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PubMed2005

Risk of maternal postpartum readmission associated with mode of delivery.

OBJECTIVE: To determine whether cesarean and operative vaginal deliveries are associated with an increased risk of maternal rehospitalization compared with spontaneous vaginal delivery. METHODS: A population-based cohort study was conducted by using the Canadian Institute for Health Information's Discharge Abstract Database between 1997/1998 and 2000/2001, which included 900,108 women aged 15-44 years with singleton live births (after excluding several selected obstetric conditions). RESULTS: A total of 16,404 women (1.8%) were rehospitalized within 60 days after initial discharge. Compared with spontaneous vaginal delivery (rate 1.5%), cesarean delivery was associated with a significantly increased risk of postpartum readmission (rate 2.7%, odds ratio [OR] 1.9, 95% confidence interval [CI] 1.8-1.9); ie, there was 1 excess postpartum readmission per 75 cesarean deliveries. Diagnoses associated with significantly increased risks of readmission after cesarean delivery (compared with spontaneous vaginal delivery) included pelvic injury/wounds (rate 0.86% versus 0.06%, OR 13.4, 95% CI 12.0-15.0), obstetric complications (rate 0.23% versus 0.08%, OR 3.0, 95% CI 2.6-3.5), venous disorders and thromboembolism (rate 0.07% versus 0.03%, OR 2.7, 95% CI 2.1-3.4), and major puerperal infection (rate 0.45% versus 0.27%, OR 1.8, 95% CI 1.6-1.9). Women delivered by forceps or vacuum were also at an increased risk of readmission (rates 2.2% and 1.8% versus 1.5%; OR forceps: 1.4, 95% CI 1.3-1.5; OR vacuum: 1.2, 95% CI 1.2-1.3, respectively). Higher readmission rates after operative vaginal delivery were due to pelvic injury/wounds, genitourinary conditions, obstetric complications, postpartum hemorrhage, and major puerperal infection. CONCLUSION: Compared with spontaneous vaginal delivery, cesarean delivery, and operative vaginal delivery increase the risk of maternal postpartum readmission. LEVEL OF EVIDENCE: II-2.

Adolescent↗
PubMed2006

Outcome of second delivery after prior macrosomic infant in women with normal glucose tolerance.

OBJECTIVE: Our aim was to estimate the obstetric outcome of second delivery in women with normal glucose tolerance whose first fetus was macrosomic (fetal weight >/= 4,500 g). METHODS: Primiparas delivering a macrosomic infant during the years 1997-2000 were identified from a hospital computer database, and the obstetric outcome of a second delivery was analyzed up until June 2003. A control group (birth weight 3,000-3,500 g) served for comparison. RESULTS: Among 13,020 first pregnancies, 301 (2.3%) were macrosomic. A similar proportion in the macrosomic group, 156 of 301 (52%), and control group, 171 of 300 (57%), returned for second delivery (P = .252). Compared with controls, first macrosomic deliveries were characterized by higher rates of operative delivery, anal sphincter injury, and shoulder dystocia. At second delivery, 32% of neonates in the macrosomic group and 0.3% in the control group weighed 4,500 g or more (P < .001). More prelabor cesareans were performed in the macrosomic group compared with controls (27 of 156, 17.3%, compared with 8 of 171, 4.7%; P < .001). Among 104 women in the macrosomic group who labored after first vaginal delivery, 99% (103 of 104) delivered vaginally again compared with 44% (11 of 25) who labored after primiparous cesarean delivery (P < .001), which compares with 97% (146 of 150) and 77% (10 of 13), respectively, in the control group. CONCLUSION: Despite a one-third recurrence of macrosomia, first vaginal delivery of a macrosomic infant was associated with a high incidence of second vaginal delivery. Conversely, primiparous macrosomic cesarean delivery conveyed a high risk (56%) for repeat intrapartum cesarean whether macrosomia recurred or not. LEVEL OF EVIDENCE: II-2.

