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American Journal of Obstetrics and... Mar 2024Globally, more than 1 in 5 women give birth by cesarean delivery, and at least 5% of these births are at full cervical dilatation. In these circumstances, and when labor... (Review)
Review
Globally, more than 1 in 5 women give birth by cesarean delivery, and at least 5% of these births are at full cervical dilatation. In these circumstances, and when labor has been prolonged in the first stage of labor, the fetal head can become low and wedged deep in the woman's pelvis, making it difficult to deliver the baby. This emergency is known as impacted fetal head. These are technically challenging births associated with serious risks to both the woman and the baby. The difficulty in disimpacting the fetal head increases maternal risks of hemorrhage and injury to adjacent organs and may have long-term consequences for future pregnancies. In addition, there can be associated neonatal consequences, such as skull fractures, brain hemorrhage, hypoxic brain injury, and, rarely, perinatal death. Globally, maternity staff are increasingly encountering this emergency, with studies in the United Kingdom suggesting that impacted fetal head may complicate as many as 1 in 10 emergency cesarean deliveries. Moreover, there has been a sharp increase in reports of perinatal brain injuries associated with impaction of the fetal head at cesarean delivery. When an impacted fetal head occurs, the maternity team can employ a range of approaches to help deliver the fetal head, including an assistant (another obstetrician or midwife) pushing the head up from the vagina, delivering the baby feet first (reverse breech extraction), administering tocolysis to relax the uterus, and using a balloon cephalic elevation device (Fetal Pillow) to elevate the baby's head. However, there is currently no consensus on how best to manage these births, resulting in a lack of confidence among maternity staff, variable practice, and potentially avoidable harm in some circumstances. This article examined the evidence for the prevention and management of this critical obstetrical emergency and outlined recommendations for best practices and training.
Topics: Infant, Newborn; Female; Pregnancy; Humans; Cesarean Section; Delivery, Obstetric; Fetus; Obstetrics; Labor, Obstetric
PubMed: 38462267
DOI: 10.1016/j.ajog.2022.10.037 -
Obstetrics & Gynecology Science May 2020This study aimed to compare the effects of vaginal misoprostol, laminaria, and extra-amniotic saline infusion (EASI) on cervical ripening.
OBJECTIVE
This study aimed to compare the effects of vaginal misoprostol, laminaria, and extra-amniotic saline infusion (EASI) on cervical ripening.
METHODS
This randomized controlled trial was conducted on 195 women with singleton pregnancies and unripe cervices. Participants were randomly allocated to 3, 65-person groups: a misoprostol, a laminaria, and an EASI group. The interventions in the misoprostol, laminaria, and EASI groups included a single 25-µg vaginal misoprostol suppository, an intracervical laminaria, and a transcervical Foley catheter, respectively. The groups were compared with each other regarding time intervals from labor induction to labor active phase and delivery, cervical dilation, Bishop scores 6 hours after induction, delivery type, length of hospital stay, and complications.
RESULTS
There were no significant differences among the groups regarding maternal ages, gestational ages, body mass indices, baseline cervical dilations, and Bishop scores (>0.05). Six hours after induction, the Bishop score and cervical dilation were significantly greater in the EASI group than in the other 2 groups (<0.001). Moreover, time intervals from labor induction to labor active phase and delivery in the EASI group were significantly short (<0.001). The rates of cesarean section, fetal distress, placental abruption, and meconium staining in the misoprostol group were significantly high (<0.05), and the length of hospital stay in the EASI group was significantly short (<0.001).
CONCLUSION
EASI is a safer and more effective method for cervical ripening. Considering its inexpensiveness, easy accessibility, and greater effectiveness, EASI is recommended for cervical ripening.
TRIAL REGISTRATION
Iranian Center for Clinical Trials Identifier: IRCT20170513033941N39.
PubMed: 32489970
DOI: 10.5468/ogs.2020.63.3.261 -
International Journal of Gynaecology... Feb 2021This good clinical practice paper provides an overview of the current evidence around second stage care, highlighting the challenges and the importance of maintaining...
