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Journal of Gynecology Obstetrics and... Jun 2024Prolonging the passive second stage of labor could increase vaginal birth rate, but the data concerning maternal and fetal morbidity are contradictory. The French...
OBJECTIVES
Prolonging the passive second stage of labor could increase vaginal birth rate, but the data concerning maternal and fetal morbidity are contradictory. The French guidelines did not specify a maximum duration of the passive second stage. Our objective was to assess if allowing a 4th hour after full dilatation before pushing increased maternal morbidity, compared to 3 hours after full dilatation.
STUDY DESIGN
This single-center, retrospective, observational cohort study took place from January 1-December 31, 2020, in a tertiary maternity unit. All consecutive term nulliparous women who delivered under epidural anesthesia and without pathological fetal heart rate and reaching a second-stage passive phase of labor lasting at least 3 hours were included. We compared 2 groups according to the duration of the passive second stage: "3-hour group" and "4-hour group". In the "3-hour group," featuring a second-stage passive phase of up to 3 hours, pushing is initiated for favorable conditions, while a cesarean section is performed if conditions are deemed unfavorable. In the "4-hour group", obstetric conditions not justifying immediate pushing after three hours, and the obstetric team believed that an additional hour of expectant management could lead to a successful vaginal delivery. The principal endpoint was a composite criterion of maternal morbidity including obstetric anal sphincter injuries, postpartum hemorrhage, transfusion and intrauterine infection.
RESULTS
We included 111 patients in the "4-hour group" and 349 in the "3-hour group". Composite maternal morbidity did not increase in the "4-hour group" compared to the "3-hour group" (21 (18.9%) versus 61 (17.5%); p = 0.73). Neonatal morbidity was similar between the two groups. In the "4-hour group, 91 (82%) patients had vaginal deliveries", 62 (55,9%) by spontaneous vaginal delivery and 29 (26,1%) with instrumental assistance.
CONCLUSION
For selected patients, waiting for 4 hours at full dilation can be beneficial due to the high rate of vaginal delivery and low incidence of maternal and fetal complications.
PubMed: 38936801
DOI: 10.1016/j.jogoh.2024.102818 -
Journal of Personalized Medicine May 2024The term dystocia refers to labor characterized by a slow progression with delayed rates or even pauses in the dilation of the cervix or the descent of the fetus.... (Review)
Review
The term dystocia refers to labor characterized by a slow progression with delayed rates or even pauses in the dilation of the cervix or the descent of the fetus. Dystocia describes the deviation from the limits that define a normal birth and is often used as a synonym for the term pathological birth. Shoulder dystocia, also known as the manual exit of the shoulders during vaginal delivery on cephalic presentation, is defined as the "failure of the shoulders to spontaneously traverse the pelvis after delivery of the fetal head". This means that obstetric interventions are necessary to deliver the fetus's body after the head has been delivered, as gentle traction has failed. Abnormal labor (dystocia) is expressed and represented in partograms or by the prolongation of the latent phase or by slowing and pausing in the phases of cervical dilatation and fetal descent. While partograms are helpful in visualizing the progress of labor, regular use of them has not been shown to enhance obstetric outcomes considerably, and no partogram has been shown to be superior to others in comparative trials. Dystocia can, therefore, appear in any phase of the evolution of childbirth, so it is necessary to simultaneously assess all the factors that may contribute to its abnormal evolution, that is, the forces exerted, the weight, the shape, the presentation and position of the fetus, the integrity and morphology of the pelvis, and its relation to the fetus. When this complication occurs, it can result in an increased incidence of maternal morbidity, as well as an increased incidence of neonatal morbidity and mortality. Although several risk factors are associated with shoulder dystocia, it has proven impossible to recognize individual cases of shoulder dystocia in practice before they occur during labor. Various guidelines have been published for the management of shoulder dystocia, with the primary goal of educating the obstetrician and midwife on the importance of a preplanned sequence of maneuvers, thereby reducing maternal and neonatal morbidity and mortality.