Adult↗
PubMed2006

Chilean women's preferences regarding mode of delivery: which do they prefer and why?

OBJECTIVE: Caesarean section rates in Chile are reported to be as high as 60% in some populations. The purpose of this study was to determine pregnant Chilean women's preferences towards mode of delivery. DESIGN: Interviewer-administered cross-sectional survey. SETTING: Prenatal clinics in Santiago, Chile. Population Pregnant women in Santiago, Chile. METHODS: Of 180 women completing the questionnaire, 90 were interviewed at a private clinic (caesarean delivery rate 60%) and 90 were interviewed at a public clinic (cesarean delivery rate 22%). Data collected included demographics, preferred mode of delivery, and women's attitudes towards vaginal and caesarean deliveries. MAIN OUTCOME MEASURES: Mode of delivery preferences, perceptions of mode of delivery measured on a 1-7 Likert scale. RESULTS: The majority of women (77.8%) preferred vaginal delivery, 9.4% preferred caesarean section, and 12.8% had no preference. There was no statistical difference in preference between the public clinic (11% preferred caesarean) and the private clinic (8% preferred caesarean, P= 0.74). Overall, women preferring caesarean birth were slightly older than other groups (31.6 years, versus 28.4 years for women who preferred vaginal and 27.3 years for women who had no preference, P= 0.05), but there were otherwise no differences in parity, income, or education. On a scale of 1-7, women preferring caesarean birth rated vaginal birth as more painful, while women preferring vaginal birth rated it as less painful (5.8 versus 3.7, P= 0.003). Whether vaginal or caesarean, each group felt that their preferred mode of delivery was safer for their baby (P < 0.001). CONCLUSIONS: Chilean women do not prefer caesarean section to vaginal delivery, even in a practice setting where caesarean delivery is more prevalent. Thus, women's preferences is unlikely to be the most significant factor driving the high caesarean rates in Chile.

Adult↗
PubMed2005

Association between method of delivery and puerperal infectious complications in the perinatal database of Baden-Württemberg 1998-2001.

The strongest argument against caesarean delivery relates to maternal complications. Evidence supporting this for elective operations is controversial. The perinatal database 1998-2001 of the German state of Baden-Württemberg was studied to assess the maternal obstetrical risk associated with caesarean delivery with regard to puerperal infectious complications. For statistical analysis the chi2 test, Fisher's exact test, Mantel-Haenszel statistics and relative risks were used to describe the risk of exposure. Surgical delivery was associated with a significantly higher risk of infectious disorders (p < 0.0001). There was a significantly higher risk of septicaemia in the group undergoing caesarean compared to vaginal delivery (p < 0.0001), for pregnancies with and without risk factors of infection, and also for caesarean delivery prior to labour and rupture of membranes (ROM) and singleton gestations (RR 8.56; 95% CI 4.4-16.65, stratum without risks). The rate of wound disorders was found to be significantly increased in the case of surgical delivery (p < 0.0001). After exclusion of pregnancies with risk factors for infectious complications and multi-fetal gestation, a significantly higher risk was also found for caesarean delivery prior to labour and ROM versus vaginal delivery (RR 16.97; 95% CI 14.16-20.34). Caesarean delivery significantly increased the likelihood that a woman would experience fever in puerperium (p < 0.0001), for pregnancies with and without ante- or perinatal risk factors for infectious complications, and also when caesarean delivery prior to labour and ROM and singletons in the cephalic presentation were considered separately (RR 11.03; 95% CI 9.39-12.96; stratum without risks). Considering the obstetrical challenge of how more women can deliver with fewer complications, reducing unnecessary caesarean delivery still seems to be an appropriate approach.

Cesarean Section↗
PubMed1992

Fetal atrial measurements before and after delivery: correlation with plasma atrial natriuretic peptide.

