Mediolateral episiotomy and risk of obstetric anal sphincter injuries and adverse neonatal outcomes during operative vaginal delivery in nulliparous women: a propensity-score analysis.

BACKGROUND: The potential protective effect of mediolateral episiotomy for obstetrical anal sphincter injuries (OASIs) remains controversial during operative vaginal delivery because of the difficulties to take into account the risk factors and clinical conditions at delivery; in addition, little is known about the potential benefits of mediolateral episiotomy on neonatal outcomes. The objectives were to investigate the associations between mediolateral episiotomy and both OASIs and neonatal outcomes, using propensity scores. METHODS: We performed a retrospective population-based observational study from a perinatal registry that includes all births in a French region between 2010 and 2017. All nulliparous women with singleton pregnancy delivering by operative vaginal deliveries at 37 weeks gestational age or later were included. Inverse-probability-of-treatment weighting with propensity scores was used to minimize indication bias. OASIs was defined as third and fourth-degree tears according to Royal College of Obstetricians and Gynecologists. Two neonatal outcomes were studied: condition at birth (5-min Apgar score less than 7 and/or umbilical artery pH less than 7.10), and admission to neonatal intensive care unit. RESULTS: The study population consisted of 7589 women; 2880 (38.0%) received mediolateral episiotomy. After applying propensity scores, episiotomy was associated with a lower rate of OASIs in forceps/spatula delivery (2.3 vs 6.8%, Risk Ratio (RR) 0.38, 95% Confidence Interval (CI) 0.28-0.52) and in vacuum delivery (1.3 vs 3.4%, RR 0.27, 95% CI 0.20-0.38) as compared with no episiotomy. Mediolateral episiotomy was associated with better condition at birth in case of forceps/spatula delivery (4.5 vs 8.8%, RR 0.56, 95% CI 0.39-0.81). In cases of fetal distress (40.7%), mediolateral episiotomy was associated with better condition of infant at birth in women who delivered by forceps/spatula (4.2 vs 13.5%, RR 0.52, 95% CI 0.31-0.89). No association was found with neonatal unit admission (RR 0.93, 95% CI 0.50-1.74). CONCLUSIONS: Use of mediolateral episiotomy was associated with a lower rate of OASIs during operative vaginal delivery, and in infants it was associated with better condition at birth following forceps/spatula delivery.

Role of Doppler ultrasound at time of diagnosis of late-onset fetal growth restriction in predicting adverse perinatal outcome: prospective cohort study.

