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PubMed2004

Diet-controlled gestational diabetes mellitus does not influence the success rates for vaginal birth after cesarean delivery.

OBJECTIVE: We sought to determine whether women with diet-controlled gestational diabetes mellitus who attempt vaginal birth after cesarean delivery are at increased risk of failure, when compared with their non-diabetic counterparts. STUDY DESIGN: We identified 13,396 women who attempted vaginal birth after cesarean delivery among 25,079 pregnant women with a previous cesarean delivery who were delivered between 1995 and 1999 at 16 community and university hospitals. Analysis was limited to 9437 women without diabetes mellitus and 423 women with diet-controlled diabetes mellitus who attempted vaginal birth after cesarean delivery with a singleton gestation and 1 previous low-flap cesarean delivery. Data that were collected by trained abstractors, included demographics, medical history, and both pregnancy and neonatal outcomes. Multivariable logistic regression analysis was performed to determine an adjusted odds ratio for vaginal birth after cesarean delivery success among women with diet-controlled gestational diabetes compared with women with no diabetes mellitus. We controlled for birth weight, maternal age, race, tobacco, chronic hypertension, hospital settings, labor management, and obstetric history. RESULTS: Forty-nine percent of the women with gestational diabetes mellitus and 67% of the women with no diabetes mellitus attempted vaginal birth after cesarean delivery. The success rate for attempted vaginal birth after cesarean delivery among gestational diabetic women was 70%, compared with 74% for non-diabetic women. We found that gestational diabetes mellitus is not an independent risk factor for vaginal birth after cesarean delivery failure. The relative risk for vaginal birth after cesarean delivery success in women with gestational diabetes mellitus compared with women without gestational diabetes mellitus was 0.94 (95% CI, 0.87-1.00). After an adjustment was made for confounding, the odds ratio for success with gestational diabetes mellitus was 0.87 (95% CI, 0.68-1.10). CONCLUSION: Women with diet-controlled gestational diabetes mellitus who were carrying singleton fetuses who had no more than 1 previous low flap cesarean delivery should be counseled that their disease does not decrease their chances for a successful vaginal birth after cesarean delivery. Among diet-controlled diabetic women, the overall success rate for vaginal birth after cesarean delivery remains acceptable, and attempted vaginal birth after cesarean delivery should not be discouraged solely on the basis of gestational diabetes mellitus.

Adult↗
PubMed1997

Neonatal resuscitation and newborn outcomes in rural Kenya.

Neonatal resuscitation methods vary in developing countries. This study describes the delivery experience at one rural Kenyan mission hospital, retrospectively analysing delivery data and newborn outcomes for a 12-month period, and prospectively characterizing neonatal resuscitation practices. Thirty-six of 878 newborns (4 per cent) suffered unfavourable outcomes, significantly associated with caesarean, breech, and vacuum deliveries (nine infants, P < 0.01) and birthweight of 2000 g or less (10 infants, P < 0.001). Observed neonatal resuscitation practices were inconsistent and notable for umbilical vein injections given in lieu of bag and mask ventilation. A basic neonatal resuscitation protocol was developed. It is concluded that at one Kenyan hospital, unfavourable newborn outcomes were significantly associated with delivery other than normal vaginal and with birthweights of 2000 g or less. Neonatal resuscitation methods could be modified for use in this setting, and might be most useful for term infants delivered by caesarean, breech, or vacuum deliveries.

Delivery, Obstetric↗
PubMed2000

Expedited versus conservative approaches for vaginal delivery in breech presentation.

BACKGROUND: In a vaginal breech birth there may be benefit from rapid delivery of the baby to prevent progressive acidosis. However, this needs to be weighed against the potential trauma of a quick delivery. OBJECTIVES: The objective of this review was to assess the effects of expedited vaginal delivery (breech delivery from umbilicus to delivery of the head within one contraction) on perinatal outcomes. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth trials register and the Cochrane Controlled Trials Register were searched. Date of last search: February 1999. SELECTION CRITERIA: Randomised trials of expedited vaginal breech delivery compared with delivery not routinely expedited in women undergoing vaginal breech delivery. DATA COLLECTION AND ANALYSIS: Eligibility and trial quality were assessed by one reviewer. MAIN RESULTS: No studies were included. REVIEWER'S CONCLUSIONS: There is not enough evidence to evaluate the effects of expedited vaginal breech delivery.

