The use of bubble charts in analyzing second stage cesarean delivery rates.

BACKGROUND: The incidence of second stage cesarean delivery has been rising globally because of the failure or the anticipated difficulty of performing instrumental delivery. Yet, the best way to interpret the figure and its optimal rate remain to be determined. This is because it is strongly influenced by the practice of other 2 modes of birth, namely cesarean delivery performed before reaching the second stage and assisted vaginal birth during the second stage. In this regard, a bubble chart that can display 3-dimensional data through its x-axis, y-axis, and the size of each plot (presented as a bubble) may be a suitable method to evaluate the relationship between the rates of these 3 modes of births. OBJECTIVE: This study aimed to conduct an epidemiologic study on the incidence of second stage cesarean deliveries rates among >300,000 singleton term births in 10 years from 8 obstetrical units and to compare their second stage cesarean delivery rates in relation to their pre-second stage cesarean delivery rates and assisted vaginal birth rates using a bubble chart. STUDY DESIGN: The territory-wide birth data collected between 2009 and 2018 from all 8 public obstetrical units (labelled as A to H) were reviewed. The inclusion criteria were all singleton pregnancies with cephalic presentation that were delivered at term (≥37 weeks' gestation). Pre-second stage cesarean delivery rate was defined as all elective cesarean deliveries and those emergency cesarean deliveries that occurred before full cervical dilatation was achieved as a proportion of the total number of births. The second stage cesarean delivery rate and assisted vaginal birth rate were calculated according to the respective mode of delivery as a proportion of the number of cases that reached full cervical dilatation. The rates of these 3 modes of births were compared among the parity groups and among the 8 units. Using a bubble chart, each unit's second stage cesarean delivery rate (y-axis) was plotted against its pre-second stage cesarean delivery rate (x-axis) as a bubble. Each unit's second stage cesarean delivery to assisted vaginal birth ratio was represented by the size of the bubble. RESULTS: During the study period, a total of 353,434 singleton cephalic presenting term pregnancies were delivered in the 8 units, and 180,496 (51.1%) were from nulliparous mothers. When compared with the multiparous group, the nulliparous group had a significantly lower pre-second stage cesarean delivery rate (18.58% vs 21.26%; P<.001) but a higher second stage cesarean delivery rate (0.79% vs 0.22%; P<.001) and a higher assisted vaginal birth rate (17.61% vs 3.58%; P<.001). Using the bubble of their averages as a reference point in the bubble chart, the 8 units' bubbles were clustered into 5 regions indicating their differences in practice: unit B and unit H were close to the average in the center. Unit A and unit F were at the upper right corner with a higher pre-second stage cesarean delivery rate and second stage cesarean delivery rate. Unit D and unit E were at the opposite end. Unit C was at the upper left corner with a low pre-second stage cesarean delivery rate but a high second stage cesarean delivery rate, whereas unit G was at the opposite end. Unit C and unit G were also in the extremes in terms of pre-second stage cesarean delivery to assisted vaginal birth ratio (0.09 and 0.01, respectively). Although some units seemed to have very similar second stage cesarean delivery rates, their obstetrical practices were differentiated by the bubble chart. CONCLUSION: The second stage cesarean delivery rate must be evaluated in the context of the rates of pre-second stage cesarean delivery and assisted vaginal birth. A bubble chart is a useful method for analyzing the relationship among these 3 variables to differentiate the obstetrical practice between different units.

Four cases of cervical varices without placenta praevia: Presentation, diagnosis, managements, and literature review.

Cervical varices are a rare condition characterized by recurrent antepartum hemorrhage and less than 20 cases were reported in the literature. It is usually associated with placenta previa. We herein describe four cases of cervical varices without placenta previa. Meticulous speculum examination, ultrasonography with Doppler and colposcopy are essential for establishing the diagnosis and assessing the extent of the cervical varix. We propose to classify it as the apparent external os type or ultrasonography-based endocervical type. Most cases presented in the literature were delivered by cesarean section. Nevertheless, one of our cases was a successful vaginal delivery. Our case illustrates that vaginal delivery is possible in isolated cervical varices. More case reports are needed to have a better understanding of this rare entity.

The use of bubble charts in analyzing the global second-stage cesarean delivery rates: a systematic review.

