Search

Summary Kinesio taping (KT) is a popular intervention among the physiotherapists since it facilitates the reduction of pain and improvement of activities. However, there is little evidence about the therapeutic application of KT in pregnant women. A 33-year-old woman with a history of one term normal vaginal delivery referred to us at the 26th weeks of her second pregnancy. Almost 2 months before her referral, she experienced constant pain in the legs, ankles, and lumbar. The patient also reported burning sensation and sweating in the sole of her feet and sleep disturbance. She had a painful functional impairment that made walking, standing, sitting, and personal activities difficult. The patient did not take any sedatives during pregnancy. Therefore, KT was applied to the lower thoracic region for 5 days at three times. The Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI) were utilized to assess pain-related disability in the patient. After KT application, both VAS and ODI scores showed a significant decrease. Furthermore, she reported a remarkable improvement in her walking ability, feet sweating, and sleep disturbance. The present case report explained the use of KT on the lower thoracic spine in a patient suffering from low back and leg pains, as well as burning sensation and sweating of the sole of feet during pregnancy. The results revealed an improvement in patient symptoms, which may be due to the application of KT on the lower thoracic region. It seemed that her symptoms were due to pregnancy-induced physiologic changes in the body and sympathetic nervous system (SNS) disorder. Based on this study, it can be concluded that KT is a safe and inexpensive technique that can be used as a complementary therapy of low back and leg pains and SNS disorder in pregnant women.

Study Objective : Assess the acceptability, expulsion and continuation rates, satisfaction, and complications associated with post-placental intrauterine device insertion (PPIUDI) in Brazilian adolescents Design : prospective cohort Setting : a single public, tertiary, teaching hospital Participants : Adolescents (≤ 19 years) giving birth by vaginal delivery or cesarean section Intervention : Post-placental IUD insertion (PPIUDI) Main Outcome Measures : Primary outcomes were PPIUDI acceptability, expulsion, continuation, and user satisfaction. Secondary outcomes were changes in menstrual bleeding and pain, infection, uterine perforation, and repeat pregnancy up to 12 months after PPIUDI Results : 294 of 1710 adolescents delivered during the study period accepted PPIUDI (acceptability 17.2%). There were no cases of infection or uterine perforation among the 91 adolescents who completed the 12 months follow-up. Overall expulsion rate was 28.6% and most cases (54%) occurred in the first six weeks after insertion. At 12 months, 85.7% of users were satisfied with the method and continuation rate was 69.2%. At the end of 12 months, there were no repeat pregnancies among the adolescents who remained with the device in place Conclusion : PPIUDI can be an effective and safe method to reduce repeat unplanned pregnancies in adolescents who have just given birth.

Objective: To describe the type of milk used to feed infants seen in private pediatric practices in Brazil. To evaluate the relationship between breastfeeding, type of delivery, and history of prematurity. Methods: This is a cross-sectional and observational study that included 4929 infants in the first year of life seen in private pediatric practices in the five geographic regions of Brazil. Mothers provided information about the type of milk used by their infant, the type of delivery (vaginal or cesarean), and whether the birth was premature. Results: Breastfeeding was the only source of milk for 56.1% (1546/2755) of infants in the first six months of life and 32.9% (716/2174) in the second. Of the infants who received other types of milk besides breastfeeding, there was a predominance of infant formula in 98.6% and 93.8% of the infants, respectively, in the first and in the second six months of life. Whole cow's milk was used by 0.7% (20/2755) of infants in the first six months and by 4.1% (90/2174) of infants in the second (p < 0.001). In the first six months of life, breastfeeding as the only type of milk was associated with vaginal delivery (OR = 1.79; p < 0.001) and not having a history of prematurity (OR = 2.48; p < 0.001). Conclusion: Breastfeeding was the only milk source for more than half of infants before 180 days of life. Birth by cesarean section and history of prematurity were negatively associated with breastfeeding as the only source of milk used in infant feeding.

Objective Uterine artery embolization is an attractive option for the management of postpartum haemorrhage, however it is not available in every hospital. We compared the clinical characteristics and haemodynamic state of patients with postpartum haemorrhage, before and after helicopter transfer to a tertiary hospital for possible uterine artery embolization. We also analysed whether the type of treatment could modify the outcome. Study design: Between 1999 and 2019 in Switzerland, we retrospectively found 82 consecutive patients with postpartum haemorrhage who were transferred by a physician-staffed helicopter emergency medical service to the tertiary hospital for potential uterine artery embolization. The collected data included the type of delivery, estimated blood loss, shock index and blood lactate levels before transfer and at destination, uterine artery embolization rate and hospital mortality rate. Our primary outcome was to describe the clinical characteristics, outcomes and haemodynamic state of the patients with postpartum haemorrhage before and after helicopter transfer. Our secondary outcome was to report the treatments performed at the tertiary hospital. The collected data were analysed with Stata version 14 (Stata Corporation, College Station, TX, USA). Continuous data are compared by using the Student's t-test or the Mann-Whitney U test, as appropriate. Results We included 69 patients. Postpartum haemorrhage occurred after vaginal delivery in 38 cases (55%). Blood loss prior to transfer exceeded 2 L in 34% of cases. The median shock index was 1 (IQR 0.8 to 1.1) before transfer and 0.9 (IQR 0.8 to 1.1) after transfer (p=0.41). The median lactate level was 2.9 mmol/L (IQR 2.1 to 6.8) before, and 2.1 mmol/L (IQR 1.55 to 3.5) after transfer (p=0.90). Forty-four patients underwent uterine artery embolization (64%), with an overall success rate of 93%. One patient died (1.4%), from a haemorrhagic shock of abdominal origin. Conclusions Interhospital helicopter transfer of patients with postpartum haemorrhage to a tertiary hospital seems to be safe in our setting, despite a significant proportion of patients exhibiting signs of haemodynamic instability. Decision criteria would be helpful to better guide choices regarding the transfer of patients with postpartum haemorrhage.

OBJECTIVES The delivery of breech presentations remains controversial. Our study analysed the impact of a service protocol on the proportion of planned vaginal delivery and its success. Immediate neonatal morbidity and factors that may influence the success of vaginal delivery were studied. METHODS Retrospective study, between 2009 and 2020 at the CHRU of Limoges, type 3 maternity hospital, on patients with a breech foetus at term. The proportion of planned vaginal delivery and the rate of effective vaginal delivery were compared before/after 2015. Neonatal morbidity was compared for planned vaginal delivery and planned cesarean delivery groups. RESULTS We included 923 patients. The rate of planned vaginal delivery was significantly higher after 2015 from 5.2% to 19% (P

Summary Background Sexual function undergoes the changes during the postpartum period and after vaginal delivery. Thus, the present study was conducted to assess the effects of sensate focus technique on the sexual function of primiparous women after their vaginal delivery. Methods This randomized clinical trial was performed on 82 primiparous women aged between 18–35 years old who had referred to health care center with their husband 2 months after their vaginal delivery. The women's baseline sexual function was assessed by the female sexual function index. Women were randomly assigned to two groups: Including intervention group where they received specific instruction on sensate focus technique and were followed up weekly for 2 months and control group where they received the information about recovery from childbirth and lactation. Sexual function of the participants was evaluated after 4 and 8 weeks. Results Mean age of the women was equal to 24.74 (4.84) years old. The two study groups were homogeneous in terms of educational level, employment, and socioeconomic status. Eight weeks after the intervention, the sexual function score was significantly higher in the intervention group than the control group (29.90 vs. 24.75, p Conclusion Our finding revealed that sensate focus technique has the potential to improve sexual function of the primiparous women after their delivery. Trial registration Approval number from Iranian Registry of Clinical Trials: IRCT20181218042041N1 (Registration date: 2019-02-22).

Purpose This study sought to evaluate whether or not the sonographic measurement of the inferior vena cava (IVC) diameter predicts severe bleeding in women with postpartum hemorrhage (PPH). It further compared the efficacy of the IVC diameter, shock index, and serum lactate levels in this prediction. Methods This prospective study included female patients with ≥500 mL of bleeding after vaginal delivery between September 1, 2019 and May 31, 2021. The IVC diameter during inspiration (IVCmin) and expiration (IVCmax), shock index and serum lactate levels of the patients were measured. The patients were divided into two groups according to the postpartum vaginal blood loss [non-severe PPH and severe PPH (SPPH)]. After multivariate logistic regression analysis revealed the significant parameters, we constructed the receiver operating characteristic (ROC) curves to determine their power in predicting SPPH. Results Of the 201 patients included in the study, SPPH developed in 21.4% of the population, while non-severe PPH occurred in 78.6%. The area under the curve (AUC) values ​​of shock index, lactate, IVCmin and IVCmax for SPPH prediction were 0.772, 0.791, 0.851 and 0.874, respectively. According to the ROC analysis, at the cut-off value of 7.3 mm, IVCmax had 90.7% sensitivity and 70.8% specificity in predicting SPPH. IVCmax was independently associated with SPPH (Odds ratio: 0.74, 95% CI: 0.63–0.86). Conclusion We found that the ultrasonographic measurement of IVC diameter is more valuable than the shock index and lactate parameters in the early detection of SPPH. Therefore, IVC diameter may be a useful prognostic marker for SPPH.

