Surgical management of dystocia in a colobus monkey (Colobus guereza).

A 14-year-old female black and white colobus monkey (Colobus guereza) presented in labor with fetal arms visible protruding from the vulva. Manual manipulation for assisted delivery of the fetus was unsuccessful. Radiographs identified a large fetal skull and hysterotomy was required with ovariohysterectomy elected to follow. The fetus was confirmed to be deceased during hysterotomy, but the dam recovered from the procedure uneventfully. The detailed description of the anesthesia and surgical procedure in this case may aid other clinicians when presented with similar dystocia cases in this species.

Comparing forces on the fetal neck in breech delivery in lithotomy versus all-fours position: a simulation model.

PURPOSE: To measure forces applied to the fetal neck, in a simulation model for breech delivery, in both lithotomy versus all-fours position. METHODS: We used a Laerdal SimMom simulator and a Birthing Baby together with PROMPT Flex Software. The descent of the fetus was accomplished using the Automatic Delivery Module 2. The baby was always in breech position; the SimMom in either all-fours or lithotomy positions. Sensors were located inside the fetal neck region to simulate forces applied to the plexus. RESULTS: The lowest force on the fetal neck region was recorded for the delivery in all-fours position without further maneuvers (mean force 58.70 Newton, standard deviation 2.54 N). As weight was added to the baby, the force increased (i.e. + 500 g, mean force 71.8 N, SD 3.08 N, p < 0.001). Delivery in lithotomy position resulted in a mean force of 81.56 N (SD 19.55 N). The force significantly increased in case of delivery of the head without assistance from contractions (mean force 127.93 N, SD 23.10 N). In all-fours position, the delivery of the fetal head from pelvic floor level without contractions (Frank's Nudge maneuver) resulted in a mean force of 118.45 N (SD 15.48 N, p = 0.02). Maneuvers for shoulder dystocia (the inverted type that can occur during breech delivery) led to significantly higher mean forces independent from birthing positions. CONCLUSION: Breech delivery in all-fours position was associated with the lowest force acting on the fetal neck in our simulation model.

Successful Resuscitation of Neonatal Kittens Delivered by a Perimortem Cesarean Section Following Maternal Cardiopulmonary Arrest.

A 9 yr old, unknown weight, intact female domestic shorthair presented for evaluation of dystocia with dyspnea. En route to the hospital for treatment, the owners noted the queen stopped breathing. On presentation, cardiopulmonary arrest was confirmed. The exact cause was unknown but suspected to be secondary to acute fulminant congestive heart failure or acute respiratory distress syndrome due to a large volume of serosanguineous fluid within the mouth and nose. Cardiopulmonary resuscitation (CPR) was immediately started. After 2 min of CPR without return of spontaneous circulation, the owners consented to perimortem Cesarean section. Two kittens were removed via emergency hysterotomy within 3-4 min. Both kittens were successfully resuscitated. CPR efforts were continued on the queen for 2 min after delivery of the kittens, at which time the owners elected to stop further resuscitative efforts. Both kittens were discharged from the hospital and were alive at last follow-up, 2 yr and 4 mo after birth. There are no previous reports regarding the use of a perimortem Cesarean section to deliver neonates in small animal medicine. Therefore, this report represents a novel treatment approach that can be considered in the case of maternal arrest during dystocia.

Caesarean section rates: applying the modified ten-group Robson classification in an Australian tertiary hospital.