OBJECTIVE: This study aimed to systematically review the worldwide second-stage cesarean delivery rate concerning pre-second-stage cesarean delivery and assisted vaginal birth rates. DATA SOURCES: PubMed, Medline Ovid, EBSCOhost, Embase, Scopus, and Google Scholar were queried from inception to February 2023, with the following terms: "full dilatation," "second stage," and "cesarean," with their word variations. Furthermore, an additional cohort of 353,434 cases from our recently published study was included. STUDY ELIGIBILITY CRITERIA: Only original studies that provided sufficient information on the number of pre-second-stage cesarean deliveries, second-stage cesarean deliveries, and vaginal births were included for the calculation of different modes of delivery. Systemic reviews, meta-analyses, or case reports were excluded. METHODS: Study identification and data extraction were independently performed by 2 authors. Selected studies were categorized on the basis of parity, study period, and geographic regions for comparison. RESULTS: A total of 25 studies were included. The overall pre-second-stage cesarean delivery rate, the second-stage cesarean delivery rate, and the second-stage cesarean delivery-to-assisted vaginal birth ratio were 17.94%, 2.65%, and 0.19, respectively. Only 5 studies described singleton, term, cephalic presenting pregnancies of nulliparous women, and their second-stage cesarean delivery rates were significantly higher than those studies with cohorts of all parity groups (4.50% vs 0.83%; P<.05). In addition, the second-stage cesarean delivery rate showed a secular increase across 2009 (0.70% vs 1.05%; P<.05). Moreover, it was the highest among African studies (5.14%) but the lowest among studies from East Asia and South Asia (0.94%). The distributions of second-stage cesarean delivery rates of individual studies and subgroups were shown with that of pre-second-stage cesarean delivery and assisted vaginal birth using the bubble chart. CONCLUSION: The overall worldwide pre-second-stage cesarean delivery rate was 17.94%, the second-stage cesarean delivery rate was 2.65%, and the second-stage cesarean delivery-to-assisted vaginal birth ratio was 0.19. The African studies had the highest second-stage cesarean delivery rate (5.14%) and second-stage cesarean delivery-to-assisted vaginal birth ratio (1.88), whereas the studies from East Asia and South Asia were opposite (0.94% and 0.11, respectively).

Sonographic measurement of cervical length and head perineum distance before labor to predict time of delivery.

OBJECTIVES: This was an observational study on cervical length and head perineum distance and the prediction of time of delivery. One-hundred and twenty-five nulliparous women with uncomplicated, term, singleton pregnancy were recruited when they presented to the labor ward with show or infrequent painful uterine contractions (less than three contractions in ten minutes on a 30 min cardiotocogram). Apart from digital vaginal examination to assess cervical length and dilatation, sonographic cervical length and head perineum distance were measured by two-dimensional ultrasound. We compared women who delivered within 72 h of presentation of labor symptoms, with women who did not. After excluding ten women whose labor was induced and delivered within 72 h of presentation, one hundred and fifteen women were included for final data analysis. MAIN FINDINGS: Forty-nine women (42.6%) delivered while sixty-six women (57.4%) remained undelivered at 72 h of presentation of symptoms of labor. There was no statistically significant difference between the two groups on age, presence of show, contractions, fetal head station and presentation and mode of delivery. For the group who had delivered within 72 h of presentation of labor symptoms, the mean sonographic cervical length was 1.87 cm ± 0.62 cm, while the head perineum distance was 6.01 cm ± 1.15 cm. For the other group, the mean sonographic cervical length was 2.10 cm ± 0.83 cm; head perineum distance was 6.03 cm ± 1.18 cm. There was no statistically significant difference between the groups for both sonographic cervical length (p = .90); and head perineum distance (p = .08). We also compared the cervical length measured by digital vaginal examination versus sonography. The median sonographic measurements were 1.47 cm, 2.11 cm and 2.79 cm at "1 cm," "2 cm" and "3 cm" digital vaginal measurement, respectively. However, there was extensive overlap between digitally and sonographically measured cervical length. Prediction accuracy of cervical length and head perineum distance was poor. The area under curve (AUC) of receiver operating characteristic (ROC) curve were 0.433 for sonographic cervical length and 0.501 for HPD. CONCLUSION: Transperineal sonographical assessment of cervical length and head perineum distance before labor was not useful in predicting the time of delivery. However, it can be explored as an alternative assessment method when digital vaginal examination is not preferred.

