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Ugeskrift For Laeger Jun 2024Shoulder dystocia is a serious obstetric complication, where one or both shoulders of a child are trapped after the head is born during vaginal delivery. The situation...
Shoulder dystocia is a serious obstetric complication, where one or both shoulders of a child are trapped after the head is born during vaginal delivery. The situation is life-threatening for the child and requires quick management with obstetric manoeuveres for delivering the shoulders. Rarely, the abdominal approach called Zavanelli manoeuvre is used to achieve delivery after a replacement of the head back in the birth canal, prior to acute caesarean section. This is a case report of a 26-year-old woman with severe shoulder dystocia, failed Zavanelli manoeuvre and vaginal delivery of a lifeless child.
Topics: Humans; Female; Pregnancy; Adult; Stillbirth; Delivery, Obstetric; Shoulder Dystocia; Infant, Newborn
PubMed: 38904285
DOI: 10.61409/V02240095 -
Best Practice & Research. Clinical... Jun 2024Labour care must balance aspirations of parents with vigilance for unanticipated calamities. The 'on-site midwife-led primary care birth unit' facilitates this. The... (Review)
Review
Labour care must balance aspirations of parents with vigilance for unanticipated calamities. The 'on-site midwife-led primary care birth unit' facilitates this. The World Health Organization have replaced the traditional partograph with the 'Labour Care Guide'. An implementation project in Botswana included the mnemonic COPE: Companion, Oral fluids, Pain relief and Eliminate the supine position. The Parto-Ma project in Tanzania used guidelines, training and support to improve childbirth outcomes. We list labour practices supported by recent evidence, and highlight new developments. Foetal macrosomia increases risk but mistaken diagnosis increases caesarean births. Obstructed labour is a complex clinical diagnosis, and is difficult to predict. For shoulder dystocia prioritise delivery of the posterior shoulder, facilitated if needed by posterior axilla sling traction. 'Extended balloon labour induction' with two or three Foley catheters side by side, may reduce risks associated with uterine stimulants. Bedside ultrasound may facilitate the diagnosis of cephalic malpositions and malpresentations.
PubMed: 38902106
DOI: 10.1016/j.bpobgyn.2024.102517 -
The Journal of Maternal-fetal &... Dec 2024The purpose of this study was to determine the factors that influence physician preference for type of hysterotomy incisions in gravidas with a singleton or twin...
OBJECTIVE
The purpose of this study was to determine the factors that influence physician preference for type of hysterotomy incisions in gravidas with a singleton or twin pregnancy undergoing cesarean section under 28 weeks, and to assess factors that result in delivery complications, defined as either intraoperative dystocia or hysterotomy extension. We hypothesized that compared to those with non-cephalic presentations, gravidas with a presenting fetus in cephalic presentation would have higher rates of low-transverse cesarean section, and reduced rates of delivery complications with low-transverse hysterotomy.
METHODS
This was a retrospective cohort chart analysis of 128 gravidas between 23 0/7 and 27 6/7 weeks undergoing cesarean section at a single academic institution between August 2010 and December 2022. Data was abstracted for factors that might influence the decision for hysterotomy incision type, as well as for documentation of difficulty with delivery of the fetus or need for hysterotomy extension to affect delivery.
RESULTS
There was a total of 128 subjects, 113 with a singleton gestation and 15 with twins. The presenting fetus was in cephalic presentation in 43 (33.6%), breech presentation in 71 (55.5%), transverse/oblique lie in 13 (10.2%), and not documented in 1 (0.8%). Sixty-eight (53.1%) had a low-transverse cesarean section (LTCS), 53 (41.4%) had a Classical, 5 (3.9%) had a low-vertical hysterotomy and 2 (1.6%) had a mid-transverse incision. There was a significantly higher rate of LTCS among gravidas with the presenting fetus in cephalic presentation (30/43, 69.8%) compared to those with breech (31/71, 43.7%) or transverse/oblique presentations (7/13, 53.8%), = .03. No other significant associations were related to hysterotomy incision, including nulliparity, racially or ethnically minoritized status, plurality, indication for cesarean delivery, or pre-cesarean labor. Twenty (15.6%) subjects experienced either an intraoperative dystocia or hysterotomy extension. For the entire cohort, there was a greater median cervical dilatation in those with delivery complications (4.0 cm, IQR .5 - 10 cm) compared to those without complications (1.5, IQR 0 - 4.0), = .03, but no significant association between delivery complications and fetal presentation, hysterotomy type, plurality, or other demographic/obstetrical factors. However, among gravidas undergoing low-transverse cesarean section, only 2/30 (6.7%) with cephalic presentations had a delivery complication, compared to 9/31 (29.0%) with breech presentations and 3/7 (42.9%) with a transverse/oblique lie, = .03.