The aim of this study was to determine the main contributors to caesarean section (CS) rates at an Australian tertiary hospital. We conducted a retrospective review of women who delivered in an Australian tertiary hospital between 2014 and 2017. Women were allocated according to a modified Robson Ten-Group Classification System and CS indications were collected in nulliparous women and women with previous CS. The largest contributor to the 35.7% overall CS rate was women with a term cephalic infant and a previous CS (31.5% relative CS rate) and the most common indication was repeat CS. The group CS rate in nulliparous women with a cephalic term infant was higher when labour was induced compared to occurring spontaneously (36.6% and 18.1% respectively). The primary CS indication for these women was labour dystocia and maternal request was the most common CS indication for nulliparous women with a pre-labour CS.IMPACT STATEMENTWhat is already known on this subject? Significantly increasing caesarean section (CS) rates continue to prompt concern due to the associated neonatal and maternal risks. The World Health Organisation have endorsed the Robson Ten-Group Classification System to identify and analyse CS rate contributors.What do the results of this study add? We have used the modified Robson Ten-Group Classification System to identify that women with cephalic term infants who are nulliparous or who have had a previous CS are the largest contributors to overall CS rates. CS rates were higher in these nulliparous women if labour was induced compared to occurring spontaneously and the primary CS indication was labour dystocia. In nulliparous women with a CS prior to labour the most common CS indication was maternal request. Majority of women with a previous CS elected for a repeat CS.What are the implications of these findings for clinical practice? Future efforts should focus on minimising repeat CS in multiparous women and primary CS in nulliparous women. This may be achieved by redefining the definition of labour dystocia, exploring maternal request CS reasoning and critically evaluating induction timing and indication. Appropriately promoting a trial of labour in women with a previous CS in suitable candidates may reduce repeat CS incidence.

Factors associated with ewe and lamb survival, and subsequent reproductive performance of sheep undergoing emergency caesarean section.

Clinical records of all 212 ewes undergoing emergency caesarean surgery at a veterinary teaching hospital between January 2008 and December 2019 were evaluated retrospectively. Their age ranged from 1 to 10 years (median = 4 years), with German merino the predominant breed (48.1% of cases). The most frequently diagnosed indications were insufficient cervical dilatation (n = 94, 44.3%), uterine torsion (n = 50, 23.6%), foetopelvic disproportion (n = 31, 14.6%) and vaginal prolapse intra partum (n = 11, 5.2%). Fifty-four (25.5%) of the 212 ewes additionally suffered from one or more concurrent, pre-existing conditions. Overall ewe mortality until hospital discharge was 10.8% (23/212), and 3.8% (n = 6) for the 158 ewes without a history of concurrent disorders. Mortality during hospitalization increased to 31.5% (17/54) for those with pre-existing conditions. Total lamb mortality was 49.1% (173/352) until hospital discharge. Pre-existing conditions (p = .001) and the presence of post-surgical complications (p = .025) were identified as significant factors influencing dam mortality, while delayed presentation for veterinary attention with an observed duration of labour of >12 hr was identified as the most influential factor on total lamb mortality (p = .010). The presence of dead or emphysematous foetuses was not significant for ewe mortality. Follow-up information on further outcomes was available for 156 (82.5%) of the 189 discharged ewes. Eighty-nine animals (57.1%) were re-bred in the following season and achieved a 93.3% (83/89) pregnancy rate, while the remainder had either been slaughtered (n = 56, 35.9%), sold (n = 5, 3.2%) or had died of unknown causes (n = 3, 1.9%). The subsequent incidence of dystocia was 15.6% (n = 12) in the 77 ewes with available information on lambing ease. Adequate management of underlying conditions and timely intervention are important factors for best possible short-term outcomes. In the long term, the subsequent pregnancy rate was good and the incidence of subsequent dystocia was within the normal range.

Complications and outcomes of swine that underwent cesarean section for resolution of dystocia: 110 cases (2013-2018).

OBJECTIVE: To report the surgical survival of dams and piglets and follow-up survival and future breeding potential of swine that underwent cesarean section for correction of dystocia. STUDY DESIGN: Retrospective study. ANIMALS: One hundred ten client-owned, female swine. All swine included in this study were breeding stock for market pigs to be used for exhibition purposes. METHODS: Medical records of swine that underwent cesarean section at The Ohio State University Hospital for Farm Animals for resolution of dystocia between January of 2013 and July of 2018 were reviewed. Signalment, history, number of piglets per litter, treatments, and surgical procedure were recorded. Follow-up information (survival, complications, and additional pregnancies) was obtained via telephone interview. RESULTS: A fetus was not palpable in 77 of 110 (70%) cases at presentation. The median litter size was eight piglets (range, 1-14), with medians of five (range, 0-13) live and one dead (range, 0-11) piglets per litter. Follow-up was available for 52 dams, of which 39 (75%) survived. Complications were recorded in 20 of 52 (38.46%) cases and included incisional seroma formation, lethargy, and anorexia. Twenty-three dams became pregnant and farrowed after the cesarean section, with no reported complication in 13 of these. CONCLUSION: Cesarean section in swine is associated with a good prognosis for recovery from the procedure and a fair to guarded prognosis for future breeding. CLINICAL SIGNIFICANCE: Cesarean section may be considered for resolution of dystocia in swine. However, owners should be advised that nearly half of sows require assistance in subsequent deliveries.