Breech Presentation↗
PubMed1997

Fetal acidemia in the absence of fluid observed at amniotomy.

The objective of this study was to determine the rate of pathological fetal acidemia in the absence of fluid observed at amniotomy. Thirty-nine consecutive patients with no fluid observed at the time of amniotomy were prospectively enrolled in this study. Ultrasound measurement of amniotic fluid index was performed. Umbilical cord gases were performed on arterial and venous samples at the time of delivery. Patient name and medical record number were noted and delivery data were extracted from review of the medical record. The median gestational age at admission was 41 weeks (range 38 to 42 weeks). Sixteen patients (41%) were subsequently noted to have meconium at the time of delivery. The median amniotic fluid index was 2.0 cm with a range of 0 to 9.0 cm. Thirty patients (76.9%) had an amniotic fluid index of less than 5.0 cm. The median umbilical artery pH in this patient population was 7.21 with a range of 6.75 to 7.42. Only one infant had an umbilical artery pH less than 7.00. The rate of cesarean section for documented fetal distress was 2.6%. The absence of observed fluid at amniotomy, while commonly associated with subsequent meconium at delivery, is not predictive of fetal acidemia or operative delivery for fetal distress.

Amnion↗
PubMed2004

Sex-specific fetal weight prediction by ultrasound.

OBJECTIVE: To improve sonographic birth-weight prediction by developing fetal gender-specific formulae. METHODS: This was a retrospective cross-sectional study. Two gender-specific formulae were produced from the data of 527 patients and the data of a further 349 patients were used to evaluate the formulae. Inclusion criteria were a singleton live fetus, gestational age above 25 weeks, birth weight between 1000 g and 4500 g and fetal biometry within 8 days of delivery. Data retrieval was specifically for the purpose of this study. RESULTS: To yield the best-fit weight formula for each fetal gender we employed step-wise regression analysis based on fractional polynomials with the biometric parameters biparietal diameter (BPD), head circumference (HC), transverse abdominal diameter (TAD), abdominal circumference (AC) and femur length (FL): estimated fetal weight for girls (g) = - 4035.275 + 1.143 x BPD3 + 1159.878 x AC1/2 + 10.079 x FL3 - 81.277 x FL2 [in cm]; estimated fetal weight for boys (g) = 43576.579 + 1913.853 x log10BPD + 0.01323 x HC3 + 55.532 x AC2 - 13602.664 x AC1/2 - 0.721 x AC3 + 2.31 x FL3 [in cm]. These formulae showed superior results compared with those of conventional weight formulae. CONCLUSION: Gender-related fetal weight calculation allows optimized prediction of fetal weight at birth.

Adolescent↗
PubMed1998

No correlation between perineal position and pudendal nerve terminal motor latency in healthy perimenopausal women.

BACKGROUND: Significant associations between perineal descent and pudendal nerve latency have previously been described in fecally incontinent patients. This has led to the hypothesis that pelvic floor muscle and nerve injury initiated by childbirth might progress and cause fecal incontinence. PURPOSE: The study contained herein was undertaken to test whether changes in perineal position and pudendal nerve latency were associated in a population of healthy middle-aged women. METHODS: A cross-sectional study of 144 women were selected randomly from the Danish National Register; they had a mean age of 50 (range, 45-57) years and a mean parity of 2 (range, 0-6). Perineal position at rest and during simulated defecation and pudendal nerve terminal motor latency were measured. All examinations were performed by one of the authors (AMR) and without the knowledge of parity. RESULTS: The perineal position both at rest and during straining was significantly lowered, and the pudendal nerve terminal motor latency was significantly prolonged with increasing numbers of vaginal deliveries (data not shown). There was, however, no association between pudendal nerve terminal motor latency and perineal position at rest (correlation coefficient, r = -0.15, P = 0.1) or during simulated defecation (r = -0.08, P = 0.4). CONCLUSION: Small but significant effects of vaginal deliveries were detected in a random population of healthy perimenopausal women. However, because perineal descent and pudendal nerve latency were not associated, our findings do not support the hypothesis that damage induced by vaginal delivery to the pudendal nerves and pelvic floor will progress.

