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PubMed1999

Intracranial delivery of recombinant nerve growth factor: release kinetics and protein distribution for three delivery systems.

PURPOSE: Three different polymeric delivery systems, composed of either poly(ethylene-co-vinyl acetate) (EVAc) or poly(lactide-co-glycolide) (PLGA), were used to administer recombinant human nerve growth factor (rhNGF) intracranially in rats. METHODS: The delivery systems were characterized with respect to release kinetics, both in the brain and in well-stirred buffer solutions. RESULTS: During incubation in buffered saline, the delivery systems released rhNGF in distinct patterns: sustained (EVAc), immediate (PLGA1) and delayed (PLGA2). One 10-mg delivery system was implanted in each rat and an ELISA technique was used to determine the amount of rhNGF in 1-mm coronal brain slices produced immediately after removal of the delivery system. High levels of rhNGF (as high as 60,000 ng in a brain slice of approximately 50 microliters) were recovered from the brain tissue at 1, 2, and 4 weeks after implantation. With all three delivery systems, the amount of rhNGF in each brain slice decreased exponentially with distance from the implant site: the distance over which concentration decreased by 10-fold was 2-3 mm for all delivery systems. When rhNGF release was moderate (10 to 200 ng rhNGF/day), the total amount of rhNGF in the brain increased linearly with release rate, suggesting an overall rate of rhNGF elimination of 0.4 hr-1 or a half-life of 1.7 hr. With higher release rates (500 to 50,000 ng rhNGF/day), total amounts of rhNGF in the brain were considerably higher than anticipated based on this rate of elimination. CONCLUSIONS: Polymeric controlled release can provide high, localized doses of rhNGF in the brain. All of the experimental data were consistent with penetration of rhNGF through the brain tissue with a diffusion coefficient approximately 8 x 10(-7) cm2/s, which is approximately 50% of the diffusion coefficient in water.

Animals↗
PubMed2001

Mode of delivery in breech presentation at term: increased neonatal morbidity with vaginal delivery.

OBJECTIVE: To compare the neonatal outcome in planned vaginal delivery and planned cesarean section in term singleton pregnancies with breech presentation in a Scandinavian clinic with a high rate of vaginal breech delivery. METHODS: A retrospective study including 1050 term singleton breech pregnancies delivered at a Swedish tertiary referral center during 1988 to 2000. For 699 patients (67%) a vaginal delivery was planned, of whom 603 (86%) were delivered vaginally. In 327 (31%) cases a cesarean section was planned and performed. These two groups were compared regarding rates of acidemia at birth (cord artery pH <7.05), low Apgar scores and neonatal neurological morbidity. Long term sequels among infants with a complicated neonatal course were also identified. RESULTS: Acidemia at birth, Apgar score below 7 at 5 minutes, and referral to neonatal intensive care unit all occurred at higher rates in planned vaginal delivery (5.3%, 3.6%, and 8.9%, respectively), than in planned cesarean delivery (0, 0, and 4.0%). The rate of neonatal neurological morbidity was 24/699 (3.4%) in planned vaginal delivery (18 cases with cerebral symptoms and six cases of brachial plexus palsy) compared to one case (cerebral symptoms) after a planned cesarean. These differences were all statistically significant (p< or =0.002). Of the neurologically affected neonates, two died and four had cerebral palsy (one delivered by planned cesarean section) at follow up. CONCLUSION: Neonatal morbidity may be reduced with planned cesarean delivery in breech presentation, also in a Scandinavian setting.

Apgar Score↗
PubMed2002

Do occult anal sphincter injuries, vector volume manometry and delivery variables have any predictive value for bowel symptoms after first time vaginal delivery without third and fourth degree rupture? A prospective study.

