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BMJ Simulation & Technology Enhanced... 2021Umbilical cord prolapse is a rare obstetric emergency requiring rapid coordination of a multidisciplinary team to effect urgent delivery. The decision to delivery...
BACKGROUND
Umbilical cord prolapse is a rare obstetric emergency requiring rapid coordination of a multidisciplinary team to effect urgent delivery. The decision to delivery interval (DDI) is a marker of quality of teamwork. Multidisciplinary team simulation-based training can be used to improve clinical and teamwork performance.
AIM
To assess the DDI for cord prolapse before and after the introduction of simulation-based training at a quaternary maternity unit in Australia.
METHOD
A retrospective, observational cohort study comparing the DDI before and after the introduction of simulation-based training activities. The general linear model was used to estimate the association between DDI and simulation training while adjusting for potential confounders including model of care (public or private) and time of birth (regular or after hours).
RESULTS
After the introduction of simulation training, mean DDI decreased by 4.1 min (difference -4.1, 95% CI -6.2 to -1.9), after adjustment for confounding factors. Despite this, there was no difference in selected neonatal outcomes including Apgar score at 5 min and arterial cord pH.
CONCLUSIONS
The introduction of simulation-based training was associated with a decrease in the DDI in the setting of cord prolapse.
PubMed: 35520957
DOI: 10.1136/bmjstel-2021-000860 -
Anesthesia, Essays and Researches 2021Regional anesthesia (RA), i.e., spinal or epidural anesthesia when performed for lower segment cesarean section (LSCS) provides excellent surgical conditions, avoiding...
INTRODUCTION
Regional anesthesia (RA), i.e., spinal or epidural anesthesia when performed for lower segment cesarean section (LSCS) provides excellent surgical conditions, avoiding manipulation of the maternal airway, maternal satisfaction, and good postoperative analgesia. However, in situations like fetal distress (fetal heart rate abnormalities), obstetric indications (abruption of placenta, antenatal placental bleeding, cord prolapse), maternal refusal for RA, contraindications to neuraxial anesthesia (anticoagulation, coagulopathy), and at times failed RA general anesthesia (GA) is administered. Several studies have demonstrated greater mortality and morbidity when LSCS is done under GA when compared to neuraxial block.
METHODS
After necessary approval, we retrospectively reviewed data over a period of 1 year (January 1, 2020-December 31, 2020) of LSCS under GA versus RA. The aim was to compare immediate postoperative complications, postoperative pulmonary complications up to 4 weeks from the time of elective and emergency LSCS under either RA or GA.
RESULTS
Of the 753 patients who underwent LSCS in one calendar year, there were 272 (36.12%) elective and 481 (63.87%) emergency LSCS. The number of elective LSCS under neuraxial block was 219 (29.09%) and under GA were 53 (7.03%). Emergency LSCS done under neuraxial block were 268 (35.59%) and under GA were 213 (28.28%). There were no adverse pulmonary complications at the end of 4 weeks in either group.
CONCLUSION
RA provides maternal satisfaction and excellent perioperative analgesia in LSCS. Safe GA can be achieved with proper airway planning, if case is attended by at least two anesthesiologist with adequate preoperative fasting, and postoperative monitoring.
PubMed: 35422556
DOI: 10.4103/aer.aer_6_22 -
BJOG : An International Journal of... Apr 2022To construct algorithms with a sequential decision analysis pathway for monitoring of the fetal heart rate and managing fetal heart rate bradycardia, late decelerations...
OBJECTIVE
To construct algorithms with a sequential decision analysis pathway for monitoring of the fetal heart rate and managing fetal heart rate bradycardia, late decelerations and tachycardia during labour.
POPULATION
Low-risk pregnant women in labour with singleton cephalic term pregnancies.
SETTING
Institutional births in low- and middle-income countries.
SEARCH STRATEGY
We sought relevant published clinical algorithms, guidelines and randomised trials/reviews by searching the Cochrane Library, PubMed and Google on the terms: "fetal AND heart AND rate AND algorithm AND (labour OR intrapartum)", up to March 2020.
CASE SCENARIOS
The two scenarios included were fetal heart rate bradycardia or late decelerations (potentially related to uterine rupture, placental abruption, cord prolapse, maternal hypotension, uterine hyperstimulation or unexplained) and fetal heart rate tachycardia (potentially related to maternal hyperthermia, infection, dehydration or unexplained). The algorithms provide pathways for definition, assessment, diagnosis, interventions to correct the abnormalities and ongoing monitoring leading to mode of birth, and linking to other algorithms in the series.