Non-adherence to labor guidelines in cesarean sections done for failed induction and arrest of dilation.

OBJECTIVES: In 2014, the American College of Obstetrics and Gynecology published guidelines for diagnosing failed induction of labor (FIOL) and arrest of dilation (AOD) to prevent cesarean delivery (CD). The objectives of this study were to determine the rate of adherence to these guidelines and to compare the association of guideline adherence with physician CD rates and obstetric/neonatal outcomes. METHODS: Retrospective cohort review of singleton primary cesarean deliveries for FIOL and AOD at a single academic institution from 2014 to 2016. Univariate and multivariate analyses were used to compare adherence to the guidelines with physician CD rates and obstetric/neonatal outcomes. RESULTS: Of the 591 cesarean deliveries in the study, 263 were for failed induction, 328 for AOD and 79% (468/591) were not adherent to the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (ACOG/SMFM) guidelines. Of the failed inductions, 82% (215/263) and of the AODs 77% (253/328) were not adherent. There was no difference between adherent and non-adherent CDs with regard to maternal characteristics, or obstetric/neonatal outcomes. Duration of oxytocin use after rupture of membranes, dilation at time of CD, and birth weight were statistically higher in adherent CDs. On multivariate linear regression, physician CD rates were inversely correlated with adherence to ACOG/SMFM guidelines (p<0.0001), gestational age (p=0.007), and parity (p=0.003). CONCLUSIONS: Our study shows that physician non-compliance with ACOG guidelines was high. Adherence to these guidelines was associated with lower physician CD rates, without an increase in obstetric or neonatal complications.

Morbidity and Mortality Associated With Forceps and Vacuum Delivery at Outlet, Low, and Midpelvic Station.

OBJECTIVE: This study sought to quantify perinatal and maternal morbidity and mortality associated with forceps and vacuum delivery compared with Caesarean delivery in the second stage of labour and to estimate whether these associations differed by pelvic station. METHODS: The investigators conducted a population-based, retrospective cohort study of term singleton deliveries by operative delivery with prolonged second stage of labour in Canada (2003-2013) using national hospitalization data. The primary study outcomes were severe perinatal morbidity and mortality (i.e., seizures, assisted ventilation, severe birth trauma, and perinatal death) and severe maternal morbidity and mortality (i.e., severe postpartum hemorrhage, cardiac complication, and maternal death). Logistic regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) after stratifying by indication (dystocia or fetal distress). The Breslow-Day chi-square test for heterogeneity in ORs was used to test effect modification by pelvic station (outlet, low, or midpelvic). RESULTS: There were 61 106 deliveries included in the study. Among women with dystocia, forceps and vacuum deliveries were associated with higher rates of perinatal morbidity and mortality compared with Caesarean delivery (forceps: aOR 1.56; 95% CI 1.13-2.17; vacuum: aOR 1.44; 95% CI 1.06-1.97). Vacuum delivery was associated with lower rates of maternal morbidity and mortality compared with Caesarean delivery (dystocia: aOR 0.64; 95% CI 0.51-0.81; fetal distress: aOR 0.43; 95% CI 0.32-0.57). Pelvic station did not significantly modify the associations between forceps or vacuum and perinatal or maternal morbidity and mortality. CONCLUSION: Forceps and vacuum delivery is associated with increased rates of severe perinatal morbidity and mortality compared with Caesarean delivery among women with dystocia, whereas vacuum delivery is associated with decreased rates of severe maternal morbidity and mortality.