Fetal and early neonatal atrial measurements correlating with plasma atrial natriuretic peptide were studied to evaluate the circulatory change before and after delivery in a longitudinal study of 10 normal fetuses from 1 week before until 5 days after delivery. Before delivery, right atrial area value was significantly larger than that of left atrial area; however, there were no significant differences between left and right atrial areas after delivery. Right atrial area value before delivery was significantly larger than those after delivery, whereas the left atrial area did not change before and after delivery. Combined atrial area value before delivery was also larger than those after delivery. Plasma atrial natriuretic peptide values did not change after delivery. These results suggest that the change from fetal to neonatal circulation mainly caused by the pulmonary circulation induces the change of right atrial size before and after delivery.

Atrial Natriuretic Factor↗
PubMed2002

Strategies for increasing drug delivery to the brain: focus on brain lymphoma.

The blood-brain barrier (BBB) is a gate that controls the influx and efflux of a wide variety of substances and consequently restricts the delivery of drugs into the central nervous system (CNS). Brain tumours may disrupt the function of this barrier locally and nonhomogeneously. Therefore, the delivery of drugs to brain tumours has long been a controversial subject. The current concept is that inadequate drug delivery is a major factor that explains the unsatisfactory response of chemosensitive brain tumours. Various strategies have been devised to circumvent the BBB in order to increase drug delivery to the CNS. The various approaches can be categorised as those that attempt to increase delivery of intravascularly administered drugs, and those that attempt to increase delivery by local drug administration. Strategies that increase delivery of intravascularly injected drugs can manipulate either the drugs or the capillary permeability of the various barriers (BBB or blood-tumour barrier), or may attempt to increase plasma concentration or the fraction of the drug reaching the tumour (high-dose chemotherapy, intra-arterial injection). Neurotoxicity is a major concern with increased penetration of drugs into the CNS or when local delivery is practised. Systemic toxicity remains the limiting factor for most methods that use intravascular delivery. This review evaluates the strategies used to increase drug delivery in view of current knowledge of drug pharmacokinetics and its relevance to clinical studies of chemosensitive brain tumours. The main focus is on primary CNS lymphoma, as it is a chemosensitive brain tumour and its management routinely utilises specialised strategies to enhance drug delivery to the affected CNS compartments.

ATP Binding Cassette Transporter, Subfamily B, Mem↗
PubMed2005

Evaluation of the effectiveness of a clean delivery kit intervention in preventing cord infection and puerperal sepsis among neonates and their mothers in rural Mwanza Region, Tanzania.

A study was carried out in Misungwi and Kwimba Districts, Tanzania to determine the effectiveness of clean delivery kits in preventing cord infection and puerperal sepsis and to provide qualitative information on community acceptability, correct use, and appropriateness of the kits. This study involved pregnant women aged 18-45 years old. In the delivery kit intervention population, the Maternal and Child Health Aide (MCHA) assigned to the health facility provided pregnant mothers with a clean delivery kit on their first antenatal visit. She explained how to use each of the kit components, with the aid of pictorial instructions included in the kit. The pregnant mothers were asked to convey the information to whoever assisted them during delivery. The MCHA also gave them health education based on the principles of the "six cleans" recognized by WHO (i.e., clean hands, clean perineum, clean delivery surface, clean cord cutting and tying instruments, clean cutting surface). Women received the clean delivery kit free of charge in accordance with the randomised stepped-wedge design schedule. During the first week following delivery, the Village Health Workers (VHWs) from both the intervention and control groups made two visits to the households of mothers who had delivered. They administered questionnaire about delivery to mother and birth attendant. During the two scheduled postpartum visits, those who were suspected to have puerperal sepsis or cord infection of the baby were referred to the health facility clinician for confirmation. Results indicated that use of clean delivery kit had a positive effect on reducing both cord infection and puerperal sepsis. The use of a clean home delivery kit coupled with an educational intervention about the "six cleans" had a significant effect on reducing the incidence of cord infection and puerperal sepsis among women enrolled in the study. In low resource settings where home birth is common and clean delivery supplies are scarce, disposable kits can be made available through health clinics, markets, pharmacies or other channels to help reduce rates of infection.