Anal Canal↗
PubMed2000

University hospital based care decreases recurrent preterm deliveries and costs in comparison to no prenatal care(1).

Objective: To compare perinatal outcomes and total health care costs for patients with a previous history of preterm delivery cared for by an inner city university hospital house staff clinic versus patients who have not received any prenatal care.Study Design: We conducted a retrospective review of women with a history of preterm delivery between 1994 and 1996. The inclusion criteria was a history of at least one preterm delivery. Data were obtained on maternal demographics, complete past obstetrical history, and number of prenatal visits.Results: The study groups consisted of 96 house staff patients and 53 patients without prenatal care. The number of prior preterm births, incidence of recurrent preterm delivery, length of neonatal intensive care unit stay, and mother-infant costs were greater in the group without prenatal care. The mean gestational age at time of delivery, and mean birth weight were greater in the house staff group.Conclusion: Our study demonstrates that university hospital-based prenatal care decreases recurrent preterm delivery rates and health care costs when compared to lack of prenatal care. Prenatal care provided at academic centers, with a coordinated multidisciplinary approach, appears to have a positive impact on the problem of preterm deliveries.

Journal Article↗
PubMed1999

Do routinely measured delivery variables predict anal sphincter outcome?

PURPOSE: Trauma to the anal sphincter is a recognized complication of primiparous childbirth. This damage may be compounded during subsequent deliveries leading to symptoms. Earlier work is inconclusive as to which delivery variables are associated with such damage and may prove useful in predicting its occurrence, thereby allowing the potential for intervention in these later deliveries to protect the traumatized anal sphincter. The purpose of the present study was to determine whether routinely recorded obstetric variables can be correlated to anal sphincter damage in a consecutive series of females. METHODS: A prospective study was undertaken in a single maternity unit. Patients delivering were assessed before discharge using a symptom questionnaire and endoanal ultrasound. Delivery data were collected prospectively and analyzed statistically to see if a significant difference existed in the presence of an anal sphincter defect. RESULTS: A total of 159 patients were assessed. Endosonography revealed sphincter injuries in 8.7 percent of the normal vaginal delivery group and 83 percent of the forceps delivery group. No correlation was found between head circumference, baby weight, maternal body mass index, epidurals, episiotomy, length of each stage of labor, and duration of active pushing. Forceps delivery was the only factor to be significantly associated with sphincter trauma. CONCLUSION: Besides forceps delivery, commonly measured delivery variables are not useful predictors of anal sphincter trauma. Normal vaginal deliveries do not warrant routine postnatal anorectal assessment, but this should be routine for all instrument deliveries.

Adult↗
PubMed2005

The thyroid and pregnancy: a novel risk factor for very preterm delivery.

The major cause of neonatal mortality and morbidity is preterm delivery in general (< 37 completed weeks), and especially very preterm delivery (< 32 completed weeks). The objective of this study is to determine if either thyroid hormonal dysfunction and/or the presence of thyroid autoantibodies in the mother are associated with an increased risk of preterm and/or very preterm delivery. Data were collected prospectively and analyzed as a nested-case control study. There were 953 delivered gravidas enrolled between 1996 and 2002. Samples were collected at entry to care and stored at -70 degrees C. Cases included all women with preterm delivery (n = 124). Controls (n = 124) were randomly selected from among the 829 women who delivered at term (> 37 completed weeks). All samples were assessed for thyroid stimulating hormone, thyroperoxidase antibody, and thyroglobulin antibody. Gravidas with high thyrotropin (TSH) levels had a greater than threefold increase in risk of very preterm delivery. In some analyses, gravidas who tested positive for thyroglobulin antibody at entry to prenatal care also had a better than twofold increased risk of very preterm delivery. There were no significant associations between TSH level or thyroglobulin antibody positivity and the risk of moderately preterm delivery.

Adult↗
PubMed1995

Spontaneously changing gravid cervix: clinical implications and prognostic features.

