Search

Background: Recent evidence supports elective induction of labor at 39 weeks in low-risk pregnancies to improve maternal and perinatal outcomes. This evidence includes the ARRIVE trial (A Randomized Trial of Induction Versus Expectant Management). However, concerns have been raised on the external validity of the ARRIVE trial, especially with regard to the demographic and clinical characteristics of the pregnant women recruited., Objective: This study compared the outcomes in a cohort of consecutive pregnant women, who fulfilled the criteria of the ARRIVE trial and were managed expectantly in an Italian referral academic hospital, with those reported in the expectant and induction arms of the ARRIVE trial., Study Design: This was a retrospective single-center study. Consecutive low-risk nulliparous women who fulfilled the ARRIVE trial criteria were evaluated for eligibility at 36-38 weeks of gestation. Those who neither developed complications nor delivered spontaneously before 39 weeks were eligible for this comparative analysis. Maternal and fetal growth and wellbeing were screened and monitored from 36 to 38 weeks of gestation., Results: A total of 1696 patients met the established criteria at recruitment. Of these, 343 spontaneously delivered in <39 weeks, 82 delivered because of maternal indication, and 37 for fetal indication. A total of 1234 pregnant women were eligible for comparison with the elective induction and the expectant management groups of the ARRIVE trial. The socioeconomic status was significantly better, maternal age was significantly higher, and body mass index was significantly lower in our cohort. Cesarean section rate in our cohort was lower than that of the expectant group of the ARRIVE trial (18.7 vs. 22.2%; p  = 0.02) and similar to that of the elective induction group (18.7 vs. 18.6%). A new diagnosis of hypertensive disorders during expectant management was noted in 1.6% in our cohort vs. 14.1% in the ARRIVE arm. Among the different obstetric outcomes, only the prevalence of postpartum hemorrhage was not significantly lower in our cohort. The primary perinatal composite outcome was significantly better in our cohort than in both arms of the ARRIVE trial (2.1 vs. 5.4% in the expectant group and 4.3% in the induction group). We did not record cases with an Apgar score ≤ 3 or hypoxic-ischemic encephalopathy., Conclusion: In our cohort, expectant management in low-risk pregnancies with late preterm screening of feto-maternal well-being seemed to achieve better maternal and perinatal outcomes than a universal policy of induction at 39 weeks. The results of the ARRIVE trial should be carefully evaluated in different demographic and clinical settings and cannot be extended to the general population.

Objective: To assess the added value of Doppler parameters, maternal history, and intrapartum clinical characteristics for the prediction of emergency delivery due to non-reassuring fetal status in low-risk pregnancies., Methods: This was a prospective cohort of low-risk pregnancies undergoing ultrasound assessment at 40 weeks' gestation within 7 days of delivery. The main outcome was emergency cesarean section due to non-reassuring fetal status. The association between Doppler parameters, intrapartum clinical characteristics, and maternal history was performed by logistic regression. The predictive performance of the constructed models was assessed by receiver operating characteristic (ROC) curve analysis and the area under the curve (AUC)., Results: From 403 included pregnancies, 18.6% ( n  = 75) underwent an emergency delivery due to non-reassuring fetal status. The mean gestational age at birth was 40.5 (SD 5) days. Middle cerebral artery pulsatility index (MCA) and cerebroplacental ratio (CPR) were lower in the emergency cesarean section group (1.16 versus 1.30; p  < .001, and 1.61 versus 1.78; p  = .001, respectively). There was a higher incidence of small-for-gestational-age neonates (20 versus 10.1%; p  = .017), lower Apgar scores at the 5th minute (9.7 versus 9.9; p  = .006), and NICU admissions (9 versus 3%; p  = .016) in the emergency cesarean section group. The base model comprised nulliparity, and the finding of meconium-stained amniotic fluid during labor, achieving an AUC of 66%, while the addition of the MCA Z-score significantly improved the previous model (AUC: 73%; DeLong: p  = .008)., Conclusions: In low-risk pregnant woman at term, the addition of MCA Z-score to a previous model comprising maternal history and intrapartum clinical findings, significantly improves the prediction of emergency delivery due to non-reassuring fetal status.

