Reverse takotsubo induced cardiogenic shock in the peripartum period: A case report and literature review.

Reverse takotsubo cardiomyopathy is a rare variant of a rare disease characterized by basal ballooning and dysfunction of the left ventricle. While it can render patients profoundly unwell and reliant on intensivist care, it is a transient phenomenon, with the worst symptoms subsiding after 2-3 days. At term, a young woman spontaneously entered labor prior to a planned repeat cesarean section. After experiencing physical and psychological distress during labor and a vacuum extraction, she developed cardiogenic shock from reverse takotsubo cardiomyopathy, quickly diagnosed with transthoracic echocardiogram. She required 2 days of intensive care support and made an excellent recovery. This very rare condition should be considered in systemically unwell women in the peripartum as it can be quickly diagnosed, providing patients with the best appropriate care.

The use of intrapartum ultrasound in operative vaginal birth: a retrospective cohort study.

BACKGROUND: Poor outcomes from operative vaginal birth have been associated with failure to recognize malposition, breakdown in interdisciplinary communication, and deviation from accepted guidelines. We recently implemented a safety bundle including routine intrapartum ultrasound and a structured time-out and procedural checklist aiming to reduce maternal and perinatal morbidity from operative vaginal birth. OBJECTIVE: This study aimed to compare births where intrapartum ultrasound was used and those where it was not used during a safety bundle implementation period at Monash Health. STUDY DESIGN: We performed a retrospective cohort study at Monash Health during the transitional phase of implementing an operative vaginal birth safety bundle. We studied all women with operative vaginal birth and fully dilated cesarean delivery with a singleton cephalic term fetus. We compared births for which intrapartum ultrasound was used and those for which it was not. The primary outcome was neonates delivered in an unexpected position. Neonatal and maternal morbidity were also assessed, including a neonatal composite of Apgar score <7 at 5 minutes, cord lactate >8 mmol/L, need for resuscitation, significant birth trauma, or neonatal intensive care unit admission. To control for confounding by indication, we estimated propensity scores for the probability of using intrapartum ultrasound for each case based on maternal and labor characteristics, and adjusted the effect estimates for the propensity scores using multivariable logistic regression models. RESULTS: From August 2022 to July 2023, there were 1205 operative vaginal births or fully dilated cesarean deliveries at Monash Health, including 743 (61.7%) forceps, 346 (28.7%) vacuum, and 116 (9.6%) fully dilated cesarean deliveries. Over this time, we observed increased uptake of intrapartum ultrasound from 26% in August 2022 to 60% (P<.001) in July 2023, of the time-out from 21% to 58% (P<.001), and the checklist from 33% to 80% (P<.001) of operative second-stage births. Among the births where intrapartum ultrasound was used (n=509), compared with those where it was not (n=696), there were significantly more forceps births (67% vs 58%; adjusted odds ratio, 1.35; 95% confidence interval, 1.05-1.74; P=.021) and a reduction in vacuum births (24% vs 32%; adjusted odds ratio, 0.77; 95% confidence interval, 0.58-1.01; P=.059). There were no significant differences in fully dilated cesarean delivery or maternal morbidity. Intrapartum ultrasound use was associated with significantly fewer infants being delivered in an unexpected position (0.2% vs 2.2%; adjusted odds ratio, 0.08; 95% confidence interval, 0.00-0.44; P=.019) and a significant reduction in composite neonatal morbidity (22% vs 25%; adjusted odds ratio, 0.73; 95% confidence interval, 0.54-0.97; P=.031). CONCLUSION: During the implementation of a safety bundle, the use of ultrasound before operative vaginal birth was associated with fewer infants delivered in an unexpected position and reduced neonatal morbidity.

Patterns of Labour Interventions and Associated Maternal Biopsychosocial Factors in Australia: a Path Analysis.

