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Spontaneous umbilical cord hematoma is very rare. We present a newborn who was discovered to have a spontaneous fetal umbilical cord hematoma. A nonreassuring fetal heart tracing complicated the first and second stages of labor. The only pathological finding was a short umbilical cord, which could have contributed to the rupture of fetal vessels.
Birth asphyxia is defined as a severe disturbance of oxygen supply to the fetus, which develops during the first or second stage of labor. The diagnosis is confirmed by a severe metabolic acidosis in the umbilical cord blood, a persistent low Apgar as well as functional disturbances as a result of hypoxic damage in various organs including the central nervous system. Apart from morbidity and mortality in the neonatal phase long term effects are of considerable significance. Only 10 - 15 % of all cerebral palsy cases developing after delivery at term are a consequence of a hypoxic encephalopathy developing during the process of labor and delivery. For a long time it was ignored, that a number of pregnancy pathologies may lead to brain damage, which could also produce the typical symptoms of cerebral palsy. An abrupt disturbance of oxygen supply may be a result of cord compression, a premature separation of the placenta or of rupture of the uterus. These situations are in general easily recognized by typical clinical symptoms together with a sudden drop in fetal heart rate with a persistent bradycardia. In these cases it is only possible to prevent hypoxic brain damage, if the fetus can be delivered by emergency caesarian section within 15 - 20 minutes after the acute event. Diagnosis and evaluation of subacute or chronic forms of insufficient supply of oxygen of the fetus in labor is considerably more difficult. Reliability of continuous heart rate monitoring of the fetus during labor as well as validity of certain heart rate changes for the detection of developing hypoxia is a matter of ongoing dispute. In the presence of clearly pathological heart rate patterns hypoxic damage may already have occurred. Suspicious or "non-reassuring" heart rate alterations are frequent and only in a small percentage a real threat to the fetus in form of severe hypoxia will develop. Up until now there is no clear scientific proof that a combination of continuous fetal heart rate monitoring with additional tests can prevent hypoxic damage to the fetus. Future efforts should be directed towards improving reliability of the description of fetal heart rate patterns, the validity of the information provided by heart rate changes as well as the proof of the benefit of continuous monitoring of the fetus during labor and delivery as a means of preventing severe hypoxia and its consequences to fetal health.
OBJECTIVE: To evaluate the effect of meconium-stained amniotic fluid (AF) on perinatal outcome. METHODS: A prospective observational study was performed, comparing perinatal outcome of parturients with thick and thin meconium-stained AF to those with clear AF. RESULTS: The rate of meconium-stained AF was 18.1% (106/586). Of those, 78 (13.3%) patients had thin and 28 (4.8%) had thick meconium-stained AF. The rate of oligohydramnios was significantly higher among pregnancies complicated with thick meconium-stained AF (OR 7.2, 95% Cl 2.1-24.1; p = 0.002). A significant linear association, using the Mantel-Haenszel test for linearity, was found between the thickness of the meconium and abnormal fetal heart rate patterns during the first and second stages of labor, low Apgar scores at 1 min and the risk for Cesarean section. A statistically significantly higher risk for neonatal intensive care unit admission was observed among patients with thick meconium as compared to those with clear AF (OR 11.4, 95% CI 2.0-59.3; p = 0.006), even after adjustment for oligohydramnios and abnormal fetal heart rate patterns. CONCLUSIONS: Thick, and not thin, meconium-stained AF, was associated with an increased risk for perinatal complications during labor and delivery. Therefore, thick meconium-stained AF should be considered a marker for possible fetal compromise, and lead to careful evaluation of fetal well-being.
We report our experience in a woman with a twin pregnancy. The patient suffered severe Escherichia coli chorioamnionitis and the outcomes were different between the two babies after birth. The first baby had only a mild infection, but the second suffered sepsis and subsequent perinatal death. These differences in outcome appeared to be due to amniotomy performed for the first baby after late labor stage I to augment uterus contractions. Removal of infectious amniotic fluid from the amniotic cavity might thus have prevented the spread of the chorioamnionitis. E. coli sometimes causes severe infection during pregnancy and the perinatal period. In this case, a large number of enteropathogenic E. coli (serotype O-6) was cultured from blood, stool, pharyngeal swab, gastric juice and puncture fluid from the thoracic cavity of the second baby. O-6 is classified an enterotoxigenic strain mainly causing diarrhea because of endotoxin released from bacteria. O-6 has not hitherto been reported as a cause of severe infection in chorioamnionitis and perinatal sepsis.