PURPOSE: To assess the implications of spontaneous changes in the length and configuration of the gravid cervix during a single ultrasound (US) examination and to correlate specific cervical dimensions with pregnancy outcome. MATERIALS AND METHODS: Sonograms in 27 pregnant patients with a spontaneously changing cervix were studied prospectively. The length and width of cervical funneling and the length of intact cervix caudal to the funneling were measured when the cervical dimensions were most normal and most abnormal. Sonographic measurements were correlated with clinical and delivery data. RESULTS: Twenty patients delivered preterm, although only six delivered within a week of the US examination. Wider funneling of the internal os and a shorter segment of intact cervix caudal to the funneling both correlated with an increased likelihood of preterm delivery. CONCLUSION: Most patients with a spontaneously changing cervix deliver preterm. Measurements obtained when the cervix appears most abnormal are most predictive of early delivery.

Adolescent↗
PubMed1999

Childbearing beyond age 40: pregnancy outcome in 24,032 cases.

OBJECTIVE: To examine pregnancy outcomes in women age 40 or older. METHODS: We used data from the California Health Information for Policy Project, which consists of linked records from the birth certificate and the hospital discharge record of both mother and newborn of all births that occurred in acute care civilian hospitals in California between January 1, 1992, and December 31, 1993. The study population consisted of all women who delivered at age 40 or over. The control population was women who delivered between age 20 and 29 years during this 2-year period. We reviewed gestational age at delivery, birth weight, mode and type of delivery, discharge summary and birth certificate demographics, birth outcome, pregnancy, and delivery data. RESULTS: Approximately 1,160,000 women delivered during the study period, and 24,032 (2%) of these women were age 40 or older. Of this latter group, 4777 (20%) were nulliparous. The cesarean delivery rate for nulliparous women in the study population was 47.0%, and the rate for multiparous patients in this group was 29.6%. The cesarean delivery rate was 22.5% for nulliparous and 17.8% for multiparous women in the control group. In the older group, the operative vaginal delivery rate (forceps and vacuum) was 14.2% for nulliparous women and 6.3% for multiparous women. Rates of birth asphyxia, fetal growth restriction, malpresentation, and gestational diabetes were significantly higher among older nulliparas (6, 2.5, 11, and 7%, respectively) compared with rates among control nulliparas (4, 1.4, 6, and 1.7%, respectively), and there were similar significant increases among older multiparas (3.4, 1.4, 6.9, and 7.8%, respectively), compared with younger multiparous controls (2.4, 1, 3.7, and 1.6%, respectively). Mean (+/- standard error) birth weight of infants delivered by older nulliparous women was 3201+/-10 g, significantly lower than that among nulliparous controls (3317+/-1 g), whereas mean birth weight in the group of older multiparas (3381+/-5 g) was no different than that among younger multiparous controls (3387+/-1 g). Gestational age at delivery was significantly lower among older nulliparas (273.4+/-0.4 days), compared with nulliparous controls (278.5+/-0.05 days), and similarly lower among older multiparous women (274.0+/-0.2 days), compared with multiparous controls (278.3+/-0.05 days). More white women age 40 or over than younger white women were having a first child (64 and 39%, respectively). CONCLUSION: Nulliparous women age 40 or over have a higher risk of operative delivery (cesarean, forceps, and vacuum deliveries: 61%) than do younger nulliparous women (35%). This increase occurs in spite of lower birth weight and gestational age and may be explained largely by the increase in other complications of pregnancy. The increased frequency at which white women are having their first child at age 40 or over may reflect career choices that involve delaying childbirth until the fifth decade of life. These data will allow us better to counsel patients about their pregnancy expectations and possible outcomes.

Adult↗
PubMed1980

A one-year study of routine fetal heart rate monitoring during the first stage of labor.

At the Department of Obstetrics and Gynecology, University Hospital, Lund, Sweden 90 per cent of all deliveries are monitored with cardiotocography (CTG). The fetal heart rate recording (FHR) together with various pregnancy- and delivery data, are continuously analysed. The present paper is an account of FHR changes during the first stage of labor of all patients registered during 1977. FHR-changes occurred already during the 1st stage of labor in more than 90 per cent of all deliveries where the newborns' Apgar score was less than 7 at 1 minute. Tachycardia, silent pattern, and late and combined decelerations, rarely occurred in the material, but were dominant at deliveries where the newborns' Apgar score was less than 7 at 1 and 5 minutes. This relationship was even more pronounced when these changes occurred together.