BACKGROUND: The aim of this study was to determine whether there exists a correlation between anal incontinence, occult sphincter injuries, anal manometry values, and delivery variables in primiparous women after first time vaginal delivery. METHODS: Eighty-six primigravida women were recruited for this study. Transanal ultrasonography (TAUS) and vector volume manometry (VVM) was performed and bowel symptoms were recorded at 25 weeks of pregnancy and 5 months after labor. Incontinent women at 5 months after vaginal delivery were interviewed again at 12 months. RESULTS: Nineteen women (25%) experienced flatus incontinence postpartum. After 12 months, only one-third of the women were still incontinent. Fourteen women (19%) showed abnormal TAUS of the anal sphincter. Of the delivery variables, only baby head circumference was significantly associated with flatus incontinence (p = 0.01). There was no correlation between flatus incontinence or delivery variables and anal sphincter injuries; VVM values were not associated with either anal sphincter injuries or flatus incontinence at 5 months, but VVM values were negatively associated with flatus incontinence at 12 months after labor. CONCLUSIONS: At 5 months after labor, flatus incontinence is relatively common, and is not associated with reduced VVM values. Two-thirds of women recover from flatus incontinence during the first year. Women who had flatus incontinence persisting for a minimum of 1 year had reduced VVM values. Anal sphincter injuries as seen by TAUS are not associated with either VVM values or any delivery variable. Baby head circumference is the only delivery variable significantly associated with flatus incontinence.

Adult↗
PubMed2006

Complications during pregnancy, delivery, and postnatal stages and place of delivery in rural Bangladesh.

The utilization of safe motherhood services including maternity care in Bangladesh is very poor. Only a very small proportion of deliveries takes place in a hospital/clinic. This study is based on data from a follow-up study on maternal morbidity in rural Bangladesh. Analysis is performed on the nature of complications by place of delivery. Most of the deliveries have taken place in the women's own or her mother's home. In addition, home deliveries are mostly assisted either by an untrained birth attendant or by relatives or others. Education, economic status, whether pregnancy was wanted or not, regular visits for antenatal care, past history of breathing problems and liver diseases, and palpitation during pregnancy appear to have significant association with place of delivery in rural Bangladesh. The utilization of a hospital/clinic instead of birth at home is higher among women with secondary or higher level of education, who desired the pregnancy, and who made regular visits for antenatal care. Delivery at a mother's home appears to be positively associated with higher economic status, desired pregnancy, gainful employment, and visits for antenatal care. If the respondents suffer from diseases/symptoms, then it is more likely that the delivery would take place in the mother's home.

Bangladesh↗
PubMed2006

Outcome of twins delivery; predictors for successful vaginal delivery: a single center experience.

The aim of this study was to compare maternal and neonatal outcome of twin births according to mode of delivery and to isolate the factors predicting a successful vaginal delivery and those predicting a failed trial of labor (TOL) leading to an emergent cesarean section. We reviewed all twin deliveries during the years 1995 to 2004. Parameters studied include maternal age, parity, gestational age, maternal antepartum complications and postpartum complications, fetal presentations, birthweight, mode of delivery of each twin, Apgar scores and cord pH. During the study period there were 40,710 deliveries of which 804 (1.9%) were twin deliveries. Of the 804 twins, 398 (49.5%) had planned cesarean sections (PCS) and 406 (50.5%) entered a TOL. Maternal age and parity were similar among the groups. Neonatal outcomes and postpartum complications did not differ between the groups. Of 406 women who had a TOL, 84.9% eventually delivered both twins vaginally. A significantly higher percentage of antepartum complications were noted among those who failed the TOL compared to those with successful TOL (8.2% vs. 1.7%, p = .01). The number of neonates with pH of less than 7.0 did not differ between the groups although more neonates (2.5% vs. 0.4%, p = .05) among the failed TOL had an Apgar score of less than 7.0 at 5 minutes compared to successful TOL. Vaginal delivery of both twins after TOL occurred in 91% of vertex/vertex compared with 71.8% of vertex/nonvertex presenting twins (p < .01). Neonatal outcomes did not differ between both groups. Our results indicate that both vaginal and PCS are comparable options for vertex presenting first twin regardless of second twin presentation.

