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Background: Maternal height has been for long a contributory anthropometric factor that can determine the obstetric outcome. There is always a need of a consistent, reliable, and simple risk indicator which is easy to use for preventing unnecessary complications in a country like India where often antenatal care is provided by dais in rural areas. The background of this research aims to ascertain the relationship between maternal height and mode of delivery based on other intrapartum factors which influence labor and consequent maternal and neonatal outcome. Materials and Methods: All primigravidae at term gestation (>37 weeks) with cephalic presentation on admission to labor suite with no other comorbidities were recruited in the study. Their mode of delivery, maternal outcome, along with neonatal outcome was documented. Results: Out of the 680 patients, 104 patients are considered for the short-stature group (15.29%) who were <150 cm in height. Other group comprised patients who were >150 cm in height, a total of 576 (84.71%). There was a higher incidence of induced labor in the study group (66.35%) and emergency lower-segment cesarean section done due to cephalopelvic disproportion (CPD) (60%) was also higher among the short-stature group. The incidence of normal labor (32.99%) was higher in the tall-stature group. Conclusion: Short height (<150 cm) is an independent risk factor for cesarean delivery due to CPD. Statistical correlation was found between mothers of short stature and babies being born with low birth weight. As labor is influenced by multiple factors, it is fair enough to give a trial of labor for short primigravidae except in uncommon circumstances. [ABSTRACT FROM AUTHOR]

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The active phase of labor begins at various degrees of dilatation when the rate of dilatation transitions from the relatively flat slope of the latent phase to a more rapid slope. No diagnostic manifestations demarcate its onset, other than accelerating dilatation. It ends with apparent slowing of dilatation, a deceleration phase, which is usually short in duration and frequently undetected. Several aberrant labor patterns can be detected during the active phase, including protracted dilatation, arrest of dilatation, prolonged deceleration phase and failure of descent. Underlying factors may include cephalopelvic disproportion, excessive neuraxial block, poor uterine contractility, fetal malpositions, malpresentations, uterine infection, maternal obesity, advanced maternal age and previous cesarean delivery. When an active-phase disorder is identified, cesarean delivery is justifiable if there is compelling clinical evidence of disproportion. A prolonged deceleration disorder is strongly associated with disproportion and second stage abnormalities. Shoulder dystocia may occur if vaginal delivery eventuates. This review discusses several issues raised by the introduction of new clinical practice guidelines for labor management. [ABSTRACT FROM AUTHOR]

Without cesarean delivery, obstructed labor can result in maternal and fetal injuries or even death given a disproportion in size between the fetus and the maternal birth canal. The precise frequency of obstructed labor is difficult to estimate because of the widespread use of cesarean delivery for indications other than proven cephalopelvic disproportion, but it has been estimated that at least 1 million mothers per year are affected by this disorder worldwide. Why is the fit between the fetus and the maternal pelvis so tight? Why did evolution not lead to a greater safety margin, as in other primates? Here we review current research and suggest new hypotheses on the evolution of human childbirth and pelvic morphology. In 1960, Washburn suggested that this obstetrical dilemma arose because the human pelvis is an evolutionary compromise between two functions, bipedal gait and childbirth. However, recent biomechanical and kinematic studies indicate that pelvic width does not considerably affect the efficiency of bipedal gait and thus is unlikely to have constrained the evolution of a wider birth canal. Instead, bipedalism may have primarily constrained the flexibility of the pubic symphysis during pregnancy, which opens much wider in most mammals with large fetuses than in humans. We argue that the birth canal is mainly constrained by the trade-off between 2 pregnancy-related functions: while a narrow pelvis is disadvantageous for childbirth, it offers better support for the weight exerted by the viscera and the large human fetus during the long gestation period. We discuss the implications of this hypothesis for understanding pelvic floor dysfunction. Furthermore, we propose that selection for a narrow pelvis has also acted in males because of the role of pelvic floor musculature in erectile function. Finally, we review the cliff-edge model of obstetric selection to explain why evolution cannot completely eliminate cephalopelvic disproportion. This model also predicts that the regular application of life-saving cesarean delivery has evolutionarily increased rates of cephalopelvic disproportion already. We address how evolutionary models contribute to understanding and decision making in obstetrics and gynecology as well as in devising health care policies. [ABSTRACT FROM AUTHOR]