Intrapartum translabial ultrasound demonstration of face presentation during first stage of labor.

We report an unusual case in which sonographic diagnosis of face presentation was made by translabial ultrasound examination during the first stage of labor. In a multigravida, induction of labor was performed at 39 weeks' gestation for suspected small-for-gestational age. The diagnosis of face presentation was confirmed by the use of intrapartum translabial ultrasound examination. In face presentation, the orbits and nasal bridge are shown in the center of the presenting part at the mid-sagittal plane. Emergency cesarean delivery was performed for labor dystocia. Here we discuss the merits and limitations of transabdominal, transvaginal and translabial ultrasound examinations in assisting clinical diagnosis of non-vertex malpresentation. We propose the use of intrapartum translabial scan in documentation, counseling and education in case of unusual non-vertex malpresentation.

Intrapartum ultrasound and the choice between assisted vaginal and cesarean delivery.

Inaccurate assessment of the fetal head position and station might increase the risk for difficult or failed assisted vaginal delivery. Compared with digital vaginal examination, an ultrasound examination is objective and more accurate. The International Society of Ultrasound in Obstetrics and Gynecology has issued practical guidelines on intrapartum ultrasound in 2018 and recommended that an ultrasound assessment should be conducted when there is suspected delay or arrest of the first or second stage of labor or before considering assisted vaginal delivery. Fetal head position is assessed transabdominally by identifying the fetal occiput, orbit, or midline cerebral echo. Studies have shown that ultrasound assessment improved the correct diagnosis of fetal head position and accuracy of instrument placement, however, it did not reduce morbidity. Studies on ultrasound assessment of asynclitism are limited but show promising results. Fetal head station is assessed transperineally in the midsagittal or axial plane. Of the various ultrasound parameters, angle of progression and head-perineum distance are the most widely studied and found to be highly correlated with the clinical fetal head station. An angle of progression of 120° correlates with a clinical head station of 0 and is an important landmark for engagement of successful vaginal delivery, whereas an angle of progression of 145° correlates with a clinical head station of ≥+2 and has been associated with successful assisted vaginal delivery. In contrast, a head perineum distance of ≥40 mm has been associated with an increased risk for difficult assisted vaginal delivery. A "head-up" direction of descent assessed transperineally in sagittal plane is also a favorable factor for successful vaginal delivery. Current evidence seems to suggest that a prediction model with >1 sonographic parameter performed better than a model that only used 1 parameter. We suggest that an algorithm model incorporating both clinical and sonographic parameters would be useful in guiding clinicians on their decision for assisted vaginal delivery.

Measuring angle of progression by transperineal ultrasonography to predict successful instrumental and cesarean deliveries during prolonged second stage of labor.

OBJECTIVE: To compare the angle of progression (AoP) measured by transperineal ultrasonography before indicating an instrumental delivery or cesarean delivery. METHODS: A prospective observational study was conducted among women with singleton term pregnancies with prolonged second stage of labor at Kwong Wah Hospital, Hong Kong, China, between May 16, 2011, and May 25, 2016. Transabdominal and transperineal ultrasonography were performed to determine fetal head position and AoP, respectively, both at rest and during uterine contraction with pushing. Mode of delivery was decided after vaginal examination without relying on ultrasonography. RESULTS: Of 143 women, 116 underwent successful instrumental delivery and 27 underwent cesarean delivery. Median AoP was 153.0° in the instrumental group versus 139.0° in the cesarean group at rest (P<0.001), and 182.5° in the instrumental group versus 156.5° in the cesarean group during contraction (P<0.001). The best predictive cutoff AoP for successful instrumental delivery was 138.7° at rest (sensitivity 86.2%, specificity 51.9%) and 160.9° during contraction (sensitivity 87.1%, specificity 74.1%). No between-group differences in AoP were found for ease of vacuum extraction at rest (P=0.457) or during contraction with pushing (P=0.095). CONCLUSION: The AoP predicted approximately 80% of successful instrumental deliveries performed for prolonged second stage of labor.

