean delivery is often recommended. We performed a prospective patient series to assess the success rate and safety of performing external cephalic version (ECV) procedures on preterm fetuses as an alternative to Cesarean delivery. Study Design  We performed a prospective clinical series of patients who required delivery with a malpresenting fetus at a preterm gestational age. Results  ECV procedures were successful in singletons 50% of the time. No significant complications or cases of fetal mortality were documented. Conclusion  ECV at preterm gestational ages may be an appropriate approach to management in patients requiring delivery. Larger series are needed to further document success rates and risks of the procedure.

Clinical factors in patients with congenital muscular torticollis treated with surgical resection

BACKGROUND

Congenital muscular torticollis (CMT) is characterized by persistent head tilt toward the affected side. No consensus exists regarding the cause of this disorder. In this study, we analyzed various clinical factors in patients with CMT who were treated with surgical release. This analysis enabled us to identify potential causative factors of CMT and to establish a basis for surgical interventions.

METHODS

In total, 584 patients who underwent surgical intervention for CMT from October 2007 to December 2016 were included in this study. Their demographic characteristics, birthrelated factors, and clinical features were analyzed.

RESULTS

Data from 525 patients were analyzed in this study after exclusion of those with insufficient information. Before birth, 31 patients (5.9%) were diagnosed with oligohydramnios, and 87 (16.6%) had a breech presentation. Seven (1.3%) cases of clavicle fracture and two (0.4%) cases of cephalohematoma were noted at birth. Before surgery, 397 patients (75.6%) underwent physiotherapy and 128 patients (24.4%) did not. The duration of physiotherapy ranged from 1 to 50 months (average, 6 months).

CONCLUSIONS

Our study shows that 16.6% of the CMT patients presented in the breech position, which is a much higher rate than that observed in the general population (3%-4%). We hypothesize that being in the breech position as a fetus appears to exert a significant influence on shortening and fibrosis of the sternocleidomastoid muscle.

Cesarean section and the risk of neonatal respiratory distress syndrome: a meta-analysis

PURPOSE

To explore the association between cesarean section (CS) and the risk of neonatal respiratory distress syndrome (RDS).

METHODS

We searched PubMed, Web of Science, and ClinicalTrials.gov database for studies related to the association between CS and the risk of neonatal RDS up to 25 August 2018. The pooled odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using a random-effects model (REM).

RESULTS

A total of 26 studies from 25 available articles were included in this meta-analysis. For the association between CS and the risk of neonatal RDS, the pooled OR was 1.76 (95% CI 1.48-2.09). The pooled OR of the risk of neonatal RDS was 2.38 (95% CI 1.89-2.99) for elective CS and 1.85 (95% CI 1.34-2.56) for emergency CS.

CONCLUSION

This meta-analysis suggested that CS, elective CS, and emergency CS were associated with an increased risk of neonatal RDS.

Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society Recommendations (Part 2)

The Enhanced Recovery After Surgery Society guideline for intraoperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for intraoperative care, with primarily a maternal focus. The "focused" pathway process for scheduled and unscheduled cesarean delivery for this Enhanced Recovery After Surgery cesarean delivery guideline will consider procedure from the decision to operate (starting with the 30-60 minutes before skin incision) through the surgery. The literature search (1966-2017) used Embase and PubMed to search medical subject headings including "cesarean section," "cesarean section," "cesarean section delivery," and all pre- and intraoperative Enhanced Recovery After Surgery items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses evaluated the quality of evidence and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system as used and described in previous Enhanced Recovery After Surgery Society guidelines. The Enhanced Recovery After Surgery cesarean delivery guideline/pathway has created a maternal focused pathway (for scheduled and unscheduled surgery starting from 30-60 minutes before skin incision to maternal discharge) with Enhanced Recovery After Surgery-directed preoperative elements, intraoperative elements, and postoperative elements. Specifics of the intraoperative care included the use of prophylactic antibiotics before the cesarean delivery, appropriate patient warming intraoperatively, blunt expansion of the transverse uterine hysterotomy, skin closure with subcuticular sutures, and delayed cord clamping. A number of specific elements of intraoperative care of women who undergo cesarean delivery are recommended based on the evidence. The Enhanced Recovery After Surgery Society guideline for intraoperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for intraoperative care with primarily a maternal focus. When the cesarean delivery pathway (elements/processes) is studied, implemented, audited, evaluated, and optimized by maternity care teams, this will create an opportunity for the focused and optimized areas of care and recommendations to be further enhanced.