PubMed: 38929807
DOI: 10.3390/jpm14060586 -
Pathophysiology : the Official Journal... Jun 2024Vaginal agenesis (VA) is frequently associated with mullerian agenesis. VA treatments include mechanical dilation and surgical vaginoplasty. We created a vaginal...
Vaginal agenesis (VA) is frequently associated with mullerian agenesis. VA treatments include mechanical dilation and surgical vaginoplasty. We created a vaginal expansion sleeve (VES) as a novel device to progressively lengthen the vaginal canal. This study evaluated the histologic effects of the VES on rat vaginal tissue. The VES is a spring-like device made of proprietary woven cylindrical material and flat resin caps. The VESs were constructed as 25-30 mm, pre-contracted springs, which were secured into the vaginas of six Sprague Dawley rats and allowed to re-expand post-surgically. After one week, the VESs were removed, and the vaginas were harvested and measured in length. Test ( = 6) and control ( = 4) formalin-fixed paraffin-embedded tissues were stained with hematoxylin and eosin (H&E), Masson's trichrome, and anti-Desmin antibodies. The VESs achieved significant vaginal lengthening. The mean vaginal canal length increased from 20.0 ± 2.4 mm to 23.8 ± 1.2 mm after removal of the VESs ( = 6, < 0.001), a 19% increase. There was a positive correlation between the expander/tension generated in the vagina and the amount of acute and chronic inflammation. H&E staining revealed increased submucosal eosinophilia in five of the six test tissues. One VES sample that was lengthened to 30 mm long showed evidence of lymphocytic and neutrophilic inflammation. Desmin immunostaining and Masson's trichrome stain revealed a thinner muscularis with more infiltrative fibrous tissue between muscle fibers in the test tissue compared to the control tissue. Although effective, the VES may provoke at least a transient increase in eosinophils consistent with a localized immune reaction during muscularis remodeling.
PubMed: 38921727
DOI: 10.3390/pathophysiology31020022 -
Cureus May 2024Background Gender dysphoria is treated with gender affirmation surgery (GAS) for assigned male at birth (AMAB) individuals. This study aimed to evaluate the...
Background Gender dysphoria is treated with gender affirmation surgery (GAS) for assigned male at birth (AMAB) individuals. This study aimed to evaluate the postoperative anatomical changes in AMAB individuals who underwent GAS using magnetic resonance imaging (MRI) and to compare it with cis-females, thereby assessing the efficacy of the surgical technique in achieving pelvic anatomy similar to cis-females. Methodology This was a prospective observational study done in a tertiary care hospital. AMAB individuals who underwent gender affirmation genital surgery using single-stage solely penile skin inversion vaginoplasty were included after informed consent and approval by the Institutional Human Ethics Committee. Patients with complications such as deep space surgical site infection (SSI) and neo-vaginal prolapse were excluded. All the study participants were advised a vaginal self-dilatation regimen, reviewed three months after the surgery, and subjected to an MRI of the pelvis with a vaginal tutor. Parameters such as neo-vaginal depth, alpha (α) angle, rectovaginal thickness, and remnant of corpora cavernosa were measured and compared with cis-female parameters measured from images in the archives from the Department of Radiology. Result A total of 21 patients were included in the study, with a mean age of 27±4.7. Between the study group and cis-females, no significant difference was seen in vaginal depth, and cis-females had significantly higher values in other parameters. There was a significant difference between the subgroups, i.e., defaulters and non-defaulters in soft tissue parameters such as vaginal depth (p=0.001), α angle (p=0.002), and rectovaginal thickness (p=0.002) with the non-defaulter patients having higher values. Conclusion Single-stage penile skin inversion vaginoplasty is capable of producing anatomical parameters, importantly neo-vaginal depth, which is fairly comparable with cis-female, as evident in the non-defaulter subgroup patients. Proper compliance with the vaginal dilatation regimen plays a significant role in the maintenance of soft tissue pelvic anatomical parameters.