OBJECTIVE: Pregnancies complicated by late-onset fetal growth restriction (FGR) are at increased risk of short- and long-term morbidities. Despite this, identification of cases at higher risk of adverse perinatal outcome, at the time of FGR diagnosis, is challenging. The aims of this study were to elucidate the strength of association between fetoplacental Doppler indices at the time of diagnosis of late-onset FGR and adverse perinatal outcome, and to determine their predictive accuracy. METHODS: This was a prospective study of consecutive singleton pregnancies complicated by late-onset FGR. Late-onset FGR was defined as estimated fetal weight (EFW) or abdominal circumference (AC) < 3rd centile, or EFW or AC < 10th centile and umbilical artery (UA) pulsatility index (PI) > 95th centile or cerebroplacental ratio (CPR) < 5th centile, diagnosed after 32 weeks. EFW, uterine artery PI, UA-PI, fetal middle cerebral artery (MCA) PI, CPR and umbilical vein blood flow normalized for fetal abdominal circumference (UVBF/AC) were recorded at the time of the diagnosis of FGR. Doppler variables were expressed as Z-scores for gestational age. Composite adverse perinatal outcome was defined as the occurrence of at least one of emergency Cesarean section for fetal distress, 5-min Apgar score < 7, umbilical artery pH < 7.10 and neonatal admission to the special care unit. Logistic regression analysis was used to elucidate the strength of association between different ultrasound parameters and composite adverse perinatal outcome, and receiver-operating-characteristics (ROC)-curve analysis was used to determine their predictive accuracy. RESULTS: In total, 243 consecutive singleton pregnancies complicated by late-onset FGR were included. Composite adverse perinatal outcome occurred in 32.5% (95% CI, 26.7-38.8%) of cases. In pregnancies with composite adverse perinatal outcome, compared with those without, mean uterine artery PI Z-score (2.23 ± 1.34 vs 1.88 ± 0.89, P = 0.02) was higher, while Z-scores of UVBF/AC (-1.93 ± 0.88 vs -0.89 ± 0.94, P ≤ 0.0001), MCA-PI (-1.56 ± 0.93 vs -1.22 ± 0.84, P = 0.004) and CPR (-1.89 ± 1.12 vs -1.44 ± 1.02, P = 0.002) were lower. On multivariable logistic regression analysis, Z-scores of mean uterine artery PI (P = 0.04), CPR (P = 0.002) and UVBF/AC (P = 0.001) were associated independently with composite adverse perinatal outcome. UVBF/AC Z-score had an area under the ROC curve (AUC) of 0.723 (95% CI, 0.64-0.80) for composite adverse perinatal outcome, demonstrating better accuracy than that of mean uterine artery PI Z-score (AUC, 0.593; 95% CI, 0.50-0.69) and CPR Z-score (AUC, 0.615; 95% CI, 0.52-0.71). A multiparametric prediction model including Z-scores of MCA-PI, uterine artery PI and UVBF/AC had an AUC of 0.745 (95% CI, 0.66-0.83) for the prediction of composite adverse perinatal outcome. CONCLUSION: While CPR and uterine artery PI assessed at the time of diagnosis are associated independently with composite adverse perinatal outcome in pregnancies complicated by late-onset FGR, their diagnostic performance for composite adverse perinatal outcome is low. UVBF/AC showed better accuracy for prediction of composite adverse perinatal outcome, although its usefulness in clinical practice as a standalone predictor of adverse pregnancy outcome requires further research. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Papel de la ecografía Doppler en el momento del diagnóstico de la restricción del crecimiento fetal de aparición tardía para la predicción de resultados perinatales adversos: estudio prospectivo de cohortes OBJETIVO: Los embarazos complicados por la restricción del crecimiento fetal (RCF) de aparición tardía tienen un mayor riesgo de morbilidad a corto y largo plazo. A pesar de ello, es difícil identificar los casos con mayor riesgo de resultados perinatales adversos en el momento del diagnóstico de RCF. Los objetivos de este estudio fueron dilucidar la fortaleza de la asociación entre los índices Doppler fetoplacentarios en el momento del diagnóstico de la RCF de aparición tardía y el resultado perinatal adverso, y determinar su precisión predictiva. MÉTODOS: Este fue un estudio prospectivo de embarazos consecutivos con feto único complicados por una RCF de aparición tardía. La aparición tardía de la RCF se definió como peso estimado del feto (PEF) o circunferencia abdominal (CA) <3er percentil, o PEF o CA <10o percentil junto con índice de pulsatilidad (IP) de la arteria umbilical (AU) >95o percentil, o una relación cerebroplacentaria (RCP) <5o percentil, diagnosticado después de las 32 semanas. El PEF, el IP de la arteria uterina (IP-AU), el IP de la arteria cerebral media fetal (ACM), la RCP y el flujo sanguíneo de la vena umbilical normalizado para la circunferencia abdominal fetal (UVBF/AC, por sus siglas en inglés) se registraron en el momento del diagnóstico de RCF. Las variables Doppler se expresaron como puntuaciones Z para la edad gestacional. El resultado perinatal adverso compuesto se definió como la ocurrencia de al menos una cesárea de emergencia por sufrimiento fetal, test de Apgar a los 5 minutos <7, pH de la arteria umbilical <7,10 y el ingreso a la unidad de cuidados especiales de recién nacidos. Se utilizó el análisis de regresión logística para dilucidar la fortaleza de la asociación entre los diferentes parámetros de la ecografía y el resultado perinatal adverso compuesto, y se empleó el análisis de la curva de características operativas del receptor (ROC, por sus siglas en inglés) para determinar su precisión predictiva. RESULTADOS: En total, se incluyeron 243 embarazos con feto único consecutivos complicados por RCF de aparición tardía. El resultado perinatal adverso compuesto se produjo en el 32,5% (IC 95%, 26,7-38,8%) de los casos. En los embarazos con resultados perinatales adversos compuestos, en comparación con los que no los tuvieron, la puntuación Z del IP de la arteria uterina media (2,23±1,34 vs 1,88±0,89, P=0,02) fue mayor, mientras que las puntuaciones Z de UVBF/AC (-1,93±0,88 vs -0,89±0,94, P≤0,0001), IP-ACM (-1,56±0,93 vs -1,22±0,84, P=0,004) y RCP (-1,89±1,12 vs -1,44±1,02, P=0,002) fueron más bajas. En el análisis de regresión logística multivariable, las puntuaciones Z del IP de la arteria uterina media (P=0,04), RCP (P=0,002) y UVBF/AC (P=0,001) estuvieron asociadas de forma independiente con el resultado perinatal adverso compuesto. La puntuación Z del UVBF/AC tuvo un área bajo la curva (ABC) ROC de 0,723 (IC 95%, 0,64-0,80) para el resultado perinatal adverso compuesto, demostrando una mejor precisión que la de la puntuación Z del IP de la arteria uterina media (ABC, 0,593; IC 95%, 0,50-0,69) y la de la puntuación Z de la RCP (ABC, 0,615; IC 95%, 0,52-0,71). Un modelo de predicción multiparamétrico que incluía las puntuaciones Z del IP-ACM, el IP de la arteria uterina y el UVBF/AC resultó en un ABC de 0,745 (IC 95%, 0,66-0,83) para la predicción de un resultado perinatal adverso compuesto. CONCLUSIÓN: Aunque la RCP y el IP de la arteria uterina evaluados en el momento del diagnóstico están asociados de forma independiente con un resultado perinatal adverso compuesto en embarazos complicados por una RCF de aparición tardía, la eficacia del diagnóstico para el resultado perinatal adverso compuesto es baja. El UVBF/AC mostró una mayor precisión para la predicción de un resultado perinatal adverso compuesto, aunque su utilidad en la práctica clínica como parámetro indicativo independiente del resultado adverso del embarazo requiere más investigación. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Disclosing suboptimal indications for emergency caesarean sections due to fetal distress and prolonged labor: a multicenter cross-sectional study at 12 public hospitals in Nepal.