Bacteriological findings in the canine uterus during Caesarean section performed due to dystocia and their correlation to puppy mortality at the time of parturition.

Canine intrauterine bacteriological flora during dystocia is unknown. Thus, frequency (bacterial growth (not) detected), quality (species and number of different bacterial isolates) and quantity (colony-forming units) of intrauterine bacteria in relation to in utero foetal death in 50 bitches undergoing emergency Caesarean section were investigated. Bacterial growth was quantified from single colonies, (+) (0.5), to strong growth, +++ (3) and was observed in 34 bitches (68%), with Staph. epidermidis (n = 12), Staph. intermedius-group (n = 7), ß-haemolytic streptococci (n = 6), Staph. aureus, α- and γ-haemolytic streptococci (n = 4 each) being most common and one to four bacteria per sample. Regarding the quantity, most often (n = 46) low growth was identified. In bitches with living pups only (group I), mean number of isolates was 0.78 ± 0.83 compared to 1.60 ± 1.10 (living + stillborn pups, group II) and 1.0 ± 1.15 (stillborn pups only, group III) and mean bacterial growth in groups I/II/III was + (1.0, quantity), + (1.4) and ++ (1.6). Taking just positive samples into consideration, mean number of bacterial isolates was significantly higher in group II compared to I (p = .0088). We concluded that the canine uterus cannot be considered free of bacteria during dystocia. Mean numbers of different bacterial isolates and quantity of bacterial growth are higher in bitches with in utero foetal death.

Is ultrasound measured fetal biometry predictive of intrapartum caesarean section for failure to progress?

BACKGROUND: There are global concerns regarding excessive caesarean rates, which could be reduced by identification of risk factors leading to preventative measures such as induction of labour. AIMS: This study aims to describe the association between antenatal ultrasound and emergency caesarean section for: (i) failure to progress; (ii) other indications; and (iii) any indication. MATERIALS AND METHODS: Women who had an ultrasound in pregnancy between 36(+0/7) to 38(+6/7) weeks at Royal Prince Alfred Hospital from January 2005 to June 2009 were included. Ultrasound parameters were linked to clinical parameters from the maternity database. Missing clinical data were imputed and multiple logistic regression performed. RESULTS: Fetal biometry data were available for 2006 pregnancies. After adjusting for maternal age, height, body mass index, parity, previous caesarean section and diabetes, caesarean section for failure to progress was associated with estimated fetal weight (odds ratio (OR) 2.24 (95% CI: 1.76-2.84) per 500 g increase); or biparietal diameter (OR 1.51 (1.16-1.97) per 5 mm increase) and abdominal circumference (OR for the 4th quartile (>75th centile) compared with the 10-25th centile group was 2.09 (1.13-3.85)).* There were also non-linear associations between components of fetal biometry and caesarean section for fetal distress and for any indication. CONCLUSIONS: Components of fetal biometry in the third trimester are associated with intrapartum caesarean section for failure to progress. These parameters could be incorporated into models to predict emergency caesarean section which could lead to implementation of preventative strategies. *[Corrections added on 29 January 2018, after first online publication, '(OR for the 4th quartile (>7th centile)' has been changed to '(OR for the 4th quartile (>75th centile)'.].

First stage of labour management practices: A survey of Australian obstetric providers.