Purpose: Dystocia is the leading indication for primary caesarean sections. Our aim is to compare two approaches in the management of dystocia in labor in nulliparous women with a singleton fetus in cephalic presentation at term in spontaneous or induced labor., Methods: Prospective cohort study. Four hundred and nineteen consecutive patients were divided into two groups: the standard management group (SM), in acceleration of labor was commenced at the "action line" in the case of arrested or protracted labor, and the comprehensive management group (CM) in which arrested or protracted labor was considered as a warning sign promoting further diagnostic assessment prior to considering intervention., Results: Caesarean sections rate was 22.2 % in the SM group (216 patients) and 10.3 % in the CM group (203 patients) (p = 0.001). The rate of oxytocin use decreased from 33.3 % in SM group to 13.8 % in the CM group (p < 0.0005). The rate of amniotomy decreased from 41.7 % in the SM group to 7.4 % in the CM group (p < 0.0005). The percentage of newborns with 5-min Apgar score <7 and/or umbilical cord arterial pH ≤ 7.00 decreased from 2.3 % in SM cohort to 0.5 % in CM cohort (p = ns). The average length of labor did not differ between the two groups of patients (264 vs 277 min; p = ns)., Conclusion: Comprehensive management of dystocia enabled us to achieve a reduction in iatrogenic interventions in labor while maintaining good neonatal outcomes.

Objective: To describe morbidity in neonates born by cesarean section (CS) before labor between 34(+0) and 38(+6) weeks, stratified by gestational age., Methods: Cohort study from five Italian tertiary care hospitals. Consecutive singleton pregnancies delivered by CS before labor between 34(+0) and 38(+6) weeks of gestation from January 2010 to August 2011 were included. Women in labor, with premature rupture of membranes, or with previous administration of steroids were excluded. The incidence of neonatal complication by gestational week was calculated., Results: A total of 1135 cases were analyzed. Composite adverse neonatal outcomes, respiratory distress syndrome, transient tachypnea and use of continuous airway positive pressure decreased from 50%, 28%, 5% and 22% at 34 weeks of gestation, to 4.7%, 1.0%, 0.9% and 0.3% at 38 weeks of gestation. Multivariate analysis showed that the only variable independently associated with composite adverse neonatal outcome was gestational age at delivery (adjusted odds ratio 0.49; 95% confidence interval 0.39-0.61)., Conclusions: The prevalence of neonatal complications in newborns delivered by CS before labor halves at each week of gestation from 34 to 38 weeks. Nonetheless complications, and mainly respiratory problems, are still present at early term gestation.

BACKGROUND: Women's memories of their childbirth experience tend to remain unchanged over time. This experience can be influenced by obstetric factors as well as by sociodemographic and psychological variables. OBJECTIVE: To examine whether women's perceived childbirth experience changes over time; to identify the predictors (obstetric, sociodemographic, and psychological variables) of this experience immediately after delivery and after 3 months. METHODS: This prospective longitudinal study comprised two hundred and twenty-one Italian women who completed a self-report questionnaire at two assessment points: immediately (1–3 days) after birth (Time 1) and 3 months postpartum (Time 2). At Time 1, the questionnaire included some questions on sociodemographic, psychological, and obstetric information, and the Wijma Delivery Experience Questionnaire (WDEQ(B); at Time 2 women compiled again the WDEQ(B). RESULTS: Repeated measures ANOVA revealed that the childbirth experience did not change from Time 1 to Time 2. However, predictors of this experience were different between Time 1 and Time 2: at Time 1, the childbirth experience (WDEQ(B)_t1) was significantly predicted nly by type of cesarean section; at Time 2, the childbirth experience (WDEQ(B)_t2) was significantly predicted by WDEQ(B)_t1, history of psychological disorders, and type of conception. DISCUSSIONS: Our findings enhance the understanding of the main predictors of a woman's childbirth experience. Identifying areas of vulnerability is important for clinical practice, as well as for developing maternal health policies to improve women's birth experiences, postpartum well-being, and the baby's development. [ABSTRACT FROM AUTHOR]