CEPHALOPELVIC DISPROPORTION IS AN IMBALANCE BETWEEN THE DIMENSIONS OF THE FETAL CRANIUM AND MATERNAL PELVIS THAT PREVENTS OPTIMAL DESCENT OF THE FETUS THROUGH THE PELVI-GENITAL CANAL. EVALUATING THE RISK OF CEPHALOPELVIC DISPROPORTION IS ESSENTIAL IN ORDER TO DECREASE BOTH MATERNAL AND FETAL MORBIDITY. WE EVALUATED 80 PATIENTS WHO DELIVERED IN THE DEPARTMENT OF OBSTETRICS AND GYNECOLOGY OF UNIVERSITY EMERGENCY HOSPITAL BUCHAREST. THE PATIENTS WERE DIVIDED INTO TWO GROUPS. IN GROUP A WE ENROLLED 40 PATIENTS THAT WERE DIAGNOSED WITH CEPHALOPELVIC DISPROPORTION AND THE FETUS WAS EXTRACTED BY CESAREAN SECTION. IN GROUP B WE INCLUDED 50 PATIENTS WITH RISK FACTORS FOR CEPHALOPELVIC DISPROPORTION WHO DELIVERED VAGINALLY. THE MATERNAL RISK FACTORS FOR CEPHALOPELVIC DISPROPORTION (AGE, HEIGHT, WEIGHT AND WEIGHT GAIN DURING PREGNANCY) WERE ANALYZED AND COMPARED BETWEEN THE TWO GROUPS WE DEVELOPED A SCORING SYSTEM THAT ALLOWS AN EARLY RISK ASSESSMENT OF CEPHALOPELVIC DISPROPORTION, FACILITATING DIAGNOSIS AND PROPER MANAGEMENT OF THESE PATIENTS. [ABSTRACT FROM AUTHOR]

Abstract: Small body size has been used in bioarchaeological contexts as an indicator of poor health and in clinical contexts as a risk factor for difficult childbirth, under the assumption that small size reflects compromised growth. Compromised growth in females may result in contracted pelvic dimensions and elevated risk of cephalopelvic disproportion. The basis for the use of clinical pelvic contracture thresholds for evaluating health and growth in skeletal populations is examined through comparisons of contracture frequencies and the relationships between pelvic canal size and body size in 11 skeletal samples (total n =195). The small-bodied samples show higher frequencies of contracted inlet and midplane posterior space dimensions. Canal breadth is correlated with femoral head diameter and bi-iliac breadth, but not femoral length. These results suggest that modern clinical standards do not take into account the variation in human body size and shape and the effect this variation may have on obstetric capacity without compromising obstetric function. It is problematic to use small pelvic dimensions, in the absence of evidence of death during childbirth, to infer compromised obstetric function resulting from biological stress, as is assuming that small size represents compromised skeletal growth. [Copyright &y& Elsevier]

Abstract: Background: Shoulder dystocia (ShD) and cephalopelvic disproportion (CPD) share some common risk factors. Whether infant male sex is an independent risk factor for ShD, or if the risk is confounded by other known factors, is uncertain. Objective: The aim of this study was to explore the unconfounded effect of infant male sex on the risk for ShD and its interaction with other risk factors compared with CPD. Methods: A retrospective data analysis was conducted of deliveries in Lamphun Hospital, Lamphun, Thailand. All vaginal deliveries complicated by ShD were collected as ShD cases. All labors terminated by cesarean delivery (CD) due to CPD were collected as CD/CPD cases. Vaginal deliveries that took place immediately before or after the index ShD cases were collected as controls. Multivariable adjusted odds ratios (AORs) for infant male sex and its 95% CI in cases of ShD and CD/CPD were computed by multichotomous logistic regression controlling for other obstetric risks. The effects of maternal height, gestational age, and birth weight on the risk for ShD or CD/CPD among male or female infants was also explored. Stability of the effect of the risk between male and female infants was tested with Chow tests. Results: Thirty-five ShD cases and 199 CD/CPD cases were collected, as were 586 controls. Infant male sex was a significant independent risk factor for ShD (AOR = 5.00; 95% CI, 1.83-13.61; P = 0.002), but not for CD/CPD (AOR = 1.09; 95% CI, 0.75-1.59; P = NS). For CD/CPD, the effects of maternal height, gestational age, and birth weight were similar for male and female infants, but the corresponding effect on ShD was more pronounced in male than in female infants (P < 0.001 for all comparisons). Conclusions: Infant male sex is a risk factor for ShD independent of other known risks. Male sex also amplified the existing effects of short maternal height, extended gestational age, and greater birth weight. If infant sex is known to be male before delivery, the obstetrician may consider avoiding vaginal delivery in mothers who have other strong risks for ShD. [Copyright &y& Elsevier]