Guidelines for Antenatal and Preoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society Recommendations (Part 1)

This Enhanced Recovery After Surgery (ERAS) Guideline for perioperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for preoperative, intraoperative, and postoperative phases with, primarily, a maternal focus. The focused pathway process for scheduled and unscheduled cesarean delivery for this ERAS Cesarean Delivery Guideline will consider from the time from decision to operate (starting with the 30-60 minutes before skin incision) to hospital discharge. The literature search (1966-2017) used Embase and PubMed to search medical subject headings that included "Cesarean Section," "Cesarean Section," "Cesarean Section Delivery" and all pre- and intraoperative ERAS items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses that evaluated the quality of evidence and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system, as used and described in previous ERAS Guidelines. The ERAS Cesarean Delivery Guideline/Pathway has created a maternal focused pathway (for scheduled and unscheduled surgery starting from 30-60 minutes before skin incision to maternal discharge) with ERAS cesarean delivery consensus recommendations preoperative elements (anesthetic medications, fasting, carbohydrate supplementation, prophylactic antibiotics/skin preparation, ), intraoperative elements (anesthetic management, maternal hypothermia prevention, surgical technique, hysterotomy creation and closure, management of peritoneum, subcutaneous space, and skin closure), perioperative fluid management, and postoperative elements (chewing gum, management of nausea and vomiting, analgesia, timing of food intake, glucose management, antithrombotic prophylaxis, timing of ambulation, urinary management, and timing of maternal and neonate discharge). Limited topics for optimized care and for antenatal education and counselling and the immediate neonatal needs at delivery are discussed. Strong recommendations for element use were given for preoperative (antenatal education and counselling, use of antacids and histamine, H2 receptor antagonists, 2-hour fasting and small meal within 6 hours surgery, antimicrobial prophylaxis and skin preparation/chlorhexidine-alcohol), intraoperative (regional anesthesia, prevention of maternal hypothermia [forced warm air, warmed intravenous fluids, room temperature]), perioperative (fluid management for euvolemia and neonatal immediate care needs that include delayed cord clamping), and postoperative (fluid management to prevent nausea and vomiting, antiemetic use, analgesia with nonsteroidal antiinflammatory drugs/paracetamol, regular diet within 2 hours, tight capillary glucose control, pneumatic compression stocking for venous thromboembolism prophylaxis, immediate removal of urinary catheter). Recommendations against the element use were made for preoperative (maternal sedation, bowel preparation), intraoperative (neonatal oral suctioning or increased inspired oxygen), and postoperative (heparin should not be used routinely venous thromboembolism prophylaxis). Because these ERAS cesarean delivery pathway recommendations (elements/processes) are studied, implemented, audited, evaluated, and optimized by the maternity care teams, this will create an opportunity for the focused and optimized areas of care research with further enhanced care and recommendation.

Brachial Plexus Birth Injury in Elective Versus Emergent Caesarean Section: A Cohort Study

OBJECTIVE

Although Caesarean section (CS) is protective for brachial plexus birth injury (BPBI), the incidence is not zero. A trial of labour with unfavourable intrauterine positioning is hypothesized to result in excessive force on the brachial plexus. The purpose of this study was to determine the risk of BPBI in emergent CS versus elective CS.

METHODS

This was a retrospective cohort study. The authors used a nationwide demographic sample of all infants born in Canada from 2004 to 2012. BPBI diagnoses, risk factors, and national incidence data were obtained from the Canadian Institute for Health Information Discharge Abstract Database and Hospital Morbidity Database. The primary outcome was risk of BPBI in emergent CS versus elective CS.

RESULTS

BPBI incidence was 1.24 per 1000 live births. Known biases may have underestimated the incidence. CS (elective and emergent) was protective for BPBI as compared with vaginal delivery (odds ratio [OR] 0.15; 95% confidence interval [CI] 0.13-0.18, P < 0.0001). Emergent CS was a moderately strong risk factor for BPBI versus elective CS (OR 3.14; 95% CI 1.79-5.10, P = 0.0001).

CONCLUSION

Emergent CS is a moderate risk factor for BPBI compared with elective CS. Intrauterine positioning with a trial of labour may provide an antenatal etiology in these distinct cases.

Nonclinical Factors of Cesarean Section Birth: A Review of the Literature

The rate of cesarean section (CS) birth has increased dramatically across the world during the last few decades, mainly in high-income and middle-income countries. The aim of this study is to explore the nonclinical risk factors of CS birth and to look into its similarities and dissimilarities influencing CS birth between developed and developing countries. A search of the existing literature was conducted on electronic databases, such as PubMed, JSTOR, SpringerLink, ScienceDirect, and so forth. The maternal age is the most common factor of CS birth in almost all studies of developed and developing countries. Furthermore, type of hospitals is another predominant factor of CS birth as seen in more than half of the studies of developing countries and in several studies of developed countries. Nevertheless, it is also found that there is variation in main findings of CS birth according to the level of development. In most of the studies in developed countries, CS birth is highly associated with maternal age and birth weight of the baby. On the contrary, in developing countries, most of the studies show that CS birth is highly associated with maternal age, maternal education, type of hospitals, place of residence, number of antenatal care, and parity.

ISUOG Practice Guidelines: intrapartum ultrasound

The purpose of these Guidelines is to review the published techniques of ultrasound in labor and their practical applications, to summarize the level of evidence regarding the use of ultrasound in labor and to provide guidance to practitioners on when ultrasound in labor is clinically indicated and how the sonographic findings may affect labor management. We do not imply or suggest that ultrasound in labor is a necessary standard of care.

A case-control study about foetal trauma during caesarean delivery

OBJECTIVE

The caesarean section rate is gradually increasing in most countries. The frequency of occurrence of foetal injury per birth is estimated to 1%. The majority of these injuries presents a low functional impact, but remains responsible for a significant neonatal morbidity. Even though the foetal risk factors are well documented in cases of vaginal birth, they have not been accurately identified for caesarean section. The aim of this study is to identify the risk factors for neonatal fracture during caesarean section.

