Incidence of early neonatal mortality and morbidity after late-preterm and term cesarean delivery

New policies on skin-to-skin contact warrant an oxytocin-based perspective on perinatal health care

Background

In 2023, the World Health Organization (WHO) published a Global Position Paper on Kangaroo Mother Care (KMC), which is applicable to all countries worldwide: from the moment of birth, every "small and sick" newborn should remain with mother in immediate and continuous skin-to-skin contact (SSC), receiving all required clinical care in that place. This was prompted by the startling results of a randomized controlled trial published in 2021: in which 1,609 infants receiving immediate SSC were compared with 1,602 controls that were separated from their mothers but otherwise received identical conventional state-of-the-art care. The intervention infants showed a 25% reduction in mortality after 28 days.

New perspectives

The new WHO guidelines are a significant change from earlier guidance and common clinical practice. The author presents that separating mothers and babies is assumed to be "normal" (a paradigm) but actually puts newborns at increased risk for morbidity and mortality. The author presents arguments and ethical perspectives for a new perspective on what is "normal," keeping newborns with their mothers is the infant's physiological expectation and critical requirement for healthy development. The author reviews the scientific rationale for changing the paradigm, based on synchronous interactions of oxytocin on both mother and infant. This follows a critique of the new policies that highlights the role of immediate SSC.

Actionable recommendations

This critique strengthens the case for implementing the WHO guidelines on KMC for small and sick babies. System changes will be necessary in both obstetric and neonatal settings to ensure seamless perinatal care. Based on the role of oxytocin, the author identifies that many current routine care practices may actually contribute to stress and increased vulnerability to the newborn. WHO has actionable recommendations about family involvement and presence in newborn intensive care units.

Discussion

The concepts of resilience and vulnerability have specific definitions well known in perinatal care: the key outcome of care should be resilience rather than merely the absence of vulnerability. Newborns in all settings and contexts need us to re-evaluate our paradigms and adopt and implement the new WHO guidelines on KMC in perinatal care.

Caesarean delivery and neonatal mortality: evidence from selected slums in and around Dhaka city, Bangladesh- A prospective cohort study

BACKGROUND

This study examined the neonatal mortality for newborn of women who delivered by caesarean section or vaginally using a prospective cohort.

METHODS

A total of 6,989 live births registered from 2016 to 2018, were followed for neonatal survival from the selected slums of Dhaka (North and South) and Gazipur city corporations, where icddr,b maintained the Health and Demographic Surveillance System (HDSS). Neonatal mortality was compared by maternal and newborn characteristics and mode of delivery using z-test. Logistic regression model performed for neonatal mortality by mode of delivery controlling selected covariates and reported adjusted odd ratios (aOR) with 95% confidence interval (CI).

RESULTS

Out of 6,989 live births registered, 27.7% were caesarean and the rest were vaginal delivery; of these births, 265 neonatal deaths occurred during the follow-up. The neonatal mortality rate was 2.7 times higher (46 vs. 17 per 1,000 births) for vaginal than caesarean delivered. Until 3rd day of life, the mortality rate was very high for both vaginal and caesarean delivered newborn; however, the rate was 24.8 for vaginal and 6.3 per 1,000 live births for caesarean delivered on the 1st day of life. After adjusting the covariates, the odds of neonatal mortality were higher for vaginal than caesarean delivered (aOR: 2.63; 95% CI: 1.82, 3.85). Additionally, the odds were higher for adolescent than elderly adult mother (aOR: 1.60; 95% CI: 1.03, 2.48), for multiple than singleton birth (aOR: 5.40; 95% CI: 2.82, 10.33), for very/moderate (aOR: 5.13; 95% CI: 3.68, 7.15), and late preterm birth (aOR: 1.48; 95% CI: 1.05, 2.08) than term birth; while the odds were lower for girl than boy (aOR: 0.74; 95% CI: 0.58, 0.96), and for 5th wealth quintile than 1st quintile (aOR: 0.59, 95% CI: 0.38, 0.91).

CONCLUSION

Our study found that caesarean delivered babies had significantly lower neonatal mortality than vaginal delivered. Therefore, a comprehensive delivery and postnatal care for vaginal births needed a special attention for the slum mothers to ensure the reduction of neonatal mortality.

Improving the external validity of Antenatal Late Preterm Steroids trial findings

BACKGROUND

The external validity of randomised trials can be compromised when trial participants differ from real-world populations. In the Antenatal Late Preterm Steroids (ALPS) trial of antenatal corticosteroids at late preterm ages, participants had systematically younger gestational ages than those outside the trial setting. As risk of respiratory morbidity (the primary trial outcome) is higher at younger gestations, absolute benefits of corticosteroids calculated in the trial population may overestimate real-world treatment benefits.

OBJECTIVES

To estimate the real-world absolute risk reduction and number-needed-to-treat (NNT) for antenatal corticosteroids at late preterm ages, accounting for gestational age differences between the ALPS and real-world populations.

METHODS

Individual participant data from the ALPS trial (which recruited 2831 women with imminent preterm birth at 34+0 to 36+5 weeks') was appended to population-based data for 15,741 women admitted for delivery between 34+0 and 36+5 weeks' from British Columbia, Canada, 2000-2013. We used logistic regression to calculate inverse odds of sampling weights for each trial participant and re-estimated treatment effects of corticosteroids on neonatal respiratory morbidity in ALPS participants, weighted to reflect the gestational age distribution of the population-based (real-world) sample.

RESULTS

The real-world absolute risk reduction was estimated to be -2.2 (95% CI -4.6, 0.0) cases of respiratory morbidity per 100, compared with -2.8 (95% CI -5.3, -0.3) in original trial data. Corresponding NNTs were 46 in the real-world setting vs 35 in the trial. Our focus on absolute measures also highlighted that the benefits of antenatal corticosteroids may be meaningfully greater at 34 weeks vs. 36 weeks (e.g., risk reductions of -3.7 vs. -1.2 per 100 respectively).

CONCLUSIONS

The absolute risk reductions and NNTs associated with antenatal corticosteroid administration at late preterm ages estimated in our study may be more appropriate for patient counselling as they better reflect the anticipated benefits of treatment when used in a real-world situation.

Impact of placenta accreta spectrum (PAS) pathology on neonatal respiratory outcomes in cesarean hysterectomies

OBJECTIVE

Placenta accreta spectrum (PAS) is a continuum of disorders characterized by the pathologically adherent placenta to the uterine myometrium. Delivery by cesarean hysterectomy at 34-36 weeks is recommended to mitigate the risks of maternal morbidity. Iatrogenic preterm delivery, has potential neonatal implications; late preterm infants are at risk for significant respiratory morbidity. Neonatal outcomes in PAS neonates are not well described in the literature, we aimed to investigate these outcomes.

METHODS

A case-control study was performed with 107 cases of pathology-confirmed PAS patients with singleton, non-anomalous, viable pregnancies, compared to 76 cases of placenta previa with prior cesarean section who underwent repeat cesarean section. All patients were delivered through our institution's Placenta Accreta Program from 2005 to 2020. Rates of neonatal respiratory morbidity and related outcomes were analyzed.

