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American Family Physician Sep 2023Gestational diabetes mellitus (GDM) is a common condition of pregnancy with increasing prevalence in the United States. GDM increases risks of complications, including...
Gestational diabetes mellitus (GDM) is a common condition of pregnancy with increasing prevalence in the United States. GDM increases risks of complications, including operative delivery, hypertensive disorders, shoulder dystocia, fetal macrosomia, large-for-gestational-age infants, neonatal hypoglycemia, and neonatal respiratory distress. In patients who are overweight or obese, prepregnancy weight loss and lifestyle modifications during pregnancy may prevent GDM. First-trimester screening can identify preexisting diabetes and early-onset GDM for prompt implementation of glucose control measures. Treatment of GDM has been shown to reduce the risk of complications and should start with lifestyle modifications. For patients who are unable to maintain euglycemia with lifestyle modifications alone, insulin is the recommended first-line medication. For patients with poor glucose control or who require medications, fetal surveillance is suggested starting at 32 weeks of gestation. For all patients with GDM, physicians should assess for fetal macrosomia (estimated fetal weight more than 4,000 g) and discuss the risks and benefits of prelabor cesarean delivery if the estimated fetal weight is more than 4,500 g. Delivery during the 39th week of gestation may provide the best balance of maternal and fetal outcomes. The recommended delivery range for patients controlling their glucose levels with lifestyle modifications alone is 39/0 to 40/6 weeks of gestation, and the ideal range for those controlling glucose levels with medications is 39/0 to 39/6 weeks of gestation. Practice patterns vary, but evidence suggests that glucose management during labor can safely include decreased glucose testing and sliding-scale dosing of insulin as an alternative to a continuous intravenous drip. Insulin resistance typically resolves after delivery; however, patients with GDM have an increased risk of developing overt diabetes. Continued lifestyle modifications, breastfeeding, and use of metformin can reduce this risk.
Topics: Female; Pregnancy; Infant; Infant, Newborn; Humans; Diabetes, Gestational; Blood Glucose; Fetal Weight; Insulin; Glucose
PubMed: 37725457
DOI: No ID Found -
Anatomical Record (Hoboken, N.J. : 2007) Aug 2023For a given body mass, hominoids have longer clavicles than typical monkeys, reflecting the lateral reorientation of the hominoid glenoid. Relative length of the...
For a given body mass, hominoids have longer clavicles than typical monkeys, reflecting the lateral reorientation of the hominoid glenoid. Relative length of the clavicle varies among hominoids, with orangutans having longer clavicles than expected for body mass and gorillas and chimpanzees having shorter clavicles than expected. Modern humans conform to the general hominoid distribution, but Neandertals and Upper Paleolithic Homo sapiens have longer clavicles than expected for their size and exhibit marked positive allometry in clavicle length. Relative to clavicle length, adult and newborn humans have broader shoulders (biacromial breadths) than comparable apes, because the reduced elevation of the human shoulder swings the acromion laterally downward away from the head. Since broadened shoulders yield an increased risk of maternal and neonatal injury and/or death from shoulder dystocia during birth, we might expect hominins to manifest trends toward reduction in shoulder breadth and clavicle length. They do not, presumably because of countering selection pressures favoring a long clavicle in the adults. The marked sexual dimorphism seen in patterns of clavicular growth and static adult allometry in humans suggests that those selection pressures have disproportionately affected the males.
Topics: Male; Animals; Infant, Newborn; Humans; Shoulder; Clavicle; Biological Evolution; Hominidae; Scapula; Neanderthals; Pan troglodytes; Haplorhini
PubMed: 36594678
DOI: 10.1002/ar.25144 -
AJOG Global Reports Nov 2023The risk of third- and fourth-degree perineal laceration after vaginal delivery in patients with obesity is relatively understudied and has mixed findings in existing...
BACKGROUND
The risk of third- and fourth-degree perineal laceration after vaginal delivery in patients with obesity is relatively understudied and has mixed findings in existing literature.
OBJECTIVE
This study aimed to examine the association of maternal obesity and obstetric anal sphincter injuries at vaginal delivery.
