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Background: Physiologic-based cord clamping (PBCC) involves deferring umbilical cord clamping until after lung aeration. It is unclear if infant is at risk of becoming hypothermic during PBCC. Objective(s): To test if PBCC would maintain core temperature more effectively than immediate cord clamping (ICC). Design(s): At 0.93 gestation, fetal lambs were surgically exteriorized and instrumented from pregnant ewes under general anesthesia. Prior to the start of the experiment, lambs were thoroughly dried, placed on hot water bottles, and core temperature was continuously monitored using a rectal thermometer. PBCC lambs (n = 21), received intermittent positive pressure ventilation (iPPV) for >=5 min prior to umbilical cord clamping. In ICC lambs (n = 23), iPPV commenced within 60 s after umbilical cord clamping. iPPV was provided with heated/humidified gas. Lambs were moved under a radiant warmer after umbilical cord clamping. Additional warmth was provided using a plastic overlay, hairdryer, and extra water bottles, as needed. Two-way mixed and repeated measures one-way ANOVAs were used to compare temperature changes between and within a single group, respectively, over time. Result(s): Basal fetal parameters including core temperature were similar between groups. ICC lambs had a significant reduction in temperature compared to PBCC lambs (p < 0.001), evident by 1 min (p = 0.002). ICC lambs decreased temperature by 0.51degreeC (+/- 0.42) and 0.79degreeC (+/- 0.55) at 5 and 10 min respectively (p < 0.001). In PBCC lambs, temperature did not significantly change before or after umbilical cord clamping (p = 0.4 and p = 0.3, respectively). Conclusion(s): PBCC stabilized core temperature at delivery better than ICC in term lambs. Hypothermia may not be a significant risk during PBCC.© Copyright © 2020 Blank, Crossley, Kashyap, Hodges, DeKoninck, McGillick, Rodgers, te Pas, Hooper and Polglase.

Background: Universal screening has been proposed as a strategy to identify asymptomatic individuals infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and mitigate transmission. Aim(s): To investigate the rate of positive tests among pregnant women in Melbourne, Australia. Method(s): We performed a cross-sectional prevalence study at three maternity hospitals (one tertiary referral hospital and two secondary maternities) in Melbourne, Australia. SARS-CoV-2 testing was offered to all pregnant women attending face-to-face antenatal visits and to those attending the hospital with symptoms of possible coronavirus disease, between 6th and 19th of May 2020. Testing was performed by multiplex-tandem polymerase chain reaction (PCR) on combined oropharyngeal and nasopharyngeal swabs. The primary outcome was the proportion of positive SARS-CoV-2 tests. Finding(s): SARS-CoV-2 testing was performed in 350 women, of whom 19 had symptoms of possible COVID-19. The median maternal age was 32 years (IQR 28-35 years), and the median gestational age at testing was 33 weeks and four days (IQR 28 weeks to 36 weeks and two days). All 350 tests returned negative results (p = 0%, 95% CI 0-1.0%). Conclusion(s): In a two-week period of low disease prevalence, the rate of asymptomatic coronavirus infection among pregnant women in Australia during the study period was negligible, reflecting low levels of community transmission.Copyright © 2020 Australian College of Midwives

Objective: It has been suggested that lockdown during the COVID-19 pandemic decreased prematurity rates. We investigated the impact of lockdown on obstetric outcomes. Study Design: We performed a cohort study on women who gave birth at three maternity hospitals in metropolitan Melbourne, Australia, between Jan 1st, 2019 and Sept 16th, 2020. Data were extracted from the common birth registry of the three maternities. The second lockdown started July 8th, 2020 and required people to stay at home, with limited exemptions. We performed interrupted time-series analysis to compare the monthly rates of preterm birth before 34 weeks prior to and after July 2020. We also compared the group of women who delivered between July and September 2020 to the group of women who delivered during the same period in 2019. Result(s): A total 15,394 women gave birth. Interrupted time-series analysis demonstrated a significantly lower monthly rate of deliveries before 34 weeks of gestational age after July 2020 (Figure 1; p = 0.001). There were 2,207 deliveries between July to Sept. 2019 and 1,870 deliveries between July to Sept. 2020. Baseline characteristics were comparable, except for a significantly difference in twins (1.5% in 2020 versus 2.6% in 2019, p = 0.012). After excluding women with pregnancies complicated by major fetal abnormalities or stillbirth, the risk of preterm delivery before 34 weeks was much lower in patients who delivered between July and September 2020 (2.1% versus 3.3%, RR 0.64, 95% CI 0.44 to 0.94, p = 0.022) (Table 1). Similar patterns were observed for iatrogenic and spontaneous preterm birth at different gestational ages. The effect persisted after logistic regression adjustment for multiple pregnancies (adjusted OR 0.65, 95% CI 0.46 to 0.96, p = 0.028). The decrease in prematurity was not at the cost of an increase in stillbirth or undetected small for gestational age neonates. Conclusion(s): Strict lockdown has a strong impact on iatrogenic and spontaneous