AIMS: To report on the opinions and reported practices of Australian obstetricians and general practice (GP) obstetricians, in the definition and management of spontaneous first stage of labour, in low-risk nulliparous women. MATERIALS AND METHODS: Cross-sectional survey sent electronically to all Australian Specialist obstetricians (FRANZCOG) and Diplomates. Respondents answered questions regarding care of nulliparous women in spontaneous labour at term across three domains: (i) practitioners' characteristics; (ii) current practice; (iii) opinion regarding joint statement by ACOG/SMFM (Society of Maternal Fetal Medicine) 'Safe prevention of primary caesarean section'. RESULTS: The dataset included responses from 664 participants, representing 29% of Specialists and 11% of Diplomates. Responses varied in the criteria used to define normal labour, and the diagnosis and management of prolonged labour. Clinicians with more post-qualification experience considered the minimal acceptable progress to be faster than those with fewer years of experience (P = 0.02). Clinicians working in higher acuity hospitals were more likely to augment labour for longer prior to recommending a caesarean section for active phase arrest, compared to those in lower acuity hospitals (P = 0.025). The majority of respondents (58.2%) already based their practice on the ACOG/SMFM 'Safe prevention of primary caesarean section' statement, or would now consider changing their practice. CONCLUSION: There is a lack of consensus among Australian obstetricians and GP obstetricians regarding definition of normal progress in first stage of labour and how to manage abnormal progress; however, many are open to new recommendations for practice.

Judicious use of oxytocin augmentation for the management of prolonged labor.

INTRODUCTION: A protocol including judicious use of oxytocin augmentation was investigated to determine whether it would change how oxytocin was used and eventually influence labor and fetal outcomes. MATERIAL AND METHODS: The population of this cohort study comprised 20 227 delivering women with singleton pregnancies ≥37 weeks, cephalic presentation, spontaneous or induced onset of labor, without previous cesarean section. Women delivering from 2009 to 2013 at Stavanger University Hospital, Norway, were included. Data were collected prospectively. Before implementing the protocol in 2010, oxytocin augmentation was used if progression of labor was perceived as slow. After implementation, oxytocin could only be started when the cervical dilation had crossed the 4-h action line in the partograph. RESULTS: The overall use of oxytocin augmentation was significantly reduced from 34.9% to 23.1% (p < 0.01). The overall frequency of emergency cesarean sections decreased from 6.9% to 5.3% (p < 0.05) and the frequency of emergency cesarean sections performed due to fetal distress was reduced from 3.2% to 2.0% (p = 0.01). The rate of women with duration of labor over 12 h increased from 4.4% to 8.5% (p < 0.01) and more women experienced severe estimated postpartum hemorrhage (2.6% vs. 3.7%; p = 0.01). The frequency of children with pH <7.1 in the umbilical artery was reduced from 4.7% to 3.2% (p < 0.01). CONCLUSIONS: The frequency of emergency cesarean section was reduced after implementing judicious use of oxytocin augmentation. Our findings may be of interest in the ongoing discussion of how the balanced use of oxytocin for labor augmentation can best be achieved.

Adverse obstetric symptoms and rural-urban difference in cesarean delivery in Rupandehi district, Western Nepal: a cohort study.

BACKGROUND: The burden of maternal morbidity is high in developing countries including Nepal. This study investigated obstetric complications and rural-urban difference in cesarean delivery rate in Western Nepal. METHODS: A community-based cohort study was conducted in the Rupandehi district of Western Nepal during January-October, 2014, by interviewing 735 mothers within one month postpartum. The prevalence of obstetric complications was reported via frequency distribution, while factors associated with cesarean delivery were assessed using logistic regression analysis. RESULTS: The prevalence of adverse obstetric symptoms during antenatal, intranatal and postnatal periods were 19.7%, 27.8% and 21.6%, respectively. In total, 81 (11.0%) mothers reported having stillbirths. The cesarean delivery rate was 14.1% overall but was four times higher in the urban (23.0%) than in the rural areas (5.8%). Prolonged labor (19.0%) and heavy bleeding (16.7%) were common among rural women. Logistic regression analysis confirmed that cesarean section was more likely for mothers residing in urban areas than in rural areas (adjusted odds ratio 3.41; 95 % confidence interval 2.01 to 5.78). CONCLUSIONS: About one in five mothers reported some adverse obstetric symptoms. Obstetric problems were more common in the rural areas, whereas cesarean delivery rate was much higher in the urban areas. Further investigations are required to determine whether these cesarean sections are medically warranted or provider induced.

Factors leading to cesarean section delivery at Felegehiwot referral hospital, Northwest Ethiopia: a retrospective record review.

