Determinants of successful labor induction in a teaching hospital in Nigeria: a 10-year review / Determinantes da indução do trabalho de parto bem sucedida em hospital-escola na Nigéria: uma revisão de 10 anos

Abstract Objectives: to evaluate the success rate of labor induction and determinants of successful outcome. Methods: retrospective cohort study of parturients that undergone labor induction between 2006 and 2015. Data was retrieved from the medical records and multivariate logistic regression was used to evaluate the determinants of successful labor induction. Results: the rate of labor induction was 10.9%. Out of the 940 women analysed, six hundred and fifty-six women (69.8%) had successful vaginal delivery. Labor induction at 39-40 weeks (OR=2.70; CI95%=1.17-6.36), 41 weeks (OR=2.44; CI95%=1.14-5.28), estimated fetal weight between 2.5 and 3.4kg (OR=4.27, CI95%=1.96-5.59) and estimated fetal weight of 3.5-3.9kg (OR=5.45; CI95%=2.81-10.60) increased the odds of achieving vaginal delivery. Conclusions: our findings suggest that 39, 40 and 41 weeks are optimal gestational ages for labor induction with respect to successful vaginal delivery. Also, estimated fetal weight between 2.5kg and 3.9kg favours successful vaginal delivery.

Resumo Objetivos: avaliar a taxa de sucesso da indução do trabalho de parto e determinantes de um resultado bem sucedido. Métodos: estudo de coorte retrospectivo de parturientes que submeteram a indução de trabalho de parto entre 2006 e 2015. Os dados foram recuperados dos registros médicos e a regressão logística multivariada foi utilizada para avaliar os determinantes da indução de trabalho de parto bem sucedida. Resultados: a taxa de indução de trabalho de parto foi de 10,9%. Das 940 mulheres analisadas, seiscentas e cinquenta e seis mulheres (69,8%) tiveram um parto vaginal bem sucedido. A indução de trabalho de parto nas 39-40 semanas (OR=2,70; IC95%=1,17-6,36), 41 semanas (OR=2,44; IC95%=1,14-5,28), peso fetal estimado entre 2,5 e 3,4kg OR=4,27; IC95%=1,96-5,59) e peso fetal estimado entre 3,5-3,9kg (OR=5,45; IC95%=2,81-10,60) aumentou as probabilidades de conseguir um parto vaginal. Conclusões: as nossas conclusões sugerem que as 39, 40 e 41 semanas são idades gestacionais ideais para a indução do trabalho de parto no que diz respeito ao sucesso do parto vaginal. Além disso, o peso fetal estimado entre 2,5kg e 3,9kg favorece o parto vaginal bem sucedido.

Obstetric and neonatal outcomes in women with pregnancy associated cancer: a population-based study in Lombardy, Northern Italy.

BACKGROUND: Pregnancy associated cancer (PAC) may lead to adverse obstetric and neonatal outcomes. This study aims to assess the association between PACs and adverse perinatal outcomes [i.e. labor induction, iatrogenic delivery, preterm birth, small for gestational age (SGA) newborn, low Apgar score, major malformations, perinatal mortality] in Lombardy, Northern Italy. METHODS: This population-based historic cohort study used the certificate of delivery assistance and the regional healthcare utilization databases of Lombardy Region to identify beneficiaries of National Health Service who delivered between 2008 and 2017. PACs were defined through oncological ICD-9-CM codes reported in the hospital discharge forms. Each woman with PAC was matched to four women randomly selected from those cancer-free (1:4). Log-binomial regression models were fitted to estimate crude and adjusted prevalence ratio (aPR) and the corresponding 95% confidence interval (CI) of each perinatal outcome among PAC and cancer-free women. RESULTS: Out of the 657,968 deliveries, 831 PACs were identified (1.26 per 1000). PAC diagnosed during pregnancy was positively associated with labor induction or planned delivery (aPR=1.80, 95% CI: 1.57-2.07), cesarean section (aPR=1.78, 95% CI: 1.49-2.11) and premature birth (aPR=6.34, 95% CI: 4.59-8.75). No association with obstetric outcomes was found among PAC diagnosed in the post-pregnancy. No association of PAC, neither during pregnancy nor in post-pregnancy was found for SGA (aPR=0.71, 95% CI: 0.36-1.35 and aPR=1.04, 95% CI: 0.78-1.39, respectively), but newborn among PAC women had a lower birth weight (p-value< 0.001). Newborns of women with PAC diagnosed during pregnancy had a higher risk of borderline significance of a low Apgar score (aPR=2.65, 95% CI: 0.96-7.33) as compared to cancer-free women. CONCLUSION: PAC, especially when diagnosed during pregnancy, is associated with iatrogenic preterm delivery, compromising some neonatal heath indicators.

Relations between second-trimester aneuploidy screening results and prediction of labour induction success in term pregnancies.