Adult↗
PubMed1991

Maternal and neonatal effects of outlet forceps delivery compared with spontaneous vaginal delivery in term pregnancies.

Previous retrospective studies have suggested that the prophylactic use of outlet forceps has a beneficial impact on the neonate because it shortens the second stage of labor and decreases the incidence of neonatal hypoxia. The purpose of this study was to compare the immediate maternal and neonatal effects of outlet forceps delivery (N = 165) with spontaneous vaginal delivery (N = 168) in term parturients. Subjects were randomized to the study or control group immediately before delivery. There were 88 nulliparas and 77 multiparas in the forceps delivery group and 90 and 78, respectively, who delivered spontaneously, a nonsignificant difference. There were no significant differences in gestational age, parity, infant birth weight, length of the first and second stages of labor, use of conduction (continuous epidural) anesthesia, decrease in hematocrit values, Apgar scores, or umbilical arterial pH values between the forceps and spontaneous delivery groups. Seventeen infants in the forceps group and 16 in the control group had cephalhematoma, facial bruising, subconjunctival hemorrhage, or scalp abrasion (not significant). No neonate had fractures, nerve palsies, or intracranial hemorrhage (determined by cranial ultrasound). In the nulliparous population, significant differences were found in the use of episiotomy (93 versus 78%) and the incidence of deep perineal lacerations (24 versus 10%) with forceps compared with spontaneous delivery, respectively (P less than .05). No significant differences between the groups were found in multiparas. We conclude that the use of outlet forceps in patients with uncomplicated labor has no immediate effect on the neonate. Furthermore, outlet forceps delivery does not significantly shorten the second stage of labor and is associated with an increased incidence of maternal perineal trauma.

Delivery, Obstetric↗
PubMed2006

Gene delivery to the spinal cord: comparison between lentiviral, adenoviral, and retroviral vector delivery systems.

Viral gene delivery for spinal cord injury (SCI) is a promising approach for enhancing axonal regeneration and neuroprotection. An understanding of spatio-temporal transgene expression in the spinal cord is essential for future studies of SCI therapies. Commonly, intracellular marker proteins (e.g., EGFP) were used as indicators of transgene levels after viral delivery, which may not accurately reflect levels of secreted transgene. This study examined transgene expression using ELISA after viral delivery of D15A, a neurotrophin with BDNF and NT-3 activities, at 1, 2, and 4weeks after in vivo and ex vivo delivery using lentiviral, adenoviral, and retroviral vectors. Further, the inflammatory responses and viral infection patterns after in vivo delivery were examined. Lentiviral vectors had the most stable pattern of gene expression, with D15A levels of 536 +/- 38 and 363 +/- 47 pg/mg protein seen at 4 weeks after the in vivo and ex vivo delivery, respectively. Our results show that protein levels downregulate disproportionately to levels of EGFP after adenoviral vectors both in vivo and ex vivo. D15A dropped from initial levels of 422 +/- 87 to 153 +/- 18 pg/mg protein at 4 weeks after in vivo administration. Similarly, ex vivo retrovirus-mediated transgene expression exhibited rapid downregulation by 2 weeks post-grafting. Compared to adenoviral infection, macrophage activation was attenuated after lentiviral infection. These results suggest that lentiviral vectors are most suitable in situations where stable long-term transgene expression is needed. Retroviral ex vivo delivery is optional when transient expression within targeted spinal tissue is desired, with adenoviral vectors in between.

Adenoviridae↗
PubMed1986

Plasma growth hormone concentration in the chronically catheterized ovine fetus during spontaneous term delivery and premature delivery induced by continuous intravascular infusion of low doses of adrenocorticotropin or cortisol to the fetus.

