Real-time ultrasound to assist during a vaginal breech delivery.

We report a novel application of intrapartum sonography, herein used to assist the internal podalic version and the vaginal delivery of a transverse-lying second twin. Following the vaginal delivery of the first cephalic twin, the internal podalic version was performed under continuous ultrasound vision, leading to the uncomplicated breech delivery of a healthy neonate.

Optimizing the management of acute, prolonged decelerations and fetal bradycardia based on the understanding of fetal pathophysiology.

Any acute and profound reduction in fetal oxygenation increases the risk of anaerobic metabolism in the fetal myocardium and, hence, the risk of lactic acidosis. On the contrary, in a gradually evolving hypoxic stress, there is sufficient time to mount a catecholamine-mediated increase in the fetal heart rate to increase the cardiac output and redistribute oxygenated blood to maintain an aerobic metabolism in the fetal central organs. When the hypoxic stress is sudden, profound, and sustained, it is not possible to continue to maintain central organ perfusion by peripheral vasoconstriction and centralization. In case of acute deprivation of oxygen, the immediate chemoreflex response via the vagus nerve helps reduce fetal myocardial workload by a sudden drop of the baseline fetal heart rate. If this drop in the fetal heart rate continues for >2 minutes (American College of Obstetricians and Gynecologists' guideline) or 3 minutes (National Institute for Health and Care Excellence or physiological guideline), it is termed a prolonged deceleration, which occurs because of myocardial hypoxia, after the initial chemoreflex. The revised International Federation of Gynecology and Obstetrics guideline (2015) considers the prolonged deceleration to be a "pathologic" feature after 5 minutes. Acute intrapartum accidents (placental abruption, umbilical cord prolapse, and uterine rupture) should be excluded immediately, and if they are present, an urgent birth should be accomplished. If a reversible cause is found (maternal hypotension, uterine hypertonus or hyperstimulation, and sustained umbilical cord compression), immediate conservative measures (also called intrauterine fetal resuscitation) should be undertaken to reverse the underlying cause. In reversible causes of acute hypoxia, if the fetal heart rate variability is normal before the onset of deceleration, and normal within the first 3 minutes of the prolonged deceleration, then there is an increased likelihood of recovery of the fetal heart rate to its antecedent baseline within 9 minutes with the reversal of the underlying cause of acute and profound reduction in fetal oxygenation. The continuation of the prolonged deceleration for >10 minutes is termed "terminal bradycardia," and this increases the risk of hypoxic-ischemic injury to the deep gray matter of the brain (the thalami and the basal ganglia), predisposing to dyskinetic cerebral palsy. Therefore, any acute fetal hypoxia, which manifests as a prolonged deceleration on the fetal heart rate tracing, should be considered an intrapartum emergency requiring an immediate intervention to optimize perinatal outcome. In uterine hypertonus or hyperstimulation, if the prolonged deceleration persists despite stopping the uterotonic agent, then acute tocolysis is recommended to rapidly restore fetal oxygenation. Regular clinical audit of the management of acute hypoxia, including the "the onset of bradycardia to delivery interval," may help identify organizational and system issues, which may contribute to poor perinatal outcomes.

Short-term morbidity and types of intrapartum hypoxia in the newborn with metabolic acidaemia: a retrospective cohort study.

