The impact of body mass index on labour management and mode of delivery: A retrospective matched cohort study

AIM

This study aims to examine the association between body mass index (BMI) and mode of delivery, progression of labour, and intrapartum interventions.

METHODS

This was a retrospective matched cohort study including Class III obese (BMI ≥40 kg/m2 ) and normal BMI (BMI <25 kg/m2 ) women planning a vaginal birth who had a live, singleton delivery from January 2015 to December 2018. Patients were matched (1:1) based on age, gestational age, parity, onset of labour and birth weight. The primary outcome was caesarean delivery (CD). Secondary outcomes were delivery outcomes, intrapartum management and interventions. Rates of each outcome were compared with matched analysis, and duration of labour with time-to-event analysis.

RESULTS

We studied two groups of 300 pregnant women. The CD rate was significantly higher for obese women than the normal BMI cohort (19.3% vs 13.3%; risk ratio (RR) 1.43, 95% CI 1.02-1.98, P = 0.035). Cervical dilation prior to CD for failure to progress was slower in obese than normal BMI (0.04 vs 0.16 cm/h). The obese cohort had a longer duration of labour in those who underwent induction (13.70 vs 11.48 h, P = 0.024). Intrapartum intervention rates were higher for obese women, with significant differences in rates of fetal scalp electrodes (72.7% vs 22.7%, RR 3.20, 95% CI 2.58-3.99, P < 0.001), intrauterine pressure catheters (18.3% vs 0%, P < 0.001), epidural analgesia (44.0% vs 37.0%, RR 1.20, 95% CI 1.01-1.44, P = 0.040) and fetal scalp lactate sampling (8.0% vs 3.0%, RR = 2.67, 95% CI 1.33-5.33, P = 0.004).

CONCLUSION

Class III obesity is associated with an increased risk of CD and intrapartum interventions.

Continuous intrapartum fetal monitoring in gestational diabetes, where is the evidence?

Introduction: Gestational Diabetes Mellitus (GDM) is one of the commonest complications in the pregnancy. It differs in pathogenesis and complications from pre gestational diabetes (PGD), yet the choices of birth and management options for women in labor do not differ between both entities. Materials and method: We have performed literature search to find any evidence behind these recommendations specifically to the subset of pregnant women who have developed diet-controlled GDM, with normal fetal growth. Results: There have been no randomized control trials behind these recommendations. The aforementioned women have comparable outcomes to pregnant women who are not affected by diabetes and can be considered as low risk till any evidence is found. Conclusion: So there is an urgent need to conduct randomized controlled trials on women with well-controlled GDM and normal fetal growth scans so that these women could be provided evidence-based information on their options of birth.

Knowledge levels of midwives regarding the interpretation of cardiotocographs at labour units in KwaZulu-Natal public hospitals

Background

The primary purpose of cardiotocography is to detect early signs of intrapartum hypoxia and improve foetal outcomes. Intrapartum hypoxia remains the major cause of perinatal deaths during monitored labours. This is attributed to the midwives’ lack of knowledge and skills in the foetal implementation and interpretation of cardiotocographs.

Objectives

This study aimed to establish midwives’ knowledge and interpretive skills of cardiotocography.

Method

The study employed a quantitative research approach with an explorative, descriptive, cross-sectional design. A total of 226 purposively selected participants were asked to complete a self-administered, structured questionnaire, of which 125 responded by completing the questionnaire. The study was conducted in labour wards in KwaZulu-Natal public hospitals in 2014. Data analysis was performed by means of descriptive and inferential statistics using analysis of variance.

Results

The findings revealed that the midwives in KwaZulu-Natal public hospitals were found to be clinically lacking in knowledge of cardiotocography.

Conclusion

The limited cardiotocographic knowledge of the midwives in KwaZulu-Natal public hospitals was possibly because of a lack of in-service training, as more than half of the participants (70%) indicated a need for this.

Professionally responsible intrapartum management of patients with major mental disorders

Pregnant women with major mental disorders present obstetricians with a range of clinical challenges, which are magnified when a psychotic or agitated patient presents in labor and there is limited time for decision making. This article provides the obstetrician with an algorithm to guide professionally responsible decision making with these patients. We searched for articles related to the intrapartum management of pregnant patients with major mental disorders, using 3 main search components: pregnancy, chronic mental illness, and ethics. No articles were found that addressed the clinical ethical challenges of decision making during the intrapartum period with these patients. We therefore developed an ethical framework with 4 components: the concept of the fetus as a patient; the presumption of decision-making capacity; the concept of assent; and beneficence-based clinical judgment. On the basis of this framework we propose an algorithm to guide professionally responsible decision making that asks 5 questions: (1) Does the patient have the capacity to consent to treatment?; (2) Is there time to attempt restoration of capacity?; (3) Is there an opportunity for substituted judgment?; (4) Is the patient accepting treatment?; (5) Is there an opportunity for active assent?; and (6) coerced clinical management as the least worst alternative. The algorithm is designed to support a deliberative, clinically comprehensive, preventive-ethics approach to guide obstetricians in decision making with this challenging population of patients.