RESULTS

Maternal characteristics and antenatal complications were similar between groups, as were gestational age, steroid exposure, and emergent delivery. PAS was associated with increased use of general anesthesia (20 vs. 54%, p = .001), larger estimated blood loss (1875 vs. 6077 ml, p = .008), and longer post-operative stays (4.8 vs. 7.3 days, p = .01). PAS was also associated with neonatal increased rates of high flow nasal cannula (HFNC) (41 vs. 58%, p = .02), intubation (17 vs. 37%, p = .008), and duration of respiratory support (0 vs. 2 days, p = .03). There were no differences in rates of continuous positive airway pressure (CPAP)/positive pressure ventilation (PPV) (21 vs. 22%, p = .85), anemia, hyperbilirubinemia, or NICU length of stay. Multivariate analysis adjusting for general anesthesia demonstrated this variable confounded the impact of PAS pathology in respiratory outcomes the risk of the respiratory composite (adjusted odds ratio (aOR) 0.57, 95% CI [0.11, 2.82]), use of HFNC (aOR 0.33, 95% CI [0.08-1.48]), and intubation (aOR 1.29, 95% CI [0.25-6.75]), were no longer significant.

CONCLUSIONS

Based on these results, we conclude that PAS neonates have higher rates of respiratory morbidity and that general anesthesia is a significant contributor to these respiratory outcomes. This is important for the antenatal counseling of cases of PAS, especially if general anesthesia is anticipated or requested. Furthermore, it supports efforts to limit general anesthesia exposure of neonates when necessary.

Isonicotinic acid hydrazide (INH) versus extra-amniotic saline infusion (EASI) for cervical ripening at term: a randomised controlled trial

The purpose of this trial was to compare extra-amniotic saline infusion (EASI) and intravaginal isoniazid (INH) for cervical ripening. This randomised clinical trial included 150 pregnant women who were undergoing induction of labour and who required pre-induction cervical ripening. Patients were randomly assigned to receive EASI or intravaginal INH. Bishop's score at the beginning of the study and before oxytocin infusion was not significantly different between INH and EASI groups. However, the time from first intervention to the beginning of the induction and also to the beginning of the active phase were significantly shorter in EASI group (p value ≤.001). Moreover, INH did not influence the labour process after the beginning of the active phase of labour. In conclusion, INH could be used for cervical ripening especially in the outpatient setting; however, it is a slower ripening agent compared to EASI.Impact StatementWhat is already known on this subject? To date there has been only one study about the safety and effectiveness of isoniazid (INH) in cervical ripening at term pregnancy which has compared INH with misoprostol.What do the results of this study add? The results of this study showed that vaginal INH is an effective agent for cervical ripening at term but in comparison to extra-amniotic saline infusion (EASI) it takes a longer time.What are the implications of these findings for clinical practice and/or further research? INH can be used in outpatient settings for cervical ripening at term pregnancy which makes it convenient for patient and cost effective for both patient and health system. Further studies are needed to discover the clinical efficacy of INH in comparison to other ripening methods and also the best dosage of INH for cervical ripening.

Ultrasound performed shortly after birth can predict the respiratory support needs of late preterm and term infants: A diagnostic accuracy study

BACKGROUND

Late preterm and term infants may develop respiratory issues with severe outcomes. Early identification of these diseases shortly after infants' birth can improve their management. Lung ultrasound (LUS) has been used to diagnose neonatal respiratory diseases. However, few LUS methods have been reported to predict the need for respiratory support, the basis of infant respiratory diseases management.

METHODS

We conducted a prospective diagnostic accuracy study following the Standards for the Reporting of Diagnostic Accuracy Studies guidelines at a tertiary academic hospital between 2019 and 2020. A total of 310 late preterm and term infants with mild respiratory symptoms were enrolled. The LUS assessment was performed for each participant at one of the following times: 0.5, 1.0, 2.0, or 4.0 h after birth. Predictive reliability was tested by receiver operating characteristic curve analysis. The main outcome was the need for any respiratory support determined according to international guidelines.

RESULTS

Seventy-four infants needed respiratory support, and 236 were healthy according to a 3-day follow-up confirmation. Six LUS imaging patterns were found. Two "high-risk" patterns were strongly correlated with respiratory support needs (area under the curve [AUC] = 0.95; 95% confidence interval [CI]: 0.92-0.98, p < .001). The optimal cut-off value for "high-risk" patterns was 2 (sensitivity = 87.8% and specificity = 91.1%). The predictive value of LUS was greater than that of a symptom-based method (the Acute Care of at-Risk Newborns assessment score) (AUCs' p < .01).

CONCLUSIONS

LUS can be used to predict the need for respiratory support in late preterm and term infants and is more reliable than tools based on respiratory symptoms.

What happens to 35 week infants that receive delivery room continuous positive airway pressure?

OBJECTIVE

Delivery room (DR) continuous positive airway pressure (CPAP) is increasing. Our study examined the risk for neonatal morbidities after DR CPAP in 35 week neonates.

STUDY DESIGN

A retrospective study of 259 infants born at 35 weeks gestational age between January 1, 2017-December 31, 2018 at a single center.

RESULTS

DR resuscitation was administered in 30.5%, with 19.7% receiving CPAP alone. Eighty percent who received DR CPAP were admitted to the NICU. DR CPAP was associated with the highest NICU admission risk, 9.3 times the risk of those without DR positive pressure, and with respiratory conditions (RDS: OR 4.22 {CI 1.46-11.51}, TTN: OR 3.30 {CI 1.36-7.64}). For the DR CPAP group, non-invasive positive pressure was administered post resuscitation in 90%.

CONCLUSIONS

In our institution, 35 week infants frequently received DR CPAP. Of these infants, a majority were admitted to the NICU for respiratory disorders.

Neonatal Morbidities in Infants Born Late Preterm at 35-36 Weeks of Gestation: A Swedish Nationwide Population-based Study

OBJECTIVE

To assess risk for neonatal morbidities among infants born late preterm at 35-36 gestational weeks, early term (37-38 weeks), and late-term (41 weeks) infants, compared with full-term (39-40 weeks) infants.

STUDY DESIGN

This nationwide population-based cohort study included 1 650 450 non-malformed liveborn singleton infants born at 35-41 weeks between 1998 and 2016 in Sweden. The relative risks for low Apgar score (0-3) at 5 minutes; respiratory, metabolic, infectious, and neurologic morbidities; and severe neonatal morbidity (composite outcome) were adjusted for maternal, pregnancy, delivery, and infant characteristics.

RESULTS

Compared with infants born at 39-40 weeks, the adjusted relative risks and proportions of infants born at 35-36 weeks were higher for metabolic morbidity 7.79 (95%, 7.61 to 7.97; 33.75% vs 3.11%), respiratory morbidity 5.54 (95% CI, 5.24 to 5.85; 5.49% vs 0.75%), severe neonatal morbidity 2.42 (95% CI, 2.27 to 2.59; 3.40% versus 1.03%), infectious morbidity 1.98 (95% CI, 1.83 to 2.14; 2.53% vs 0.95%), neurologic morbidity 1.74 (95% CI, 1.48 to 2.03; 0.54% vs 0.23%), and low Apgar score 2.07 (95% CI, 1.72 to 2.51; 0.42% vs 0.12%). The risks for respiratory, severe neonatal morbidity, infectious, neurologic morbidities, and low Apgar score were highest at 35 weeks, gradually decreased until 39 weeks, and increased during 39-41 weeks.