OBJECTIVES: To assess labour characteristics in relation to the occurrence of Composite Adverse neonatal Outcome (CAO) within a cohort of fetuses with metabolic acidaemia. DESIGN: Retrospective cohort study. SETTING: Three Italian tertiary maternity units. POPULATION: 431 neonates born with acidaemia ≥36 weeks. METHODS: Intrapartum CTG traces were assigned to one of these four types of labour hypoxia: acute, subacute, gradually evolving and chronic hypoxia. The presence of CAO was defined by the occurrence of at least one of the following: Sarnat Score grade ≥2, seizures, hypothermia and death <7 days from birth. MAIN OUTCOME MEASURES: To compare the type of hypoxia on the intrapartum CTG traces among the acidaemic neonates with and without CAO. RESULTS: The occurrence of a CAO was recorded in 15.1% of neonates. At logistic regression analysis, the duration of the hypoxia was the only parameter associated with CAO in the case of an acute or subacute pattern (odds ratio [OR] 1.3; 95% CI 1.02-1.6 and OR 1.04; 95% CI 1.0-1.1, respectively), whereas both the duration of the hypoxic insult and the time from PROM to delivery were associated with CAO in those with a gradually evolving pattern (OR 1.13; 95% CI 1.01-1.3 and OR 1.04; 95% CI 1.0-1.7, respectively). The incidence of CAO was higher in fetuses with chronic antepartum hypoxia than in those showing CTG features of intrapartum hypoxia (64.7 vs. 13.0%; P < 0.001). CONCLUSIONS: The frequency of CAO seems related to the duration and the type of the hypoxic injury, being higher in fetuses showing CTG features of antepartum chronic hypoxia. TWEETABLE ABSTRACT: This study demonstrates that in a large population of neonates with metabolic acidaemia at birth, the overall incidence of short-term adverse outcome is around 15%. Such risk seems closely correlated to the duration and the type of hypoxic injury, being higher in fetuses admitted in labour with antepartum chronic hypoxia than those experiencing intrapartum hypoxia.

Achieving an appropriate cesarean birth (CB) rate and analyzing the changes using the Robson Ten-Group Classification System (TGCS): Lessons from a Tertiary Care Hospital in Italy.

BACKGROUND: To describe the interventions that were implemented at a Tertiary University Hospital and how they affected the rate of cesarean birth (CB) and main obstetrics and neonatal outcomes. STUDY DESIGN: An analysis of the contemporaneously collected data from all deliveries that occurred from 2014 to 2018. Major obstetric and neonatal outcomes were analyzed and grouped according to the Ten-Group Classification System (TGCS). RESULTS: A significant decrease in CB rates, from 28.4% to 23.0% (P < 0.001), was found over the study period. Although the relative sizes of both nulliparous (groups 1 + 2) and multiparous (groups 3 + 4) women remained stable over the study period, a significantly higher incidence of CB was reported in 2014 for both groups, compared with 2018 (2.6% vs. 13.0%, P < 0.001 for nulliparous women and 7.5% vs. 3.3%, P < 0.001 for multiparous women). In contrast, the relative size of Group 5 was significantly lower in 2014 than in 2018 (9.9% vs. 11.5%, P = 0.003), but a 13.3% reduction in CB was also reported for this group. No significant differences were noted in the occurrence of major obstetrics and neonatal outcomes that were reported. CONCLUSIONS: A reduction in CB rate may be safely achieved through implementing a multifaceted strategy.

Intrapartum fetal heart rate between 150 and 160 bpm at or after 40 weeks and labor outcome.

INTRODUCTION: A baseline fetal heart rate between 110 and 160 bpm is considered normal. However, among normal fetuses the average baseline heart rate has been shown to diminish progressively and the 90th centile of the fetal heart rate at 40 weeks of gestation has been consistently found at around 150 bpm. The aim of our study was to assess the labor and neonatal outcome of fetuses at 40 gestational weeks or beyond, whose intrapartum baseline fetal heart rate was between 150 and 160 bpm. MATERIAL AND METHODS: Retrospective cohort study including singleton pregnancies with spontaneous onset of labor, gestational age between 40+0 and 42+0 weeks, category I CTG trace according to the FIGO guidelines 2015 with baseline fetal heart rate between 110 and 160 bpm during the first 60 minutes of active labor. Exclusion criteria were maternal hyperpyrexia at admission, fetal arrhythmias, maternal tachycardia (>110 bpm) and uterine tachysystole (>5 contractions/10 minutes). The following outcomes were compared between fetuses with a baseline ranging between 110 and 149 bpm and those with a baseline ranging between 150 and 160 bpm: incidence of meconium-stained amniotic fluid, intrapartum hyperpyrexia, mode of delivery, Apgar at 5 minutes <7, arterial pH <7.1 and Neonatal Intensive Care Unit admission, incidence of a composite adverse neonatal outcome. RESULTS: In all, 1004 CTG traces were included in the analysis, 860 in Group 110-149 bpm and 144 in Group 150-160 bpm. Group 150-160 bpm had a significantly higher incidence of meconium-stained amniotic fluid (odds ratio [OR] 2.6; 95% CI 1.8-3.8), maternal intrapartum hyperpyrexia (OR 4.7; 95% CI 1.1-14.6), urgent/emergent cesarean section for suspected fetal distress (OR 13.4; 95% CI 3.3-54.3), Apgar <7 at 5th min (OR 9.13; 95% CI 1.5-55.1) and neonatal acidemia (OR 3.5; 95% CI 1.5-55.1). Logistic regression including adjustiing for potential confounders showed that fetal heart rate between 150 and 160 bpm is an independent predictor of meconium-stained amniotic fluid (adjusted odds ratio [aOR] 2.2; 95% CI 1.5-3.3), cesarean section during labor for fetal distress (aOR 10.7; 95% CI 2.9-44.6), neonatal acidemia (aOR 2.6; 95% CI 1.1-6.7) and adverse composite neonatal outcome (aOR 2.6; 95% CI 1.2-5.6). CONCLUSIONS: In fetuses at 40 weeks or beyond, an intrapartum fetal heart rate baseline ranging between 150 and 160 bpm seems associated with a higher incidence of labor complications.