METHODS

We conducted a retrospective case-control study comparing complicated caesarean sections foetal fracture with uncomplicated caesarean sections in a tertiary teaching hospital. We collected all the caesarean sections carried out between 1st January 2003 and 1st September 2015 and selected those the medical files of which presented a foetal fracture diagnosis.

RESULTS

We identified 10 fractures during the study period, including four skull fractures, three long bone fractures, three clavicle fractures. In all these cases there were no complications with a median perspective of six years (median=6, IQR=4). The push method, which is performed during a caesarean section at the second stage of labour, is identified as a risk factor for foetal trauma in our study (OR: 20.2 [2.8-116.85], p<0.01). A significant correlation was found between transverse lie and foetal trauma (OR: 16.67, CI [1.39; 123.18], p=0.0137).

CONCLUSION

Foetal trauma during caesarean delivery is a rare event for which the prognosis is most often favourable. Data in the literature on the subject are minimal. This study highlighted transverse lie and the push method as risks factors for foetal fractures during caesarean sections. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Perinatal and maternal morbidity and mortality after attempted operative vaginal delivery at midpelvic station

BACKGROUND

Increased use of operative vaginal delivery (i.e., forceps or vacuum application), of which 20% occurs at midpelvic station, has been advocated to reduce the rate of cesarean delivery. We aimed to quantify severe perinatal and maternal morbidity and mortality associated with attempted midpelvic operative vaginal delivery.

METHODS

We studied all term singleton deliveries in Canada between 2003 and 2013, by attempted midpelvic operative vaginal or cesarean delivery with labour (with and without prolonged second stage). The primary outcomes were composite severe perinatal morbidity and mortality (e.g., convulsions, assisted ventilation, severe birth trauma and perinatal death), and composite severe maternal morbidity and mortality (e.g., severe postpartum hemorrhage, shock, sepsis, cardiac complications, acute renal failure and death).

RESULTS

The study population included 187 234 deliveries. Among women with dystocia and prolonged second stage of labour, midpelvic operative vaginal delivery was associated with higher rates of severe perinatal morbidity and mortality compared with cesarean delivery (forceps, adjusted odds ratio [AOR] 1.81, 95% confidence interval [CI] 1.24 to 2.64; vacuum, AOR 1.81, 95% CI 1.17 to 2.80; sequential instruments, AOR 3.19, 95% CI 1.73 to 5.88), especially with higher rates of severe birth trauma. Rates of severe maternal morbidity and mortality were not significantly different after operative vaginal delivery, although rates of obstetric trauma were higher (forceps, AOR 4.51, 95% CI 4.04 to 5.02; vacuum, AOR 2.70, 95% CI 2.35 to 3.09; sequential instruments, AOR 4.24, 95% CI 3.46 to 5.19). Among women with fetal distress, similar associations were seen for severe birth trauma and obstetric trauma, although vacuum was associated with lower rates of severe maternal morbidity and mortality (AOR 0.52, 95% CI 0.33 to 0.80). Associations tended to be stronger among women without a prolonged second stage.

INTERPRETATION

Midpelvic operative vaginal delivery is associated with higher rates of severe birth trauma and obstetric trauma, whereas overall rates of severe perinatal and maternal morbidity and mortality vary by indication and operative instrument.

Bilateral Humerus and Right Femur Fracture in a Newborn after Cesarean Section for Breech Presentation in a Twin Pregnancy: A Very Rare Case Report

Introduction:

The most common fractures during vaginal delivery occur in the clavicle, humerus, and femur. Cesarean section reduces the chances of a child having a birth injury. However, in some difficult extractions, long bone fractures may occur. Cesarean section further reduces the incidence of birth injuries, especially in a breech delivery. Maneuvers employed during cesarean section, energetic traction, improper uterine incisions, and contracted uterus may cause these injuries. In the medical literature, there are few articles highlighting the occurrence of long bone fractures during cesarean section. There has been no case reported with a combined bilateral humerus and femur fracture in the medical literature.

Case Report:

A 2-day-old neonate born after cesarean section for breech presentation in a twin pregnancy presented with restricted movements of both his arms and right leg. Infantogram revealed bilateral humerus and right femur fracture. Biochemical tests were normal, and there were no other findings on clinical examination. There was no evidence of child abuse or any positive family history. Child was splinted for 3 weeks. X-rays suggested good callus at the fracture site of the right femur and bilateral humerus fracture were united.

Conclusion:

To conclude, we would like to emphasize that long bone fractures can happen with cesarean section also. To prevent such untoward complications, during delivery of the baby the surgeon should be very careful, avoid energetic traction and should plan his incisions. Appropriate relaxation of the uterus must be achieved. Clavicles and other long bones should be palpated after a difficult delivery. However, it is important to note that long bone fractures in children heal rapidly without the need for any major intervention.

