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Objective: When uterotonics fail to cause sustained uterine contractions and satisfactory control of hemorrhage after delivery, tamponade of the uterus can be effective in decreasing hemorrhage secondary to uterine atony., Study Design: These data are from a postmarketing surveillance study of a novel dual-balloon catheter tamponade device, the Belfort-Dildy Obstetrical Tamponade System (ebb)., Results: A total of 57 women were enrolled: 55 women had the diagnosis of postpartum hemorrhage, and 51 women had uterine balloon placement within the uterine cavity. This study reports the outcomes in the 51 women who had uterine balloon placement within the uterine cavity for treatment of postpartum hemorrhage, as defined by the "Instructions for Use." We further assessed 4 subgroups: uterine atony only (n = 28 women), placentation abnormalities (n = 8 women), both uterine atony and placentation abnormalities (n = 9 women), and neither uterine atony nor placentation abnormalities (n = 6 women). The median (range) time interval between delivery and balloon placement was 2.2 hours (0.3-210 hours) for the entire cohort (n = 51 women) and 1.3 hours (0.5-7.0 hours) for the uterine atony only group (n = 28 women). Bleeding decreased in 22/51 of cases (43%), stopped in 28/51 of cases (55%), thus decreased or stopped in 50/51 of the cases (98%) after balloon placement. Nearly one-half (23/51) of all women required uterine balloon volumes of >500 mL to control bleeding., Conclusion: We conclude that uterine/vaginal balloon tamponade is very useful in the management of postpartum hemorrhage because of uterine atony and abnormal placentation., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Background: Bladder flaps are commonly created during routine cesarean deliveries and often require multiple steps that increase operating time and expose the surgeon to inadvertent injury., Objective: We report a simple method of creating a bladder flap that eliminates the need for multiple instrument handoffs and repositioning., Conclusion: The simplicity of this method allows the surgeon decreased operative entry time while decreasing exposure to injuries from multiple instrument handoffs during bladder flap development.

Background: Umbilical artery aneurysm is a rare condition associated with increased risk for aneuploidy and fetal demise., Case: We report a case of umbilical artery aneurysm discovered at 27 weeks of gestation in one fetus of a dichorionic, diamniotic twin pregnancy. The patient was hospitalized to monitor for expansion of the aneurysm. Corticosteroids were administered, and, after genetic amniocentesis revealed a normal karyotype, cesarean delivery was performed at 28 2/7 weeks of gestation. Pathologic examination confirmed an umbilical artery aneurysm in the cord of the affected fetus., Conclusion: Given the high incidence of aneuploidy associated with umbilical artery aneurysm, it is important to consider karyotype analysis of the affected fetus. If a normal karyotype is identified, early delivery may be warranted to decrease the risk of fetal demise.

Objective: To determine outcome in patients with chronic abruption., Study Design: A retrospective review was performed of all patients delivering at a tertiary medical center during a 54-month period. All patients with a diagnosis of placental abruption with oligohydramnios or ruptured membranes were included. Chronic abruption-oligohydramnios sequence (CAOS) was defined by the following criteria: (1) clinically significant vaginal bleeding in the absence of placenta previa or other identifiable source of bleeding, (2) amniotic fluid volume initially documented as normal, and (3) oligohydramnios (amniotic fluid index < or = 5) eventually developing without concurrent evidence of ruptured membranes., Results: Twenty-four patients with CAOS were identified. Fourteen had first evidence of abruption at < 20 weeks' gestational age. A clot was identified between the chorion and uterus in 18/24. The mean gestational age at the first bleeding episode was 19.4 +/- 5.5 (SD) weeks, with the mean gestational age at delivery 28.1 +/- 4.5 weeks. Preterm premature membrane rupture occurred in 15/24. In these 15 there was a mean of 11.5 +/- days between the diagnosis of oligohydramnios and of ruptured membranes. Patients whose first blood occurred at < 20 weeks' gestation delivered at a gestational age of 26.1 +/- 3.9 weeks versus 33.0 +/- 5.3 weeks for the control group., Conclusion: CAOS can occur in pregnancies complicated by abruptio placentae. If it develops, the mean gestational age at delivery is 28 weeks.