Adolescent↗
PubMed2000

Outcome of singleton term breech cases in the pretext of mode of delivery.

OBJECTIVE: A study was carried out to ascertain maternal and perinatal outcome of cases presented as breech versus their mode of delivery so that appropriate management strategy could be mapped out without compromising fetomaternal wellbeing. METHODS: The study was carried out in one of the units of the Department of Obstetrics and Gynaecology of Sir Ganga Ram Hospital, affiliated with Fatima Jinnah Medical College, from August, 1996 to July, 1999. Management of 352 singleton term breech cases was analyzed. Data gathered were socio-demographic variables, detailed obstetrical history, important features of index pregnancy, type of breech presentation, selection of mode of delivery and reason for choosing a particular route of delivery, indications of elective or emergency caesarean sections in the cases applicable, fetal outcome and maternal complications. RESULTS: In 135 (38%) patients C-section (94 elective and 41 emergency) was done straightaway and trial of vaginal breech delivery was given to the remaining 217 (62%). Of these vaginal delivery could be done in 161 (74%) cases and 56 (26%) required caesarean section due to fetal distress and or failure to progress. About 32% primiparas could manage vaginally 55% multiparas while the ratio of caesareans done in both the groups was 68% vs 45%. A direct proportion was observed between C-section rate and neonatal birthweight. Route of delivery did not influence significantly neonatal outcome which become evident when no marked difference could be detected in corrected neonatal mortality rates calculated for the groups having elective C-section, emergency section and vaginal delivery. Perinatal mortality rate and corrected neonatal mortality rate of the study population and the same values computed for all the deliveries conducted during the study period were found to comparable. Maternal and neonatal complications were seen more frequently in the group requiring emergency caesarean section. CONCLUSION: Proper selection of cases for vaginal delivery, vigilant intrapartum monitoring and employing proper technique of breech delivery have been established as the most important determinants for successful vaginal breech delivery without compromising fetomaternal well being and curtailing the percentage of caesareans being done for this malpresentation.

Adult↗
PubMed2003

The circadian rhythm of "urgent" operative deliveries.

BACKGROUND: Even operative deliveries defined as "urgent" show marked diurnal variation with a significant increase during regular working hours. OBJECTIVE: To investigate the diurnal variation of urgent operative deliveries and its potential implications on the outcome of newborns. METHODS: We conducted a retrospective study of all deliveries in a public hospital from 1 January 1990 to 31 December 1998. Delivery mode variables analyzed were spontaneous vaginal delivery, urgent cesarean section and operative vaginal delivery. Deliveries were stratified hourly throughout the day. The rate of operative deliveries was calculated and the analysis was then performed according to the daily routine shifts of the medical staff. Birth weight and Apgar scores at 1 and 5 minutes were retrieved as outcome measures. RESULTS: The rate of urgent cesarean deliveries increased significantly between 8 a.m. and 2 p.m. (150%-230%) from that predicted. The lowest rate of urgent cesarean sections was found between 5 a.m. and 6 a.m. (5.3%). Mean birth weight in spontaneous deliveries was higher in the morning hours than during the night shift (3,293 +/- 520 g vs. 3,277 +/- 510 g, respectively, P < 0.005). Apgar scores of newborns delivered by urgent cesarean section during the morning were higher compared to those delivered during night shifts and the rate of low Apgar scores was lower in the morning than in evening and night shifts. CONCLUSIONS: Our results indicate a marked diurnal variation in urgent operative deliveries, caused perhaps by varying definition of "urgency" according to the time of day.

Apgar Score↗
PubMedDate not supplied

Spontaneous and stimulated interleukin-6 and tumor necrosis factor-alpha production at delivery and three months after birth.