Fetal plasma growth hormone concentrations were measured in 15 pregnant ewes over the last 5 days before delivery. In five chronically catheterized pregnant ewes that underwent spontaneous vaginal delivery 146 +/- 2 days (mean +/- SD) of gestation, fetal plasma growth hormone concentrations fell from 124.6 +/- 44.1 ng X ml-1 5 days before delivery to 35.2 +/- 31.3 ng X ml-1 at delivery. In three fetuses in which premature delivery was induced by the infusion of cortisol to the fetus at 128 days of gestation, fetal plasma growth hormone levels fell from 195 +/- 19.1 ng X ml-1 to 70.7 +/- 25.5 ng X ml-1 over the last 5 days of intrauterine life. In seven fetuses in which premature delivery was induced with infusion of synthetic adrenocorticotropin to the fetus beginning at 120 or 130 days of gestation, the fetal plasma growth hormone level did not fall (175.6 +/- 75.7 to 158.9 +/- 60.1 ng X ml-1). Fetal plasma cortisol concentrations at delivery were significantly higher in the cortisol-infused fetuses (214 +/- 38.4 ng X ml-1) than in both control (94.4 +/- 33.7 ng X ml-1) and adrenocorticotropic hormone-infused fetuses (94.5 +/- 31.9 ng X ml-1). The fall in the fetal plasma growth hormone level in cortisol-induced fetuses may be due to the higher fetal plasma cortisol concentrations achieved in the cortisol-infused compared with the adrenocorticotropic hormone-infused fetuses in which no comparable decrease in growth hormone was observed. These findings suggest that there are significant differences in the fetal response to various experimental regimens used for the induction of premature labor in the sheep.

Adrenocorticotropic Hormone↗
PubMed2006

Vaginal birth after cesarean delivery in twin gestations: a large, nationwide sample of deliveries.

OBJECTIVE: The purpose of this study was to assess the maternal morbidity associated with attempted vaginal birth after cesarean (VBAC) in twin gestations using a large, nationwide sample of deliveries. STUDY DESIGN: Data for this study were obtained from an administrative dataset, the Nationwide Inpatient Sample, a representative sample of discharges from non-Federal hospitals, for the years 1993 to 2002. Patients admitted nonemergently for the delivery of twin gestations who had a history of previous cesarean delivery were selected. Patients that either delivered vaginally or who had discharge codes that indicated labor before cesarean delivery were defined as the trial of labor group, while patients who had a cesarean delivery without discharge codes that indicated labor were defined as the elective cesarean group. Various complications of delivery were analyzed for each group. RESULTS: We identified 4705 women who underwent an elective cesarean delivery and 1850 women who underwent a trial of labor. For women who had a trial of labor, 836 (45.2%) delivered vaginally. The rate of uterine rupture was higher in the trial of labor group than in the elective cesarean group (0.9% vs 0.1%, P < .001), and the rate of wound complications was lower (0.6% vs 1.3%, P < .02). The rates of other complications including hysterectomy, transfusion, major postpartum infection, thromboembolism, uterine dehiscence, and pelvic hematoma were not significantly different between the 2 groups. CONCLUSION: Our study showed a significantly higher rate of uterine rupture in the trial of labor group that is similar to the rates reported for trial of labor after cesarean in singleton pregnancies.

Adult↗
PubMed2006

Previous caesarean or vaginal delivery: which mode is a greater risk of perinatal death at the second delivery?

OBJECTIVE: To compare the risk of perinatal death after previous caesarean versus previous vaginal delivery, and pre-labour repeat caesarean versus trial of labour after previous caesarean. STUDY DESIGN: Using the data of the Berlin Perinatal Registry from 1993 to 1999, 7556 second parous women with a previous caesarean delivery were compared with 55142 second parous women with a previous vaginal delivery, and those 1435 women with pre-labour repeat caesarean were compared with 6121 women with a trial of labour after previous caesarean delivery. The rates of perinatal death, stillbirth and intrapartum/neonatal death were analysed using multivariable logistic regression to adjust for confounding variables and obstetric history. RESULTS: A previous caesarean delivery was associated with a 40% excess risk of perinatal death and a 52% excess risk of stillbirth (p<0.05); the risk of intrapartum/neonatal death was not significantly increased. There were no significantly higher rates of intrapartum/neonatal death and of stillbirth in women trying a vaginal birth versus pre-labour repeat caesarean. But in most cases of antepartum death, labour was induced for that reason. CONCLUSION: Consulting women about caesarean delivery for maternal request, the increased risk of perinatal death in further pregnancies should be discussed. After a previous caesarean delivery, a careful screening for several risk factors is necessary before recommending a trial of labour.