The Effect of Epidural Analgesia Alone and in Association With Other Variables on the Risk of Cesarean Section

Introduction:

Epidural analgesia (EA) is the most widespread pharmacologic method of labor pain relief. There remains disagreement, however, regarding its adverse effects. The objective of this study was to determine the effect of EA administration on the risk of cesarean delivery and its causes (e.g., stalled labor, risk of loss of fetal well-being, among others) and the degree to which this effect may be modulated by mother-, newborn-, and labor-related variables.

Method:

A retrospective cohort observational study was conducted including all deliveries in a Spanish public hospital between March 2010 and March 2013 ( N = 2,450; EA = 562, non-EA = 1,888).

Results:

Risk of a cesarean section was significantly increased by EA administration (odds ratio [ OR] = 2.673; p < .0001). The percentage of cesarean deliveries due to the risk of loss of fetal well-being was significantly higher in the EA (47.8%) versus non-EA group (27.5%; OR = 1.739; p = 0.0012,). The EA-associated risk of cesarean section was not significantly modified as a function of maternal age or parity, fetal position, newborn weight, weeks of gestation, or sedation administration alone. However, these variables in combination may increase the risk. We present multivariate models for each group that account for these variables, allowing for estimation of the risk of a cesarean delivery if EA is administered.

Conclusion:

EA is associated with an increased risk of cesarean delivery. Other variables in combination (maternal age or parity, fetal position, newborn weight, weeks of gestation, or sedation administration) may increase this risk.

Bilateral Femoral Fracture in a newborn with Myelomeningocele at Cesarean section: A Case Report

Introduction:

Femur fractures as a result of birth trauma can still occur during the C/S, in spite of recent developments of surgical and anesthetic techniques. In this study, we aimed to present a rare case of a newborn with myelomeningocele who delivered by cesarean section due to breech presentation and sustained bilateral fracture of femoral shaft.

Case Presentation:

A 2690 g female newborn with myelomeningocele sustained bilateral femoral shaft fractures during cesarean section. Complete healing was obtained without sequelae after 21 days ofimmobilization with long leg splints.

Conclusion:

Despite the development of early diagnosis and treatment modalities, there is a probability of significant birth traumas. The C/S with accurate technique and gentle obstetrical maneuvers is seemed to be the most important factor for preventing such incidents and considerable complications during abnormal delivery.

[Macrosomia, shoulder dystocia and elongation of the brachial plexus: what is the role of caesarean section?]

The delivery of a macrosomic infant is associated with a higher risk for maternofoetal complications. Shoulder dystocia is the most feared fetal complication, leading sometimes to a disproportionate use of caesarean section. This study aims to evaluate the interest of preventive caesarean section. We conducted a retrospective study of 400 macrosomic births between February 2010 and December 2012. We also identified cases of infants with shoulder dystocia occurred in 2012 as well as their respective birthweight. Macrosomic infants weighed between 4000g and 4500g in 86.25% of cases and between 4500 and 5000 in 12.25% of cases. Vaginal delivery was performed in 68% of cases. Out of 400 macrosomic births, 9 cases with shoulder dystocia were recorded (2.25%). All of these cases occurred during vaginal delivery. The risk for shoulder dystocia invaginal delivery has increased significantly with the increase in birth weight (p <10-4). The risk for elongation of the brachial plexus was 11 per thousand vaginal deliveries of macrosomic infants. This risk was not correlated with birthweight (p = 0.38). The risk for post-traumatic sequelae was 0.71%. Shoulder dystocia affectd macrosoic infants in 58% of cases. Shoulder dystocia is not a complication exclusively associated with macrosomia. Screening for risky deliveries and increasing training of obstetricians on maneuvers in shoulder dystocia seem to be the best way to avoid complications.

Neonatal clavicle fracture in cesarean delivery: incidence and risk factors

BACKGROUND

Neonatal clavicle fracture in cesarean delivery is rare and has not been extensively studied.

METHODS

We performed a retrospective review of cesarean deliveries with neonatal clavicle fracture during a 12-year period. Maternal and neonatal factors as well as surgical factors related to cesarean delivery for the fracture were determined and compared to the control group to analyze their significance.

RESULTS

Among a total 89 367 deliveries during the study period, 36 286 babies were born via cesarean section. Nineteen cases of clavicle fractures in cesarean section were identified (0.05% of total live births via cesarean section). In the analysis of maternal and neonatal risk factors, birthweight, birthweight ≥ 4000  g and maternal age were significantly associated with clavicle fracture in cesarean section. However, clavicle fractures were not correlated with the selected surgical factors such as indication for cesarean section, skin incision to delivery time and incision type of skin and uterus. Logistic regression analysis showed that birthweight was the major risk factor for clavicle fracture.

CONCLUSION

Clavicle fractures complicated 0.05% of cesarean deliveries. The main risk factor related to a clavicle fracture in cesarean section was the birthweight of an infant. As reported in previous studies associated with vaginal delivery, clavicle fracture is considered to be an unavoidable event and may not be eliminated, even in cesarean delivery.