Introduction: We investigated the role of body mass index (BMI) and maternal age on the risk of late-term induction, prolonged induction time and caesarean section (CS) after induction.Material and Methods: This is a retrospective, observational study. All women without any fetal or maternal pathological condition, uterine scars or any other indication for an elective caesarean birth and had a singleton foetus in the cephalic position at term were included.Results: A total of 4006 women had a spontaneous onset of labour and 612 were induced for a late-term pregnancy. Labour induction was significantly more common in overweight (Adj Odds Ratio (OR) 1.48 95%CI 1.22-1.78) and obese (Adj OR 1.63 95%CI 1.24-2.14) women. Among induced women, a BMI ≥ 30 was a risk factor for a prolonged induction time in both nulliparous (AdjOR 2.4, 95%CI 1.02-5.67) and multiparous women (AdjOR 4.24, 95%CI 1.02-17.6). A BMI > 25-29.9 was significantly associated with a prolonged induction time only in nulliparous women (AdjOR 1.86 95%CI 1.05-3.30). A CS was more frequent in overweight (AdjOR 1.74, 95% CI 1.052.89) and obese women (AdjOR 2.72, 95%CI 1.42-5.25). Nulliparous women ageed 30-34 years had an induction time longer than women <30 years (OR 2.04 95%CI 1.07-3.91).Conclusions: The results of this study suggest that a BMI > 25 kg/m2 at term of pregnancy is a risk factor for the induction of labour during a late-term pregnancy, a prolonged induction time and higher caesarean section rate. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effectiveness and safety of 25 mcg sublingual misoprostol for induction of Labor at term according to parity and membrane integrity.Methods: We conducted a prospective observational study on singleton pregnancies undergoing induction of Labor at term. Twenty-five mcg of misoprostol were administered sublingually every 4 h. Main outcomes were vaginal deliveries within 24 h, time-to-vaginal-delivery, hyper-stimulation syndrome, cesarean section rate, arterial pH< 7.0 and NICU admission rate.Results: We studied 508 patients, 375 nulliparous and 133 multiparous women. Sixty-five percent and 78%, respectively, delivered vaginally within 24 h from first administration. Median time-to-vaginal-delivery was significantly shorter in PROM than in women with intact membranes (p < 0.001). Epidural analgesia prolonged time-to-vaginal-delivery among nulliparous women (p < 0.0005). A positive correlation between BMI and time to delivery was observed in both nulliparous and multiparous women (p < 0.05). Cesarean section rate was 22% in nulliparous and 6% in multiparous group. Induction failure was 1.4% and uterine hyper-stimulation 1%. No pH≤ 7.00 was recorded; overall 7 (1.4%) newborns were admitted to NICU.Conclusions: Sublingually administered misoprostol is an effective and safe method for induction of Labor at term. Parity, status of membranes and BMI significantly affect time to delivery. [ABSTRACT FROM AUTHOR]

Objective: To analyze maternal and neonatal outcomes of midwife-led labor in low-risk women at term. Methods: Prospective observational cohort of 1788 singleton low-risk pregnancies in spontaneous term labor, managed according to a specific midwife-led labor protocol. Primary outcomes were mode of delivery, episiotomy, 3rd–4th degree lacerations, post-partum hemorrhage (PPH), need for blood transfusions, pH and Apgar score and NICU admissions. Results: A total 1754 low-risk women (50.3% of all deliveries) were included in the analysis. Epidural analgesia was performed in 29.8% of cases. The rate of cesarean section was 3.7%. Episiotomy was performed in 17.6% of women. PPH > 1000 ml occurred in 1.7% of cases. 3.2% and 0.3% of the cases had an Apgar score <7 and pH < 7.10, respectively, while 0.3% of the newborns were admitted to NICU. Consultant-led labor was required for emerging risk factors during 1st and 2nd stage of labor in 16.1 and 8.6% of cases, respectively. Although maternal outcome were worse in women with emerging risk factors in labor, while neonatal outcomes were not affected by the presence these complications. Conclusions: In hospital settings, midwife-led labor in low-risk women might unfold its major advantages without additional risks of medicalization for the mother and the neonate. [ABSTRACT FROM AUTHOR]