OBJECTIVE: To investigate complications and outcome of pregnancies with male and female fetuses. METHODS: A population-based study comparing all singleton deliveries between the years 1988 and 1999 was performed. We compared pregnancies with male vs. female fetuses. Patients with a previous cesarean section (CS) were excluded from the study. Statistical analyses with the Mantel-Haenszel technique and multiple logistic regression models were performed to control for confounders. RESULTS: During the study period there were 55,891 deliveries of male and 53,104 deliveries of female neonates. Patients carrying male fetuses had higher rates of gestational diabetes mellitus (OR = 1.1; 95% CI 1.01-1.12; p = 0.012), fetal macrosomia (OR = 2.0; 95% CI 1.8-2.1; p < 0.001), failure to progress during the first and second stages of labor (OR = 1.2; 95% CI 1.1-1.3; p < 0.001 and OR = 1.4; 95% CI 1.3-1.5; p < 0.001, respectively), cord prolapse (OR = 1.3; 95% CI 1.1-1.6; p = 0.014), nuchal cord (OR = 1.2; 95% CI 1.1-1.2; p < 0.001) and true umbilical cord knots (OR = 1.5; 95% CI 1.3-1.7; p < 0.001). Higher rates of CS were found among male compared with female neonates (8.7 vs. 7.9%; OR = 1.1; 95% CI 1.06-1.16; p < 0.001). Using three multivariate logistic regression models and controlling for birth weight and gestational age, male gender was significantly associated with non-reassuring fetal heart rate patterns (OR = 1.5; 95% CI 1.4-1.6; p < 0.001), low Apgar scores at 5 min (OR = 1.5; 95% CI 1.3-1.8; p < 0.001) and CS (OR = 1.2; 95%CI 1.2-1.3; p < 0.001). Controlling for possible confounders like gestational diabetes, cord prolapse, failed induction, nonprogressive labor, fetal macrosomia, nuchal cord and true umbilical cord knots using the Mantel-Haenszel technique did not change the significant association between male gender and CS. CONCLUSION: Male gender is an independent risk factor for adverse pregnancy outcome.
AIMS: To investigate the incidence of severe fetal-to-maternal transfusion after delivery and to identify risk factors. MATERIAL AND METHODS: In a prospective study at the Department of Obstetrics, Charité, Campus Virchow-Klinikum, Berlin, Germany, we analyzed the incidence of severe fetal-to-maternal transfusion (>10 ml) and fetal-to-maternal hemorrhage (>25 ml) in Rh D-negative pregnant women after delivery of Rh D-positive infants. 942 women were included in the study and Kleihauer-Betke tests were performed. The results were compared to perinatal data. RESULTS: Fetal-to-maternal hemorrhage occurred in 13 cases out of 942 (incidence of 1.3%) and severe fetal-to-maternal transfusion in 61 cases (6.5%). In all of the cases with fetal-to-maternal hemorrhage, mothers were compatible with their infants in ABO-system. The incidence of fetal-to-maternal transfusion and its severe form was significantly higher in twin pregnancies (7/21 cases and 5/21 cases respectively, 33.3% and 23.8%) than in singleton pregnancies (22.5%, and 5.9%, P<0.001). All other factors, such as maternal age, parity, ethnicity, mode of delivery, presentation, duration of first and second stage of labor, CTG, or Apgar score were not associated with an increased risk of severe fetal-to-maternal transfusion. CONCLUSIONS: Twin pregnancy is the only independent risk factor for severe fetal-to-maternal transfusion. ABO-incompatibility between mother and infant seems to be protective against Rh D-alloimmunization.
The current study applies a neurophysiological model based on the Polyvagal Theory (Porges, 1995) to interpret fetal heart rate patterns. Beat-to-beat heart rate data from 7 fetuses monitored during the first and second stages of labor were analyzed. Transitory heart rate accelerations and reduced beat-to-beat variability reliably preceded heart rate decelerations. The data are interpreted within the context of the Polyvagal Theory, which provides a plausible explanation of the neurophysiological mechanisms that mediate fetal heart rate decelerations. Specifically, it is proposed that both the transitory heart rate accelerations and the depression of the respiratory rhythm in the beat-to-beat heart rate pattern reflect a withdrawal of the vagal tone determined by myelinated vagal pathways originating in the nucleus ambiguus. Functionally, withdrawal of vagal tone originating in the nucleus ambiguus results in the cardiac pacemaker becoming vulnerable to sympathetic influences and to the more-primitive unmyelinated vagal pathways originating in the dorsal motor nucleus of the vagus, which may contribute to clinically relevant bradycardia.