OBJECTIVE: To investigate the effect of restriction measures implemented to mitigate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission during the coronavirus disease 2019 (COVID-19) pandemic on pregnancy duration and outcome. METHOD(S): A before-and-after study was conducted with cohort sampling in three maternity hospitals in Melbourne, Australia, including women who were pregnant when restriction measures were in place during the COVID-19 pandemic (estimated conception date between 1 November 2019 and 29 February 2020) and women who were pregnant before the restrictions (estimated conception date between 1 November 2018 and 28 February 2019). The primary outcome was delivery before 34weeks' gestation or stillbirth. The main secondary outcome was a composite of adverse perinatal outcomes. Pregnancy outcomes were compared between women exposed to restriction measures and unexposed controls using the chi-square test and modified Poisson regression models, and duration of pregnancy was compared between the groups using survival analysis. RESULT(S): In total, 3150 women who were exposed to restriction measures during pregnancy and 3175 unexposed controls were included. Preterm birth before 34weeks or stillbirth occurred in 95 (3.0%) exposed pregnancies and in 130 (4.1%) controls (risk ratio (RR), 0.74 (95%CI, 0.57-0.96); P=0.021). Preterm birth before 34weeks occurred in 2.4% of women in the exposed group and in 3.4% of women in the control group (RR, 0.71 (95%CI, 0.53-0.95); P=0.022), without evidence of an increase in the rate of stillbirth in the exposed group (0.7% vs 0.9%; RR, 0.83 (95%CI, 0.48-1.44); P=0.515). Competing-risks regression analysis showed that the effect of the restriction measures on spontaneous preterm birth was stronger and started earlier (subdistribution hazard ratio (HR), 0.81 (95%CI, 0.64-1.03); P=0.087) than the effect on medically indicated preterm birth (subdistribution HR, 0.89 (95%CI, 0.70-1.12); P=0.305). The eff

OBJECTIVES: To investigate the effect of restriction measures during the COVID-19 pandemic on pregnancy duration and outcomes. METHOD(S): We conducted a before and after study with cohort sampling in three maternity hospitals in Melbourne, Australia, including women who were pregnant during the COVID-19 pandemic restriction measures (estimated conception between 1 November 2019 and 29 February 2020) and women who were pregnant before the restrictions (estimated conception between 1 November 2018 and 28 February 2019). The primary outcome was delivery before 34weeks' gestation or stillbirth. The main secondary outcome was a composite of adverse perinatal outcomes. Pregnancy outcomes were compared between the groups using chi-squared tests and modified Poisson regression models, and pregnancy duration was compared between the groups using and survival analysis. RESULT(S): There were 3150 exposed women and 3175 women in the control group. Preterm birth before 34weeks' gestation or stillbirth occurred in 95 (3.0%) of the pregnancies during restrictions and 130 (4.1%) in the control group (Risk ratio (RR) 0.74, 95% CI 0.57 to 0.96, p = 0.021). The effect was stronger in women with a previous preterm birth (RR 0.42, 95% CI 0.21 to 0.82, p = 0.008). The composite adverse perinatal outcome was less frequent in the exposed group (2.1% versus 2.9%, RR 0.73, 95% CI 0.54 to 0.99, p = 0.042 in all women and 4.5% versus 8.4%, RR 0.54, 95% CI 0.25 to 1.18, p = 0.116 in women with a previous preterm birth). CONCLUSION(S): Restrictions to mitigate COVID-19 transmission were associated with reduced rates of preterm birth before 34weeks. This effect was not associated with increased stillbirth rates and was stronger in women with previous preterm delivery. This article is protected by copyright. All rights reserved.

