Uterotonics for management of retained placenta.

RATIONALE: Retained placenta is a significant cause of maternal death from postpartum haemorrhage. Traditionally, it is managed by manual removal under anaesthesia, which carries risks of haemorrhage, infection, and uterine perforation. Uterotonics may offer an alternative for delivering the retained placenta since they induce uterine contractions. However, evidence regarding uterotonic agents for retained placenta is still limited. OBJECTIVES: To assess the benefits and harms of uterotonics for women with retained placenta after vaginal delivery for preventing postpartum haemorrhage. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, and WHO ICTRP; and checked references of included studies and pertinent systematic reviews to identify additional studies. The latest search date was 25 April 2024. ELIGIBILITY CRITERIA: We included randomised controlled trials (RCTs) and non-randomised studies of interventions in women who underwent vaginal delivery with retained placenta comparing one uterotonic with another uterotonic, placebo, or no treatment. We excluded studies that compared different uterotonics administered by umbilical vein injection. OUTCOMES: Our main outcomes were manual removal of the placenta; postpartum haemorrhage of 1000 mL or more; adverse effects, such as shivering; blood transfusion; maternal death; severe morbidity (admission to the intensive care unit); and blood loss in millilitres. The primary time point of interest for all outcomes was the end of the study period. RISK OF BIAS: We used the Cochrane RoB 2 tool to assess bias in RCTs and the ROBINS-I tool to assess bias in non-randomised studies of interventions. SYNTHESIS METHODS: We synthesised results for each outcome using a random-effects meta-analysis, where possible, employing Mantel-Haenszel with risk ratio (RR) or inverse variance with mean difference (MD), as appropriate. Where this was not possible due to the nature of the data, we synthesised results using narrative synthesis methods. We used GRADE to assess the certainty of evidence for each outcome. INCLUDED STUDIES: We included five studies with 560 women, comprising four RCTs and one non-randomised study. The studies were conducted in the Netherlands, Tanzania, and Egypt. Three RCTs compared uterotonics (sulprostone or misoprostol) with placebo or no treatment. One RCT compared oxytocin, intravenous carbetocin, and sublingual misoprostol. One non-randomised study compared intraumbilical oxytocin to oxytocin infusion. SYNTHESIS OF RESULTS: Systemic uterotonic agents versus placebo or no treatment Sulprostone or misoprostol may result in little to no difference in the rate of manual removal of the placenta (RR 0.82, 95% confidence interval (CI) 0.54 to 1.27; 3 RCTs, 244 women; low-certainty evidence), and probably results in little to no difference in postpartum haemorrhage (RR 0.80, 95% CI 0.55 to 1.15; 2 RCTs, 194 women; moderate-certainty evidence), and blood transfusion (RR 0.72, 95% CI 0.43 to 1.22; 3 RCTs, 244 women; moderate-certainty evidence) compared to placebo or no treatment. We are very uncertain about the effect of misoprostol on shivering (RR 10.00, 95% CI 1.40 to 71.49; 1 RCT, 70 women; very low-certainty evidence) and the effects of uterotonic agents on mean blood loss (MD -205.26 mL, 95% CI -536.31 to 125.79; 3 RCTs, 244 women; very low-certainty evidence). No study assessed maternal death or severe morbidity. Intravenous carbetocin versus sublingual misoprostol Intravenous carbetocin probably does not reduce the need for manual removal of the placenta (RR 0.79, 95% CI 0.52 to 1.20; 1 RCT, 185 women; moderate-certainty evidence), and may not reduce blood transfusion (RR 0.48, 95% CI 0.09 to 2.58; 1 RCT, 185 women; low-certainty evidence) compared to sublingual misoprostol. The study did not assess postpartum haemorrhage of 1000 mL or more, adverse effects (shivering), maternal death, severe morbidity, and blood loss. Sublingual misoprostol versus oxytocin intraumbilical venous injection Sublingual misoprostol probably results in little to no difference in the rate of manual removal of the placenta (RR 1.09, 95% CI 0.73 to 1.61; 1 RCT, 187 women; moderate-certainty evidence) and may not reduce the need for blood transfusion (RR 1.05, 95% CI 0.27 to 4.09; 1 RCT, 187 women; low-certainty evidence) compared to oxytocin intraumbilical venous injection. The study did not assess postpartum haemorrhage of 1000 mL or more, adverse effects (shivering), maternal death, severe morbidity, and blood loss. Intravenous carbetocin versus oxytocin intraumbilical venous injection Intravenous carbetocin probably does not reduce the rate of manual removal of the placenta (RR 0.86, 95% CI 0.56 to 1.32; 1 RCT, 190 women; moderate-certainty evidence), and may result in little to no difference in reducing blood transfusions (RR 0.51, 95% CI 0.10 to 2.72; 1 RCT, 190 women; low-certainty evidence) compared to intraumbilical venous injection. The study did not assess postpartum haemorrhage of 1000 mL or more, adverse effects (shivering), maternal death, severe morbidity, and blood loss. Oxytocin infusion versus oxytocin intraumbilical venous injection The evidence from one non-randomised study is very uncertain about the effect of oxytocin infusion on manual removal of the placenta compared to oxytocin intraumbilical venous injection (RR 0.90, 95% CI 0.71 to 1.13; 1 study, 35 women; very low-certainty evidence). The study did not assess our other outcomes of interest. AUTHORS' CONCLUSIONS: Current evidence suggests that uterotonic agents (such as misoprostol and sulprostone) may result in little to no difference in the rates of manual removal of the placenta, and probably result in little to no difference in postpartum haemorrhage and the need for blood transfusions, compared to placebo or no treatment in the management of retained placenta. The evidence is very uncertain about their effects on blood loss and the effect of misoprostol on shivering. There is probably little to no difference in effects and there may be no difference in safety between one uterotonic agent over another. We found no useable data for maternal death and admission to the intensive care unit. Further large-scale studies are necessary to evaluate uterotonics versus placebo, compare different uterotonic agents, or assess combined uterotonic regimens. Additional research should focus on identifying specific adverse effects, maternal satisfaction and well-being, breastfeeding rates at discharge, and postpartum anaemia. FUNDING: This Cochrane review was funded by UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP). REGISTRATION: Registration (13 July 2024): Prospero, CRD42024564386.