Berlin↗
PubMed1999

Omphalocele delivery enigma: the best mode of delivery still remains dubious.

OBJECTIVE: To determine an optimal route of delivery for fetuses with prenatally diagnosed omphalocele. DATA SOURCE: MEDLINE search of years 1966-1996. RESULTS: Descriptive retrospective analyses do not support the idea that cesarean delivery of fetuses with omphalocele is associated with an improved survival rate. However, most of those studies do not control for confounding variables like type and severity of associated anomalies, omphalocele size, prematurity rate, presence of trial of vaginal delivery, rate of intrapartum sac rupture, tertiary treatment centers accessibility, time and type of surgical correction, and postoperative morbidity. There is no evidence that vaginal delivery is safer than cesarean for fetuses with isolated small omphalocele. Fetuses with giant (>5 cm) omphalocele should be delivered by cesarean section. Vaginal delivery at term is offered for fetuses with coexisting life-threatening anomalies. CONCLUSIONS: We propose that until randomized trial of vaginal and cesarean delivery for fetal omphalocele is available, the preferred mode of delivery would be the vaginal route as that is safer for the mother.

Abnormalities, Multiple↗
PubMed2005

Previous cesarean delivery: understanding and satisfaction with mode of delivery in a subsequent pregnancy in patients participating in a formal vaginal birth after cesarean counseling program.

The objective of this study was to determine patient satisfaction with delivery experience in a pregnancy subsequent to primary cesarean and to evaluate knowledge about a trial of labor after cesarean in patients enrolled in a formal vaginal birth after cesarean educational program. During a 12-month period, women with a history of cesarean delivery who were participating in a formal counseling program regarding the risks and benefits of vaginal birth after cesarean were surveyed in the antepartum and postpartum periods. Patient demographics, past birth experience, understanding of the risks and benefits of vaginal birth after cesarean, pregnancy outcomes, and ratings of satisfaction and recovery following the current delivery were collected. Patients were divided into four groups depending on their mode of delivery in the current pregnancy: group 1 succeeded at vaginal birth, group 2 underwent repeat cesarean in labor, group 3 delivered by cesarean before labor, and group 4 chose repeat cesarean. Ninety-five patients enrolled in the study. There were 26 patients in group 1, 18 patients in group 2, 16 patients in group 3, and 35 patients in group 4. The four groups had significant differences in patient satisfaction following the current delivery compared with the previous cesarean delivery ( p = 0.001). The patients who had a successful trial of labor exhibited the largest median change in score. The patients who delivered by cesarean during labor had the smallest median change in score. Nonetheless, 92% of these patients were pleased that they had attempted a vaginal birth. When questioned about the risks associated with a trial of labor after cesarean delivery, 92% of postpartum patients answered all questions correctly. Patients participating in a formal counseling program exhibit a high level of understanding about the risks and benefits of a trial of labor. Although the most satisfied patients were those who succeeded at vaginal birth, most women valued the opportunity to attempt a vaginal birth regardless of outcome.

Apgar Score↗
PubMed1980

[The problem of the increased perinatal mortality in premature breech deliveries, compared to premature vertex deliveries (author's transl)].