CONCLUSIONS
The algorithms provide a framework for monitoring and managing fetal heart rate bradycardia, late decelerations and tachycardia during labour. We emphasise the inherent diagnostic inaccuracy of fetal heart rate monitoring, the tendency to over-diagnose fetal compromise, the need to consider fetal heart rate information in the context of other clinical features and the need to engage in informed, shared, family-centred decision-making. We note the need for further research on methods of fetal assessment during labour including clinical fetal arousal testing and the rapid biophysical profile test.
TWEETABLE ABSTRACT
Decision analysis algorithms for fetal bradycardia, late decelerations and tachycardia highlight diagnostic limitations.
PubMed: 35415966
DOI: 10.1111/1471-0528.16731 -
Geburtshilfe Und Frauenheilkunde Apr 2022According to current guidelines, inpatient management until birth is considered standard in pregnant women with preterm premature rupture of membranes (PPROM). With the...
According to current guidelines, inpatient management until birth is considered standard in pregnant women with preterm premature rupture of membranes (PPROM). With the increasing burden on obstetric departments and the growing importance of satisfaction and right to self-determination in pregnant women, outpatient management in PPROM is a possible alternative to inpatient monitoring. The most important criterion for this approach is to ensure the safety of both the mother and the child. Due to the small number of cases (n = 116), two randomised controlled trials (RCTs) comparing inpatient and outpatient management were unable to draw any conclusions. By 2020, eight retrospective comparative studies (cohort/observational studies) yielded the following outcomes: no significant differences in the rate of maternal complications (e.g., chorioamnionitis, premature placental abruption, umbilical cord prolapse) and in neonatal morbidity, significantly prolonged latency period with higher gestational age at birth, higher birth weight of neonates, and significantly shorter length of stay of preterm infants in neonatal intensive care, shorter hospital stay of pregnant women, and lower treatment costs with outpatient management. Concerns regarding this approach are mainly related to unpredictable complications with the need for rapid obstetric interventions, which cannot be performed in time in an outpatient setting. Prerequisites for outpatient management are the compliance of the expectant mother, the adherence to strict selection criteria and the assurance of adequate monitoring at home. Future research should aim at more accurate risk assessment of obstetric complications through studies with higher case numbers and standardisation of outpatient management under evidence-based criteria.
PubMed: 35392068
DOI: 10.1055/a-1515-2801 -
Taiwanese Journal of Obstetrics &... Mar 2022To elucidate the impact of the intended delivery mode on long-term outcomes among extremely preterm infants.
OBJECTIVE
To elucidate the impact of the intended delivery mode on long-term outcomes among extremely preterm infants.
MATERIALS AND METHODS
Women who delivered singletons between 23 0/7 and 25 6/7 weeks of gestation from January 2010 to March 2014 and their infants were included in this study. The cases of fetal growth restriction and those with a chromosomal or major structural abnormality were excluded. The cases of fetal death that was diagnosed before labor onset and cases of non-reassuring fetal status, placental abruptions or umbilical cord prolapse that was diagnosed at labor onset were also excluded. The primary outcome was the incidence of composite adverse events, including death, cerebral palsy, or neurodevelopmental delay, at the age of three years. The composite adverse events, including death, grade III or IV intraventricular hemorrhage, cystic periventricular leukomalacia, necrotizing enterocolitis, focal intestinal perforation, and sepsis of neonatal period, were assessed as short-term outcomes. The association between the intended delivery mode and primary outcome, short-term outcome, and each component was analyzed using a multivariate logistic regression model.
RESULTS
Eighty cases were included in the analyses. Primary outcomes could be assessed in 72 cases. Infantile composite adverse events before discharge were observed in 19 cases (24%). The prevalence of primary outcomes was 40% (29 cases). The intended delivery mode was not associated with primary and short-term outcomes and each component complication.
CONCLUSION
An advantage of intended cesarean delivery in terms of prognosis at three years of age in extremely preterm infants was not observed.
Topics: Cesarean Section; Child, Preschool; Female; Humans; Infant; Infant, Extremely Premature; Infant, Newborn; Placenta; Pregnancy; Pregnancy Outcome; Retrospective Studies
PubMed: 35361393
DOI: 10.1016/j.tjog.2022.02.020 -
Journal of Ultrasound in Medicine :... Nov 2022To compare maternal and perinatal outcomes in pregnancies with transient and persistent idiopathic polyhydramnios to those with normal amniotic fluid volume.