Coronary events in pregnancy are a rare but growing cause of maternal morbidity and mortality. Pregnancy presents unique challenges across a broad spectrum of disciplines and requires a multidisciplinary approach to optimize maternal and fetal outcomes. The early involvement of the “cardio-obstetrics” team in pre-pregnancy counselling, the antenatal period, delivery and post-partum is vital to ensuring better outcomes for patients at high risk of coronary pathology. The overall risk for coronary events complicating pregnancy is increasing due to a number of factors including advancing maternal age and increases in traditional cardiac risk factors; contributing to higher rates of maternal morbidity and mortality. The majority of pregnant women experiencing a coronary event do not have prior coronary disease, and the pathological mechanisms involved are predominantly non-atherosclerotic. Diagnosis and management should follow standard guideline-based practices for acute coronary syndrome (ACS), including the use of diagnostic coronary angiography to guide percutaneous intervention when needed. Management of ACS should not be delayed to facilitate delivery, which can proceed following stent implantation and dual antiplatelet therapy. The timing and mode of delivery should be based on assessment of maternal and fetal status, but vaginal delivery is preferred when possible. This review aims to provide an overview of the major etiologies, risk factors, diagnosis and management strategies for patients at risk of or presenting with coronary events in pregnancy.

Background Ovarian cysts are uncommon gestational complications. Because of high-level progesterone, ovarian endometriomas may undergo decidualization during pregnancy, manifesting as enlarging cysts with papillae and rich blood flow. Such cases can mimic malignant or borderline tumors, causing dilemmas in clinical management. Here, we present two cases of enlarging ovarian cysts during pregnancy with evidence suggesting decidualized endometrioma. The diagnosis and treatment are further discussed, which add to our limited knowledge and might help future clinical practice. Case summary In the first case, a right ovarian cyst was detected by ultrasound in a 32-year-old pregnant woman. The cyst measured 4.2 cm in diameter at 7+6 weeks of gestation, and gradually increased to 9.6 cm ​× ​7.6 cm ​× ​5.6 cm at 37+5 weeks, with multiple solid papillae lining the inner wall. During cesarean section, an ovarian mass of approximately 9 cm in diameter was surgically removed, which was later identified by pathological review as an endometrioma with decidualization. The second case also presented as an enlarging ovarian mass during the first and second trimester. The size of the cyst peaked at 24+5 weeks of gestation, measuring 6.9 cm ​× ​5.6 cm ​× ​4.1 cm. But in the third trimester, the tumor slightly regressed. Careful follow-up was adopted after successful vaginal delivery, and the cyst was found to have undergone quick regression shortly after pregnancy. Both patients recovered well after delivery with no further complications. Conclusion Endometriomas with decidualization during gestation may resemble borderline or malignant tumors. Close monitoring and proper management are essential for guiding clinical management.

Objective We present a case of choriocarcinoma in a viable pregnancy with the rare presentation of intractable lower back pain. Case report The patient is a 34-year-old multiparous woman with her second pregnancy, and a history of scoliosis with spinal fixation. Her first pregnancy was uneventful, with a term vaginal delivery. She was hospitalized four times due to intractable back pain from 25 to 31 weeks, and terminated at 31 weeks. The placenta was unremarkable on gross examination. Postpartum, the patient developed obstructive ileus, requiring a rectosigmoid resection. She was diagnosed with metastatic choriocarcinoma to the liver, para-aortic lymph nodes, and mesentery. A week later, she developed micro-thrombosis of all limbs, massive ascites, pleural effusion. Patient refused chemotherapy and died on post-operative Day 15. Conclusion Presentation of choriocarcinoma in pregnancy varies widely. Clinicians should consider the differential diagnosis of choriocarcinoma when faced with abnormal unexplained symptoms during pregnancy.

Umbilical cord prolapse is an unpredictable obstetrical emergency with an incidence ranging from 1 to 6 per 1000 pregnancies. It is associated with high perinatal mortality, ranging from 23% to 27% in low-income countries to 6% to 10% in high-income countries. In this review, we specifically addressed 3 issues. First, its definition is not consistent in the current literature, and "occult cord prolapse" is a misnomer because the cord is still above the cervix. We proposed that cord prolapse, cord presentation, and compound cord presentation should be classified according to the positional relationship among the cord, the fetal presenting part, and the cervix. All of them may occur with either ruptured or intact membranes. The fetal risk is highest in cord prolapse, followed by cord presentation, and lastly by compound cord presentation, which replaces the misnomer "occult cord prolapse." Second, the mainstay of treatment of cord prolapse is urgent delivery, which means cesarean delivery in most cases, unless vaginal delivery is imminent. The urgency depends on the fetal heart rate pattern, which can be bradycardia, recurrent decelerations, or normal. It is most urgent in cases with bradycardia, because a recent study showed that cord arterial pH declines significantly with the bradycardia-to-delivery interval at a rate of 0.009 per minute (95% confident interval, 0.0003-0.0180), and this may indicate an irreversible pathology such as vasospasm or persistent cord compression. However, cord arterial pH does not correlate with either deceleration-to-delivery interval or decision-to-delivery interval, indicating that intermittent cord compression causing decelerations is reversible and less risk. Third, while cesarean delivery is being arranged, different maneuvers should be adopted to relieve cord compression by elevating the fetal presenting part and to prevent further cord prolapse beyond the vagina. A recent study showed that the knee-chest position provides the greatest elevation effect, followed by filling of the maternal urinary bladder with 500 mL of fluid, and then the Trendelenburg position (15°) and other maneuvers. However, each maneuver has its own advantages and limitations; thus, they should be applied wisely and with great caution, depending on the actual clinical situation. Therefore, we have proposed an algorithm to guide this acute management.

To evaluate the maternal and neonatal outcomes associated with vacuum-assisted vaginal delivery (VAVD) in a subset of parturients with congenital uterine anomalies.A retrospective database study was conducted at a single tertiary center between 2005 and 2019. Parturients with known congenital uterine anomalies who had vaginal deliveries were enrolled, whereas parturients with failed VAVD, didelphic uterus, and delivery after intrauterine fetal death were excluded. Various maternal and neonatal outcomes were compared between parturients who achieved spontaneous vaginal delivery (SVD) and those who delivered via VAVD. The maternal composite outcome was calculated for each group and included one or more of the following: post-partum hemorrhage, hemoglobin drop ≥ 4 gr/dL, blood transfusions, retained placental products, and obstetric anal sphincter injuries. Univariate analysis was performed followed by multivariate logistic regression analysis controlling for potential confounders. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated.After the application of the exclusion criteria, 332 parturients were found eligible. Of those, 289 (87%) had SVD and 43 (13%) had VAVD. VAVD was more common among primiparous parturients and epidural analgesia users. Parturients with VAVD had higher rates of third-degree perineal tear, postpartum hemorrhage, and blood transfusions. The maternal composite outcome was significantly more prevalent in the VAVD group (44.2% vs. 20.8%, p 0.01). After controlling for potential confounders, the maternal composite outcome was found to be independently associated with VAVD (aOR 2.3, 95% CI 1.10-4.60). The neonatal results were overall comparable, except for scalp trauma and Erb's palsy/clavicular fracture, which were more prevalent in the VAVD group.In a special population of parturients with congenital uterine anomalies, VAVD was found to be associated with significantly higher rates of adverse maternal outcomes and perinatal birth trauma. These findings should be presented to parturients during consultations about modes of delivery.

Objective Forceps delivery is associated with a higher risk of maternal birth trauma. It is speculated that it is due to sub-optimal use of forceps in inexperienced hands. The aim of this study was to determine the association between time of forceps birth and prevalence of levator avulsion over the last six decades. Study Design This was a retrospective analysis of datasets of women with a history of forceps delivery, seen at a tertiary urogynaecological centre between January 2014 and August 2018. They had undergone a standardized interview, clinical examination and four-dimensional translabial ultrasound. Archived imaging data was reviewed for levator avulsion offline at a later date, blinded against all clinical data. Associations between levator avulsion, maternal age at first vaginal birth, the weight of the first vaginally born baby, and time since forceps delivery categorised by decade were tested by univariable analysis. Factors found to be significant on univariable analysis were included in a multivariable logistic regression model to test the association between prevalence of levator avulsion and time of forceps delivery while controlling for confounders. Results In total, 2026 patients were seen during the study period. Among them 511 (25.2%) had a history of forceps delivery. Fourteen volume datasets were incomplete or missing, leaving 497 complete datasets for analysis. Mean age at presentation was 58 ± 12 years (23–91). Mean body mass index was 29 ± 6 kg/m2. Mean age at first delivery was 25 ± 5 years. Mean birth weight of the first vaginal birth was 3454 ± 557 g. 457 women (92%) had had one forceps delivery, 31 had two forceps deliveries (6%) and 9 had three forceps deliveries (2%). Mean time interval between forceps delivery and assessment was 32 ± 13 years (0.3–64.8). 229 women (46%) were diagnosed with levator avulsion. The prevalence of avulsion after forceps increased significantly from 34% to 56% between 1950 and 2017 (P = 0.04). However this difference became insignificant when controlling for maternal age at 1st vaginal delivery and birth weight. Conclusions We found no evidence of a changed prevalence of levator avulsion at forceps delivery over the last 67 years.