Objective: To test the hypothesis that women receiving intrapartum amnioinfusion have more rapid labors than do controls., Data Sources: Prospective clinical trials of amnioinfusion published in major American obstetric and gynecologic journals between 1985 and 1995, identified through a literature search using MEDLINE and manual index review, were examined., Method of Study Selection: Eleven studies that presented data regarding the length of labor were identified. Each study was reviewed for the design, number of subjects enrolled, volume of amnioinfusate, birth weight, maternal parity, interval from amniorrhexis to delivery, and total length of labor., Tabulation, Integration and Results: Meta-analysis revealed no differences between amnioinfusion groups and controls with regard to length of labor or the interval between membrane rupture and delivery., Conclusion: Amnioinfusion has no effect on the duration of labor.

Background: Umbilical vascular coiling may function as a rudimentary pump that facilitates venous return from the placenta., Cases: Three consecutive twin gestations with twin-twin transfusion syndrome were evaluated prospectively at delivery. The birth weights and umbilical coiling indices of donor and recipient twins were compared. The umbilical coiling index was determined by dividing the number of complete vascular coils in a given umbilical cord by the cord's length in centimeters. In each case, the recipient twin was larger at birth and had an umbilical coiling index value that was at least twice that of the corresponding donor twin., Conclusion: Differential umbilical vascular coiling densities among monochorionic twins may play a role in the pathogenesis of twin-twin transfusion syndrome.

We have frequently observed that fetuses born with nuchal cords have umbilical cords that contain less vascular coiling. To study the association between umbilical vascular coiling and nuchal entanglement, the density of umbilical coiling was objectively assessed in relationship to nuchal entanglement of the umbilical cord using the "umbilical coiling index" in 200 consecutive liveborn neonates. The umbilical coiling index of each cord was determined by dividing the number of complete vascular coils by the total length of the cord in centimeters. The mean umbilical coiling index among those with nuchal cords (0.18 +/- 0.09 coils/cm) was significantly less than that among the group without nuchal entanglement (0.21 +/- 0.07 coils/cm), P = 0.01. Among those with umbilical coiling indices < or = 0.10 coils/cm, 42% had nuchal cords, while only 4.8% of cords with indices > or = 0.30 coil/cm had nuchal cords (P = 0.007). It is concluded that a relationship exists between the density of umbilical vascular coiling and nuchal entanglement of the cord.

Objective: To examine the relationship between trisomy and neonates with noncoiled umbilical blood vessels., Study Design: The incidence of and risk factors for trisomy were evaluated among 48 consecutive, live-born neonates with noncoiled umbilical vessels., Results: Four cases (8.3%) of trisomy were identified. One case of mosaicism was also noted (2.1%). In no case was noncoiling of the umbilical vessels the only identifiable risk factor. The remaining 43 infants (89.6%) were phenotypically normal, although not all underwent karyotype analysis., Conclusion: Noncoiled umbilical blood vessels alone do not appear to represent an independent risk factor for trisomy. Rather, identification of noncoiled blood vessels should prompt a thorough search for other abnormalities.

Objective: To evaluate fetal acoustic stimulation (FAS) as an adjunct to external cephalic version in a midline fetal spine presentation., Study Design: Breech presentation in a woman presenting for attempted version at 37 weeks' gestation with a fetus in a midline position and the spine anterior is difficult to convert to a vertex. An evaluation of FAS to assist in repositioning the fetus in a more spine lateral position was carried out. Patients with a failed version attempt and a midline breech presentation were enrolled in the study. The patient served as her own control. If that attempt failed, an electrolarynx device was used to produce a one- to three-second stimulus, and then another version attempt was made., Results: Sixteen patients were enrolled. Prior to FAS, 0/16 fetuses were successfully turned. FAS altered the position in 100% of patients from spine midline to lateral. After FAS, 15/16 (94%) were successfully converted to vertex presentation. The one patient whose fetus failed to convert also failed her second version attempt (P < .0005)., Conclusion: FAS may improve the opportunity for successful external cephalic version in the properly selected candidate with a fetus in a midline position with the spine anterior.