The perinatal mortality of 115 premature breech deliveries is compared to that of 843 vertex deliveries. No difference is found when birth weights at 100 gram intervals are compared. These results are statistically checked. The authors show that comparisons at 500 gram intervals are insufficient and can lead to wrong conclusions. When all premature deliveries without birth weight groups are compared the contrary results are statistically very significant. These results are in concordance with the perinatal mortality figures of mature infants born by various methods. The investigations lead to the conclusion that the mode of delivery has no essential influence on the neonatal prognosis. Mere breech presentation by itself is no indication for different delivery than for all premature deliveries. It is not so important to treat the breech presentation as it is to prevent premature deliveries.

Berlin↗
PubMed2000

Umbilical cord blood collection before placental delivery during cesarean delivery increases cord blood volume and nucleated cell number available for transplantation.

OBJECTIVE: We sought to determine whether umbilical cord blood collection during cesarean delivery can be improved by collecting cord blood before delivery of the placenta. STUDY DESIGN: Patients undergoing cesarean delivery were randomly assigned to cord blood collection before or after placental delivery. Closed sterile collection systems were used for blood sampling. Cord blood characteristics and maternal outcome parameters were compared between the 2 groups. RESULTS: A total number of 40 patients were available for analysis. No differences in maternal and neonatal characteristics were found. A larger amount of cord blood volume (mean +/- SEM, 93 +/- 7.5 vs 66 +/- 6.6 mL; P =.013) and total nucleated cell number (11.1 +/- 1.2 vs 7.4 +/- 0.8 x 10(8) cells; P =.026) was obtained in the samples collected before compared with those collected after placental delivery. Similarly, there was a trend toward higher total CD34(+) cell number in samples collected in situ (30.0 +/- 6.0 vs 17.4 +/- 2.4 x 10(5) cells; P =.076). Estimated intraoperative blood loss, difference between prepartum and postpartum hemoglobin values, operating time, and puerperal infection rates were similar in both groups. CONCLUSION: If a cesarean delivery is performed, cord blood sampling is more efficacious if performed before delivery of the placenta. This collection method seems beneficial and safe and might therefore be preferably used for related, as well as unrelated, cord blood stem cell banking and transplantation.

Antigens, CD34↗
PubMed2000

Effects of a policy of elective cesarean delivery in cases of suspected fetal macrosomia on the incidence of brachial plexus injury and the rate of cesarean delivery.

OBJECTIVE: The aim of this study was to examine the effects of a policy of elective cesarean delivery for suspected fetal macrosomia on the incidence of brachial palsy and on the cesarean delivery rate. STUDY DESIGN: We performed a retrospective assessment of a policy that recommends cesarean delivery for macrosomia (fetal weight > or =4500 g). Fetal weight was estimated by palpation, and ultrasonographic weight estimation was carried out whenever macrosomia was suspected. RESULTS: During the 4 years of the study 16,416 deliveries resulted in 133 infants with macrosomia (0.8%). Macrosomia was suspected in 47 cases and confirmed by birth weight in 21 (45%). Antenatal estimation of fetal weight was carried out for 115 of the fetuses with macrosomia (86%). Macrosomia was correctly predicted in 21 of 115 cases (18.3%). Thirteen infants with undiagnosed macrosomia were delivered by emergency cesarean procedures, and 99 were delivered vaginally. Three infants with macrosomia (3%) and 14 infants without macrosomia (0.1%) sustained brachial plexus injury. Our policy prevented at most a single case of brachial palsy, and it contributed 0.16% to our cesarean delivery rate. CONCLUSIONS: A policy of elective cesarean delivery in cases of suspected fetal macrosomia had an insignificant effect on the incidence of brachial plexus injury. Its contribution to the rate of cesarean delivery was also small.

Birth Injuries↗
PubMed2002

Hemodynamic effects of inhaled nitric oxide using pulse delivery and continuous delivery systems in pulmonary hypertension.