In the prospective multicenter Genesis study, we developed a prediction model for Cesarean delivery (CD) in term nulliparous women. The objective of this secondary analysis was to determine whether the Genesis model has the potential to predict maternal and neonatal morbidity associated with vaginal delivery.The national prospective Genesis trial recruited 2,336 nulliparous women with a vertex presentation between 39 + 0- and 40 + 6-weeks' gestation from seven tertiary centers. The prediction model used five parameters to assess the risk of CD: maternal age, maternal height, body mass index, fetal head circumference and fetal abdominal circumference. Simple and multiple logistic regression analyses were used to develop the Genesis model. The risk score calculated using this model were correlated with maternal and neonatal morbidity in women who delivered vaginally: postpartum hemorrhage (PPH), obstetric anal sphincter injury (OASI), shoulder dystocia, one- and five-minute Apgar score ≤ 7, neonatal intensive care (NICU) admission, cephalohematoma, fetal laceration, nerve palsy and fractures. The morbidities associated with spontaneous vaginal delivery were compared with those associated with operative vaginal delivery (OVD). The likelihood ratios for composite morbidity and the morbidity associated with OVD based on the Genesis risk scores were also calculated.A total of 1,845 (79%) nulliparous women had a vaginal delivery. A trend of increasing intervention and morbidity was observed with increasing Genesis risk score, including OVD (p 0.001), PPH (p 0.008), NICU admission (p 0.001), low Apgar score at one-minute (p 0.001) and OASI (p = 0.009). The morbidity associated with OVD was significantly higher compared to spontaneous vaginal delivery, including NICU admission (p 0.001), PPH (p = 0.022), birth injury (p 0.001), shoulder dystocia (p = 0.002) and Apgar score of7 at one-minute (p 0.001). The positive likelihood ratios for composite outcomes (where the OVD was excluded) increases with increasing risk score from 1.005 at risk score of 5% to 2.507 for risk score of50%.In women who ultimately achieved a vaginal birth, we have shown more maternal and neonatal morbidity in the setting of a Genesis nomogram-determined high-risk score for intrapartum CD. Therefore, the Genesis prediction tool also has the potential to predict a more morbid vaginal delivery.

Objective To demonstrate the feasibility and the simplified surgical techniques of intraabdominal suturing and knot–tying in robotic transvaginal natural orifice transluminal endoscopic surgery (RV–NOTES) sacrocolpopexy. Materials and Methods We report on two patients with symptomatic stage II apical pelvic organ prolapse who underwent a new technique of RV–NOTES sacrocolpopexy. Case one: A 69-year-old G2P2002 with a history of two prior vaginal deliveries presented with a vaginal bulge and pressure symptoms. She was initially fitted for a pessary but was unsatisfied and elected to proceed with surgical intervention. Case two: A 50-year-old G2P0011 female with a history of one prior vacuum-assisted vaginal delivery presented with symptoms of vaginal mass and bleeding due to an endometrial polyp. She was noted to have stage 2 apical prolapse and opted for transvaginal sacrocolpopexy. Results Both patients were observed overnight and discharged home twelve hours after surgery on postoperative day 1, after completing a voiding trial. For both patients, the postoperative course was unremarkable, and they only required one day of pain medications. At the three–week follow–up visit, they endorsed no postoperative pain or complications, and the POP-Q stage was noted to be 0. Patients had telemedicine visits at eight weeks postoperatively, at which time they had returned to their regular activities and denied symptoms of vaginal bulge or pressure. Conclusion Robotic assisted transvaginal NOTES sacrocolpopexy is a feasible and an alternative to traditional laparoscopic NOTES sacrocolpopexy.

Background Bariatric surgery has been a popular way for many women to reach a healthy body mass index, and as a consequence, a decreased body mass, which causes a greater chance of fertility, with improved pregnancy and better maternal outcomes. Objective Describe a single-center experience of pregnancies complicated by internal hernias after gastric bypass. Setting Academic Medical Center. Methods During 2011 and 2019 a series of patients were treated for internal hernia after gastric bypass at our teaching hospital. The hospital records were retrospectively reviewed. Results Seven women were treated. Median age was 33 years (range: 24–39 yr). Median gestational age was 25.6 weeks (range: 5–33 wk). Median time from Roux-en-Y gastric bypass to pregnancy was 4 years (range: 1–7 yr). Median body mass index was 24 kg/m2 (range: 24–31 kg/m2). Five (71.4%) patients underwent an exploratory laparotomy, and 2 (28.5%) patients a diagnostic laparoscopy. In all patients, an internal hernia of the small bowel in the Petersen space was encountered. Median length of pregnancy was 38 weeks (range: 33.6–39.6 wk). Six (85.7%) patients underwent C-section, and 1 (14.2%) patient gave birth by vaginal delivery. There was only 1 maternal postoperative complication and no fetal postoperative complications. Median follow-up was 9 months (range: 2–20 mo). Conclusion The rapid growth in bariatric surgery on obese women of fertile age could result in more cases of internal herniation during pregnancy in the future. An internal hernia should be suspected when encountering a postgastric bypass pregnant patient with abdominal pain, nausea, and vomiting.

Background Femoral neuropathy is a rare complication of vaginal delivery that is often under-reported. It is marked by weakness and sensory loss in the lower limbs. This report presents 3 cases to outline possible prevention strategies, as well as to describe the process of diagnosis, management, and recovery for this injury. Cases Diagnosis is made clinically, and prognosis is determined by clinical follow-up along with nerve conduction studies and electromyography. Management involves interdisciplinary efforts with physiotherapy. Prevention includes frequent repositioning and avoidance of hip hyperflexion during labour. The expected recovery period ranges from 2 to 24 months. Conclusion Femoral neuropathy after vaginal delivery is under-reported. Though prognosis is often excellent, special attention to positioning during labour, prompt clinical diagnosis, and interdisciplinary management are essential for this rare injury.

To explore the role of maternal ethnicity as a risk factor for obstetrical anal sphincter injury (OASI).A retrospective cohort study of all women with singleton gestations who had a vaginal delivery at term, between January 2014 and October 2017, at a single center. OASI was defined as a third-degree perineal tear (anal sphincter complex) or a fourth-degree perineal tear (anorectal mucosa). The characteristics of women with and without OASIs were compared. Multiple logistic regression was performed to account for potential confounders, including ethnicity.During the study period, 11 012 women were eligible for inclusion, of whom 336 (3.1%) had an OASI; 313 (93.1%) had a third-degree tear, and 23 (6.9%) had a fourth-degree tear. Women with OASIs were characterized by younger maternal age (35 years), Asian ethnicity, nulliparity, neonatal birth weight ≥3500 grams, midline and mediolateral episiotomy, second stage of labour lasting ≥60 minutes, and assisted vaginal delivery. After adjusting for potential confounders, Asian ethnicity remained independently associated with increased risk of OASI (adjusted odds ratio 2.07; 95% CI 1.6-2.7) whereas mediolateral episiotomy was independently associated with decreased risk of OASI (adjusted odds ratio 0.64; 95% CI 0.5-0.9).Asian ethnicity is independently associated with increased risk of OASI. Although midline episiotomy increases the risk of OASI, mediolateral episiotomy may protect against OASI, and should be considered in high-risk patients.

The effects of SARS-COV-2 infection on the pregnant women and their fetus growth have attracted worldwide concern. Our case study aimed to investigate the neonatal clinical outcomes of the recovered pregnant women from COVID-19 in China, expecting to provide the clinical references of urgent need for other countries. Our study recruited a total of 12 recovered pregnant women from COVID-19 prior to pregnancy termination. The maternal and neonatal clinical characteristics were recorded. Of them, the placental pathological characteristics of five participants were evaluated following the standard guidelines. Two of them chose induced labour due to being worry about the potential adverse effects of medical treatment for COVID-19 by themselves. For the others, 8 gave birth by cesarean section with certain indications and 2 by vaginal delivery. Their neonates were all live birth with ≥ 37 gestational weeks and high Apgar scores of 9 ∼ 10. For the neonate related biological samples, they all have negative results of RNA test, including nasopharyngeal swab, umbilical cord blood, amniotic fluid, vaginal fluid, placenta, or umbilical cord. Most of other pathological indicators of placental examination suggested no abnormal syndromes. Overall, we did not find any abnormal pregnancy complications and neonatal outcomes among them. We concluded that excess adverse effect on the fetus development due to COVID-19 in the recovered pregnant women should be less influential, especially, induce abortion due to the anxiety of COVID-19 treatment should be not advisable.