Amnioinfusion is a relatively new technique with a variety of uses. Its most common application is the treatment of variable decelerations in the fetal heart rate during labor. By artificially increasing the amniotic fluid volume, the umbilical cord is better protected from compression. Amnioinfusion can represent the difference between operative intervention and spontaneous vaginal delivery. This simple, inexpensive technique appears to pose little risk and warrants consideration for the properly selected patient.

Objective: The null hypothesis is that fetuses with noncoiled umbilical cords diagnosed in the antepartum period will have outcomes no different from those with normally coiled cords., Study Design: We prospectively gathered data from Jan. 1 through May 18, 1992, from all fetuses undergoing routine ultrasonographic evaluation. The outcomes of fetuses noted to have noncoiled umbilical cords were compared with those of a control group of fetuses with normally coiled cords. The control group consisted of those subjects undergoing ultrasonography during the study period who were ultimately transferred to our perinatal practice for the remainder of the pregnancy (i.e., the highest-risk patients). Two outcome parameters were selected for comparison: fetal anomalies and fetal death., Results: Six hundred eighty-seven consecutive ultrasonographic examinations were performed. Twenty-five subjects (3.7%) had noncoiled umbilical cords identified ultrasonographically (mean gestational age at diagnosis 20.3 +/- 3.5 [SD] weeks). The control group had 197 subjects. The combined incidence of fetal anomalies or death in the noncoiled group (16%) was significantly greater (p < or = 0.05, relative risk 4.6 [95% confidence interval 1.41 to 14.15]) than that of the control group (3.5%). The noncoiled group had two fetal deaths (8%), whereas two deaths (1%) occurred among controls (p < or = 0.05, relative risk 8 [95% confidence interval 1.16 to 50]). Two (8%) fetal anomalies (anencephaly, prune-belly syndrome) occurred in the noncoiled group, whereas the controls (n = 197) had five fetuses (2.5%) with anomalies (not significant)., Conclusion: The antepartum identification of noncoiled umbilical cords appears to be a risk factor for suboptimal pregnancy outcome.

Objective: Our purpose was to objectively quantitate umbilical vascular coiling., Study Design: In this prospective study the umbilical cords and delivery records of 100 consecutive liveborn neonates were studied. The umbilical coiling index of each cord was determined by dividing the total number of complete umbilical vascular coils by the umbilical cord length (in centimeters). The obstetric history, intrapartum fetal heart rate tracing, and pregnancy outcome of each fetus were evaluated without knowledge of the umbilical coiling index., Results: The mean umbilical coiling index was 0.21 +/- 0.07 (SD) coils per centimeter. The 100 values were normally distributed. Among those whose umbilical coiling index values fell < or = 10th percentile, there was a significantly greater incidence of karyotypic abnormalities (p = 0.04), meconium staining (p = 0.03), and operative intervention for fetal distress (p = 0.03). There was a significantly greater incidence of moderate or severe variable fetal heart rate decelerations for those whose umbilical coiling index value was either < or = 10th percentile (0.1 coils per centimeter) or > 90th percentile (0.3 coils per centimeter) (p = 0.03)., Conclusion: The umbilical coiling index may have utility for objectively describing the degree of umbilical vascular coiling.

Objective: The purpose was to summarize five cases where subtotal immersion was associated with an increase in the amniotic fluid index., Study Design: Five women with oligohydramnios, as defined by an amniotic fluid index < 8 cm, who underwent subtotal (shoulder-deep) immersion therapy are described., Results: The mean pretreatment amniotic fluid index was 4.9 +/- 3 cm. After immersion therapy was instituted, the amniotic fluid index increased an average of 6 +/- 2.2 cm. In three subjects whose immersion therapy was discontinued, the amniotic fluid index fell an average of 4.7 cm., Conclusion: Subtotal immersion may help reverse oligohydramnios stemming from uteroplacental insufficiency.