Caesarean delivery in the Limbé and the Buea regional hospitals, Cameroon: frequency, indications and outcomes

INTRODUCTION

Neonatal outcomes can be directly and indirectly affected by caesarean delivery (CD). Data on CD rates in semi-urban and rural hospitals in resource-limited settings are scarce and yet are needed to better guide the care of women and neonates in these settings. we carried out this study to determine the frequency of CD, its indications and the frequency of the various adverse neonatal outcomes (ANO) in the Limbe Regional Hospital (LRH) and the Buea Regional Hospital (BRH), Cameroon. We also assessed the relationship between the indication for CD and ANO in the said hospitals.

METHODS

This was a hospital-based retrospective and prospective cross-sectional study using descriptive and analytic methods conducted in the LRH and the BRH maternity units within a nine months period in 2015. Informed consent was obtainedfrom mothers of the neonates. Data analyses were performed using Epi-Info 3.5.4 software.

RESULTS

We recruited 199 neonates born through CD. The prevalence of CD was 13.3% with cephalopelvic disproportion (CPD) being the most frequent (32.2%) indication for CD. There were 52 (26.1%) ANO following CD and respiratory distress was the most common 24 (46.2%) of all ANO. Emergency indications for CD were associated with more ANO 49 (34.5%) as compared to elective indications for CD 3 (5.3%) [p-value<0.001]. We noted a significant association between indications for CD and the various type of ANO, with CPD having the worse prognostic neonatal outcomes 30.8% [p-value=0.02].

CONCLUSION

The prevalence of ANO associated with CD in our hospitals was high with a worrying prognosis. While the exact reasons are unknown, the creation of well-equipped neonatal units with trained staff, may contribute to reduce neonatal morbidity and fatalities. Furthermore, the association of CPD to worse prognostic neonatal outcomes calls for clinicians, to consider additional management options, such as antibiotic prophylaxis and oxygen therapy to the neonates, prior to CD.

Impact of surgeon annual volume on short-term maternal outcome in cesarean delivery

BACKGROUND

The annual procedure volume is an accepted marker for quality of care and has been documented in various medical fields. Surgeon volume has been shown to correlate with morbidity and mortality rates in surgical and high-risk medical procedures. Although cesarean delivery is 1 of the most common surgical procedures in the United States, the link between a surgeon's annual cesarean delivery volume and maternal outcome has never been tested.

OBJECTIVE

The purpose of this study was to evaluate the impact of a surgeon's annual volume on short-term maternal outcome in cesarean deliveries.

STUDY DESIGN

We performed a retrospective cohort study in a single tertiary center between 2006 and 2013. Cesarean deliveries were categorized into 2 groups based on the annual volume of cesarean delivery of the attending obstetrician. The "low" group included obstetricians with a low annual volume, whose annual volume of cesarean delivery was lower than median. The "high" group comprised obstetricians with a high annual volume whose annual volume was at median and above. Further analyses were done for quartiles and for 4 clinical relevant groups according to the annual number of cesarean deliveries that were performed/supervised by the attending obstetrician (≤20, 21-60, 61-120, and >120). The primary outcome was a composite adverse maternal outcome that included ≥1 of the following outcomes: urinary or gastrointestinal tract injuries, hemoglobin drop >3 g/dL, blood transfusion, relaparotomy, puerperal fever, prolonged maternal hospitalization, and readmission. Secondary outcomes were operative times (skin incision to delivery and overall).

RESULTS

A total of 11,954 cesarean deliveries were included; the median annual number of cesarean deliveries that were performed/supervised by 1 obstetrician was 48. Unadjusted analysis suggested that the patients in the high group had fewer urinary and gastrointestinal injuries (18/9278 [0.2%] vs 16/2676 [0.6%] injuries; P < .001), less blood loss as measured by hemoglobin drop >3 g/dL (1053/9278 [11.5%] vs 366/2676 [13.8%]; P < .001), and fewer cases of prolonged maternal hospitalization (80/9278 [0.9%] vs 39/2676 [1.5%]; P = .006). The rate of blood transfusion, relaparotomy, puerperal febrile morbidity, and readmission to hospital did not differ between groups. Multivariable regression analysis showed that cesarean delivery performed/supervised by the high group resulted in a significantly lower composite adverse maternal outcome (15.8% vs 18.9%; odds ratio, 0.86; 95% confidence interval, 0.78-0.95; P = .004). This was related primarily to a decreased frequency of urinary and gastrointestinal injuries, lower likelihood of hemoglobin drop >3 g/dL, and lower incidence of prolonged maternal hospitalization. Operative times were significantly shorter for the high group. Composite adverse maternal outcome ranged from 21.8% in the lowest quartile to 17.9% in quartile 2, to 17.4% in quartile 3, and 15.6% in quartile 4. quartile 4 served as the reference; quartile 3 had an odds ratio of 1.14 (95% confidence interval, 1.01-1.29; P = .029); quartile 2 had an odds ratio of 1.18 (95% confidence interval, 1.02-1.36; P = .021, and quartile 1 had an odds ratio of 1.51 (95% confidence interval, 1.14-1.99; P = .004) for composite adverse maternal outcome. Composite adverse maternal outcome ranged from 21.5% in clinical group 1 to 17.5% in clinical group 2, to 17.9% in clinical group 3, and 15.2% in clinical group 4 (P = .001). Cesarean delivery performed/supervised by clinical groups 2, 3, and 4 in comparison with clinical group 1 were associated with a statistically significant risk reduction, (23%, 25%, and 34% respectively).