This good clinical practice paper provides an overview of the current evidence around second stage care, highlighting the challenges and the importance of maintaining high-quality, safe, and respectful care in all settings. It includes a series of recommendations based on best available evidence regarding length of second stage, judicious use of episiotomy, and the importance of competent attendants and adequate resource to facilitate all aspects of second stage management, from physiological birth to assisted vaginal delivery and cesarean at full dilatation. The second stage of labor is potentially the most dangerous time for the baby and can have significant consequences for the mother, including death or severe perineal trauma or fistula, especially where there are failures to recognize and repair. This paper sets out principles of care, including the vital role of skilled birth attendants and birth companions, and the importance of obstetricians and midwives working together effectively and speaking with one voice, whether to women or to policy makers. The optimization of high-quality, safe, and personalized care in the second stage of labor for all women globally can only be achieved by appropriate attention to the training of birth attendants, midwives, and obstetricians. FIGO is committed to this aim alongside the WHO, ICM, and all FIGO's 132 member societies.
Topics: Delivery, Obstetric; Episiotomy; Female; Humans; Labor Stage, Second; Midwifery; Parturition; Pregnancy
PubMed: 33340411
DOI: 10.1002/ijgo.13552 -
Frontiers in Global Women's Health 2021Approximately 40% of cases of spontaneous preterm birth (sPTB) are associated with ascending intrauterine infections. The cervix serves as a physical and immunological... (Review)
Review
Approximately 40% of cases of spontaneous preterm birth (sPTB) are associated with ascending intrauterine infections. The cervix serves as a physical and immunological gatekeeper, preventing the ascent of microorganisms from the vagina to the amniotic cavity. The cervix undergoes remodeling during pregnancy. It remains firm and closed from the start until the late third trimester of pregnancy and then dilates and effaces to accommodate the passage of the fetus during delivery. Remodeling proceeds appropriately and timely to maintain the pregnancy until term delivery. However, risk factors, such as acute and chronic infection and local inflammation in the cervix, may compromise cervical integrity and result in premature remodeling, predisposing to sPTB. Previous clinical studies have established bacterial (i.e., chlamydia, gonorrhea, mycoplasma, etc.) and viral infections (i.e., herpesviruses and human papillomaviruses) as risk factors of PTB. However, the exact mechanism leading to PTB is still unknown. This review focuses on: (1) the epidemiology of cervical infections in pregnant patients; (2) cellular mechanisms that may explain the association of cervical infections to premature cervical ripening and PTB; (3) endogenous defense mechanisms of the cervix that protect the uterine cavity from infection and inflammation; and (4) potential inflammatory biomarkers associated with cervical infection that can serve as prognostic markers for premature cervical ripening and PTB. This review will provide mechanistic insights on cervical functions to assist in managing cervical infections during pregnancy.
PubMed: 35118439
DOI: 10.3389/fgwh.2021.777643 -
Avicenna Journal of Phytomedicine 2023To determine whether addition of evening primrose to a misoprostol-based abortion regimen can increase the success of abortion.
OBJECTIVE
To determine whether addition of evening primrose to a misoprostol-based abortion regimen can increase the success of abortion.
MATERIALS AND METHODS
In this randomized clinical trial., 148 women referring to Niknafas Hospital in Rafsanajn with diagnosis of missed abortion were randomly allocated into two 74-subject groups. The intervention group used 2000 mg vaginal evening primrose capsules the night before the hospitalization, while the control group did not receive any medication. Both groups received an initial dose of 800 μg of vaginal misoprostol after admission and the next dose was given three hours later if necessary.
RESULTS
The two groups had significant differences in terms of full abortion, consistency and dilatation of cervix, duration between the first dose of misoprostol until the ejection of fetus, the misoprostol dose administered, and the level of vaginal bleeding during the hospitalization. They had no significant differences regarding curettage, duration of hospitalization, or side effects. The mean pain score had no significant difference between the two groups, though the score was lower in the intervention group (p>0.05).
CONCLUSION
Administration of vaginal evening primrose before vaginal misoprostol was found to be more effective compared to misoprostol alone in missed abortion.
PubMed: 38089421
DOI: 10.22038/AJP.2023.22179 -
Ginekologia Polska 2021The purpose of this study was to determine the risk factors for caesarean sections in the second stage of labour after a previous caesarean section among women who...
OBJECTIVES
The purpose of this study was to determine the risk factors for caesarean sections in the second stage of labour after a previous caesarean section among women who underwent trial of labour (TOL).
MATERIAL AND METHODS
From a total of 639 women who experienced one caesarean section, 456 women were qualified for TOL. From this group, 105 women were subjected to a caesarean section in the first stage of labour and another 351 women reached the second stage of labour. From the latter group, 309 women delivered naturally and 42 were subjected to a caesarean section.
