Management of pregnancy at and beyond 41 completed weeks of gestation in low-risk women: a secondary analysis of two WHO multi-country surveys on maternal and newborn health

Likelihood of primary cesarean section following induction of labor in singleton cephalic pregnancies at term, compared with expectant management: An Australian population-based, historical cohort study

INTRODUCTION

There has been increased use of both induction of labor (IOL) and cesarean section for women with term pregnancies in many high-income countries, and a trend toward birth at earlier gestational ages. Existing evidence regarding the association between IOL and cesarean section for term pregnancies is mixed and conflicting, and little evidence is available on the differential effect at each week of gestation, stratified by parity.

MATERIAL AND METHODS

To explore the association between IOL and primary cesarean section for singleton cephalic pregnancies at term, compared with two definitions of expectant management (first: at or beyond the week of gestation at birth following IOL; and secondary: only beyond the week of gestation at birth following IOL), we performed analyses of population-based historical cohort data on women who gave birth in one Australian state (Queensland), between July 1, 2012 and June 30, 2018. Women who gave birth before 37+0 or after 41+6 weeks of gestation, had stillbirths, no-labor, multiple births (twins or triplets), non-cephalic presentation at birth, a previous cesarean section, or missing data on included variables were excluded. Four sub-datasets were created for each week at birth (37-40). Unadjusted relative risk, adjusted relative risk using modified Poisson regression, and their 95% confidence intervals were calculated in each sub-dataset. Analyses were stratified by parity (nulliparas vs. parous women with a previous vaginal birth). Sensitivity analyses were conducted by limiting to women with low-risk pregnancies.

RESULTS

A total of 239 094 women were included in the analysis, 36.7% of whom gave birth following IOL. The likelihood of primary cesarean section following IOL in a Queensland population-based cohort was significantly higher at 38 and 39 weeks, compared with expectant management up to 41+6 weeks, for both nulliparas and paras with singleton cephalic pregnancies, regardless of risk status of pregnancy and definition of expectant management. No significant difference was found for nulliparas at 37 and 40 weeks; and for paras at 40 weeks.

CONCLUSIONS

Future studies are suggested to investigate further the association between IOL and other maternal and neonatal outcomes at each week of gestation in different maternal populations, before making any recommendation.

Neonatal outcomes according to different degrees of maternal morbidity: cross-sectional evidence from the Perinatal Information System (SIP) of the CLAP network

BACKGROUND

The burden of maternal morbidity in neonatal outcomes can vary with the adequacy of healthcare provision and tool implementation to improve monitoring. Such information is lacking in Latin American countries, where the decrease in severe maternal morbidity and maternal death remains challenging.

OBJECTIVES

To determine neonatal outcomes according to maternal characteristics, including different degrees of maternal morbidity in Latin American health facilities.

METHODS

This is a secondary cross-sectional analysis of the Perinatal Information System (SIP) database from eight health facilities in five Latin American and Caribbean countries. Participants were all women delivering from August 2018 to June 2021, excluding cases of abortion, multiple pregnancies and missing information on perinatal outcomes. As primary and secondary outcome measures, neonatal near miss and neonatal death were measured according to maternal/pregnancy characteristics and degrees of maternal morbidity. Estimated adjusted prevalence ratios (PRadj) with their respective 95% CIs were reported.

RESULTS

In total 85,863 live births were included, with 1,250 neonatal near miss (NNM) cases and 695 identified neonatal deaths. NNM and neonatal mortality ratios were 14.6 and 8.1 per 1,000 live births, respectively. Conditions independently associated with a NNM or neonatal death were the need for neonatal resuscitation (PRadj 16.73, 95% CI [13.29-21.05]), being single (PRadj 1.45, 95% CI [1.32-1.59]), maternal near miss or death (PRadj 1.64, 95% CI [1.14-2.37]), preeclampsia (PRadj 3.02, 95% CI [1.70-5.35]), eclampsia/HELPP (PRadj 1.50, 95% CI [1.16-1.94]), maternal age (years) (PRadj 1.01, 95% CI [<1.01-1.02]), major congenital anomalies (PRadj 3.21, 95% CI [1.43-7.23]), diabetes (PRadj 1.49, 95% CI [1.11-1.98]) and cardiac disease (PRadj 1.65, 95% CI [1.14-2.37]).

CONCLUSION

Maternal morbidity leads to worse neonatal outcomes, especially in women suffering maternal near miss or death. Based on SIP/PAHO database all these indicators may be helpful for routine situation monitoring in Latin America with the purpose of policy changes and improvement of maternal and neonatal health.

