An evaluation into the use of procalcitonin levels as a biomarker of bacterial sepsis to aid the management of intrapartum pyrexia and chorioamnionitis.

BACKGROUND: Procalcitonin is an established biomarker for bacterial sepsis in the nonpregnant population with better diagnostic and prognostic value for bacterial infections. OBJECTIVE: This study aimed to evaluate whether procalcitonin levels could be used in the diagnosis and management of intrapartum sepsis in women and their neonates suspected of intrapartum bacterial sepsis. STUDY DESIGN: A prospective observational cohort study was conducted at the University Hospitals of Bristol and Weston NHS Foundation Trust. Overall, 117 women and their neonates managed for suspected intrapartum sepsis from June 2020 to October 2020 were included. Procalcitonin levels were measured in addition to routine biomarkers white cell count and C-reactive protein in women and their neonates during the initial septic screen and follow-up blood samples. The placentas underwent detailed histopathology. Maternal and neonatal parameters were used to categorize cases into "high-suspicion bacterial sepsis," "equivocal bacterial sepsis," and "low-suspicion bacterial sepsis." The Kruskal-Wallis test was used to compare categories with biomarker values and placental histology scores. RESULTS: Procalcitonin level was increased in 6 women in the initial septic screen sample, compared with 100 women with an increased C-reactive protein level. There was a significant difference in maternal postnatal procalcitonin results between "high-suspicion bacterial sepsis" and "low-suspicion bacterial sepsis" categories (P=.004). Moreover, 71.2% of placentas showed varying degrees of chorioamnionitis. CONCLUSION: In our cohort of women, 94.6% had normal procalcitonin levels while in labor at the time of the septic screen, consistent with the low number of confirmed bacteremia. The result provided a basis that procalcitonin may complement clinical judgment and interpretation of already used prognostic and diagnostic tests, improving patient care in the management of intrapartum sepsis.

Cohort study of maternal views on future mode of delivery after operative delivery in the second stage of labor.

OBJECTIVE: The purpose of this study was to assess maternal views on the future mode of delivery after either previous instrument vaginal delivery or cesarean delivery at full dilatation. STUDY DESIGN: We conducted a prospective cohort study of 393 women with term singleton cephalic pregnancies. RESULTS: More than one half of the cohort intended to have a further pregnancy, with no significant differences between the instrument vaginal delivery and caesarean delivery groups (51% vs 54% before discharge; adjusted odds ratio, 1.04; 95% CI, 0.2, 6.0), and there was little change in maternal views over time. Women were more likely to aim for a future vaginal delivery after an instrument vaginal delivery (79% vs 39% before discharge; adjusted odds ratio, 4.5; 95% CI, 2.2, 9.2), but the proportion decreased over time (68% vs 42% at 1 year; adjusted odds ratio, 3.6; 95% CI, 1.6, 8.1). There were no significant differences in preferred future mode of delivery for women who had a caesarean delivery after a failed instrument delivery and those who were delivered by immediate caesarean delivery. CONCLUSION: A high proportion of women who have had a previous difficult instrument vaginal delivery would still prefer vaginal delivery in a future pregnancy.

Effect of operative delivery in the second stage of labor on breastfeeding success.

BACKGROUND: Operative delivery rates are currently rising in many countries, but the effects of this factor on the initiation and duration of breastfeeding are unclear. The purpose of this study was to evaluate breastfeeding success after instrumental vaginal delivery or cesarean section at full dilatation, and to investigate whether timing of discharge after operative delivery affects breastfeeding rates. METHODS: A prospective cohort study was conducted of 393 women with term, singleton, live, cephalic pregnancies who required delivery in theater during the second stage of labor between February 1999 and February 2000. Postal questionnaires were mailed to participants at 6 weeks and 1 year. Logistic regression models were used to explore the relationships between infant feeding and mode of delivery, controlling for factors previously correlated with breastfeeding success. RESULTS: Rates of exclusive breastfeeding at discharge and 6 weeks postpartum were 70 and 44 percent, respectively. No significant differences occurred when instrumental vaginal delivery was compared with cesarean section, adjusted OR 0.84 (95% CI 0.50, 1.41) and 1.15 (95% CI 0.69, 1.93) respectively. Breastfeeding rates after failed instrumental delivery were similar to those after immediate cesarean section, adjusted OR 0.99 (95% CI 0.72, 1.38) and 1.28 (95% CI 0.91, 1.78). Women who had a longer in-patient stay after cesarean section were more likely to achieve exclusive breastfeeding at hospital discharge (78% vs 66%, p = 0.03). CONCLUSIONS: Method of operative delivery in the second stage of labor does not appear to influence initiation or duration of exclusive breastfeeding. A longer inpatient stay may help cesarean-delivered women to initiate breastfeeding.

