Fetal biparietal diameter as a potential risk factor for prolonged second stage of labor: A retrospective observational cohort study.

Prolonged second stage of labor is a common abnormality of labor progression. Very little research exists regarding the relationship between prolonged second stage of labor and antepartum sonographic fetal head biometry parameters, especially fetal biparietal diameter (BPD). Fetal BPD assessment is essential for estimating fetal weight, and these measurements are readily available to Japanese obstetricians. We conducted a retrospective observational cohort study to evaluate the association between BPD fetal Z-score and prolonged second stage of labor in a Japanese cohort. Individual BPD data measured using a GE Voluson 730 expert ultrasound system (GE, Healthcare Japan, Tokyo, Japan) were converted to Z-scores for a particular gestational age. After excluding patients with multiple pregnancies and emergency or elective cesarean sections, a total of 2,711 (nulliparity, n = 1341) Japanese women who delivered at term were included. We analyzed the incidence of prolonged second stage of labor and the association between BPD Z-score measured <7 days before delivery and prolonged second stage of labor by parity. The overall incidence of prolonged second stage of labor was 18.3% (246/1,341) in nulliparous women and 4.6% (63/1,370) in multiparous women. In nulliparous women, multivariable analysis indicated that BPD Z-score was significantly associated with prolonged second stage of labor (adjusted odds ratio, 1.18; 95% confidence interval, 1.02-1.37). Kaplan-Meier survival analysis showed that at each time point during the second stage of labor, the percentage of women who had not yet delivered was higher among those who delivered neonates with large BPD Z-scores than among those who delivered neonates with smaller BPD Z-scores. On the contrary, in multiparous women, BPD Z-score was not statistically associated with prolonged second stage of labor. Our results suggest that considering BPD Z-score is helpful in the management of nulliparous women who are at risk of developing a prolonged second stage of labor.

Risk Factors for Shoulder Dystocia: the Impact of Mother's Race and Ethnicity.

Shoulder dystocia is a rare but severe birth trauma where the neonate's shoulders fail to deliver after delivery of the head. Failure to deliver the shoulders quickly can lead to severe, long-term injury to the infant, including nerve injury, skeletal fractures, and potentially death. This observational study examined shoulder dystocia risk factors by race and ethnicity using a sample of 19,236 pregnant women who presented for labor and delivery from July 1, 2010 until June 30, 2013 at five locations. Multivariate analyses were used to identify risk factors associated with shoulder dystocia occurrence in racial/ethnic groups with high incidence rates. For White non-Hispanic mothers, the strongest risk factors were delivering past 40 weeks' gestation (odds ratio [OR] = 2.4; 95% confidence interval [CI] = 1.5, 3.9; p < .01) and use of epidural anesthesia during delivery (OR = 4.4; 95% CI = 3.0, 6.4; p < .01). Among Black non-Hispanic mothers, the risk factors with the greatest impact were use of epidural (OR = 5.3; 95% CI = 3.2, 8.7; p < .01) and having gestational diabetes and controlling the condition with insulin (OR = 4.6; 95% CI = 1.5, 13.8; p < .01). Additionally, among Hispanic mothers, having Spanish as primary language increased shoulder dystocia likelihood compared to those who did not cite it as their primary language (OR = 2.3; 95% CI = 1.1, 4.6; p < .05). This study provides evidence that risk factors for a labor and delivery condition can vary significantly across racial and ethnic subgroups. These differences emphasize the importance of evaluating risk by population subgroups and might provide a basis for labor and delivery clinicians to enhance personalized medicine to reduce adverse events.

Obstetric Outcomes of First- and Second-Generation Pakistani Immigrants: A Comparison Study at a Low-Risk Maternity Ward in Norway.

This population-based study compares obstetric outcomes of first- and second-generation Pakistani immigrants and ethnic Norwegians who gave birth at the low-risk maternity ward in Baerum Hospital in Norway from 2006 to 2013. We hypothesized that second-generation Pakistani immigrants are more similar to the ethnic Norwegians because of increased acculturation. Outcome measures were labor onset, epidural analgesia, labor dystocia, episiotomy, vaginal/operative delivery, postpartum hemorrhage, preterm birth, birth weight, transfer to a neonatal intensive care unit, and neonatal jaundice. Compared to first-generation Pakistani immigrants, the second-generation reported more health issues before pregnancy, and they had a higher proportion of preterm births compared to Norwegians. Newborns of first-generation immigrants were more often transferred to a neonatal intensive care compared to Norwegian newborns. Few intergenerational differences in the obstetric outcomes were found between the two generations. A high prevalence of consanguinity in second-generation immigrants suggests the maintenance of a traditional Pakistani marriage pattern.