We aimed to assess whether the second-trimester maternal serum markers could be used for the prediction of labour induction success. This prospective study enrolled women planned labour induction at term. Women were assigned to one of two groups: vaginal prostaglandin or balloon dilatation. All patients were evaluated for Bishop score, maternal serum oestriol, human chorionic gonadotropin and progesterone at the time of second-aneuploidy screening. The total successful rate for induction of labour was 63.9% in both groups. Maternal serum oestriol multiple of median (MoM) values were significantly lower among the caesarean section group compared to the vaginal delivery group (p < .001). A MoM value of 0.74 for oestriol was associated with a sensitivity of 75.9%, specificity of 41.0%, a positive predictive value of 76.6% and a negative predictive value of 58.0% for a successful induction of labour. Oestriol had a good performance in the prediction of successful induction of labour at term.IMPACT STATEMENTWhat is already known on this subject? Induction of labour is a common procedure undertaken whenever the benefits of prompt delivery outweigh the risks of expectant management. Previous studies have reported that a decreased progesterone/oestradiol ratio and increased maternal plasma oestriol levels are associated with successful labour. What the results of this study add? The results of this study showed that second-trimester oestriol multiple of median (MoM) value provide a significant contribution to the efforts of the prediction of successful induction of labour in term pregnancy, having a sensitivity of 69.8%, specificity of 92.4%, positive predictive value of 83.3% and negative predictive value of 82.5%.What the implications are of these findings for clinical practice and/or further research? This finding can be used as an additional method for prediction of labour induction as well as multiparity and Bishop score. This adds new valuable data to the literature which could be used for systematic reviews and for implementing guidelines and protocols on labour induction.

Do you pay to go private?: a single centre comparison of induction of labour and caesarean section rates in private versus public patients.

BACKGROUND: The aim of this study was to compare rates of induction and subsequent caesarean delivery among nulliparous women with private versus publicly funded health care at a single institution. This is a retrospective cohort study using the electronic booking and delivery records of nulliparous women with singleton pregnancies who delivered between 2010 and 2015 in an Irish Tertiary Maternity Hospital (approx. 9000 deliveries per annum). METHODS: Data were extracted from the National Maternity Hospital (NMH), Dublin, Patient Administration System (PAS) on all nulliparous women who delivered a liveborn infant at ≥37 weeks gestation during the 6-year period. At NMH, all women in spontaneous labour are managed according to a standardised intrapartum protocol. Twenty-two thousand two hundred thirty-two women met the inclusion criteria. Of these, 2520 (12.8%) were private patients; the remainder (19,712; 87.2%) were public. Mode of and gestational age at delivery, rates of and indications for induction of labour, rates of pre-labour caesarean section, and maternal and neonatal outcomes were examined. Rates of labour intervention and subsequent maternal and neonatal outcomes were compared between those with and without private health cover. RESULTS: Women attending privately were more than twice as likely to have a pre-labour caesarean section (12.7% vs. 6.5%, RR = 2.0, [CI 1.8-2.2])); this finding persisted following adjustment for differences in maternal age and body mass index (BMI) (adjusted relative risk 1.74, [CI 1.5-2.0]). Women with private cover were also more likely to have induction of labour and significantly less likely to labour spontaneously. Women who attended privately were significantly more likely to have an operative vaginal delivery, whether labour commenced spontaneously or was induced. CONCLUSIONS: These findings demonstrate significant differences in rates of obstetric intervention between those with private and public health cover. This division is unlikely to be explained by differences in clinical risk factors as no significant difference in outcomes following spontaneous onset of labour were noted. Further research is required to determine the roots of the disparity between private and public decision-making. This should focus on the relative contributions of both mothers and maternity care professionals in clinical decision making, and the potential implications of these choices.

Cesarean-section rates in Brazil from 2014 to 2016: cross-sectional Aanalysis using the robson classification / Taxas de cesariana no Brasil de 2014 a 2016: análise transversal utilizando a classificação de robson

Abstract Objective To obtain cesarean-section (CS) rates according to the Robson Group Classification in five different regions of Brazil. Methods A descriptive epidemiological study using data from secondary birth records fromthe Computer Science Department of the Brazilian Unified Health System (Datasus, in Portuguese) between January 1st, 2014, and December 31st, 2016, including all live births in Brazil. Results The overall rate of CSwas of 56%. The sample was divided into 11 groups, and vaginal births were more frequent in groups 1 (53.6%), 3 (80.0%) and 4 (55.1%). The highest CS rates were found in groups 5 (85.7%), 6 (89.5%), 7 (85.2%) and 9 (97.0%). The overall CS rate per region varied from 46.2% in the North to 62.1% in the Midwest. Group 5 was the largest obstetric population in the South, Southeast and Midwest, and group 3 was the largest in the North and Northeast. Group 5 contributed the most to the overall CS rate, accounting for 30.8% of CSs. Conclusion Over half of the births in Brazil were cesarean sections. The Midwest had the highestCS rates,while theNorth had the lowest. The largestobstetric population in the North and in the Northeast was composed of women in group 3, while in the South, Southeast and Midwest it was group 5. Among all regions, the largest contribution to the overall CS rate was from group 5.

Resumo Objetivo Identificar as taxas de cesárea de acordo com a Classificação de Robson nas cinco regiões do Brasil. Métodos Estudo epidemiológico descritivo utilizando dados secundários obtidos do Departamento de Informática do Sistema Único de Saúde (Datasus) entre 1° de janeiro de 2014 e 31 de dezembro de 2016, incluindo todos os nascidos vivos no Brasil. Resultados Cesáreas representaram 56% de todos os nascimentos. A amostra foi dividida em 11 grupos, e partos vaginais forammais frequentes nos grupos 1 (53,6%), 3(80,0%) e 4 (55,1%). As maiores taxas de cesárea foram encontradas nos grupos 5 (85,7%), 6 (89,5%), 7 (85,2%) e 9 (97,0%). A taxa geral de cesárea variou de 46,2% no Norte a 62,1% no Centro-Oeste. O grupo 5 representou a maior população obstétrica no Sul, Sudeste e Centro-Oeste, e o grupo 3, no Norte e Nordeste. O grupo 5 contribuiu mais para a taxa geral de cesárea, totalizando 30,8%. Conclusão Mais da metade dos nascimentos no Brasil ocorreu por cesárea. O Centro- Oeste apresentou a maior taxa, e o Norte, a mais baixa. A maior população obstétrica no Norte e no Nordeste foi o grupo 3, enquanto no Sul, Sudeste e Centro-Oeste foi o grupo 5. Entre todas as regiões, amaior contribuição para a taxa geral de cesárea foi do grupo 5.