BACKGROUND: Cesarean section is the commonest obstetric operative procedure worldwide. When used appropriately cesarean sections can improve infant and/or maternal outcomes. However, when used inappropriately the potential harm may exceed the potential benefit of cesarean section. Appreciating the limited information in this area the current study assessed the rate and factors associated with cesarean section in Felegehiwot referral hospital, Bahir Dar, northwest Ethiopia. METHOD: The study was a retrospective analysis of eligible patient records that included 2967 pregnant women who had underwent either cesarean or vaginal delivery from July 1, 2012 to June 31, 2013. The data were double entered to EPI-INFO 3.5.2 and analyzed with SPSS. Binary logistic regression model was fitted to identify independent factors associated with cesarean section. RESULT: The proportion of women who underwent cesarean section in this study was 25.4%. Obstructed labor (30.7%), fetal distress (15.9%) and abnormal presentation (13.4%) were the major obstetric indications for cesarean section. The odd of undergoing cesarean section was higher among mothers in rural residence (AOR = 1.63, 95% CI: 1.21, 2.20), mothers reported to have pregnancy risk factors (AOR = 2.31, 95% CI: 1.74, 3.07) and lower among mothers in age category of 15-19 (AOR = 0.63, 95% CI: 0.43, 0.93). CONCLUSION: Obstetric factors occurring around birth, including obstructed labor and fetal distress were the main reasons leading to Cesarean Section rather than background characteristics assumed to be a risk. The results imply that there is a need for timely and accurate screening of women during obstetric care and, decision to perform cesarean section should be based on clear, compelling and well-supported justifications.

Is neonatal head circumference related to caesarean section for failure to progress?

BACKGROUND: There is global concern about rising caesarean section rates. Identification of risk factors could lead to preventative measures. AIMS: To describe the association between neonatal head circumference and (i) caesarean section for failure to progress, (ii) intrapartum caesarean section overall. MATERIALS AND METHODS: This was a retrospective cohort study of 11 687 singleton live births with cephalic presentation, attempted vaginal birth and at least 37 completed weeks gestation from January 2005 to June 2009. Neonatal head circumference was grouped into quartiles and multiple logistic regressions performed. RESULTS: The rates of caesarean section for failure to progress were 4.1, 6.4, 8.8 and 14.3% in successive head circumference quartiles. Rates of intrapartum caesarean section overall were 8.7, 12.1, 15.8 and 21.5%. The odds ratios for caesarean section for failure to progress were: 1.00, 1.33 (95% CI 1.02- 1.73), 1.54 (1.18-2.02) and 1.93 (1.44-2.57) for successive head circumference quartiles after adjusting for multiple demographic and clinical factors. The adjusted odds ratios for intrapartum caesarean section for any indication were: 1.00, 1.52 (95% CI 1.24-1.87), 1.99 (1.62-2.46) and 2.38 (1.89-3.00), respectively. CONCLUSIONS: There is a strong positive relationship between head circumference quartile and both caesarean section for failure to progress and caesarean for any indication. If this finding is confirmed using ultrasound measurements, there is potential for head circumference to be incorporated into predictive models for intrapartum caesarean section with a view to offering interventions to reduce the risk of caesarean section.

Emergency Caesarean Section in Obese Parturients: Is a 30-Minute Decision-to-Incision Interval Feasible?

OBJECTIVE: To determine the effect of obesity on decision-to-incision and decision-to-delivery time intervals in emergency Caesarean section. METHODS: We performed a retrospective study of emergency Caesarean sections performed between 2005 and 2009. Indications for emergency Caesarean section were defined as those posing an immediate threat to the life of the mother or fetus. The primary outcomes were the time intervals from decision for emergency delivery to skin incision, and decision to delivery of the infant. The secondary outcome was a composite of poor neonatal outcomes comprising umbilical cord artery pH lt; 7.20, Apgar score lt; 7 at five minutes, admission to NICU, or neonatal death. RESULTS: A total of 232 women underwent emergency Caesarean section, and 140 of these met the inclusion criteria. At the time of delivery, 78/140 (55.7%) patients were categorized as obese (BMI ≥ 30kg/m2). The median decision-to-incision and decision-to-delivery intervals were significantly longer in the obese group, with a median delay of 4.5 minutes in both time intervals. Time-to-event analysis demonstrated prolongation of the decision-to-incision interval in the obese group (hazard ratio 0.71, P lt; 0.05). There was no difference in the neonatal composite outcome, but there was a significant reduction in median five-minute Apgar score in the obese group (P = 0.02). CONCLUSION: Obesity is associated with prolonged decision-to-incision and decision-to-delivery intervals, without associated neonatal morbidity, in a tertiary hospital setting. Further studies are required to assess the specific factors limiting expedient delivery in this population.