In Australia, nearly half of births involve labour interventions. Prior research in this area has relied on cross-sectional and administrative health data and has not considered biopsychosocial factors. The current study examined direct and indirect associations between biopsychosocial factors and labour interventions using 19 years of population-based prospective data. The study included singleton babies among primiparous women of the 1973-1978 cohort of the Australian Longitudinal Study on Women's Health. Data from 5459 women who started labour were analysed using path analysis. 42.2% of babies were born without intervention (episiotomy, instrumental, or caesarean delivery): Thirty-seven percent reported vaginal birth with episiotomy and instrumental birth interventions, 18% reported an unplanned caesarean section without episiotomy and/or instrumental interventions, and 3% reported unplanned caesarean section after episiotomy and/or instrumental interventions. Vaginal births with episiotomy and/or instrumental interventions were more likely among women with chronic hypertension (RRR(95%-CI):1.50(1.12-2.01)), a perceived length of labour of more than 36 h (RRR(95%-CI):1.86(1.45-2.39)), private health insurance (RRR(95%-CI):1.61(1.41-1.85)) and induced labour (RRR(95%-CI):1.69(1.46-1.94)). Risk factors of unplanned caesarean section without episiotomy and/or instrumental birth intervention included being overweight (RRR(95%-CI):1.30(1.07-1.58)) or obese prepregnancy (RRR(95%-CI):1.63(1.28-2.08)), aged ≥ 35 years (RRR(95%-CI):1.87(1.46-2.41)), having short stature (< 154 cm) (RRR(95%-CI):1.68(1.16-2.42)), a perceived length of labour of more than 36 h (RRR(95%-CI):3.26(2.50-4.24)), private health insurance (RRR(95%-CI):1.38(1.17-1.64)), and induced labour (RRR(95%-CI):2.56(2.16-3.05)). Prevention and management of hypertension, diabetes, and obesity during preconception and/or antenatal care are keys for reducing labour interventions and strengthening the evidence-base around delivery of best practice obstetric care.

Association between high levels of comorbid anxiety and depressive symptoms and decreased likelihood of birth without intervention: A longitudinal prospective cohort study.

OBJECTIVE: To assess the association between trajectories of comorbid anxiety and depressive (CAD) symptoms assessed in each pregnancy trimester and physiological birth. DESIGN: Large longitudinal prospective cohort study with recruitment between January 2013 and September 2014. SETTING: Primary care, in the Netherlands. POPULATION: Dutch-speaking pregnant women with gestational age at birth ≥37 weeks, and without multiple pregnancy, severe psychiatric disorder or chronic disease history. METHODS: Pregnancy-specific anxiety and depressive symptoms were measured prospectively in each trimester of pregnancy using the negative affect subscale of the Tilburg Pregnancy Distress Scale and Edinburgh (Postnatal) Depression Scale. Data on physiological birth were obtained from obstetric records. Multivariate growth mixture modelling was performed in MPLUS to determine longitudinal trajectories of CAD symptoms. Multiple logistic regression analysis was used to examine the association between trajectories and physiological birth. MAIN OUTCOME MEASURES: Trajectories of CAD symptoms and physiological birth. RESULTS: Seven trajectories (classes) of CAD symptoms were identified in 1682 women and subsequently merged into three groups: group 1-persistently low levels of symptoms (reference class 1; 79.0%), group 2-intermittently high levels of symptoms (classes 3, 6 and 7; 11.2%), and group 3-persistently high levels of symptoms (classes 2, 4 and 5; 9.8%). Persistently high levels of CAD symptoms (group 3) were associated with a lower likelihood of physiological birth (odds ratio 0.67, 95% confidence interval 0.47-0.95, P = 0.027) compared with the reference group (persistently low levels of symptoms), after adjusting for confounders. CONCLUSIONS: This study is the first showing evidence that persistently high CAD levels, assessed in each pregnancy trimester, are associated with a lower likelihood of physiological birth.

Prognostic accuracy of ultrasound measures of fetal head descent to predict outcome of operative vaginal birth: a comparative systematic review and meta-analysis.