CONCLUSION
In pregnancies under 28 weeks, the performance of a low-transverse cesarean section was significantly associated only with presentation of the presenting fetus. Among those with cephalic presentations, the rate of intrapartum dystocia or hysterotomy extension was low after a low-transverse hysterotomy, suggesting that in this subgroup, a low-transverse cesarean section should be considered.
Topics: Humans; Female; Pregnancy; Cesarean Section; Retrospective Studies; Hysterotomy; Adult; Pregnancy, Twin; Gestational Age; Breech Presentation; Labor Presentation
PubMed: 38887786
DOI: 10.1080/14767058.2024.2358385 -
Cureus May 2024We report a case of uterine prolapse in pregnancy, which was successfully managed before delivery. A 35-year-old woman (G2P1) complained consistently of a protruding...
We report a case of uterine prolapse in pregnancy, which was successfully managed before delivery. A 35-year-old woman (G2P1) complained consistently of a protruding uterus at 36 weeks gestation, and an engorged uterine cervix without tenderness, urinary disturbance, and incontinence were recognized (Pelvic Organ Prolapse Quantification (POP-Q) score C: +7). Manual retraction of the edematous cervix was gently performed with gauze packing, and strikingly improved edema of the cervix with a POP-Q score of C: -2 was observed one day after the gauze packing. Induction of labor was planned due to a suspected large-for-gestational-age infant, and the patient uneventfully delivered at 39 weeks gestation without any obstacles to delivery and cervical laceration. Cervical edema in pregnancy increases the risk of cervical dystocia and cervical lacerations. However, lacerations with edema are predicted to have a poor wound-healing process. The technique with gauze packing presented in this case may be useful in the protective handling of the uterine cervix during pregnancy.
PubMed: 38883038
DOI: 10.7759/cureus.60456 -
American Journal of Obstetrics &... Jun 2024It is clinically challenging to determine when to intervene in the prolonged second stage. Although individualized prediction of spontaneous vaginal delivery is crucial...
BACKGROUND
It is clinically challenging to determine when to intervene in the prolonged second stage. Although individualized prediction of spontaneous vaginal delivery is crucial to avoid maternal and neonatal complications associated with operative deliveries, the approach has not been fully established.
OBJECTIVES
We aimed to evaluate the predictability of spontaneous vaginal delivery using the difference in angle of progression between pushing and rest, delta angle of progression, to establish a novel method to predict spontaneous vaginal delivery during the prolonged second stage in nulliparous women with epidural anesthesia.
STUDY DESIGN
We retrospectively analyzed deliveries of nulliparous women with epidural anesthesia between September 2018 and October 2023. Women were included if their delta angle of progression during the second stage was available. Operative deliveries were defined as the cases that required forceps, vacuum, and cesarean deliveries due to labor arrest. Women requiring operative deliveries due to fetal and maternal concerns, or women with fetal occiput posterior presentation were excluded. The second stage was stratified into the prolonged second stage, the period after three hours in the second stage, and the normal second stage, the period from the beginning until the third hour of the second stage. The association of the delta angle of the progression measured during each stage with spontaneous vaginal delivery and operative deliveries was investigated. Furthermore, the predictability of spontaneous vaginal delivery was evaluated by combining the delta and rest angle of progression.
RESULTS
A total of 129 women were eligible for analysis. The delta angle of progression measured during the prolonged second stage and normal second stage were significantly larger in women who achieved spontaneous vaginal delivery compared to operative deliveries (p<0.001 and p<0.05, respectively). During the prolonged second stage, a cutoff of 18.8 derived from the receiver operative characteristic curves in the context of the delta angle of progression predicted the possibility of spontaneous vaginal delivery (sensitivity, 81.8%; specificity, 60.0%; AUC, 0.76). Combining the rest angle of progression (>140) and delta angle of progression (>18.8) also provided quantitative prediction of spontaneous vaginal delivery (sensitivity, 86.7%; specificity, 70.0%; AUC, 0.80).
CONCLUSION
The delta angle of progression alone or in combination with the rest angle of progression can be used to predict spontaneous vaginal delivery in the second stage in nulliparous women with epidural anesthesia. Quantitative analysis of the effect of pushing using the delta angle of progression provides an objective guide to assist with an assessment of labor dystocia in the prolonged second stage on an individualized basis, which may optimize labor management in the prolonged second stage by reducing neonatal and maternal complications related to unnecessary operative deliveries and prolonged second stage of labor.
PubMed: 38880239
DOI: 10.1016/j.ajogmf.2024.101403 -
Birth (Berkeley, Calif.) Jun 2024To evaluate the association of labor induction on cesarean delivery and other maternal and neonatal outcomes in low-risk, full-term patients in community hospitals...