OBJECTIVE: To study the production and interrelations of maternal and neonatal cytokines (IL-6 and TNF-alpha) during labor, after vaginal delivery and at three months after delivery. METHOD: The unstimulated concentrations of cytokines in the supernatants of whole-blood cultures and concentrations after PMA (phorbol 12-myristate 13-acetate) and concanavalin (conA) stimulation were determined by enzyme-linked immunosorbent assays (ELISAs). The blood samples were from the peripheral veins of 27 healthy women during term labor and immediately after delivery and three months after delivery. Neonatal samples were taken at birth (cord blood) and three months after delivery. RESULTS: IL-6 responses to stimulation were increased in the parturients and in umbilical cord blood at delivery compared with maternal and neonatal samples obtained 3 months postpartum. In contrast, the production of maternal TNF-alpha in peripheral blood was down-regulated at delivery compared with values 3 months postpartum. After an IL-6 and TNF-alpha burst in umbilical cord samples, neonatal cytokine production was at a low level three months after delivery. IL-6 production tended to be higher in both umbilical cord blood as well as in maternal samples after delivery in women who were younger. In addition, TNF-alpha production in umbilical cord blood was significantly higher in those women who were younger. CONCLUSIONS: The production of IL-6 was up-regulated in both the maternal and in umbilical cord blood at delivery. The production of TNF-alpha was up-regulated in umbilical cord blood compared with neonatal values 3 months after birth. Maternal age had effects on IL-6 and TNF-alpha production at delivery.

Adult↗
PubMed1991

Drug delivery systems.

New and emerging drug delivery systems for traditional drugs and the products of biotechnology are discussed, and the role of the pharmacist in ensuring the appropriate use of these systems is outlined. Advantages of advanced drug delivery systems over traditional systems are the ability to deliver a drug more selectively to a specific site; easier, more accurate, less frequent dosing; decreased variability in systemic drug concentrations; absorption that is more consistent with the site and mechanism of action; and reductions in toxic metabolites. Four basic strategies govern the mechanisms of advanced drug delivery: physical, chemical, biological, and mechanical. Oral drug delivery systems use natural and synthetic polymers to deliver the product to a specific region in the gastrointestinal tract in a timely manner that minimizes adverse effects and increases drug efficacy. Innovations in injectable and implantable delivery systems include emulsions, particulate delivery systems, micromolecular products and macromolecular drug adducts, and enzymatic-controlled delivery. Options for noninvasive drug delivery include the transdermal, respiratory, intranasal, ophthalmic, lymphatic, rectal, intravaginal, and intrauterine routes as well as topical application. Rapid growth is projected in the drug delivery systems market worldwide in the next five years. Genetic engineering has mandated the development of new strategies to deliver biotechnologically derived protein and peptide drugs and chemoimmunoconjugates. The role of the pharmacist in the era of advanced drug delivery systems will be broad based, including administering drugs, compounding, calculating dosages based on pharmacokinetic and pharmacodynamic monitoring, counseling, and research. The advent of advanced drug delivery systems offers pharmacists a new opportunity to assume an active role in patient care.

Administration, Oral↗
PubMed1991

A randomized comparison of assisted vaginal delivery by obstetric forceps and polyethylene vacuum cup.

The assisted vaginal delivery methods of rigid obstetric forceps and polyethylene vacuum cup extraction were compared in a prospective, randomized study. The 99 women studied had all completed 35 full weeks' gestation, required attempted assisted vaginal delivery, and were randomly assigned to either attempted forceps or vacuum-assisted delivery. All presentations were cephalic, with stations ranging from +1 to +4. Neonates were evaluated at 24 hours by neonatal staff. The infants underwent intracranial ultrasound screening during the first 24 hours of life and ophthalmologic examination within 48 hours. Vaginal delivery was successful with the intended method in 83% of vacuum-assisted deliveries and in 78% of forceps deliveries (not statistically significant). Neonatal retinal hemorrhage was found in 17 and 38% (P less than .043) of the randomized forceps and vacuum deliveries, respectively. No intraventricular hemorrhage was found. Apart from associations between vacuum-assisted delivery and mild hyperbilirubinemia and neonatal retinal hemorrhage (of uncertain clinical significance), and between assisted forceps delivery and an increased potential for facial injury, neonatal outcomes did not differ significantly. Maternal outcomes also did not differ significantly. No significant differences in safety or efficacy were found between polyethylene cup vacuum extraction and rigid obstetric forceps-assisted vaginal delivery in this population of predominantly low-pelvic assisted deliveries. Patients delivered by sequential use of forceps after vacuum or by vacuum after failed forceps application did not suffer significantly increased morbidity relative to those delivered by forceps or vacuum alone. Use of alternate or sequential methods allowed an overall cesarean rate of 3% in this population.