Objective: The purpose of this study was to determine if intrapartum contractions of a particular shape (rapid rise with slower return to baseline) are predictive of cephalopelvic disproportion (CPD). Stuffy design: In an institutional review board (IRB)-approved study, cohorts of 100 women who underwent spontaneous vaginal delivery (SVD) and 100 who underwent cesarean section (C/S) for CPD or arrest of labor were consecutively identified between January 2004 and March 2005. Inclusion criteria included term, singleton pregnancies, nulliparity, and absence of fetal anomalies. One hour of interpretable electronic fetal monitoring (EFM) was obtained in active labor. Fall to rise (F:R) ratio was calculated by measuring the time for a contraction to return to its baseline from its peak (‘fall’) and the time for a contraction to rise to its peak (‘rise’). The F:Rs were then averaged over the number of contractions. Data were analyzed using Student t test, Chi-square, and Fisher exact tests where appropriate. Results: Maternal demographics are listed in Table I. The average F:R ratio was 1.55 for SVD versus 1.77 for C/S, a statistically significant difference (P = .00003). Analysis of variance revealed this difference persists when controlled for the potentially confounding factors shown. At F:R > 1.76, moreover, there was a trend towards larger birth weight (P = .06) Conclusion: Our study demonstrates there is a difference in uterine contraction configuration that is more common in those labors destined for C/S due to CPD. This may indicate the presence of a heretofore unknown feedback mechanism as the uterus adapts to the dysfunctional labor. [ABSTRACT FROM AUTHOR]

Objective: This study was undertaken to develop an easily usable integrated formula for predicting the probability of cephalopelvic disproportion/failure to progress (CPD) and cesarean delivery (CS) as a function of demographic factors in a middle-class private practice, and to evaluate risk factors for CS in a low-risk primiparous population. Methods: We studied 3355 primiparous women who delivered singleton births between February 1993 and July 2001 in a large private practice. We calculated body mass index (BMI) and weight gain during pregnancy by using clinical data from a comprehensive clinical database. Multivariable logistic regression analysis was used to estimate the relationship between the probability of CS and CS carried out for CPD and 6 demographic factors: maternal age, maternal height, initial pregnancy BMI, pregnancy weight gain, gestational age, and birth weight. Three methods were used to assess the accuracy of the model: the Hosmer-Lemeshow goodness-of-fit statistic, association of predicted probabilities, and direct comparison of the formula to the actual data. Odds ratios with a 95% CI are also calculated for each of these factors. Results: The overall rate of primiparous CS for the practice is 21.7%, with 11.7% carried out for CPD. Formulas were developed to predict the probability of CS and the probability of CS caused by CPD. Our analysis shows that both the risk of CS and the risk of CS caused by CPD are significantly associated with all 6 demographic factors. We also develop an easily usable Web page-based calculator to instantly estimate any woman's probability of a CS or CPD at the beginning or at the end of her pregnancy. Conclusion: The probability of CS and CS performed for CPD is higher for shorter, older, more obese women with large pregnancy weight gains, larger fetal birth weights, and longer gestation ages. Accurate formulas that predict the probabilities of CS and CS performed for CPD in this large private practice have been developed. [ABSTRACT FROM AUTHOR]