OBJECTIVE: To determine the risk factors for third-degree perineal tears during vaginal delivery and to investigate the relation between different types of episiotomy and the occurrence of such tears. STUDY DESIGN: This retrospective multicenter study consisted of an analysis of data from the delivery databases of the University Hospital of Vienna and Semmelweis Frauenklinic Wien between February and July 1999. The study was restricted to a sample that included all women with uncomplicated pregnancy as well as uncomplicated first and second stages of labor, gestational age > 37 weeks and a pregnancy with cephalic presentation. Women with multiple gestations, noncephalic presentation, cesarean deliveries, shoulder dystocia and gestational age < or = 37 weeks were excluded from the study. RESULTS: Among the 1,118 births, 37 women (3.3%) experienced third-degree perineal tears. The use of episiotomy per se and the type of episiotomy (midline) as well as forceps delivery, primiparity, large infant head diameter, prolonged second stage of labor and use of oxytocin were identified as risk factors for third-degree perineal tears during vaginal delivery. When analyzing different types of episiotomy, there was approximately a sixfold-higher risk of third-degree perineal tears in women undergoing midline episiotomy as compared to mediolateral episiotomy. A stepwise logistic regression analysis revealed that episiotomy, prolonged second stage of labor and large infant head diameter remained independent risk factors for third-degree perineal tears. CONCLUSION: We found several risk factors for third-degree perineal tears. The use of midline episiotomy was associated especially with an increased risk of severe anal sphincter tears. To prevent women from long-term sequelae due to third-degree perineal tears, avoidable risk factors should be minimized whenever possible.
OBJECTIVE: To analyse the relationship between intrapartum fetal heart rate disturbances and electrocardiographic changes and umbilical venous troponin-I (T-I), concentrations as well. MATERIAL AND METHODS: 14 fetuses were continuously surveyed by CTG and ECG recordings in the first and second stage of labor, using STAN S-21 analyser. After birth, umbilical venous blood samples were collected for determination of acid-base balance, base excess and troponin-I concentrations. RESULTS: From among monitored fetuses, in 8 cases the CTG and FECG patterns were correct. Vaginally delivered neonates were born in good clinical status, with normal acid-base balance, base excess and T-I < 0.3 ng/ml. In 3 cases abnormal CTG patterns were observed with early decelerations but FECG patterns were correct. Vaginally delivered neonates were born in good clinical status, with normal acid-base balance, base excess and T-I < 0.3 ng/ml. In 2 cases abnormal CTG patterns were observed with variable decelerations but FECG patterns were correct. Vaginally delivered neonates were born in good clinical status, with normal acid-base balance, base excess and T-I < 0.3 ng/ml. In one case abnormal CTG pattern were observed with late decelerations but FECG patterns was correct. The pregnancy was terminated by caesarean section because of fetal distress. The neonate was born in good clinical status with normal acid-base balance and base excess but T-I concentration was increased (1.5 ng/ml).
On the basis of our own experience and the literature the risk of acidosis, which corresponds to the risk of asphyxia, during vaginal delivery of breech presentations is examined. Compared with delivery of vertex presentation it is 3-10 times greater. The risk of acidosis does not depend on the duration of pregnancy and only a little on the parity of the mother. Even with carefully selective indication for primary Caesarean section it cannot be reduced below the high level. Typically there is acute compression of the cord at the end of the first or later stages of labor. Even with intensive intra-partum care it cannot safely be predicted with sufficient certainty. As a criterion of the efficiency of modern obstetrics the impact of acidosis in umbilical blood and its increase in breech presentation is discussed. Only systematic Caesaren section before or early in labor will lower the risk to that of vertex presentation. This is done and recommended by the authors. Links between acdosis in umbilical blood and permanent cerebral damage are probable but by no means certain and their importance in unknown. Selective indication for Caesarean section which has to be made generously, represents an acceptable alternative.
ADP and collagen induced platelet aggregation were determined in 34 newborns immediately after birth. Blood was drawn from the pulsating not clamped umbilical vein. Parameters of aggregation were correlated to pH values of umbilical artery and vein, Apgar score and to the duration of the first and second stage of labor. No significant correlations were found between parameters of labor and platelet aggregation. It is demonstrated, however, that a decrease of the pH values in the umbilical artery and vein is well correlated with an increase of the main parameters of platelet aggregation. Changes of disaggregation of platelets were only moderate, they showed a tendency to decrease with falling pH values. Altogether there is an increase of platelet aggregability if pH values go down. The results emphasize that the changes of platelet function described should be regarded in the concept of therapy of newborns with severe acidosis or shock as they may accentuate preexisting hypercoagulability.