CONCLUSIONS

Infants born late preterm at 35-36 weeks of gestation are at increased risk of neonatal morbidities, although the absolute risks for severe neonatal morbidities are low. Our findings reinforce the need of preventing late preterm delivery to decrease the burden of neonatal morbidity and help professionals and families with a better risk assessment.

The Effect of the No Pain Labor & Delivery-Global Health Initiative on Cesarean Delivery and Neonatal Outcomes in China: An Interrupted Time-Series Analysis

BACKGROUND

The proportion of live births by cesarean delivery (CD) in China is significant, with some, particularly rural, provinces reporting up to 62.5%. The No Pain Labor & Delivery-Global Health Initiative (NPLD-GHI) was established to improve obstetric and neonatal outcomes in China, including through a reduction of CD through educational efforts. The purpose of this study was to determine whether a reduction in CD at a rural Chinese hospital occurred after NPLD-GHI. We hypothesized that a reduction in CD trend would be observed.

METHODS

The NPLD-GHI program visited the Weixian Renmin Hospital, Hebei Province, China, from June 15 to 21, 2014. The educational intervention included problem-based learning, bedside teaching, simulation drill training, and multidisciplinary debriefings. An interrupted time-series analysis using segmented logistic regression models was performed on data collected between June 1, 2013 and May 31, 2015 to assess whether the level and/or trend over time in the proportion of CD births would decline after the program intervention. The primary outcome was monthly proportion of CD births. Secondary outcomes included neonatal intensive care unit (NICU) admissions and extended NICU length of stay, neonatal antibiotic and intubation use, and labor epidural analgesia use.

RESULTS

Following NPLD-GHI, there was a level decrease in CD with an estimated odds ratio (95% confidence interval [CI]) of 0.87 (0.78-0.98), P = .017, with odds (95% CI) of monthly CD reduction an estimated 3% (1-5; P < .001), more in the post- versus preintervention periods. For labor epidural analgesia, there was a level increase (estimated odds ratio [95% CI] of 1.76 [1.48-2.09]; P < .001) and a slope decrease (estimated odds ratio [95% CI] of 0.94 [0.92-0.97]; P < .001). NICU admissions did not have a level change (estimated odds ratio [95% CI] of 0.99 [0.87-1.12]; P = .835), but the odds (95% CI) of monthly reduction in NICU admission was estimated 9% (7-11; P < .001), greater in post- versus preintervention. Neonatal intubation level and slope changes were not statistically significant. For neonatal antibiotic administration, while the level change was not statistically significant, there was a decrease in the slope with an odds (95% CI) of monthly reduction estimated 6% (3-9; P < .001), greater post- versus preintervention.

CONCLUSIONS

In a large, rural Chinese hospital, live births by CD were lower following NPLD-GHI and associated with increased use of labor epidural analgesia. We also found decreasing NICU admissions. International-based educational programs can significantly alter practices associated with maternal and neonatal outcomes.

Morbidity in Late Preterm Birth: A Retrospective Cohort Study Assessing the Role of Immaturity versus Antecedent Factors

INTRODUCTION

Late preterm infants (LPIs) are infants born between 340/7 and 366/7 weeks gestation. Morbidities in these infants are commonly considered a result of prematurity; however, some research has suggested immaturity may not be the sole cause of morbidities. We hypothesize that antecedents leading to late preterm birth are associated with different patterns of morbidities and that morbidities are the result of gestational age superimposed by the underlying etiologies of preterm delivery.

METHODS

This is a retrospective cohort study of late preterm neonates born at a single tertiary care center. We examined neonatal morbidities including apnea of prematurity, hyperbilirubinemia, hypoglycemia, and the requirement for continuous positive airway pressure (CPAP). Multivariable logistic regression analysis was performed to estimate the risk of each morbidity associated with 3 categorized antecedents of delivery, that is, spontaneous preterm labor, preterm premature rupture of membranes (PPROM), and medically indicated birth. We calculated the predictive probability of each antecedent resulting in individual morbidity across gestational ages.

RESULTS

279 LPIs were included in the study. Decreasing gestational age was associated with significantly increased risk of apnea of prematurity, hyperbilirubinemia, and requirement of CPAP. In our cohort, the risk of hypoglycemia increased with gestational age, with the greatest incidence at 360-6 weeks. There was no significant association of risk of selected morbidities and the antecedents of late preterm delivery, with or without adjustment for gestational age, multiple gestation, small for gestational age (SGA), antenatal steroids, and delivery method.

DISCUSSION AND CONCLUSION

This study found no difference in morbidity risk related to 3 common antecedents of preterm birth in LPIs. Our research suggests that immaturity is the primary factor in determining adverse outcomes, intensified by factors resulting in prematurity.

Improving Neonatal and Maternal Outcome by Inducing Mild Labor before Elective Cesarean Section: The Lacarus Randomized Controlled Trial

BACKGROUND

Newborns delivered by elective cesarean section (CS) are at higher respiratory risk than those delivered vaginally or by CS proceeded by labor (secondary CS). The oxytocin challenge test (OCT) induces uterine contractions that trigger the release of fetal hormones regulating lung fluid clearance during transition from the uterine to an air-breathing environment.

OBJECTIVES

The aim is to summarize current evidence and outline the Lacarus trial protocol.

METHODS

Literature review informed the design of a randomized placebo-controlled multicenter trial of OCT preceding elective CS in 1,450 women with a singleton pregnancy due for CS at >35 weeks gestation, without preceding contractions, rupture of the membranes, or antenatal steroids. OCT comprises the infusion of oxytocin 5 IU/500 mL Ringer lactate at a rate of 12 mL/h, doubling every 10 min until inducing 5 uterine contractions per 15-min interval. The primary endpoint is the occurrence of neonatal respiratory morbidity within 24 h after birth. Secondary endpoints include biochemical and physiological parameters of fetal and maternal well-being, such as breastfeeding rate and fetal plasma copeptin concentrations.

CONCLUSION

This is the first trial to test the hypothesis that oxytocin-induced contractions before elective CS is a promising application of physiologic principles gleaned from natural birth to improve neonatal and maternal outcomes.

Bayes Theorem and Protopathic Bias: Methodological Concerns When Addressing the Impact of Fetal Heart Rate Patterns on the Cesarean Section Rate

Over the last 30 years, the caesarean section rate has reached global epidemic proportions. This trend is driven by multiple factors, an important one of which is the use and inconsistent interpretation of the electronic fetal monitoring (EFM) system. Despite its introduction in the 1960s, the EFM has not definitively improved neonatal outcomes, yet it has since significantly contributed to a seven-fold increase in the caesarean section rate. As we attempt to reduce the caesarean rates in the developed world, we should consider focusing on areas that have garnered little attention in the literature, such as physician sensitization to the poor predictive power of the EFM and the research method biases that are involved in studying the abnormal heart rate patterns-umbilical cord pH relationship. Herein, we apply Bayes theorem to different clinical scenarios to illustrate the poor predictive power of the EFM, as well as shed light on the principle of protopathic bias, which affects the classification of research outcomes among studies addressing the effects of the EFM on caesarean rates. We propose and discuss potential solutions to the aforementioned considerations, which include the re-examination of guidelines with which we interpret fetal heart rate patterns and the development of noninvasive technologies that evaluate fetal pH in real time.