OBJECTIVE
To evaluate the association of labor induction on cesarean delivery and other maternal and neonatal outcomes in low-risk, full-term patients in community hospitals during a period of concerted effort to safely prevent cesarean delivery.
METHODS
We performed a retrospective cohort study using the California Maternal Data Center comprised linked discharge diagnoses and birth certificate data for all low-risk, nulliparous, term, singleton, vertex (NTSV) individuals between 39 and 41 weeks from three Sacramento Valley community hospitals from 2016 to 2022 (N = 10,821) during a period of state-wide efforts to safely reduce cesarean rates. Logistic regression was used to calculate odds ratios (ORs) and adjusted odds ratios (aORs) after labor induction in two time periods before and after the ARRIVE trial.
RESULTS
During the study period, labor induction increased from 14.7% to 23.1%. Controlling for maternal age, pre-pregnancy BMI, birthweight, maternal race and ethnicity, birthplace, English language, gestational age, Medicaid status, delivery year, and labor induction was associated with an increased aOR of 1.67 (95% CI 1.48-1.89) for cesarean delivery. We found a trend toward increased aOR of chorioamnionitis but no differences in blood transfusion, severe maternal morbidity, unexpected newborn complications, chorioamnionitis, operative vaginal delivery, maternal lacerations, and shoulder dystocia with labor induction. A decrease aOR of cesarean delivery was observed comparing all births in 2019-2021 to 2016-2018.
CONCLUSION
Labor induction was associated with an increased aOR for cesarean delivery both before and after the ARRIVE trial. A decreased aOR for cesarean delivery was observed during the period of statewide efforts to safely reduce cesarean delivery both with and without labor induction.
PubMed: 38877812
DOI: 10.1111/birt.12845 -
BMC Pregnancy and Childbirth Jun 2024Peripartum asphyxia is one of the main causes of neonatal morbidity and mortality. In moderate and severe cases of asphyxia, a condition called hypoxic-ischemic...
BACKGROUND
Peripartum asphyxia is one of the main causes of neonatal morbidity and mortality. In moderate and severe cases of asphyxia, a condition called hypoxic-ischemic encephalopathy (HIE) and associated permanent neurological morbidities may follow. Due to the multifactorial etiology of asphyxia, it may be difficult prevent, but in term neonates, therapeutic cooling can be used to prevent or reduce permanent brain damage. The aim of this study was to assess the significance of different antenatal and delivery related risk factors for moderate and severe HIE and the need for therapeutic hypothermia.
METHODS
We conducted a retrospective matched case-control study in Helsinki University area hospitals during 2013-2017. Newborn singletons with moderate or severe HIE and the need for therapeutic hypothermia were included. They were identified from the hospital database using ICD-codes P91.00, P91.01 and P91.02. For every newborn with the need for therapeutic hypothermia the consecutive term singleton newborn matched by gender, fetal presentation, delivery hospital, and the mode of delivery was selected as a control. Odds ratios (OR) between obstetric and delivery risk factors and the development of HIE were calculated.
RESULTS
Eighty-eight cases with matched controls met the inclusion criteria during the study period. Maternal and infant characteristics among cases and controls were similar, but smoking was more common among cases (aOR 1.46, CI 1.14-1.64, p = 0.003). The incidence of preeclampsia, diabetes and intrauterine growth restriction in groups was equal. Induction of labour (aOR 3.08, CI 1.18-8.05, p = 0.02) and obstetric emergencies (aOR 3.51, CI 1.28-9.60, p = 0.015) were more common in the case group. No difference was detected in the duration of the second stage of labour or the delivery analgesia.
CONCLUSIONS
Smoking, induction of labour and any obstetric emergency, especially shoulder dystocia, increase the risk for HIE and need for therapeutic hypothermia. The decisions upon induction of labour need to be carefully weighed, since maternal smoking and obstetric emergencies can hardly be controlled by the clinician.
Topics: Humans; Hypoxia-Ischemia, Brain; Female; Infant, Newborn; Hypothermia, Induced; Case-Control Studies; Risk Factors; Pregnancy; Retrospective Studies; Male; Adult; Asphyxia Neonatorum; Finland; Delivery, Obstetric
PubMed: 38867160
DOI: 10.1186/s12884-024-06596-8 -
Journal of Family & Reproductive Health Mar 2024Precise assessment of cervical conditions before labor induction is crucial for predicting the success of normal vaginal delivery. The cervix primary condition has a...