To examine the association between vaginal delivery of a previous macrosomic neonate (birthweight (BW)≥ 4000) among non-diabetic women and the rate of shoulder dystocia (SD) in the subsequent pregnancy.A historical prospective cohort study in a university affiliated medical center from 2005 to 2019. Women who had a singleton pregnancy and two consecutive deliveries in our medical center were included. Women with previous GDM, SD or cesarean delivery were excluded. Univariate analysis was followed by multivariate logistic regression.A total of 38,942 women were included. SD incidence among the subsequent pregnancies was 0.44 % (172 women). In univariate analysis women with previous delivery of large neonates: BW≥90th percentile for gestational age and BW ≥ 4000 g had higher risk for subsequent SD (odds ratio 2.69 [95 % confidence interval 1.89-3.84], p0.01 and 2.71 [1.66-4.44], p0.01, respectively). However, a backward stepwise multivariate logistic regression model adjusted for significant confounders for SD in the univariate analysis, showed that women with a previous delivery of macrosomic neonate ≥4000 g were not found to have higher or lower risk for SD in the subsequent delivery.Previous uneventful delivery of a macrosomic neonate to a non-diabetic mother should not be regarded as a risk factor for SD in the subsequent delivery.

Background Postpartum hemorrhage is the most common midwifery hemorrhage that occurs in 1 %–5 % of childbirths, causing an estimated 140,000 deaths per year. After pain is also one of the common postpartum pains and approximately 70 % of women with vaginal delivery complain of it. Due to the side-effects of chemical medications, researchers have a particular interest in using traditional and complementary therapies. Reflexology is one such method. The present randomized clinical trial will be conducted to assess the effectiveness of reflexology on hemorrhage and after pain following vaginal delivery. Methods The present randomized controlled trial will be conducted on women presenting to the maternity wards of Allameh Bohlool Gonabadi and 17th Shahrivar hospitals in Gonanbd and Mashhad, Iran. After obtaining informed consent from the eligible women, sampling will begin through the convenience method. The subjects will be randomly divided into intervention and control groups by permuted blocks of four. The sample size will be 40 per group. After the removal of the placenta, the intervention group will be given a four-minute general massage on each foot, followed by two minutes of specific reflexology on the uterus, pituitary and solar plexus points by exerting rotational pressure. The control group will also be given a four-minute general massage on each foot, followed by six minutes of rotational pressure on a point on the outer edge of the heel. Ten minutes are required for each foot, and this procedure is to be repeated two hours after childbirth. After pain will be measured using the Visual Analogue Scale (VAS) and bleeding by weighing the pads every one to four hours. Data will be analyzed in SPSS 16. Discussion The results will provide accurate scientific evidence for the use of reflexology to control postpartum hemorrhage and after pain. If the results are favorable, the routine use of this technique will be recommended for women in the fourth stage of labor.

Background Prolonged vaginal delivery times and episiotomy are associated with damage to the muscles of the pelvic floor, and with complications that include postpartum sexual dysfunction and urinary stress incontinence. This study was to compare the pelvic floor function among postpartum women who underwent three midwifery practices during labor: lateral episiotomy, traditional midwifery without episiotomy, and hands-off techniques delivery. Methods We included 320 primipara who were full-term pregnancy and underwent vaginal delivery in Department of Obstetrics, Peking University People’s Hospital, China. 117 women had episiotomy during labor and were classified into the lateral episiotomy group; 103 had traditional midwifery without episiotomy and were classified into the traditional midwifery practice group; and 100 experienced hands-off techniques during labor and were classified into the hands-off techniques delivery group. The duration of the second stage of labor, and postpartum pelvic floor muscle strength were compared between the three study groups. Results There were no significant differences between the three groups for the duration of the second stage of labor and postpartum pelvic floor muscle strength (P ​> ​0.05). However, the incidence of postpartum urinary stress incontinence and sexual dysfunction in the hands-off techniques delivery group was significantly lower than in the lateral episiotomy groups and the traditional midwifery practice group (P ​ Conclusions Hands-off techniques delivery could reduce damage to the pelvic floor and improve the quality of life for women after delivery.

Valvular heart disease (VHD) is generally well tolerated during pregnancy; however, the dramatic changes in hemodynamics that occur during pregnancy can lead to clinical decompensation in high-risk women. Women with VHD considering pregnancy should undergo preconception counseling with a high-risk obstetrician and cardiologist to review the maternal, fetal, and obstetric risks of pregnancy and delivery. Vaginal delivery is recommended for most women with VHD. Given the complexity of managing VHD during pregnancy, women should be managed by a multidisciplinary Pregnancy Heart Team during pregnancy, consisting of a high-risk obstetrician, cardiologist, and cardiac anesthesiologist.

Background Depression is a common and serious complication in new mothers. We investigated the hypothesis that neuraxial labor analgesia is associated with a decreased risk of postpartum depression. Methods In this multicenter prospective cohort study with propensity score matching, 599 nulliparous women with single term cephalic pregnancy who planned vaginal delivery were enrolled and self-selected neuraxial analgesia or not. The primary outcome was 6-week postpartum depression assessed with the Chinese version Edinburgh Postnatal Depression Scale; a score of ≥10 was set as the threshold of postpartum depression. Logistic regression models were established to assess the association between neuraxial labor analgesia and postpartum depression. Results Of the 577 parturients who completed the study, 417 (72.3%) received neuraxial analgesia and 160 (27.7%) did not. After propensity score matching, 433 parturients were included in the analysis; of whom, 279 (64.4%) received neuraxial analgesia and 154 (35.6%) did not. The incidence of postpartum depression was lower in parturients with neuraxial analgesia than in those without (14.9% [62/417] vs. 23.8% [38/160], P=0.012 before matching; 13.3% [37/279] vs. 23.4% [36/154], P=0.007 after matching). After adjustment for confounding factors, neuraxial analgesia was associated with decreased odds of postpartum depression (odds ratio [OR] 0.50, 95% CI 0.28-0.88, P=0.015 before matching; OR 0.40, 95% CI 0.21-0.77, P=0.006 after matching). Limitations As an observational study, unidentified confounders might influence the results. Conclusions In nulliparae with single term cephalic pregnancy preparing to give vaginal delivery neuraxial analgesia during labor was associated with a decreased risk of 6-week postpartum depression.

Shock index and continuous non-invasive haemoglobin monitoring (SpHb) have both been proposed for the timely recognition of postpartum haemorrhage (PPH). We sought to determine, in parallel, the association of each of shock index and SpHb with blood loss after vaginal delivery.Sixty-six women were recruited to this prospective observational study. Shock index and SpHb were recorded postpartum for 120 min. The association between each of shock index and SpHb with quantitative blood loss (QBL) at 30, 60 and 120 min postpartum was determined using linear mixed models. Area-under-the-receiver-operator-characteristic (AUROC) curves were constructed to evaluate the diagnostic ability of shock index and SpHb to detect PPH (defined as QBL ≥1000 mL).Shock index trend was associated with QBL over the first 30 min (r=0.37, P=0.002), but not over 60 or 120 min. There was an association of SpHb trend with QBL over the first 30 min (P=0.06), but not over 60 min (r=-0.32, P=0.009) or 120 min (r=-0.26, P=0.03). Maximum shock index within 60 min correlated with QBL (r=0.54, P0.001) and was a predictor of PPH (P=0.0012, AUROC 0.796). Maximum change in SpHb within 60 min negatively correlated with QBL (r=-0.4, P0.001) and was a predictor of PPH (P=0.048, AUROC 0.761).The trend of shock index and its peak values are associated with blood loss after vaginal delivery and are early indicators of PPH. Negative trend of SpHb is a late sign of PPH and has a weaker association with blood loss than shock index.