Do lifetime anxiety disorders (anxiety liability) and pregnancy-related anxiety predict complications during pregnancy and delivery?

BACKGROUND: Evidence suggests that maternal anxiety is associated with adverse pregnancy and delivery outcomes, such as preterm birth, vaginal bleedings and low birth weight. AIMS: To examine the association of lifetime anxiety disorders and pregnancy-related anxiety and complications during pregnancy and delivery. STUDY DESIGN: Prospective-longitudinal study (MARI). SUBJECTS: N = 306 pregnant women who were investigated repeatedly during the peripartum period. OUTCOME MEASURES: Information on lifetime anxiety disorders was assessed using a dimensional score (lifetime anxiety liability index) based on the standardized Composite International Diagnostic Interview for Women (CIDI-V). Pregnancy-related anxiety was surveyed with the Pregnancy and Childbirth Related Fears (PCF) questionnaire. Common pregnancy (e.g. vaginal bleedings) and delivery complications (e.g. labor induction) were assessed via medical records, interviews and questionnaires. RESULTS: The global tests on the association between lifetime anxiety liability and pregnancy complications and on the association between pregnancy-related anxiety and pregnancy/delivery complications revealed significant associations. Further analyses revealed associations of lifetime anxiety liability with preterm labor (OR = 1.6, 95% CI = 1.2-2.0) as well as pregnancy-related anxiety with vaginal bleedings (OR = 1.4, 95% CI = 1.0-1.8), preterm labor (OR = 1.3, 95% CI = 1.0-1.7), gestational diabetes (OR 0.5, 95% CI = 0.2-0.9), labor induction (OR = 1.5, 95% CI = 1.1-1.9) and use of labor medication (OR = 1.6, 95% CI = 1.2-2.0). After adjustment for maternal age, maternal body mass index, maternal smoking, socioeconomic status (occupation, household income) and social support (cohabitation), the associations between pregnancy-related anxiety and labor induction as well as use of labor medication remained significant. CONCLUSIONS: Pregnancy-related anxiety should be regularly assessed and, if necessary, treated during (early) pregnancy to minimize risks for complications during delivery.

Development and Validation of a Risk Prediction Model for Cesarean Delivery After Labor Induction.

Objective: The goal of the study was to develop and validate a prediction model for cesarean delivery after labor induction that included factors known before the start of induction, unlike prior studies that focused on characteristics at the time of induction. Materials and Methods: Using 17,370 term labor inductions without documented medical indications occurring at 14 U.S. hospitals, 2007-2012, we created and evaluated a model predicting cesarean delivery. We assessed model calibration and discrimination, and we used bootstrapping for internal validation. We externally validated the model by using 2122 labor inductions from a hospital not included in the development cohort. Results: The model contained eight variables-gestational age, maternal race, parity, maternal age, obesity, fibroids, excessive fetal growth, and history of herpes-and was well calibrated with good risk stratification at the extremes of predicted probability. The model had an area under the curve (AUC) for the receiver operating characteristic curve of 0.82 (95% confidence interval 0.81-0.83), and it performed well on internal validation. The AUC in the external validation cohort was 0.82. Conclusion: This prediction model can help providers estimate a woman's risk of cesarean delivery when planning a labor induction.

Pregnancy outcome in women with cerebral palsy: A nationwide population-based cohort study.

INTRODUCTION: Cerebral palsy (CP) is a lifelong disorder with a high rate of comorbidities and complications. We hypothesized that women with CP are at increased risk of adverse pregnancy outcome. MATERIAL AND METHODS: In this nationwide population-based cohort study 1997-2011, we examined the outcome of 770 births in women with CP vs 1 247 408 births in women without a CP diagnosis using the Swedish Medical Birth Register. We used unconditional logistic regression, adjusting for maternal age, smoking, parity, year of birth and epilepsy, to calculate adjusted odds ratios for adverse pregnancy outcome. Main adverse outcome was preterm birth. Secondary outcomes were cesarean section, induction of labor, low 5-min Apgar score, small for gestational age, large for gestational age, and stillbirth. RESULTS: After adjusting for potential confounders, maternal CP was associated with increased risk of preterm birth (12.9% vs 4.9%; adjusted odds ratio [aOR] 2.8, 95% CI 2.3-3.5), cesarean delivery (aOR 1.9, 95% CI 1.6-2.2), induced delivery (aOR 1.4, 95% CI 1.1-1.6), low 5-min Apgar score (aOR 1.8, 95% CI 1.1-2.9) and small of gestational age birth (aOR 1.6, 95% CI 1.2-2.3). We found no increased risk of large for gestational age or stillbirth. CONCLUSIONS: Women with CP are at increased risk of preterm birth and other adverse pregnancy outcomes, suggesting that they deserve extra surveillance during antenatal care. Further studies, with information on type of CP and gross motor function, are warranted to better understand the association between CP and pregnancy outcome.

Screening for small-for-gestational-age fetuses.

