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American Journal of Perinatology May 2022This study aimed to develop and validate a model to predict the probability of vaginal delivery (VD) in low-risk term nulliparous patients, and to determine whether it... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
This study aimed to develop and validate a model to predict the probability of vaginal delivery (VD) in low-risk term nulliparous patients, and to determine whether it can predict the risk of severe maternal and neonatal morbidity.
METHODS
Secondary analysis of an obstetric cohort of patients and their neonates born in 25 hospitals across the United States ( = 115,502). Trained and certified research personnel abstracted the maternal and neonatal records. Nulliparous patients with singleton, nonanomalous vertex fetuses, admitted with an intent for VD ≥ 37 weeks were included in this analysis. Patients in active labor (cervical exam > 5 cm), those with prior cesarean and other comorbidities were excluded. Eligible patients were randomly divided into a training and test sets. Based on the training set, and using factors available at the time of admission for delivery, we developed and validated a logistic regression model to predict the probability of VD, and then estimated the prevalences of severe morbidity according to the predicted probability of VD.
RESULTS
A total of 19,611 patients were included. Based on the training set ( = 9,739), a logistic regression model was developed that included maternal age, body mass index (BMI), cervical dilatation, and gestational age on admission. The model was internally validated on the test set ( = 9,872 patients) and yielded a receiver operating characteristic-area under the curve (ROC-AUC) of 0.71 (95% confidence interval [CI]: 0.70-0.72). Based on a subset of 18,803 patients with calculated predicted probabilities, we demonstrated that the prevalences of severe morbidity decreased as the predicted probability of VD increased ( < 0.01).
CONCLUSION
In a large cohort of low-risk nulliparous patients in early labor or undergoing induction of labor, at term with singleton gestations, we developed and validated a model to calculate the probability of VD, and maternal and neonatal morbidity. If externally validated, this calculator may be clinically useful in helping to direct level of care, staffing, and adjustment for case-mix among various systems.
KEY POINTS
· A model to predict the probability of vaginal delivery in low-risk nulliparous patients at term.. · The model also predicts the risk of severe maternal and neonatal morbidity.. · The prevalences of severe morbidity decrease as the probability of vaginal delivery increases..
Topics: Cohort Studies; Delivery, Obstetric; Female; Gestational Age; Humans; Infant, Newborn; Labor Stage, First; Labor, Induced; Labor, Obstetric; Pregnancy; United States
PubMed: 33075842
DOI: 10.1055/s-0040-1718704 -
Journal of Obstetrics and Gynaecology... Dec 2020This systematic review and meta-analysis assessed the effectiveness and safety of camylofin compared with other antispasmodics (drotaverine, hyoscine, valethamate,... (Review)
Review
This systematic review and meta-analysis assessed the effectiveness and safety of camylofin compared with other antispasmodics (drotaverine, hyoscine, valethamate, phloroglucinol, and meperidine) in labor augmentation. A systematic literature search until March 27, 2018, was performed, and data on the cervical dilatation rate (CDR) and duration of stages of labor reported in 39 eligible articles were analyzed using a random-effects model. CDR was significantly higher (0.38 cm/h, 95% confidence interval (CI) 0.10 to 0.67, = 0.007), and the duration of the first stage of labor was significantly shorter (- 41.21 minutes, 95% CI, - 77.19 to - 5.22, = 0.02) in women receiving camylofin than those receiving other antispasmodics for labor augmentation. CDR was significantly higher with camylofin compared with valethamate (0.6 cm/h, 95% CI 0.4 to 0.9, < 0.0001) and hyoscine (20 mg) (0.5 cm/h, 95% CI 0.1 to 0.8, = 0.02). The duration of the first stage of labor was significantly shorter with camylofin compared with hyoscine (20 mg) (- 59.9 min, 95% CI, - 117.9 to - 1.8, = 0.04). However, CDR and the duration of first stage of labor were not statistically different between camylofin and drotaverine groups. The percentage of women having nausea and vomiting, cervical/vaginal tear, and postpartum hemorrhage were comparable with all antispasmodics, whereas tachycardia was least reported in women receiving camylofin (3, 2.07%) than those receiving other antispasmodics. This meta-analysis demonstrated the benefit of camylofin in labor augmentation with a faster CDR and reduction in the active first stage of labor in Indian women.