Small-for-gestational age and large-for-gestational age thresholds to predict infants at risk of adverse delivery and neonatal outcomes: are current charts adequate? An observational study from the Born in Bradford cohort.

OBJECTIVES: Construct an ethnic-specific chart and compare the prediction of adverse outcomes using this chart with the clinically recommended UK-WHO and customised birth weight charts using cut-offs for small-for-gestational age (SGA: birth weight <10th centile) and large-for-gestational age (LGA: birth weight >90th centile). DESIGN: Prospective cohort study. SETTING: Born in Bradford (BiB) study, UK. PARTICIPANTS: 3980 White British and 4448 Pakistani infants with complete data for gestational age, birth weight, ethnicity, maternal height, weight and parity. MAIN OUTCOME MEASURES: Prevalence of SGA and LGA, using the three charts and indicators of diagnostic utility (sensitivity, specificity and area under the receiver operating characteristic (AUROC)) of these chart-specific cut-offs to predict delivery and neonatal outcomes and a composite outcome. RESULTS: In White British and Pakistani infants, the prevalence of SGA and LGA differed depending on the chart used. Increased risk of SGA was observed when using the UK-WHO and customised charts as opposed to the ethnic-specific chart, while the opposite was apparent when classifying LGA infants. However, the predictive utility of all three charts to identify adverse clinical outcomes was poor, with only the prediction of shoulder dystocia achieving an AUROC>0.62 on all three charts. CONCLUSIONS: Despite being recommended in national clinical guidelines, the UK-WHO and customised birth weight charts perform poorly at identifying infants at risk of adverse neonatal outcomes. Being small or large may increase the risk of an adverse outcome; however, size alone is not sensitive or specific enough with current detection to be useful. However, a significant amount of missing data for some of the outcomes may have limited the power needed to determine true associations.

Association between hyperglycaemia and adverse perinatal outcomes in south Asian and white British women: analysis of data from the Born in Bradford cohort.

BACKGROUND: Diagnosis of gestational diabetes predicts risk of infants who are large for gestational age (LGA) and with high adiposity, which in turn aims to predict a future risk of obesity in the offspring. South Asian women have higher risk of gestational diabetes, lower risk of LGA, and on average give birth to infants with greater adiposity than do white European women. Whether the same diagnostic criteria for gestational diabetes should apply to both groups of women is unclear. We aimed to assess the association between maternal glucose and adverse perinatal outcomes to ascertain whether thresholds used to diagnose gestational diabetes should differ between south Asian and white British women. We also aimed to assess whether ethnic origin affected prevalence of gestational diabetes irrespective of criteria used. METHODS: We used data (including results of a 26-28 week gestation oral glucose tolerance test) of women from the Born in Bradford study, a prospective study that recruited women attending the antenatal clinic at the Bradford Royal Infirmary, UK, between 2007 and 2011 and who intended to give birth to their infant in that hospital. We studied the association between fasting and 2 h post-load glucose and three primary outcomes (LGA [defined as birthweight >90th percentile for gestational age], high infant adiposity [sum of skinfolds >90th percentile for gestational age], and caesarean section). We calculated adjusted odds ratios (ORs) and their 95% confidence intervals (CIs) for a 1 SD increase in fasting and post-load glucose. We established fasting and post-load glucose thresholds that equated to an OR of 1·75 for LGA and high infant adiposity in each group of women to identify ethnic-specific criteria for diagnosis of gestational diabetes. FINDINGS: Of 13,773 pregnancies, 3420 were excluded from analyses. Of 10,353 eligible pregnancies, 4088 women were white British, 5408 were south Asian, and 857 were of other ethnic origin. The adjusted ORs of LGA per 1 SD fasting glucose were 1·22 (95% CI 1·08-1·38) in white British women and 1·43 (1·23-1·67) in south Asian women (pinteraction with ethnicity = 0·39). Results for high infant adiposity were 1·35 (1·23-1·49) and 1·35 (1·18-1·54; pinteraction with ethnicity=0·98), and for caesarean section they were 1·06 (0·97-1·16) and 1·11 (1·02-1·20; pinteraction with ethnicity=0·47). Associations between post-load glucose and the three primary outcomes were weaker than for fasting glucose. A fasting glucose concentration of 5·4 mmol/L or a 2 h post-load level of 7·5 mmol/L identified white British women with 75% or higher relative risk of LGA or high infant adiposity; in south Asian women, the cutoffs were 5·2 mmol/L or 7·2 mml/L; in the whole cohort, the cutoffs were 5·3 mmol/L or 7·5 mml/L. The prevalence of gestational diabetes in our cohort ranged from 1·2% to 8·7% in white British women and 4% to 24% in south Asian women using six different criteria. Compared with the application of our whole-cohort criteria, use of our ethnic-specific criteria increased the prevalence of gestational diabetes in south Asian women from 17·4% (95% CI 16·4-18·4) to 24·2% (23·1-25·3). INTERPRETATION: Our data support the use of lower fasting and post-load glucose thresholds to diagnose gestational diabetes in south Asian than white British women. They also suggest that diagnostic criteria for gestational diabetes recommended by UK NICE might underestimate the prevalence of gestational diabetes compared with our criteria or those recommended by the International Association of Diabetes and Pregnancy Study Groups and WHO, especially in south Asian women. FUNDING: The National Institute for Health Research.