Acid-Base Equilibrium↗
PubMed1989

[Delivery at an alternative clinic or a special department].

With the object of assessing the safety of deliveries in the Maternity Clinic in Glostrup Hospital, consecutive registration of all 196 deliveries which commenced in the clinic during a period of seven months was undertaken. On account of various complications, 36.2% of these were transferred to the Special Department during delivery. As a control material, 313 so-called "no risk" deliveries which occurred in the Maternity Department of the Special Department during the same period were employed. The corresponding number of "complicated" deliveries in this material was 45.7%. Interventions such as early rupture of the membranes and stimulation of contractions with intravenous oxytocin were employed significantly more frequently in the Special Department. Delivery with vacuum-extractor or caesarean section was employed in 12.3% of the deliveries which commenced in the Clinic as compared with 16.6% in the Special Department. This difference was not significant. No differences could be demonstrated in the conditions of the infants on delivery and in the neonatal period which could be attributed to the choice of place of delivery. It is concluded that, with the rules for referral, monitoring during delivery and transfer to the Special Department which hold for the Maternity Clinic, the safety for deliveries corresponds to that which the Maternity Unit of the Special Department can offer.

Adult↗
PubMed1996

The effectiveness and costs of elective cesarean delivery for fetal macrosomia diagnosed by ultrasound.

OBJECTIVE: To quantitate the potential effectiveness and monetary costs of a policy of elective cesarean delivery for fetal macrosomia diagnosed by ultrasound. DESIGN: A decision analytic model was constructed to compare 3 policies: (1) management without ultrasound; (2) ultrasound and elective cesarean delivery for estimated fetal weight of 4000 g or more (4000-g policy); and (3) ultrasound and elective cesarean delivery for estimated fetal weight of 4500 g or more (4500-g policy). The impact of maternal diabetes was analyzed separately. Probability data used in the decision analytic model were summarized from the literature and supplemented with unpublished data from the Collaborative Trial of Preterm Birth Prevention. Costs were estimated from the literature, regional reimbursements, and clinical practice data. MAIN OUTCOME MEASURES: Rates of shoulder dystocia and permanent brachial plexus injury, and both the number of additional cesarean births and monetary costs per permanent brachial plexus injury averted. RESULTS: In the baseline analysis for nondiabetic women, the ultrasound policies increased both the cesarean delivery rate and costs, while decreasing the rate of shoulder dystocia and brachial plexus injury. For each permanent brachial plexus injury prevented by the 4500-g policy, 3695 cesarean deliveries were performed at an additional cost of $8.7 million, vs 2345 cesarean deliveries and $4.9 million with the 4000-g policy. In the baseline analysis for diabetic women, with all 3 policies, rates of cesarean delivery, shoulder dystocia and brachial plexus injury, and total costs were higher than for nondiabetic women. However, more favorable ratios for both cesarean deliveries and cost per permanent injury avoided were observed: 443 deliveries and $930 000, respectively, with the 4500-g policy, and 489 deliveries and $880 000, respectively, with the 4000-g policy. Sensitivity analysis confirmed the general robustness of these findings. CONCLUSIONS: For the 97% of pregnant women who are not diabetic, a policy of elective cesarean delivery for ultrasonographically diagnosed fetal macrosomia is medically and economically unsound. In pregnancies complicated by diabetes, such a policy appears to be more tenable, although the merits of such an approach are debatable.