Apgar Score↗
PubMedDate not supplied

[Effect of maternal age on the course of labor--analysis of women over 40 years of age].

In order to determine the birth risk for pregnant women in the age group > or = 40, the delivery data of 143 pregnant women in this age group were retrospectively evaluated over a 3-year period. Here, 37 of these 143 women (25.9%) were primiparae. The following was examined: The number of prenatal examinations (including ultrasound examinations), the incidence of genetic examinations, the delivery methods with the percentage of surgical deliveries, complications at the time of delivery as well as the fetal outcome with APGAR values, umbilical artery pH, birth weights, neonatal morbidity and mortality. The delivery results were compared with representative populations of women between 20-29 years (n = 2252) and 30-39 years (n = 1980). Pregnancy in older women still ends significantly more often with cesarean section than in younger women. Here, the rate of cesarean sections was 32.7% compared to 21.9% in 30-39-year-olds and 15.8% in 20-29-year-olds. However, parity has an even greater influence on the mode of delivery than age. Only 30.1% of multi-parae over 40 years underwent surgical delivery (vaginal and abdominal) compared to 77.3% of primiparae. It was also found that multiparae more rarely had surgical delivery than younger primiparae (30-39 years 53.3%, 20-29 years 39.3%). Despite the high surgical delivery rate being in the group of primiparae over 40 years, the fetal outcome was comparatively poor, so that the less restrictive indication for surgical delivery seems justified.

Adult↗
PubMed1981

Patterns of obstetrical care in hospitals.

This article examines the determinants of length of stay and ancillary service use for a single diagnostic category: normal delivery. Data for a systematic sample of 945 obstetrical admissions to 48 New England hospitals during 1969-70 are used to estimate a simultaneous equations model. The exogenous variables include socioeconomic and medical characteristics of the mother, medical condition of the newborn, type of labor and delivery, and hospital and physician characteristics. The important findings are threefold: First, evidence is found supportive of a simultaneous relationship between length of stay and ancillary services for normal deliveries. Second, the results show the importance of controlling for the performance of surgery, the presence of complications, the length of labor and the death of the baby in analyzing obstetrical utilization patterns. Third, holding maternal medical and socioeconomic factors constant, hospital size, teaching status, control and location, as well as physician mode of practice and relationship to the hospital, are important determinants of hospital use. It is concluded that the diagnostic-specific approach to utilization analysis is appropriate and useful. Only within such a narrowed focus can researchers disentangle the confounding effects of the attributes of the disease itself from the impact of hospital and physician characteristics on hospital use.

Adolescent↗
PubMed2005

Decrease in pregnancy loss rates in patients with systemic lupus erythematosus over a 40-year period.

OBJECTIVE: To determine if there has been a statistically significant change in pregnancy loss and preterm delivery rates in patients with systemic lupus erythematosus (SLE). METHODS: We analyzed the pregnancy outcomes of our SLE patients over the past 3 years and reviewed the literature over the past 40 years. We extracted pregnancy loss and preterm delivery data from reports of postdiagnosis SLE pregnancies. Studies were grouped into 5-year periods and weighted according to sample size. Group means, calculated for each study period, were plotted using linear regression to determine significance, and compared with population norms for the same periods. RESULTS: The rate of loss in SLE pregnancies over the past 40 years decreased from a mean of 43% in 1960-1965 to 17% in 2000-2003 (r2 = 0.648). This approximates the pregnancy loss rate in the general US population. Preterm deliveries were not uniformly reported and were rarely stratified into spontaneous or physician-initiated. Prior to 1980, it was not possible to derive group means for each time period. From 1980 to 2002, however, there was a trend toward a decrease in preterm births in SLE pregnancies, although they continue to be more frequent in SLE than in the general population. CONCLUSION: Improvements in disease management and perinatal monitoring have resulted in a significant decrease in pregnancy loss in SLE over the last 40 years and a trend toward decreased preterm deliveries over the last 20 years in comparison to the general population. These advances highlight the importance of collaboration between rheumatologists and perinatologists. Given these data, the description of SLE-associated pregnancy could be revised to reflect a more positive prognosis for mother and fetus.