Hyperechoic amniotic membranes in patients with preterm premature rupture of membranes (p-PROM) and pregnancy outcome.

OBJECTIVES: The early identification of women with preterm premature rupture of membranes (p-PROM) who are at higher risk of imminent delivery remains challenging. The aim of our study was to evaluate if an increased echogenicity of the amniotic membranes may represent a sonographic marker of impending delivery in women with p-PROM. METHODS: This was a prospective study including women with singleton pregnancies and diagnosis of p-PROM between 22 and 37 gestational weeks. A sonographic examination was performed within 24 h from the hospital admission and the appearance of the amniotic membranes close to the internal os was specifically evaluated. The membranes were defined as hyperechoic when their echogenicity was similar to that of the fetal bones or normoechoic in the other cases. The primary aim of the study was to compare the admission to spontaneous onset of labor interval and the pregnancy outcome between the cases of p-PROM with and without hyperechoic membranes. RESULTS: Overall, 45 women fulfilled the inclusion criteria with similar characteristics at admission. In women with hyperechoic membranes, the admission to spontaneous onset of labor interval was significantly shorter (11.5 [5.3-25.0] vs. 3.0 [1.5-9.0] p=0.04) compared to women with normo-echoic membranes. At binomial logistic regression after adjustment for GA at hospital admission, the presence of hyperechoic membranes was found as the only independent predictor of spontaneous onset of labor ≤72 h (aOR: 6.1; 95% CI: 1.0-36.9). CONCLUSIONS: The presence of hyperechoic membranes is associated with a 6-fold higher incidence of spontaneous onset of labor within 72 h independently from the gestational age at p-PROM.

Risk factors associated with adverse fetal outcomes in pregnancies affected by Coronavirus disease 2019 (COVID-19): a secondary analysis of the WAPM study on COVID-19.