The effect of rupture of membranes and labour on the risk of hepatitis B vertical transmission: Prospective multicentre observational study.

OBJECTIVE: To evaluate the effect of rupture of membranes and labour on the risk of hepatitis B virus (HBV) vertical transmission. STUDY DESIGN: A prospective multicentre observational study was carried out in Hong Kong between 2014-2016. Pregnant HBV carriers were recruited. The duration of rupture of membranes, labour and mode of delivery were collected prospectively. HBV DNA was examined at 28-30 weeks of gestation. All newborns received standard HBV vaccination and immunoglobulin. Hepatitis B surface antigen of infants was tested at 9-12 months of age. RESULTS: 641 pregnancies were recruited and analyzed. No statistically significant difference was found in gravida, parity, gestational age at delivery, mode of delivery, duration of rupture of membranes, duration of labour, preterm delivery, preterm rupture of membranes or birth weight (p > 0.05). Subgroup analysis in viral load > 7log10IU/ml and 8log10IU/ml also did not find a significant association between duration of rupture of membranes and labour with immunoprophylaxis failure. CONCLUSIONS: Duration of rupture of membranes and labour would not affect the risk of HBV vertical transmission in infants following standard HBV vaccination and hepatitis B immunoglobulin administration.

Is intrapartum translabial ultrasound examination painless?

OBJECTIVES: To find out whether intrapartum translabial ultrasound examination is painless by comparing pain score of ultrasound-based versus digital vaginal examination of foetal head station. METHODS: In 94 women carrying uncomplicated-term singleton pregnancies, labour progress was assessed by translabial ultrasound, followed immediately by conventional digital vaginal examination. Pain scores (0-10) using visual analogue pain scale were obtained for both examinations. Forty-eight and forty-six sets of data were obtained in first and second stage of labour, respectively. The difference in pain scores between digital vaginal examination and translabial ultrasound was analysed. RESULTS: The median pain score for translabial ultrasound was 0 (range 0-8), while that for vaginal examination was 4.5 (range 0-10), p < 0.05. There was no significant difference in pain scores between first and second stages of labour for translabial ultrasound (p = 0.123) and for vaginal examination (p = 0.680). The pain score for vaginal examination was higher than that of translabial ultrasound in 81.9%, similar in 13.8% and lower in 4.3% of cases. There was no statistically significant difference in pain scores obtained for digital vaginal examination by clinicians with different experience (p = 0.941). CONCLUSIONS: Intrapartum translabial ultrasound is generally better tolerated than digital vaginal examination for assessment of labour progress, making it an acceptable adjunctive assessment tool during labour.

Twin pregnancy outcomes after increasing rate of vaginal twin delivery: retrospective cohort study in a Hong Kong regional obstetric unit.

OBJECTIVE: To determine any change in adverse neonatal/maternal outcomes after increasing the rate of vaginal twin delivery by comparing vaginal twin delivery and caesarean delivery with our previous cohort study. METHODS: In a retrospective cohort study, all twins booked at a Hong Kong regional obstetrics unit were evaluated during a 3-year period from 1 April 2009 to 31 March 2012. RESULTS: Out of the 269 sets of twins who eventually delivered in our unit, 68 (25.3%) of them were delivered vaginally, compared to 15.8% in our previous cohort study (p = 0.02). For those who were suitable for vaginal delivery, significantly more women attempted vaginal delivery: 93/133 (69.9%) versus 47/100 (47%) (p = 0.0005). The success rate for vaginal delivery and rate of requiring caesarean delivery for the 2nd twin were similar between these two periods. There were significantly more 2nd twins with cord blood pH < 7.2 when both twins were delivered by vaginal delivery. Otherwise, there was no significant difference between other neonatal/maternal morbidities. CONCLUSION: With proper counseling, significantly more women who were suitable for vaginal twin delivery would opt to do so. There was no significant increase in neonatal/maternal morbidities despite the increased rate of vaginal twin delivery.

Relationship between intrapartum transperineal ultrasound measurement of angle of progression and head-perineum distance with correlation to conventional clinical parameters of labor progress and time to delivery.