OBJECTIVE: Inhaled nitric oxide (NO) has been used for pulmonary vasodilation therapy in patients with pulmonary hypertension. Inhaled NO for awake and ambulatory patients, however, is unusual because it requires intubation or a tightly fitting facemask, and a large-scale delivery system for the safe management of toxic nitrogen oxides. We undertook this study to investigate the possibility of using inhaled NO therapy for awake and ambulatory patients with pulmonary hypertension. METHODS: Patients with pulmonary hypertension underwent cardiac catheterization and hemodynamic variables were measured at the baseline, after inhaled NO using our pulse delivery system, which involved a nasal cannula and a pulse device, and after inhaled NO using a continuous delivery system. PATIENTS OR MATERIALS: We studied seventeen patients with precapillary pulmonary hypertension (4 men and 13 women; age, 41+/-3, ranging from 19 to 61). RESULTS: Cardiac output was increased significantly by each system. Pulmonary vascular resistance was decreased significantly by each system. There was no significant change in mean pulmonary artery pressure, mean systemic artery pressure, or systemic vascular resistance. The concentrations of NO and nitrogen dioxide (NO2) in the expiratory gas using the pulse delivery system were 0.0 ppm as long as the pulse device was synchronized with the patient's respiratory cycle. CONCLUSION: Inhaled NO using our pulse delivery system changed the hemodynamic variables similarly to those when using the continuous delivery system. The concentrations of NO and NO2 in the expiratory gas using the pulse delivery system were within safe limits.

Administration, Inhalation↗
PubMed2003

Management of the perineum during forceps delivery. Association of episiotomy with the frequency and severity of perineal trauma in women undergoing forceps delivery.

OBJECTIVE: To examine the association of the frequency and severity of perineal trauma with episiotomy performed at forceps delivery. STUDY DESIGN: This retrospective study analyzed all forceps deliveries at the Semmelweis Women's Hospital Vienna between February 1999 and July 1999. Evaluation of a possible association of episiotomy with the frequency and severity of perineal trauma was the main objective of the study. Episiotomy was not performed routinely and was either midline or mediolateral. RESULTS: In conjunction with forceps delivery episiotomy, 76/87 women (87%) underwent forceps delivery episiotomy; among those, 49/76 (64%) had a mediolateral episiotomy and 27/76 (36%) a midline episiotomy. The frequency and severity of perineal tears were significantly lower in forceps deliveries when an episiotomy was performed. When analyzing the type of episiotomy, the data revealed a statistically significantly lower frequency of perineal trauma when mediolateral episiotomy was performed as compared to midline episiotomy. CONCLUSION: If obstetric indications necessitate forceps delivery, performance of an episiotomy decreases the risk of perineal tears of all degrees. When analyzing the type of episiotomy, mediolateral episiotomy seems to be more protective against perineal trauma in women undergoing forceps delivery.

Adult↗
PubMedDate not supplied

The relationship of health care delivery system characteristics and legal factors to mode of delivery in women with prior cesarean section: a systematic review.

OBJECTIVE: To evaluate the relationship of health care delivery system characteristics and legal factors to mode of delivery in women with prior cesarean section. METHODS: We identified relevant studies by searching MEDLINE and HealthSTAR (1980 to May 2002), reference lists of pertinent articles, and recommendations of local and national experts. We also searched the online Cochrane systematic reviews and controlled trials registries, Database of Abstracts and Reviews on Effectiveness, and EMBASE databases. RESULTS: Studies of guidelines suggested that opinion leaders influence provider behavior regarding repeat cesarean delivery versus trial of labor decisions. Studies of hospital and insurance characteristics provided inconsistent results. There was insufficient evidence to evaluate the relationship between provider characteristics and delivery outcomes. Legislation and liability-related factors effected limited change. CONCLUSION: Studies of health care system characteristics and other factors focused primarily on rates of delivery modes (vaginal birth after cesarean or repeat cesarean delivery) rather than patient safety or health outcomes. Future studies must account for case mix, time trends, and other potential confounders, especially concerning associations of provider characteristics.

Cesarean Section, Repeat↗