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Although perimortem delivery has been recorded in the medical literature for millennia, the procedural intent has evolved to the current fetocentric approach, predicating timing of delivery following maternal cardiopulmonary arrest to optimize neonatal outcome. We suggest a call to action to reinforce the concept that if the uterus is palpable at or above the umbilicus, preparations for delivery should be made simultaneous with initiation of maternal resuscitative efforts; if maternal condition is not rapidly reversible, hysterotomy with delivery should be performed regardless of fetal viability or elapsed time since arrest. Cognizant of the difficulty in determining precise timing of arrest in clinical practice, if fetal status is already compromised further delay while attempting to assess fetal heart rate, locating optimal surgical equipment, or transporting to an operating room will result in unnecessary worsening of both maternal and fetal condition. Even if intrauterine demise has already occurred, maternal resuscitative efforts will typically be markedly improved following delivery with uterine decompression. Consequently we suggest that perimortem cesarean delivery be renamed "resuscitative hysterotomy" to reflect the mutual optimization of resuscitation efforts that would potentially provide earlier and more substantial benefit to both mother and baby., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To identify independent risk factors for cesarean delivery after induction of labor and to develop a nomogram for predicting cesarean delivery among nulliparous women undergoing induction of labor at term., Methods: This is a retrospective cohort study including nulliparous women with singleton, term (37 0/7 weeks of gestation or greater), cephalic pregnancies undergoing induction of labor from July 1, 2006, through May 31, 2012, at a tertiary care academic center. Inductions were identified using International Classification of Diseases, 9th Revision codes. Demographic, delivery, and outcome data were abstracted manually from the medical record. Women with a contraindication to vaginal delivery (malpresentation, abnormal placentation, prior myomectomy) were excluded. Independent risk factors for cesarean delivery were identified using logistic regression., Results: During the study period, there were 785 nulliparous inductions that met study criteria; 231 (29.4%) underwent cesarean delivery. Independent risk factors associated with an increased risk of cesarean delivery included older maternal age, shorter maternal height, greater body mass index, greater weight gain during pregnancy, older gestational age, hypertension, diabetes mellitus, and initial cervical dilation less than 3 cm. A nomogram was constructed based on the final model with a bias-corrected c-index of 0.709 (95% confidence interval 0.671-0.750)., Conclusion: We identified independent risk factors that can be used to predict cesarean delivery among nulliparous women undergoing induction of labor at term. If validated in other populations, the nomogram could be useful for individualized counseling of women with a combination of identifiable antepartum risk factors., Level of Evidence: II.

Background: Uterine incarceration is an infrequent complication of pregnancy in the early second trimester. Although imaging can be confirmatory, the diagnosis is made primarily on clinical grounds, and definitive treatment involves manual reduction to restore the proper anatomic position. Except for preexisting uterine retroversion, often this event is idiopathic., Case: A 30-year-old primigravida presented at 15 weeks' gestation with uterine incarceration. Manual replacement was unsuccessful. Spontaneous resolution occurred at 20 weeks, followed by uneventful pregnancy. The patient underwent a classical cesarean section at term due to fetal malpresentation., Conclusion: Uterine incarceration may be managed conservatively, with a favorable outcome.

Background/aims: The aim of this study was to evaluate the impact of a restrictive labor induction approval process on induction and primary cesarean delivery rates.Methods: A retrospective cohort study was conducted at a tertiary care academic center from 2006 through 2012. The cohort of deliveries before (pre-intervention) and after (post-intervention) the process included term, singleton pregnancies with no contraindication to vaginal delivery. The primary outcome was induction of labor rates, subgrouped on the basis of whether it was medically or nonmedically indicated. Secondary outcomes included the primary cesarean rate and other maternal and neonatal outcomes.Results: Of 13,753 deliveries, 6,746 met study inclusion criteria. There was a significant decrease in induction rates comparing the pre- and post-intervention periods (21.0 vs. 18.5%, p = 0.01). Nonmedically indicated induction rates also decreased significantly (2.9 vs. 0.6%, p < 0.001). No difference was observed in medically indicated induction (18.1 vs. 17.9%, p = 0.84), the primary cesarean rate (14.4 vs. 15.8%, p = 0.12), or any of the measured neonatal outcomes (p > 0.05).Conclusions: Implementation of a labor induction approval process was associated with a significant reduction in overall and non-indicated induction rates but did not affect the primary cesarean rate or neonatal outcomes. [ABSTRACT FROM AUTHOR]

Objective The objective of this study was to determine the maternal and fetal pharmacokinetic (PK) profiles of acetaminophen after administration of a therapeutic oral dose. Study Design After obtaining Institutional Review Board approval and their written informed consent, pregnant women were given a single oral dose (1,000 mg) of acetaminophen upon admission for scheduled cesarean delivery. Maternal venous blood and fetal cord blood were obtained at the time of delivery and acetaminophen levels were measured using gas chromatography-mass spectroscopy. PK parameters were calculated by noncompartmental analysis. Nonparametric correlation of maternal/fetal acetaminophen levels and PK curves were calculated. Results In this study, 34 subjects were enrolled (median, 32 years; range, 25-39 years). The median maternal weight was 82 kg (range, 62-100 kg). All but two subjects were delivered beyond 39 weeks' gestation. The median newborn birth weight was 3,590 g (interquartile range, 3,403-3,848 g). Noncompartmental analysis described similar PK parameters in the maternal (T1/2, 84 minutes; apparent clearance [Cl/F], 28.8 L/h; apparent volume of distribution [Vd/F], 57.5 L) and fetal compartments (T1/2, 82 minutes; Cl/F, 31.2 L/h; Vd/F, 61.2 L). Paired maternal/fetal acetaminophen levels were highly correlated (p < 0.0001). Conclusion Fetal acetaminophen PKs in the fetus parallels that in the mother suggesting that placental transfer is flow limited. Maternal acetaminophen levels can be used as a surrogate for fetal exposure. [ABSTRACT FROM AUTHOR]

Evaluates whether increased pregnancy and body mass are associated with an increased rate or cesarean delivery. Participants in the evaluation; Details on the rise of cesarean delivery rates in the United States; Factors which attribute to this rise; Results from the evaluation.

Background: Incarceration of the pregnant uterus is a rare condition and can lead to bladder obstruction, renal failure, or uterine rupture. We present a novel, noninvasive technique to reduce an incarcerated uterus.Method: With conscious sedation, the patient was placed in all-fours position. The physician's hands were placed on the patient's abdomen and pressure applied until the uterine fundus was palpated. Gentle, steady fundal pressure on both sides was directed toward the maternal chest (bilateral mediocephalad pressure) elevating the uterus out of the pelvis. This approach successfully reduced the gravid incarcerated uterus and was well tolerated by the patient and fetus.Experience: The author's experience with this method is limited to this case. Prior experience with reduction of the incarcerated uterus has been with methods previously described in the literature.Conclusion: In conjunction with conscious sedation and all-fours positioning, transabdominal manipulation of the uterine fundus with bilateral mediocephalad pressure may facilitate reduction of an incarcerated uterus. This method may obviate the need for more invasive procedures. [ABSTRACT FROM AUTHOR]