Objectives To evaluate the strength of association between maternal and pregnancy characteristics and the risk of adverse perinatal outcomes in pregnancies with laboratory confirmed COVID-19. Methods Secondary analysis of a multinational, cohort study on all consecutive pregnant women with laboratory-confirmed COVID-19 from February 1, 2020 to April 30, 2020 from 73 centers from 22 different countries. A confirmed case of COVID-19 was defined as a positive result on real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay of nasal and pharyngeal swab specimens. The primary outcome was a composite adverse fetal outcome, defined as the presence of either abortion (pregnancy loss before 22 weeks of gestations), stillbirth (intrauterine fetal death after 22 weeks of gestation), neonatal death (death of a live-born infant within the first 28 days of life), and perinatal death (either stillbirth or neonatal death). Logistic regression analysis was performed to evaluate parameters independently associated with the primary outcome. Logistic regression was reported as odds ratio (OR) with 95% confidence interval (CI). Results Mean gestational age at diagnosis was 30.6±9.5 weeks, with 8.0% of women being diagnosed in the first, 22.2% in the second and 69.8% in the third trimester of pregnancy. There were six miscarriage (2.3%), six intrauterine device (IUD) (2.3) and 5 (2.0%) neonatal deaths, with an overall rate of perinatal death of 4.2% (11/265), thus resulting into 17 cases experiencing and 226 not experiencing composite adverse fetal outcome. Neither stillbirths nor neonatal deaths had congenital anomalies found at antenatal or postnatal evaluation. Furthermore, none of the cases experiencing IUD had signs of impending demise at arterial or venous Doppler. Neonatal deaths were all considered as prematurity-related adverse events. Of the 250 live-born neonates, one (0.4%) was found positive at RT-PCR pharyngeal swabs performed after delivery. The mother was tested positive during the third trimester of pregnancy. The newborn was asymptomatic and had negative RT-PCR test after 14 days of life. At logistic regression analysis, gestational age at diagnosis (OR: 0.85, 95% CI 0.8-0.9 per week increase; p<0.001), birthweight (OR: 1.17, 95% CI 1.09-1.12.7 per 100 g decrease; p=0.012) and maternal ventilatory support, including either need for oxygen or CPAP (OR: 4.12, 95% CI 2.3-7.9; p=0.001) were independently associated with composite adverse fetal outcome. Conclusions Early gestational age at infection, maternal ventilatory supports and low birthweight are the main determinants of adverse perinatal outcomes in fetuses with maternal COVID-19 infection. Conversely, the risk of vertical transmission seems negligible.

Maternal cardiac parameters can help in differentiating the clinical profile of preeclampsia and in predicting progression from mild to severe forms.

BACKGROUND: A primary role of maternal heart dysfunction in the pathophysiology of preeclampsia had been previously advocated although if contradictory results have been reported. OBJECTIVES: The objectives of the study were to describe maternal hemodynamic parameters according to 2 main preeclampsia phenotypes and to investigate whether cardiac findings may be helpful in characterizing the severity and the progression of the disease. STUDY DESIGN: This was a prospective cohort study. We used an ultrasonic cardiac output monitor system to compare the hemodynamic parameters of women with preeclampsia with a group of healthy normotensive women enrolled as controls with a ratio of 1:2. Cardiac output, systemic vascular resistance, and stroke volume were compared among controls and preeclamptic women who were grouped in accordance to the following characteristics: early preeclampsia (<34 weeks' gestation) vs late preeclampsia onset (≥34 weeks' gestation); preeclampsia associated with appropriate for gestational age or small-for-gestational-age newborns. Hemodynamic characteristics were also compared between preeclamptic women with a mild form vs those who progressed toward a severe form. RESULTS: A total of 38 preeclamptic women and 61 normotensive women were included in the study. Both cases of preeclampsia associated with small-for-gestational-age neonates as those with normal-sized ones showed higher systemic vascular resistance compared with the control group (respectively, 1580.6 ± 483.2 vs 1479.1 ± 433.3 vs 1105.3 ± 293.1; P < .0001), while a lower cardiac output was reported only for preeclamptic women with small-for-gestational-age neonates compared with controls (5.7 ± 1.5 vs 6.5 ± 1.3; P = .02). Maternal cardiac parameters were comparable between these 2 groups of preeclamptic women (small-for-gestational-age vs appropriate-for-gestational-age preeclampsia) with the exception of a lower stroke volume in the former one (64.8 ± 24.4 vs 75.2 ± 17.8; P = .04). Similarly, women with both early and late preeclampsia showed higher systemic vascular resistance compared with controls (1559.5 ± 528.3 vs 1488.5 ± 292.9 vs 1105.3 ± 293.1, respectively; P < .001), while a lower cardiac output was noted only in the early-onset group compared with controls (5.5 ± 1.2 P = .02). Maternal cardiac findings were similar between women with early vs late-onset preeclampsia. Hemodynamic parameters are significantly different between those women with mild preeclampsia who remained stable compared with those who progressed toward a severe disease. Cardiac output Z-score, systemic vascular resistance Z-score, and uterine arteries' pulsatility index Z-score showed similar sensitivity (80% vs 75% vs 80%, respectively) and specificity (73% vs. 73% vs 74%, respectively), while the association of systemic vascular resistance Z-score and uterine arteries pulsatility index Z-score showed a sensitivity of 95% and a specificity of 80% (area under the curve, 0.90) in predicting evolution toward severe forms. CONCLUSION: Evaluation of maternal cardiovascular system could help clinician in defining a subset of preeclamptic patients with more profound placental impairment and might predict the likelihood of progression toward a severe condition in cases with a mild preeclampsia at clinical onset.