Caesarean delivery and its correlates in Northern Region of Bangladesh: application of logistic regression and cox proportional hazard model.

BACKGROUND: Caesarean delivery (C-section) rates have been increasing dramatically in the past decades around the world. This increase has been attributed to multiple factors such as maternal, socio-demographic and institutional factors and is a burning issue of global aspect like in many developed and developing countries. Therefore, this study examines the relationship between mode of delivery and time to event with provider characteristics (i.e., covariates) respectively. METHODS: The study is based on a total of 1142 delivery cases from four private and four public hospitals maternity wards. Logistic regression and Cox proportional hazard models were the statistical tools of the present study. RESULTS: The logistic regression of multivariate analysis indicated that the risk of having a previous C-section, prolonged labour, higher educational level, mother age 25 years and above, lower order of birth, length of baby more than 45 cm and irregular intake of balanced diet were significantly predict for C-section. With regard to survival time, using the Cox model, fetal distress, previous C-section, mother's age, age at marriage and order of birth were also the most independent risk factors for C-section. By the forward stepwise selection, the study reveals that the most common factors were previous C-section, mother's age and order of birth in both analysis. As shown in the above results, the study suggests that these factors may influence the health-seeking behaviour of women. CONCLUSIONS: Findings suggest that program and policies need to address the increase rate of caesarean delivery in Northern region of Bangladesh. Also, for determinant of risk factors, the result of Akaike Information Criterion (AIC) indicated that logistic model is an efficient model.

Brachial plexus injury: a 23-year experience from a tertiary center.

OBJECTIVE: The purpose of this study was to analyze the data on brachial plexus injury and its relationship with shoulder dystocia from a tertiary center for a 23-year period. STUDY DESIGN: A review of the logbooks on labor and delivery and the nursery and the International Classification of Diseases codes identified all newborn infants with brachial plexus injury who were delivered at our center. RESULTS: During the 23 years (1980-2002), there were 89,978 deliveries, of which there were 85 cases of brachial plexus injury (1/1000 births) with vaginal delivery. The injury was permanent (> or =1 year) in 12% of the cases, and only 2 cases have been litigated. Newborn infants that weighed > or =4 kg were significantly more common among those infants who had shoulder dystocia and brachial plexus injury than those infants without injury (odds ratio, 6.55; 95% CI, 2.30, 18.63). The rate of permanent brachial plexus injury was similar between the 2 groups. CONCLUSION: A case of brachial plexus injury occurs 1 time in every 1000 births, is permanent in 1 of every 10,000 deliveries, and is litigated 1 time for every 45,000 deliveries. The infrequent nature of injury may preclude prevention.