Perineal techniques during the second stage of labour for reducing perineal trauma and postpartum complications.

RATIONALE: Postpartum haemorrhage (PPH) is responsible for around 27% of global maternal deaths. Perineal tears are common in vaginal births and a significant contributor to excessive blood loss. A diversity of perineal techniques are utilised to prevent perineal trauma and reduce the incidence of PPH; however, they lack evidence-based comparisons to understand their effects. OBJECTIVES: To assess the effect of perineal techniques during the second stage of labour on the incidence of and morbidity associated with perineal trauma to prevent postpartum complications. SEARCH METHODS: We searched four databases and two trial registers up to 16 April 2024. We checked references, searched citations and contacted study authors to identify additional studies. ELIGIBILITY CRITERIA: We included randomised controlled trials (RCTs) of women in the second stage of labour who intended to give birth vaginally, comparing any perineal techniques with control or another perineal technique. We excluded studies that performed perineal techniques outside the second stage of labour. OUTCOMES: Our critical outcomes were second-, third- and fourth-degree tears measured immediately after birth, and PPH ≥ 500 mL measured within 24 hours after birth. RISK OF BIAS: We used the Cochrane risk of bias 2 tool to assess bias in the included RCTs. SYNTHESIS METHODS: We synthesised results for each outcome within each comparison using meta-analysis where possible. Where this was not possible due to the nature of the data, we synthesised results narratively. We used GRADE to assess the certainty of evidence for each outcome. INCLUDED STUDIES: We included a total of 17 studies with 13,695 participants. SYNTHESIS OF RESULTS: Hands off (or poised) versus hands on Hands off (poised) may result in little to no difference in second-degree tears (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.32 to 1.64; 2 studies; low-certainty evidence) and third- or fourth-degree tears when data are combined (RR 1.27, 95% CI 0.81 to 1.99; 2 studies; low-certainty evidence). The evidence is very uncertain about the effect of hands off (poised) on third-degree tears and fourth-degree tears when reported separately (RR 0.50, 95% CI 0.05 to 5.27; 1 study; very low-certainty evidence and RR 3.00, 95% CI 0.13 to 71.22; 1 study; very low-certainty evidence). Hands off (poised) may result in little to no difference in PPH ≥ 500 mL (RR 1.16, 95% CI 0.92 to 1.47; 1 study; low-certainty evidence). Hands off (poised) probably results in little to no difference in breastfeeding two days after birth (RR 1.02, 95% CI 0.99 to 1.06; 1 study; moderate-certainty evidence) and perineal pain (RR 0.98, 95% CI 0.94 to 1.01; 1 study; moderate-certainty evidence). Vocalisation versus control Vocalisation may result in a reduction in second-degree tears (RR 0.56, 95% CI 0.23 to 1.38; 1 study; low-certainty evidence) and third-degree tears (RR 0.13, 95% CI 0.01 to 2.32; 1 study; low-certainty evidence), but the CIs are wide and include the possibility of no effect. No events were reported for fourth-degree tears (low-certainty evidence). Vocalisation may increase maternal satisfaction (RR 1.19, 95% CI 0.93 to 1.51; 1 study; low-certainty evidence). The evidence is very uncertain about the effect of vocalisation on perineal pain (RR 1.44, 95% CI 0.81 to 2.58; 1 study; very low-certainty evidence). Warm compress on the perineum versus control (hands off or no warm compress) Warm compress on the perineum may result in little to no difference in second-degree tears (RR 0.94, 95% CI 0.72 to 1.21; 2 studies; low-certainty evidence), but likely results in a reduction in third- or fourth-degree tears (RR 0.46, 95% CI 0.27 to 0.79; 3 studies; moderate-certainty evidence). Evidence from two smaller studies is very uncertain about the effect of warm compress on the perineum on third-degree tears (RR 0.51, 95% CI 0.04 to 7.05; 2 studies; very low-certainty evidence) or fourth-degree tears (RR 0.11, 95% CI 0.01 to 2.06; 2 studies; very low-certainty evidence) when reported separately. Warm compress likely results in a large reduction in perineal pain (mean difference (MD) -0.81, 95% CI -1.18 to -0.44; 1 study; moderate-certainty evidence). The