Background: Little evidence is available on the use of telehealth for antenatal care. In response to the COVID-19 pandemic, we developed and implemented a new antenatal care schedule integrating telehealth across all models of pregnancy care. To inform this clinical initiative, we aimed to assess the effectiveness and safety of telehealth in antenatal care. Method(s): We analysed routinely collected health data on all women giving birth at Monash Health, a large health service in Victoria (Australia), using an interrupted time-series design. We assessed the impact of telehealth integration into antenatal care from March 23, 2020, across low-risk and high-risk care models. Allowing a 1-month implementation period from March 23, 2020, we compared the first 3 months of telehealth integrated care delivered between April 20 and July 26, 2020, with conventional care delivered between Jan 1, 2018, and March 22, 2020. The primary outcomes were detection and outcomes of fetal growth restriction, pre-eclampsia, and gestational diabetes. Secondary outcomes were stillbirth, neonatal intensive care unit admission, and preterm birth (birth before 37 weeks' gestation). Finding(s): Between Jan 1, 2018, and March 22, 2020, 20 031 women gave birth at Monash Health during the conventional care period and 2292 women gave birth during the telehealth integrated care period. Of 20 154 antenatal consultations provided in the integrated care period, 10 731 (53%) were delivered via telehealth. Overall, compared with the conventional care period, no significant differences were identified in the integrated care period with regard to the number of babies with fetal growth restriction (birthweight below the 3rd percentile; 2% in the integrated care period vs 2% in the conventional care period, p=0.72, for low-risk care models; 5% in the integrated care period vs 5% in the conventional care period, p=0.50 for high-risk care models), number of stillbirths (1% vs 1%, p=0.79; 2% vs 2%, p=0.70), or

Objective Lung hypoplasia associated with congenital diaphragmatic hernia (CDH) results in respiratory insufficiency and pulmonary hypertension after birth. We have investigated whether aerating the lung before removing placental support (physiologically based cord clamping (PBCC)), improves the cardiopulmonary transition in lambs with a CDH. Methods At =138 days of gestational age, 17 lambs with surgically induced left-sided diaphragmatic hernia (=d80) were delivered via caesarean section. The umbilical cord was clamped either immediately prior to ventilation onset (immediate cord clamping (ICC); n=6) or after achieving a target tidal volume of 4 mL/kg, with a maximum delay of 10 min (PBCC; n=11). Lambs were ventilated for 120 min and physiological changes recorded. Results Pulmonary blood flow (PBF) increased following ventilation onset in both groups, but was 19-fold greater in PBCC compared with ICC lambs at cord clamping (19+/-6.3 vs 1.0+/-0.5 mL/min/kg, p<0.001). Cerebral tissue oxygenation was higher in PBCC than ICC lambs during the first 10 min after cord clamping (59%+/-4% vs 30%+/-5%, p<0.001). PBF was threefold higher (23+/-4 vs 8+/-2 mL/min/kg, p=0.01) and pulmonary vascular resistance (PVR) was threefold lower (0.6+/-0.1 vs 2.2+/-0.6 mm Hg/(mL/min), p<0.001) in PBCC lambs compared with ICC lambs at 120 min after ventilation onset. Conclusions Compared with ICC, PBCC prevented the severe asphyxia immediately after birth and resulted in a higher PBF due to a lower PVR, which persisted for at least 120 min after birth in CDH lambs.Copyright © Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.