The Effect of Chorionicity on Maternal Cardiac Adaptation to Uncomplicated Twin Pregnancy: A Prospective Longitudinal Study.

OBJECTIVE: The objective of this study was to longitudinally evaluate maternal echocardiographic findings in uncomplicated twin gestations according to chorionicity. METHODS: Healthy women with twin pregnancy were assessed with transthoracic echocardiography across the first, second, and third trimesters. Cardiac findings were compared within each group and between monochorionic (MC) and dicho-rionic (DC) pregnancies. RESULTS: Overall, 19 MC and 48 DC uncomplicated twin pregnancies were included. In the MC group, no significant maternal haemodynamic changes were documented across gestation, with the exception of a decrease in ejection fraction. Compared to DC pregnancies, in the MC set lower cardiac output (second and third trimester, p = 0.001 and p = 0.006, respectively) and higher total vascular resistance (first trimester, p = 0.032) were observed. Regarding the diastolic function in MC twins, significantly higher values were observed for mitral E/A ratio (third trimester, p = 0.014), septal mitral E1/A1 ratio (third trimester, p = 0.030), lateral mitral E1 (second and third trimester, p = 0.014 and p = 0.029, respectively), and E1/A1 ratio (third trimester, p = 0.006). CONCLUSIONS: Maternal cardiac adaptation in twin pregnancy seems to differ significantly according to chorionicity. In particular, in MC pregnancies the impairment of diastolic function is less pronounced, presumably due to the lower circulating volume.

Correlation between intrapartum CTG findings and interleukin-6 levels in the umbilical cord arterial blood: A prospective cohort study.

OBJECTIVE: to investigate the correlation between the intrapartum CardioTocoGraphic (CTG) findings "suggestive of fetal inflammation" ("SOFI") and the interleukin (IL)-6 level in the umbilical arterial blood. STUDY DESIGN: prospective cohort study conducted at a tertiary maternity unit and including 447 neonates born at term. METHODS: IL-6 levels were systematically measured at birth from a sample of blood taken from the umbilical artery. The intrapartum CTG traces were retrospectively reviewed by two experts who were blinded to the postnatal umbilical arterial IL-6 values as well as to the neonatal outcomes. The CTG traces were classified into "suggestive of fetal inflammation (SOFI)" and "no evidence of fetal inflammation (NEFI) according to the principles of physiologic interpretation the CTG traces. The CTG was classified as "SOFI" if there was a persistent fetal heart rate (FHR) increase > 10 % compared with the observed baseline FHR observed at the admission or at the onset of labor without any preceding repetitive decelerations. The occurrence of Composite Adverse Outcome (CAO) was defined as Neonatal Intensive Care Unit (NICU) or Special Care Baby Unit (SCBU) admission due to one or more of the following: metabolic acidaemia, Apgar score at 5 min ≤ 7, need of neonatal resuscitation, respiratory distress, tachypnoea/polypnea, jaundice requiring phototherapy, hypotension, body temperature instability, poor perinatal adaptation, suspected or confirmed early neonatal sepsis. MAIN OUTCOME MEASURES: To compare the umbilical IL-6 values between the cases with intrapartum CTG traces classified as "SOFI" and those classified as "NEFI"; to assess the correlation of umbilical IL-6 values with the neonatal outcome. RESULTS: 43 (9.6 %) CTG traces were categorized as "SOFI"; IL-6 levels were significantly higher in this group compared with the "NEFI" group (82.0[43.4-325.0] pg/ml vs. 14.5[6.8-32.6] pg/mL; p <.001). The mean FHR baseline assessed 1 h before delivery and the total labor length showed an independent and direct association with the IL-6 levels in the umbilical arterial blood (p <.001 and p = 0.005, respectively). CAO occurred in 33(7.4 %) cases; IL-6 yielded a good prediction of the occurrence of the CAO with an AUC of 0.72 (95 % CI 0.61-0.81). CONCLUSION: Intrapartum CTG findings classified as "SOFI" are associated with higher levels of IL-6 in the umbilical arterial blood.