Objective: Our purpose was to assess early postcesarean hospital dismissal., Study Design: A retrospective review was performed of all women receiving cesarean delivery over the most recent 6-month period in a busy private obstetrics practice that routinely dismisses its cesarean patients on postoperative day 2. Women who meet certain criteria (uncomplicated pregnancy, Pfannenstiel incision, uncomplicated surgery, no febrile morbidity, stable vital signs, ability to ambulate without assistance, ability to urinate without assistance, and auscultation of active bowel sounds) on postoperative day 2 are dismissed from the hospital. Outcomes were compared against women undergoing cesarean delivery during the 6 months immediately before the institution of the early dismissal program., Results: Among 147 women undergoing cesarean deliveries, 117 (80%) met the criteria for early dismissal. When compared with controls (n = 93), there was no difference in outcomes. No one in the early dismissal group required readmission to the hospital., Conclusion: Among properly selected candidates, early postcesarean hospital admission is a reasonable option.

Amnioinfusion is an intrapartum technique that is not usually attempted in twin gestations. This report describes infusion of normal saline into the amniotic sacs of three twin gestations with oligohydramnios. All the twins were safely delivered vaginally. No untoward effects were noted. Ultrasound is advised following amnioinfusion to assess the increase in the amniotic fluid volume.

A fetal heart rate recording containing a variable deceleration was played for 120 physicians and nurses. Although mean estimates for baseline and nadir of the fetal heart rate and duration of the deceleration were not significantly different from the actual values, individual estimates of the three parameters were widely distributed. Adjunctive techniques for intrapartum fetal heart rate auscultation are recommended.

Objective: To evaluate the perinatal outcomes of fetuses born with non-coiled umbilical blood vessels., Methods: We performed a prospective study of umbilical cords that lacked umbilical vascular coiling. The perinatal outcomes were compared with those of neonates born with coiled umbilical blood vessels., Results: Thirty-eight (4.3%) of 894 fetuses were born with non-coiled umbilical vessels. The non-coiled group had a significantly increased incidence of intrauterine death (P = .009), preterm delivery (P = .006), repetitive intrapartum fetal heart rate decelerations (P < .00005), operative delivery for fetal distress (P < .00005), meconium staining (P = .007), and anatomical-karyotypic abnormalities (P = .03)., Conclusions: Our findings suggest that the fetus with non-coiled (ie, straight) umbilical blood vessels is at increased risk for perinatal morbidity and mortality. Non-coiled umbilical vessels may represent a pathologic developmental process that places the fetus at risk. Moreover, absence of the normal coiled umbilical configuration may result in a cord that is structurally less able to resist external compressive forces.

A reassuring fetal recoil test has positive and negative predictive values of 98% and 8%, respectively, for a reactive nonstress test (sensitivity 89%, specificity 33%). Among 21 of 30 subjects in whom recoil was present immediately before delivery, none had umbilical arterial pH values < or = 7.20 versus 5 of 9 (56%) with nonreassuring recoil (p = 0.005). We concluded that a reassuring fetal recoil test is a reliable marker for fetal well-being.

Objective: Our objective was to determine whether amnioinfusion prolongs or shortens the length of labor in patients who have an accepted indication for amnioinfusion., Study Design: We performed a retrospective post hoc analysis of the length of labor of 437 patients who were enrolled in three prospective, randomized, controlled studies of amnioinfusion., Results: The length of labor was not significantly different for patients who received amnioinfusion compared with those who did not receive amnioinfusion (control group). Among the subgroup with vaginal delivery, the duration of labor after amnioinfusion did not differ from the duration of labor among the controls. The length of labor (mean +/- SD, in hours) for the amnioinfusion group was 9.3 +/- 6.3 versus 10.6 +/- 6.9 for the control groups (p not significant). Among the subgroup that required cesarean delivery, the duration of labor after amnioinfusion did not differ from the duration of labor among the controls. The length of labor (mean +/- SD, in hours) in patients requiring cesarean delivery in the amnioinfusion group was 11.1 +/- 6.3 versus 13.0 +/- 7.5 for the control group (p not significant)., Conclusion: Amnioinfusion does not prolong or shorten the length of labor among patients who have an accepted indication for the treatment.