PubMed: 33417640
DOI: 10.1007/s13224-020-01343-3 -
BMC Pregnancy and Childbirth Jul 2022With the development of China's two-child-policy, vaginal birth after cesarean section (VBAC) has aroused public concern. It is important to understand the... (Observational Study)
Observational Study
BACKGROUND
With the development of China's two-child-policy, vaginal birth after cesarean section (VBAC) has aroused public concern. It is important to understand the labour characteristics and intrapartum management of women attempting VBAC to enhance the rates of successful VBAC. The purpose of our research was to investigate the differences in the characteristics of labor, intervention measures and perinatal outcomes between women who had a VBAC and primiparas or multiparas not undergoing VBAC, providing clinical references of intrapartum management for women who are planning a VBAC.
MATERIAL AND METHODS
This observational retrospective study enrolled all women who laboured spontaneously and who had a VBAC (n = 139) at the Second Affiliated Hospital of Wenzhou Medical University in China between 2016 and 2019. They were allocated into VBAC group A (the previous cesarean section was performed before dilation of the cervix) and VBAC group B (the previous cesarean section was performed after dilation of the cervix). The primipara control group included 149 primiparae, and the multipara control group included 155 multiparae with second vaginal birth. Durations of labor, intervention measures and perinatal outcomes were compared among the groups.
RESULTS
The durations of labor, intrapartum interventions and maternal and neonatal outcomes in VBAC group A were similar to those of the VBAC group B. However, all women who had a VBAC and those in VBAC group A had shorter first, second and the total stages of labor than primiparae. All women with VBAC and those in VBAC group B had longer second stage of labor, but shorter third stage of labor than multiparae. Oxytocin, labor analgesia and artificial rupture of membranes were administered less often in women with VBAC than in primiparae, while phloroglucinol was administered more often in women with VBAC than in multiparae. Women who had a VBAC were more likely to receive episiotomy and had higher incidences of postpartum hemorrhage than primipara and multipara women.
CONCLUSIONS
Labor characteristics, intrapartum interventions and perinatal outcomes in women who had a VBAC with cervical dilation were similar to those in women who had a VBAC without cervical dilation before the previous cesarean section, but differed significantly from those of multiparae and primiparae who did not undergo VBAC.
Topics: Cesarean Section; Female; Humans; Infant, Newborn; Labor, Obstetric; Parturition; Pregnancy; Retrospective Studies; Trial of Labor; Vaginal Birth after Cesarean
PubMed: 35870907
DOI: 10.1186/s12884-022-04919-1 -
Obstetrics and Gynecology Jun 2021To assess the comparative effectiveness and potential harms of cervical ripening in the outpatient compared with the inpatient setting, or different methods of ripening... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To assess the comparative effectiveness and potential harms of cervical ripening in the outpatient compared with the inpatient setting, or different methods of ripening in the outpatient setting alone.
DATA SOURCES
Searches for articles in English included MEDLINE, EMBASE, CINAHL, Cochrane Library, ClinicalTrials.gov, and reference lists (up to August 2020).
METHODS OF STUDY SELECTION
Using predefined criteria and DistillerSR software, 10,853 citations were dual-reviewed for randomized controlled trials (RCTs) and cohort studies of outpatient cervical ripening using prostaglandins and mechanical methods in pregnant women at or beyond 37 weeks of gestation.