Objective To assess the relationship between postpartum hemorrhage and ABO blood type for vaginal delivery and cesarean delivery. Study design This is a retrospective cohort study of data abstracted from the PeriBank database regarding demographics and delivery outcomes. All live singleton deliveries from January 2011 until March 2018 were included in this study. Exclusion criteria were sickle cell disease and multiple gestations. Analyses were conducted separately for cesarean delivery and vaginal delivery. Quantitative variables were analyzed with analysis of variance testing and categorical variables with chi square testing. Significant demographic differences between groups were controlled for using multivariate logistical regression. The primary outcome was the rate of postpartum hemorrhage by blood type (A, B, AB, and O), defined as blood loss >500 mL in vaginal delivery and >1000 mL in cesarean delivery. 43,437 patients were screened and 32,023 women met inclusion criteria (22,484 vaginal deliveries (70.2%) and 9539 cesarean deliveries (29.8%)). Results In the vaginal delivery group there were differences in age, parity, race, use of regional anesthesia, rate of induction of labor, and thrombocytopenia between blood types. In the cesarean delivery group, age, parity, and race were significantly different between blood types. There was no observed difference in the rate of postpartum hemorrhage by blood type for those who delivered via vaginal delivery when controlling for demographic differences (p = 0.2). In the cesarean delivery group, there was a significantly higher rate of postpartum hemorrhage in women with type O blood (5.2% type O vs 3.8% type A vs 4.4% type B vs 4.2% type AB, p = 0.035), including when controlling for demographic differences (p = 0.02). In both vaginal and cesarean delivery groups, there was no difference in rates of any of the secondary outcomes, including blood transfusion, hysterectomy, intrapartum dilation and curettage, and intensive care unit admission. Conclusion Although this study found no statistically significant difference in clinical outcomes between blood types, type O blood may be an additional risk factor to consider for postpartum hemorrhage at the time of cesarean delivery.

Objective To assess the current antenatal and intrapartum management options for primigravid women of short stature with a clinically large fetus by a survey of UK Obstetricians. Study design An online survey comprised of 15 questions including the options on timing and mode of delivery, counselling about the risk of long-term pelvic floor morbidity following spontaneous vaginal and instrumental deliveries, choice of instruments and the role of episiotomy. The survey was sent to the participants as a part of Royal College of Obstetricians and Gynaecologists (RCOG) Newsletter between September 2017 to October 2018. The scenario described was of a primigravid short stature woman (i.e. height of 160 cm or less) who presents with a clinically large fetus at 38 weeks gestation. Results 424 Obstetricians participated in the survey. The participation ratio cannot be identified as the survey was emailed as a part of the RCOG Newsletter. Sixty five percent respondents stated that they would scan for estimated fetal weight, 48 % would offer induction of labour at 40 weeks and 14 % would offer an elective/planned caesarean section (CS) at 39–40 weeks. Fifty nine percent would discuss all these risks: obstructed labour, shoulder dystocia, instrumental delivery and obstetric anal sphincter injury (OASI). 73 % would not discuss the long-term risks of urinary and/or faecal incontinence and pelvic organ prolapse. In the presence of failure to progress in the second stage of labour, 69 % would attempt a rotational instrumental delivery and 5% would offer a caesarean section. Manual rotation and ‘straight’ forceps application were the most frequent type of rotational delivery, followed by Ventouse and Kiellands forceps. Thirty four percent stated that they do not routinely perform an episiotomy in this scenario. Seventy three percent stated that their choice of instrument was not based on the long-term risk of urinary and faecal incontinence. Conclusion The results suggest that 40 % of the respondents would not discuss all of the complications after vaginal delivery in women of short stature. The most common delivery option would be vaginal delivery.

Prior vaginal delivery (VD), including vaginal birth after cesarean (VBAC), is one of the greatest predictors of successful trial of labor after cesarean (TOLAC) and uterine rupture. We aimed to evaluate VBAC and uterine rupture rates associated with TOLAC in women with VD prior to cesarean delivery (CD) or with prior VBAC, and the cumulative effect of the number of prior VD's.This retrospective study included women having TOLAC between 2005-2019. The study compared the caesarean and uterine rupture rates of TOLAC in women with only prior VD as compared to women with only prior VBAC. Comparison analysis was performed by univariate analysis and followed by adjusted multiple logistic regression models. Receiver operating characteristic (ROC) and decision tree analyses (chi-square automatic interaction detection algorithm) was conducted to evaluate the influence of the number of prior VD's on the likelihood of successful TOLAC.Overall, 9,038 women met the inclusion criteria. Women with prior VBAC and prior VD showed significantly higher rates of successful VBAC compared to those with no prior VD or prior VBAC (96 % and 86 % vs 76 %; p0.01). However, women with prior VBAC but not women with prior VD showed significantly lower rates of uterine rupture compare to women with no prior VD or VBAC (0.1 % vs 0.6 % and 0.6 %; p0.01). The prevented fraction of TOLAC success was significantly higher in women with prior VBAC than that of women with VD prior to CD (83 % vs. 42 %, p0.01). ROC curve showed that the number of prior VBACs was a better predictor of TOLAC success and uterine rupture than the number of prior VD's. However, each single variable was found to have low positive predictive value (PPV) and requires other variables to improve the prediction. Finally, decision tree analysis demonstrated significant association between TOLAC success rate and prior VBAC, prior VD, and CD indications, without any association with the number of prior deliveries.Prior VBAC has some prediction value for TOLAC success and uterine rupture. However, it has low PPV as a single variable and requires other variables to improve the prediction. The number of prior VDs is not improving prediction.

Background Candidates for trial of labor after cesarean must be carefully screened to maximize success and minimize morbidity. Demographic and obstetric characteristics affecting success rates must be delineated. Objective We examined whether the labor stage of the primary delivery in which a woman underwent an unplanned cesarean delivery would affect the likelihood that she could achieve a subsequent vaginal birth. Study design Electronic medical records-based study of 676 parturients. Trial of labor rates and outcomes were compared between women whose primary cesarean delivery was performed in the first vs. the second stage of labor. Setting Hadassah Medical Center, Israel Population Women in their second pregnancies, with singleton fetuses, who underwent unplanned cesarean delivery in their first pregnancy and elected trial of labor in the second delivery. The main outcome measures were maternal and neonatal complications and vaginal birth rates in first vs. second stage of labor groups. Results In our population, 76 % of women attempt trial of labor after cesarean. Rates of successful vaginal delivery did not differ significantly between those who underwent primary cesarean in the first vs. second stage of labor: 67.4 % vs. 70.2 %, p = 0.483, respectively. Among women whose primary UCD was in the second stage, only 18.2 % (35/192) required a UCD in the second stage in the subsequent delivery, while 58.9 % (113/192) underwent UCD in the first stage in both deliveries. Conclusion Labor stage of the primary unplanned cesarean delivery, should not dissuade women from a trial of labor after cesarean in their second delivery.

Objective Inflammatory bowel diseases (IBD) are a group of pathologies associated with an increased rate of abortions, premature deliveries, cesarean sections and other morbidity during the peripartum period. The objective of this retrospective study was to investigate the anesthetic management for delivery of women with IBD. Material and methods The records of patients with IBD, who delivered at our Center, were obtained for data which included anesthetic and obstetric management as well as neonatal outcome. Five subgroups were defined based on mode of delivery, presence or absence of epidural in normal vaginal delivery (NVD) and urgency of cesarean section, each of which was compared with control groups of healthy parturients in the same period. Additionally, the rate of cesarean sections and the use of epidural analgesia for NVD were compared with the general obstetric population of our center in the same period. Results 107 patients with IBD who delivered at our center were studied. The rates of cesarean sections and emergency cesarean sections were significantly higher compared to the general population. However, the rate of instrumental delivery and of epidural analgesia use for NVD were similar. Among those who underwent cesarean sections, no significant differences were found in anesthesia type, surgery duration, number of complications, type of monitoring or postoperative management compared to the control group. Conclusion Peripartum anesthetic management of patients with IBD does not differ significantly from that of parturients without it. Anesthesiologists can plan their anesthesia in a similar way as they do in healthy parturients.

The ability to predict the need for emergency Cesarean delivery holds the potential to facilitate birth choices. The objective of the RECIPE study (Reducing Emergency Cesarean delivery and Improving the Primiparous Experience) was to externally validate a Cesarean delivery risk prediction model. This model, developed by the Genesis study, identified five key predictive factors for emergency Cesarean delivery: maternal age, maternal height, BMI, fetal head circumference (HC) and fetal abdominal circumference (AC).This prospective, observational study was conducted in two tertiary referral perinatal centers. Inclusion criteria were as follows: primiparous women with a singleton, cephalic presentation fetus in the absence of fetal growth restriction (FGR), oligohydramnios, pre-eclampsia, pre-existing diabetes mellitus or an indication for planned Cesarean delivery. Between 38 + 0 and 40 + 6 weeks' gestational age, participants attended for prenatal assessment that enabled the determination of an individualized risk calculation for emergency Cesarean delivery during labour based on maternal height, BMI, fetal HC and AC, with crucially both participants and care providers being blinded to the resultant risk prediction score. Labor, delivery and postnatal outcomes were ascertained. Calibration and receiver operator curves were generated to determine the predictive capacity for emergency Cesarean delivery of the Genesis risk prediction model in this cohort.559 primiparous participants were enrolled from May 2017 to April 2019, of whom 142 (25 %) had an emergency Cesarean delivery during labour. Participants with a low predicted risk score (10 %) had a mean predicted rate of 8% (+/- standard deviation of 2%) and a similarly low actual observed rate of Cesarean delivery (8%). Participants with a high predicted risk (50 %) had a mean predicted Cesarean delivery rate of 64 % (+/- standard deviation of 9%) and also had a high actual observed Cesarean delivery rate (62 %). The calibration curve and receiver operating characteristic curve demonstrated that this validation study had comparable discriminatory power for emergency Cesarean delivery to that described in the original Genesis study. The Area Under the Curve (AUC) in Genesis was 0.69, whereas the AUC in RECIPE was 0.72, which reflects good predictive capacity of the risk prediction model.The accuracy of the Genesis Cesarean delivery prediction tool is supported by this validation study.