This prospective observational study compared the middle cerebral artery (MCA) Doppler characteristics of FGR neonates (N = 20) with abnormal antenatal Dopplers, with those of appropriately grown (AGA) neonates (N = 20), in the immediate postnatal period. MCA peak systolic velocity (PSV), end-diastolic velocity (EDV), pulsatility index (PI), and resistive index (RI) were measured on day 1 and day 3. MCA PSV and EDV values were not significantly different between FGR (mean (SD) gestation: 31.4 (3.1) weeks, weight 1205 (463) grams) and AGA (31.1 (3.0) weeks; 1668 (490) grams) groups, on day 1 and day 3. Both FGR (30.85 (10.02) vs. 42.12 (9.16) cm/s, p = 0.007) and AGA groups (31.77 (9.32) vs. 42.0 (8.98) cm/s, p = 0.001) showed a significant increase in MCA PSV, but only the FGR group showed significant increase in EDV values (7.01 (4.23) vs. 11.78 (4.98), p = 0.002) from day 1 to day 3. This was associated with significant differences in RI (0.72 (0.10) vs. 0.79 (0.07), p = 0.01) and PI (1.36 (0.47) vs. 1.73 (0.4), p = 0.01) values between FGR and AGA groups on day 3. Conclusion(s): Significant differences in MCA resistive and pulsatility indices were noted in the first few days of life of FGR neonates with abnormal antenatal Doppler as compared with AGA neonates. This may suggest a delayed transition or persistence of cerebral redistribution in FGR neonates.What is Known:* FGR infants have increased risk of neonatal morbidity and mortality, and long-term neuro-disabilities.* Antenatal Doppler Ultrasound is the most common modality used to assess fetal growth restriction.What is New:* Antenatally detected abnormal cerebral Dopplers may persist during the neonatal period in growth-restricted neonates.* Early cerebral Doppler values may be a useful marker to identify "at risk" growth-restricted neonates.Copyright © 2019, Springer-Verlag GmbH Germany, part of Springer Nature.

OBJECTIVES: Infants with congenital diaphragmatic hernia (CDH) are predisposed to pulmonary hypertension after birth, owing to lung hypoplasia that impairs fetal pulmonary vascular development. Antenatal sildenafil treatment attenuates abnormal pulmonary vascular and alveolar development in rabbit and rodent CDH models, but whether this translates to functional improvements after birth remains unknown. We aimed to evaluate the effect of antenatal sildenafil on neonatal pulmonary hemodynamics and lung function in lambs with diaphragmatic hernia (DH). METHOD(S): DH was surgically induced at approximately 80days' gestation in 16 lamb fetuses (term in lambs is approximately 147days). From 105days' gestation, ewes received either sildenafil (0.21mg/kg/h intravenously) or saline infusion until delivery (n=8 fetuses in each group). At approximately 138days' gestation, all lambs were instrumented and then delivered via Cesarean section. The lambs were ventilated for 120min with continuous recording of physiological (pulmonary and carotid artery blood flow and pressure; cerebral oxygenation) and ventilatory parameters, and regular assessment of arterial blood gas tensions. Only lambs that survived until delivery and with a confirmed diaphragmatic defect at postmortem examination were included in the analysis; these comprised six DH-sildenafil lambs and six DH-saline control lambs. RESULT(S): Lung-to-body-weight ratio (0.016+/-0.001 vs 0.013+/-0.001; P=0.06) and dynamic lung compliance (0.8+/-0.2 vs 0.7+/-0.2mL/cmH2 O; P=0.72) were similar in DH-sildenafil lambs and controls. Pulmonary vascular resistance decreased following lung aeration to a greater degree in DH-sildenafil lambs, and was 4-fold lower by 120min after cord clamping than in controls (0.6+/-0.1 vs 2.2+/-0.6mmHg/(mL/min); P=0.002). Pulmonary arterial pressure was also lower (46+/-2 vs 59+/-2mmHg; P=0.048) and pulmonary blood flow higher (25+/-3 vs 8+/-2mL/min/kg; P=0.02) in DH-sildenafil than in DH-saline lambs