PubMed: 38910612
DOI: 10.7759/cureus.60823 -
American Family Physician Jun 2024Pregnancy dating is determined by the patient's last menstrual period or an ultrasound measurement. A full-term pregnancy is considered 37 weeks' gestation or more.... (Review)
Review
Pregnancy dating is determined by the patient's last menstrual period or an ultrasound measurement. A full-term pregnancy is considered 37 weeks' gestation or more. Spontaneous labor begins when regular painful uterine contractions result in a cervical change. Active labor begins at 6 cm dilation and is marked by more predictable, accelerated cervical change. In the absence of pregnancy complications, intermittent fetal auscultation may be considered as an alternative to continuous electronic fetal monitoring, which is associated with a high false-positive rate. Intravenous antibiotic prophylaxis is indicated in patients with group B streptococcus colonization or those at high risk to prevent newborn early-onset group B streptococcus. The likelihood of vaginal delivery is increased by providing continuous nonmedical support during labor, encouraging mobility, and using a peanut ball with epidural analgesia. Neuraxial analgesia is more effective for pain control than systemic opioids and is associated with fewer adverse effects. Delayed pushing during the second stage of labor has risks but does not affect the mode of delivery. Routine oropharyngeal suctioning of the newborn is not recommended, even with meconium-stained amniotic fluid. Delayed cord clamping reduces newborn anemia. Prevention of postpartum hemorrhage in patients at risk includes prophylactic uterotonic administration and controlled cord traction. Perineal lacerations that alter anatomy or are not hemostatic should be repaired. (Am Fam Physician. 2024;109(6):525-532.
Topics: Humans; Female; Pregnancy; Delivery, Obstetric; Infant, Newborn; Labor, Obstetric
PubMed: 38905550
DOI: No ID Found -
Archives of Gynecology and Obstetrics Jun 2024Tumors affecting the female genital tract and their treatments have the potential to induce adverse modifications in vaginal health and impact personal aspects of... (Review)
Review
PURPOSE
Tumors affecting the female genital tract and their treatments have the potential to induce adverse modifications in vaginal health and impact personal aspects of patient's lives. Vulvovaginal atrophy is one of the morphological changes observed in individuals with a history of gynecological cancer, influenced both by the biological environment of tumors and the main therapeutic modalities employed. Therefore, the purpose of this study was to identify approaches to treat vulvovaginal atrophy while assessing the impact on the emotional and sexual health of women diagnosed with gynecological cancers.
METHODS
To achieve this goal, a systematic review was conducted following the methodological guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The databases used for literature research were PubMed and Web of Science.
RESULTS
Initially, 886 articles were obtained. After eliminating duplicates and applying inclusion/exclusion criteria, seven articles were selected for analysis. The period of highest publication activity spanned from 2017 to 2020, with the majority conducted in Italy. Five treatment modalities were identified and categorized as vaginal suppository, oral medication, surgical procedure, CO2 laser therapy, and vaginal dilator. Twenty-four outcomes related to vaginal health and 30 outcomes related to overall, sexual, and emotional quality of life were analyzed.
CONCLUSION
In general, all interventions demonstrated the ability to improve vaginal health or, at the very least, the sexual health of patients. Thus, despite limitations, all treatments have the potential to address vulvovaginal atrophy in patients with a history of gynecological cancer.
PubMed: 38898186
DOI: 10.1007/s00404-024-07552-9 -
American Journal of Obstetrics &... Jun 2024To systematically review randomized controlled trials (RCTs) and perform a meta-analysis comparing early amniotomy with delayed amniotomy in individuals undergoing... (Review)
Review
OBJECTIVES
To systematically review randomized controlled trials (RCTs) and perform a meta-analysis comparing early amniotomy with delayed amniotomy in individuals undergoing pre-induction cervical ripening by Foley balloon. The primary outcome was the rate of cesarean delivery. Understanding the impact of the timing of amniotomy on the rate of cesarean delivery is crucial for obstetricians and healthcare providers when making decisions about the management of labor induction.
