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PubMed2005

Neurologic complications of neuraxial analgesia for labor.

PURPOSE OF REVIEW: In today's anesthesia practice, provision of neuraxial anesthesia and analgesia is increasing. Along with the patient's fear of paralysis that accompanies placement of a needle near the spinal cord, any subsequent nerve deficit is usually blamed on the neuraxial block provided. Knowing the side effects from labor, neuraxial anesthesia or both is important as anesthesiologists are the first consultants to evaluate whenever a complication arises in these patients if there is a sensory or motor deficit in the lower extremities. RECENT FINDINGS: Neuraxial anesthesia may be associated with complaints of back pain, postdural puncture headache and severe complications (e.g., hematoma, abscess), but most complications following neuraxial blocks are associated with pregnancy and delivery, not the anesthetic. Signs and symptoms of the most common neurologic complications are described so that the clinician can promptly diagnose and treat these patients and seek appropriate consultation. SUMMARY: Even though the incidence of true neurologic complications arising from neuraxial anesthesia is not known, they appear to be very rare. As anesthesiologists, providing care encompasses knowing the side effects and complications of the anesthetic we provide. Many of the nerve palsies that present in the postpartum patient may be of an obstetric origin, but anesthesiologists should be aware of anesthetic-related complications.

Journal Article↗
PubMed1999

Physical violence during pregnancy: maternal complications and birth outcomes.

OBJECTIVE: To assess the association between physical violence during the 12 months before delivery and maternal complications and birth outcomes. METHODS: We used population-based data from 6143 women who delivered live-born infants between 1993 and 1995 in South Carolina. Data on women's physical violence during pregnancy were based on self-reports of "partner-inflicted physical hurt and being involved in a physical fight." Outcome data included maternal antenatal hospitalizations, labor and delivery complications, low birth weights, and preterm births. Odds ratios and 95% confidence intervals were calculated to measure the associations between physical violence, maternal morbidity, and birth outcomes. RESULTS: The prevalence of physical violence was 11.1%. Among women who experienced physical violence, 54% reported having been involved in physical fights only and 46% had been hurt by husbands or partners. In the latter group, 70% also reported having been involved in fighting. Compared with those not reporting physical violence, women who did were more likely to deliver by cesarean and be hospitalized before delivery for maternal complications such as kidney infection, premature labor, and trauma due to falls or blows to the abdomen. CONCLUSION: Physical violence during the 12 months before delivery is common and is associated with adverse maternal conditions. The findings support the need for research on how to screen for physical violence early in pregnancy and to prevent its consequences.

Abdominal Injuries↗
PubMed1976

[Complications at the end of pregnancy and during labor due to hematoma of the umbilical cord].

One of the rare complications at the end of pregnancy and during birth is a haematoma of the umbilical cord with and without the subsequent rupturing of the umbilical cord. The characteristic symptom of this is intrauterine asphyxia. A haematoma of the umbilical cord is frequently fatal for the foetus. In selected cases it is possible to proved the existence of a haematoma. A brief description of the anatomy and physiology of the umbilical cord is followed by a discussion of the pathological or pathophysiological reasons for the onset of a haematoma of the umbilical cord. Two groups of factors are mentioned here, the mechanical and the dynamic changes of the blood vessels of the umbilical cord. This is followed by a description of two cases from the writer's own experience. In the first case the asphyxial after term infant died of pulmonary seventeen hours after birth; in the second case of the foetus had died in the uterus. The second case must be regarded as fatal. Dynamic factors affecting the umbilical cord had resulted in a rupture of the umbilical vein with a subsequent rupture of the umbilical sheath. In the first case the fact that the infant was overdue is discussed as a partial cause for the onset of the haematoma of the umbilical cord. This is one of the reasons why satisfactory ante natal care is considered essential, particularly towards the end of pregnancy.

Adult↗
PubMed1990

True rupture/scar dehiscence in delivery following prior section.

Fear of uterine rupture has led to the widespread practice of 'Once a section, always a section'. Between 1972 and 1982, 1498 patients with one or more previous cesarean sections were delivered at University College Hospital, Galway. Trial of labor was undertaken in 844 patients, while the remaining 654 patients underwent repeat elective section because they had two or more prior sections. Eight true ruptures and 22 scar dehiscences were found. Regional analgesia and oxytocin did not significantly affect the rate of true rupture. The mean parity with uterine rupture was five, and it occurred most frequently in the initial trial of labor. There were four perinatal deaths associated with true rupture. Failure to detect the already compromised fetus before labor and delivery, rather than the method of delivery, was responsible for fetal demise in some instances. Five true ruptures were found in the trial of labor group (i.e. a ratio of 1:169), with the loss of three babies. A further baby was stillborn in a mother who ruptured a classical scar before labor. There were no maternal deaths in trial-of-labor patients and one in the elective section group. Two patients with true rupture had their uterus repaired, and were subsequently delivered by section. Another two patients with bloodless dehiscence and no repair, had two subsequent elective repeat sections each, and the unrepaired scar dehiscence was not evident.