Objective : Déterminer l'effet de l'obésité sur les intervalles décision-incision et décision-accouchement en ce qui concerne la tenue d'une césarienne d'urgence. Méthodes : Nous avons mené une étude rétrospective portant sur les césariennes d'urgence menées entre 2005 et 2009. Les indications menant à la tenue d'une césarienne d'urgence ont été définies comme étant celles qui constituaient une menace immédiate pour la vie de la mère ou celle du fœtus. Les critères d'évaluation principaux ont été l'intervalle entre la décision de procéder à un accouchement d'urgence et l'exécution de l'incision cutanée, et l'intervalle entre cette décision et la naissance de l'enfant. Le critère d'évaluation secondaire était un composite de diverses mauvaises issues néonatales, dont un pH artériel (cordon ombilical) lt; 7,20, un indice d'Apgar lt; 7 à cinq minutes, l'admission à l'UNSI et le décès néonatal. Résultats : Au total, 232 femmes ont subi une césarienne d'urgence et 140 d'entre elles répondaient aux critères d'inclusion. Au moment de l'accouchement, 78/140 (55,7 %) patientes ont été catégorisées comme étant obèses (IMC ≥ 30kg/m2). Les intervalles décision-incision et décision-accouchement médians étaient considérablement plus longs dans le groupe des femmes obèses (délai médian de 4,5 minutes pour ce qui est de ces deux intervalles). L'analyse du délai avant la survenue de l'événement a démontré la prolongation de l'intervalle décision-incision au sein du groupe des femmes obèses (rapport de risque, 0,71; P lt; 0,05). Bien qu'aucune différence n'ait été constatée en ce qui concerne l'issue composite néonatale, une baisse significative de l'indice d'Apgar médian à cinq minutes a été observée au sein du groupe des femmes obèses (P = 0,02). Conclusion : L'obésité est associée à une prolongation des intervalles décision-incision et décision-accouchement, sans répercussions connexes sur la morbidité néonatale, en milieu hospitalier tertiaire. La tenue d'autres études s'avère requise pour l'évaluation des facteurs particuliers qui limitent la tenue d'un accouchement en temps opportun au sein de cette population.

Double balloon catheter for induction of labour in Chinese women with previous caesarean section: one-year experience and literature review.

OBJECTIVES: To evaluate the efficacy and safety of double balloon catheter for induction of labour in Chinese women with one previous caesarean section and unfavourable cervix at term. DESIGN: Retrospective cohort study. SETTING: A regional hospital in Hong Kong. PATIENTS: Women with previous caesarean delivery requiring induction of labour at term and with an unfavourable cervix from May 2013 to April 2014. MAJOR OUTCOME MEASURES: Primary outcome was to assess rate of successful vaginal delivery (spontaneous or instrument-assisted) using double balloon catheter. Secondary outcomes were double balloon catheter induction-to-delivery and removal-to-delivery interval; cervical score improvement; oxytocin augmentation; maternal or fetal complications during cervical ripening, intrapartum and postpartum period; and risk factors associated with unsuccessful induction. RESULTS: All 24 Chinese women tolerated double balloon catheter well. After double balloon catheter expulsion or removal, the cervix successfully ripened in 18 (75%) cases. The improvement in Bishop score 3 (interquartile range, 2-4) was statistically significant (P<0.001). Overall, 18 (75%) cases were delivered vaginally. The median insertion-to-delivery and removal-to-delivery intervals were 19 (interquartile range, 13.4-23.0) hours and 6.9 (interquartile range, 4.1-10.8) hours, respectively. Compared with cases without, the interval to delivery was statistically significantly shorter in those with spontaneous balloon expulsion or spontaneous membrane rupture during ripening (7.8 vs 3.0 hours; P=0.025). There were no major maternal or neonatal complications. The only factor significantly associated with failed vaginal birth after caesarean was previous caesarean section for failure to progress (P<0.001). CONCLUSIONS: This is the first study using double balloon catheter for induction of labour in Asian Chinese women with previous caesarean section. Using double balloon catheter, we achieved a vaginal birth after caesarean rate of 75% without major complications.