OBJECTIVE: This study aimed to compare the prognostic accuracy of intrapartum transperineal ultrasound measures of fetal descent before operative vaginal birth in predicting complicated or failed procedures. DATA SOURCES: We performed a predefined systematic search in Medline, Embase, CINAHL, and Scopus from inception to June 10, 2022. STUDY ELIGIBILITY CRITERIA: We included studies assessing the following intrapartum transperineal ultrasound measures before operative vaginal birth to predict procedure outcome: angle of progression, head direction, head-perineum distance, head-symphysis distance, midline angle, and/or progression distance. METHODS: Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Bivariate meta-analysis was used to pool sensitivities and specificities into summary receiver operating characteristic curves for each intrapartum transperineal ultrasound measure. Subgroup analyses were performed for measures taken at rest vs with pushing and prediction of failed vs complicated operative vaginal birth. RESULTS: Overall, 16 studies involving 2848 women undergoing attempted operative vaginal birth were included. The prognostic accuracy of intrapartum transperineal ultrasound measures taken at rest to predict failed or complicated operative vaginal birth was high for angle of progression (area under the receiver operating characteristic curve, 0.891; 9 studies) and progression distance (area under the receiver operating characteristic curve, 0.901; 3 studies), moderate for head direction (area under the receiver operating characteristic curve, 0.791; 6 studies) and head-perineum distance (area under the receiver operating characteristic curve, 0.747; 8 studies), and fair for midline angle (area under the receiver operating characteristic curve, 0.642; 4 studies). There was no study with sufficient data to assess head-symphysis distance. Subgroup analysis showed that measures taken with pushing tended to have a higher area under the receiver operating characteristic curve for angle of progression (0.927; 4 studies), progression distance (0.930; 2 studies), and midline angle (0.903; 3 studies), with a similar area under the receiver operating characteristic curve for head direction (0.802; 4 studies). The prediction of failed vs complicated operative vaginal birth tended to be less accurate for angle of progression (0.837 [4 studies] vs 0.907 [6 studies]) and head direction (0.745 [3 studies] vs 0.810 [5 studies]), predominantly because of lower specificity, and was more accurate for head-perineum distance (0.812 [6 studies] vs 0.687 [2 studies]). CONCLUSION: Angle of progression, progression distance, and midline angle measured with pushing demonstrated the highest prognostic accuracy in predicting complicated or failed operative vaginal birth. Overall, the measurements seem to perform better with pushing than at rest.

Mother-infant contact after birth can reduce postpartum post-traumatic stress symptoms through a reduction in birth-related fear and guilt.

OBJECTIVES: Despite the well-documented negative effects of posttraumatic stress symptoms following childbirth (PTSS-FC), research on protective factors for PTSS-FC is still missing. Aiming to fill this gap, we proposed and examined a process model through which maternal-infant skin-to-skin contact after birth reduces PTSS-FC by decreasing negative emotions, especially for women who had operative births. METHOD: In this longitudinal study, pregnant women (N = 1833) were recruited at community and hospital medical centres in the center of Israel and through internet forums. At Time 1, during pregnancy, they rated their prenatal depressive symptoms which served as an indicator for prenatal vulnerabilities. At Time 2, two-months postpartum (N = 1371, 75% of the sample), they reported their mode of birth, whether they had skin-to-skin contact with their newborn after birth, their emotions during birth, and rated their current PTSS-FC. A moderated mediation analysis was used to examine the proposed model. RESULTS: Guilt and fear during birth mediated the association between mode of birth (instrumental or cesarean versus vaginal) and PTSS-FC. Skin-to-skin contact was related to reduced feelings of guilt and fear during birth, especially for women who had a cesarean section. CONCLUSIONS: Our results recognize the specific emotions that contribute to the development of PTSS-FC following operative births and show how skin-to-skin contact can possibly reduce them. As such they emphasize the importance of the implementation of skin-to-skin contact following childbirth, and especially following a cesarean section as recommended by the Baby Friendly Health Initiative (World Health Organization & UNICEF, 2009).

Risk of obstetric anal sphincter injury among women who birth vaginally after a prior caesarean section: A state-wide cohort study.

OBJECTIVE: Vaginal birth after caesarean (VBAC) has been suggested to be associated with an increased risk of obstetric anal sphincter injury (compared with primiparous women who birth vaginally). However, prior studies have been small or have used outdated methodology. We set out to validate whether the risk of obstetric anal sphincter injury among women having their first VBAC is greater than that among primiparous women having a vaginal birth. DESIGN: State-wide retrospective cohort study. SETTING: Victoria, Australia. POPULATION: All births (455 000) between 2009 and 2014. METHODS: The risk of severe perineal injury between the first vaginal birth and the first VBAC was compared, after adjustment for potential confounding variables. Covariates were examined using logistic regression for categorical data and the Wilcoxon rank-sum test for continuous data. Missing data were handled using multiple imputation; the analysis was performed using regression adjustment and stata 16 multiple imputation and suite of effects commands. RESULTS: Women having a VBAC (n = 5429) were significantly more likely than primiparous women (n = 123 353) to sustain a third- or fourth-degree tear during vaginal birth (7.1 versus 5.7%, p < 0.001). After adjustment for mode of birth, body mass index, maternal age, infant birthweight, episiotomy and epidural, there was a 21% increased risk of severe perineal injury (RR 1.21, 95% CI 1.07-1.38). CONCLUSIONS: Women having their first VBAC have a significantly increased risk of sustaining a third- or fourth-degree tear, compared with primiparous women having a vaginal birth. Patient counselling and professional guidelines should reflect this increased risk.