OBJECTIVES
To compare maternal and perinatal outcomes in pregnancies with transient and persistent idiopathic polyhydramnios to those with normal amniotic fluid volume.
METHODS
This retrospective cohort study included subjects delivering a singleton pregnancy between January 1, 2015, and June 30, 2020, with sonography ≥26 weeks' gestation demonstrating transient or persistent idiopathic polyhydramnios (amniotic fluid index [AFI] ≥24.0 cm) or normal AFI (referent group). The primary maternal outcome was a composite of spontaneous preterm delivery <37 weeks, cesarean delivery for malpresentation, abnormal labor progress, or nonreassuring fetal status, operative vaginal delivery, hemorrhage requiring transfusion, and umbilical cord prolapse. The primary perinatal outcome was a composite of birthweight >4500 g, fetal or neonatal death, 5-minute Apgar score <7, and neonatal intensive care unit admission for >24 hours.
RESULTS
Patients with transient polyhydramnios (n = 259) exhibited maternal outcomes similar to those of the referent group (n = 435) but had significantly increased odds for the primary perinatal outcome (odds ratio [OR] 1.70, 95% confidence interval [CI] 1.15-2.53; P = .008) and for birthweight ≥4500 g (OR 8.70, 95% CI 1.89-40.0; P = .005). Persistent polyhydramnios (n = 176) was significantly associated with both the primary maternal (OR 1.93, 95% CI 1.27-2.95, P = .002) and primary perinatal outcome (OR 2.15, 95% CI 1.40-3.30; P < .001), and individually with cesarean delivery for abnormal labor (OR 3.22, 95% CI 1.55-6.68; P = .002) and birthweight ≥4500 g (OR 8.97, 95% CI 1.84-43.6; P = .007).
CONCLUSIONS
Transient idiopathic polyhydramnios does not impact maternal outcomes but is associated with increased odds of newborn birthweight >4500 g. Persistent polyhydramnios is associated with both adverse maternal and perinatal outcomes.
Topics: Pregnancy; Infant, Newborn; Female; Humans; Polyhydramnios; Birth Weight; Pregnancy Outcome; Retrospective Studies; Amniotic Fluid
PubMed: 35312096
DOI: 10.1002/jum.15974 -
BMC Pregnancy and Childbirth Mar 2022The aim of the present study was to clarify fetal heart rate (FHR) evolution patterns in infants with cerebral palsy (CP) according to different types of umbilical cord...
BACKGROUND
The aim of the present study was to clarify fetal heart rate (FHR) evolution patterns in infants with cerebral palsy (CP) according to different types of umbilical cord complications.
METHODS
This case-control study included children born: with a birth weight ≥2000 g, at gestational age ≥33 weeks, with disability due to CP, and between 2009 and 2014. Obstetric characteristics and FHR patterns were compared among patients with CP associated with (126 cases) and without (594 controls) umbilical cord complications.
RESULTS
There were 32 umbilical cord prolapse cases and 94 cases with coexistent antenatal umbilical cord complications. Compared with the control group, the persistent non-reassuring pattern was more frequent in cases with coexistent antenatal umbilical cord complications (p = 0.012). A reassuring FHR pattern was observed on admission, but resulted in prolonged deceleration, especially during the first stage of labor, and was significantly identified in 69% of cases with umbilical cord prolapse and 35% of cases with antenatal cord complications, compared to 17% of control cases (p < 0.001).
CONCLUSION
Hypercoiled cord and abnormal placental umbilical cord insertion, may be associated with CP due to acute hypoxic-ischemic injury as well as sub-acute or chronic adverse events during pregnancy, while umbilical cord prolapse may be characterized by acute hypoxic-ischemic injury during delivery.
Topics: Adult; Birth Injuries; Case-Control Studies; Cerebral Palsy; Female; Heart Rate, Fetal; Humans; Hypoxia-Ischemia, Brain; Infant, Newborn; Infant, Newborn, Diseases; Male; Obstetric Labor Complications; Pregnancy; Pregnancy Complications; Prolapse; Umbilical Cord
PubMed: 35241026
DOI: 10.1186/s12884-022-04508-2 -
Heliyon Feb 2022Birth asphyxia is a condition of impaired gas exchange in newborns when the Apgar score is < 7 in the first 5 min. It accounts 31.6% of all neonatal deaths, and the...
INTRODUCTION
Birth asphyxia is a condition of impaired gas exchange in newborns when the Apgar score is < 7 in the first 5 min. It accounts 31.6% of all neonatal deaths, and the leading causes of neonatal mortality in Ethiopia. Identifying its determinant factors is very important to prevent the problem.Therefore, this study was aimed at identifying the determinant factors of birth asphyxia among newborns at Benishangul Gumuz region hospital.