TABULATION, INTEGRATION, AND RESULTS
Using prespecified criteria, study data abstraction and risk of bias assessment were conducted by two reviewers, random-effects meta-analyses were conducted and strength of evidence was assessed. We included 30 RCTs and 10 cohort studies (N=9,618) most generalizable to women aged 25-30 years with low-risk pregnancies. All findings were low or insufficient strength of evidence and not statistically significant. Incidence of cesarean delivery was not different for any comparison of inpatient and outpatient settings, or comparisons of different methods in the outpatient setting (most evidence available for single-balloon catheters and dinoprostone). Harms were inconsistently reported or inadequately defined. Differences were not found for neonatal infection (eg, sepsis) with outpatient compared with inpatient dinoprostone, birth trauma (eg, cephalohematoma) with outpatient compared with inpatient single-balloon catheter, shoulder dystocia with outpatient dinoprostone compared with placebo, maternal infection (eg, chorioamnionitis) with outpatient compared with inpatient single-balloon catheters or outpatient prostaglandins compared with placebo, and postpartum hemorrhage with outpatient catheter compared with inpatient dinoprostone. Evidence on misoprostol, hygroscopic dilators, and other outcomes (eg, perinatal mortality and time to vaginal birth) was insufficient.
CONCLUSION
In women with low-risk pregnancies, outpatient cervical ripening with dinoprostone or single-balloon catheters did not increase cesarean deliveries. Although there were no clear differences in harms when comparing outpatient with inpatient cervical ripening, the certainty of evidence is low or insufficient to draw definitive conclusions.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO, CRD42020167406.
Topics: Ambulatory Care; Catheters; Cervical Ripening; Cesarean Section; Dilatation; Dinoprostone; Female; Hospitalization; Humans; Labor, Induced; Obstetric Labor Complications; Oxytocics; Pregnancy
PubMed: 33752219
DOI: 10.1097/AOG.0000000000004382 -
International Journal of Particle... 2022Sexual dysfunction is a common toxicity and detrimental for the quality of life of women treated with chemoradiotherapy for anal cancer. Sexual dysfunction occurs...
Sexual dysfunction is a common toxicity and detrimental for the quality of life of women treated with chemoradiotherapy for anal cancer. Sexual dysfunction occurs because the vagina is closely approximated to the anal canal and typically receives substantial doses of radiation. Strategies for mitigation have largely been focused on posttreatment therapy and symptom management. The use of daily vaginal dilator placement during radiotherapy to mitigate dose to the vagina has been previously explored with modest gains, while proton therapy is under active investigation for the treatment of anal cancer. Use of proton therapy for anal cancer reduces dose to some organs at risk but may inadvertently increase vaginal toxicity if the proton beam terminates in the vaginal tissue. Herein, we present the case histories of 2 women treated for squamous cell carcinoma of the anal canal with the novel combination of intensity-modulated proton therapy and daily vaginal dilator placement to maximally reduce dose to the vagina and protect it from areas of increased energy deposition at the end of the proton range.
PubMed: 35774492
DOI: 10.14338/IJPT-21-00025 -
International Journal of Surgery... 2022Vaginal birth may have a negative impact on nerve structure and function, pelvic floor muscle structure, and function. Reducing the risk of pelvic floor injuries during...
BACKGROUND
Vaginal birth may have a negative impact on nerve structure and function, pelvic floor muscle structure, and function. Reducing the risk of pelvic floor injuries during vaginal birth is one of the most effective ways to prevent labor morbidity in women. There is a lack of tools developed based on this approach, especially in Indonesia. Therefore, we aimed to know the efficacy of a vaginal dilator called Divabirth based on labor outcomes.
METHODS
This clinical study involved subjects who are randomly grouped in to the control and treatment groups. Subjects in the treatment group are told to utilize vaginal dilator devices for 20 minutes each session, a maximum of two sessions per day, lasting 5 minutes every cycle, from 35 weeks of gestation until delivery.
DISCUSSIONS
The current research contributes valuable information to developing a vaginal dilator intervention program for pregnant women to reduce perineal laceration and improve labor outcomes. It may also help to lower their medical and treatment expenditures. We expect its success to be a step forward in improving reproductive health status.
HIGHLIGHTS
Vaginal birth may have negative impact on nerve and pelvic floor muscle structure and functionLack of tool has been developed to reduce the risk of pelvic floor injuries during vaginal birthA study protocol of vaginal dilator usage to know the efficacy based on labor outcomes.
PubMed: 36382128
DOI: 10.29337/ijsp.179 -
Journal of Clinical Research in... Feb 2020In patients with Mayer-Rokitansky-Küster-Hauser syndrome and complete androgen insensitivity syndrome (CAIS), management of vaginal hypoplasia includes non-surgical or...