Cesarean Section↗
PubMed1997

The case for trial of labor in the patient with a prior low-segment vertical cesarean incision.

OBJECTIVE: Our purpose was to review recent obstetric literature detailing the subsequent delivery experience of patients with a prior low-segment vertical cesarean incision and to derive recommendations for practice on the basis of this information. STUDY DESIGN: Ten studies that included information about pregnancy outcome in patients with prior low-segment vertical cesarean operations were retrieved and reviewed from the American obstetric literature since 1981 and from a review of all abstracts presented annually since 1981 to the Society of Perinatal Obstetricians. RESULTS: Altogether, information about subsequent pregnancy outcome for 382 patients with prior low-segment vertical cesarean delivery was available for analysis. Among the 372 patients with complete patient population information, vaginal delivery was safely accomplished in 306 (82%). Four uterine ruptures (1.05%) have been reported, only one of which occurred after a single prior unextended low-segment vertical cesarean incision. Two ruptures occurred elsewhere on the lateral or posterior aspect of the uterus in subsequent pregnancies, and the fourth rupture occurred at the juncture of prior low vertical and transverse incisions. No perinatal mortality or permanent perinatal morbidity was encountered with these pregnancies. CONCLUSIONS: In the otherwise uncomplicated pregnancy the patient with one previous nonextended low-segment vertical cesarean incision should be considered to have a prior low-segment scar and as such be a candidate for trial of labor in her current singleton pregnancy. The same care, counseling, and caution should be exercised for this patient as for one with a prior low-segment transverse incision.

Birth Weight↗
PubMed2004

Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery.

BACKGROUND: The proportion of women who attempt vaginal delivery after prior cesarean delivery has decreased largely because of concern about safety. The absolute and relative risks associated with a trial of labor in women with a history of cesarean delivery, as compared with elective repeated cesarean delivery without labor, are uncertain. METHODS: We conducted a prospective four-year observational study of all women with a singleton gestation and a prior cesarean delivery at 19 academic medical centers. Maternal and perinatal outcomes were compared between women who underwent a trial of labor and women who had an elective repeated cesarean delivery without labor. RESULTS: Vaginal delivery was attempted by 17,898 women, and 15,801 women underwent elective repeated cesarean delivery without labor. Symptomatic uterine rupture occurred in 124 women who underwent a trial of labor (0.7 percent). Hypoxic-ischemic encephalopathy occurred in no infants whose mothers underwent elective repeated cesarean delivery and in 12 infants born at term whose mothers underwent a trial of labor (P<0.001). Seven of these cases of hypoxic-ischemic encephalopathy followed uterine rupture (absolute risk, 0.46 per 1000 women at term undergoing a trial of labor), including two neonatal deaths. The rate of endometritis was higher in women undergoing a trial of labor than in women undergoing repeated elective cesarean delivery (2.9 percent vs. 1.8 percent), as was the rate of blood transfusion (1.7 percent vs. 1.0 percent). The frequency of hysterectomy and of maternal death did not differ significantly between groups (0.2 percent vs. 0.3 percent, and 0.02 percent vs. 0.04 percent, respectively). CONCLUSIONS: A trial of labor after prior cesarean delivery is associated with a greater perinatal risk than is elective repeated cesarean delivery without labor, although absolute risks are low. This information is relevant for counseling women about their choices after a cesarean section.

Adolescent↗
PubMed2004

Effect of prior vaginal delivery or prior vaginal birth after cesarean delivery on obstetric outcomes in women undergoing trial of labor.

OBJECTIVE: We sought to study the effects of prior vaginal delivery or prior vaginal birth after cesarean delivery (VBAC) on the success of a trial of labor after a cesarean delivery. METHODS: An observational study of patients who underwent a trial of labor after a single low-transverse cesarean delivery. Patients with a previous cesarean delivery and no vaginal birth were compared with patients with a single vaginal delivery before or after the previous cesarean delivery. The rates of successful VBAC, uterine rupture, and scar dehiscence were analyzed. Multivariable regression was performed to adjust for confounding variables. RESULTS: Of 2,204 patients, 1,685 (76.4%) had a previous cesarean delivery and no vaginal delivery, 198 (9.0%) had a vaginal delivery before the cesarean delivery, and 321 (14.6%) had a prior VBAC. The rate of successful trial of labor was 70.1%, 81.8%, and 93.1%, respectively (P <.001). A prior VBAC was associated with fewer third- and fourth-degree lacerations (8.5% versus 2.5% versus 3.7%, P <.001) and fewer operative vaginal deliveries (14.7% versus 5.6% versus 1.9%, P <.001) but not with uterine rupture (1.5% versus 0.5% versus 0.3%, P =.12). Patients with a prior VBAC had, in addition, a higher rate of uterine scar dehiscence (21.8%) compared with patients with a previous cesarean delivery and no vaginal delivery (5.3%; P =.001). CONCLUSION: A prior vaginal delivery and, particularly, a prior VBAC are associated with a higher rate of successful trial of labor compared with patients with no prior vaginal delivery. In addition, prior VBAC is associated with an increased rate of uterine scar dehiscence.

Adult↗