RESULTS
Risk factors for the necessity of performing a caesarean section in the second stage of labour after a previous caesarean section was the weight gain during pregnancy (OR = 1.07), the height of fundus uteri (OR = 1.25) before delivery, and the estimated foetal weight (OR = 1.01), a past delivery of a child with a birth weight exceeding 4.000 g (OR = 2.14), the presence of pre-gestational diabetes (OR = 15.4) and gestational diabetes (OR = 2.22), necessity of applying a delivery induction (OR = 2.52), stimulation of uterine activity during delivery (OR = 2.43) and application of epidural analgesia (OR = 4.04). A factor reducing the risk of a caesarean section in the second stage was a vaginal delivery in a woman's history (OR = 0.21).
CONCLUSIONS
Women should be encouraged to deliver naturally after a previous caesarean section, especially when their history includes a vaginal delivery and if there is no need for labour induction.
Topics: Adolescent; Adult; Cesarean Section; Cesarean Section, Repeat; Diabetes, Gestational; Dilatation; Female; Humans; Middle Aged; Pregnancy; Risk Factors; Trial of Labor; Vaginal Birth after Cesarean; Young Adult
PubMed: 33576488
DOI: 10.5603/GP.a2020.0140 -
Hong Kong Medical Journal = Xianggang... Oct 2020Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is an uncommon congenital malformation characterised by agenesis or hypoplasia of the vagina and uterus. Here, we...
INTRODUCTION
Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is an uncommon congenital malformation characterised by agenesis or hypoplasia of the vagina and uterus. Here, we describe the treatment of patients with MRKH syndrome in a tertiary hospital.
METHODS
This retrospective study included patients with MRKH syndrome attending the Paediatric and Adolescent Gynaecology Clinic in a tertiary hospital. Their clinical manifestations, examinations, and methods for neovagina creation were recorded. Among patients who underwent vaginal dilation (VD), therapy duration, vaginal width and length at baseline and after VD, complications, and sexual activity and dyspareunia outcomes were evaluated.
RESULTS
Forty nine patients with MRKH syndrome were identified. Their mean age at presentation was 17.9 years; 69.4% and 24.5% of patients presented for primary amenorrhoea treatment and vaginoplasty, respectively. Forty eight patients had normal renal imaging findings and 46 XX karyotypes. Seventeen (34.7%) patients underwent VD as first-line therapy; three did not complete the therapy. Two had surgical vaginoplasty, whereas five achieved adequate vaginal length by sexual intercourse alone; 25 had not yet requested VD. The mean duration of VD was 16±10.2 (range, 4-35) weeks. The widths and lengths of the vagina at baseline and after VD were 1.1±0.28 cm and 1.3±0.7 cm, and 3.1±0.5 cm and 6.9±0.9 cm, respectively. The overall success rate of VD was 92.3%. Vaginal spotting was the most common complication (21%); only one patient reported dyspareunia.
CONCLUSIONS
Mayer-Rokitansky-Küster-Hauser syndrome is an uncommon condition that requires multidisciplinary specialist care. Vaginal dilation is an effective first-line approach for neovagina creation.
Topics: 46, XX Disorders of Sex Development; Adolescent; Congenital Abnormalities; Dilatation; Female; Humans; Mullerian Ducts; Plastic Surgery Procedures; Retrospective Studies; Tertiary Care Centers; Treatment Outcome; Vagina
PubMed: 33060366
DOI: 10.12809/hkmj208467 -
AJOG Global Reports Nov 2023Vaginal stenosis is a common complication following construction of a neovagina with vascularized myocutaneous flaps. This is primarily because of inconsistent or...
INTRODUCTION
Vaginal stenosis is a common complication following construction of a neovagina with vascularized myocutaneous flaps. This is primarily because of inconsistent or inappropriate vaginal dilator use. Image-guided recanalization, especially for obstructed genitourinary tracts, is an emerging idea in interventional radiology. Although multiple surgical techniques have been reported to treat vaginal agenesis or obstruction, the idea of image-guided recanalization of vaginal stenosis is a relatively new management strategy for vaginal stenosis.
CASE
We present a challenging case of a patient who initially presented with the complaint of increasing pelvic pressure after the creation of a neovagina via vaginoplasty. She had a distal neovagina created after extensive surgical resection for a large infiltrating pelvic rectal adenocarcinoma. A computed tomography scan revealed a fluid-filled neovaginal abscess. Examination under anesthesia revealed complete stenosis of the neovagina with no identifiable tract for dilation.