evidence is very uncertain about the effect of warm compress on the perineum on maternal satisfaction and PPH ≥ 500 mL. Massage of the perineum versus control (hands off or no usual care) Massage of the perineum may have little to no effect on second-degree tears (RR 1.04, 95% CI 0.89 to 1.21; 4 studies; low-certainty evidence). The evidence is very uncertain about the effect of massage of the perineum on third-degree tears (RR 0.57, 95% CI 0.16 to 2.02; 4 studies; very low-certainty evidence). Massage of the perineum may reduce fourth-degree tears but the CIs are wide and include the possibility of no effect (RR 0.26, 95% CI 0.04 to 1.61; 4 studies; low-certainty evidence). The evidence suggests that massage likely results in little to no difference in perineal pain (RR 0.97, 95% CI 0.90, 1.05; 1 study; moderate-certainty evidence). One study reported 10 participants with postpartum haemorrhage across three interventions (warm compress, massage, control). Combined warm compress and massage of the perineum versus control Combined warm compress and massage of the perineum likely results in a reduction in second-degree tears when compared to a control (RR 0.63, 95% CI 0.46 to 0.86; 1 study; moderate-certainty evidence), but the evidence is very uncertain about the effect on third-degree tears (RR 2.92, 95% CI 0.12 to 70.72; 1 study; very low-certainty evidence). The intervention may result in a reduction in PPH ≥ 500 mL but the CIs are wide and include the possibility of no effect (RR 0.43, 95% CI 0.14 to 1.35; 1 study; low-certainty evidence). Combined warm compress and massage likely results in an increase in maternal satisfaction (MD 0.4, 95% CI -0.01 to 0.81; 1 study; moderate-certainty evidence). Combined warm compress and massage of the perineum versus massage alone Combined warm compress and massage of the perineum may result in little to no difference in second-degree tears (RR 0.95, 95% CI 0.86 to 1.06; 1 study; low-certainty evidence) when compared to massage alone, but the evidence is very uncertain about the effect on third- or fourth-degree tears (RR 0.98, 95% CI 0.06 to 15.49; 1 study; very low-certainty evidence). It may also result in little to no difference in PPH ≥ 500 mL (RR 1.10, 95% CI 0.59 to 2.07; 1 study; low-certainty evidence). The evidence suggests that combined warm compress and massage may result in little to no difference in maternal satisfaction (1 study; low-certainty evidence). Other perineal techniques We also assessed evidence on the following comparisons, but since they are used less frequently in global clinical practice to optimise birth outcomes, we have not presented the results summary here: Ritgen's manoeuvre versus standard care; primary delivery of posterior versus anterior shoulder; massage with enriched oil on the perineum versus massage with liquid wax; petroleum jelly on the perineum versus control; and perineal protection device versus control. AUTHORS' CONCLUSIONS: Overall, the evidence for the effectiveness of perineal techniques to reduce perineal trauma and postpartum haemorrhage is very uncertain. Very few studies reported rates of postpartum haemorrhage, adverse events, women's or health workers' experience or other important outcomes that allow us to understand the effectiveness and acceptability of perineal techniques to reduce perineal trauma. Prior to any further large trials, research is needed to clarify the types of interventions, including a clear description of the process of development and involvement of relevant stakeholders. There is a need to clarify how the intervention is proposed to achieve its effects. Trials would benefit from process evaluation alongside, to explore context, mechanisms and effects. FUNDING: This Cochrane review was funded (in part) by WHO (APW 2024/1475460). TF, VL and the CIDG editorial base are funded by UK aid from the UK government for the benefit of low- and middle-income countries (project number 300342-104). The views expressed do not necessarily reflect the UK government's official policies. REGISTRATION: Registration and protocol: PROSPERO, CRD42024537252. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024537252.

Magnitude and predictors of obstetric complications during delivery among postpartum women in Ethiopia: evidence from PMA Ethiopia longitudinal survey.