BACKGROUND: Global caesarean section (CS) rates have raised concern of a potential overuse of the procedure in both high- and low-resource settings. We sought to assess management and outcomes of deliveries with emergency CSs due to fetal distress and prolonged labor at 12 public hospitals in Nepal and determine factors associated with suboptimal CS indications. METHODS: We conducted a cross-sectional study on all deliveries between the 14th of April 2017 and the 17th of October 2018 at 12 public hospitals in Nepal and included all emergency CSs due to fetal distress and prolonged labor. Analysis was conducted using Pearson chi-square test and bivariate and multivariate logistic regression. RESULTS: The total cohort included 104,322 deliveries of which 18,964 (18%) were CSs (13,095 [13%] emergency CSs and 5230 [5.0%] elective CSs). We identified 1806 emergency CSs due to fetal distress and 1322 emergency CSs due to prolonged labor. Among CSs due to fetal distress, only 36% had fetal heart rate monitoring performed according to protocol, and among CSs due to prolonged labor, the partograph was completely filled in only 8.6%. Gestational age < 37 weeks and birth weight < 2500 g were associated with more suboptimal CS indications due to fetal distress (adjusted odds ratio [aOR] 1.4, 95% confidence interval [CI] 1.1-1.8 and aOR 1.7, 95% CI 1.3-2.2 respectively) than those with gestational age > 37 weeks and birth weight > 2500 g. We found no association between suboptimal CS indications and maternal ethnicity or education level. CONCLUSIONS: As fetal heart rate monitoring and partograph are fundamental to diagnose fetal distress and prolonged labor, the inappropriate monitoring proceeding CS decisions disclosed in our study indicate that CSs were performed on suboptimal indications. We call for improved quality of intrapartum monitoring, enhanced documentation in medical records, and structured auditing of CS indications in order to curb the potentially harmful CS trend.

Maternal hemodynamics in screen-positive and screen-negative women of the ASPRE trial.

OBJECTIVE: To compare maternal hemodynamics and perinatal outcome, in pregnancies that do not develop pre-eclampsia (PE) or deliver a small-for-gestational-age (SGA) neonate, between those identified at 11-13 weeks' gestation as being screen positive or negative for preterm PE, by a combination of maternal factors, mean arterial pressure, uterine artery pulsatility index, serum placental growth factor and pregnancy associated plasma protein-A. METHODS: This was a prospective longitudinal cohort study of maternal cardiovascular function, assessed using a bioreactance method, in women undergoing first-trimester screening for PE. Maternal hemodynamics and perinatal outcome were compared between screen-positive and screen-negative women who did not have a medical comorbidity, did not develop PE or pregnancy-induced hypertension and delivered at term a live neonate with birth weight between the 5th and 95th percentiles. A multilevel linear mixed-effects model was used to compare the repeated measures of cardiac variables, controlling for maternal characteristics. RESULTS: The screen-negative group (n = 926) had normal cardiac function changes across gestation, whereas the screen-positive group (n = 170) demonstrated static or reduced cardiac output and stroke volume and higher mean arterial pressure and peripheral vascular resistance with advancing gestation. In the screen-positive group, compared with screen-negative women, birth-weight Z-score was shifted toward lower values, with prevalence of delivery of a neonate below the 35th , 30th or 25th percentile being about 70% higher, and the rate of operative delivery for fetal distress in labor also being higher. CONCLUSION: Women who were screen positive for impaired placentation, even though they did not develop PE or deliver a SGA neonate, had pathological cardiac adaptation in pregnancy and increased risk of adverse perinatal outcome. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Morbidity and Mortality Associated With Forceps and Vacuum Delivery at Outlet, Low, and Midpelvic Station.