INTRODUCTION: It is well established that correct antenatal identification of small-for-gestational-age (SGA) fetuses reduces their risk of adverse perinatal outcome with long-term consequences. Ultrasound estimates of fetal weight (EFWus ) are the ultimate tool for this identification. It can be conducted as a "universal screening", that is, all pregnant women at a specific gestational age. However, in Denmark it is conducted as "selective screening", that is, only on clinical indication. The aim of this study was to assess the performance of the Danish national SGA screening program and the consequences of false-positive and false-negative SGA cases. MATERIAL AND METHODS: In this retrospective cohort study, we included 2928 women with singleton pregnancies with due dates in 2015. We defined "risk of SGA" by an EFWus  ≤ -15% of expected for the gestational age and "SGA" as birthweight ≤-22% of expected for gestational age. RESULTS: At birth, the prevalence of SGA was 3.3%. The overall sensitivity of the Danish screening program was 62% at a false-positive rate of 5.6%. Within the entire cohort, 63% had an EFWus compared with 79% of the SGA cases. The sensitivity was 79% for those born before 37 weeks of gestation but only 40% for those born after 40 weeks of gestation. The sensitivity was also associated with birthweight deviation; 73% among extreme SGA cases (birthweight deviation ≤-33%) and 55% among mild SGA (birthweight deviation between -22% and -27%). False diagnosis of SGA was associated with an increased rate of induction of labor (ORadj  = 2.51, 95% CI 1.70-3.71) and cesarean section (ORadj  = 1.44, 95% CI 0.96-2.18). CONCLUSIONS: The performance of the Danish national screening program for SGA based on selective EFWus on clinical indication has improved considerably over the last 20 years. Limitations of the program are the large proportion of women referred to ultrasound scan and the low performance post-term.

Prediction of adverse perinatal outcome by serum placental growth factor and soluble fms-like tyrosine kinase-1 in women undergoing induction of labor.

OBJECTIVE: To investigate the additive value of serum placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1), measured within 24 h prior to induction of labor, to the performance of screening for adverse perinatal outcome provided by maternal risk factors and the cerebroplacental ratio (CPR). METHODS: This was a prospective observational study of 795 singleton pregnancies undergoing induction of labor at ≥ 37 weeks' gestation. Before induction of labor, Doppler ultrasound was used to measure the pulsatility index (PI) in the umbilical artery (UA) and fetal middle cerebral artery (MCA) and maternal blood was obtained for measurement of serum PlGF and sFlt-1. The measured UA-PI, MCA-PI and their ratio (CPR) were converted to multiples of the median (MoM) after adjustment for gestational age, and the measured PlGF and sFlt-1 were converted to MoM after adjustment for gestational age, maternal characteristics and the machine used for the assays. Univariable and multivariable logistic regression analysis was used to determine factors that provided a significant contribution in the prediction of adverse perinatal outcome, defined as the presence of any one of Cesarean section for non-reassuring fetal status in labor, umbilical arterial or venous cord blood pH ≤ 7 and ≤ 7.1, respectively, 5-min Apgar score < 7 or admission to the neonatal intensive care unit for ≥ 24 h. The detection rate (DR) and false-positive rate (FPR) in screening for adverse perinatal outcome were determined. RESULTS: In pregnancies with adverse perinatal outcome, compared to those without, median serum PlGF MoM was lower (0.44; interquartile range (IQR), 0.30-0.82 vs 0.60; IQR, 0.36-1.07; P = 0.003), but median sFlt-1 MoM was not significantly different (P = 0.080). Multivariable regression analysis demonstrated that, in the prediction of adverse perinatal outcome, there was significant contribution from maternal risk factors and CPR MoM but not PlGF MoM or sFlt-1 MoM. The performance of screening for adverse perinatal outcome achieved by maternal risk factors alone (DR of 28.9% at FPR of 10%) was not improved by the addition of CPR (DR of 33.8% at FPR of 10%) (area under the curve, 0.702; 95% CI, 0.654-0.750 vs 0.712; 95% CI, 0.664-0.760; P = 0.233). CONCLUSION: Serum PlGF and sFlt-1, measured within 24 h prior to induction of labor, do not provide a significant additional contribution to maternal risk factors in the prediction of adverse perinatal outcome. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Ultrasound Evaluation of the Cervix to Predict Failed Labor Induction.

OBJECTIVE: Labor induction does not always result in vaginal delivery, and can expose both the mother and the fetus to the risks inherent to the induction procedure or a possible cesarean section. Transvaginal sonography (TVS) of the cervix is a useful tool to predict prematurity; in the present study, this tool was used to evaluate postterm induction. METHODS: We evaluated the ultrasound characteristics of the cervix (cervical length, cervical funneling, internal os dilation, the presence or absence of the cervical gland area [CGA], and the morphological changes of the cervix as a result of applying fundal pressure) before the onset of labor induction among women with postterm pregnancy to identify the possible predictors of failed labor induction. The Bishop score (BS) was used for comparison purposes. Three groups were evaluated: successful versus unsuccessful induction; vaginal delivery versus cesarean delivery (excluding cases of acute fetal distress [AFD]); and vaginal delivery versus cesarean delivery (including cases of AFD). A fourth group including only the primiparous women from the three previous groups was also evaluated. RESULTS: Based on the studied characteristics and combinations of variables, a cervical length ≥ 3.0 cm and a BS ≤ 2 were the best predictors of induction failure. CONCLUSION: Although TVS is useful for screening for induction failure, this tool should not be used as an indication for cesarean section.