STUDY DESIGN
The Healthcare Cost and Utilization Project's National Inpatient Sample was retrospectively queried to examine 7,385,341 vaginal deliveries from January 2017 to December 2019. The exposure assignment was obesity status. The main outcomes were third- and fourth-degree perineal lacerations after vaginal delivery. Statistical analysis examining the exposure-outcome association included (1) inverse probability of treatment weighting with log-Poisson regression generalized linear model to account for prepregnant and pregnant confounders for the exposure and (2) multinomial regression model to account for delivery factors in the inverse probability of treatment weighting cohort. The secondary outcomes included (1) the temporal trends of fourth-degree laceration and its associated factors at cohort level and (2) risk factor patterns for fourth-degree laceration by constructing a classification tree model.
RESULTS
In the inverse probability of treatment weighting cohort, patients with obesity were less likely to have fourth-degree lacerations and third-degree lacerations than patients without obesity (fourth-degree laceration: 2.3 vs 3.9 per 1000 vaginal deliveries, respectively; adjusted odds ratio, 0.62; 95% confidence interval, 0.56-0.69; third-degree laceration: 15.6 vs 20.1 per 1000 vaginal deliveries, respectively; adjusted odds ratio, 0.79; 95% confidence interval, 0.76-0.82). In contrast, in patients with obesity vs those without obesity, forceps delivery (54.7 vs 3.3 per 1000 vaginal deliveries, respectively; adjusted odds ratio, 17.73; 95% confidence interval, 16.17-19.44), vacuum-assisted delivery (19.8 vs 2.9 per 1000 vaginal deliveries, respectively; adjusted odds ratio, 5.18; 95% confidence interval, 4.85-5.53), episiotomy (19.2 vs 2.8 per 1000 vaginal deliveries, respectively; adjusted odds ratio, 3.95; 95% confidence interval, 3.71-4.20), and shoulder dystocia (17.8 vs 3.4 per 1000 vaginal deliveries, respectively; adjusted odds ratio, 2.60; 95% confidence interval, 2.29-2.94) were associated with more than a 2-fold increased risk of fourth-degree perineal laceration. Among the group with obesity, patients who had forceps delivery and shoulder dystocia had the highest incidence of fourth-degree laceration (105.3 per 1000 vaginal deliveries). Among the group without obesity, patients who had forceps delivery, shoulder dystocia, and macrosomia had the highest incidence of fourth-degree laceration (294.1 per 1000 vaginal deliveries). The incidence of fourth-degree perineal laceration decreased by 11.9% over time ( trend=.004); moreover, forceps delivery, vacuum-assisted delivery, and episiotomy decreased by 3.8%, 7.6%, and 29.5%, respectively (all, trend<.05).
CONCLUSION
This national-level analysis suggests that patients with obesity are less likely to have obstetric anal sphincter injuries at the time of vaginal delivery. Furthermore, this analysis confirms other known risk factors for fourth-degree laceration, such as forceps delivery, vacuum-assisted delivery, episiotomy, and shoulder dystocia. However, we noted a decreasing trend in fourth-degree lacerations, which may be due to evolving obstetrical practices.
PubMed: 37885968
DOI: 10.1016/j.xagr.2023.100272 -
Acta Obstetricia Et Gynecologica... Jun 2024Managing obstetric shoulder dystocia requires swift action using correct maneuvers. However, knowledge of obstetric teams' performance during management of real-life...
INTRODUCTION
Managing obstetric shoulder dystocia requires swift action using correct maneuvers. However, knowledge of obstetric teams' performance during management of real-life shoulder dystocia is limited, and the impact of non-technical skills has not been adequately evaluated. We aimed to analyze videos of teams managing real-life shoulder dystocia to identify clinical challenges associated with correct management and particular non-technical skills correlated with high technical performance.
MATERIAL AND METHODS
We included 17 videos depicting teams managing shoulder dystocia in two Danish delivery wards, where deliveries were initially handled by midwives, and consultants were available for complications. Delivery rooms contained two or three cameras activated by Bluetooth upon obstetrician entry. Videos were captured 5 min before and after activation. Two obstetricians assessed the videos; technical performances were scored as low (0-59), average (60-84), or high (85-100). Two other assessors evaluated non-technical skills using the Global Assessment of Team Performance checklist, scoring 6 (poor) to 30 (excellent). We used a spline regression model to explore associations between these two score sets. Inter-rater agreement was assessed using interclass correlation coefficients.
