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PubMed2000

Is vaginal delivery preferable to elective cesarean delivery in fetuses with a known ventral wall defect?

OBJECTIVE: We sought to test the hypothesis that vaginal delivery compared with elective cesarean delivery results in improved neonatal outcome in fetuses with a known isolated ventral wall defect. STUDY DESIGN: We performed a retrospective chart review. RESULTS: Between 1989 and 1999, we identified 102 infants with a confirmed antenatal diagnosis of an isolated ventral wall defect with either the diagnosis of an omphalocele or gastroschisis. Sixty-six infants were delivered by cesarean and 36 were delivered vaginally. There were no significant demographic differences between the study groups or between the two sites except that one center (Cincinnati) usually delivered these fetuses by cesarean whereas the other (Louisville) usually delivered such fetuses vaginally. Overall, there were a greater number of infants with gastroschisis than omphalocele (gastroschisis, n = 71; omphalocele, n = 31). After we controlled for primary versus staged closure of ventral wall defect and gestational age at delivery; the medians and interquartile ranges for cesarean and vaginal delivery were 39 (25, 63) days versus 42 (26, 75) days, respectively (P =.32), for neonatal length of stay and 13 (9, 18) days versus 13 (9, 26) days, respectively (P =.16), for days to enteral feeding. After we controlled for the size of the defect and the amount of bowel resected, the odds of primary closure given a vaginal delivery was about half that given a cesarean delivery (odds ratio, 0.56; 95% confidence interval, 0.18-1. 69), but this was not statistically significant. There was no statistically significant difference in the rates of neonatal death (2 [3%] vs 2 [6%]; P =.61) and neonatal sepsis (2 [3%] vs 4 [11%]; P =.18) for cesarean versus vaginal delivery. Maternal length of stay after delivery was found to be 1 day less after vaginal delivery [vaginal, 2 (2, 2) days; cesarean, 3 (2, 3) days; P =.0001]. There were 5 instances of maternal complications, and all 5 pregnancies were delivered by cesarean (P =.16). CONCLUSION: Fetuses with an antenatal diagnosis of an isolated ventral wall defect may safely be delivered vaginally, and cesarean delivery should be performed for obstetric indications only.

Adult↗

PubMed2000

Decision to delivery intervals for assisted vaginal vertex delivery.

OBJECTIVE: To describe the time interval between decision for assisted vaginal delivery and the birth of the baby in different clinical circumstances. DESIGN: A prospective analysis of 225 consecutive women with a singleton fetal cephalic presentation in the second stage of labour requiring an operative vaginal delivery for various reasons. SETTING: A maternity unit in a district general hospital delivering more than 6,000 women annually. MAIN OUTCOME MEASURES: The decision to delivery interval and the immediate and short term maternal and neonatal outcomes according to indication for operative vaginal delivery. RESULTS: The mean (SD) decision to delivery interval was 34.4 minutes (28.3) with a range of 5 to 101 minutes. For those delivered because of suspected fetal distress, the interval of 26.5 minutes (14.0) was significantly shorter than for those performed without fetal distress 39.5 minutes (19.0) (P < 0.0001); for cases with fetal distress, forceps were significantly quicker at 23.3 minutes (14.3) than the ventouse 29.2 minutes (13.2) (P = 0.04). The longer the interval in cases of fetal distress the less favourable the condition of the neonate at birth, although this trend did not reach statistical significance and was not seen for deliveries expedited for other reasons. Perineal repair was required following 96% forceps deliveries compared with 87% ventouse (P = 0.015). Perineal trauma was not influenced by the interval between decision and delivery. CONCLUSIONS: If speed of delivery is important, use of forceps results in a quicker birth than use of the ventouse, without any compromise to the condition of the baby at delivery, and with similar rates of perineal trauma.

Adult↗

PubMed2005

Comparison of maternal satisfaction following vaginal delivery after caesarean section and caesarean section after previous vaginal delivery.

OBJECTIVES: To compare (i) satisfaction levels among women who delivered vaginally after one previous caesarean (VBAC) with women delivered by caesarean after previous vaginal delivery (CSAVD) and (ii) to assess reasons why women may request caesarean delivery on subsequent pregnancies. STUDY DESIGN: We conducted a prospective questionnaire-based study of maternal satisfaction following both modes of delivery during an 8-month period. RESULTS: One hundred and forty women completed an early postnatal questionnaire, 70 each in VBAC and CSAVD cohorts. The vast majority in both groups were satisfied with their respective mode of delivery, but would opt for vaginal delivery in their next pregnancy (89% in VBAC versus 94% in CSAVD). The VBAC group experienced minimal pain after delivery and had felt better prepared for delivery (74% versus 41% in the CSAVD group). Reasons for dissatisfaction in the VBAC group included the physical stress of labour and inadequacy of analgesia. CONCLUSION: Maternal satisfaction with vaginal delivery is high. Those who have experienced both modes of delivery would prefer vaginal birth on future pregnancies. These findings are reassuring to women contemplating vaginal delivery.