OBJETIVO: Nem sempre a indução do parto termina em parto vaginal, expondo tanto a mãe quanto o feto aos riscos inerentes ao procedimento de indução, ou a uma possível cesárea. A ultrassonografia transvaginal (UTV) se mostrou interessante instrumento na predição da prematuridade e, neste estudo, utilizamos este instrumento na situação inversa: indução do parto no pós-datismo. MéTODOS: Avaliamos variáveis ultrassonográficas do colo uterino (comprimento, presença de afunilamento, dilatação do orifício interno do colo, eco glandular endocervical [EGE] evidente ou não, e alterações morfológicas do colo uterino à compressão fúndica uterina) antes do início da indução em gestantes com pós-datismo, na tentativa de encontrar um possível preditor de falha de indução. O índice de Bishop (IB) também foi utilizado para fins de comparação. Três grupos foram avaliados: indução bem-sucedida x malsucedida; parto vaginal x cesárea (excluindo casos de sofrimento fetal agudo[SFA]); e parto vaginal x cesárea (incluindo casos de SFA). Além disso, um quarto grupo composto apenas pelas primíparas dos outros três grupos também foi avaliado. RESULTADOS: Com base em todas as características estudadas e combinações de variáveis, o comprimento do colo uterino ≥ 3,0 cm e IB ≤ 2 foram os melhores preditores em todos os grupos analisados. CONCLUSãO: Apesar de a UTV do colo uterino ser um bom exame para rastreamento de indução malsucedida, não deve ser usado para se indicar uma cesariana.

Ultrasound evaluation of the cervix to predict failed labor induction / Avaliação ultrassonográfica do colo uterino na predição do insucesso na indução do parto

Abstract Objective Labor induction does not always result in vaginal delivery, and can expose both the mother and the fetus to the risks inherent to the induction procedure or a possible cesarean section. Transvaginal sonography (TVS) of the cervix is a useful tool to predict prematurity; in the present study, this tool was used to evaluate postterm induction. Methods We evaluated the ultrasound characteristics of the cervix (cervical length, cervical funneling, internal os dilation, the presence or absence of the cervical gland area [CGA], and the morphological changes of the cervix as a result of applying fundal pressure) before the onset of labor induction among women with postterm pregnancy to identify the possible predictors of failed labor induction. The Bishop score (BS) was used for comparison purposes. Three groups were evaluated: successful versus unsuccessful induction; vaginal delivery versus cesarean delivery (excluding cases of acute fetal distress [AFD]); and vaginal delivery versus cesarean delivery (including cases of AFD). A fourth group including only the primiparous women from the three previous groups was also evaluated. Results Based on the studied characteristics and combinations of variables, a cervical length ≥ 3.0 cm and a BS ≤ 2 were the best predictors of induction failure. Conclusion Although TVS is useful for screening for induction failure, this tool should not be used as an indication for cesarean section.

Resumo Objetivo Nem sempre a indução do parto termina emparto vaginal, expondo tanto a mãe quanto o feto aos riscos inerentes ao procedimento de indução, ou a uma possível cesárea. A ultrassonografia transvaginal (UTV) semostrou interessante instrumento na predição da prematuridade e, neste estudo, utilizamos este instrumento na situação inversa: indução do parto no pós-datismo. Métodos Avaliamos variáveis ultrassonográficas do colo uterino (comprimento, presença de afunilamento, dilatação do orifício interno do colo, eco glandular endocervical [EGE] evidente ou não, e alterações morfológicas do colo uterino à compressão fúndica uterina) antes do início da indução em gestantes com pósdatismo, na tentativa de encontrar um possível preditor de falha de indução. O índice de Bishop (IB) também foi utilizado para fins de comparação. Três grupos foram avaliados: indução bem-sucedida x malsucedida; parto vaginal x cesárea (excluindo casos de sofrimento fetal agudo[SFA]); e parto vaginal x cesárea (incluindo casos de SFA). Além disso, um quarto grupo composto apenas pelas primíparas dos outros três grupos também foi avaliado. Resultados Com base em todas as características estudadas e combinações de variáveis, o comprimento do colo uterino ≥ 3,0 cm e IB ≤ 2 foram os melhores preditores em todos os grupos analisados. Conclusão Apesar de a UTV do colo uterino ser um bomexame para rastreamento de indução malsucedida, não deve ser usado para se indicar uma cesariana.

Adverse obstetric outcomes among female childhood and adolescent cancer survivors in Sweden: A population-based matched cohort study.

INTRODUCTION: Cancer treatment during childhood may lead to late adverse effects, such as reduced musculoskeletal development or vascular, endocrine and pulmonary dysfunction, which in turn may have an adverse effect on later pregnancy and childbirth. The aim of the present study was to investigate pregnancy and obstetric outcomes as well as the offspring's health among childhood and adolescent female cancer survivors. MATERIAL AND METHODS: This register-based study included all women born between 1973 and 1977 diagnosed with cancer in childhood or adolescence (age <21), as well as an age-matched comparison group. A total of 278 female cancer survivors with their first childbirth were included in the study, together with 829 age-matched individuals from the general population. Logistic regression and analysis of variance were used to investigate associations between having been treated for cancer and the outcome variables, adjusting for maternal age, nicotine use and comorbidity. RESULTS: Survivors were more likely to have preeclampsia (adjusted odds ratio [aOR] 3.46, 95% confidence interval [CI] 1.58 to 7.56), undergo induction of labor (aOR 1.66, 95% CI 1.05 to 2.62), suffer labor dystocia (primary labor dystocia aOR 3.54, 95% CI 1.51 to 8.34 and secondary labor dystocia aOR 2.43, 95% CI 1.37 to 4.31), malpresentation of fetus (aOR 2.02, 95% CI 1.12 to 3.65) and imminent fetal asphyxia (aOR 2.55, 95% CI 1.49 to 4.39). In addition, deliveries among survivors were more likely to end with vacuum extraction (aOR 2.53, 95% CI 1.44 to 4.47), with higher risk of clitoral lacerations (aOR 2.18, 95% CI 1.47 to 3.23) and anal sphincter injury (aOR 2.76, 95% CI 1.14 to 6.70) and emergency cesarean section (aOR 2.34 95% CI 1.39 to 3.95). Survivors used pain-reliving methods to a higher extent compared with the comparison group. There was no increased risk of neonate diagnoses and malformations. The results showed that survivors who had been diagnosed with cancer when they were younger than 14 had an increased risk of adverse obstetric outcomes. CONCLUSIONS: The study demonstrates increased risk of pregnancy and childbirth complications among childhood and adolescent cancer survivors. There is a need to optimize perinatal care, especially among survivors who were younger than 14 at time of diagnosis.