Determinants of fetomaternal complication of instrumental vaginal delivery among women who gave childbirth in Southern Ethiopia: a facility-based cross-sectional study

BACKGROUND

In Ethiopia, one in five instrumental deliveries among women giving birth resulted in an unfavourable outcome. This study aimed to assess the determinants of feto-maternal complications of instrumental delivery in selected public hospitals of Gamo and Gofa zones, Southern Ethiopia.

METHODS

An institution-based cross-sectional study was conducted among 399 women attending selected public hospitals in the Gamo and Gofa zones. Data were collected using data extraction tools using a systematic random sampling technique. The collected data was entered into Epi-data version 3.1 and then analyzed using SPSS version 25. Logistic regression analysis was conducted to determine an association.

RESULTS

One hundred eighty-three (45.9%, n = 183/399) instrumental deliveries were found to be complicated. Primigravida women (AOR: 95% CI: 2.21 (1.35, 3.63), infant birth weight (AOR: 95% CI: 2.56 (1.37, 4.77), post-term pregnancy (AOR: 95% CI: 12.77 (2.92, 55.78), and maternal age (AOR: 95% CI: 7.00 (2.16, 22.64) were associated with fetomaternal complications in instrumental delivery among women who gave birth.

CONCLUSIONS AND RECOMMENDATION

A high proportion of women developed fetomaternal complications when compared to local studies. Promotion of antenatal care services, increasing women's education and empowerment as well as working on capacity building of health care professionals through education and training is cost-effective to reduce the occurrence of fetomaternal complications.

Effect of Castor Oil on Cervical Ripening and Labor Induction: a systematic review and meta-analysis

Objectives

Post-term pregnancy is a condition associated with increased maternal and fetal complications. Administration of castor oil causes cervical stimulation by increasing the production of prostaglandins. We examined the effects of castor oil on cervical ripening and labor induction through a systematic review and meta-analysis.

Methods

The search process was performed to obtain relevant articles from databases including Pubmed, Cochrane library, Scopus, Science direct, SID, Iran Medex, and Google Scholar using the English keywords of cervical ripening, post-term, castor oil, labor induction, Bishop score, and pregnancy considering all possible combinations without time constraints and their Persian equivalents from national databases.

Results

A total of eight related articles from the 19 primary studies were extracted and systematically reviewed. According to a cumulative chart, the difference in the post-intervention Bishop score was statistically significant (standard mean difference [SMD] 1.64, 95% confidence interval [CI] 1.67-2.11, p = 0.001), indicating an effect of castor oil on increasing the Bishop score. In addition, the difference in labor induction was statistically significant after the intervention (odds ratio 11.67, 95% CI 3.34-40.81, p = 0.001), indicating an effect of castor oil on increasing the odds ratio of labor induction (experience of vaginal delivery).

Conclusion

This meta-analysis showed that oral administration of castor oil is effective for cervical ripening and labor induction. Midwives should closely monitor pregnant women with prolonged labor and collaborate with obstetricians to employ castor oil as a safe intervention to induce cervical ripening and labor to prevent undue caesarean surgery.

The effect of evening primrose oil on labor induction and cervical ripening: A systematic review and meta-analysis

The evening primrose oil has prostaglandin effects and is applied to soften the cervix. This systematic review and meta-analysis aimed to establish the results of clinical trials performed on the effect of evening primrose oil on labor induction and cervical ripening in pregnant women. Research studies were searched from 1990 to September 2019 in Pubmed, Science Direct, Embase, and Cochrane Library using the keywords: cervical ripening, Bishop score, labor induction, post-term pregnancy, evening primrose, and any possible combination of these keywords (Farsi, English). Data analysis was conducted using STATA (version 14.1), and I² index and random effect forest plots to assess the heterogeneity between the studies and perform the meta-analysis, respectively. Six articles that met the inclusion criteria were extracted in which four were entered into quantitative meta-analysis. The results' high heterogeneity was 91.4% based on I² index (p ≤ .001) and the random model was applied for meta-analysis. The result demonstrated no significant difference between the intervention and control groups in terms of mean difference of the Bishop score before and after intervention (SMD: 0.27, 95%CI: -0.41, 0.96, p = .43). Based on current meta-analysis on four studies, effectiveness of oral consumption of evening primrose on cervical ripening was not approved.

Against medical advice for induction of labor due to post-term pregnancies - the impact on pregnancy outcome

OBJECTIVE

To determine the impact of deciding against medical advice and refusing labor induction in post-term pregnancies on pregnancy outcome.