Objective Infants with a congenital diaphragmatic hernia (CDH) are at high risk of developing pulmonary hypertension after birth, but little is known of their physiological transition at birth. We aimed to characterise the changes in cardiopulmonary physiology during the neonatal transition in an ovine model of CDH. Methods A diaphragmatic hernia (DH) was surgically created at 80 days of gestational age (dGA) in 10 fetuses, whereas controls underwent sham surgery (n=6). At 138 dGA, lambs were delivered via caesarean section and ventilated for 2 hours. Physiological and ventilation parameters were continuously recorded, and arterial blood gas values were measured. Results DH lambs had lower wet lung-to-body-weight ratio (0.016+/-0.002vs0.033+/-0.004), reduced dynamic lung compliance (0.4+/-0.1mL/cmH 2 O vs1.2+/-0.1 mL/cmH 2 O) and reduced arterial pH (7.11+/-0.05vs7.26+/-0.05), compared with controls. While measured pulmonary blood flow (PBF) was lower in DH lambs, after correction for lung weight, PBF was not different between groups (4.05+/-0.60mL/min/gvs4.29+/-0.57 mL/min/g). Cerebral tissue oxygen saturation was lower in DH compared with control lambs (55.7+/-3.5vs67.7%+/-3.9%). Conclusions Immediately after birth, DH lambs have small, non-compliant lungs, respiratory acidosis and poor cerebral oxygenation that reflects the clinical phenotype of human CDH. PBF (indexed to lung weight) was similar in DH and control lambs, suggesting that the reduction in PBF associated with CDH is proportional to the degree of lung hypoplasia during the neonatal cardiopulmonary transition.Copyright © Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.

Objective Fetoscopic endoluminal tracheal occlusion (FETO) aims to reverse pulmonary hypoplasia associated with congenital diaphragmatic hernia (CDH) and mitigate the associated respiratory insufficiency and pulmonary hypertension after birth. We aimed to determine whether FETO improves the cardiopulmonary transition at birth in an ovine model of CDH. Methods In 12 ovine fetuses with surgically induced diaphragmatic hernia (DH; 80 dGA), an endotracheal balloon was placed tracheoscopically at =110 dGA and removed at =131 dGA (DH+FETO), while 10 were left untreated (DH). At =138 dGA, all lambs (survival at delivery: 67% [DH+FETO], 70% [DH]) were delivered via caesarean section and ventilated for 2 hours. Physiological and ventilation parameters were continuously recorded, and arterial blood-gas values were measured. Results Compared with DH, DH+FETO lambs had increased wet lung-to-body-weight ratio (0.031+/-0.004 vs 0.016+/-0.002) and dynamic lung compliance (0.7+/-0.1 vs 0.4+/-0.1 mL/cmH 2 O). Pulmonary vascular resistance was lower in DH+FETO lambs (0.44+/-0.11 vs 1.06+/-0.17 mm Hg/[mL/min]). However, after correction for lung weight, pulmonary blood flow was not significantly different between the groups (4.19+/-0.57 vs 4.05+/-0.60 mL/min/g). Alveolar-arterial difference in oxygen tension was not significantly different between DH+FETO and DH (402+/-41mm Hg vs 401+/-45 mm Hg). Conclusions FETO accelerated lung growth in fetuses with CDH and improved neonatal respiratory function during the cardiopulmonary transition at birth. However, despite improved lung compliance and reduced pulmonary vascular resistance, there were less pronounced benefits for gas exchange during the first 2 hours of life.Copyright © Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.

This chapter describes the methodologies which may be used in the development of a randomized controlled trial investigating a therapy of choice in preventing preeclampsia.Copyright © 2018, Springer Science+Business Media LLC.

The benefits of fetoscopic laser photocoagulation (FLP) for treatment of twin-to-twin transfusion syndrome (TTTS) have been recognized for over a decade, yet access to FLP remains limited in many settings. This means at a population level, the potential benefits of FLP for TTTS are far from being fully realized. In part, this is because there are many centers where the case volume is relatively low. This creates an inevitable tension; on one hand, wanting FLP to be readily accessible to all women who may need it, yet on the other, needing to ensure that a high degree of procedural competence is maintained. Some of the solutions to these apparently competing priorities may be found in novel training solutions to achieve, and maintain, procedural proficiency, and with the increased utilization of 'competence based' assessment and credentialing frameworks. We suggest an under-utilized approach is the development of collaborative surgical services, where pooling of personnel and resources can improve timely access to surgery, improve standardized assessment and management of TTTS, minimize the impact of the surgical learning curve, and facilitate audit, education, and research. When deciding which centers should offer laser for TTTS and how we decide, we propose some solutions from a collaborative model.Copyright © The Author(s) 2016.