OBJECTIVE
Precise assessment of cervical conditions before labor induction is crucial for predicting the success of normal vaginal delivery. The cervix primary condition has a significant value in determining the succession of induction of labour. Traditionally, assessment of cervix before induction has been based on a cervix digital examination using Bishop's scoring method.This study compares transvaginal ultrasonographic (TVS) cervical assessment with the traditional Bishop score in nulliparous women undergoing labor induction, aiming to evaluate their predictive abilities for labor dystocia.
MATERIALS AND METHODS
In a prospective observational study of 200 pregnant women at Al Hussein University Hospital between October 2022 and July 2023, cervical length, funneling, and posterior cervical angle were measured using transvaginal ultrasound. The Bishop score was recorded before induction. Statistical analyses, including Student's "t"-test and ROC curve, were conducted using SPSS.
RESULTS
68% delivered via normal vaginal delivery (NVD) and 32% via cesarean section (CS). The NVD group exhibited significantly higher Bishop scores (6.82±1.36 vs 3.70±0.94), lower cervical length (25.46±3.99 vs 37.34±2.09), and higher cervical angle (121.39±5.70 vs 89.01±6.09), than the CS group. ROC curve analysis revealed that a Bishop score ≥4.5 had 89% sensitivity and 87.5% specificity, a cervical angle ≥ 92.5 had 98.5% sensitivity and 95.3% specificity, and a cervical length ≥31.5 had 96.9% sensitivity and 97.1% specificity for predicting NVD.
CONCLUSION
The posterior cervical angle, alongside cervical length, proves to be a more sensitive indicator for predicting labor dystocia during induction compared to the traditional Bishop score.
PubMed: 38863845
DOI: 10.18502/jfrh.v18i1.15439 -
Frontiers in Physiology 2024Parturition in dogs is subjected to complex hormonal regulation, with the involvement of prostaglandin F2α (PGF2α) still not fully understood. To investigate uterine...
Parturition in dogs is subjected to complex hormonal regulation, with the involvement of prostaglandin F2α (PGF2α) still not fully understood. To investigate uterine inertia (UI), the most prevalent maternal reason for dystocia in the bitch, a better understanding of undisturbed uterine, especially myometrial function, is crucial. Our aim was to gain deeper insights into the role of PGF2α in the canine parturient myometrium. Uterine biopsies were obtained during medically indicated cesarean sections. To test for stimulatory effects of PGF2α , circular and longitudinal myometrial layer tissue strips were challenged with 50 pM, 0.5 µM, and 50 µM PGF2α. 2 () and () mRNA expressions were compared between primary UI (PUI) and obstructive dystocia (OD) samples in isolated parturient myometrium. PTGFR protein expression was assessed in full thickness uterine samples. PGF2α concentrations were analyzed in canine interplacental tissue around term. In the organ bath, the contractile response to PGF2α was limited to the circular layer at the highest dosage. Correspondingly, PTGFR immunohistochemical staining was significantly stronger in the circular layer ( ≤ 0.01). gene expression did not differ between PUI and OD, whereas gene expression could not be quantified. Local uterine PGF2α concentrations correlated negatively with serum P4 levels and were the highest during prepartum luteolysis while being significantly lower in PUI. Conclusively, despite the significant increase in local PGF2α concentrations at birth, confirming the interplacental tissue as a production site, our results suggest that PGF2α might affect uterine contractility during labor, mainly indirectly.
PubMed: 38863475
DOI: 10.3389/fphys.2024.1392080 -
Biology of Reproduction Jun 2024Over 35% of reproductive-age women in the US are obese, putting them at increased risk for numerous obstetric complications due to abnormal labor. While the association...
Over 35% of reproductive-age women in the US are obese, putting them at increased risk for numerous obstetric complications due to abnormal labor. While the association between maternal obesity and abnormal labor has been well documented, the mechanisms responsible for this remain understudied. The uterine smooth muscle, myometrium, has high energy needs in order to fuel regular uterine contractions during parturition. However, the precise mechanisms by which the myometrium meets its energy demands has not been defined. Here, our objective was to define the effects of obesity on energy utilization in the myometrium during labor. We generated a mouse model of maternal diet-induced obesity (DIO) and found that these mice had a higher rate of dystocia than control chow-fed (CON) mice. Moreover, compared to CON mice, DIO mice at term, both before and during labor had lower in vivo spontaneous uterine contractility. Untargeted transcriptomic and metabolomic analyses suggest that DIO is associated with elevated long-chain fatty acid uptake and utilization in the uterus, but also an accumulation of medium-chain fatty acids. DIO uteri also had an increase in the abundance of long chain-specific β-oxidation enzymes, which may be responsible for the observed increase in long-chain fatty acid utilization. This altered energy substrate utilization may be a contributor to the observed contractile dysfunction.
PubMed: 38857377
DOI: 10.1093/biolre/ioae086