Birth Injuries↗
PubMed2004

Treatment for cervical intraepithelial neoplasia and risk of preterm delivery.

CONTEXT: It is unclear whether treatments for cervical intraepithelial neoplasia (CIN) increase the subsequent risk of preterm delivery. Most studies have lacked sufficient sample size, mixed heterogeneous subtypes of preterm delivery, and failed to control for confounding factors. OBJECTIVE: To determine whether cervical laser and loop electrosurgical excision procedure (LEEP) treatments increase risk of preterm delivery and its subtypes. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study conducted among women evaluated at a colposcopy clinic serving Auckland, New Zealand (1988-2000), comparing delivery outcomes of untreated women (n = 426) and those treated (n = 652) with laser conization, laser ablation, or LEEP. Record linkage using unique health identifiers identified women who had subsequent deliveries. MAIN OUTCOME MEASURES: Total preterm delivery and its subtypes, spontaneous labor and premature rupture of membranes before 37 weeks' gestation (pPROM). RESULTS: The overall rate of preterm delivery was 13.8%. The rate of pPROM was 6.2% and the rate of spontaneous preterm delivery was 3.8%. Analyses showed no significant increase in risk of total preterm delivery (adjusted relative risk [aRR], 1.1; 95% confidence interval [CI], 0.8-1.5) or spontaneous preterm delivery (aRR, 1.3; 95% CI, 0.7-2.6) for any treatment. Risk of pPROM was significantly increased following treatment with laser conization (aRR, 2.7; 95% CI, 1.3-5.6) or LEEP (aRR, 1.9; 95% CI, 1.0-3.8), but not laser ablation (aRR, 1.1; 95% CI, 0.5-2.4). Moreover, risk of pPROM and total preterm delivery increased significantly with increasing height of tissue removed from the cervix in conization. Women in the highest tertile of cone height (> or =1.7 cm) had a greater than 3-fold increase in risk of pPROM compared with untreated women (aRR, 3.6; 95% CI, 1.8-7.5). CONCLUSIONS: LEEP and laser cone treatments were associated with significantly increased risk of pPROM. Careful consideration should be given to treatment of CIN in women of reproductive age, especially when treatment might reasonably be delayed or targeted to high-risk cases.

Cervix Uteri↗
PubMed1997

Maternal urological injuries associated with vaginal deliveries: change of pattern.

Injury to the maternal lower urinary tract is related to the standard of obstetric care and to different techniques utilized in delivery. In comparison with operative delivery, maternal urinary tract injury in association with vaginal delivery had always been exceptionally rare. However, with the recent progress in obstetric care and the introduction of new concepts such as vaginal delivery after caesarian section (VDAC), the pattern of maternal urological injuries associated with vaginal deliveries might have changed. In a retrospective study it was found that significant injuries to the lower urinary tract occurred in seven females in the course of vaginal delivery in the period between 1992 and 1994 in two major hospitals in the Riyadh area. These included rupture of the posterior bladder wall, trigone and bladder neck. Distal ureteric and urethral injuries, as well as bladder contusion were also encountered. Two patients developed vesico-uterine and vesico-vaginal fistulas. History of previous caesarian section was present in 4 patients. All deliveries were with cephalic presentation and six patients received oxytocin for induction or acceleration of labour. Episiotomy was done in 6 patients and instrumental delivery was performed in 3 patients. Gross haematuria immediately after delivery was the most common presentation, followed by urinary incontinence. Flank pain and fever were associated with ureteric injury and were delayed for few days. Urological injury should be suspected after vaginal delivery in females with previous caesarian section, if instrumental delivery is applied, and in patients with deep vaginal tears. The presence of gross haematuria, incontinence and flank pain should indicate full urological evaluation.