Exploring Obstetrical Interventions and Stratified Cesarean Section Rates Using the Robson Classification in Tertiary Care Hospitals in the United Arab Emirates.

OBJECTIVE: The objective of the present study was to explore obstetric management in relation to clinical, maternal and child health outcomes by using the Robson classification system. METHODS: Data was collected from obstetrics registries in tertiary care hospitals in Dubai, United Arab Emirates (UAE). RESULTS: The analysis of > 5,400 deliveries (60% of all the deliveries in 2016) in major maternity hospitals in Dubai showed that groups 5, 8 and 9 of Robson's classification were the largest contributors to the overall cesarean section (CS) rate and accounted for 30% of the total CS rate. The results indicate that labor was spontaneous in 2,221 (45%) of the women and was augmented or induced in almost 1,634 cases (33%). The birth indication rate was of 64% for normal vaginal delivery, of 24% for emergency CS, and of 9% for elective CS. The rate of vaginal birth after cesarean was 261 (6%), the rate of external cephalic version was 28 (0.7%), and the rate of induction was 1,168 (21.4%). The prevalence of the overall Cesarean section was 33%; with majority (53.5%) of it being repeated Cesarean section. CONCLUSION: The CS rate in the United Arab Emirates (UAE) is higher than the global average rate and than the average rate in Asia, which highlights the need for more education of pregnant women and of their physicians in order to promote vaginal birth. A proper planning is needed to reduce the number of CSs in nulliparous women in order to prevent repeated CSs in the future. Monitoring both CS rates and outcomes is essential to ensure that policies, practices, and actions for the optimization of the utilization of CS lead to improved maternal and infant outcomes.

Exploring obstetrical interventions and stratified cesarean section rates using the Robson classification in tertiary Care hospitals in the united arab emirates

Abstract Objective The objective of the present study was to explore obstetric management in relation to clinical, maternal and child health outcomes by using the Robson classification system. Methods Data was collected from obstetrics registries in tertiary care hospitals in Dubai, United Arab Emirates (UAE). Results The analysis of > 5,400 deliveries (60% of all the deliveries in 2016) in major maternity hospitals in Dubai showed that groups 5, 8 and 9 of Robson's classification were the largest contributors to the overall cesarean section (CS) rate and accounted for 30% of the total CS rate. The results indicate that labor was spontaneous in 2,221 (45%) of the women and was augmented or induced in almost 1,634 cases (33%). The birth indication rate was of 64% for normal vaginal delivery, of 24% for emergency CS, and of 9% for elective CS.The rate of vaginal birth after cesarean was 261(6%), the rate of external cephalic version was 28 (0.7%), and the rate of induction was 1,168 (21.4%). The prevalence of the overall Cesarean section was 33%; with majority (53.5%) of it being repeated Cesarean section. Conclusion The CS rate in the United Arab Emirates (UAE) is higher than the global average rate and than the average rate in Asia, which highlights the need for more education of pregnant women and of their physicians in order to promote vaginal birth. A proper planning is needed to reduce the number of CSs in nulliparous women in order to prevent repeated CSs in the future. Monitoring both CS rates and outcomes is essential to ensure that policies, practices, and actions for the optimization of the utilization of CS lead to improved maternal and infant outcomes.

Unexpected term NICU admissions: a marker of obstetrical care quality?