CONCLUSION

Maternal composite morbidity is decreased as the volume of cesarean deliveries that are performed or supervised by obstetricians increases.

Maternal collapse: Challenging the four-minute rule

Introduction

The current approach to, cardiopulmonary resuscitation of pregnant women in the third trimester has been to adhere to the “four-minute rule”: If pulses have not returned within 4 min of the start of resuscitation, perform a cesarean birth so that birth occurs in the next minute. This investigation sought to re-examine the evidence for the four-minute rule.

Methods

A literature review focused on perimortem cesarean birth was performed using the same key words that were used in formulating the “four-minute rule.” Maternal and neonatal injury free survival rates as a function of arrest to birth intervals were determined, as well as actual incision to birth intervals.

Results

Both maternal and neonatal injury free survival rates diminished steadily as the time interval from maternal arrest to birth increased. There was no evidence for any specific survival threshold at 4 min. Skin incision to birth intervals of 1 min occurred in only 10% of women.

Conclusion

Once a decision to deliver is made, care providers should proceed directly to Cesarean birth during maternal cardiac arrest in the third trimester rather than waiting for 4 min for restoration of the maternal pulse. Birth within 1 min from the start of the incision is uncommon in these circumstances.

•

Half of maternal/fetal pairs who are delivered by Cesarean birth within 25 min survive without injury.

•

The injury free survival rate for both has a roughly linear decrease as the time interval from arrest to birth increases.

•

Very few babies could be delivered within 1 min of the Cesarean section incision.

This information suggests that the current cardio-pulmonary resuscitation guideline in pregnancy, known as the four-minute rule, needs to be changed. Injury free survival for both mother and baby decreases steadily from the moment of cardiac arrest until cesarean birth. Furthermore, in actual practice, the baby usually cannot be delivered within 1 min of the start of surgery. Once a decision for delivery has been made, Cesarean birth should be initiated promptly without waiting for 4 min. In practice, the recommendation to proceed to cesarean birth without delay is also likely to result in less confusion than the current “Four-Minute rule.”

The association between umbilical cord abnormalities and the development of non-reassuring fetal heart rate leading to emergent cesarean deliveries

OBJECTIVE

To study the contribution of umbilical cord (UC) abnormalities in emergent cesarean deliveries (ECDs) for non-reassuring fetal heart rate (NRFHR) and to explore their association with placental histopathology and neonatal outcome.

STUDY DESIGN

Data from 530 ECDs for NRFHR were reviewed for the occurrence of UC abnormalities. Those included the presence of UC entanglements, the number and location of loops, true knots and short cord (<50 cm). Multiple UC entanglements were defined as ⩾ 2 UC loops. Results were compared with 530 vaginal deliveries (VD group) matched for maternal age, parity and gestational age. Additionally, we compared neonatal outcome and placental histopathology in cases of ECDs with a single vs multiple UC entanglements. Neonatal outcome consisted of low Apgar score (⩽ 7 at 5 min), cord blood pH ⩽ 7.1 and composite neonatal outcome that was defined as one or more of respiratory distress, necrotizing enterocolitis, sepsis, transfusion, ventilation, seizure, hypoxic-ischemic encephalopathy, phototherapy or death. Placental lesions were classified as: lesions related to maternal vascular supply, lesions related to fetal vascular supply (consistent with fetal thrombo-occlusive disease), and maternal and fetal inflammatory responses.

RESULTS

UC entanglements, true knots and short cords were all more common in the ECD group compared with the VD group, P<0.001, P=0.002, P=0.004, respectively. The rate of one loop entanglement did not differ between the groups. The rate of multiple UC entanglements was higher in the ECD group compared with the VD group, 20.6% vs 6.4%, respectively, P<0.001. ECDs with multiple compared with single UC entanglement had higher rate of adverse neonatal outcome, P=0.031, and more placental fetal vascular lesions 19.3% vs 8.1%, P=0.027, respectively.

CONCLUSION

Multiple UC entanglements, true knots and short cords were more common in ECDs for NRFHR, suggesting their role in the development of fetal placental vascular lesions and adverse neonatal outcome.

[Neonatal complications related to shoulder dystocia]

OBJECTIVE

To describe neonatal complications related to shoulder dystocia.

METHODS

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

RESULTS

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

CONCLUSION

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

Maternofetal Trauma in Craniosynostosis

BACKGROUND

Premature cranial suture fusion may prevent neonatal skull malleability during birth, increasing the risk of unplanned cesarean delivery and neonatal birth trauma caused by cephalopelvic disproportion. We sought to determine the incidence of perinatal maternofetal complications in cases of craniosynostosis.

METHODS

Records of children presenting with nonsyndromic craniosynostosis to a tertiary pediatric hospital from 1996 to 2012 were reviewed retrospectively with focus on birth history and birth-related complications.