Objective The objective of these guidelines is to define for women at low obstetric risk modalities that respect the physiology of delivery and guarantee the quality and safety of maternal and newborn care. Methods These guidelines were made by a consensus of experts based on an analysis of the scientific literature and the French and international recommendations available on the subject. Results It is recommended to conduct a complete initial examination of the woman in labor at admission (Consensus agreement). The labor will be monitored using a partogram that is a useful traceability tool (Consensus agreement). A transvaginal examination may be offered every two to four hours during the first stage of labor and every hour during the second stage of labor or before if the patient requests it, or in case of a warning sign. It is recommended that if anesthesia is required, epidural or spinal anesthesia should be used to prevent bronchial inhalation (grade A). The consumption of clear fluids is permitted throughout labor in patients with a low risk of general anesthesia (grade B). It is recommended to carry out a "low dose" epidural analgesia that respects the experience of delivery (grade A). It is recommended to maintain the epidural analgesia through a woman's self-administration pump (grade A). It is recommended to give the woman the choice of continuous (by cardiotocography) or discontinuous (by cardiotocography or intermittent auscultation) monitoring if the conditions of maternity organization and the permanent availability of staff allow it and, after having informed the woman of the benefits and risks of each technique (Consensus agreement). In the active phase of the first stage of labor, the dilation rate is considered abnormal if it is less than 1cm/4h between 5 and 7 cm or less than 1cm/2h above 7cm (level of Evidence 2). It is then recommended to propose an amniotomy if the membranes are intact or an oxytocin administration if the membranes are already ruptured, and the uterine contractions considered insufficient (Consensus agreement). It is recommended not to start expulsive efforts as soon as complete dilation is identified, but to let the presentation of the fetus drop (grade A). It is recommended to inform the gynecologist-obstetrician in case of nonprogression of the fetus after two hours of complete dilation with sufficient uterine dynamics (Consensus agreement). It is recommended not to use abdominal expression (grade B). It is recommended to carry out preventive administration of oxytocin at 5 or 10 IU to prevent PPH after vaginal delivery (grade A). In the case of placental retention, it is recommended to perform a manual removal of the placenta (grade A). In the absence of bleeding, it should be performed 30 minutes but not more than 60 minutes after delivery (Consensus agreement). It is recommended to assess at birth the breathing or screaming, and tone of the newborn to quickly determine if resuscitation is required (Consensus agreement). If the parameters are satisfactory (breathing present, screaming frankly, and normal tonicity), it is recommended to propose to the mother that she immediately place the newborn skin-to-skin with her mother if she wishes, with a monitoring protocol (grade B). Delayed cord clamping is recommended beyond the first 30 seconds in neonates, not requiring resuscitation (grade C). It is recommended that the first oral dose (2 mg) of vitamin K (Consensus agreement) be given systematically within two hours of birth. Conclusion These guidelines allow women at low obstetric risk to benefit from a better quality of care and optimal safety conditions while respecting the physiology of delivery.

Neuraxial anesthesia in obstetric patients may be difficult to achieve due to anatomical changes in pregnancy. The crossed-leg position may help in optimizing patient position. We prospectively evaluated the utility of the crossed-leg position compared with a standard position using ultrasound measurements.Thirty women with term singleton pregnancy admitted for vaginal delivery were recruited. Women with a history of spinal trauma or surgery, congenital spinal abnormality, advanced first stage of labor or a language barrier were excluded. Two anesthesiologists, blinded to each other's measurements, scanned each subject in the crossed-leg position and standard position. Measurements of the lengths of the posterior longitudinal ligament, ligamentum flavum and interlaminar distance were recorded at the L3-L4 interspace. Comfort level in each position was scored on a Likert Scale.Twenty-nine women completed the study (complete data n=28). Significant increases were observed in the lengths of the posterior longitudinal ligament (mean difference 2.2 mm, 95% CI 1.3 to 3.2; P0.001), ligamentum flavum (mean difference 1.4 mm, 95% CI 0.7 to 2.1; P0.001) and interlaminar distance (mean difference 1.4 mm, 95% CI 0.4 to 2.5; P=0.006) in the crossed-leg position. No significant differences in comfort were observed.We demonstrated a significant increase in the sonographically measured lengths of the posterior longitudinal ligament, ligamentum flavum and interlaminar distance in the crossed-leg position when compared with the standard position. Both positions were comfortable. Further studies should explore whether these findings translate clinically into easier needle placement in the crossed-leg position.

The objective of our study was to derive accurate estimates of risks of maternal and neonatal complications associated with Kielland's rotational forceps delivery (KRFD) compared to rotational ventouse delivery (RVD) or 2nd stage caesarean section (CS).This was a retrospective cohort study undertaken at a large tertiary maternity and neonatal unit in the United Kingdom between January 2010 and June 2018. Pregnancies with fetal demise, major fetal defects, those lost to follow-up, those delivering by elective or emergency CS in the first stage of labour and non-rotational instrumental deliveries were excluded. The study population included singleton pregnancies delivering by Kielland's forceps, rotational ventouse, 2nd stage CS or spontaneous unassisted cephalic vaginal delivery; the latter forming the control group. The maternal outcomes examined included post-partum haemorrhage (PPH) and obstetric anal sphincter injury (OASIS). The neonatal outcomes included admission to neonatal intensive care unit (NICU), 5-minute Apgar scores7, hypoxic ischaemic encephalopathy (HIE), jaundice, shoulder dystocia and birth trauma. Absolute risks with 95 % confidence intervals (CI) were calculated in the study groups. Univariate and multivariate logistic regression analysis was carried out to estimate crude and adjusted odds ratio (OR) with 95 % CI.The study population of 23,786 pregnancies included: 491 (2.1 %) requiring KRFD, 344 (1.4 %) requiring RVD, 840 (3.5 %) that had a 2nd stage CS and 22,111 (93.0 %) spontaneous cephalic vaginal deliveries. With regard to maternal adverse outcomes, in pregnancies that had a KRFD compared to RVD, there was no significant difference in the incidence of OASIS (p = 0.599) or PPH (p = 0.982). In contrast, the risk of PPH was significantly higher in those delivering by a 2nd stage CS compared to KRFD (27.5 % vs. 12.4 %; p0.0001). With regard to neonatal adverse outcomes, in those delivering by KRFD compared to RVD and 2nd stage CS, there was no significant difference in the incidence of admission to NICU (p = 0.912; p = 0.746, respectively), 5-minute Apgar score7 (p = 0.335; p = 0.150, respectively), jaundice (p = 0.810; p = 0.332, respectively), mild shoulder dystocia (p = 0.077), severe shoulder dystocia (p = 0.603) or birth trauma (p = 0.265; p = 0.323, respectively). The risk of maternal composite adverse outcome was highest after 2nd stage CS (OR 7.68; 95 %CI: 6.52-9.04) and lowest after KRFD (OR 3.82; 95 %CI: 2.98-4.91). The risk of composite neonatal adverse outcome was higher in those delivering by RVD (OR 2.87; 95 %CI: 2.10-3.91), compared to KRFD (OR 2.23; 95 %CI: 1.67-2.97) or 2nd stage CS (OR 2.02; 95 %CI: 1.60-2.54).Our study demonstrates that KRFD is a safer management option when compared to RVD or 2nd stage CS for the management of persistent fetal malposition in labour.