Who benefits most from skin-to-skin mother-infant contact after birth? Survey findings on skin-to-skin and birth satisfaction by mode of birth.

OBJECTIVE: Previous research has shown that skin-to-skin contact in the delivery room is associated with an increase satisfaction with childbirth. The purpose of the present study was to examine whether this association differs as a function of mode of birth, such that the positive effect of skin-to-skin contact would be especially pronounced for women who had operative births. DESIGN: Survey design using self-administered questionnaires during pregnancy (Time 1) and at two months postpartum (Time 2). SETTING: At Time 1, women were recruited at community and hospital medical centres in two large metropolitan areas in the centre of Israel and through home midwives and internet forums. At Time 2, women completed a second questionnaire in which they reported whether they had skin-to-skin contact with their infant immediately after birth and their birth satisfaction. PARTICIPANTS: Pregnant women, gestation week ≥24, with singleton pregnancy, who took part in both T1 and T2 (N = 1371, 75% of the 1833 women recruited at T1). MEASUREMENTS: Analysis of covariance (ANCOVA) was used to examine whether the association between skin-to-skin contact after birth and birth satisfaction two months post-partum, differs as a function of mode of birth. Maternal or infant complications during birth, parity, and whether the pregnancy was planned, served as covariates. Birth satisfaction was measured using the Childbirth Satisfaction Scale. All measures were self-reported. FINDINGS: The frequency of skin-to-skin was high (83%) for women who had vaginal birth, but lower for women who had an instrumental birth (66%) or a caesarean section (31%). At two months postpartum, women who had operative births reported less satisfaction with their birth than women who gave birth via vaginal birth. A significant interaction between skin-to-skin and mode of birth showed that although skin-to-skin was associated with higher birth satisfaction among women across all three modes of birth, i.e., vaginal (Cohen's d = .41), instrumental (Cohen's d = .64) and caesarean (Cohen's d = .87), the effect for the difference in birth satisfaction between women with and without skin-to-skin was especially large for operative births, particularly for caesarean sections. KEY CONCLUSIONS: Operative birth is related to lower satisfaction with childbirth and lower rates of skin-to-skin contact immediately after birth. Yet, the association between skin-to-skin and birth satisfaction is especially strong for women who had operative births and specifically a caesarean section, suggesting that the possible contribution of skin-to-skin to birth satisfaction should be emphasised particularly after operative births. IMPLICATIONS FOR PRACTICE: It is recommended that maternity care providers, managers, policy makers and medical teams facilitate skin-to-skin contact between the woman and her infant immediately, or as soon as possible, after childbirth, in both operative and non-operative births.

Characteristics and changes in characteristics of women and babies admitted to residential parenting services in New South Wales, Australia in the first year following birth: a population-based data linkage study 2000-2012.

OBJECTIVE: To examine the characteristics of women and babies admitted to the residential parenting services (RPS) of Tresillian and Karitane in the first year following birth. DESIGN: A linked population data cohort study was undertaken for the years 2000-2012. SETTING: New South Wales (NSW), Australia. PARTICIPANTS: All women giving birth and babies born in NSW were compared with those admitted to RPS. RESULTS: During the time period there were a total of 1 097 762 births (2000-2012) in NSW and 32 991 admissions to RPS. Women in cohort 1: (those admitted to RPS) were older at the time of birth, more likely to be admitted as a private patient at the time of birth, be born in Australia and be having their first baby compared with women in cohort 2 (those not admitted to an RPS). Women admitted to RPS experienced more birth intervention (induction, instrumental birth, caesarean section), had more multiple births and were more likely to have a male infant. Their babies were also more likely to be resuscitated and have experienced birth trauma to the scalp. Between 2000 and 2012 the average age of women in the RPS increased by nearly 2 years; their infants were older on admission and women were less likely to smoke. Over the time period there was a drop in the numbers of women admitted to RPS having a normal vaginal birth and an increase in women having an instrumental birth. CONCLUSION: Women who access RPS in the first year after birth are more socially advantaged and have higher birth intervention than those who do not, due in part to higher numbers birthing in the private sector where intervention rates are high. The rise in women admitted to RPS (2000-2012) who have had instrumental births is intriguing as overall rates did not increase.