RESULTS

Six hundred eighteen births were reviewed. Rates of cesarean delivery among mothers of children with craniosynostosis [n = 201 (32.5 percent)] exceeded the overall regional rate of 24.5 percent (OR, 1.50; p < 0.0001). Unplanned cesarean delivery occurred in 19.7 percent of births, and were most associated with nulliparous mothers, breech fetal presentations, and lambdoid or multisuture synostosis patterns. Eleven neonates (1.8 percent) exhibited cranial birth trauma, including cephalohematoma and subgaleal hematoma. Neonates with sagittal or multisuture synostosis patterns were more likely to suffer birth trauma and had a higher mean head circumference than those who did not (81st versus 66th percentile, p < 0.05).

CONCLUSIONS

In the setting of craniosynostosis, birth trauma is increased-for mothers in the form of increased cesarean delivery risk, and for fetuses in the form of subgaleal and subperiosteal perinatal bleeding. Difficult maternal labor may be mediated especially by multisuture or lambdoid synostosis, whereas fetal birth trauma may be mediated to a greater extent by large head size. Prenatal diagnosis of craniosynostosis could influence decision-making in the management of labor.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, IV.

Unilateral femoral fracture in a low birth weight infant: a case report

Femoral fractures due to birth trauma are an extremely rare but important birth injury. While vaginal breech delivery, although rare, can cause femur fracture, abdominal breech delivery is not expected to cause fracture. Here we report on a low birth weight infant who was delivered by cesarean section for breech presentation at 30 1/7 weeks of gestation and sustained a unilateral fracture of the femoral shaft.

Fetal laceration during caesarean section and its medico-legal sequelae

Fetal laceration is a recognized complication of caesarean delivery. The aim of this study was to investigate the incidence, type, location, risk factors and long-term consequences of accidental fetal incised wounds during caesarean delivery. During a five-year period, we observed 25 cases of fetal lacerations caused by the scalpel during hysterotomy. In 20 of these cases, we observed these lesions as consultants for the Neonatologic Care Unit; the other five cases came under our care after an insurance claim for damages against the gynaecologist. All the infants had a lesion located to the head. In only 5 of the 25 cases the lesion was reported in the operative summary, and only 16 of the 25 mothers had signed an informed consent before surgery. With regard to the 20 cases diagnosed at the Neonatologic Care Unit, the lesion was closed using single stitches in nine cases, and with biological glue in 11 cases. Concerning the five cases that underwent legal proceedings against the gynaecologist, a clinical examination was performed by an expert in Public Health and Social Security in collaboration with a paediatric surgeon to evaluate the degree of biological damage. In all five cases, the result of the legal challenge was monetary compensation for the physical and moral damage caused by the gynaecologists to the patients and their parents. Accidental fetal lesions may occur during caesarean delivery; the incidence is significantly higher during emergency caesarean delivery compared to elective procedures. Patients should sign an informed consent in which they should be informed about the risk of the occurrence of fetal lacerations during caesarean delivery in order to avoid legal complications.

Incidence of Neonatal Birth Injuries and Related Factors in Kashan, Iran

Background:

Birth injuries are defined as the impairment of neonatal body function due to adverse events that occur at birth and can be avoidable or inevitable. Despite exact prenatal care, birth trauma usually occurs, particularly in long and difficult labor or fetal malpresentations.

Objectives:

This study aimed to investigate the incidence of birth injuries and their related factors in Kashan, Iran, during 2012-2013.

Patients and Methods:

In this cross-sectional study, all live-born neonates in the hospitals of Kashan City were assessed prospectively by a checklist included demographic variables (maternal age, weight, and nationality), reproductive and labor variables (prenatal care, parity, gestational age, premature rupture of membrane (PROM), fetal heart rate (FHR) pattern, duration of PROM, induction of labor, fundal pressure, shoulder dystocia, fetal presentation, duration of second stage, type of delivery, and delivery attendance), and neonatal variables (sex, birth weight, height, head circumference, Apgar score, and neonatal trauma). Birth trauma was diagnosed based on pediatrician or resident examination and in some cases confirmed by paraclinic methods. Statistical analyses were performed by chi-square, student’s t-test, and multiple logistic regression analyses using SPSS version 17. P ≤ 0.05 was considered statistically significant.

Results:

In this study, the incidence of birth trauma was 2.2%. Incidence of trauma was 3.6% in vaginal deliveries and 1.2% in cesarean sections (P < 0.0001). The most common trauma was cephalohematoma (57.2%) and then asphyxia (16.8%). In multiple logistic regression analyses, decreased fetal heart rate (FHR), fundal pressure, shoulder dystocia, vaginal delivery, male sex, neonatal weight, delivery by resident, induction of labor, and delivery in a teaching hospital were predictors of birth trauma.

Conclusions:

Overall, incidence of birth trauma in Kashan City was lower in comparison with most studies. Considering existing risk factors, further monitoring on labor, and delivery management in teaching hospitals are recommended to prevent birth injuries. In addition, careful supervision on students and residents' training should be applied in teaching hospitals.

Blunt versus sharp uterine incision expansion during low transverse cesarean delivery: a metaanalysis

OBJECTIVE

We sought to review and update available evidence regarding outcomes after cesarean delivery (CD) using blunt vs sharp expansion of the uterine incision.