OBJECTIVE: This study sought to quantify perinatal and maternal morbidity and mortality associated with forceps and vacuum delivery compared with Caesarean delivery in the second stage of labour and to estimate whether these associations differed by pelvic station. METHODS: The investigators conducted a population-based, retrospective cohort study of term singleton deliveries by operative delivery with prolonged second stage of labour in Canada (2003-2013) using national hospitalization data. The primary study outcomes were severe perinatal morbidity and mortality (i.e., seizures, assisted ventilation, severe birth trauma, and perinatal death) and severe maternal morbidity and mortality (i.e., severe postpartum hemorrhage, cardiac complication, and maternal death). Logistic regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) after stratifying by indication (dystocia or fetal distress). The Breslow-Day chi-square test for heterogeneity in ORs was used to test effect modification by pelvic station (outlet, low, or midpelvic). RESULTS: There were 61 106 deliveries included in the study. Among women with dystocia, forceps and vacuum deliveries were associated with higher rates of perinatal morbidity and mortality compared with Caesarean delivery (forceps: aOR 1.56; 95% CI 1.13-2.17; vacuum: aOR 1.44; 95% CI 1.06-1.97). Vacuum delivery was associated with lower rates of maternal morbidity and mortality compared with Caesarean delivery (dystocia: aOR 0.64; 95% CI 0.51-0.81; fetal distress: aOR 0.43; 95% CI 0.32-0.57). Pelvic station did not significantly modify the associations between forceps or vacuum and perinatal or maternal morbidity and mortality. CONCLUSION: Forceps and vacuum delivery is associated with increased rates of severe perinatal morbidity and mortality compared with Caesarean delivery among women with dystocia, whereas vacuum delivery is associated with decreased rates of severe maternal morbidity and mortality.

Fetoscopy-Assisted Percutaneous Decompression of the Distal Trachea and Lungs Reverses Hydrops Fetalis and Fetal Distress in a Fetus with Laryngeal Atresia.

We present a case of prenatal hydrops secondary to congenital high airway obstruction syndrome (CHAOS) that was treated with fetoscopy-assisted needle decompression. A 22-year-old G3P2 woman presented after a 21-week ultrasound demonstrated CHAOS. The fetus developed hydrops at 25 weeks, characterized by abdominal ascites, pericardial effusion, and scalp edema. Fetal MRI showed complete obstruction of the glottis and subglottic airway, suggestive of laryngeal atresia. At 27 weeks, due to the progression of the hydrops, operative fetoscopy was proposed and performed. Fetal laryngoscopy confirmed fusion of the vocal cords and laryngeal atresia. The atretic segment was a solid cartilaginous block, preventing intubation. Using the fetoscope to stabilize the fetal head and neck, we performed ultrasound-guided percutaneous needle drainage of the cervical trachea through the anterior fetal neck. We removed 17 mL of viscous fluid from the lower trachea, resulting in immediate lung decompression. Two weeks later, ultrasound confirmed hydrops resolution. The patient was delivered and tracheostomy performed at 30 weeks via an ex utero intrapartum treatment (EXIT) procedure after progression of preterm labor. At 27 days of life, the infant was stable on minimal ventilator support. To our knowledge, this is the first successful report of an ultrasound-guided percutaneous tracheal decompression through the anterior neck of a fetus with CHAOS secondary to laryngeal atresia.

Maternal demographic factors associated with emergency caesarean section for non-reassuring foetal status.

OBJECTIVES: This study aimed to determine maternal and obstetric factors associated with emergency caesarean section (CS) for non-reassuring foetal status (NRFS). MATERIALS AND METHODS: This was a retrospective analysis of term singleton births between January 2007 and December 2015 at the Mater Mother's Hospital in Brisbane. The study group comprised all cases of emergency CS for NRFS, and the control cohort comprised all other births meeting the inclusion criteria but excluding those in the study cohort. RESULTS: Over the study period, there were 74,177 births fulfilling the inclusion criteria. The overall rate of emergency CS for NRFS was 4.2% (3132/74,177). Multivariate analysis showed that being overweight and obese, Indian and "other" ethnicity, artificial reproductive techniques, smoking, induction of labour and gestation at 39-42 weeks were associated with an increased risk, whereas being underweight, female sex, hypertension and birth without labour conferred a lower risk. CONCLUSION: Many maternal and obstetric factors were associated with emergency CS for NRFS and influenced adverse perinatal outcomes. Recognition of these risk factors could help risk stratify women prior to labour.

Intrapartum intervention rates and perinatal outcomes following induction of labour compared to expectant management at term from an Australian perinatal centre.