Women with cerebrospinal fluid (CSF) shunts for correction of hydrocephalus are rapidly joining the reproductive age population. These patients can have uncomplicated pregnancies and spontaneous vaginal deliveries. Careful attention to signs of CSF shunt malfunction, historical and ultrasonic screening for familial hydrocephalus, and antibiotic prophylaxis for delivery are recommended. Management of the first and second stages of labor is discussed. There is no apparent advantage to any particular technique for intrapartum analgesia.
Umbilical cord arterial blood gas (UCABG) analysis is recommended in addition to Apgar scoring for assessing newborns. A prospective study was performed to determine whether UCABG values should be obtained in all deliveries, or only in selected deliveries in which the UCABG values are likely to be informative. During a predefined study period, maternal and neonatal data were collected for all live births (n = 604). UCABG test results were available for 505 births. Of these, 98 (19.4%) had UCABG pH < 7.2 (acidotic group), and they were compared with the other 407 live births (nonacidotic group). There were significantly more primiparous women in the acidotic group, whereas grandmultiparity (parity > 7) was significantly lower. The first and second stages of labor were significantly prolonged and there were more assisted births in the acidotic group. Fetal distress and the incidence of Apgar scores < 3 were significantly higher in the acidotic group. The selective determination of UCABG values in primiparous pregnancies, prolonged labors, assisted deliveries. or in the presence of fetal distress may be more informative than universal UCABG determination. Although these factors were highly sensitive, their specificity was poor; thus we cannot recommend criteria for the selective determination of UCABG values.
OBJECTIVE: One variable that has the potential to affect the course of labor but has not been evaluated previously is the adequacy of maternal hydration. Typical orders provide for 125 mL of intravenous fluids per hour in patients taking limited oral fluids. Many such patients are clinically dehydrated. Physiologists have shown that increased fluids improve skeletal muscle performance in prolonged exercise. This study was designed to determine whether increased intravenous fluids affect the progress of labor. STUDY DESIGN: Nulliparous women with uncomplicated singleton gestations at term, in spontaneous active labor with dilatation between 2 and 5 cm, and with a cephalic presentation were included. Patients who gave consent were randomly selected to receive either 125 mL or 250 mL of intravenous fluids per hour. RESULTS: One hundred ninety-five patients were randomly selected, 94 to the 125-mL group and 101 to the 250-mL group. Prerandomization variables were well matched between the 2 groups. The mean volume of total intravenous fluids was significantly greater in the 250-mL group (2008 mL vs 2487 mL; P =.002), as was the mean hourly rate (152 mL/h in the 125-mL group vs 254 mL/h in the 250-mL group; P =.001). The frequency of labor lasting >12 hours was statistically higher in the 125-mL group (20/78 [26%] vs 12/91 [13%]; P =.047). In addition, there was a trend favoring longer mean duration of the first stage and total duration of labor in patients delivered vaginally in the 125-mL group, by 70 and 68 minutes, respectively (P =.06). There was a trend toward a lower frequency of oxytocin administration for inadequate labor progress in the higher fluid rate group (61 [65%] in the 125-mL group vs 51 [49%] in the 250-mL group; P =.06). Cesarean deliveries were more frequent in the 125-mL group (n = 16) than in the 250-mL group (n = 10) but did not reach statistical significance. CONCLUSION: This study presents the novel finding that increasing fluid administration for nulliparous women in labor above rates commonly used is associated with a lower frequency of prolonged labor and possibly less need for oxytocin. Thus inadequate hydration in labor may be a factor contributing to dysfunctional labor and possibly cesarean delivery. Consideration of this factor in clinical management and in future studies considering variables that affect labor is warranted.
OBJECTIVES: Acute puerperal uterine inversion is a rare but very feared obstetrical complication. It determines an almost immediate shock and serious metrorrhagia. It is a introflexion of parietes uteri which takes place during the third stage of labor or during the first hours of puerperium. It can be distinguished in inversion of I, II or III degree according to the zone concerned by the introflexion: only the fundus of the uterus, all the corpus emerging in the vagina or the entirety of the uterus coming out from the vulvar orifice. RESULTS: This is report a case of inversion of the uterus during third stage of labor in multiparous aged 24 years admitted to Department of Gynecology & Obstetric in Hospital of Słupsk. The uterine III degree inversion was spontaneous during third stage of labor and was immediately diagnosed. Manual manipulation was attempted immediately to reverse the inversion but it was not successful. Because patient fell in cardiovascular shock she was resusciated and the inverted uterus repositioned using Huntington's method under general anaesthesia. After intra-abdominal repositioning of the uterus the placenta was removed manually and intramural injection of oxitocine was done to avoid immediate relapse. Whole obstetrical procedure was carried out within one-half hour after inversion. CONCLUSIONS: Although uncommon, in left unrecognized, uterine inversion will result in severe hemorrhage and shock, leading to maternal death. Manual manipulation should be attempted immediately to reverse the inversion. In the most resistant of inversions, surgical correction might be required. Following inversion of the uterus, further normal pregnancies can be expected.