RESULTS
Interclass correlation coefficients were 0.71 (95% confidence interval 0.23-0.89) and 0.82 (95% confidence interval 0.52-0.94) for clinical and non-technical performances, respectively. Two teams had low technical performance scores; four teams achieved high scores. Teams adhered well to guidelines, demonstrating limited head traction, McRoberts maneuver, and internal rotation maneuvers. Several clinical skills posed challenges, notably recognizing shoulder impaction, applying suprapubic pressure, and discouraging women from pushing. Two non-technical skills were associated with high technical performance: effective patient communication, with teams calming the mother and guiding her collaboration during internal rotational maneuvers, and situation awareness, where teams promptly mobilized all essential personnel (senior midwife, consultant, pediatric team). Team communication, stress management, and task management skills were not associated with high technical performance.
CONCLUSIONS
Videos capturing teams managing real-life shoulder dystocia are an effective tool to reveal challenges with certain technical and non-technical skills. Teams with high technical performance are associated with effective patient communication and situational awareness. Future training should include technical skills and non-technical skills, patient communication, and situation awareness.
PubMed: 38925557
DOI: 10.1111/aogs.14900 -
Tierarztliche Praxis. Ausgabe K,... Aug 2023Diagnostic imaging represents an important part during modern pregnancy management of the dog. Ultrasound has become the modality of choice for an early pregnancy...
Diagnostic imaging represents an important part during modern pregnancy management of the dog. Ultrasound has become the modality of choice for an early pregnancy diagnosis, enabling a verification as early as 17-20 days after LH surge. Furthermore an evaluation of fetal viability and development is possible as well as the depiction of malformations and an early assessment of fetal stress. Doppler imaging may also be of supporting value in this context . Using fetal maturity as well as measurements of fetal and extrafetal structures, a calculation of the gestational age and therefore the time of parturition is achievable. Radiographs of the caudal abdomen enable pregnancy diagnosis from the 43 day after LH surge onward. In addition, an assessment of fetal size as well as litter size is possible. Both modalities allow for complementary statements concerning possible labor complications and possess supporting value concerning the decision of necessary obstetric intervention and further management in patients with dystocia.
Topics: Pregnancy; Female; Dogs; Animals; Ultrasonography, Prenatal; Ultrasonography; Delivery, Obstetric; Gestational Age; Litter Size
PubMed: 37820618
DOI: 10.1055/a-2147-4051 -
International Journal of Gynaecology... Dec 2023Scarce data exist regarding obstetric complications of short-stature patients. This study aimed to investigate obstetric and perinatal outcomes in women with short...
OBJECTIVE
Scarce data exist regarding obstetric complications of short-stature patients. This study aimed to investigate obstetric and perinatal outcomes in women with short stature; specifically, to investigate whether short-stature patients are at an increased risk for cesarean delivery.
METHODS
A population-based cohort study was conducted, including all singletons born between the years 1991 and 2021 at a tertiary medical center. Obstetric and perinatal outcomes of short-stature patients were compared with those of non-short patients. A generalized estimation equation binary logistic model was constructed to adjust for confounders and maternal recurrence in the cohort.
RESULTS
The study population included 356 356 parturient; among them, 14 035 (3.9%) were short-stature patients. Short-stature patients had significantly higher rates of cesarean delivery (20.7% vs 13.7%, odds ratio = 1.64, 95% confidence interval 1.57-1.71, P < 0.001), induction of labor, pathologic presentations, prolonged second stage of labor, non-reassuring fetal monitoring, and meconium-stained amniotic fluid. Newborns of short-stature patients had a significantly higher risk of being small for gestational age as compared with those of non-short patients. In the generalized estimation equation models, the association between short stature and risk of cesarean delivery remained significant (adjusted odds ratio = 1.32, 95% confidence interval 1.27-1.38, P < 0.001), as well as the risk of small for gestational age newborns (adjusted odds ratio = 1.51, 95% confidence interval 1.40-1.63, P < 0.001), but not for the other adverse outcomes.
CONCLUSIONS
Maternal short stature is an independent risk factor for cesarean delivery and is associated with small for gestational age newborns.
Topics: Pregnancy; Humans; Infant, Newborn; Female; Cohort Studies; Labor, Induced; Gestational Age; Cesarean Section; Parturition; Infant, Newborn, Diseases; Fetal Growth Retardation; Retrospective Studies
PubMed: 37269046
DOI: 10.1002/ijgo.14907 -
Acta Obstetricia Et Gynecologica... Jan 2024Previous studies have established a history of shoulder dystocia as an important risk factor for shoulder dystocia, but studies on shoulder dystocia by severity are...