BACKGROUND: Induction of labor (IOL) is a common obstetric intervention, yet its impact on intervention rates and perinatal outcomes is conflicting. AIMS: To evaluate the impact of IOL on intrapartum intervention rates and perinatal outcomes in women with singleton pregnancies at term. MATERIAL AND METHODS: This was a retrospective, cross-sectional study of term singleton deliveries at the Mater Mother's Hospital in Brisbane, Australia in 2007-2013. The IOL cohort was compared to an expectantly managed group. RESULTS: Of the final cohort (44 698 women), 64.4% had expectant management and 35.6% had IOL. Multivariate analyses showed that IOL was associated with lower odds of spontaneous vaginal delivery from ≥37 weeks gestation. The risk of emergency caesarean for non-reassuring fetal status was also higher in the IOL cohort at 40 and 41 weeks gestation. For women who were managed expectantly, the highest rate of spontaneous vaginal delivery and the lowest rate of emergency caesareans occurred at 39 weeks gestation. For women who underwent IOL, the nadir emergency caesarean rate and the highest spontaneous vaginal delivery rate was also at 39 weeks. Rates of neonatal intensive car unit admission were higher in the IOL group at 37 weeks (adjusted odds ratio (aOR) 3.11, 95% CI: 2.62-3.68) and 38 weeks (aOR 1.78, 95% CI: 1.55-2.04) and lower at >42 weeks (OR 0.35, 95% CI: 0.14-0.81) respectively. CONCLUSION: IOL compared to expectant management is associated with lower spontaneous vaginal delivery rates and increased risk of emergency caesarean for intrapartum fetal compromise with broadly comparable perinatal outcomes.

Idiopathic spontaneous hemoperitoneum during pregnancy.

Spontaneous hemoperitoneum is defined as bleeding within the peritoneal cavity of non-traumatic and non-iatrogenic etiology. It is a rare and life-threatening condition during pregnancy. Spontaneous hemoperitoneum is considered idiopathic when the source of bleeding is not detected during the exploratory laparotomy. The authors report two cases of spontaneous hemoperitoneum during pregnancy with sudden onset of abdominal pain during the third trimester of their pregnancy. Cesarean section was performed for fetal distress. In both cases, hemoperitoneum with a large quantity of blood was found, but the source of bleeding could not be identified during surgical exploration.

Judicious use of oxytocin augmentation for the management of prolonged labor.

INTRODUCTION: A protocol including judicious use of oxytocin augmentation was investigated to determine whether it would change how oxytocin was used and eventually influence labor and fetal outcomes. MATERIAL AND METHODS: The population of this cohort study comprised 20 227 delivering women with singleton pregnancies ≥37 weeks, cephalic presentation, spontaneous or induced onset of labor, without previous cesarean section. Women delivering from 2009 to 2013 at Stavanger University Hospital, Norway, were included. Data were collected prospectively. Before implementing the protocol in 2010, oxytocin augmentation was used if progression of labor was perceived as slow. After implementation, oxytocin could only be started when the cervical dilation had crossed the 4-h action line in the partograph. RESULTS: The overall use of oxytocin augmentation was significantly reduced from 34.9% to 23.1% (p < 0.01). The overall frequency of emergency cesarean sections decreased from 6.9% to 5.3% (p < 0.05) and the frequency of emergency cesarean sections performed due to fetal distress was reduced from 3.2% to 2.0% (p = 0.01). The rate of women with duration of labor over 12 h increased from 4.4% to 8.5% (p < 0.01) and more women experienced severe estimated postpartum hemorrhage (2.6% vs. 3.7%; p = 0.01). The frequency of children with pH <7.1 in the umbilical artery was reduced from 4.7% to 3.2% (p < 0.01). CONCLUSIONS: The frequency of emergency cesarean section was reduced after implementing judicious use of oxytocin augmentation. Our findings may be of interest in the ongoing discussion of how the balanced use of oxytocin for labor augmentation can best be achieved.

Cervical condition and fetal cerebral Doppler as determinants of adverse perinatal outcome after labor induction for late-onset small-for-gestational-age fetuses.

OBJECTIVE: To estimate the combined value of fetal cerebral Doppler examination and Bishop score for predicting perinatal outcome after labor induction for small-for-gestational-age (SGA) fetuses in the presence of normal umbilical artery Doppler recordings. METHODS: We conducted a cohort study in two tertiary centers, including 164 women with normal umbilical artery Doppler recordings who underwent induction of labor because of an estimated fetal weight < 10(th) percentile. The fetal middle cerebral artery pulsatility index and cerebroplacental ratio (CPR) were obtained in all cases within 24 h before induction. Cervical condition was assessed at admission using the Bishop score. A predictive model for perinatal outcomes was constructed using a decision-tree analysis algorithm. RESULTS: Both a very unfavorable cervix, defined as a Bishop score < 2, (odds ratio (OR), 3.18; 95% CI, 1.28-7.86) and an abnormal CPR (OR, 2.54; 95% CI, 1.18-5.61) were associated with an increased likelihood of emergency Cesarean section for fetal distress, but only the latter was significantly associated with the need for neonatal admission (OR, 2.43; 95% CI, 1.28-4.59). In the decision-tree analysis, both criteria significantly predicted the likelihood of Cesarean section for fetal distress. CONCLUSION: Combined use of the Bishop score and CPR improves the ability to predict overall Cesarean section (for any indication), emergency Cesarean section for fetal distress, and neonatal admission after labor induction for late-onset SGA in the presence of normal umbilical artery Doppler recordings.