Effect of the "shoulder-up" bundle on the incidence of spontaneous perineal injury after vaginal delivery: comparison of 2 historic cohorts after propensity score matching.

BACKGROUND: Perineal injury following vaginal delivery represents a major cause of long-term maternal morbidity, and its prevention is among the priorities of modern obstetrical practice. OBJECTIVE: This study aimed to investigate whether the systematic implementation of a bundle of maneuvers to prevent perineal injury (ie, the "shoulder-up" bundle) may reduce the rate of spontaneous perineal tears in women delivering at a single tertiary maternity unit. STUDY DESIGN: This was a single-center retrospective intervention study including all vaginal deliveries between April 1, 2020 and March 31, 2022. On March 1, 2021, a bundle focused on perineal injury prevention in vaginal deliveries was implemented and introduced as a standard of care. The "shoulder-up" bundle includes the addition of a hands-on technique for the delivery of the posterior shoulder, which is slowly lifted up under the direct visualization of the perineal body, immediately after the disengagement of the anterior shoulder. The labor ward staff underwent dedicated training to acquire expertise on the "shoulder-up" bundle. Little changes in terms of medical and midwifery staffing were recorded during the study period. The incidence of spontaneous second-degree or higher perineal tears was compared between the patients who gave birth before the clinical implementation of the bundle (standard-care group) and those who were delivered following the implementation of the bundle (shoulder-up group). A 1:1 propensity score matching of the 2 groups was done for the variables that proved to be independently associated with the perineal outcome. RESULTS: From April 1, 2020 to March 31, 2022, 3671 patients had a vaginal birth at our tertiary care unit (1786 in the standard-care group and 1885 in the "shoulder-up" group) and were enrolled in the study population. Of these, 1191 (32.4%) had a spontaneous second-degree or higher perineal tear. At univariate analysis, nulliparity (59.6% vs 39.1%; P<.001), higher gestational age at delivery (39.8±1.28 vs 39.4±1.97 weeks; P<.001), epidural analgesia (40.6% vs 31.2%; P<.001), vacuum-assisted delivery (9.6% vs 4.0%; P<.001), and birthweight >4 kg (11.0% vs 6.3%; P<.001) were independently associated with the perineal outcome. Following propensity score matching for the above cited factors, the 1703 patients of each group were compared. A significant increase in the rate of intact perineum (71.0% vs 64.1%; P=.014) and a reduction in the incidence of second- (27.2% vs 32.9%; P=.006) and third to fourth-degree perineal tears (1.3% vs 3.0%; P<.001) was demonstrated in the "shoulder-up" group. Among the subgroup of patients undergoing vacuum-assisted delivery, a borderline significant reduction in the rate of obstetrical anal sphincter injury (10.4% vs 2.9%; P=.052) was also observed. CONCLUSION: Our study showed that the clinical implementation of the "shoulder-up" bundle at vaginal delivery is associated with a significant reduction in the incidence of spontaneous second-degree or higher perineal tears.

Impact of ultrasound guided training in the diagnosis of the fetal head position during labor: A prospective observational study.