Relative effectiveness and cost-effectiveness of the midwifery-led care in Nova Scotia, Canada: A retrospective, cohort study.

OBJECTIVES: To compare neonatal and maternal outcomes, and the relative risk of interventions between mothers attended to by midwives, general practitioners, and obstetricians, and to assess the cost-effectiveness of the employee-model of midwifery-led care in Nova Scotia, Canada, when compared with general practitioners. DESIGN, SETTING, AND PARTICIPANTS: The study was a retrospective cohort study involving routinely collected clinical and administrative data from all low-risk births from January 1st, 2013 to December 31st, 2017. There were 24,662 observations. MEASUREMENTS: Descriptive statistics were used to summarise the mother's socio-demographic characteristics. We used a nearest-neighbour matching estimator in assessing differences in outcomes, and generalized linear models in the estimation of the risks of interventions, adjusting for potential confounders. An analytic decision tree served as the vehicle for the cost-effectiveness analysis, assessed using the net monetary benefit approach. All health care resources utilized were measured and valued. Neonatal intensive care admissions avoided was the measure of outcome. We performed probabilistic sensitivity and subgroup analyses. FINDINGS: Mothers attended to by midwives spent less time at the hospital during birth admissions, were less likely to have interventions, instrumental births, and more likely to have exclusive breastfeeding at discharge from birth admission. There were no differences in Apgar scores and neonatal intensive care unit admissions. The employee-model of midwifery-led care was found to be cost-effective. KEY CONCLUSIONS: The midwifery program is both effective and cost-effective for low-risk pregnancies IMPLICATIONS FOR PRACTICE: Increasing the number of midwives will increase access and represents value for money.

Effect of planned place of birth on obstetric interventions and maternal outcomes among low-risk women: a cohort study in the Netherlands.

BACKGROUND: The use of interventions in childbirth has increased the past decades. There is concern that some women might receive more interventions than they really need. For low-risk women, midwife-led birth settings may be of importance as a counterbalance towards the increasing rate of interventions. The effect of planned place of birth on interventions in the Netherlands is not yet clear. This study aims to give insight into differences in obstetric interventions and maternal outcomes for planned home versus planned hospital birth among women in midwife-led care. METHODS: Women from twenty practices across the Netherlands were included in 2009 and 2010. Of these, 3495 were low-risk and in midwife-led care at the onset of labour. Information about planned place of birth and outcomes, including instrumental birth (caesarean section, vacuum or forceps birth), labour augmentation, episiotomy, oxytocin in third stage, postpartum haemorrhage >1000 ml and perineal damage, came from the national midwife-led care perinatal database, and a postpartum questionnaire. RESULTS: Women who planned home birth more often had spontaneous birth (nulliparous women aOR 1.38, 95 % CI 1.08-1.76, parous women aOR 2.29, 95 % CI 1.21-4.36) and less often episiotomy (nulliparous women aOR 0.73, 0.58-0.91, parous women aOR 0.47, 0.33-0.68) and use of oxytocin in the third stage (nulliparous women aOR 0.58, 0.42-0.80, parous women aOR 0.47, 0.37-0.60) compared to women who planned hospital birth. Nulliparous women more often had anal sphincter damage (aOR 1.75, 1.01-3.03), but the difference was not statistically significant if women who had caesarean sections were excluded. Parous women less often had labour augmentation (aOR 0.55, 0.36-0.82) and more often an intact perineum (aOR 1.65, 1.34-2.03). There were no differences in rates of vacuum/forceps birth, unplanned caesarean section and postpartum haemorrhage >1000 ml. CONCLUSIONS: Women who planned home birth were more likely to give birth spontaneously and had fewer medical interventions.