Newborn outcomes in british columbia after caesarean section for non-reassuring fetal status.

OBJECTIVE: To assess the incidence in British Columbia of severe morbidity in neonates delivered by Caesarean section for non-reassuring fetal status, and to examine the accuracy of Apgar score and umbilical cord gas values in predicting severe neonatal morbidity. METHODS: We assessed rates of hypoxic ischemic encephalopathy, NICU admission, and ventilator days, individually and as a composite outcome with neonatal death, among a total of 8466 term singletons delivered by Caesarean section for non-reassuring fetal status between January 1, 2007, and December 31, 2011. We calculated the predictive accuracy of Apgar scores and umbilical cord blood gas values using the area under the receiver operating characteristic (ROC) curve and the sensitivity and specificity for each outcome. RESULTS: The incidence of Apgar score at one minute < 4 was 8.0%, and for Apgar score at five minutes < 4 it was 0.6%. The incidence of umbilical cord pH < 7.10 was 6.5%, and for base-excess < -12 it was 2.9%. Apgar score at one minute < 7 had the greatest predictive accuracy for the composite outcome (81% for both sensitivity and specificity). The area under the ROC curve for Apgar score at one minute and at five minutes, umbilical cord pH, and base-excess was 0.87, 0.86, 0.76, and 0.78, respectively. CONCLUSION: The incidence of abnormal Apgar score and abnormal umbilical cord gas values is very low among neonates in British Columbia delivered by Caesarean section for non-reassuring fetal status. Apgar score at one minute < 7 is a good predictor of severe neonatal morbidity. Electronic fetal monitoring remains a non-specific method for detection of fetal compromise in the intrapartum period.

Objectif : Évaluer l'incidence (en Colombie-Britannique) de la morbidité grave chez les enfants nés par césarienne en raison d'un état fœtal non rassurant et examiner la précision de l'indice d'Apgar et des valeurs de la gazométrie du cordon ombilical pour ce qui est de la prévision de la morbidité néonatale grave. Méthodes : Nous avons évalué le taux d'encéphalopathie hypoxique ischémique, le taux d'admission à l'UNSI et le nombre de jours de soutien au moyen d'un appareil à ventilation artificielle, de façon individuelle et sous forme d'issue composite conjointement avec le décès néonatal, chez un total de 8 466 enfants étant nés à terme à la suite d'une grossesse monofœtale accouchée par césarienne en raison d'un état fœtal non rassurant entre le 1er janvier 2007 et le 31 décembre 2011. Nous avons calculé la précision prévisionnelle des indices d'Apgar et des valeurs de la gazométrie du cordon ombilical au moyen de la surface sous la courbe de la fonction d'efficacité du récepteur (ROC), ainsi qu'au moyen de leur sensibilité et de leur spécificité pour chacune des issues. Résultats : L'incidence de l'obtention d'un indice d'Apgar à une minute < 4 était de 8,0 %, tandis qu'elle était de 0,6 % pour ce qui est de l'indice d'Apgar à cinq minutes < 4. L'incidence de l'obtention d'un pH de cordon ombilical < 7,10 était de 6,5 %, tandis que l'incidence de l'obtention d'un excès basique < −12 était de 2,9 %. L'indice d'Apgar à une minute dont la valeur était < 7 constituait le paramètre disposant de la meilleure précision prévisionnelle pour ce qui est de l'issue composite (81 %, tant pour la sensibilité que pour la spécificité). Les surfaces sous la courbe ROC en ce qui concerne les indices d'Apgar à une minute et à cinq minutes, le pH du cordon ombilical et l'excès basique étaient de 0,87, de 0,86, de 0,76 et de 0,78, respectivement. Conclusion : L'incidence de l'obtention d'un indice d'Apgar anormal et de valeurs anormales de gazométrie du cordon ombilical est très faible en Colombie-Britannique chez les enfants nés par césarienne en raison d'un état fœtal non rassurant. L'indice d'Apgar à une minute dont la valeur est < 7 constitue un bon facteur prédictif de la morbidité néonatale grave. Le monitorage fœtal électronique demeure une méthode non spécifique en ce qui concerne la détection d'un danger grave pour le fœtus pendant la période intrapartum.

Nonreassuring fetal status during trial of labor after cesarean.