Adrenocorticotropic hormone (ACTH) concentrations in umbilical arterial and venous plasma were measured in newborn infants delivered both vaginally and by cesarean section. Mean ACTH was significantly higher in the arterial (602.0 pg. per milliliter) than venous (261.5 pg. per milliliter) plasma in vaginal deliveries (pless than 0.01). Arterial plasma of babies born by elective cesarean section before initiation of labor contained less ACTH (384.7 pg. per milliliter) when compared to those delivered after labor had started (698.7 pg. per milliliter). Serial determinations of ACTH in pooled fetal blood obtained during labor showed that the average hormone titers increased significantly from first stage (295.2 pg. per milliliter) to second stage of labor (440.5 pg. per milliliter), and reached a peak at delivery (645.4 pg. per milliliter). The pituitary gland of the fetus at midtrimester contained ACTH. Possible mechanisms for fetal secretion of ACTH at delivery are discussed.
OBJECTIVE: A critical analysis of the United States randomized controlled trial of fetal pulse oximetry concluded that nonreassuring fetal heart rate patterns used for study entry may have been a marker for dystocia. We prospectively studied nulliparous women in labor whose progress was monitored with fetal pulse oximetry to examine the relationship between nonreassuring fetal heart rate patterns and operative delivery for dystocia. STUDY DESIGN: A prospective nonrandomized observational cohort study compared two distinct classes of nonreassuring fetal heart rate patterns (class I: intermittent, mildly nonreassuring; class II: persistent, progressive, and moderate to severely nonreassuring) among nulliparous patients with the use of fetal pulse oximetry to confirm fetal well-being. Definitions of dystocia included the cessation of labor progress in the first (3 hours) or second (2 hours) stage of labor, despite adequate uterine activity that was assessed with an intrauterine pressure catheter. Independent review confirmed the classification of nonreassuring fetal heart rate patterns and study entry criteria. RESULTS: Two hundred seventy-four patients met study criteria and had sufficient information for fetal heart rate tracing interpretation. Two hundred thirty-seven patients (86.5%) were class II, and 37 patients (13.5%) were class I. The two classes of patients were comparable in a variety of obstetric, demographic, and perinatal variables. Twelve percent of all patients were delivered for nonreassuring fetal status. Significantly more class II patients (22%) were delivered by cesarean for dystocia than were class I patients (8%). Higher doses and a longer number of hours of oxytocin were required among class II patients. Significantly more occiput posterior positions were noted among all patients who underwent cesarean delivery for dystocia compared with other modes of delivery. CONCLUSION: Significantly nonreassuring fetal heart rate patterns predict cesarean delivery for dystocia among nulliparous patients with normally oxygenated fetuses in a setting of a standardized labor management protocol. This confirms the observations in the randomized controlled trial of fetal pulse oximetry in the United States and may provide insight into the treatment of nonprogressive labor in contemporary practice.
The relationship between maternal plasma levels of beta-endorphin (beta-Ep) during labor and various obstetrical factors was investigated in 115 healthy pregnant women. beta-Ep was determined by radioimmunoassay using double-antibody RIA kit (INCSTAR Corporation, Stillwater, M'S.). The results were as follows: (1) The primiparous women showed a significant increase of maternal plasma levels of beta-Ep at delivery compared with the multiparous women. In addition, the group of women whose Bishop's score at the onset of labor was 5 points or less showed a significant increase of maternal plasma levels of beta-Ep at delivery compared with that in the group of women whose Bishop's score was 6 points or more. (2) The increase in maternal plasma levels of beta-Ep during the first and the second stage of labor was significantly higher in obese women (pre-pregnancy BMI > or = 24) than in normal weight women (pre-pregnancy BMI < 24). In normal weight women in pre-pregnancy, the group of women whose weight gain during pregnancy was 11kg or more showed a significantly higher increase of beta-Ep compared with that in the group of women whose weight gain was less than 11 kg. These results suggest that a stressful delivery caused a significant increase of maternal plasma levels of beta-Ep during labor. Moreover, obesity and marked weight gain during pregnancy caused a remarkable increase in beta-Ep probably due to latent dystocia.