The chasm in neonatal outcomes in relation to time of birth in Lebanon

Optimising daytime deliveries when inducing labour using prostaglandin vaginal inserts

OBJECTIVE

To determine induction start time(s) that would maximise daytime deliveries when using prostaglandin vaginal inserts.

METHODS

Women enrolled into the Phase III trial, EXPEDITE (clinical trial registration: NCT01127581), had labour induced with either a misoprostol or dinoprostone vaginal insert (MVI or DVI). A secondary analysis was conducted to determine the optimal start times for induction by identifying the 12-h period with the highest proportion of deliveries by parity and treatment.

RESULTS

Optimal start times for achieving daytime deliveries when using MVI appear to be 19:00 in nulliparae and 23:00 in multiparae. Applying these start times, the median time of onset of active labour would be approximately 08:30 for both parities and the median time of delivery would be the following day at approximately 16:30 for nulliparae and 12:00 (midday) for multiparae. Optimal start times when using DVI appear to be 07:00 for nulliparae and 23:00 for multiparae. Using these start times, the median time of onset of active labour would be the following day at approximately 04:00 and 11:50, and the median time of delivery would be approximately 13:40 and 16:10, respectively.

CONCLUSIONS

When optimising daytime deliveries, different times to initiate induction of labour may be appropriate depending on parity and the type of retrievable prostaglandin vaginal insert used.

Factors associated with iatrogenesis in neonatal intensive care units: an observational multicenter study

The objective of our study was to assess factors associated with iatrogenic events in Neonatal Intensive Care Units (NICUs). This was a retrospective analysis based on a cohort of patients who participated in our previous prospective study (Pediatrics 122:550-555, 2008), conducted in four tertiary university-affiliated NICUs in Israel, that included all consecutive infants (n = 615) hospitalized during the study period. Ongoing monitoring of iatrogenic events was performed by designated "iatrogenesis advocates." The main outcome measures were the association of individual infant characteristics and NICUs' environmental characteristics with iatrogenic events assessed by univariate and multiple logistic regression analysis. We found that four infant characteristics were significantly (p < 0.001) associated with iatrogenic events in a univariate analysis: gestational age, birth weight, severity of initial illness as assessed by the Score for Neonatal Acute Physiology and Perinatal Extension (SNAPPE II), and length of stay (LOS). All four factors demonstrated a significant (p < 0.001) dose-response relationship with iatrogenic events. Univariate analysis for environmental characteristics showed that type of shift, but not nursing workload, was significantly associated with iatrogenic events (p < 0.001). In a multiple logistic regression analysis, only LOS (adjusted OR 1.02 [95 % CI, 1.01-1.03]) and type of shift, morning vs. evening (adjusted OR 3.44 [95 % CI, 2.33-5.08]) and morning vs. night (adjusted OR 6.07 [95 % CI, 3.86-9.56]), remained independently associated with iatrogenic events (p < 0.001). Prolonged LOS and morning shifts were found to be significantly associated with iatrogenic events. Further prospective research is warranted to identify the specific causes for iatrogenic events in order to target active interventions to prevent them.

Infant births during the internal night are at increased risk for operative delivery and NICU admission

PURPOSE

The purpose of the present study was to compare neonatal morbidity between night and the rest of day and investigate potential differences of birth outcomes during the internal night.

METHODS

We conducted a retrospective study based on maternal and neonatal data of period 2004-2007, enrolling exclusively spontaneous deliveries of term (≥ 37 weeks), singleton pregnancies with cephalic presentation that were in labor. Time of day was divided into the night-shift period, from 11.00 p.m. to 7.00 a.m. (period 1) and the rest-of-day period, from 7.00 a.m. to 11.00 p.m. (period 2). The night-shift period was further sub-divided into period 1a (11.00 p.m.-3.00 a.m.) and period 1b (3.00 a.m.-7.00 a.m.). Epidemiological and obstetric characteristics as well as neonatal outcomes were initially compared between periods 1 and 2 and thereafter between sub-periods 1a and 1b.

RESULTS

There were 3,055 cases with complete data meeting our inclusion criteria, of which 871 (28.5%) were delivered during period 1 and 2,184 (71.5%) during period 2. Furthermore, 51.3% of night-born infants were delivered during period 1a and the remaining 48.7% during period 1b. All examined parameters were not significantly different between periods 1 and 2. Analyzing night internally, the rate of emergent CS was significantly higher for period 1a (13.2%), compared with period 1b (4%). Furthermore, incidence of NICU admission was significantly higher for the first half of the night-shift period (2.7%) compared to the relative of the second half (0.5%).

CONCLUSIONS

Neonatal morbidity was comparable between night-shift and rest-of-day periods, but the rates of emergent CS and NICU admission were significantly increased in the first half of the night-shift period (11.00 p.m.-3.00 a.m.).