INTERVENTION
A computed tomography scan and fluoroscopy-guided sharp recanalization of the stenosed neovagina was performed, followed by serial fluoroscopic balloon angioplasty to dilate the stenosed neovagina. Finally, the patient underwent a gynecologic surgery for the excision of remaining granulation tissue to produce a more permanent patent neovagina, followed by regular and proper use of vaginal dilators to ensure patency.
CONCLUSION
This case report demonstrates that image-guided techniques can be used to aid in vaginal recanalization in the postoperative setting.
PubMed: 37701754
DOI: 10.1016/j.xagr.2023.100257 -
Frontiers in Global Women's Health 202298% of stillbirths occur in low- and middle- income countries. Obstructed labor is a common cause for both neonatal and maternal mortality, with a lack of skilled birth...
BACKGROUND
98% of stillbirths occur in low- and middle- income countries. Obstructed labor is a common cause for both neonatal and maternal mortality, with a lack of skilled birth attendants one of the main reasons for the reduction in operative vaginal birth, especially in low- and middle- income countries. We introduce a low cost, sensorized, wearable device for digital vaginal examination to facilitate accurate assessment of fetal position and force applied to the fetal head, to aid training in safe operative vaginal birth.
METHODS
The device consists of flexible pressure/force sensors mounted onto the fingertips of a surgical glove. Phantoms of the neonatal head were developed to replicate sutures. An Obstetrician tested the device on the phantoms by performing a mock vaginal examination at full dilatation. Data was recorded and signals interpreted. Software was developed so that the glove can be used with a simple smartphone app. A patient and public involvement panel was consulted on the glove design and functionality.
RESULTS
The sensors achieved a 20 Newton force range and a 0.1 Newton sensitivity, leading to 100% accuracy in detecting fetal sutures, including when different degrees of molding or caput were present. They also detected sutures and force applied with a second sterile surgical glove on top. The software developed allowed a force threshold to be set, alerting the clinician when excessive force is applied. Patient and public involvement panels welcomed the device with great enthusiasm. Feedback indicated that women would accept, and prefer, clinicians to use the device if it could improve safety and reduce the number of vaginal examinations required.
CONCLUSION
Under phantom conditions to simulate the fetal head in labor, the novel sensorized glove can accurately determine fetal sutures and provide real-time force readings, to support safer clinical training and practice in operative birth. The glove is low cost (approximately 1 USD). Software is being developed so fetal position and force readings can be displayed on a mobile phone. Although substantial steps in clinical translation are required, the glove has the potential to support efforts to reduce the number of stillbirths and maternal deaths secondary to obstructed labor in low- and -middle income countries.
PubMed: 36793358
DOI: 10.3389/fgwh.2022.1039477 -
Translational Andrology and Urology May 2022The mechanisms of the microenergy acoustic pulse (MAP) therapy on restoring structure and function of pelvic floor muscles (PFM) after simulated birth injury are not...
BACKGROUND
The mechanisms of the microenergy acoustic pulse (MAP) therapy on restoring structure and function of pelvic floor muscles (PFM) after simulated birth injury are not well understood.
METHODS
A total 24 female Sprague-Dawley rats were randomly grouped into sham control (sham), vaginal balloon dilation and ovariectomy (VBDO), VBDO + β-aminopropionitrile (BAPN, an irreversible LOX inhibitor), and VBDO + BAPN and treated with MAP (n=6 in each group). The MAP therapy was administered 2 times per week for 4 weeks with 1-week washout, the functional and histological studies were conducted in all 24 rats. The viscoelastic behavior of the PFM, including iliococcygeus (IC) and pubococcygeus (PC), was examined with a biomechanical assay. The structure of the PFM was assessed by immunofluorescence and Masson's trichrome staining.
RESULTS
The leak point pressure (LPP) assay demonstrated that the MAP therapy group had higher LPPs compared to that of VBDO and BAPN groups. In the sham group, the muscular stiffness (K) of IC muscle was significantly higher than that of PC muscle while the pelvic floor muscle rebound activity (MRA) of PC muscle was stronger than that of IC muscle (291.26±45.33 and 241.18±14.23 N/cm, respectively). Both VBDO and BAPN decreased the MRA and increased the K in both IC and PC. Histologic examination revealed increased fibrous tissue (collagen) and degeneration of muscle fibers in both VBDO and BAPN groups. MAP therapy significantly reduced the collagen content and improved the architecture of muscle fibers.
CONCLUSIONS
MAP appears to restore the structure and function of PFM by regenerating muscular fibers and improving biomechanical properties in an animal model of simulated birth injury.
PubMed: 35693721
DOI: 10.21037/tau-22-30