Outcome of late preterm newborns in Upper Egypt

Background

The incidence of preterm births is increasing and has become a global health concern. This study aimed to compare the outcome of late preterm (LPT) to full term (FT) neonates at two large hospitals in Upper Egypt.

Results

Out of 250 newborns included in the study, 180 (72%) were FT and 70 (28%) were LPT. More than half of the LPT newborns (52.9%) were admitted to the neonatal intensive care unit (NICU), compared with 26.7% of FT newborns. Delivery of LPT was associated with an increased risk of neonatal morbidity, including jaundice requiring phototherapy (34.3% vs. 7.8%), respiratory morbidities (32.9% vs. 13.9%), hypoglycemia (8.6% vs. 1.7 %), and convulsions (4.3% vs. 0.6%).

Conclusions

LPT neonates were more susceptible to suffer from jaundice and respiratory distress among other morbidities. They also had a higher rate of NICU admission, longer duration of NICU stay, as well as a higher mortality rate. The best treatment of late prematurity is to prevent it. Public and professional awareness of the problems associated with late prematurity should be highlighted. Follow-up programs for early detection and intervention for long term complications are recommended.

Association of Labor With Neonatal Respiratory Outcomes at 36-40 Weeks of Gestation

OBJECTIVE

To evaluate whether labor is associated with lower odds of respiratory morbidity among neonates born from 36 to 40 weeks of gestation and to assess whether this association varies by gestational age and maternal diabetic status.

METHODS

We conducted a secondary analysis of women in the Assessment of Perinatal Excellence obstetric cohort who delivered across 25 U.S. hospitals over a 3-year period. Women with a singleton liveborn nonanomalous neonate who delivered from 36 to 40 weeks of gestation were included in our analysis. Those who received antenatal corticosteroids, underwent amniocentesis for fetal lung maturity, or did not meet dating criteria were excluded. Our primary outcome was composite neonatal respiratory morbidity, which included respiratory distress syndrome, ventilator support, continuous positive airway pressure, or neonatal death. Maternal characteristics and neonatal outcomes between women who labored and those who did not were compared. Multivariable logistic regression models were used to evaluate the association between labor and the primary outcome. Interactions between labor and diabetes mellitus and labor and gestational age were tested.

RESULTS

Our analysis included 63,187 women who underwent labor and 10,629 who did not. There was no interaction between labor and diabetes mellitus (P=.90). However, there was a significant interaction between labor and gestational age (P=.01). In the adjusted model, labor was associated with lower odds of neonatal respiratory morbidity compared with no labor for neonates delivered from 36-39 weeks of gestation. A 1-week increase in gestational age was associated with a 1.2 times increase in the adjusted odds ratio for the neonatal outcome comparing labor and no labor.

CONCLUSION

Labor was associated with lower odds of the composite outcome among neonates delivered from 36-39 weeks of gestation. The magnitude of this association varied by gestational age. The association was similar for women with or without diabetes mellitus.

Risk Factors of Respiratory Diseases Among Neonates in Neonatal Intensive Care Unit of Qena University Hospital, Egypt

Background:

Respiratory diseases in newborns are considered major causes of neonatal morbidity and mortality especially in developing countries. Its causes are diverse and require early detection and management. This study aimed for detection of the prevalence and risk factors of respiratory diseases in addition to outcome among neonates admitted in neonatal intensive care unit.

Methods:

Our study was a prospective observational study that was undertaken at the neonatal intensive care unit of Qena University Hospital, Egypt from July 2017 to July 2018. Demographic and clinical data of newborns and their mothers were evaluated and tabulated.

Results:

In this period, 312 neonates were admitted to the neonatal intensive care unit, out of them 145 suffered respiratory diseases giving a prevalence of (46.5%), and (55.9%) were males. The mean neonatal age at admission was 4.33 ± 7.19 days and mean gestational age was 34.49 ± 3.31 weeks. The most common detected respiratory diseases were respiratory distress syndrome (RDS; 49.6%), transient tachypnea of newborn (TTN; 22%), neonatal pneumonia (17.2%) and meconium aspiration syndrome (MAS; 6.21%). Premature rupture of membrane (PROM), maternal diabetes and fetal prematurity had the highest risk factors for respiratory diseases occurrence in neonates. Neonatal mortality rate was 26.2%, mainly due to hyaline membrane disease and pneumonia.

Conclusion:

Respiratory diseases constitute major part of total admission in neonatal intensive care unit especially RDS, TTN, pneumonia and MAS. Prematurity and maternal diabetes were the most important risk factors associated with respiratory diseases. Respiratory distress syndrome carried the highest risk of mortality and TTN carried the highest survival rate.

Changes in Infant and Neonatal Mortality and Associated Factors in Eight Cohorts from Three Brazilian Cities

Stillbirth (SBR), perinatal (PMR), neonatal (NMR) and infant mortality rates (IMR) are declining in Brazil and the factors associated with these falls are still being investigated. The objective of the present study was to assess changes in SBR, PMR, NMR and IMR over time and to determine the factors associated with changes in NMR and IMR in eight Brazilian cohorts. All cohorts are population-based (Ribeirão Preto in 1978/79, 1994 and 2010; Pelotas in 1982, 1993 and 2004; and São Luís in 1997/98 and 2010). Were included data on 41440 children. All indicators were decreased, except in the city of Pelotas, from 1993 to 2004, and except SBR in São Luís. Sociodemographic variables seem to be able to explain reductions of NMR and IMR in Ribeirão Preto, from 1978/79 to 1994, and in São Luís. In Ribeirão Preto, from 1994 to 2010 declines in NMR and IMR seem to be explained by reductions in intrauterine growth restriction (IUGR). Newborn’s gestational age had diminished in all cohorts, preventing even greater reductions of NMR and IMR. Improved sociodemographic variables and reduction of IUGR, seem to be able to explain part of the decrease observed. NMR and IMR could have been reduced even more, were it not for the worsening in gestational age distribution.

The majority of early term elective cesarean sections can be postponed

INTRODUCTION

To minimize the risk of neonatal respiratory morbidity it is recommended that elective cesarean sections should not be done before 39-week gestation unless medically indicated. However, elective cesarean sections are still being performed at early term (at 37⁰-38⁶ weeks gestation) without sound medical indications. In this study, we evaluated the indications for elective cesarean sections performed at early term to assess the proportion of procedures that could possibly have been postponed until ≥39 weeks to avoid neonatal respiratory morbidity.

MATERIAL AND METHODS

Maternal and neonatal information was collected from medical records on all elective cesarean sections performed in singleton pregnancies at ≥37⁰ weeks gestation over a 20-year period in a population with secure ultrasound gestational age assignment. Indications were grouped and uterine scar, breech, or transverse presentation and maternal request classified as nonurgent.