OBJECTIVE: Concern for uterine rupture has led to the decline in vaginal births after cesarean. Nonreassuring fetal status (NRFS) may precede uterine rupture. The objective of this study was to estimate the risks of uterine rupture, uterine dehiscence, and adverse fetal outcomes associated with NRFS during trial of labor after cesarean (TOLAC). STUDY DESIGN: In a retrospective cohort study of the previously reported Maternal-Fetal Medicine Units Network prospective cohort cesarean registry, we compared women undergoing repeat cesarean for NRFS after TOLAC to those requiring repeat cesarean for other intrapartum indications. Exclusion criteria included women with a prior cesarean who underwent elective or indicated repeat cesarean or women with a multiple gestation. Primary outcomes included uterine rupture or dehiscence. Secondary outcomes included 5-minute Apgar score <7 and neonatal intensive care unit admission. Planned subanalyses for term and preterm deliveries were performed. Stratified and logistic regression analyses were used. RESULTS: Of 17,740 women undergoing TOLAC, 4754 (26.8%) had a failed vaginal birth after cesarean. Of those, NRFS was the primary indication for cesarean in 1516 (31.9%). Women with NRFS as the primary indication for repeat cesarean were at increased risk of uterine rupture (adjusted odds ratio, 3.32; 95% confidence interval, 2.21-5.00), uterine dehiscence (adjusted odds ratio, 1.70; 95% confidence interval, 1.09-2.65), 5-minute Apgar score <7, and neonatal intensive care unit admission compared to women with other primary indications. CONCLUSION: Women attempting TOLAC who require repeat cesarean for NRFS are at increased risk of uterine rupture and uterine dehiscence.

Fetal scalp blood sampling in labor--a review.

During the 1970s and 1980s, electronic fetal monitoring and fetal scalp blood sampling were introduced without robust evidence. With a methodical review of the published literature, and using one randomized controlled trial, seven controlled studies, nine randomized studies of various surveillance methods and data from the Danish National Birth Registry, we have assessed the usefulness of fetal scalp blood sampling as a complementary tool to improve the specificity and sensitivity of electronic cardiotocography. Based on heterogeneous studies of modest quality with somewhat inconsistent results, we conclude that fetal scalp blood sampling in conjunction with cardiotocography can reduce the risk of operative delivery. Fetal scalp blood sampling can provide additional information on fetal wellbeing and fetal reserves at a time before decisions are made concerning the need for and timing of operative delivery and the choice of anesthesia, and be an adjunct in the interpretation of cardiotocography patterns.

A critical appraisal of the evidence for using cardiotocography plus ECG ST interval analysis for fetal surveillance in labor. Part I: the randomized controlled trials.

We reappraised the five randomized controlled trials that compared cardiotocography plus ECG ST interval analysis (CTG+ST) vs. cardiotocography. The numbers enrolled ranged from 5681 (Dutch randomized controlled trial) to 799 (French randomized controlled trial). The Swedish randomized controlled trial (n = 5049) was the only trial adequately powered to show a difference in metabolic acidosis, and the Plymouth randomized controlled trial (n = 2434) was only powered to show a difference in operative delivery for fetal distress. There were considerable differences in study design: the French randomized controlled trial used different inclusion criteria, and the Finnish randomized controlled trial (n = 1483) used a different metabolic acidosis definition. In the CTG+ST study arms, the larger Plymouth, Swedish and Dutch trials showed lower operative delivery and metabolic acidosis rates, whereas the smaller Finnish and French trials showed minor differences in operative delivery and higher metabolic acidosis rates. We conclude that the differences in outcomes are likely due to the considerable differences in study design and size. This will enhance heterogeneity effects in any subsequent meta-analysis.

A critical appraisal of the evidence for using cardiotocography plus ECG ST interval analysis for fetal surveillance in labor. Part II: the meta-analyses.

We appraised the methodology, execution and quality of the five published meta-analyses that are based on the five randomized controlled trials which compared cardiotocography (CTG)+ST analysis to cardiotocography. The meta-analyses contained errors, either created de novo in handling of original data or from a failure to recognize essential differences among the randomized controlled trials, particularly in their inclusion criteria and outcome parameters. No meta-analysis contained complete and relevant data from all five randomized controlled trials. We believe that one randomized controlled trial excluded in two of the meta-analyses should have been included, whereas one randomized controlled trial that was included in all meta-analyses, should have been excluded. After correction of the uncovered errors and exclusion of the randomized controlled trial that we deemed inappropriate, our new meta-analysis showed that CTG+ST monitoring significantly reduces the fetal scalp blood sampling usage (risk ratio 0.64; 95% confidence interval 0.47-0.88), total operative delivery rate (0.93; 0.88-0.99) and metabolic acidosis rate (0.61; 0.41-0.91).

A descriptive analysis of the indications for caesarean section in mainland China.