BACKGROUND: Unexpected admissions of term neonates to the neonatal intensive care unit and unexpected postnatal complications have been proposed as neonatal-focused quality metrics for intrapartum care. Previous studies have noted significant variation in overall hospital neonatal intensive care unit admission rates; however, little is known about the influence of obstetric practices on these rates or whether variation among unanticipated admissions in low-risk, term neonates can be attributed to systemic hospital practices. OBJECTIVE: The objective of the study was to examine the relative effects of patient characteristics and intrapartum events on unexpected neonatal intensive care unit admissions and to quantify the between-hospital variation in neonatal intensive care unit admission rates among this group of neonates. STUDY DESIGN: We performed a retrospective cross-sectional study using data collected as part of the Consortium for Safe Labor study. Women who delivered term (≥37 weeks), singleton, nonanomalous, liveborn infants without an a priori risk for neonatal intensive care unit admission were included. The primary outcome was neonatal intensive care unit admission among this population. Multilevel mixed-effect models were used to calculate adjusted odds ratios for demographics (age, race, insurer), pregnancy characteristics (parity, gestational age, tobacco use, birthweight), maternal comorbidities (chronic and pregnancy-induced hypertension), hospital characteristics (delivery volume, hospital and neonatal intensive care unit level, academic affiliation), and intrapartum events (prolonged second stage, induction of labor, trial of labor after cesarean delivery, chorioamnionitis, meconium-stained amniotic fluid, and abruption). Intraclass correlation coefficients were used to estimate the between-hospital variance in a series of hierarchical models. RESULTS: Of the 143,951 infants meeting all patient and hospital inclusion criteria, 7995 (5.6%) were admitted to the neonatal intensive care unit after birth. In the fully adjusted model, the factors associated with the highest odds for neonatal intensive care unit admission included: nulliparity (adjusted odds ratio, 1.62 [95% confidence interval, 1.53-1.71]), large for gestational age (adjusted odds ratio, 1.59 [95% confidence interval, 1.47-1.71]), and small for gestational age (adjusted odds ratio, 1.60 [95% confidence interval, 1.47-1.73]). Induction of labor (adjusted odds ratio, 0.95 [95% confidence interval, 0.89-1.01]) was not associated with increased odds of neonatal intensive care unit admission compared with women who labored spontaneously. The events associated with higher odds of neonatal intensive care unit admission included: prolonged second stage (adjusted odds ratio, 1.66 [95% confidence interval, 1.51-1.83]); chorioamnionitis (adjusted odds ratio, 3.89 [95% confidence interval, 3.42-4.44]), meconium-stained amniotic fluid (adjusted odds ratio, 1.96 [95% confidence interval, 1.82-2.10]), and abruption (adjusted odds ratio, 2.64 [95% confidence interval, 2.16-.21]). Compared with women who did not labor, the odds of neonatal intensive care unit admission were lower for women who labored: adjusted odds ratio, 0.48 (95% confidence interval, 0.45-0.52) for women with no uterine scar and adjusted odds ratio, 0.83 (95% confidence interval, 0.73-0.94) for women with a uterine scar. There was significant variation in neonatal intensive care unit admission rates by hospital, ranging from 2.9% to 11.2%. After accounting for case mix and hospital characteristics, the between-hospital variance was 1.9%, suggesting that little of the variation was explained by the effect of the hospital. CONCLUSION: This study contributes to the currently limited understanding of term, neonatal intensive care unit admission rates as a marker of obstetrical care quality. We demonstrated that significant variation exists in hospital unexpected neonatal intensive care unit admission rates and that certain intrapartum events are associated with an increased risk for neonatal intensive care unit admission after delivery. However, the between-hospital variation was low. Unmeasured confounders and extrinsic factors, such as neonatal intensive care unit bed availability, may limit the ability of unexpected term neonatal intensive care unit admissions to meaningfully reflect obstetrical care quality.

Exercise in pregnancy: the impact of an intervention program in the duration of labor and mode of delivery / Exercício na gravidez: impacto de um programa de intervenção na duração do trabalho de parto e via de parto

Abstract Objective To access the benefits or harms of an exercise program, based on the current American College of Obstetricians and Gynecologists guidelines, on the mode of delivery, duration and onset of labor. Methods A study performed at the Hospital Senhora da Oliveira between October 2015 and February 2017. This was a quasi-experimental study involving 255 women divided into two groups: an intervention group engaged in a controlled and supervised exercise program during pregnancy (n = 99), and a control group that did not participate in the exercise program (n = 156). Data were collected in two stages: during the 1st trimester biochemical screening (before the beginning of the program), through a written questionnaire, and after delivery, from the medical files of the patients. The significance level in the present study was 5% (p = 0.05). Results The control group had higher odds of induced labor (odds ratio [OR] 2.71; 95% confidence interval [CI]: 1.42-5.17; p = 0.003), when compared with women who underwent the intervention. No differences were found between the groups in instrumental vaginal deliveries, cesarean rate, time until the beginning of the active phase, duration of the active phase, and duration of the second stage of labor. Conclusion The implementation of a controlled and supervised exercise program in pregnancy was associated with significantly lower odds of induced deliveries.

Resumo Objetivo Avaliar o efeito de um programa de exercícios na gravidez (baseado nas recomendações do American College of Obstetricians and Gynecologists) na via, duração e início do trabalho de parto. Métodos Estudo realizado no Hospital Senhora da Oliveira entre outubro de 2015 e fevereiro de 2017. Trata-se de um estudo quasi-experimental com 255 grávidas, divididas em dois grupos: grupo de intervenção, constituído por mulheres que participaram de um programa controlado e supervisionado de exercícios físicos (n = 99), e um grupo de controle, formado por grávidas que não participaram do programa de exercícios (n = 156). Os dados foram colhidos em dois momentos: durante o rastreio bioquímico do primeiro trimestre (antes do início do programa), através de um questionário escrito, e após o parto, através da consulta do processo clínico da paciente. O nível de significância estatística adotado neste projeto foi de 5% (p = 0,05). Resultados O grupo controle apresentou maior probabilidade de indução do trabalho de parto (razão de chances [RC] 2,71; intervalo de confiança [IC] 95%: 1,42-5,17; p = 0,003) quando comparado com o grupo de intervenção. Não foram encontradas diferenças estatisticamente significativas entre os dois grupos em relação à via de parto, tempo até início da fase ativa, duração da fase ativa e duração do segundo estadio do trabalho de parto. Conclusão A implementação de um programa de exercícios controlado e supervisionado na gravidez foi associada a uma probabilidade significativamente menor de indução do trabalho de parto.

Adverse obstetric and neonatal outcomes complicated by psychosis among pregnant women in the United States.