Objective To examine maternal morbidity in primary surgical management of placenta accreta. Design Retrospective case series. Setting Quaternary perinatal referral center in Melbourne, Australia. Population Clinically suspected and histologically confirmed cases of placenta accreta, increta and percreta. Methods Women were identified from our hospital database coded for placenta accreta, increta, percreta and peripartum hysterectomy. Relevant details were sought from medical records. Main outcome measures Predefined maternal morbidities: blood loss, transfusion requirements, surgical complications, reoperation rate, duration in hospital. Predefined neonatal outcomes: gestational age at birth, birth-weight, admission to intensive (NICU) or special care nurseries (SCN), respiratory distress syndrome. Results Between 1999 and 2009, 33 women were diagnosised with invasive placentation. A total of 27 were confirmed histologically after hysterectomy: 12 accreta, one increta, and 14 percreta. Median blood loss was 2 L. There was a 1.8-L reduction in mean blood loss with elective vs. emergency hysterectomy (p = 0.04). Nearly two-thirds of women required four or more units of packed red-blood-cells. Half of the women suffered from surgical complications, mostly from bladder injury. The risk of returning to theater for further surgery was 20%. Women with placenta percreta were more likely to require additional blood products (p = 0.03), sustain renal tract injury (p = 0.003) and require intensive care admission (p = 0.002). Conclusions A primary surgical approach to management of placenta accreta is associated with significant maternal morbidity, even when managed in a dedicated quaternary perinatal referral center. © 2013 The Authors Acta Obstetricia et Gynecologica Scandinavica © 2013 Nordic Federation of Societies of Obstetrics and Gynecology.

Cell-based therapies may soon be used to treat disorders in the perinatal period. Our aim was to assess pregnant women's knowledge, attitudes, and acceptance of different types of stem cell therapies. Pregnant women attending an Australian tertiary center were asked to complete a questionnaire to seek their views on the potential therapeutic use of stem cells in the future. Outcome measures were women's acceptability of different types of stem cell therapies for themselves and their baby, ethical concerns, knowledge, and willingness to use stem cells for different indications. A total of 150 women completed the questionnaire. More women were happy to use any stem cell type (82%) than placental stem cells only (12.5%), adult stem cells only (2%), embryonic stem cells only (0), and 3.5 percent would not use. With respect to use for their baby, more women were happy to use any stem cell type (83%) than placental stem cells only (13%), embryonic stem cells only (2%), adult stem cells only (0), and 2 percent would not use. Ethical concerns were highest with embryonic stem cells (25%), than adult stem cells (11%), and placental stem cells (10%). Twelve percent of women were very confident and 66 percent reasonably confident with their knowledge, whereas 17 percent understood little and 5 percent reported no understanding. Acceptance of using any stem cell therapy was 75 percent for severe medical disorders, 57 percent for moderate disorders, and 25 percent for mild medical disorders. Pregnant women are confident with their knowledge of stem cells and overwhelmingly support their use to treat both themselves and their baby. The level of this support, however, is proportionate to the severity of the medical disorder. (BIRTH 39:2 June 2012). © 2012, Copyright the Authors Journal compilation © 2012, Wiley Periodicals, Inc.

For over 30 years, antenatal diagnosis of Down syndrome has been offered on the basis of advanced maternal age. While this was appropriate in the 1970s, developments in antenatal screening have rendered this a most inefficient strategy that is associated with excessive costs and procedure-related pregnancy losses. In this article we argue for a review of how we test for Down syndrome in the older woman. © 2005 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Clinical and experimental studies suggest that the growth-restricted fetus at increased risk of impaired cardiovascular function that likely contributes to both increased mortality rate and in survivors, to cardiovascular dysfunction apparent in childhood and later life. Fetal growth restriction is also associated with a high risk of preterm birth. Accordingly, the growth-restricted fetus is more likely than average to receive antenatal glucocorticoids to accelerate lung maturation in preparation for birth. However, glucocorticoids are powerful regulators of vascular tone and antenatal glucocorticoid administration to the intrauterine growth restriction (IUGR) fetus results in systemic cardiovascular changes that are not observed in the healthy normal grown fetus. These responses to glucocorticoids may disturb the IUGR fetus' ability to appropriately compensate to placental insufficiency. Indeed is it possible that in the setting of severe IUGR exogenous glucocorticoids are detrimental rather than beneficial to the fetus © 2012 Informa UK, Ltd.