STUDY DESIGN

We queried the database of PubMed (US National Library of Medicine, 1946 through December 2013), the Cochrane Library Database of Systematic Reviews, ClinicalTrials.gov, and Web of Science. All relevant bibliographies were reviewed. Randomized controlled trials comparing blunt with sharp expansion of the lower segment during CD were evaluated for inclusion and methodological quality. The primary outcome was occurrence of unintended extensions. Secondary outcomes were drop in hematocrit or hemoglobin and estimated maternal blood loss, need for transfusion, operative time, use of uterotonics, rate of endometritis, and neonatal outcomes. Data extraction, analysis, and results were based on the preferred reporting items for systematic review and metaanalysis guidelines.

RESULTS

Six randomized controlled trials (2908 patients) were included. Blunt expansion technique was associated with lower drop in postoperative hematocrit (weighted mean difference [WMD], -1.07%; P = .05) and hemoglobin (WMD, -0.64 g/dL; P < .05), lower rate of unintended extensions (pooled relative risk, 0.47; P < .05), and a shorter operative time (WMD, -2 minutes; P < .05). Lower estimated blood loss was also observed but the difference was not significant (WMD, -88.07 mL; P > .05). There were no differences in the rates of blood transfusion, endometritis, use of uterotonics, and neonatal outcomes between both techniques.

CONCLUSION

Blunt expansion of uterine incision during CD is associated with less unintended extensions and favorable maternal outcomes. Although the drop in hemoglobin, hematocrit, and operative times were in favor of blunt expansion, the degree of reduction may not be clinically relevant.

The cost-effectiveness of a trial of labor accrues with multiple subsequent vaginal deliveries

OBJECTIVE

The purpose of this study was to estimate costs and outcomes of subsequent trials of labor after cesarean delivery (TOLAC) compared with elective repeat cesarean deliveries (ERCD).

STUDY DESIGN

To compare TOLAC and ERCD, maternal and neonatal decision analytic models were built for each hypothetic subsequent delivery. We assumed that only women without previa would undergo TOLAC for their second delivery, that women with successful TOLAC would desire future TOLAC, and that women who chose ERCD would undergo subsequent ERCD. Main outcome measures were maternal and neonatal mortality and morbidity rates, direct costs, and quality-adjusted life years. Values were derived from the literature. One-way and Monte-Carlo sensitivity analyses were performed.

RESULTS

TOLAC was less costly and more effective for most models. A progression of decreasing incremental cost and increasing incremental effectiveness of TOLAC was found for maternal outcomes with increasing numbers of subsequent deliveries. This progression was also displayed among neonatal outcomes and was most prominent when neonatal and maternal outcomes were combined, with an incremental cost and effectiveness of -$4700.00 and .073, respectively, for the sixth delivery. Net-benefit analysis showed an increase in the benefit of TOLAC with successive deliveries for all outcomes. The maternal model of the second delivery was sensitive to cost of delivery and emergent cesarean delivery. Successive maternal models became more robust, with the models of the third-sixth deliveries sensitive only to cost of delivery. Neonatal models were not sensitive to any variables.

CONCLUSION

Although nearly equally effective relative to ERCD for the second delivery, TOLAC becomes less costly and more effective with subsequent deliveries.

The effect of a program to shorten the decision-to-delivery interval for emergent cesarean section on maternal and neonatal outcome

OBJECTIVE

To study the effect of a departmental program designed to shorten the decision-to-delivery interval (DDI) for emergency cesarean section (ECS) for nonreassuring fetal heart rate (NRFHR) on maternal and neonatal outcome.

STUDY DESIGN

A protocol for managing ECS that included documenting precise time-intervals, identification of delaying obstacles and debriefing of each case, was implemented from March 2011. All women who delivered by ECS for NRFHR, as the only indication were included. Detailed information regarding DDI, maternal intraoperative and postoperative complications, and neonatal early outcomes were compared before (period-P1) (-27 months) and after (period 2) (+27 months) program implementation.

RESULTS

During 54 months of study, 593 ECS DDI were included. Mean DDI decreased at period 2 (12.3 ± 3.8 min, n = 301) compared with period 1 (21.7 ± 9.1 min, n = 292), P < .001. Rate of cord pH ≤7.1 and 5 min Apgar score ≤7 decreased at period 2 compared with period 1, P = .016 and P = .031, respectively. Worse composite neonatal outcome decreased at period 2 compared with period 1, 15.6% vs 32.2%, respectively, P ≥ .001. Composite maternal outcome did not differ between the groups. Worse neonatal outcome was dependent on time period (period 1), odds ratio, 2.12; 95% confidence interval, 1.27-3.55; P = .004 and on gestational age at delivery, odds ratio, 0.68; 95% confidence interval, 0.62-0.76; P < .001.

CONCLUSION

Introduction of a management protocol to shorten DDI in ECS for NRFHR was associated with improved early neonatal outcome without change in maternal complications.

Bilateral humerus fracture following birth trauma

Birth injuries especially to humerus are rare in Caesarean sections as compared to vaginal deliveries. But in some difficult extractions even with expert care, injury may be sustained by the newborn. This is a report of a case of birth trauma induced fractures of both humerus during Caesarean section.