METHODS AND MATERIALS
The hospital-based unmatched case-control study was done from March 04 to July 16, 2019 in Benishangul Gumuz Region Hospitals. Total sample size is 275 with 69 cases and 206 controls. Newborns with an Apgar score of less than 7 at 5 min were taken as cases, and those with greater or equal to 7 were taken as controls. All asphyxiated newborns were enrolled as cases, where as in every three-step non-asphyxiated newborns were taken as controls. The data was entered into Epi Info 7 and exported to SPSS for analysis. Bivariable logistic regression analysis was used. Those variables with a p-value <0.05 were identified as significant determinants of birth asphyxia.
RESULTS
In the current study, anemia during pregnancy [AOR = 2.95, 95% CI: (1.02, 8.54)], no ANC visit at all [AOR = 4.26, 95% CI: (1.23,14.7)], prolapsed cord [AOR = 4.52, 95% CI: (1.3, 21)], and low birth weight [AOR = 4.1, 95% CI: (1.11, 15.36] were all determinant factors for birth asphyxia.
CONCLUSION
and Recommendations: The identified determinants of birth asphyxia were anemia during pregnancy, no ANC visit at all, prolapsed cord, cesarean birth, and low birth weight.Based on our study, most of identified determinant factors of birth asphyxia were preventable so, policy makers, clinicians, and other stakeholders need to invest their maximum effort on prevention of birth asphyxia.
PubMed: 35198758
DOI: 10.1016/j.heliyon.2022.e08875 -
BMC Pregnancy and Childbirth Feb 2022In twin pregnancies, the cord prolapse of either fetus during the pre-viable period leads to fetal death but can also cause an intrauterine infection, leading to...
BACKGROUND
In twin pregnancies, the cord prolapse of either fetus during the pre-viable period leads to fetal death but can also cause an intrauterine infection, leading to death or prematu-re birth of the remaining fetus. However, there are no validated protocols to prolong the gestational period or decrease the morbidity and mortality of the remaining fetus.
CASE PRESENTATION
The present cases were PPROM and cord prolapse very early during the second trimester (around 17 weeks in the first case and 19 weeks in the second case). The first fetus was evacuated, and cervical cerclage was performed at 23 and 20 weeks in the two cases, respectively. After maintaining the pregnancy, the second baby was born around 27 and 39 weeks in the first and second cases, respectively. The delivery interval between the first and second fetuses was 46 days in the first case and 126 days in the second case.
CONCLUSION
If cord prolapse is identified at a pre-viable time in twin fetuses, evacuation and cerclage should be performed as soon as possible after the cord prolapse to reduce intrauterine infection and increase the survival chances of the remaining fetus.
Topics: Adult; Cerclage, Cervical; Delivery, Obstetric; Female; Fetal Membranes, Premature Rupture; Humans; Live Birth; Pregnancy; Pregnancy Outcome; Pregnancy Trimester, Second; Pregnancy, Twin; Prolapse; Umbilical Cord
PubMed: 35144573
DOI: 10.1186/s12884-022-04438-z -
NMC Case Report Journal 2021Saccular limited dorsal myeloschisis (LDM) is characterized by a fibroneural stalk linking the saccular skin lesion to the underlying spinal cord. Since untethering...
Saccular limited dorsal myeloschisis (LDM) is characterized by a fibroneural stalk linking the saccular skin lesion to the underlying spinal cord. Since untethering surgery during the early postnatal period is often indicated to prevent sac rupture, saccular LDM should be distinguished from myelomeningocele (MMC) during the perinatal period. We treated two patients with the spinal cord deviation from the spinal canal to the sac, which mimicked a prolapse of the neural placode into the MMC sac. In patient 1, pre- and postnatal magnetic resonance imaging (MRI) revealed that the spinal cord was strongly tethered to the thick stalk. During surgery, the dorsally bent cord and stalk were united, and the border between these two was determined with intraoperative neurophysiological mapping (IONM). In patient 2, the spinal cord was tethered to two slender stalks close to each other, which was visible with the combined use of sagittal and axial postnatal three-dimensional heavily T2-weighted imaging (3D-hT2WI). The preoperative MRI hallmark of saccular LDM is the visualization of a stalk that links the bending cord and sac. Complete untethering surgery to return the cord into the spinal canal and correct its dorsal bending is recommended.
PubMed: 35079542
DOI: 10.2176/nmccrj.cr.2021-0168