DATA SOURCES
Data were sourced from electronic databases, including PubMed, OVID, Cochrane Library, Web of Science, and ClinicalTrials.gov through February 2024. The review adhered to Preferred Reporting Item for Systematic Reviews guidelines and registered with PROSPERO (ID CRD42023454520).
STUDY ELIGIBILITY CRITERIA
Inclusion criteria comprised RCTs comparing early amniotomy with delayed amniotomy in individuals undergoing cervical ripening by Foley balloon. Early amniotomy was defined as amniotomy soon after cervical ripening. Delayed amniotomy was defined as withholding amniotomy until after the onset of the active phase of labor, until at least 4 hours from either initiation of oxytocin or Foley balloon removal/expulsion, or until achieving > 4 cm of dilation. Participants included nulliparous or multiparous individuals with singleton pregnancies undergoing labor induction at 37 weeks or later.
STUDY APPRAISAL AND SYNTHESIS
A systematic literature search was conducted using defined search terms including "early amniotomy", "delayed amniotomy", "induction of labor", "cervical ripening", and "Foley balloon", and "Foley catheter." The quality of the included trials was assessed using the Cochrane Risk of Bias Tool for randomized controlled trials. The primary outcome was cesarean delivery. Secondary outcomes included outcomes related to labor duration and neonatal outcomes. Pooled relative risks (RR) and weighted mean differences (WMD) with 95% confidence intervals were calculated.
RESULTS
Five trials involving 849 participants undergoing induction and cervical ripening by Foley balloon were included. The rate of cesarean delivery did not differ between individuals randomly assigned to the early amniotomy group compared with those assigned to the delayed amniotomy group (22.9% vs 23.3%; RR 1.00; 95%CI, 0.65-1.55). Early amniotomy compared to delayed amniotomy was associated with a higher proportion of delivery within 24 hours (79.9% vs. 67.1%; RR 1.19; 95%CI 1.04-1.36). Early amniotomy compared with delayed amniotomy was associated with a shorter interval from oxytocin to delivery (WMD -1.5 hours; 95%CI -2.1- -0.8), from Foley expulsion to vaginal delivery (WMD -2.5 hours; 95%CI -4.8- -0.1), and from the start of oxytocin to vaginal delivery (WMD -1.8 hours; 95%CI -3.2- -0.4). Other outcomes were not significantly different.
CONCLUSION
Early amniotomy following cervical ripening by Foley balloon in individuals with singleton pregnancies did not impact rates of cesarean delivery compared with delayed amniotomy but led to shorter duration for various labor progress outcomes.
PubMed: 38897352
DOI: 10.1016/j.ajogmf.2024.101408 -
Cureus May 2024An ectopic ureter is a condition characterized by a ureter, whether single or duplex, that fails to open in the trigone area of the urinary bladder but instead drains...
An ectopic ureter is a condition characterized by a ureter, whether single or duplex, that fails to open in the trigone area of the urinary bladder but instead drains outside of it. This anomaly arises congenitally due to abnormal migration of the ureteric bud during its insertion into the urinary bladder. Here, we present a case involving an ectopic ureter draining into the vagina, with continuous urinary incontinence. We discuss the diagnosis, evaluation, and management of urinary incontinence in a female because of an ectopic ureter. A 9-year-old girl child presented with a continuous urinary leak or incontinence requiring the use of one to two pads per day that progressively became wetter throughout the day. Physical examination revealed a normal urethral meatus and vagina without obvious visible dribbling of urine at the introitus. CT urography showed significant dilation of the right ureter, causing hydroureter and ectopic insertion of the tortuous right ureter near the external urethral orifice at the vaginal vestibule, along with an atrophic right kidney. A DTPA (diethylenetriamine pentaacetate) scan indicated the nonfunctional status of the right kidney. The patient underwent a right nephroureterectomy, leading to a complete resolution of urinary incontinence. Ectopic ureter causing nonfunctional kidney and urinary leak or incontinence is rare. This case emphasizes the importance of a comprehensive diagnostic workup for achieving a better prognosis and initiating early treatment of ectopic ureter.