Background: Because nearly one-third of births in the United States are now achieved by cesarean delivery, comprising more than 1.27 million women each year, national organizations have recently published revised guidelines for the management of labor. These new guidelines stipulate that labor arrest should not be diagnosed unless ≥6 cm cervical dilatation has been reached or labor has been stimulated for at ≥6 hours.Objective: To determine the cervical dilatation and hours of labor stimulation prior to cesarean delivery for arrest of dilatation.Materials and Methods: Between January 1, 1999, andDecember 31, 2000, a prospective observational study of all primary cesarean deliveries was conducted at 13 university centers comprising the Eunice Kennedy Shriver National Institute for Child Health and Human Development, Maternal-Fetal Medicine Units Network. This secondary analysis includes all live-born, singleton, nonanomalous, cephalic gestations delivered by primary cesarean delivery at ≥37 weeks. A cesarean delivery was considered to have been performed for arrest of dilatation if the indication for the procedure was failure to progress, cephalopelvic disproportion, or failed induction. Augmentation was defined as stimulation after spontaneous labor had been previously diagnosed. Analysis included both the latent and active phases of labor. The active phase of labor was diagnosed when cervical dilatation was ≥4 cm in the presence of uterine contractions.Results: A total of 13,269 primary cesarean deliveries were available for analysis, 8,546 (65%) of which were performed for inadequate progress of labor with cervical dilatation recorded at the time of cesarean delivery. Of these cesarean deliveries for labor arrest, a total of 719 (8%) were performed in the latent phase of labor and 7827 (92%) were performed when cervical dilatation was ≥4 cm (active phase). Approximately two-thirds (n = =5876; 69%) received intrauterine pressure monitoring. A total of 5636 women (66% of those reaching the active phase of labor) had reached ≥6 cm cervical dilatation before cesarean delivery was performed. Moreover, 7440 (95%) of the 7827 women in active labor had ≥6 cm dilatation or had received labor stimulation ≥6 hours prior to cesarean delivery for arrest of dilatation.Conclusion: Women undergoing primary cesarean delivery for arrest of dilatation 15 years before the recommendations of the Obstetrics Care Consensus had received bona fide efforts to achieve adequate labor consistent with the recommendations of the Consensus. Because 95% of these women had ≥6 cm dilatation or had received labor stimulation ≥6 hours prior to cesarean delivery for arrest of dilatation, these new recommendations are unlikely to change the cesarean delivery rates. [ABSTRACT FROM AUTHOR]

A Continuing Medical Education (CME) on prostatitis, prostate cancer and gastro-oesophageal reflux disease (GORD) is presented.

Background: Obesity is a known risk factor for cesarean delivery. Limited data are available regarding the reasons for the increased rate of primary cesarean in obese women. It is important to identify the factors leading to an increased risk of cesarean to identify opportunities to reduce the primary cesarean rate.Objective: We evaluated indications for primary cesarean across body mass index (kg/m(2)) classes to identify the factors contributing to the increased rate of cesarean among obese women.Study Design: In the Consortium of Safe Labor study from 2002 through 2008, we calculated indications for primary cesarean including failure to progress or cephalopelvic disproportion, nonreassuring fetal heart tracing, malpresentation, elective, hypertensive disease, multiple gestation, placenta previa or vasa previa, failed induction, HIV or active herpes simplex virus, history of uterine scar, fetal indication, placental abruption, chorioamnionitis, macrosomia, and failed operative delivery. For women with primary cesarean for failure to progress or cephalopelvic disproportion, dilation at the last recorded cervical examination was evaluated. Women were categorized according to body mass index on admission: normal weight (18.5-24.9), overweight (25.0-29.9), and obese classes I (30.0-34.9), II (35.0-39.9), and III (≥40). Cochran-Armitage trend test and χ(2) tests were performed.Results: Of 66,502 nulliparous and 76,961 multiparous women in the study population, 19,431 nulliparous (29.2%) and 7329 multiparous (9.5%) women underwent primary cesarean. Regardless of parity, malpresentation, failure to progress or cephalopelvic disproportion, and nonreassuring fetal heart tracing were the common indications for primary cesarean. Regardless of parity, the rates of primary cesarean for failure to progress or cephalopelvic disproportion increased with increasing body mass index (normal weight, overweight, and classes I, II, and III obesity in nulliparous women: 33.2%, 41.6%, 46.4%, 47.4%, and 48.9% [P < .01] and multiparous women: 14.5%, 20.3%, 22.8%, 27.2%, and 25.3% [P < .01]), whereas the rates for malpresentation decreased (normal weight, overweight, and classes I, II, and III obesity in nulliparous women: 23.7%, 17.2%, 14.6%, 12.0%, and 9.1% [P < .01] and multiparous women: 35.6%, 30.6%, 26.5%, 24.3%, and 22.9% [P < .01]). Rates of primary cesarean for nonreassuring fetal heart tracing were not statistically different for nulliparous (P > .05) or multiparous (P > .05) women. Among nulliparous women who had a primary cesarean for failure to progress or cephalopelvic disproportion, rates of cesarean prior to active labor (6 cm) increased as body mass index increased, accounting for 39.3% of women with class I, 47.1% of women with class II, and 56.8% of women with class III obesity compared to 35.2% for normal-weight women (P < .01).Conclusion: Similar to normal-weight women, the indication of cesarean for failure to progress or cephalopelvic disproportion was the major factor contributing to the increase in primary cesarean in obese women, but was even more prevalent with increasing obesity class. The rates of intrapartum primary cesarean prior to achieving active labor increased with increasing obesity class in nulliparous women. [ABSTRACT FROM AUTHOR]