Adolescent↗

PubMed2000

Outcome of 306 twin deliveries according to first twin presentation and method of delivery.

The objective of this manuscript is to examine the effect of presentation of the first twin and mode of delivery on perintal outcome in twin deliveries. We reviewed all records of twin deliveries at a gestational age of 32 weeks and more from January 1, 1989 to December 31, 1995. Study cases were divided according to the first twin presentation (vertex = group A, nonvertex = group B) and then subdivided according to the planned mode of delivery, vaginal trial of labor (VTOL), and cesarean section (CS). The protocol for group A facilitated an attempt at vaginal delivery and for group B, vaginal delivery was considered as for a singleton fetus in breech presentation. Of 306 pairs of twins, 235 were in group A and 71 in group B. In group A, 219 women (93.2%) were eligible for VTOL, and the remaining 16 underwent CS. Thirty-three group B women were eligible for VTOL (46.5%; p<0.001) and 38 had CS. In group A, of the 219 candidates for VTOL, 199 (90.9%) delivered vaginally and 20 underwent a CS. In group B, of the 33 VTOL candidates 18 (54.5%) delivered vaginally and 15 underwent CS. Neonatal outcome did not differ in relation to the presentation of the first twin or the planned/actual mode of delivery. There were no cases of birth trauma, neurological complications, or perinatal mortality. Trial of vaginal labor is safe in twin deliveries with the first twin in vertex presentation. Provided criteria for vaginal breech delivery are adhered to, this also appears to be a reasonable option in twin deliveries with the first twin in nonvertex presentation.

Adult↗

PubMed2001

Mode of delivery for the morbidly obese with prior cesarean delivery: vaginal versus repeat cesarean section.

OBJECTIVE: We sought to describe the peripartum outcome of women weighing >300 pounds (135 kg) who were candidates for trial of labor after a prior cesarean delivery. STUDY DESIGN: All pregnant women who weighed in excess of 300 pounds and had a prior cesarean delivery were included in this prospective investigation. Student t test, chi(2) analysis, or Fisher exact tests were used. Odds ratios and 95% confidence intervals were calculated. P <.05 was considered significant. RESULTS: During a 2-year period, 69 patients met the inclusion criteria; 39 (57%) underwent an elective repeat cesarean delivery, and 30 (43%) women attempted a vaginal delivery after prior cesarean delivery. The demographics of age, race, gravidity, maternal weight, and preexisting medical conditions were similar for the two groups. Vaginal birth after prior cesarean delivery occurred in 13% (4/30). Reasons for failure included a labor arrest disorder in 46%, fetal distress in 38%, and failed induction in 15%. The rates of endometritis and wound breakdown were higher in the women undergoing trial of labor (30% and 23%, respectively) than in those undergoing repeat elective cesarean delivery (20% and 8%). The combined infectious morbidity rate was significantly higher for women attempting trial of labor (53%) than those undergoing elective repeat cesarean delivery (28%; odds ratio 1.78, 95% confidence intervals 1.05, 3.02). CONCLUSION: The success rate for a vaginal delivery in the morbidly obese woman with a prior cesarean delivery is less than 15%, and more than half of the patients undergoing a trial of labor have infectious morbidity.

Adult↗

PubMed1997

Intramural drug delivery by direct injection within the arterial wall: first clinical experience with a novel intracoronary delivery-infiltrator system.

Local drug delivery at the lesion site in patients with coronary artery disease is being intensively studied to prevent restenosis after percutaneous coronary intervention. However, the effective penetration of the delivered agents into the vessel wall and delivery time remain considerable problems for all currently existing devices. A unique, new catheter has been invented, the infiltrator Angioplasty Balloon Catheter (IABC), which has the capability to allow intramural drug delivery by direct injection within the arterial wall. We describe the first clinical experience with this catheter. IABC is an angioplasty catheter with 3 lumens: one for inflating the balloon, one central for the guidewire, and a third for drug delivery. On the surface of the balloon there are 3 longitudinal strips of 6 injection needles, which on inflation stand 0.01" high, and are connected to the drug-delivery lumen. With inflation of the balloon, the needles penetrate the lesion, allowing drug delivery into the media of the vessel wall. We used the IABC in 17 patients (age = 58 +/- 9 years) undergoing coronary angioplasty. All patients were symptomatic, with significant lesions (13 LAD, 3 LCX, 1 RCA) and documented ischemia. Following initial dilatation with a conventional angioplasty balloon (stenosis from 72 +/- 8% to 26 +/- 14%, P < 0.001), the IABC was used to infiltrate the lesion with 0.4 ml (6,000 IU) of low-molecular-weight heparin (Fraxiparine). For the delivery, the IABC was inflated to 1-2 atm for 30-45 s, and the heparin was injected by hand in 5 s. Lesion residual stenosis and morphology remained unchanged after IABC use (26 +/- 14% to 22 +/- 11%, P = NS). In 10 patients, stent placement followed the IABC use. The decision to proceed with stent placement was made after the initial dilatation with the conventional balloon, and it was not influenced by the IABC use. Stent placement greatly improved the final result (for the whole patient group: 22 +/- 11% to 5 +/- 18%, for the stented patients: 22 +/- 13% to -7 +/- 10%, P < 0.001 for both). Hospital course was uneventful, with no electrocardiogram changes and normal cardiac enzymes for all patients. We have shown that the use of a unique new catheter (IABC) for intramural drug delivery in human patients undergoing coronary angioplasty is feasible and safe. This catheter is the first of a new generation of catheters and represents a significant step in local drug delivery. It is very promising as a vehicle to modify plaque behavior and potentially influence restenosis after angioplasty.