RESULTS

There were 3411 elective cesarean sections performed at ≥37-week gestation, of which 790 (23.2%) were at 37⁰-38⁶ weeks. Medical indications were present for 34% (272/790), but 65.6% (518/790) could possibly have been postponed until ≥39⁰ weeks. Of the neonates 5.7% developed respiratory morbidity if delivery was at 37⁰-38⁶ weeks gestation compared to 2.4% at 39⁰-42¹ weeks gestation (p < .001).

CONCLUSION

Of elective cesarean sections before 39-week gestation two-thirds were done without a clear medical indication, thereby exposing the newborn to an increased risk of respiratory morbidity. Scheduling elective cesarean sections at ≥39-week gestation is important to minimize the risk of neonatal respiratory morbidity, unless a clear medical indication dictates earlier delivery.

Respiratory distress in newborn infants in Western Switzerland

AIM

To assess epidemiological data about respiratory distress (RD) in newborn infants hospitalized in Western Switzerland.

METHODS

During 1 year, two questionnaires were sent out to the seven neonatal and pediatric units of a well-defined geographic region in Switzerland. Data about their obstetrical activity and details about all newborn infants hospitalized with RD were collected, asking for pre-, peri-, and postnatal clinical data in association with RD.

RESULTS

Almost 6% of all newborn infants born in the Canton of Vaud had to be hospitalized for RD. All newborn infants below 32 weeks of gestational age (GA) had developed RD, accounting for 14.6% of all neonates, hospitalized with RD, whereas the moderate to late preterm infants contributed with 36.8% much more to the RD hospitalizations. Associated factors to hospitalizations with RD were prematurity, cesarean delivery, and multiple births.

CONCLUSIONS

Efforts should be made to reduce avoidable RD by reconsidering the management of pregnancies with premature rupture of the membranes around 34 weeks of GA and by delaying elective cesarean sections after 39 completed weeks of gestation.

Timing of Delivery in Women With Chronic Hypertension

OBJECTIVE

To assess whether routine induction of labor at 38 or 39 weeks in women with chronic hypertension is associated with the risk of superimposed preeclampsia or cesarean delivery.

METHODS

We conducted a retrospective population-based study of women with chronic hypertension who had a singleton hospital birth at 38 0/7 weeks of gestation of gestation in Ontario, Canada, between 2012 and 2016. Women who underwent induction of labor at 38 0/7 to 38 6/7 weeks of gestation for chronic hypertension (n=281) were compared with those who were managed expectantly during that week and remained undelivered at 39 0/7 weeks of gestation (n=1,606). Separately, women who underwent induction of labor at 39 0/7 to 39 6/7 weeks of gestation for chronic hypertension (n=259) were compared with women who remained undelivered at 40 0/7 weeks of gestation (n=801).

RESULTS

Of 534,529 women gave birth during the study period, 6,054 (1.1%) had chronic hypertension and 2,420 met the inclusion criteria. Women managed expectantly at 38 or 39 weeks of gestation were at risk of new-onset superimposed preeclampsia (19.2% [308/1,606] and 19.0% [152/801], respectively) and eclampsia (0.6% [10/1,606] and 0.7% [6/801], respectively), and more than half underwent induction of labor later in gestation (56.8% and 57.8%, respectively). The risk of cesarean delivery in the induction groups was lower (38 weeks of gestation) or similar (39 weeks of gestation) to that observed in women managed expectantly at the corresponding weeks (38 weeks of gestation: 17.1% vs 24.0%, adjusted relative risk 0.74 [95% CI 0.57-0.95]; 39 weeks of gestation: 20.1% vs 26.0%, adjusted relative risk 0.90 [95% CI 0.69-1.17]).

CONCLUSION

Our findings suggest that in women with isolated chronic hypertension, induction of labor at 38 or 39 weeks of gestation may prevent severe hypertensive complications without increasing the risk of cesarean delivery.

Severe neonatal outcomes associated with emergency cesarean section at term

Objective: To describe the incidence of severe neonatal outcomes in infants delivered by emergency cesarean section (CS) at term and to identify risk factors predisposing to these outcomes.Methods: This was a retrospective study of women that underwent a term emergency CS at the Mater Hospital in Brisbane between January 2007 and April 2017. Neonatal outcomes was defined as a composite of Neonatal Intensive Care Unit (NICU) admission, severe acidosis, Apgar score ≤3 and 5 min, and death (intrapartum stillbirth and neonatal death).Results: The risk of adverse outcome was highest for infants born by emergency CS. They had lower median BW (3388 versus 3503 g, p < .001), were born later (40 versus 39 weeks, p = .02) and had higher odds of birth >41 + 0 weeks (aOR 1.34, 95% CI 1.187-1.52, p < .001) birth. Birth weight <5th centile was associated with a tripling and BW <10th centile a doubling of odds of the composite outcome. Indications for emergency cesarean births that had the highest odds for the severe composite outcomes were cord prolapse (aOR 3.06, 95% CI 1.87-5.01, p < .001), failed instrumental delivery (aOR 2.50, 95% CI 1.95-3.21, p < .001), and non-reassuring fetal status (NRFS) (aOR 2.39, 95% CI 2.13-2.69, p < .001).Conclusions: Emergency cesarean is associated with a greater risk of severe neonatal outcome; with low birth weight, an additional independent risk factor for poor condition at birth.

Implementing an intervention to promote normal labour and birth: A study of clinicians' perceptions

OBJECTIVE

Prior to implementation of a Normal Labour and Birth Bundle (NLBB) at a regional maternity service in Victoria, Australia, this study aimed to understand clinician factors that may influence the uptake, acceptance and use of the NLBB.

DESIGN

This was a mixed methods study in which The Theory of Planned Behaviour (TPB) provided the framework for the conduct and analysis of the staff survey and focus groups. Descriptive and multiple regression were used to analyse the survey data and thematic analysis was used for the focus group data.

PARTICIPANTS

Participants for the survey and focus groups included clinicians providing publicly funded care and management of labour for women birthing at the health service. Maternity care clinicians were invited to participate in both the survey and the focus groups.

FINDINGS

Seventy-six clinicians (88.8%) responded to the survey. Mean scores for TPB constructs were well above the mid-scale score of 4, indicating strong positive attitudes, high levels of self-efficacy and positive social pressure to use the NLBB and strong intentions to use it in the future. Self-efficacy was the strongest independent predictor (β = 0.45, p < 0.001) of intention to use the NLBB (overall model R2=0.38). A valued consequence of implementing standardised and objective guidelines, highlighted in the focus groups, was the positive impact on clinicians' confidence in their decision-making.

KEY CONCLUSIONS

This study found that midwives and obstetricians were in favour of using a normal labour and birth care bundle and perceived the bundle to align with the expectations of work colleagues and the women they care for. The findings of this study show that clinicians at the health service had strong intentions to use the normal labour and birth care bundle in the future.

IMPLICATIONS FOR PRACTICE

Implementation science is important in embedding and sustaining practice change. Understanding staff perceptions is an essential first step of this process.

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.