METHODS

Maternal and neonatal outcomes of women who refused induction of labor due to post term pregnancy (study group) were retrospectively compared to a control group of women who agreed labor induction (1:2 ratio) in a university-affiliated tertiary single medical center.

RESULTS

A total of 83 women who refused labor induction were identified and compared to 166 womenwho consented to labor induction. Women who refused labor induction had higher rates of cesarean deliveries (21.7 vs. 10.2% p = .04), longer post-delivery hospitalization (2.9 vs. 2.4 days p < .05) and more advanced gestational age at delivery (41 + 6 vs. 41 + 4 days, p < .05). No significant differences were found in the rate of operative vaginal deliveries, need for antibiotics treatment or blood transfusion between the studied groups. Adverse neonatal outcomes among women who refused labor induction were significantly higher with higher rates of meconium (44.6 vs. 15.7%, p < .01), admission to NICU (9.6 vs. 5%, p < .01) and need for mechanical ventilation (4.8 vs. 0.6%, p < .01).

CONCLUSION

Refusing induction of labor due to post- term pregnancy is associated with higher rate of adverse maternal and neonatal outcomes, with a significant higher risk for cesarean section.

Factors affecting failed trial of labor and countermeasures: A retrospective analysis

BACKGROUND

Vaginal delivery is the ideal mode of delivery for the termination of a pregnancy. However, the cesarean section rate in China is much higher than the published by the World Health Organization in the Lancet in 2010.

AIM

To retrospectively analyze the factors related to failed trial of labor and the clinical indications for cesarean section conversion, explore how to promote the trial of labor success rate, and determine the feasibility of reducing the rate of conversion to cesarean section.

METHODS

A retrospective analysis was performed on 9240 maternal women who met vaginal delivery conditions and required a trial of labor from January 2016 to December 2018 at our hospital. Among them, 8164 pregnant women who had a successful trial of labor were used as a control group, and 1076 pregnant women who had a failed trial of labor and converted to an emergency cesarean section were used as an observation group. The patients’ clinical data during hospitalization were collected for comparative analysis, the related factors of the failed trial of labor were discussed, and reasonable prevention and resolution strategies were proposed to increase the success rate of trial of labor.

RESULTS

The analysis revealed that advanced age (≥ 35 years old), macrosomia (≥ 4000 g), delayed pregnancy (≥ 41 wk), use of uterine contraction drugs, primipara, and fever during labor were associated with conversion to an emergency cesarean section in the failed trial of labor. Multivariate regression analysis showed that age, gestational age, primipara, use of uterine contraction drugs, fever during birth, and newborn weight led to a higher probability of conversion to an emergency cesarean section in the failed trial of labor. The analysis indicated that the following clinical indications were associated with the conversion to cesarean section in the failed trial of labor: Fetal distress (44.3%), social factors (12.8%), malpresentation (face presentation, persistent occipitoposterior position, and persistent occipitotransverse position) (9.4%), and cephalopelvic disproportion (8.9%).

CONCLUSION

The conversion to emergency cesarean section in failed trial of labor is affected by many factors. Medical staff should take appropriate preventive measures for the main factors, increase the trial of labor success rate, improve the quality of delivery, ensure the safety of mother and child during the perinatal period, and improve the relationship between doctors and patients.

Agreement between antenatal gestational age by ultrasound and clinical records at birth: A prospective cohort in the Brazilian Amazon

This study aimed to assess agreement between antenatal estimates of gestational age by ultrasound and clinical records at birth in the Brazilian Amazon. Ultrasound examinations were scheduled during the second trimester for 578 pregnant women prospectively screened at primary health care units, following a standardized protocol for image quality control. A multistage algorithm was used to assess the best estimate of gestational age during the antenatal period, considering reliability of last menstrual period (LMP) and acceptable differences in relation to ultrasound estimates derived from fetal biparietal diameter and femur length. Agreement of antenatal estimates of gestational age confirmed by ultrasound and clinical records at birth was analyzed with Bland-Altman plots and kappa coefficients (preterm and postterm births). Overall, ultrasound examinations presented high quality (>90% of satisfactory images), and were adopted as the best estimate of gestational age among 83.4% of pregnant women, confirming reliable LMP in the remaining proportion. On average, difference in gestational age between antenatal estimates and clinical records was 0.43 week (95% CI: 0.32, 0.53). Classification of preterm births had a good agreement (kappa: 0.82, p<0.001), but a poor performance was observed for postterm births (kappa: -0.06, p = 0.92). Higher differences in gestational age were noted for participants with >11 years of education and cases of caesarean deliveries. In conclusion, high-quality ultrasound images from the second trimester of pregnancy based the assessment of gestational age, while reliability of LMP was limited. Information from clinical records at birth presented an acceptable agreement on average and for classification of preterm births, which is relevant for properly interpreting perinatal outcomes. Discrepancies in caesarean deliveries may warrant further investigation.