OBJECTIVE: To assess whether angle of progression (AOP) and head-perineum distance (HPD) measured by intrapartum transperineal ultrasound (ITU) correlate with clinical fetal head station (station); and whether AOP versus HPD varies during uterine contraction and relaxation. In a subset of primiparous women, whether these ITU parameters correlate with time to normal spontaneous delivery (TD). METHODS: We evaluated prospectively 100 primiparous and multiparous women at term in active labor. Transabdominal and transperineal ultrasound (sagittal and transverse plane) were used to measure fetal head position and ITU parameters, respectively. Digitally palpated station and cervical dilatation were also noted. The results were compared using regression and correlation coefficients. RESULTS: Station was moderately correlated with AOP (r = 0.579) and HPD (r = -0.497). AOP was highly correlated with HPD during uterine contraction (r = -0.703) and relaxation (r = -0.647). In the subgroup of primiparous women, natural log of TD has the highest correlation with HPD and AOP during uterine contraction (r = 0.742), making prediction of TD similar to that of using cervical dilatation. CONCLUSION: ITU parameters were moderately correlated with station. There was constant high correlation between AOP and HPD. Prediction of TD in primiparous women using ITU parameters was similar to that of using cervical dilatation.

Use of second-line therapies for management of massive primary postpartum hemorrhage.

OBJECTIVE: To determine rates of use and success of second-line therapies for massive primary postpartum hemorrhage (PPH). METHODS: A retrospective cohort study was conducted among 91 women who gave birth at Kwong Wah Hospital, Hong Kong, between January 1, 2006, and December 31, 2011. Inclusion criteria were gestational age of at least 24 weeks and massive PPH (defined as blood loss ≥1500 mL within 24 hours after birth). Second-line therapies assessed were uterine compression sutures, uterine artery embolization, and balloon tamponade after failure of uterine massage and uterotonic agents to stop bleeding. RESULTS: The rate of massive PPH was 2.65 per 1000 births. Second-line therapies were used among 42 women with PPH, equivalent to a rate of 1.23 per 1000 births. Only 21.4% of the women who received second-line therapies required rescue hysterectomy. A rising trend was observed for the use of second-line therapies, whereas the incidence of rescue hysterectomy and estimated blood loss were found to concomitantly decrease. CONCLUSION: Increasing use of second-line therapies among women with massive PPH was associated with a decreasing trend for rescue hysterectomy. Obstetricians should, therefore, consider all available interventions to stop PPH, including early use of second-line options.

A new policy for prenatal screening and diagnosis of Down syndrome for pregnant women with advanced maternal age in a public hospital.

OBJECTIVE: Before April 2006, women with singleton pregnancy and advanced maternal age (AMA, 35 years and older) were offered either direct invasive tests or a variety of screening tests for Down syndrome (DS) with routine anomaly scan at 18-20 weeks. After April 2006, to reduce procedure-related fetal loss, invasive test was performed only for positive screening result or the presence of major fetal anomaly on ultrasound. We reviewed our 2-year experience after the policy change. METHODS: Two-year data after policy change were compared to the 1-year historic control before policy change. RESULTS: A total of 2257 eligible women were counselled in the 2 years after policy change. The uptake of screening was 96.7%. The overall detection rate for DS was 90% (18/20) at a false positive rate of 10.9%. The number of invasive tests performed to diagnose one case of DS was reduced 7-fold from 97 to 13. CONCLUSIONS: The number of direct invasive tests was markedly reduced. With effective DS screening policy, it is possible to do away with direct invasive testing for the majority of women with AMA.

Pregnancy outcome of a patient with atypical polypoid adenomyoma.

OBJECTIVE: Detailed description and follow-up of a patient with atypical polypoid adenomyoma and infertility, from investigation until delivery of a healthy baby. DESIGN: Case report. SETTING: Tertiary infertility center. PATIENT(S): A patient suffering from persistent APA and infertility. INTERVENTION(S): Danggui (Angelica sinensis) and low-dose aspirin. MAIN OUTCOME MEASURE(S): Pregnancy and live birth. RESULT(S): Conception after Danggui but intrauterine death at 25 weeks. Successful live birth after Danggui plus low-dose aspirin. CONCLUSION(S): Danggui corrected atypical polypoid adenomyoma and led to pregnancy twice in the same patient. Low-dose aspirin may improve the circulation in the placental bed and lead to live birth.