Effect of delivery management on first-week neonatal outcome: How to improve it in Great Danes

A different incidence of neonatal complications has been reported in several species according to the duration of the various labour stages and the type of delivery. Trauma associated with dystocia may result in the release of neonatal catecholamines and cortisol that negatively affect neonatal metabolism, thus survival. Aim of the present study was to assess how the first-week neonatal outcome is affected by a different management of parturition. Clinical records of 46 Great Dane litters from 8 different kennels were evaluated retrospectively. Data were grouped in 3 categories: vaginal delivery (VD), emergency C-section (ES), planned C-section (PS). The risk of stillbirth, early neonatal mortality and perinatal mortality was calculated at puppy and at litter level in each group. Data were statistically compared by the ANOVA and Chi-Square test (p < 0.05). Seventy-eight puppies were naturally delivered (VD), 120 experienced dystocia at birth that required emergency C-section (ES) and 105 came from planned C-section (PS). No statistical difference in neonatal bodyweight and litter size was observed among groups. In PS, both stillbirth and neonatal mortality resulted significantly lower than in VD and ES, resulting in the lowest observed perinatal mortality. The number of litters with stillbirth was significantly higher in ES than VD and PS. The number of litters with neonatal mortality resulted significantly lower in PS than VD and ES. The overall perinatal mortality in VD resulted statistically influenced from both stillbirth and neonatal mortality, while it resulted strongly affected by the high stillbirth in ES. No difference was observed for PS perinatal mortality. Present results, reporting a high incidence of dystocia as well as high perinatal and neonatal mortality, lead us to evaluate the opportunity to plan an elective C-section in Great Dane bitches, in order to minimize perinatal mortality.

Respiratory morbidities in late preterm and term infants with myelomeningocele

OBJECTIVE

To describe the incidence of respiratory morbidities in late preterm and term newborns with myelomeningocele (MMC) born by c-section.

STUDY DESIGN

Single center retrospective cohort study of infants born between 34 0/7 and 40 6/7 weeks gestation with the diagnosis of MMC. The primary outcome was the incidence of respiratory morbidities and the secondary outcome was caffeine treatment for apnea at discharge.

RESULTS

A total of  293 infants with MMC born by cesarean section were included in this cohort: 106 born late preterm, 120 early term, and 67 at term. Respiratory morbidity was present in 50.5% within the first 24 h after birth. Treatment with caffeine for persistent apnea or periodic breathing at discharge was present in 17.8% with an overall incidence of apnea throughout the hospital admission of 20.5%.

CONCLUSION

There is a markedly increased risk of respiratory distress in late preterm and term infants with myelomeningocele at all gestational ages.

Foetal Macrosomia and Foetal-Maternal Outcomes at Birth

To investigate how macrosomia affects foetal-maternal birth outcomes, we conducted a retrospective cohort study of singleton pregnant women who gave birth at gestational age ≥37+0 weeks. The patients were divided into three groups according to birth weight: “macrosomia” group, ≥4500 g, n=285; “upper-normal” group, 3500–4499 g, n=593; and “normal” group, 2500–3499 g, n=495. Foetal-maternal and delivery outcomes were compared among the three groups after adjustment for confounders. Caesarean section was more frequent in the macrosomia group than in upper-normal and normal groups. The duration of labour (p < 0.05) and postpartum care at the hospital (p < 0.001) were the highest in the macrosomia group. Increased birth weight was associated with higher risks of shoulder dystocia (p < 0.001), increased bleeding volume (p < 0.001), and perineal tear (p < 0.05). The Apgar score at 5 minutes (p < 0.05), arterial cord pH (p < 0.001), and partial pressure of O2 (p < 0.05) were lower, while the arterial cord partial pressure of CO2 was higher (p < 0.001), in the macrosomia group. Macrosomia has potentially serious impacts for neonate and mother as a result of a complicated and occasionally traumatic delivery.

Organisational interventions designed to reduce caesarean section rates: a systematic review protocol

INTRODUCTION

There is a growing body of evidence to indicate that both primary and subsequent caesarean sections are associated with increased maternal and perinatal morbidity. Efforts to reduce the number of clinically unnecessary caesarean sections are urgently required. Our objective is to systematically review published evidence on the effectiveness of maternity service organisational interventions, such as models of maternity care, that aim to reduce caesarean section rates.

METHODS AND ANALYSIS

Databases will be searched, including the Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Maternity and Infant Care, EMBASE and SCOPUS. Search terms related to caesarean section and organisational intervention will be used. Research published before 1980 will be excluded and only randomised controlled trials, cluster-randomised controlled trials, quasi-randomised controlled trials, controlled before and after studies and interrupted time series studies will be included. Data extraction and quality assessments will be undertaken by two authors.

ETHICS AND DISSEMINATION

Ethics approval is not required for this systematic review. The results of this study will be disseminated via peer-reviewed publication and presentation at professional conferences.

PROSPERO REGISTRATION NUMBER

CRD42016039458.

[Occiput posterior presentation at delivery: Materno-foetal outcomes and predictive factors of rotation]

OBJECTIVES

To describe the maternal and foetal outcomes of an occiput posterior foetal position at delivery; to evaluate predictive factors of anterior rotation during labour.

METHODS

Descriptive retrospective analysis of a cohort of 439 women with foetuses in occiput posterior position during labour. Logistic regression analysis to quantify the effect of factors that may favour anterior rotation.

RESULTS

Most of foetuses (64%) do an anterior rotation during labour and 13% during the expulsive phase. The consequences of a persistent foetal occiput posterior position during delivery are a significantly increased average time of second stage labour compared to others positions (65.19minutes vs. 43.29, P=0.001, respectively); a higher percentage of caesarean sections (72.0% versus 4.7%, P<0.001) and instrumental delivery (among low-birth deliveries, 60.7% versus 25.2%, P<0.001); more frequent third-degree perineal tears (14.3% vs. 0.6%, P<0.001) and more abundant blood loss (560mL versus 344mL, P<0.001). In a multi-variable model including nulliparity, station of the presenting part and degree of flexion of the foetal head at complete dilatation, the only predictive factor independent of rotation at delivery is a good flexion of the foetal head at complete dilatation, which multiplies the anterior rotation probability by six.

CONCLUSION

A good flexion of the foetal head is significantly associated with anterior rotation. Other studies exploring ways to increase anterior rotation during labour are needed to reduce the very high risk of caesarean section and instrumentation associated with the foetal occiput posterior position.

Factors relating caesarean section to persistent pulmonary hypertension of the newborn

BACKGROUND

Several studies have clearly demonstrated a significantly higher incidence of persistent pulmonary hypertension of the newborn (PPHN) in neonates delivered by caesarean section (CS) compared to those delivered vaginally. The pathophysiological factors underlying the link between CS and PPHN are still poorly understood. In this review, we describe the mechanisms that could explain the association between CS delivery and subsequent PPHN, as well as potential preventive measures.

DATA SOURCES

A literature search was conducted by electronic scanning of databases such as PubMed and Web of Science using the key words "persistent pulmonary hypertension of the newborn", "caesarean section", "iatrogenic prematurity", "oxidative stress", "late preterm", "labor" and "vasoactive agents".