OBJECTIVES: To assess whether the additional training with transabdominal ultrasound may improve the accuracy of the transvaginal digital examination in the assessment of the fetal head position during the active stage of labor. METHODS: Prospective observational study involving 2 residents in their 1 st year of training in Obstetrics with no prior experience in neither transvaginal digital examination nor ultrasound. Women with term, cephalic presenting fetus and active labor with cervical dilation ≥ 8 cm and ruptured membranes were included. In the preliminary phase of the study, the resident A ("blinded") was assigned to assess the fetal head position by transvaginal digital examination, while the resident B ("unmasked") performed transvaginal digital examination following transabdominal ultrasound, which was considered to be the gold standard to determine the fetal head position. After 50 examinations independently performed by each resident in the training phase, a post-training phase of the study was carried out to compare the accuracy of each resident in the diagnosis of fetal head position by digital assessment. The occiput position was eventually confirmed by ultrasound performed by the main investigator. RESULTS: Over a 6 months period, 90 post-training vaginal examinations were performed by each resident. The number of incorrect diagnoses of head position was higher for the "blinded" resident compared with the "unmasked" resident subjected to the ultrasound training (28/90 or 31.1 % vs 15/90 or 16.7 % p = 0.02). For both residents a wrong diagnosis was more likely with non-OA vs OA fetuses but this difference was statistically significant for the "blinded" Resident (10/20 or 50 % vs 18/70 or 25.7 % p = 0.039) but not for the "unmasked" Resident (5/18 or 27.9 % vs 10/72 or 13.9 % p = 0.16). CONCLUSION: The addition of transabdominal ultrasound as a training tool in the determination of the fetal head position during labor seems to improve the accuracy of the transvaginal digital examination in unexperienced residents.

A case of postpartum headache post dural puncture. Post Dural Puncture Headache or Reversible Cerebral Vasoconstriction Syndrome - Posterior Reversible Encephalopathy Syndrome?

Reversible Cerebral Vasoconstriction Syndrome (RCVS) and Posterior Reversible Encephalopathy Syndrome (PRES) are two rare neurological conditions, clinically characterized by headache. In our case a diagnosis of PDPH was made though imaging showed signs of RCVS-PRES. We present a case of RCVS-PRES in a postpartum woman who presented headache as first symptom and only later experienced seizures. Dural puncture worked as a confounding factor in the clinical postpartum evaluation. We want to focus the attention on changes of clinical characteristics of headache as an important factor to be analysed, in order to have a prompt diagnosis. We therefore propose a diagnostic algorithm. Moreover, we evaluate possible triggers of RCVS and PRES; in our case dural puncture is probably not the trigger, in fact there were no liquoral hypotension signs on imaging.

STAN: a reappraisal of its clinical usefulness.

The automatic analysis of fetal ECG in labor has been introduced as an adjunct of traditional cardiotocography with the aim to improve the identification of fetuses with intrapartum hypoxia. Several randomized controlled trials and meta-analyses have produced conflicting results, with the most recent randomized controlled trial not demonstrating any improvement in either neonatal outcomes or reduction in operative birth rates. The objective of this review article is to present the state of art about the use of STAN technology in labor ward.

Childbirth Care among SARS-CoV-2 Positive Women in Italy.

The new coronavirus emergency spread to Italy when little was known about the infection's impact on mothers and newborns. This study aims to describe the extent to which clinical practice has protected childbirth physiology and preserved the mother-child bond during the first wave of the pandemic in Italy. A national population-based prospective cohort study was performed enrolling women with confirmed SARS-CoV-2 infection admitted for childbirth to any Italian hospital from 25 February to 31 July 2020. All cases were prospectively notified, and information on peripartum care (mother-newborn separation, skin-to-skin contact, breastfeeding, and rooming-in) and maternal and perinatal outcomes were collected in a structured form and entered in a web-based secure system. The paper describes a cohort of 525 SARS-CoV-2 positive women who gave birth. At hospital admission, 44.8% of the cohort was asymptomatic. At delivery, 51.9% of the mothers had a birth support person in the delivery room; the average caesarean section rate of 33.7% remained stable compared to the national figure. On average, 39.0% of mothers were separated from their newborns at birth, 26.6% practised skin-to-skin, 72.1% roomed in with their babies, and 79.6% of the infants received their mother's milk. The infants separated and not separated from their SARS-CoV-2 positive mothers both had good outcomes. At the beginning of the pandemic, childbirth raised awareness and concern due to limited available evidence and led to "better safe than sorry" care choices. An improvement of the peripartum care indicators was observed over time.

Determinants of neonatal hypoglycemia after antenatal administration of corticosteroids (ACS) for lung maturation: Data from two referral centers and review of the literature.