BACKGROUND: In recent decades we have observed a remarkable increase in the rate of caesarean section (CS) in both developed and developing countries, especially in China. However, the real reasons for this phenomenon are uncertain. Notably, the number of women requesting elective CS without accepted valid medical indication has also increased, generating a nationwide debate because several studies have shown that this may be the underlying cause of the increase in CS rates observed recently. Therefore, we carried out a multicentre, large-sample, cross-sectional study to describe the CS rate and indications for CS in mainland China during 2011. METHODS: This was a multicentre, large-sample, cross-sectional study of women who delivered infants in 39 hospitals in 14 provinces in China during 2011. We selected 111, 315 deliveries that occurred during 2011, excluding miscarriages or termination of pregnancy before 28 gestational weeks. RESULTS: The overall rate of CS in mainland China was 54.90%. The most common indication for CS was caesarean delivery on maternal request (CDMR; 28.43%), followed by cephalo-pelvic disproportion (14.08%), fetal distress (12.46%), previous CS (10.25%), malpresentation and breech presentation (6.56%), macrosomia (6.10%) and other indications (22.12%). CDMR accounted for 15.53% of all the deliveries and 28.43% of all CS deliveries in mainland China. CONCLUSIONS: CDMR appears to be a considerable driver behind the increasing CS rate in mainland China. The relaxation of China's "one-child policy" may translate into a greater number of CS because of previous CS delivery. To decrease the CS rate, we should first decrease the rate of CS on maternal request. Appropriate policies and guidelines should be considered to accomplish the goal.

Changes in cerebral oxygenation during early postnatal adaptation in newborns delivered by vacuum extraction measured by near-infrared spectroscopy.

BACKGROUND: Newborns delivered by vacuum extraction quite often show clinical signs of a hemodynamic compromise, which is difficult to assess in terms of severity. The conventional means to measure the hemodynamic status are not sensitive enough to appreciate the severity of general, and more specifically of cerebral circulatory imbalance. The aim was to study cerebral tissue oxygenation during postnatal adaptation in these infants using near-infrared spectroscopy. METHODS: The tissue hemoglobin index (THI), tissue oxygenation index (TOI), arterial oxygen saturation (pre-ductal SaO2) and heart rate (HR) were recorded immediately after birth, and again after 12-24 hours of life in 15 newborns delivered by vacuum extraction due to fetal distress. A comparison with 19 healthy newborns delivered by elective cesarean section was performed. RESULTS: Newborns delivered by vacuum extraction had significantly higher THI 10 to 15 minutes after birth. TOI and HR were significantly higher in the first 5 min and SaO2 in the first 10 minutes but then did not differ from those after cesarean section. CONCLUSION: Infants delivered by vacuum extraction following fetal distress show transient deviations in cerebral oxygenation and perfusion after birth which were not detectable after 24 hours.

The timing of adverse events with Foley catheter preinduction cervical ripening; implications for outpatient use.

OBJECTIVE: We sought to determine the rate and timing of adverse events that occur during preinduction cervical ripening using the Foley catheter before extrusion of the balloon and institution of oxytocin. STUDY DESIGN: Using electronic medical records, we identified all women who presented for preinduction cervical ripening using a Foley catheter with a term (≥37 weeks) singleton vertex live fetus from January 1, 2006, to June 14, 2009. Women were excluded if they had had a previous cesarean delivery, gestational hypertension or preeclampsia, pregestational diabetes, rupture of membranes before induction, fetal anomaly, or antepartum stillbirth. Outcomes were cesarean delivery for nonreassuring fetal tracing, vaginal bleeding, placental abruption, or intrapartum stillbirth occurring between 2 hours after Foley catheter placement and 6 am. RESULTS: Among 2,514 women, 1,905 met the inclusion criteria. No adverse outcomes were noted among term, singleton uncomplicated pregnancies receiving a Foley catheter for preinduction cervical ripening who met inclusion criteria (relative risk, 0.0; 95% confidence interval, 0.0-0.002). CONCLUSIONS: In a low-risk population, the use of the Foley catheter for preinduction cervical ripening was associated with no adverse outcomes. It appears to be a safe mechanism for cervical ripening and has the potential for use in the outpatient setting in a selected subset of women.

Isolated torsion of fallopian tube complicating pregnancy: case report.

OBJECTIVE: Isolated fallopian tube torsion is a very uncommon condition in pregnancy. Most of the cases presented were in the third trimester. Only one case was reported in labor. The authors report the second case of the isolated tubal torsion during labor. CASE REPORT: A 18-year-old primigravid woman at 37 weeks of gestation was admitted to labor room with painful uterine contraction. Cervix was one-cm dilated and 70% effaced. Her sonographic and laboratory findings were unremarkable. Approximately four hours later the patient reported sudden pain at lower abdomen. The fetal heart rate tracing showed late deceleration. Preoperative diagnosis was considered as ablatio placenta. Isolated torsion of the right fallopian tube was revealed in cesarean delivery. Healthy infant was delivered and right salpingectomy was performed. Postoperative course was uncomplicated. CONCLUSION: In case of pain unrelated to uterine contraction during labor may be a sign of fallopian tube torsion which is an uncommon condition complicating pregnancy. In such condition, fallopian tube torsion should be kept in mind since early diagnosis may help to preserve the affected tube during labor.