PubMed: 38854205
DOI: 10.7759/cureus.60052 -
Annals of Medicine and Surgery (2012) Jun 2024Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a congenital anomaly characterized by the absence of the uterus and the upper two-thirds of the vagina. It is a rare...
INTRODUCTION
Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a congenital anomaly characterized by the absence of the uterus and the upper two-thirds of the vagina. It is a rare congenital anomaly with an incidence of 1 in 5000 female live births.
CASE SERIES
The authors describe three cases of females presenting with primary amenorrhoea who were diagnosed with MRKH syndrome. The patients were managed with McIndoe's vaginoplasty with neovagina creation with an amnion graft.
DISCUSSION
Management of MRKH syndrome involves vaginoplasty with neovagina creation. The approach to neovagina creation can be done surgically or non-surgically. Non-surgical creation of the vaginal cavity involves serial use of vaginal dilators, while there are several ways for surgical creation of neovagina. The modified Abbe-McIndoe procedure using amnion to create neovagina is a minimally invasive, rapid, and simple procedure with no risk of immune rejection because the amnion membrane lacks histocompatibility antigens. In addition, the graft is also readily available, storable, and inexpensive.
CONCLUSION
Diagnosis of MRKH syndrome can be made when a young female with primary amenorrhoea and normal secondary sexual characteristics has agenesis of the uterus, and upper two-thirds of the vagina revealed on ultrasonography or magnetic resonance imaging. The patient can be offered treatment with vaginoplasty with neovagina creation.
PubMed: 38846829
DOI: 10.1097/MS9.0000000000001877 -
European Journal of Obstetrics,... Jun 2024Malposition of the fetal head, defined as occiput transverse or posterior positions, occurs in approximately 5% of births. At full cervical dilatation, fetal malposition...
INTRODUCTION
Malposition of the fetal head, defined as occiput transverse or posterior positions, occurs in approximately 5% of births. At full cervical dilatation, fetal malposition is associated with an increased risk of rotational vaginal birth. There are three different rotational methods: manual rotation, rotational ventouse or rotational (Kielland's) forceps. In the absence of robust evidence, it is not currently known which of the three methods is most efficacious, and safest for parents and babies.
OBJECTIVE
To gain greater insights into opinions and preferences of rotational birth to explore the acceptability and feasibility of performing a randomised trial comparing different rotational methods.
MATERIAL AND METHODS
A survey was sent via email to obstetricians from the British Maternal Fetal Medicine Society, as well as expert obstetricians and active academics in ongoing research in the UK. The questions focussed on perceived competence, preferred rotational method, location (theatre or labour room), willingness to recruit to an RCT, and its outcome measures. Closed questions were followed by the option of free text to allow further comments. The free text answers underwent thematic analysis.
RESULTS
252 consultant obstetricians responded. The majority stated they were competent in performing manual rotation (88.1%). Half felt proficient using Kielland's rotational forceps (54.4%). Most obstetricians felt skilled in rotational ventouse (76.2%). Manual rotation was the preferred first rotational method of choice in cases of both occiput transverse and posterior positions. The decision for which rotational method to attempt first was considered case-dependent by many. Two thirds of obstetricians would usually conduct rotational births in theatre (67.9%). Over half (52%) do not routinely use intrapartum ultrasound. Most (62.7%) would be willing to recruit to a randomised controlled trial comparing manual versus instrumental rotation. Over half (57.2%) would be willing to recruit to the same RCT if they were the most senior doctor competent in rotational vaginal birth supervising a junior.
CONCLUSION
There is a wide range of practice in conducting rotational vaginal births in the UK. An RCT to investigate the impact of different rotational methods on outcome would be both feasible and desirable, especially in research-active hospitals.
PubMed: 38843726
DOI: 10.1016/j.ejogrb.2024.05.045