INTRODUCTION: The majority of pregnancy-related complications were preventable. However, the magnitude of complications during pregnancy and childbirth was high in sub-Saharan Africa. There was limited evidence on the magnitude of obstetric complications during childbirth and its predictors among postpartum women in Ethiopia. METHODS AND MATERIALS: The research used secondary data sources based on performance monitoring for action in Ethiopia's second cohort longitudinal survey. It was a national survey that was conducted in three large, predominantly agrarian regions (Oromia, Amhara, and SNNP) and one urban region (Addis Ababa) of Ethiopia between 2021 and 2023. It was conducted to track pregnant women's use of essential maternal and newborn health services. It involved the enrollment of pregnant women and tracking them at six weeks, six months, and one year after giving birth. The data collected at the beginning of the survey and six weeks after childbirth were used for the analysis. Sample weights were applied to account for differences in sample allocation and response rates across regions and urban/rural areas. Multi-collinearity and intra-cluster correlation were assessed before fitting the multilevel models to ensure the accuracy of the estimates. A multi-level logistic regression model was used to assess the magnitude and predictors for the occurrence of obstetric complications during delivery. The model fit was evaluated using Akaike's Information Criterion and Bayesian Information Criterion. Adjusted odds ratio with its 95% confidence interval was used to measure the strength of association for this study. RESULTS: The magnitude of obstetric complications during delivery was found to be 33.86% with 95% CI (31.56, 36.24. Among the obstetric complications that occurred during delivery, about 15.73%with 95% CI(14.02, 17.61) of women experienced bleeding, 4.14% with 95% CI (3.30, 5.17) had their membrane rupture but labor did not start within 24 h, 2.29% with 95% CI(1.67, 3.13) had their membrane rupture before 9 months, 3.95% with 95% CI(3.16, 4.93) had faced malpresentation or malposition of the baby, 12.70% with 95% CI (11.18, 14.39) had prolonged labor lasting more than 12 h, and 12.40% with 95% CI (10.83,14.17) had convulsions. The odds of occurrence of obstetric complication during delivery among women from severely food insecure households were 1.88 times [AOR = 1.88; 95% CI (1.22, 2.90)] more likely to occur than women from food secure households. Moreover, the odds of occurrence for obstetric complications during delivery among women who had complications during their pregnancy were 2.39 times [AOR = 2.39; 95% CI (1.81, 3.16)] more likely to occur as compared to those women who had no complication during their pregnancy. On the other hand, women's who had 1-4 live births given before this delivery were 0.61 times [AOR = 0.61; 95% (0.43, 0.88)] less likely to develop complications as compared to those women's who had no prior live birth. CONCLUSION AND RECOMMENDATION: Delivery-related obstetric complications during delivery in Ethiopia were high. Approximately one-third of postpartum women in Ethiopia experienced obstetric complications during delivery. Based on this study, women's from severely food insecure households, those women's who had no prior live birth, and women's who had complications during their pregnancy were more likely to develop delivery-related obstetric complications. Thus, policy makers and program implementers who were working on maternal and newborn health should give special attention for women's from severely food insecure households, women's who had no prior live births, and those women's who encountered obstetric complications during their pregnancy to decrease the occurrence of obstetric complications during delivery. In Ethiopia, various governmental organizations, such as the Ministry of Health and the Ministry of Agriculture, are dedicated to addressing food insecurity and improving nutritional access. The country has launched several effective nutritional programs, including the Productive Safety Net Program, the Targeted Supplementary Feeding Program, and the National Nutrition Program, aimed at alleviating food insecurity and enhancing nutrition. Ongoing efforts are crucial to tackle the food insecurity experienced by women, which can help to reduce obstetric related complications of women's during delivery. It is crucial for everyone involved in maternal and newborn health to prioritize addressing the factors that lead to obstetric complications during delivery in women in order to reach the goal of ending all preventable maternal and newborn deaths by 2030.

The association of obstetric anal sphincter injury and mediolateral episiotomy with increasing birth weight and duration of second stage of labour in spontaneous vaginal delivery.

OBJECTIVES: Analysis of the association of mediolateral episiotomy (MLE) with obstetric anal sphincter injury (OASI) in women with spontaneous vaginal delivery. DESIGN: Population-based cohort study with data from the Netherlands Perinatal Registry, describing 541 055 women who delivered a singleton live born infant in cephalic presentation spontaneously at term. Risk indicators for OASI were tested using univariate and multivariate analysis. Additional analysis for the interaction of MLE with other risk indicators was performed. RESULTS: The rate of OASI was 4.2 % in 215 241 nulliparous and 1.4 % in 325 814 multiparous women. In nulliparous and multiparous women MLE was associated with a reduction of OASI (adjusted OR (aOR) 0.3, 95 % CI 0.30-0.34 and aOR 0.32, 95 % CI 0.30-0.34). The association of MLE with a reduced rate of OASI was stronger in high birthweight and in prolonged 2nd stage groups. In nulliparous women, the number needed to treat (NNT) for the use of MLE to prevent one OASI is 31 in general. With MLE, the OASI rate reduced from 11.5 % to 2.9 with a NNT of 12 in the group with a birth weight ≥ 4000 g and a duration of the second stage of labour of 60-120 min. The NNT is 9 In the group with a birth weight ≥ 4000 g and a duration of the second stage of labour ≥ 120 min (reduction rate of OASI from 14.2 % to 3.5 %). CONCLUSIONS: Use of MLE is associated with a reduction of OASI in spontaneous vaginal delivery. In nulliparous women, an episiotomy with an anticipated birth weight > 4000 g and a duration of the 2nd stage of more than 60 min should be considered.

Clinical practices in the management and follow-up of obstetric anal sphincter injuries: a comprehensive review.