In patients with Mayer-Rokitansky-Küster-Hauser syndrome and complete androgen insensitivity syndrome (CAIS), management of vaginal hypoplasia includes non-surgical or surgical vaginal elongation techniques. For these patients, primary vaginal dilation is considered a first-line option to avoid the risks of having surgery and complications that may occur due to these procedures. Non-surgical dilation is a highly successful treatment if treatment is initiated when the patient is emotionally mature and ready. Here, we present a case of CAIS with vaginal hypoplasia managed successfully with non-surgical dilation therapy.
Topics: Adolescent; Androgen-Insensitivity Syndrome; Conservative Treatment; Dilatation; Female; Humans; Male; Vagina
PubMed: 32041393
DOI: 10.4274/jcrpe.galenos.2020.2019.S0222 -
Sexual Medicine Dec 2022No nomogram exists to predict maximum achievable neovaginal depth before penile inversion vaginoplasty (PIV) based on available penile & scrotal skin (SS). Maximal depth...
INTRODUCTION
No nomogram exists to predict maximum achievable neovaginal depth before penile inversion vaginoplasty (PIV) based on available penile & scrotal skin (SS). Maximal depth is important to patients and is determined by available skin and available anatomic space within the pelvis and varies with surgical technique.
AIM
We endeavored to create a nomogram to predict expected postoperative vaginal depth.
METHODS
Retrospective review of all patients undergoing primary PIV at a single institution from June 2017 to February 2020 (n = 60). Pre-op: Dorsal penile and midline scrotal skin length were measured. Intra-op: Tubularized scrotal skin length measured on a dilator. Immediate post-op: Final vaginal depth measured with a dilator.
OUTCOMES
The amount of available penile and scrotal skin was not associated with vaginal depth. The only variable that did significantly increase depth was the use of penile + scrotal skin, as compared to penile skin alone. (P < .001) RESULTS: In patients who underwent PIV-SS, the final vaginal depth (13.3 ± 1.9 cm) was 87% of pre-op measured penile skin length (15.3 ±- 3.0 cm). In patients who underwent PIV+SS, pre-op penile skin length was 11.1 ± 4.7±cm and pre-op midline scrotal length was 22.8 ± 2.6 cm. with a final post-op vaginal canal depth of 15.2 ± 1.3 cm. In 45/46 (98%) surgeries utilizing SS grafts, SS tube length exceeded the length necessary to achieve maximal vaginal depth, and required trimming and discard. Given that in most cases there was an excess of SS, final post-op depth equaled the maximal vaginal depth that could be surgically dissected, and was not limited by the amount of available skin.
CLINICAL IMPLICATIONS
Our findings suggest that for most patients it should not be necessary to include additional tissue sources (eg, peritoneum) to create a vaginal canal during primary vaginoplasty.
STRENGTHS AND LIMITATIONS
Any penile skin that was discarded due to poor quality (eg, tight phimosis, poor viability) was not measured and accounted for. This likely resulted in a slight overestimation of the contribution of the penile skin to the final vaginal depth, but did not change the overall finding that final depth was not limited by available skin.
CONCLUSION
SS grafts, when harvested and tubularized using optimized technique, supplied an excess of skin necessary to line a vaginal canal space of maximal achievable depth. We found that additional tissue sources can, instead, be reserved for future salvage surgery if it becomes necessary to augment depth. Smith SM, Yuan N, Stelmar J, et al. Penile and Scrotal Skin Measurements to Predict Final Vaginal Depth With Penile Inversion Vaginoplasty. Sex Med 2022;10:100569.