BACKGROUND: Adverse obstetric and neonatal outcomes among women with psychosis, particularly affective psychosis, has rarely been studied at the population level. We aimed to assess the risk of adverse obstetric and neonatal outcomes among women with psychosis (schizophrenia, affective psychosis, and other psychoses). METHODS: From the 2007 - 2012 National (Nationwide) Inpatient Sample, 23,507,597 delivery hospitalizations were identified. From the same hospitalization, International Classification of Diseases diagnosis codes were used to identify maternal psychosis and outcomes. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were obtained using logistic regression. RESULTS: The prevalence of psychosis at delivery was 698.76 per 100,000 hospitalizations. After adjusting for sociodemographic characteristics, smoking, alcohol/substance abuse, and pregnancy-related hypertension, women with psychosis were at a heightened risk for cesarean delivery (aOR = 1.26; 95% CI: 1.23 - 1.29), induced labor (aOR = 1.05; 95% CI: 1.02 - 1.09), antepartum hemorrhage (aOR = 1.22; 95% CI: 1.14 - 1.31), placental abruption (aOR = 1.22; 95% CI: 1.13 - 1.32), postpartum hemorrhage (aOR = 1.18; 95% CI: 1.10 - 1.27), premature delivery (aOR = 1.40; 95% CI: 1.36 - 1.46), stillbirth (aOR = 1.37; 95% CI: 1.23 - 1.53), premature rupture of membranes (aOR = 1.22; 95% CI: 1.15 - 1.29), fetal abnormalities (aOR = 1.49; 95% CI: 1.38 - 1.61), poor fetal growth (aOR = 1.26; 95% CI: 1.19 - 1.34), and fetal distress (aOR = 1.14; 95% CI: 1.10 - 1.18). Maternal death during hospitalizations (aOR = 1.00; 95% CI: 0.30 - 3.31) and excessive fetal growth (aOR = 1.06; 95% CI: 0.98 - 1.14) were not statistically significantly associated with psychosis. CONCLUSIONS: Pregnant women with psychosis have elevated risk of several adverse obstetric and neonatal outcomes. Efforts to identify and manage pregnancies complicated by psychosis may contribute to improved outcomes.

Obstetric and perinatal health outcomes related to schizophrenia: A national register-based follow-up study among Finnish women born between 1965 and 1980 and their offspring.

BACKGROUND: This national register-based study assesses obstetric and perinatal health outcomes in women with schizophrenia and their offspring. METHODS: Using the Care Register for Health Care, we identified Finnish women who were born in 1965- 1980 and diagnosed with schizophrenia. For each case, five age- and place-of-birth- matched controls were obtained from the Central Population Register of Finland. They were followed from the day when the disorder was diagnosed in specialized health-care (the index day) until 31.12.2013. Information related to births was obtained from the Medical Birth Register and the Register of Congenital Malformations. We focused on singleton pregnancies that led to a delivery after the index day. We restricted the analysis of deliveries in controls to those that occurred after the index day of the case. Maternal age, marital status, smoking status, sex of the newborn, and parity were used as covariates in adjusted models. RESULTS: We identified 1162 singleton births among women with schizophrenia and 4683 among controls. Schizophrenic women had a 1.4-fold increased risk of induction of labor, delivery by cesarean section, and delivery by elective cesarean section. Regarding offspring, the risk of premature birth and the risk of low Apgar score at 1 min (<7) were 1.6-fold, of resuscitation 2.5-fold, and of neonatal monitoring 2.1-fold higher. CONCLUSIONS: Schizophrenia associates with some specific delivery methods, but delivery complications are rare and their prevalence does not differ from that observed among community women. Maternal schizophrenia associates with some negative perinatal health outcomes of the offspring.

To ignore or not to ignore placental calcifications on prenatal ultrasound: a systematic review and meta-analysis.

OBJECTIVE: The human placenta is known to calcify with advancing gestational age, and, in fact, the presence of significant calcifications is one of the components of grade III placenta, typical of late gestation. As such, the presence of significant placental calcifications often prompts obstetric providers to expedite delivery. This practice has been attributed, in part, to the presumed association between grade III placenta and adverse pregnancy outcomes. Such approach, however, can be the source of major anxiety and may lead to unnecessary induction of labor, with its associated predisposition to cesarean delivery as well as a myriad of maternal and neonatal morbidities. The objective of this study was to examine the association between grade III placental calcifications and pregnancy outcomes. MATERIALS AND METHODS: A systematic review of the literature was performed for studies evaluating the association between grade III placenta and a number of pregnancy outcomes, including labor induction, fetal distress (abnormal fetal heart tracing), low Apgar score (less than 7 at 5 min), need for neonatal resuscitation, admission to the Neonatal Intensive Care Unit, perinatal death, meconium liquor, and low birth weight. RESULTS: There was a five-fold increase in risk of labor induction with the presence of grade III placenta (OR 5.41; 95% CI 2.98-9.82). There was no association between grade III placenta and the incidence of abnormal fetal heart tracing (OR 1.62; 95% CI 0.94-2.78), low Apgar score of less than 7 at 5 min (OR 1.68; 95% CI 0.84-3.36), need for neonatal resuscitation (OR 1.08; 95% CI 0.67-1.75), and admission to the Neonatal Intensive Care Unit (OR 0.90; 95% CI 0.21-3.74). In turn, the incidence of meconium liquor was higher in the setting of grade III placentae (OR 1.68; 95% CI 1.17-2.39). Similarly, a positive association between grade III placental calcifications and low birth weight (OR 1.63; 95% CI 1.19-2.22) and perinatal death (OR 7.41; 95% CI 4.94-11.09) was identified. CONCLUSION: The study alerts us to a significant association between grade 3 placental calcifications and labor induction, although it demonstrates that these sonographic findings do not appear to predispose to fetal distress, low Apgar score, need for neonatal resuscitation, or admission to the NICU.