Among 70 women delivering infants with nuchal cords, there was a significantly higher incidence of meconium passage and severe variable fetal heart rate decelerations/fetal bradycardia in those who had intrapartum oligohydramnios, as defined by an amniotic fluid index less than or equal to 5.0 cm. Oligohydramnios in the presence of nuchal cord entanglement might represent an increased risk of ominous intrapartum fetal heart rate patterns.

Excluding labor, the greatest risks to the fetus from preterm PROM are umbilical cord accidents and infection. Heretofore, the clinical options for the PROM patient have been limited. With the advent and refinement of amnioinfusion, the utility of expectant management may be greatly increased. Through the use of amnioinfusion or its permutations, a number of diagnostic and therapeutic procedures previously unavailable to the PROM patient may become routine, including amniotic fluid volume expansion and direct in utero prophylaxis/treatment of amnionitis.

A rapid, very simple technique for establishing fetal pulmonary maturity status is presented. Among 100 receiving amniocenteses, aspiration of turbid amniotic fluid that would not permit the reading of newsprint through it was associated with a lecithin/sphingomyelin (LS) ratio of greater than or equal to 2.0, or the presence of phosphatidyl glycerol (PG) in 97% (specificity 98%, positive predictive value 97%). The authors conclude that when turbid fluid is aspirated, delay until LS and PG results are known may not be necessary.

Eighteen of 901 women (2%) attempting vaginal birth after cesarean delivery (VBAC) received amnioinfusion. No untoward effects occurred in the subjects or their fetuses. We conclude that, though amnioinfusion in the setting of a VBAC attempt is needed only infrequently, it appears to be a reasonable intrapartum management option. The usual safeguards for a VBAC attempt should be followed.

An intrauterine probe electrode was inserted into 100 laboring women and 366 bipolar electrode combinations were tested. A noise-cancelling technique was used with the final 28 subjects to remove competing maternal cardiac signals. Twenty-four (86%) had fetal heart rate tracings with sufficient technical quality to allow determination of the baseline fetal heart rate.

Electronic fetal heart rate and uterine activity monitoring during labor requires expensive equipment and a source of electricity. However, it is not available to most of the women in the world. Intrauterine manometry provides a method which can be employed in underdeveloped settings to assess uterine contractions and to time auscultation. The vertical column of fluid in a standard intrauterine pressure catheter (IUPC) correlated well (R = 0.93) with the intrauterine pressure measurements obtained by a standard IUPC/pressure transducer system. Intrauterine manometry provides an alternative measure of uterine tone which may be employed in underdeveloped areas.

Amnioinfusion was performed in a prospective, randomized trial of 60 women in the latent phase of labor with oligohydramnios, as defined by an amniotic fluid index less than or equal to 5.0 cm. All fetuses were at least 37 weeks' gestational age, had normal baseline fetal heart rate variability, and no clinically significant fetal heart rate decelerations at the outset. Subjects in the amnioinfusion group (n = 30) were titrated to and maintained at an amniotic fluid index level greater than or equal to 8.0 cm throughout labor. In the group receiving amnioinfusion, significantly lower rates of meconium passage (p = 0.04), severe variable decelerations (p = 0.04), end-stage bradycardia (p = 0.05), and operative delivery for fetal distress (p = 0.002) occurred. Significantly higher umbilical arterial blood pH values were also noted in the infusion group (p = 0.02). We conclude that prophylactic intrapartum amnioinfusion is an important technique for the reduction of intrapartum morbidity.

One hundred forty-seven cases of congenital skull depression are analyzed, including two presented by the authors, and a review of the literature follows. A management plan emphasizing a conservative approach is outlined.