OBJECTIVES: To review and compare existing guidelines on the intrapartum management and postpartum follow-up of obstetric anal sphincter injuries (OASIS) METHODS: We conducted a systematic review of clinical guidelines related to OASIS management, focusing on intrapartum care and postpartum follow-up. Searches were performed in July 2024 across multiple databases, including PubMed, Embase, and the Cochrane Library. Guidelines published after 2010 in English were included. RESULTS: Nine national guidelines were included. There was a consensus on OASIS classification and immediate management, particularly regarding suture techniques, materials, and the necessity of adequate analgesia. However, notable variations were identified in the timing of repair, specialist involvement, use of prophylactic antibiotics, and post-operative care protocols. Postpartum follow-up practices also varied, especially regarding the role of physiotherapy and the timing of specialist consultations, reflecting inconsistencies in long-term care recommendations. CONCLUSION: Significant variability existed in the guidelines for the management and follow-up of OASIS, particularly in postpartum care. This study underscored the need for standardized, evidence-based guidelines to ensure consistent and optimal care for women affected by OASIS.

Postpartum hemoperitoneum - A rare case of uterine artery pseudoaneurysm rupture after uncomplicated vaginal delivery.

OBJECTIVE: Our aim is to demonstrate a rare cause of hemoperitoneum without vaginal bleeding resulting from the rupture of a uterine artery pseudoaneurysm after uncomplicated vaginal delivery. CASE REPORT: A 39-year-old woman who had experienced a normal vaginal delivery 8 days previously to being seen in our hospital, was presented to the emergency room with hypovolemic shock. Computed tomography angiography (CTA) showed massive internal bleeding and a ruptured pseudoaneurysm arising from the left uterine artery. The patient was successfully treated through transcatheter arterial embolization (TAE). CONCLUSION: A pseudoaneurysm is a rare disease which can occur during an uncomplicated vaginal delivery. The clinical presentation can vary from asymptomatic, vaginal bleeding or hemoperitoneum. The diagnosis can be made by using Doppler sonography, CTA or Magnetic Resonance Imaging. The use of TAE is now the most common treatment option and possesses a high success rate.

Safety of Pregnancy and Delivery With Shunted Hydrocephalus.

This cohort study examines the safety of cerebrospinal fluid shunts during pregnancy.

Reducing maternal infection after assisted vaginal birth in a diverse and deprived population.

Postpartum maternal sepsis is a leading cause of maternal mortality and morbidity. A single dose of prophylactic antibiotics following assisted vaginal births has been shown to significantly reduce postpartum maternal infection in a landmark multicentre randomised controlled trial, which led to its national recommendation. This project aimed to improve the local implementation of prophylactic antibiotics following assisted vaginal births to reduce postnatal maternal infections.Using a prospectively collated birth register, data were collected retrospectively on prophylactic antibiotics administration and postnatal maternal infection rates after assisted vaginal births at the Sandwell and West Birmingham Hospitals National Health Service Trust in North-West Birmingham of the UK. The data were collected from routinely used electronic health records over three audit cycles (n=287) between 2020 and 2023.A mixed-method approach was used to improve the use of prophylactic antibiotics: (1) evidence-based journal clubs targeting doctors in training, (2) presentations of results after all three audit cycles at our and (3) expedited a formal change of local guidelines to support prophylactic antibiotics use.Prophylactic antibiotic administration increased from 13.2% (December 2021) to 90.7% (July 2023), associated with a reduction in maternal infection rates (18.2% when prophylaxis was given vs 22.2% when no prophylaxis was given). However, we observed a gradual increase in the overall postnatal maternal infection rates during the project period.Our repeat audit identified prophylactic antibiotics were regularly omitted after deliveries in labour ward rooms (59.3%), compared with 100% of those achieved in theatre. After further interventions, prophylactic antibiotics administration rates were comparable between these clinical areas (>90%) in 2023.Together, we have demonstrated a simple set of interventions that induced sustainable changes in practice. Further evaluation of other modifiable risk factors and infection rates following all deliveries is warranted in view of the gradual increase in the overall postnatal maternal infection rates.

Association between mode of delivery and early neurodevelopment: A prospective birth cohort study.