A systematic scoping review of clinical indications for induction of labour

BACKGROUND

The proportion of women undergoing induction of labour (IOL) has risen in recent decades, with significant variation within countries and between hospitals. The aim of this study was to review research supporting indications for IOL and determine which indications are supported by evidence and where knowledge gaps exist.

METHODS

A systematic scoping review of quantitative studies of common indications for IOL. For each indication, we included systematic reviews/meta-analyses, randomised controlled trials (RCTs), cohort studies and case control studies that compared maternal and neonatal outcomes for different modes or timing of birth. Studies were identified via the databases PubMed, Maternity and Infant Care, CINAHL, EMBASE, and ClinicalTrials.gov from between April 2008 and November 2019, and also from reference lists of included studies. We identified 2554 abstracts and reviewed 300 full text articles. The quality of included studies was assessed using the RoB 2.0, the ROBINS-I and the ROBIN tool.

RESULTS

68 studies were included which related to post-term pregnancy (15), hypertension/pre-eclampsia (15), diabetes (9), prelabour rupture of membranes (5), twin pregnancy (5), suspected fetal compromise (4), maternal elevated body mass index (BMI) (4), intrahepatic cholestasis of pregnancy (3), suspected macrosomia (3), fetal gastroschisis (2), maternal age (2), and maternal cardiac disease (1). Available evidence supports IOL for women with post-term pregnancy, although the evidence is weak regarding the timing (41 versus 42 weeks), and for women with hypertension/preeclampsia in terms of improved maternal outcomes. For women with preterm premature rupture of membranes (24-37 weeks), high-quality evidence supports expectant management rather than IOL/early birth. Evidence is weakly supportive for IOL in women with term rupture of membranes. For all other indications, there were conflicting findings and/or insufficient power to provide definitive evidence.

CONCLUSIONS

While for some indications, IOL is clearly recommended, a number of common indications for IOL do not have strong supporting evidence. Overall, few RCTs have evaluated the various indications for IOL. For conditions where clinical equipoise regarding timing of birth may still exist, such as suspected macrosomia and elevated BMI, researchers and funding agencies should prioritise studies of sufficient power that can provide quality evidence to guide care in these situations.

Women's information needs, decision-making and experiences of membrane sweeping to promote spontaneous labour

OBJECTIVE

To explore and synthesise evidence of women's information needs, decision-making and experiences of membrane sweeping to promote spontaneous labour.

DESIGN

A systematic review following the Joanna Briggs Institute (JBI) meta-aggregative approach to qualitative evidence synthesis. Relevant databases were searched for literature published in English between 2000-19. Study quality was assessed using the JBI quality assessment tool for qualitative studies.

SETTING

Qualitative research conducted in OECD countries describing women's information needs, decision-making and/or experiences of membrane sweeping to promote spontaneous labour.

FINDINGS

One article met the criteria for inclusion. This article describes the experience of a membrane sweep given without consent.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

There is a lack of evidence around women's information needs, decision-making and experiences of membrane sweeping. This is concerning, especially in the context of rising rates of formal induction of labour. Further research is needed to investigate how women are being offered membrane sweeping and what information women need to make informed choices about membrane sweeping to promote spontaneous labour.

Apgar score of 0 at 10 min and survival to 1 year of age: a retrospective cohort study in Washington state

OBJECTIVE

To determine 1-year survival in a cohort of newborns with an Apgar score of 0 at 5 and 10 min of age.

STUDY DESIGN

A retrospective cohort study of the Washington State Comprehensive Hospital Abstract Reporting System from 2005 to 2014.

RESULTS

Of 879,340 births, 199 (0.02%) had an Apgar score of 0 at 5 min, and 109 (0.01%) also had a score of 0 at 10 min. One-year survival was 46% for newborns with Apgar score of 0 at 5 and 10 min. One-year survival by gestational age was 4% for newborns <30 weeks, 38% for 30-35 weeks, and 67% for ≥36 weeks.

CONCLUSION

Survival at 1 year of age for newborns with an Apgar score of 0 at 5 and 10 min has improved, as compared with historic cohorts. Cautious optimism is warranted since morbidity-free survival could not be assessed.