BACKGROUND: A correlation between ACS and neonatal hypoglycemia has been recently demonstrated. AIMS: The aim of the study was to evaluate the determinants of neonatal hypoglycemia in women exposed to ACS for respiratory distress syndrome prevention. MATERIAL AND METHODS: Retrospective, multicenter, cohort study conducted in two Tertiary University Units. All fetuses delivered from 2016 to 2017 after ACS (two doses i.m. of Betamethasone 12 mg 24 h apart) were considered eligible for the study purpose. The primary outcome was the incidence of hypoglycemia, defined as a glycemic value ≤45 mg/dl within the first 48 h of neonatal life. The effect on neonatal glycaemia due to timing (interval from exposure to delivery) and type (single completed, single partial or repeated course) of ACS administration was also assessed. RESULTS: Overall, 99 neonates met the inclusion criteria. Hypoglycemia occurred in 38/99 (38.4%) of the included newborns. Compared to normoglycemic neonates, those with hypoglycemia had lower gestational age at delivery (33.06 ±â€¯3.37 vs. 35.94 ±â€¯3.17 g; p < 0.0001). Lower birthweight (1747.28 ±â€¯815.29 vs. 2499.24 ±â€¯780.51 g; p < 0.0001), a shorter interval time from administration to delivery (1.85 ±â€¯2.59 vs. 3.34 ±â€¯3.39 weeks; p = 0.02) and a higher incidence of single partial course (23.7 vs. 8.72%; p = 0.03). Multivariate logistic regression found that only birthweight was significantly associated with neonatal hypoglycemia (OR 0.4 95% CI -1.16/-0.04; p < 0.038). CONCLUSION: Hypoglycemia occurs in a large proportion of fetuses exposed to ACS independently from the type of exposure (single partial/single completed) and from the time interval between ACS administration and delivery. Birthweight seems to be the strongest determinant for the occurrence neonatal hypoglycemia after antenatal administration of steroids for lung maturation.

Elective induction of labour in low risk nulliparous women at term: Caution is needed.

The recently published ARRIVE trial demonstrated that "policies aimed at the avoidance of elective labour induction among low-risk nulliparous women at 39 weeks of gestation are unlikely to reduce the rate of caesarean delivery on a population level". In this commentary we discuss some controversial aspects of the study that in our opinion may undermine its validity at wide population level.

Correlation between umbilical vein-to-artery delta pH and type of intrapartum hypoxia in a cohort of acidemic neonates: A retrospective analysis of CTG findings.

INTRODUCTION: Umbilical artery blood analysis is assumed to give a picture of the acid-base balance of the infant at birth and is considered the gold standard to diagnose neonatal acidemia at birth. The evaluation of umbilical vein pH has been suggested as an adjunct in order to optimize the understanding of the pathophysiology of the hypoxic events in labor. The objective of this study was to assess the correlation between the Delta pH (vein-to-artery) on the umbilical cord and the intrapartum cardiotocography (CTG) patterns in a selected cohort of acidemic neonates. METHODS: Retrospective analysis of all CTG traces from non-anomalous term neonates consecutively born with acidemia (pH < 7.05 on the arterial cord) at four European tertiary Maternity Units. Intrapartum CTG traces were collected and their characteristics were reviewed in consensus by three senior Obstetricians. Each case was assigned to one of these four types of intrapartum hypoxia according to the CTG features: acute hypoxia, subacute hypoxia, slowly evolving hypoxia, and chronic hypoxia. The relationship between the different categories of intrapartum hypoxia and the Delta pH on the umbilical cord were evaluated. RESULTS: Overall, 83 acidemic neonates were included. Acute hypoxia, subacute hypoxia, slowly evolving hypoxia, and chronic hypoxia accounted for 19 (22.9%), 24 (28.9%), 24 (28.9%) and 16 (19.3%) cases, respectively. No difference of the Delta pH (p 0.61) was noted across the CTG subclasses, while significantly lower birthweight among cases with chronic hypoxia was found (p 0.03). The mean Delta pH did not vary at comparison between the cases with rapid onset hypoxia (acute + subacute hypoxia) and those with long lasting hypoxia (chronic + slowly evolving) (p 0.59). CONCLUSIONS: Within a selected cohort of acidemic neonates, our data do not demonstrate an association between the different CTG patterns of intrapartum hypoxia and the artery-to-vein Delta pH on the umbilical cord.