RESULTS

Iatrogenic prematurity, higher rates of late preterm delivery and lack of physiological changes of labor play an important role in the association between CS and PPHN. CS delivery also results in limited endogenous pulmonary vasodilator synthesis and lower levels of protective anti-oxidants in the neonates. In addition, CS delivery exposes infants to a higher risk of respiratory distress syndrome and its concomitant increase in endothelin-1 levels, which might indirectly lead to a higher risk of developing PPHN. We believe that neonates delivered by CS are exposed to a combination of these pathophysiological events, culminating in an endpoint of respiratory distress, hypoxia, acidosis, and delayed transition and thereby increased risks of PPHN. The use of antenatal corticosteroids prior to elective CS in late preterm deliveries, promoting accurate informedconsent process, delaying elective CS to 39 weeks of gestation or beyond and antenatal maternal anti-oxidant supplementation could potentially mitigate the effects of CS delivery and minimize CS-related PPHN.

CONCLUSIONS

The link between CS delivery and PPHN is complex. In view of the rising rates of CS worldwide, there is an urgent need to further explore the mechanisms linking CS to PPHN and experimentally test therapeutic options in order to allow effective targeted interventions.

Emotional and behavioral outcomes and quality of life in school-age children born as late preterm: retrospective cohort study

Aim

To determine the effect of late preterm birth and treatment at the intensive care unit (ICU) on school-age children’s emotional and behavioral problems and quality of life (QoL).

Methods

Emotional and behavioral problems and QoL were investigated in 6-12-year-olds who were born late preterm at the University Hospital Center Split in the period from January 2002 to March 2008. The study included 126 late preterm children treated in ICU (LP-ICU group), 127 late preterm children not treated in ICU (LP-non-ICU group), and 131 full-term children treated in ICU (FT-ICU group). Emotional and behavioral difficulties were assessed using the Child Behavior Checklist. QoL was evaluated with the Royal Alexandra Hospital for Children Measure of Function questionnaire. The data was collected via telephone interview with mothers during 2014.

Results

Late preterm children had a nearly 5-fold risk for internalizing problems in comparison with FT-ICU children (OR 4.76, 95% confidence interval [CI] 2.37-9.56 and OR 4.82, 95% CI 2.25-10.37 in LP-ICU and LP-non-ICU children, respectively). They also had a greater risk for externalizing problems (OR 3.08, 95% CI 1.44-6.61 and OR 2.68, 95% CI 1.14-6.28, respectively) and total problems (OR 6.29, 95% CI 2.86-13.83 and OR 7.38, 95% CI 3.08-17.69, respectively) and a considerably increased risk for lower QoL (OR 12.79, 95% CI 5.56-29.41 and OR 5.05, 95% CI 2.04-12.48, respectively).

Conclusion

Children born late preterm had a greater risk for emotional and behavioral problems and lower QoL during childhood than their full-term born peers and they experienced serious health problems upon birth.

Relationship between thyroid hormone levels and transient tachypnea of the newborn in late-preterm, early-term, and term infants

PURPOSE

We aimed to investigate the association between thyroid hormone levels and transient tachypnea of the newborn (TTN) among late-preterm, early-term, and term infants admitted to neonatal intensive care unit (NICU).

MATERIALS AND METHOD

In the current retrospective study, neonates admitted to the NICU due to TTN were assigned to the TTN group (n = 404). Healthy neonates who were followed up in the well-baby nursery comprised the control group (n = 7335). Infants were grouped by gestational age into late-preterm (34-36⁶ weeks), early-term (37-38⁶ weeks), and term subgroups (39-41⁶ weeks). Serum levels of thyroid-stimulating hormone (TSH) and thyroxin (T₄) were determined from venipuncture samples taken at least 48 hours after birth. The relationship between thyroid hormone levels and the need for NICU admission for TTN was compared between groups.

RESULTS

Compared to control infants, term neonates with TTN had significantly higher TSH levels, whereas late-preterm and early-term neonates with TTN had significantly lower T₄ levels. Birth weight and mode of delivery had no effect on NICU admission for TTN.

CONCLUSIONS

Infants admitted to NICU due to TTN had significantly different thyroid hormone levels with differences depending on gestational age.

Giving birth: Expectations of first time mothers in Switzerland at the mid point of pregnancy

PROBLEM AND BACKGROUND

Despite a generally affluent society, the caesarean section rate in Switzerland has steadily climbed in recent years from 22.9% in 1998 to 33.7% in 2014. Speculation by the media has prompted political questions as to the reasons. However, there is no clear evidence as to why the Swiss rate should be so high especially in comparison with neighbouring countries.

AIM

To describe the emerging expectations of giving birth of healthy primigravid women in the early second semester of pregnancy in four Swiss cantons.

METHODS

Qualitative individual interviews with 58 healthy primigravid women, were audio recorded, transcribed and subjected to thematic analysis. Recruitment took place through public and private hospitals, birth centres, obstetricians and independent midwives. The main ethical issues were informed consent, autonomy, confidentiality and anonymity.

FINDINGS

The three main themes identified were taking or avoiding decisions, experiencing a continuum of emotions and planning the care.

DISCUSSION

Being pregnant was part of a project women had mapped out for their lives. Only three women in our sample expressed a wish for a caesarean section. One of the strongest emotions was that of fear but in contrast some participants expressed faith that their bodies would cope with the experience.

CONCLUSION

Bringing together the three languages and cultures produced a truly "Swiss" study showing contrasts between a matter of fact approach to pregnancy and the concept of fear. Such a contrast is worthy of further and deeper exploration by a multi-disciplinary research team.

New approaches for assessing childbirth positions

BACKGROUND

An overview of labor based only on epidemiological data cannot identify or explain the mechanisms involved in childbirth. Data about the position that women should take in giving birth are discordant. None of the studies of birth positions adequately define or describe them or their biomechanical impact (pelvic orientation, position of the back). The measurement of the effect of one position relative to that of another requires precise definitions of each position and of their maternal biomechanical consequences, as well as safe measurement methods.

METHODOLOGY

We have developed a system to analyze the position of labor by quantifying the posture of the woman's body parts (including thighs, trunk, and pelvis), using an optoelectronic motion capture device (Vicon™, Oxford Metrics) widely used in human movement analysis and a system for measuring the lumbar curve (Epionics spine system). A specific body model has also been created to conduct this biomechanical analysis, which is based on external markers. With this methodology and model, it should be possible to define: (1) the hip joint angles (flexion/extension, abduction/adduction, internal/external rotation); (2) the ante/retroversion of the pelvis; (3) the lumbar curve.

DISCUSSION

This methodology could become a reference for assessing delivery postures, one that makes it possible to describe the relation between the postures used in the delivery room and their impact on the pelvis and the spine in an integrated and comprehensive model.

TRIAL REGISTRATION

No. Eudract 2013-A01203-42.

The respiratory consequences of early-term birth and delivery by caesarean sections

In England and Wales, 19% of live births in 2012 were at 37-38 weeks' gestation, equating to nearly 140 000 early-term births each year. Since caesarean sections (CS) are often performed at early-term gestations, this accounts for some of the increased proportion of the early-term births. Infants born early-term are at an increased risk of neonatal respiratory morbidity particularly if they are delivered by caesarean section. The long term lung function data are limited but available data suggest that early-term delivery is associated with respiratory morbidity in childhood. CS also appears to be associated with increased neonatal morbidity and future development of respiratory symptoms. However, future studies need to confirm the independent effects of caesarean sections and early-term deliveries particularly for long term outcomes as both are likely to affect the respiratory system differently.