Adult↗
PubMed2005

The choice of elective cesarean delivery in obstetrics: a voluntary survey of Canadian health care professionals.

To survey Canadian health care professionals about their willingness to offer elective cesarean delivery and to evaluate how their knowledge of obstetric-related pelvic-floor injury influences their practice. A voluntary questionnaire was distributed to health care professionals attending the 58th Annual Meeting of the Society of Obstetricians and Gynaecologists of Canada in 2002. Appropriate statistical analysis was used. One hundred and sixty-two questionnaires were completed. One hundred respondents were female (62%). Twenty-three percent (37/162) of respondents approved elective cesarean delivery after informed request in nulliparous women without an obstetrical indication. Males were more likely than females to perform cesarean delivery in these circumstances (34% versus 16%; OR 2.7, CI 1.2, 6.0). When questioned about the impact of mode of delivery on bladder and bowel continence, the number of respondents who answered "usually" or "always has a detrimental effect" were: vaginal birth, 16%; forceps, 20%; and cesarean delivery "reduces bladder and bowel problems", 44%. Males were more likely to emphasize a protective effect of cesarean delivery (55% versus 38%; OR 1.9, CI 1.0, 4.0). Health care professionals would opt for cesarean delivery for themselves when forceps delivery was the alternative more often than they would offer cesarean delivery to their patients (OR 1.98, CI 1.1, 3.5). While a significant number of women's health care professionals are prepared to offer cesarean delivery to nulliparous women, informed choice seems to motivate the offer rather than a conviction that cesarean delivery will protect the pelvic floor.

Adult↗
PubMed1993

The presence of cervical and vaginal fetal fibronectin predicts preterm delivery in an inner-city obstetric population.

OBJECTIVE: It has previously been shown that fibronectin bearing a specific oncofetal domain is present at the chorionic-decidual interface and that its release into cervical and vaginal secretions accurately predicts preterm delivery in patients with uterine contractions. This study examines whether serial assessment of cervical and vaginal fetal fibronectin allows for the prediction of preterm delivery in symptom-free patients derived from an inner-city, general obstetric population. STUDY DESIGN: Cervical and vaginal samples were obtained from 429 consenting patients who received routine prenatal care between 24 and 37 weeks' gestation. A sensitive immunoassay was used to quantitate cervical and vaginal fetal fibronectin levels, and clinicians were blinded to fetal fibronectin results. Post hoc receiver operating characteristic curve analysis was used to determine which sample site (cervical or vaginal), fetal fibronectin concentration, and number of consecutive positive samples optimized screening efficacy. Logistic regression was employed to determine whether fetal fibronectin was an independent predictor of preterm delivery. RESULTS: The spontaneous preterm delivery rate was 11% (49/429). Among the 326 patients sampled within 28 days of delivery, receiver operating characteristic curve analysis indicated that the presence of a single cervical fetal fibronectin value > 60 ng/ml between 24 and 36 weeks' gestation predicted preterm delivery with a sensitivity of 73%, a specificity of 72%, and positive and negative predictive values of 25% and 95%, respectively. A vaginal fetal fibronectin value > 50 ng/ml predicted preterm delivery with a sensitivity of 68%, a specificity of 80%, and positive and negative predictive values of 30% and 95%, respectively. Cervical and vaginal fetal fibronectin predicted preterm deliveries resulting from both membrane rupture and preterm labor with intact membranes. A positive fetal fibronectin result preceded preterm delivery by 3.4 (+/- 3.2) weeks. Stepwise logistic regression demonstrated that cervical and vaginal fetal fibronectin levels were independent predictors of preterm delivery with adjusted odds ratios of 8.9 (95% confidence interval 3.6 to 22.1) and 6.0 (95% confidence interval 2.6 to 13.7), respectively. CONCLUSIONS: Among patients undergoing monthly cervical and vaginal sampling between 24 and 36 weeks' gestation, the presence of fetal fibronectin is a sensitive and specific predictor of preterm delivery.

Cervix Uteri↗