Adult↗

PubMed2005

Occurrence and clinical predictors of operative delivery for the vertex second twin after normal vaginal delivery of the first twin.

OBJECTIVE: This study was undertaken to estimate occurrence and explore clinical predictors of abdominal and vaginal operative delivery in vertex second twin after normal vaginal delivery of the first twin. METHODS: Data from a historical cohort study that was based on a twin registry in the United States (1995-1997) were used. RESULTS: Among 42,417 vertex second twins following normal vaginal delivery of the first twins, rates of abdominal and vaginal operative delivery were 6.3% and 8.3%, respectively. Cord prolapse, fetal distress, maternal complications, abnormal labor, and birth weight 25% larger than first twin were the most important predicators for operative deliveries. Fetal distress and cord prolapse had a stronger effect on abdominal than vaginal operative delivery. CONCLUSION: In general population, abdominal and vaginal operative delivery rates were 6.3% and 8.3%, respectively, in vertex second twin after normal vaginal delivery of the first twin. The most important predictors for operative delivery are cord prolapse and fetal distress.

Adult↗

PubMed2004

Maternal and neonatal morbidity after elective repeat Cesarean delivery versus a trial of labor after previous Cesarean delivery in a community teaching hospital.

OBJECTIVE: To compare maternal and fetal outcomes after elective repeat Cesarean section versus a trial of labor in women after one prior uterine scar. STUDY DESIGN: All women with a previous single low transverse Cesarean section delivered at term with no contraindications to vaginal delivery were retrospectively identified in our database from January 1995 to October 1998. Outcomes were first analyzed by comparing mother-neonate dyads delivered by elective repeat Cesarean section to those undergoing a trial of labor. Secondarily, outcomes of mother-neonatal dyads who achieved a vaginal delivery or failed a trial of labor were compared to those who had elective repeat Cesarean delivery. RESULTS: Of 1408 deliveries, 749/927 (81%) had a successful vaginal birth after a prior Cesarean delivery. There were no differences in the rates of transfusion, infection, uterine rupture and operative injury when comparing trial of labor versus elective repeat Cesarean delivery. Neonates delivered by elective repeat Cesarean delivery were of earlier gestation and had higher rates of respiratory complications (p < 0.05). Mother-neonatal dyads with a failed trial of labor sustained the greatest risk of complications. CONCLUSION: Overall, neonatal and maternal outcomes compared favorably among women undergoing a trial of labor versus elective repeat Cesarean delivery. The majority of morbidity was associated with a failed trial of labor. Better selection of women likely to have a successful vaginal birth after a prior Cesarean delivery would be expected to decrease the risks of trial of labor.

Adult↗

PubMed1995

Intramural delivery of agent via a novel drug-delivery sleeve. Histological and functional evaluation.

BACKGROUND: The infusion sleeve is a novel drug-delivery catheter system designed to deliver an agent under controlled conditions into the arterial wall at the site of angioplasty. The purpose of the present study was to characterize the delivery agent via the infusion sleeve in ex vivo and in vivo models. METHODS AND RESULTS: The delivery of horseradish peroxidase via the infusion sleeve was studied in a porcine explanted heart model. Under physiological conditions, arteries underwent balloon injury (approximately 10% overstretch), after which horseradish peroxidase (2.5 mL) was delivered at specific pressures. Cross-sectional analysis demonstrated greater staining when the agent was delivered at increasing pressures. The infusion sleeve was evaluated in an in vivo canine coronary model. With an infusion sleeve loaded over a standard dilatation catheter through a 9F guide, overstretch balloon injury was performed, after which fluoresceinated heparin was delivered. Animals were killed 2 hours after delivery. Fluoresceinated heparin-treated segments demonstrated high fluorescence signals, localizing with smooth muscle cell nuclei with less activity in the interstitium. The functional significance of intramural heparin delivery was studied in a porcine carotid model. In the presence of 111In-labeled platelets, arteries underwent overstretch injury followed by delivery of heparin (50 or 100 units/kg) or vehicle. Platelet deposition was reduced at 30 minutes (57%, P < .01) and 12 hours (39%, P = .06) compared with saline controls. CONCLUSIONS: Agent delivery via the infusion sleeve is pressure dependent; transmural delivery is possible with minimal disruption of arterial wall architecture; the infusion sleeve is compatible with standard angioplasty equipment; and heparin delivery at the site of balloon injury significantly reduces platelet deposition in a porcine model for a minimum of 12 hours.

Angioplasty, Balloon↗

PubMed1953