Previous research has assessed the effects of caesarean delivery (CD) on child neurodevelopment; however, whether the effects stem from the surgical procedure itself or its related medical conditions has not been conclusively determined. This study aimed to evaluate the associations among delivery mode, CD-related medical conditions and early childhood neurodevelopment. A total of 3829 maternal-infant pairs from a longitudinal birth cohort in Wuhan City, China, were included in the primary analysis. The neurodevelopment of the children was assessed by the Bayley Scales of Infant Development (BSID), the Conners Comprehensive Behaviour Rating Scale and the Chinese version of the Autism Behavior Checklist. Data on delivery mode and medical conditions were collected via medical records from the study hospital. Among the 3829 children for whom the BSID test was completed at two years of age, 50%, 27%, and 23% were delivered vaginally, by necessary CD, and by elective CD, respectively. Compared with vaginally delivered children, Necessary CD was associated with a 16.67% decrease in Mental Development Index (MDI) scores and a 13.37% decrease in Psychomotor Development Index (PDI) scores, while elective CD showed a 20.63% and 20.99% decrease after FDR correction, respectively. Similarly, among the 2448 children for whom the CBRS was completed, necessary CD was found to be associated with conduct disorders (adjusted ß: 0.06; 95% CI: 0.02, 0.09), hyperactivity (adjusted ß: 0.06; 95% CI: 0.02, 0.11), and hyperactivity index (adjusted ß: 0.07; 95% CI: 0.03, 0.11), while elective CD was significantly associated with hyperactivity problem scores (adjusted ß: 0.08, 95% CI: 0.03, 0.13). However, no significant association was found between CD and symptoms of autism in children, as assessed by the Autism Behavior Checklist (ABC). CONCLUSION: This study suggested that the adverse impact of CD on child neurodevelopment stems from the procedure itself rather than CD-related medical conditions. It is important to minimize the use of CD when there is no medical necessity. WHAT IS KNOWN: • Caesarean delivery (CD) may influence child neurodevelopment and other long-term outcomes. • In China, approximately one-quarter of CD are performed due to maternal request without medical indications. WHAT IS NEW: • The negative impact of CD on the neurodevelopmental outcomes of children may be primarily attributed to the procedure itself, as opposed to related medical conditions. • In the absence of medical indications, unnecessary CD may have adverse impacts on children's neurodevelopment.

Antenatal Perineal Training for Injuries Prevention: Follow Up after Puerperium.

Background and Objectives: This retrospective analysis investigated the impact of preparation of the pelvic floor for childbirth with stretching balloons and perineal massage on the risk of pelvic floor injuries. Materials and Methods: We analyzed 150 primiparous women who accessed private clinics in Padua (Italy) in the period 2019-2023 regarding the rate of perineal trauma and postpartum dysfunction across three groups: the balloon stretching group (BSG, N = 50, 33.3%), the perineal massage group (PMG, N = 39, 26.0%), and the control group (CG, 61, 40.7%). Results: Prenatal perineal training had a significant impact on reducing the rate of perineal injury and episiotomy (27.5% in BSG vs. 48.7% in PMG and 68.3% in CG, p = 0.008, respectively, 9.8% vs. 26% and 40%, p = 0.046) and the duration of the second stage of labor (BSG and PMG had a shorter duration compared to CG with a mean difference of -0.97892 h, p < 0.001, respectively, -0.63372 h, p = 0.002). Patients who carry out the preparation with the stretching balloon are less likely to develop urinary and anal incontinence and pain during intercourse. Specifically, the rate of urinary incontinence in BSG stands at around 23.5% compared to 43.6% in PMG (p = 0.345) and 55% in CG (p = 0.034). Dyspareunia in BSG was detected in 11.8% of cases compared to 35.5% in PMG (p = 0.035) and 61.7% in CG (p < 0.01). Symptomatology inherent to the posterior compartment was reported in 9.8% of cases in BSG vs. 23.11% in PMG (p = 0.085) and 33.3% in CG (p = 0.03%). Conclusions: Stretching balloons and perineal massage can be chosen as tools to prevent and reduce the rates of obstetric trauma during childbirth and to reduce the use of episiotomies as well as protect against the development of dysfunctions of the pelvic floor.

Incidence, risk factors and diagnostic accuracy of clinical palpation in picking up post-void residual urine in postnatal women.

PURPOSE: To determine the incidence of covert and overt postpartum urinary retention after vaginal delivery and the associated risk factors for postpartum urinary retention. To determine how well clinical examination by abdominal palpation correlates with ultrasound findings of urinary retention. METHODS: Patients after delivery were screened with ultrasound and examined clinically to check for retention of urine after voiding. RESULTS: A total of 822 of women were recruited in the study of which 86 (10.5%) women had significant post-void residue of urine. 33 (38.4%) had overt retention, while 53 (61.6%) had covert retention. Duration of labour and an increased VAS score were found to be significantly higher among those with urinary retention. Using clinical examination to diagnose postpartum urinary retention had a sensitivity of 66.1%, specificity of 88.6%, positive predictive value of 76.5% and negative predictive value of 82.3%. CONCLUSIONS: Clinical examination by abdominal palpation is not a very sensitive test in diagnosing PPUR.

Tranexamic acid in preventing postpartum blood loss in vaginal delivery: a double-blinded randomized controlled trial.