Cervical dilation at the time of cesarean section for dystocia -- effect on subsequent trial of labor.

OBJECTIVE: To investigate the effect of cervical dilation at the time of cesarean section due to dystocia and success in a subsequent pregnancy of attempted vaginal delivery. DESIGN: Retrospective study. SETTING: University hospital in Copenhagen capital area. POPULATION: All women with a prior cesarean section due to dystocia who had undergone a subsequent pregnancy with a singleton delivery during 2006-2010. METHODS: Medical records were reviewed for prior vaginal birth, cervical dilation reached before cesarean section and induction of labor, gestational age, use of oxytocin, epidural anesthesia and mode of birth was collected. RESULTS: A total of 889 women were included; 373 had had a trial of labor. The success rate for vaginal birth among women with prior cesarean section for dystocia at 4-8 cm dilation was 39%, but 59% for women in whom prior cesarean section had been done at a fully or almost fully dilated cervix (9-10 cm) (p < 0.001). Among the women with a previous vaginal delivery prior to their cesarean section, the success rate for vaginal birth was 76.2%, in contrast to 48.9% in the group without a previous vaginal delivery (p < 0.01). CONCLUSION: Women who had a trial of labor after a prior cesarean section for dystocia done late in labor and women with a vaginal delivery prior to their cesarean section had a greater chance of a successful vaginal birth during a subsequent delivery.

Elevated maternal lipids in early pregnancy are not associated with risk of intrapartum caesarean in overweight and obese nulliparous women.

BACKGROUND: Maternal overweight and obesity are associated with slower labour progress and increased caesarean delivery for failure to progress. Obesity is also associated with hyperlipidaemia and cholesterol inhibits myometrial contractility in vitro. Our aim was, among overweight and obese nulliparous women, to investigate 1. the role of early pregnancy serum cholesterol and 2. clinical risk factors associated with first stage caesarean for failure to progress at term. METHODS: Secondary data analysis from a prospective cohort of overweight/obese New Zealand and Australian nullipara recruited to the SCOPE study. Women who laboured at term and delivered vaginally (n=840) or required first stage caesarean for failure to progress (n=196) were included. Maternal characteristics and serum cholesterol at 14-16 weeks' of gestation were compared according to delivery mode in univariable and multivariable analyses (adjusted for BMI, maternal age and height, obstetric care type, induction of labour and gestation at delivery ≥41 weeks). RESULTS: Total cholesterol at 14-16 weeks was not higher among women requiring first stage caesarean for failure to progress compared to those with vaginal delivery (5.55 ± 0.92 versus 5.67 ± 0.85 mmol/L, p= 0.10 respectively). Antenatal risk factors for first stage caesarean for failure to progress in overweight and obese women were BMI (adjusted odds ratio [aOR (95% CI)] 1.15 (1.07-1.22) per 5 unit increase, maternal age 1.37 (1.17-1.61) per 5 year increase, height 1.09 (1.06-1.12) per 1cm reduction), induction of labour 1.94 (1.38-2.73) and prolonged pregnancy ≥41 weeks 1.64 (1.14-2.35). CONCLUSIONS: Elevated maternal cholesterol in early pregnancy is not a risk factor for first stage caesarean for failure to progress in overweight/obese women. Other clinically relevant risk factors identified are: increasing maternal BMI, increasing maternal age, induction of labour and prolonged pregnancy ≥41 weeks' of gestation.