Sustained lung inflation in late preterm infants: a randomized controlled trial

OBJECTIVE

To assess the need for respiratory support in late preterm infants treated with sustained lung inflation (SLI) at birth.

STUDY DESIGN

In this controlled trial, we randomly assigned infants born at 34(+0) to 36(+6) weeks of gestation to receive SLI (25 cmH2O for 15 s) at birth, followed by continuous positive airway pressure (CPAP) or assistance according to the recommendations of the American Academy of Pediatrics. The primary outcome was the need for any type of respiratory support. The secondary outcomes included neonatal intensive care unit (NICU) admission for respiratory distress and length of stay. The risk ratios (RRs) and 95% confidence intervals (CIs) of the outcomes were calculated for the SLI group in reference to the control group.

RESULTS

A total of 185 infants were enrolled: 93 in the SLI group and 92 in the control group. No difference was found in the need for any type of respiratory support between the infants treated with SLI and the control group (10.6 vs 8.7%, RR 1.24, 95% CI 0.51 to 2.99). The NICU admission for respiratory distress and the length of stay did not differ between the groups.

CONCLUSION

Providing SLI at birth in late preterm infants does not affect their need for respiratory support.

Fetal outcome in emergency versus elective cesarean sections at Souissi Maternity Hospital, Rabat, Morocco

INTRODUCTION

Perinatal mortality rates have come down in cesarean sections, but fetal morbidity is still high in comparison to vaginal delivery and the complications are more commonly seen in emergency than in elective cesarean sections. The objective of the study was to compare the fetal outcome and the indications in elective versus emergency cesarean section performed in a tertiary maternity hospital.

METHODS

This comparative cross-sectional prospective study of all the cases undergoing elective and emergency cesarean section for any indication at Souissi maternity hospital of Rabat, Morocco, was carried from January 1, to February 28, 2014. Data were analyzed with emphasis on fetal outcome and cesarean sections indications. Mothers who had definite antenatal complications that would adversely affect fetal outcome were excluded from the study.

RESULTS

There was 588 (17.83%) cesarean sections among 3297 births of which emergency cesarean section accounted for 446 (75.85%) and elective cesarean section for 142 cases (24.15%). Of the various factors analyzed in relation to the two types of cesarean sections, statistically significant associations were found between emergency cesarean section and younger mothers (P < 0.001), maternal illiteracy (P = 0.049), primiparity (P = 0.005), insufficient prenatal care (P < 0.001), referral from other institution for pregnancy complications or delivery (P < 0.001), cesarean section performed under general anesthesia (P < 0.001), lower birth weight (P < 0.016), neonatal morbidity and early mortality (P < 0.001), and admission in neonatal intensive care unit (P = 0.024). The commonest indication of emergency cesarean section was fetal distress (30.49%), while the most frequent indication in elective cesarean section was previous cesarean delivery (47.18%).

CONCLUSION

The overall fetal complications rate was higher in emergency cesarean section than in elective cesarean section. Early recognition and referral of mothers who are likely to undergo cesarean section may reduce the incidence of emergency cesarean sections and thus decrease fetal complications.

[Insulin treatment of gestational diabetes and respiratory outcome in late-preterm and term babies]

While the incidence of diabetes mellitus (DM) during pregnancy has been steadily increasing in recent years, the link between gestational DM and respiratory outcome in neonates has not been firmly established. To address this gap in understanding, we asked whether DM status and its treatment during pregnancy influence risk of neonatal respiratory distress. We conducted retrospective analysis of a large cohort to determine the relationship between maternal DM status (non-DM, insulin-treated DM [DTI], and non-insulin-treated DM [DTR]) and respiratory distress in term and near-term singletons, born at Robert-Debré Hospital over a 7-year period. Of 18,095 singletons delivered at 34 weeks of gestation or later, 412 (2.3%) were admitted to the NICU for respiratory distress within the first hours of life. The incidence of NICU admissions due to respiratory distress was 2.2% in the non-DM group, 2.1% in the DTR group, and 5.7% in the DTI group. Insulin treatment of DM, together with several other perinatal factors, was associated with an increased risk for severe respiratory distress. In a multivariate model, we found that DTI, but not DTR, was a risk factor independent of gestational age and cesarean section, with an IRR of 1.44 (95% CI, 1.00-2.08). The data indicate that newborns of mothers with DM treated with diet are not at risk for severe respiratory distress. Conversely, newborns of mothers with DM treated with insulin are associated with elevated risk for severe respiratory disease and should therefore be closely monitored.

Three-Dimensional Power Doppler Ultrasonography for Diagnosing Abnormally Invasive Placenta and Quantifying the Risk

OBJECTIVE

To test an objective ultrasound marker for diagnosing the presence and severity of abnormally invasive placenta.

METHODS

Women at risk of abnormally invasive placenta underwent a three-dimensional power Doppler ultrasound scan. The volumes were examined offline by a blinded observer. The largest area of confluent three-dimensional power Doppler signal (Area of Confluence [Acon], cm) at the uteroplacental interface was measured and compared in women subsequently diagnosed with abnormally invasive placenta and women in a control group who did not have abnormally invasive placenta. Receiver operating characteristic curves were plotted for prediction of abnormally invasive placenta and abnormally invasive placenta requiring cesarean hysterectomy.

RESULTS

Ninety-three women were recruited. Results were available for 89. Abnormally invasive placenta was clinically diagnosed in 42 women; 36 required hysterectomy and had abnormally invasive placenta confirmed histopathologically. Median and interquartile range for Acon was greater for abnormally invasive placenta (44.2 [31.4-61.7] cm) compared with women in the control group (4.5 cm [2.9-6.6], P<.001) and even greater in the 36 requiring hysterectomy (46.6 cm [37.2-72.6], P<.001). Acon rose with histopathologic diagnosis: focal accreta (32.2 cm [17.2-57.3]), accreta (59.6 cm [40.1-89.9]), and percreta (46.6 cm [37.5-71.5]; P<.001 analysis of variance for linear trend). Receiver operating characteristic analysis for prediction of abnormally invasive placenta revealed that with an Acon of 12.4 cm or greater, 100% sensitivity (95% confidence interval [CI] 91.6-100) could be obtained with 92% specificity (95% CI 79.6-97.6); area under the curve is 0.99 (95% CI 0.94-1.0). For prediction of abnormally invasive placenta requiring hysterectomy, 100% sensitivity (95% CI 90.3-100) can be obtained with an Acon of 17.4 cm or greater with 87% specificity (95% CI 74.7-94.5; area under the curve 0.98 [0.93-1.0]).

CONCLUSION

The marker Acon provides a quantitative means for diagnosing abnormally invasive placenta and assessing severity. If further validated, subjectivity could be eliminated from the diagnosis of abnormally invasive placenta.

LEVEL OF EVIDENCE

II.