Amnioinfusion of 250 ml of normal saline solution was performed in 30 laboring women at greater than or equal to 37 weeks' gestation with oligohydramnios as defined by an amniotic fluid index of less than or equal to 5 cm. A total of 50 amnioinfusions were performed. Amniotic fluid volumes, as assessed by the amniotic fluid index, increased by a mean of 4.3 +/- 1.5 cm after infusion. We conclude that in women with oligohydramnios, 250 ml of amnioinfusate will increase the amniotic fluid index by approximately 4 cm.

An intrapartum fetal death within 20 minutes of a reassuring acoustically stimulated fetal heart rate acceleration is reported. The cause of death in this instance was congenital pneumonia, gram-negative sepsis, and meconium aspiration. Umbilical cord pH values obtained at delivery did not demonstrate asphyxia (ie, low pO2, high pCO2, and low pH), but suggested a metabolic acidosis typical of sepsis.

The incidence of placenta previa in twin gestations was compared to that found in singleton pregnancies over a ten-year period. During this period, eight placenta previas occurred in 1,464 twin pregnancies, for an incidence of 0.55%, which was significantly higher (P less than .05) than the incidence of 0.31% in singleton pregnancies (458 placenta previas in 148,197 singleton pregnancies). We conclude that a twin gestation confers an added risk of placenta previa.

A newly available intrauterine pressure transducer was evaluated clinically in 100 patients. Successful insertion was accomplished in 95%. There were no significant intrapartum maternal or fetal complications. Partial dehiscence of a surgically scarred uterus did occur in one patient who received the device, but a clear relationship between its attempted insertion and the dehiscence was not apparent. Early in the clinical trial, a number of devices malfunctioned; the manufacturer defined and remedied the problem. The intrauterine transducer required no maintenance and appeared to be practical in laboring women. We suggest that the utility of the intrauterine pressure transducer might be enhanced with several modifications, including the addition of a re-zeroing mechanism and a reduction in the device's length.

Vaginal birth after cesarean delivery in a woman with breech presentation is a controversial issue. In this prospective study, 137 patients had a breech presentation. Of them, 27 (19.7%) met the protocol criteria for attempted vaginal delivery and desired a trial of labor. Thirteen (48%) achieved vaginal delivery, with no increase in fetal or maternal morbidity. Our data suggest that in selected patients, a trial of labor after a cesarean delivery with a breech presentation is a reasonable consideration.

Electrical shock in pregnancy is associated with significant perinatal morbidity and mortality. A case of such an electrical shock in pregnancy is reported. A review of the literature follows. The severity of maternal injury does not correlate with the injury sustained by the fetus. Close fetal surveillance following electrical injury is necessary.

The pregnancy outcomes of 56 women with a twin gestation and a prior cesarean birth were analyzed to determine whether a trial of labor was a reasonable consideration. Of these patients, 31 (55%) underwent an elective repeat cesarean delivery and 25 (45%) attempted vaginal delivery. Of those who attempted vaginal delivery, 18 (72%) were vaginally delivered of both infants. The dehiscence rate among women with twin pregnancies who attempted a trial of labor was 4% compared with 2% in women with singleton pregnancies. There were no significant differences in maternal or neonatal morbidity or mortality rates in trial of labor versus no trial of labor groups. We conclude in this limited population that a trial of labor in a twin gestation after a previous cesarean delivery appears to be a reasonable consideration. The usual safeguards for attempted vaginal delivery in the twin gestation should be followed.

Perimortem cesarean section probably represents an underemphasized procedure on the skills list of the emergency physician. Although fraught with emotional and medicolegal overtones, the procedure can yield viable infants in at least 15% of cases and occasionally alters maternal hemodynamics so as to restore the pulse in a clinically dead woman. This article reviews the physiology and hemodynamics of the maternal-fetal unit and discusses prognostic factors for the survival of healthy mother and infant, leading to recommendations for when to perform a perimortem cesarean section. The article then describes the technical aspects of the procedure.