BACKGROUND: Postpartum hemorrhage (PPH) is an obstetrical emergency that occurs in 1% to 10% of all deliveries and contributes to nearly one-quarter of all maternal deaths worldwide. Tranexamic acid has been established as an adjunct in the treatment of PPH but its role in its prevention of PPH following vaginal delivery has not been widely studied. OBJECTIVE: This study aimed to assess the effect of prophylactic tranexamic acid (1 g) along with active management of the third stage of labor in reducing postpartum blood loss and the incidence of postpartum hemorrhage after vaginal delivery. STUDY DESIGN: In this randomized controlled trial, 650 women with singleton pregnancies at ≥34 weeks of gestation who were undergoing vaginal delivery were included. Eligible women were randomly assigned to receive either 1 g of tranexamic acid or placebo intravenously along with active management of the third stage of labor. Calibrated blood collection bags were used to measure postpartum blood loss during the third and fourth stages of labor. RESULTS: Of 886 women approached for the study, 650 who met the inclusion criteria were enrolled, and 320 in group A and 321 in group B were analyzed. The maternal characteristics were similar between the groups. The mean blood loss did not differ significantly between the intervention and placebo groups (378.5±261.2 mL vs 383.0±258.9 mL; P=.93). The incidence of primary postpartum hemorrhage was comparable in both groups (15.9% in group A and 15.3% in group B; P=.814). The median quantitative decreases in hemoglobin levels within 12 to 24 hours after delivery were 0.60 g% (interquartile range, 0.40-0.90) in group A and 0.60 g% (interquartile range, 0.40-0.80) in group B, which were comparable in both groups (P=.95). The most common adverse effect reported was dizziness, and there was no thromboembolic event at 3 months follow-up in either group. CONCLUSION: The use of tranexamic acid as a prophylactic measure along with active management of the third stage of labor does not provide additional benefit in reducing the postpartum blood loss and incidence of postpartum hemorrhage after vaginal delivery. El resumen está disponible en Español al final del artículo.

Comparison of photobiomodulation with cryotherapy in the immediate postpartum period of parturients with grade I, grade II lacerations and/or episiotomy in reducing perineal and vulvar and edema: A randomized clinical trial.

INTRODUCTION: Vaginal delivery has several benefits for the parturient; however, during labor, some injuries, such as lacerations and/or episiotomy, can occur. Perineal pain may occur in the puerperium and can be aggravated in cases of perineal injury during childbirth, potentially impacting the physical and emotional aspects of the parturient. For this reason, it is necessary to use techniques that can relieve pain and edema in the immediate postpartum period, directly influencing recovery. OBJECTIVE: To compare the reduction of pain and improvement in healing using two techniques, namely photobiomodulation and cryotherapy, performed in the immediate postpartum period of up to 12 h, in parturients who suffered grade I and II lacerations and/or episiotomy. METHODS: Data collection was carried out through an evaluation questionnaire. Photobiomodulation was applied using the red and infrared laser from the DMC brand. The EVA and McGill scales were used for pain assessment, and the REEDA scale was used for the evaluation of edema and healing. RESULTS: The techniques were evaluated and applied to 56 patients, with 28 in each group (cryotherapy and LBI). Patients who received photobiomodulation showed superior improvement compared to cryotherapy. In the immediate postpartum period, there was a greater reduction in pain in favor of photobiomodulation (p = 0.008); and after 24 h, the difference was even more significant (p < 0.001).

The burden of iatrogenic obstetric fistulas in Sub-Saharan Africa: Systematic review and meta-analysis protocol.

BACKGROUND: Obstetric fistulas are abnormal open connection(s) between the vagina and the urinary tract or the rectum resulting from tragic injuries sustained by mothers during childbirth that lead to urine and/or faecal incontinence. Due to the rapidly growing middle class in sub-Saharan Africa (SSA) and the corresponding quest for hospital delivery and caesarean section, surgery-related (iatrogenic) obstetric fistulas are on the rise. Worryingly, there is scanty data on surgery-related fistulas. This review aims to collate empirical evidence on the magnitude of iatrogenic obstetric fistulas in SSA, generate country-specific data and explore factors that influence obstetric surgery-related fistulas. METHODS: All relevant databases, PubMed, LILACS, CINAHL, SCOPUS and Google Scholar will be searched from 1st January 2000 to 31st March 2024 using search terms developed from the major concepts in the title without restrictions by language. The Cochrane Library, African Journals Online, Data Base of African Thesis and Dissertations Including Research (DATAD-R D Space) and preprint repositories will also be searched. Reference lists of relevant studies will be searched and experts in the field will be contacted for additional (unpublished) studies. The search output will be exported to Endnote where duplicate studies will be removed. The deduplicated studies will be exported to Rayyan where study screening and selection will be conducted. At least two authors will independently select studies, extract data and assess quality in the included studies using pretested tools. Disagreements between reviewers will be resolved through discussion. Data analysis will be performed with RevMan 5.4. Comparative binary outcomes will be reported as odds ratio (OR) or risk ratio (RR) and for continuous outcomes, mean difference and standard deviations (SDs) will be used. Non-comparative studies will be analysed as weighted proportions. Heterogeneity between studies will be assessed graphically and statistically, and where a significant level is detected, the random-effects model meta-analysis will be performed. All estimates will be reported with their 95% confidence intervals (CIs). Where data permit, we will conduct subgroup and sensitivity analyses to test the robustness of the estimates on key quality domains. The overall quality of the evidence will be assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation). EXPECTED STUDY OUTCOMES: This systematic review and meta-analysis uses rigorous methods and best practices to attempt to collate all empirical evidence and estimate country-specific proportions of iatrogenic (surgery-related) fistulas among obstetric fistula patients across countries in SSA. This review will explore context-specific variables, provide insights into their impact and relate them to the type and experience of personnel performing the obstetric procedures that lead to obstetric fistulas. The findings of the full review are expected to inform the development of national and regional Training Programs for Medical Officers, support the development of a consensus "minimum acceptable standard of care" and inform quality assurance standards for clinicians involved in the provision of surgical obstetric care.