Study Objective To evaluate urinary incontinence (UI) risk factors in primiparous adolescents between 7 and 48 months after vaginal delivery. Design Cohort study. Setting Physical Therapy Laboratory on Women's Health and Pelvic Floor at the Federal University of Pernambuco. Participants, Interventions, and Main Outcome Measures Cohort follow-up time was 7-48 months after delivery, guaranteeing that no participant presented with UI until 7 months after the infant's birth. Primiparous adolescents aged 10-19 years were included in the study, and those who had UI during pregnancy were excluded. Sample size was estimated at 140 volunteers, considering the calculation for logistic regression, with 20 observation units for each of the 7 variables proposed in the theoretical model developed for the study. The volunteers answered the evaluation form, providing information on the outcome of interest and possible risk factors. Univariate logistic regression analysis was performed. Results The following risk factors for UI were identified in primiparous adolescents after vaginal delivery: episiotomy (Relative risk [RR]a, 2.75; 95% confidence interval [CI], 1.22-6.06), large newborn for gestational age (RRa, 4.58; 95% CI, 1.68–12.46) and less than six prenatal appointments (RRa, 2.51; 95% CI, 1.05–6.04). Conclusion Professionals working in maternal health care should pay special attention to primigravid mothers, guide prenatal appointments, avoid routine episiotomy, and use obstetric practices recommended by the World Health Organization.

Objectives This review aimed to explore the independent risk factors of postpartum urinary retention (PUR) after a vaginal delivery. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed and relevant studies were retrieved from eleven databases. The quality of the included articles was assessed using Critical Appraisal Skills Programme tools or the Appraisal tool for Cross-Sectional Studies. The data analysis was performed using Review Manager version 5.3. Results A total of nine articles were included and five risk factors were identified, namely, episiotomy (OR = 2.99, 95%CI = 1.31–6.79, P = 0.009), epidural analgesia (OR = 2.48, 95%CI = 1.09–5.68, P = 0.03), primiparity (OR = 2.17, 95%CI = 1.06–4.46, P = 0.03), instrumental delivery (OR = 4.01, 95%CI = 1.97–8.18, P

This study aimed to explore the feasibility of transperineal virtual touch tissue quantification (VTQ) for predicting the outcome of labor induction. A total of 80 nulliparous pregnant women were included. Before labor induction, cervical length was measured by B-mode sonography, cervical stiffness was measured by VTQ, and Bishop score was assessed by vaginal examination. Subsequently, labor was induced using standard oxytocin infusion in all patients. Delivery within 24 hours after labor induction was classified as spontaneous delivery; otherwise, cesarean delivery was performed. Out of 80 participants, 48 (60%) delivered vaginally and 32 (40%) underwent cesarean delivery. The cervical length was significantly longer and the shear wave velocity (SWV) was greater in the cesarean delivery group than in the vaginal delivery group (p = 0.004 and p0.000, respectively). Logistic regression analysis indicated that only the mean SWV had independent predictive value for the outcome of labor induction (p = 0.011). The best diagnostic cut-off point of the mean SWV was 1.23 m/s, with a sensitivity of 93.8% and a specificity of 89.6%. Transperineal VTQ technique could predict the outcome of labor induction using oxytocin.

Background Obstetric anal sphincter injuries (OASIS) are the commonest cause of anal incontinence in women of reproductive age. We determined the risk of anal sphincter defects diagnosed by ultrasound, and the risk of anal incontinence in (i) all women who deliver vaginally, (ii) in women without clinical suspicion of OASIS, and (iii) after primary repair of sphincter injury, by systematic review. Methods We searched major databases until June 2018, without language restrictions. Random effects meta-analysis was used to obtain pooled estimates of ultrasound diagnosed OASIS and risk of anal incontinence symptoms at various time points after delivery, and of persistent sphincter defects after primary repair. We reported the association between ultrasound diagnosed OASIS and anal incontinence symptoms using relative risk (RR) with 95 % CI. Results We included 103 studies involving 16,110 women. Of all women who delivered vaginally, OASIS were diagnosed on ultrasound in 26 % (95 %CI, 21–30, I2 = 91 %), and 19 % experienced anal incontinence (95 %CI, 14–25, I2 = 92 %). In women without clinical suspicion of OASIS (n = 3688), sphincter defects were observed in 13 % (10–17, I2 = 89 %) and anal incontinence experienced by 14 % (95 % CI: 6–24, I2 = 95 %). Following primary repair of OASIS, 55 % (46–63, I2 = 98 %) of 7549 women had persistent sphincter defect with 38 % experiencing anal incontinence (33–43, I2 = 92 %). There was a significant association between ultrasound diagnosed OASIS and anal incontinence (RR 3.74, 2.17−6.45, I2 = 98 %). Interpretation Women and clinicians should be aware of the high risk for sphincter defects following vaginal delivery even when clinically unsuspected. This underlines the need of careful and systematic perineal assessment after birth to mitigate the risk of missing OASIS. We also noted a high rate of persistent defects and symptoms following primary repair of OASIS. This dictates the need for provision of robust training for clinicians to achieve proficiency and sustain competency in repairing OASIS.

Introduction The best way to deliver a term breech infant is still a much discussed topic among obstetricians. The question whether nulliparity should be considered an exclusion criterion for an intended vaginal breech delivery is not fully answered. Objective We compared maternal and neonatal outcome of intended vaginal breech deliveries of nulliparous versus multiparous women at term. Study design We conducted a prospective case-control study between January 2004 and December 2016. 1046 women expecting singletons at term with favorable pelvic measurements were enrolled in the study. Results Neonatal morbidity and mortality was not significantly different in deliveries of nulliparous (n = 647) versus multiparous (n = 399) women. Nulliparous women had a significantly higher rate of a cesarean section during labor than multiparous women. Maternal birth-injury rates and the use of epidural anesthesia were significantly higher comparing vaginal births of nulliparous (n = 384) versus multiparous (n = 331) women. Conclusion Nulliparity seems not be an exclusion criterion for intended vaginal breech birth at term. It is still important to inform the women of an increased risk of a cesarean section during labor. A clinical management built on this evidence might reduce negative implications for future pregnancies.

Objective It is well understood that advanced skills are required for operative vaginal delivery to ensure a woman’s birth experience is safe, positive and to prevent adverse long term harm. We sought to identify non-technical skills determined by women to enhance experience of operative vaginal delivery by qualitative analysis of interviews conducted during the postpartum period. Design A qualitative study using semi structured interviews took place at a University teaching hospital. Sixteen women who had an operative delivery of a term baby underwent a semi structured interview at 6–8 weeks postnatal. The women were asked to reflect on good and bad experiences of their delivery and the interview was recorded verbatim. Thematic coding of data was carried out and then analysed. Women were given the option to review the transcript for respondent validation. The anonymised transcripts were independently coded by two researchers and then compared for consistency of interpretation. The themes that emerged following the final coding were used to identify a framework of behavioural and clinical skills. Results We identified several non-technical skills that were important to women’s’ experience of operative delivery. Professional behaviour and relationships, decision making and communication, preconceptions and preparation for operative birth, teamwork, environment and consent were themes that emerged from women’s experiences which can now provide clinicians with a comprehensive behavioural framework for operative vaginal delivery. Conclusion This illustration of detailed non-technical skills that has been validated by women could be used as part of clinical training and revalidation.

Objectives Today all pregnant women are recommended to participate in moderate intensity aerobic and resistance-based physical activity/exercise ≥150 min/week. However, there are still controversies and scant knowledge on the role of regular exercise on delivery outcomes, including mode of delivery and length of active labour. In addition, nutritional counselling have often been examined together with exercise, which may independently effect the outcomes. Hence, the aims of the present study were to investigate the sole effect of supervised group exercise, including pelvic floor muscle training on course of labour and mode of delivery. Study design A single blind, randomized controlled trial, performed in the municipality of Oslo, Norway. Out of 105 healthy, inactive nulliparous women, initially enrolled (gestation week 17.7 ± 4.2) to study the effect regular aerobic exercise (60 min 2/week) on health benefits for both mother and her baby, 90 (85.7%) completed postpartum follow-up (7.7 ± 1.7) on labour outcomes (exercise: 43 and control: 47). Data were collected via standardized interviews and birth partographs from hospital records, reported on the postpartum visit (weeks after labour 7.6 ± 1.6). The primary investigator was unaware of the original randomization at the time of the interviews. The principal analysis was done on an intention to treat basis (ITT). For the planned subgroup analyses (per protocol), acceptable intervention adherence was defined as attending ≥ 80% of the recommended exercise program (≥ 19 exercise sessions). Results There were no differences between the exercise and control groups in induction of labour, use of analgesia, duration of active labour or prolonged labour, according to ITT. Per protocol analyses, showed a shorter duration of total active labour in the exercise group (6.8 ± 5.5 h) than the control group (9.8 ± 5.4 h), with a mean between group difference of 3.1 h (95% CI 0.31–5.9, p = 0.029). Rate of normal vaginal delivery was 85.7% among adherent participants and 62.3% in the control group (p = 0.051). Conclusions Regular exercise during pregnancy decreased duration of total active labour and showed a trend towards more normal vaginal deliveries among participants who adhered to the prescribed program. Trial registration ClinicalTrials.gov: NCT00617149

A pseudoaneurysm of the uterine artery or its branches is usually a result of vascular trauma during invasive procedures such as a cesarean section, vaginal delivery, myomectomy, hysterotomy, or dilatation and curettage. A uterine artery pseudoaneurysm rupture is a rare, yet life-threatening event. Deep infiltrating endometriosis usually involves a decrease in symptoms and imaging findings throughout pregnancy, with the notable exception of the phenomenon of decidualization. We present the case of a pregnant woman with a recent diagnosis of endometriosis, who conceived spontaneously and presented with disabling pain at 13 weeks' gestation. She was diagnosed with a left, huge (and rapidly growing) retrocervical endometriosis nodule encompassing a uterine artery pseudoaneurysm. Selective transarterial embolization was performed at 22 weeks' gestation owing to enlargement of the pseudoaneurysm sac, and the pseudoaneurysm was obliterated successfully. The patient was followed intensively throughout the pregnancy and the baby was delivered at term by cesarean section. After delivery, the nodule returned to the pregestational size.