Abortion, Spontaneous↗
PubMed2005

Frequency of persistent anal symptoms after first instrumental delivery.

PURPOSE: This study was designed to evaluate persistent anal symptoms after first instrumental delivery beyond the postpartum period. METHODS: This prospective study was performed in a cohort of primiparas who underwent instrumental delivery from January 1, 2001 to September 30, 2002. Questionnaires for anal symptoms were completed in the maternity ward on the day after delivery and by mail or telephone up to 12 months after the end of the inclusion period. Symptoms of fecal incontinence (solid and/or liquid stool) and precursor symptoms (flatus incontinence, soiling, and/or fecal urgency) were recorded. RESULTS: Of the 212 females who completed the first questionnaire, 159 (75 percent) responded to the second. Overall, 8.8 percent of females had solid and/or liquid stool incontinence, 7.5 percent had involuntary flatus, 8.2 percent had symptoms of fecal urgency, and 24.5 percent experienced new anal symptoms, Of the five females with third-degree tears, none complained of anal incontinence. The only significant difference in delivery data between females who did and did not develop new anal symptoms was larger fetal head size in the new symptom group (96.4 vs. 93.9 mm, respectively; P < 0.05). CONCLUSIONS: Frequency of new anal symptoms other than incontinence beyond postpartum period is underestimated in primiparas after instrumental delivery. Only fetal head size was found to predict occurrence of persistent anal incompetence after instrumental delivery.

Adult↗
PubMed2006

[Liberal versus restrictive practice of episiotomy: do there exist specific obstetrical indications for episiotomy?].

PURPOSE: To analyze the literature comparing two different policies for episotomy practice: liberal versus restrictive use. To search and discuss specific indications for episiotomy. METHODS: The Medline base was analyzed from 1970 to 2005. The articles where selected by using the key word episiotomy and selective or restrictive and routine or liberal. Every potential indications was crossed with episotomy. RESULTS: A policy implying a liberal practice of episiotomy is not better compared to a restrictive policy. The evidence-based medical literature favors avoiding routine episiotomy in low risk deliveries. Data are quite scarce concerning the different specific indications for episiotomy, and finally we can retain only one specific indication which is the short perineum when the distance between the fourchette and the center of the anus is less than 3 cm. Nevertheless, in order to improve delivery conditions obstetricians can advisably use episiotomy in accordance with their clinical assessment. CONCLUSION: There is no evidence in the literature favoring a liberal policy over a restrictive policy for the use of episiotomy, both in terms of fetal (Grade C) and maternal (Grade A) indications. A number of obstetrical situations considered as at risk do not systematically indicate an episiotomy. There are however circumstances in which a pertinent and prudent clinical assessment will lead the obstetrician to use an episiotomy.

Adult↗
PubMed2003

Pregnancy outcomes among Palestinian refugee women with sickle cell trait in Damascus, Syria.

OBJECTIVE: The results on pregnancy outcomes of mothers afflicted with sickle cell trait are still contradictory. This study aimed to examine the fetal and maternal outcomes among a cohort of pregnant women. METHODS: This is a prospective cohort study that examined the fetal and maternal outcomes among 98 women with sickle cell trait (HbAS) and 402 women with normal hemoglobin (HbAA). The study was carried out in 4 health centers serving Palestinian Refugees in Damascus, during the period November 2000 to May 2002. Hemoglobin electrophoresis was carried out for all newly registered pregnancy women. Women were then followed up until 40 days after delivery. Data was collected from antenatal records and interviews with women. RESULTS: Outcomes of pregnancy were compared between women with HbAS and HbAA hemoglobin. There was no statistical difference in the rate of abortion, distribution of birth weight and perinatal mortality. Women with AS hemoglobin reported higher incidence of complications after delivery, namely, fever (risks ratio=4.05, 95% confidence interval=1.34-12.3). CONCLUSION: In this study, pregnancies among women with sickle cell trait demonstrated high risk of complications after delivery. Watchful follow up of pregnancies among women with sickle cell trait is very necessary. Doctors and women must know that although the course of pregnancy among women with HbAS can be benign; it may well carry a high risk on women.

Arabs↗