Challenging biases in delivery mode decisions for women with pelvic fracture history: a call for evidence-based practices and patient-centered care.

Pelvic fractures significantly impact young individuals, with a prevalence of 20 per 100,000, leading to long-term complications such as chronic pain and genitourinary dysfunction. Notably, women with a history of pelvic fractures face increased cesarean section (C-sections) rates during childbirth. This editorial investigates the factors contributing to higher C-section rates in these women, including provider assumptions about delivery complications and systemic hospital biases. Despite these trends, evidence suggests that vaginal delivery can be successful, especially when considering factors like pelvic displacement and the timing of delivery post-fracture. We advocate for education programs to challenge provider biases, transparent patient communication, and evidence-based practices prioritizing patient-centered care. Addressing these issues can enhance maternal and fetal outcomes, supporting women in making informed decisions about their delivery options.

Postpartum perineal pain and its association with sub-classified second-degree tears and perineal trauma-A follow-up of a randomized controlled trial.

INTRODUCTION: Postnatal perineal pain is prevalent following childbirth and can impact women both physically and emotionally. The aim of the study was to study the effect of collegial midwifery assistance on perineal pain and pain medication 1 month after birth and to investigate the associations between the type of tear and perineal pain, satisfaction with healing, and resumption of intercourse. MATERIAL AND METHODS: A follow-up questionnaire was sent 1 month postpartum to women with a first spontaneous vaginal birth participating in a randomized controlled trial (Oneplus trial). Data were collected from December 2019 to May 2020. Differences in perineal pain between women attended by one or two midwives were analyzed according to intention-to-treat using bivariate analyses. Associations between the type of tear and perineal pain, satisfaction with healing, and resumption of sexual intercourse were investigated using univariable and multivariable logistic regression. The category no tear/first-degree tear was compared separately to each of the other tear categories. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, NCT03770962. RESULTS: Out of 2233 women, 1762 responded within 30-60 days postpartum. Of women in the no tear/first-degree tear category, 27.7% reported perineal pain during the past week, in contrast to women with OASI, where 64.2% reported perineal pain. Women with OASI experienced the highest odds of perineal pain (aOR 4.51, 95% CI 2.72-7.47) compared to those with no tear/first-degree tear, followed by women with major second-degree tears (aOR 1.87, 95% CI 1.45-2.41), women with an episiotomy (aOR 1.78, 95% CI 1.11-2.87), and those with minor second-degree tears (aOR 1.43, 95% CI 1.06-1.94). Women with episiotomy reported the highest odds ratios for dissatisfaction with tear healing (aOR 3.48, 95% CI 1.92-6.31). No significant differences in perineal pain and pain medication were observed between women allocated to collegial midwifery assistance and those allocated to standard care. CONCLUSIONS: Women with OASI reported the highest odds of perineal pain 30-60 days after birth compared to women with no tear or first-degree tear, followed by women with major second-degree tears. Women subjected to an episiotomy reported highest odds ratios of dissatisfaction with tear healing.

Effect of an Intrapartum Pelvic Dilator Device on Levator Ani Muscle Avulsion During Primiparous Vaginal Delivery: A Pilot Randomized Controlled Trial.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the safety and effectiveness of an intrapartum electromechanical pelvic floor dilator designed to reduce the risk of levator ani muscle (LAM) avulsion during vaginal delivery. METHODS: A multicenter, randomized controlled trial enrolled nulliparous participants planning vaginal delivery. During the first stage of labor, participants were randomized to receive the intravaginal device or standard-of-care labor management. The primary effectiveness endpoint was the presence of full LAM avulsion on transperineal pelvic-floor ultrasound at 3 months. Three urogynecologists performed blinded interpretation of ultrasound images. The primary safety endpoint was adverse events (AEs) through 3 months. RESULTS: A total of 214 women were randomized to Device (n = 113) or Control (n = 101) arms. Of 113 Device assignees, 82 had a device placed, of whom 68 delivered vaginally. Of 101 Control participants, 85 delivered vaginally. At 3 months, 110 participants, 46 Device subjects who received full device treatment, and 64 Controls underwent ultrasound for the per-protocol analysis. No full LAM avulsions (0.0%) occurred in the Device group versus 7 out of 64 (10.9%) in the Control group (p = 0.040; two-tailed Fisher's test). A single maternal serious AE (laceration) was device related; no neonate serious AEs were device related. CONCLUSIONS: The pelvic floor dilator device significantly reduced the incidence of complete LAM avulsion in nulliparous individuals undergoing first vaginal childbirth. The dilator demonstrated an acceptable safety profile and was well received by recipients. Use of the intrapartum electromechanical pelvic floor dilator in laboring nulliparous individuals may reduce the rate of LAM avulsion, an injury associated with serious sequelae including pelvic organ prolapse.