Cohort study of operative delivery in the second stage of labour and standard of obstetric care.

OBJECTIVE: To assess the maternal and neonatal morbidity following operative delivery in the second stage of labour in relation to the standard of obstetric care. DESIGN: Cohort study. SETTING: Maternity units in two teaching hospitals in Bristol, United Kingdom. Three hundred and ninety-three women with term, singleton, cephalic pregnancies who required operative delivery in theatre at full dilatation between February 1999 and February 2000. METHODS: Morbidity was compared for completed instrumental delivery, failed instrumental delivery and immediate caesarean section in relation to duration of second stage of labour, number of pulls at attempted instrumental delivery, number of instruments used and operator experience. MAIN OUTCOME MEASURES: Maternal trauma, admission to special care baby unit, neonatal trauma. RESULTS: Failed instrumental delivery after a long second stage of labour was associated with increased maternal trauma (adjusted odds ratios [OR] 4.1, 95% confidence interval [CI] 1.1, 16.5). More than three pulls at attempted instrumental delivery was associated with increased neonatal trauma for completed (adjusted OR 4.2, 95% CI 1.6, 9.5) and failed deliveries (adjusted OR 7.2, 95% CI 2.1, 24.0). Babies delivered after failed instrumental delivery with more than three pulls were at increased risk of admission to special care baby unit (adjusted OR 6.2, 95% CI 1.6, 22.8) The use of multiple instruments was associated with increased neonatal trauma (adjusted OR 3.1, 95% CI 1.5, 6.8; adjusted OR 4.4, 95% CI 1.3, 14.4, for completed and failed deliveries, respectively). Excessive pulls and multiple instrument use were associated with an initial attempt at vaginal delivery by an inexperienced operator, 25/48 (52%) and 34/75 (45%). CONCLUSIONS: Guidelines for safe operative delivery in the second stage of labour should be developed and adhered to in order to reduce morbidity, particularly neonatal trauma.

Women's views on the impact of operative delivery in the second stage of labour: qualitative interview study.

OBJECTIVE: To obtain the views of women on the impact of operative delivery in the second stage of labour. DESIGN: Qualitative interview study. SETTING: Two urban teaching hospitals in the United Kingdom. PARTICIPANTS: Purposive sample of 27 women who had undergone operative delivery in the second stage of labour between January 2000 and January 2002. KEY THEMES: Preparation for birth, understandings of the indications for operative delivery, and explanation or debriefing after birth. RESULTS: The women felt unprepared for operative delivery and thought that their birth plan or antenatal classes had not catered adequately for this event. They emphasised the importance of maintaining an open mind about the management of labour. They had difficulty understanding the need for operative delivery despite a review by medical and midwifery staff before discharge. Operative delivery had a noticeable impact on women's views about future pregnancy and delivery. CONCLUSIONS: Women consider postnatal debriefing and medical review important deficiencies in current care. Those who experienced operative delivery in the second stage of labour would welcome the opportunity to have a later review of their intrapartum care, physical recovery, and management of future pregnancies.

Pelvic floor morbidity up to one year after difficult instrumental delivery and cesarean section in the second stage of labor: a cohort study.

OBJECTIVE: This study was undertaken to assess symptoms of pelvic floor morbidity at 6 weeks and at 1 year after difficult instrumental vaginal delivery or cesarean section during the second stage of labor. STUDY DESIGN: Prospective cohort study of 393 women with term, singleton, cephalic pregnancies who required operative delivery in surgery at full dilatation between February 1999 and February 2000. Postal questionnaires were used for follow-up at 6 weeks and at 1 year. RESULTS: Instrumental delivery was associated with a greater risk of urinary incontinence at 6 weeks and at 1-year postdelivery, adjusted odds ratio [OR] 7.8 (95% CI, 2.6-23.6) and OR 3.1 (95% CI, 1.3-7.6), respectively. Although instrumental delivery was associated with an increased risk of moderate-to-severe dyspareunia at 6 weeks, adjusted OR 3.35 (95% CI, 1.36-8.25), this difference was not significant at 1 year. Cesarean section after attempted instrumental delivery was associated with an increased risk of moderate-to-severe pain during intercourse at 1 year compared with immediate cesarean section, (18% vs 9%) P=.01. CONCLUSION: Although cesarean section at full dilatation does not completely protect women from pelvic floor morbidity, those that followed instrumental delivery had a significantly greater prevalence of urinary symptoms and dyspareunia. Urinary symptoms persist up to 1 year after delivery.