PubMed: 36152492
DOI: 10.1016/j.esxm.2022.100569 -
The Journal of Maternal-fetal &... Oct 2019Vaginal examination is widely used to assess the progress of labor; however, it is subjective and poorly reproducible. We aim to assess the feasibility and accuracy of... (Observational Study)
Observational Study
Vaginal examination is widely used to assess the progress of labor; however, it is subjective and poorly reproducible. We aim to assess the feasibility and accuracy of transabdominal and transperineal ultrasound compared to vaginal examination in the assessment of labor and its progress. Women were recruited as they presented for assessment of labor to a tertiary inner city maternity service. Paired vaginal and ultrasound assessments were performed in 192 women at 24-42 weeks. Fetal head position was assessed by transabdominal ultrasound defined in relation to the occiput position transformed to a 12-hour clock face; fetal head station defined as head-perineum distance by transperineal ultrasound; cervical dilatation by anterior to posterior cervical rim measurement and caput succedaneum by skin-skull distance on transperineal ultrasound. Fetal head position was recorded in 99.7% (298/299) of US and 51.5% (154/299) on vaginal examination ( < .0001 ). Bland-Altman analysis showed 95% limits of agreement, -5.31 to 4.84 clock hours. Head station was recorded in 96.3% (308/320) on vaginal examination (VE) and 95.9% (307/320) on US ( = .79 ). Head station and head perineum distance were negatively correlated (Spearman's = -.57, < .0001). 54.4% (178/327) of cervical dilatation measurements were determined using US and 100% on VE/speculum ( < .0001). Bland-Altman analysis showed 95% limits of agreement -2.51-2.16 cm. The presence of caput could be assessed in 98.4% (315/320) of US and was commented in 95.3% (305/320) of VEs, with agreement for the presence of caput of 76% ( < .05). Fetuses with caput greater than 10 mm had significantly lower head station ( < .0001). We describe comprehensive ultrasound assessments in the labor room that could be translated to the assessment of women in labor. Fetal head position is unreliably determined by vaginal examination and agrees poorly with US. Head perineum distance has a moderate correlation with fetal head station in relation to the ischial spines based on vaginal examination. Cervical dilatation is not reliably assessed by ultrasound except at dilatations of less than 4 cm. Caput is readily quantifiable by ultrasound and its presence is associated with lower fetal head station. Transabdominal and transperineal ultrasound is feasible in the labor room with an accuracy that is generally greater than vaginal examinations.
Topics: Adolescent; Adult; Cervix Uteri; Delivery Rooms; Feasibility Studies; Female; Gynecological Examination; Head; Humans; Infant, Newborn; Labor Presentation; Labor Stage, First; Male; Perineum; Pregnancy; Prospective Studies; Reproducibility of Results; Ultrasonography, Prenatal; Young Adult
PubMed: 29712501
DOI: 10.1080/14767058.2018.1465553 -
European Journal of Obstetrics,... Jan 2023Objectives Digital examination has many uses in obstetrics and gynaecology, including cervical assessment in labour and measuring for vaginal pessaries. Clinicians must...
Objectives Digital examination has many uses in obstetrics and gynaecology, including cervical assessment in labour and measuring for vaginal pessaries. Clinicians must be adequately trained to perform accurate digital assessments and use this information to make decisions. We aimed to evaluate the accuracy of a clinician’s estimate for three different measuring tasks and assess whether there was any difference in the accuracy in relation to seniority or job role. Study design Doctors and midwives were recruited from two perineal trauma training events. Estimates and measurements for three different activities were recorded: length of own index finger, length of an anal sphincter model and cervical dilatation at two different dilatations (7 cm and 9 cm) using a pocket guide cervical dilatation tool. The results were analysed for accuracy of measurements according to job role and seniority. Results A total of 369 participants took part. Only 4.6% of participants accurately (to 0.1 cm) estimated the length of their index finger (0% of midwives and 5.5% of doctors). There was a significant difference (p < 0.05) when comparing average differences between estimated and actual lengths measured for doctors and midwives for almost all measurements. When comparing doctors based on seniority there was no significant difference in the accuracy of estimated lengths. A higher percentage of midwives than doctors were accurate at both 7 cm (22% vs 16.1%) and 9 cm (30.5% vs 29.5%) dilated. Conclusion We found that accuracy was poor for both doctors and midwives when asked to estimate various measurements. We suggest that training will improve awareness of finger length and therefore improve accuracy when performing digital examinations in clinical practice.
Topics: Humans; Certification; Educational Measurement
PubMed: 36495777
DOI: 10.1016/j.ejogrb.2022.11.026