INTRODUCTION
Previous studies have established a history of shoulder dystocia as an important risk factor for shoulder dystocia, but studies on shoulder dystocia by severity are scarce. It is unknown if shoulder dystocia tends to be passed on between generations. We aimed to assess the recurrence risk of shoulder dystocia by severity in the same woman and between generations on both the maternal and paternal side. We also assessed the likelihood of a second delivery and planned cesarean section after shoulder dystocia.
MATERIAL AND METHODS
This was a population-based cohort study, using data from the Medical Birth Registry of Norway. To study recurrence in the same mother, we identified 1 091 067 pairs of first and second, second and third, and third and fourth births in the same mother. To study intergenerational recurrence, we identified an individual both as a newborn and as a mother or father in 824 323 mother-offspring pairs and 614 663 father-offspring pairs. We used Bayesian log-binomial multilevel regression to calculate relative risks (RR) with 95% credible intervals.
RESULTS
In subsequent deliveries in the same woman the unadjusted RR of recurrence was 7.05 (95% credible interval 6.39-7.79) and 2.99 (2.71-3.31) after adjusting for possible confounders, including current birthweight. The RRs were higher with severe shoulder dystocia as exposure or outcome. With severe shoulder dystocia as both exposure and outcome, unadjusted and adjusted RR was 20.42 (14.25-29.26) and 6.29 (4.41-8.99), respectively. Women with severe and mild shoulder dystocia and those without had subsequent delivery rates of 71.1, 68.9 and 69.0%, respectively. However, the rates of planned cesarean section in subsequent deliveries for those without shoulder dystocia, mild and severe were 1.3, 5.2 and 16.0%, respectively. On the maternal side the unadjusted inter-generational RR of recurrence was 2.82 (2.25-3.54) and 1.41 (1.05-1.90) on the paternal side. Corresponding adjusted RRs were 1.90 (1.51-2.40) and 1.19 (0.88-1.61), respectively.
CONCLUSIONS
We found a strong recurrence risk of shoulder dystocia, especially severe, in subsequent deliveries in the same woman. The inter-generational recurrence risk was higher on the maternal than paternal side. Women with a history of shoulder dystocia had more often planned cesarean section.
PubMed: 38186187
DOI: 10.1111/aogs.14766 -
Medwave Nov 2023Obstetric emergencies are critical situations that jeopardize the health of both the mother and the baby during pregnancy or childbirth. This study aimed to validate the... (Review)
Review
Obstetric emergencies are critical situations that jeopardize the health of both the mother and the baby during pregnancy or childbirth. This study aimed to validate the effectiveness of clinical simulation training in managing these situations. We conducted a narrative review of studies published between 2008 and 2022, collected from databases including Scopus, Sciencedirect, PubMed, Springer, Scielo, and Google Scholar. Data from studies that met our inclusion criteria were meticulously gathered and summarized. Our findings strongly emphasize that clinical simulation emerges as a highly effective tool in the training of healthcare professionals. This training translates into substantial improvements in various aspects, including performance, knowledge, confidence, satisfaction, attitudes, self-efficacy, teamwork abilities, and the skills necessary to confront critical obstetric situations such as postpartum hemorrhage, eclampsia, shoulder dystocia, maternal cardiac arrest, umbilical cord prolapse, and cesarean sections. Importantly, this training reduces the inherent risks associated with learning on real patients and aligns with the highest ethical standards. Additionally, our results underscore that interdisciplinary collaboration in the management of obstetric emergencies proves to be an effective strategy for providing comprehensive patient care. However, it is crucial to highlight that, in order to ensure patient safety and promote a teamwork approach, it is imperative for healthcare professionals to receive adequate training and be duly qualified. Although we acknowledge that implementing clinical simulation training can entail significant costs and require substantial resources, we firmly believe that this strategy continues to hold immeasurable value in the education of professionals in this field. Ultimately, we anticipate that future high-quality research will further fortify the evidence base regarding best practices in clinical simulation training for obstetric emergencies, thus contributing to enhanced patient outcomes and the overall quality of healthcare in this critical domain.
Topics: Pregnancy; Female; Humans; Emergencies; Delivery, Obstetric; Simulation Training; Learning; Health Personnel; Clinical Competence
PubMed: 37922430
DOI: 10.5867/medwave.2023.10.2712 -
Animals : An Open Access Journal From... Jul 2023The objective of this study was to explore the effect of dam body conformations on birth traits including stillbirth, dystocia, gestation length and birth weight of...