We present the unique case of a 44-year-old gravida 3 para 2 woman with complaints of monolateral perception of fetal movements who underwent elective cesarean section and hysterectomy for the presence of an exceptionally voluminous infralegamentary leiomyoma. Cesarean section required in-depth preoperative planning and was possible only after gravid uterus exteriorization. Myomectomy and hysterectomy were then necessary to reestablish the physioanatomical pelvic environment. The patient was discharged after regular and uncomplicated postoperative time. In recent years, the paradigma of avoiding cesarean myomectomy due to fear of hemorrhage has been questioned by many authors and in certain cases cesarean myomectomy may even be undeferrable. We describe an innovative surgical technique which could be useful to obstetricians approaching similar uterine masses during cesarean sections. [ABSTRACT FROM AUTHOR]

Objective: To assess the effectiveness of the implementation of a multilevel institutional program to reduce the rate of emergency peripartum hysterectomy (EPH) secondary to postpartum haemorrhage (PPH) in a Western world referral centre for obstetrics.Study Design: Women who delivered at a tertiary care regional obstetric hub in Milan between 2012 and 2020 were retrospectively reviewed to identify cases of EPH. During the study period, several measures aimed at preventing EPH were progressively implemented: reduction of primary and repeated caesarean, update of PPH treatment protocol, implementation of massive transfusion protocol, dedicated clinical pathway for high-risk patients, regular educational sessions, daily review of critical cases with senior consultant, and periodical review of near miss cases by quality improvement committee. To investigate the possible benefits, we divided the detected cases into two groups based on the historical period (Period I, 2012-2016 vs. Period II, 2017-2020) with the main aim of comparing the rate of EPH calculated as EPH ratio per 1000 deliveries.Results: During Period I and II there were 30,241 and 21,270 births; a total of 60 and 25 EPH were performed, respectively. EPH incidence decreased from 2.0 to 1.2‰ across the study periods (p = 0.027). Between Period I and II, we observed a reduction of institutional caesarean section rate (44.4% vs. 40.4%, p < 0.0001); among cases undergoing EPH, we reported a significant reduction of massive blood transfusion (83.3% vs. 52.2%, p = 0.002), increased use (56.7% vs. 96.0%, p = 0.0004) and appropriate administration (25.0% vs. 88.0%, p < 0.0001) of tranexamic acid, increased use of non-invasive Bakri Balloon tamponade (3.3% vs. 32.0%, p = 0.0002) instead of surgical techniques (38.3% vs. 16.0%, p = 0.043).Conclusion: A reduction of EPH incidence as a severe outcome of obstetric haemorrhage is achievable through a multilevel institutional effort. Our study may inspire a larger-scale program to improve the safety of patients experiencing PPH. [ABSTRACT FROM AUTHOR]

Background: Few case reports and clinical series exist on pregnant women infected with SARS-CoV-2 who delivered.Objective: To review the available information on mode of delivery, vertical/peripartum transmission, and neonatal outcome in pregnant women infected with SARS-CoV-2.Search Strategy: Combination of the following key words: COVID-19, SARS-CoV-2, and pregnancy in Embase and PubMed databases.Selection Criteria: Papers reporting cases of women infected with SARS-CoV-2 who delivered.Data Collection and Analysis: The following was extracted: author; country; number of women; study design; gestational age at delivery; selected clinical maternal data; mode of delivery; selected neonatal outcomes.Main Results: In the 13 studies included, vaginal delivery was reported in 6 cases (9.4%; 95% CI, 3.5-19.3). Indication for cesarean delivery was worsening of maternal conditions in 31 cases (48.4%; 95% CI, 35.8-61.3). Two newborns testing positive for SARS-CoV-2 by real-time RT-PCR assay were reported. In three neonates, SARS-CoV-2 IgG and IgM levels were elevated but the RT-PCR test was negative.Conclusions: The rate of vertical or peripartum transmission of SARS-CoV-2 is low, if any, for cesarean delivery; no data are available for vaginal delivery. Low frequency of spontaneous preterm birth and general favorable immediate neonatal outcome are reassuring. [ABSTRACT FROM AUTHOR]