The risk of vertical transmission during vaginal delivery in COVID-19 pregnant patients is currently a topic of debate. Obstetric norms on vaginal birth assistance to reduce the potential risk of perinatal infection should be promoted by ensuring that the risk of contamination from maternal anus and faecal material is reduced during vaginal delivery.

Introduction To examine the effects and safety of oxytocin administered intramuscularly or intravenously for preventing postpartum hemorrhage (PPH) in the third stage of labor after vaginal deliveries. Material and methods Before data extraction, the review was registered with the PROSPERO International Prospective Register of Systematic Reviews (registration No. CRD42019145912). We searched the published electronic databases, including Medline, EMBASE, PubMed, Web of Science, CNKI, VIP, Wanfang, the Cochrane Library, clinicaltrial.gov and PROSPERO database, from their inception until February 2019. We included all randomized controlled trials (RCTs) comparing intramuscular and intravenous oxytocin administered just after the birth of the anterior shoulder or soon after the birth of the baby during a vaginal delivery. The primary outcomes were the incidence of PPH and severe PPH. PPH was defined as a blood loss ≥500 ml within 24 hours after vaginal birth. Severe PPH refers to a clinically estimated blood loss equal to or greater than 1000 mL within 24 hours after vaginal birth. Statistical heterogeneity was assessed by the I2 test, the Cochran Q statistic and the Galbraith plot for heterogeneity. Results Six RCTs, including 7320 women undergoing vaginal delivery, were identified in the meta-analysis. Women who were randomized to have intravenous oxytocin for the third stage of labor had a significantly lower incidence of PPH (relative risk 1.35, 95% CI 1.11-1.64, p = 0.003), severe PPH (relative risk 1.61, 95% CI 1.05-2.46, p = 0.03) and blood transfusion (relative risk 2.50, 95% CI 1.37-4.59, p = 0.003) compared with those who were randomized to have intramuscular oxytocin during the third stage of labor after vaginal delivery. There was no significant difference with regard to changes in hemoglobin level, third stage of labor duration, mean postpartum blood loss, or the incidences of a need for additional uterotonics and of retained placenta or manual removal of placenta between groups. Conclusions For women in the third stage of labor who are undergoing a vaginal delivery, the use of intravenous oxytocin reduces the incidence of PPH, severe PPH and blood transfusion and does not increase the risk of adverse effects compared with intramuscular oxytocin.

Objective Previous systematic reviews have reported that cesarean birth is associated with reduced rate of subsequent fertility. However, other common mode of delivery was poorly understood. The aim of this study was to systematically investigate the subsequent fertility in patients having different modes of non-spontaneous vaginal delivery, if compared to normal vaginal delivery. Study Designs Medline (via PubMed), Web of Science, Embase (via Dialog), CENTRAL (via Cochrane Library), ScienceDirect (via Elsevier) and ClinicalTrial.gov were searched up to October 2019, without language restrictions in this systematic review and meta-analysis. Articles assessing the mode of delivery and subsequent fertility were included. Quality assessment was evaluated using the nine-point Newcastle Ottawa Scale by two independent reviewers. Results Twenty-one articles, including 4,423,544 women of reproductive age, were included. Results showed that women had a 9% (RR: 0.91 [95 %CI 0.88, 0.94]) lower probability of subsequent fertility in primary cesarean birth group, compared with spontaneous vaginal delivery. Further analysis discovered that a 13 % (0.87, [0.85, 0.90]) lower probability of subsequent fertility was observed in women delivered by emergency cesarean birth, a 14 % (0.86, [0.82, 0.91) lower probability by elective cesarean birth, a 39 % (0.61, [0.57, 0.66]) by maternal-requested cesarean birth, and a 2% (0.98, [0.97, 1.00]) by instrumental vaginal delivery. Conclusions Non-spontaneous vaginal delivery may be associated with lower probability of subsequent fertility. Decision makers and obstetricians should be cautious when choosing the mode of delivery.

Breech presentation is the most common form of malpresentation, and associated with perinatal asphyxia and mortality, and maternal morbidity. Data associated with labor induction in breech presentation are limited. The aim of this study was to compare maternal and fetal complication rates in induced and spontaneous vaginal, and cesarean delivery with breech presentation.Pregnant women with breech presentation were grouped: spontaneous vaginal delivery (Group 1, n = 72) induced or augmented vaginal delivery (Group 2, n = 32), and cesarean delivery (Group 3, n = 253). Fetal complications were as follows: clavicle fracture, femur fracture, humerus fracture, brachial plexus injury, cephalic hematoma, pneumothorax, need for intensive care unit (ICU), and 5th minute APGAR7. Maternal complications were as follows: vaginal hematoma, deep vaginal laceration, perineal injury (≥3rd degree), decline in hemoglobin level (2 g/dL), and postpartum endometritis. Data were collected and analyzed retrospectively.The highest fetal complication rate was in Group 2, and the lowest in Group 3 (p = 0.001). Clavicle fracture was significantly less in Group 3 compared with the other groups (p = 0.024). The rate of lower APGAR scores at the 5th minute was similar in all groups. Maternal complications were significantly higher in Group 2 compared with the other groups (p = 0.001). Fetal complications were 5.66-fold higher in Group 1 than in Group 3 (p = 0.002). Fetal and maternal complications were 9.48-fold and 7.48-fold higher, respectively, in Group 2 than in Group 3 (p 0.001).This study is the first in literature to have investigated and analyzed neonatal complications in breech delivery according to different delivery modes including induced vaginal delivery. Due to possible complications, the risks and benefits of a specific type of delivery should be considered in breech presentation.

The frequency of operative vaginal delivery has been declining, even though it can be an attractive alternative to cesarean delivery in selected cases. Performance of operative vaginal delivery required consideration of many indications, contraindications, and prerequisites. Optimal documentation of operative vaginal delivery requires the recording of several specific elements that are unique to forceps or vacuum delivery. A cognitive aid such as a checklist is well suited to this situation in which there are numerous elements to consider, a low frequency of performance, and teams with variable expertise. We propose 2 checklists to help ensure that all relevant elements are considered for every operative vaginal delivery: (1) a checklist for preparation and performance of the procedure and (2) a checklist for documentation. We suggest practical tips to help facilities adapt these checklists to their own circumstances and implement them on their units.

Objective To evaluate current availability and needs of simulation training among obstetrics/gynecology (OB/GYN) residency programs. Design Cross-sectional survey. Setting Accreditation Council for Graduate Medical Education accredited OB/GYN residency programs in the United States. Participants Residency program directors, gynecology simulation faculty, obstetrics simulation faculty, and fourth-year residents. Results Of 673 invited participants, 251 (37.3%) completed the survey. Among the survey responses, OB procedures were more broadly represented compared to the GYN procedures for simulation teaching: 8 (50%) of 16 OB procedures versus 4 (18.2%) of 22 GYN procedures had simulation teaching. Among the simulated procedures, a majority of residents and faculty reported that simulation teaching was available for operative vaginal delivery, postpartum hemorrhage, shoulder dystocia, perineal laceration repair, conventional laparoscopic procedures, and robotic surgery. There were significant differences between residents and faculty perceptions regarding the availability and needs of simulated procedures with a minority of residents having knowledge of Council on Resident Education in Obstetrics and Gynecology (47.2%) and American College of Obstetrics and Gynecology (27.8%) simulation tools compared to the majority of faculty (84.7% and 72.1%, respectively). More than 80% of trainees and faculty reported they felt the average graduating resident could perform vaginal, laparoscopic, and abdominal hysterectomies independently. Conclusions Simulation is now widely available for both gynecologic and obstetric procedures, but there remains tremendous heterogeneity between programs and the perceptions of residents, program directors, and faculty. The variations in simulation training and readiness for performing different procedures following residency support the need for objective, validated assessments of actual performance to better guide resident learning and faculty teaching efforts.