The objective of this study was to explore the effect of dam body conformations on birth traits including stillbirth, dystocia, gestation length and birth weight of Chinese Holstein calves and to provide a reference for improving cow reproductive performance. We collected phenotype data on 20 conformation traits of Chinese Holstein cows and analyzed the impact of dam conformation trait linear scores on stillbirth, dystocia, gestation length and calf birth weight. The feet angle, set of rear legs, fore udder attachment and rear attachment height traits of the dairy cows significantly affected the risk of stillbirth. The risk of dystocia decreases with the increase in stature and pin width. The bone quality of dairy cows had a significant positive correlation with gestation length. There was a significant positive correlation between fore udder attachment and calf weight at birth. The birth weight of calves from cows with high body conformation traits was significantly higher than that of calves with a low composite score. These results suggest that improving the body conformation traits, especially the selection of mammary system and body shape total score, will be beneficial in improving the reproductive performance of dairy cows.
PubMed: 37508031
DOI: 10.3390/ani13142253 -
Ultrasound in Obstetrics & Gynecology :... Jan 2024To describe the perinatal outcome of fetuses predicted to be large-for-gestational age (LGA) on universal third-trimester ultrasound in non-diabetic pregnancies of women...
OBJECTIVE
To describe the perinatal outcome of fetuses predicted to be large-for-gestational age (LGA) on universal third-trimester ultrasound in non-diabetic pregnancies of women attempting vaginal delivery.
METHODS
This was a prospective population-based cohort study of patients from a single tertiary maternity unit in the UK offering universal third-trimester ultrasound and practicing expectant management of suspected LGA until 41-42 weeks. All women with a singleton pregnancy and an estimated due date between January 2014 and September 2019 were included. Women delivering before 37 weeks, those having a planned Cesarean delivery, those with pre-existing or gestational diabetes, those with fetal abnormalities and those who did not undergo a third-trimester scan were excluded from the assessment of perinatal outcome of cases with LGA predicted on ultrasound after implementation of the universal scan period. Association of LGA on universal third-trimester ultrasound screening and perinatal adverse outcome was assessed, with the exposures of interest being estimated fetal weight (EFW) at the 90 -95 , > 95 and > 99 percentile. The reference group was composed of fetuses with EFW at the 30 -70 percentile. Analysis was performed using multivariate logistic regression. The evaluated adverse perinatal outcomes included a composite outcome of admission to neonatal intensive care unit, Apgar score < 7 at 5 min and arterial cord pH < 7.1 (CAO1) and a composite outcome of stillbirth, neonatal death and hypoxic ischemic encephalopathy (CAO2). Secondary maternal outcomes were induction of labor, mode of delivery, postpartum hemorrhage, shoulder dystocia and obstetric anal sphincter injury.
RESULTS
Cases with EFW > 95 percentile on universal third-trimester scan were at increased risk of CAO1 (adjusted odds ratio (aOR), 2.18 (95% CI, 1.69-2.80)) and CAO2 (aOR, 2.58 (95% CI, 1.05-6.34)). Cases with EFW at the 90 -95 percentile had a less pronounced increase in the risk of CAO1 (aOR, 1.35 (95% CI, 1.02-1.78)) and were not at increased risk of CAO2. All pregnancies with a fetus predicted to be LGA were at increased risk of all of the evaluated secondary maternal outcomes except for obstetric anal sphincter injury. The risk of adverse maternal outcome was typically higher with increasing EFW. Post-hoc exploration of data suggested that shoulder dystocia had a limited contribution to composite adverse perinatal outcomes in LGA cases (population attributable fraction of 10.8% for CAO1 and 29.1% for CAO2).
CONCLUSIONS
Cases with EFW > 95 percentile are at increased risk of severe adverse perinatal outcome, such as death and hypoxic ischemic encephalopathy. These findings should aid antenatal counseling regarding the associated risk and delivery options. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
Topics: Female; Humans; Infant, Newborn; Pregnancy; Cohort Studies; Fetal Weight; Fetus; Gestational Age; Hypoxia-Ischemia, Brain; Predictive Value of Tests; Pregnancy Outcome; Pregnancy Trimester, Third; Prospective Studies; Shoulder Dystocia; Stillbirth; Ultrasonography, Prenatal; Infant, Large for Gestational Age
PubMed: 37428957
DOI: 10.1002/uog.26305