The efficacy and complications of retropubic tension-free vaginal tapes after 20 years: A prospective observational study.

OBJECTIVE: Long-term data regarding risks associated with tension-free vaginal tapes (TVT) are sparse, and where available are limited to small numbers. We analyse patient-reported outcomes of TVT after 16-24 years. DESIGN: Prospective observational study. SETTING: Single-centre study in a tertiary referral urogynaecology unit. POPULATION: A cohort of 350 women who had a TVT inserted between 1999 and 2004, in which 96% had urodynamically proven stress incontinence. METHODS: Postal questionnaire survey using the International Consultation on Incontinence Questionnaire, a visual analogue scale and a yes/no question as to whether they would have the procedure again. MAIN OUTCOME MEASURES: The primary outcome was cure of stress urinary incontinence, which was assessed using the ICIQ-FLUTS questionnaire. Secondary outcomes included overactive bladder symptoms, pain, sexual dysfunction, and patient satisfaction with the procedure. RESULTS: A total of 183/350 (52%) responses were received. The median age of women at follow up was 67 years (range 53-93 years) and the median follow up was 20 years (17-24 years). Stress urinary incontinence was denied by 39.3% of women. Urgency was reported by 42.1%. Bladder pain was reported either 'never' or 'occasionally' by 92.3% of women. The median satisfaction rate was 98/100 and 92.4% said they would have the TVT procedure again. CONCLUSIONS: Tension-free vaginal tape has high levels of satisfaction and cure up to 24 years after placement. Pain was uncommon and its impact on quality of life was low. Symptoms of urgency were prevalent but may be related to age. TVT is an effective treatment for SUI more than 20 years after initial placement.

Validation of online delivery of the Australian Pelvic Floor Questionnaire in an Irish obstetric population.

INTRODUCTION AND HYPOTHESIS: Childbirth remains an important risk factor for the development of pelvic floor disorders, regardless of the mode of delivery. To accurately assess these symptoms, accurate, woman-centric assessments are needed. Online versions of these assessments may be especially useful in the COVID-19 era. Women may potentially answer questions differently in an online format, and this study aimed to validate an online version of the paper-based self-administered Australian Pelvic Floor Questionnaire (APFQ). METHODS: The questionnaire was completed antenatally and at 3 months postpartum by 647 and 481 women respectively. Test- validity was assessed in subgroups of 61 and 57 women in each period, using intraclass correlation coefficients and Cohen's kappa. Sensitivity to change was assessed by comparing responses during pregnancy to those at 3 months postpartum. Internal consistency was assessed using Cronbach's alpha. Construct validity was assessed by comparing women with and without subjective bothersomeness. RESULTS: Intraclass correlation coefficients were above 0.9 for all domains and the overall questionnaire. Cohen's kappa for individual questions ranged from 0.71-1.00 across the antenatal and postnatal questionnaires. Cronbach's alpha was acceptable for all domains except the prolapse domain. The APFQ was sensitive to changes occurring between antenatal recruitment and 3 months postpartum. Effect sizes ranged from 0.83-7.99. CONCLUSIONS: This online version of the APFQ is valid for assessing pelvic floor disorders in an Irish obstetric population. The APFQ is reproducible and responsive to change occurring with childbirth, and can be used to research longitudinal changes in pelvic floor disorders. As an online tool, this questionnaire may be useful in increasing response rates to clinical research.

Effect of the length of the second stage of labor on pelvic floor dysfunction.

BACKGROUND: Pelvic floor dysfunction refers to any combination of incontinence, overactive bladder, pelvic organ prolapse, and sexual dysfunction. Pelvic floor dysfunction affects approximately 25% to 30% of women and is linked to parity and age. Some obstetrical risk factors have been highlighted, though the second stage of labor has not been as thoroughly investigated. Allowing a longer second stage has been suggested as a method of reducing the rates of cesarean delivery in nulliparous women, though it has also been linked to pelvic floor injuries. OBJECTIVE: This study aimed to determine the effect of the length of the second stage of labor on self-reported pelvic floor dysfunction. STUDY DESIGN: This was a single-center prospective cohort study in a tertiary referral obstetrical unit. Nulliparous women attending routine antenatal clinics were recruited to complete the Australian Pelvic Floor Questionnaire during pregnancy and again 3 months after delivery. The primary outcome in this study was the effect of the length of the second stage of labor on total pelvic floor scores when analyzed using multiple regression. The models were adjusted for the mother's age, mother's body mass index, length of the second stage of labor, fetal birthweight, mode of delivery, and perineal trauma. The secondary outcomes included the comparison of maternal, obstetrical, and functional pelvic floor outcomes based on the mode of delivery and the length of the second stage of labor. RESULTS: Among the 295 women who were recruited, the length of the second stage of labor and body mass index were associated with self-reported bladder dysfunction on multiple regression, whereas maternal age was protective. Compared with those with 60 to 120 minutes or <60 minutes of second stage of labor, women with that longer than 120 minutes had higher rates of stress incontinence (85.7% [>120 minutes] vs 41.7% [60-120 minutes] or 52.5% [<60 minutes], P=.001), urinary urgency (89.3% [>120 minutes] vs 39.6% [60-120 minutes] or 53.8% [<60 minutes], P<.001), and fecal incontinence (10.7% [>120 minutes] vs 0% [60-120 minutes] or 1.2% [<60 minutes], P=.027). There were no differences in the rates of sexual activity or dyspareunia. Women delivering vaginally had higher rates of stress incontinence (57.6% vs 38.0%, P=.006) than those undergoing cesarean delivery, though there were no differences in other pelvic floor symptoms or pelvic floor scores. CONCLUSION: A prolonged second stage of labor is associated with more self-reported bladder dysfunction at 3 months postnatal in primiparous women. Women with a longer second stage of labor should be informed about the risk of short-term bladder dysfunction, though the prevalence of long-term sequelae is unknown.

Antenatal urinary retention: Risk factors, treatment, and effect on pelvic floor dysfunction.

OBJECTIVE: Physiological changes to the urinary tract begin early in the first trimester and continue throughout pregnancy. Bladder symptoms vary throughout pregnancy and can remain after the puerperium. Antenatal urinary retention is a severe form of pelvic floor dysfunction and research into this topic is sparse. Little is known about the longer-term effects of antenatal urinary retention on pelvic floor dysfunction. This study aimed to establish the incidence of and risk factors for antenatal urinary retention in our population, and whether this had any impact on pelvic floor dysfunction. STUDY DESIGN: This was a cross-sectional study. Women were included if they were currently pregnant when they required catheterisation-either indwelling, intermittent self-catheterisation or both. The Australian Pelvic Floor Questionnaire was posted to all women. No follow-up reminders were sent and any woman who did not return their questionnaire was recorded as a non-responder. RESULTS: From January 2016 to December 2020, 41 women were identified as needing some form of catheterisation for treatment of antenatal urinary retention. During the same period, 44,646 women attended the National Maternity Hospital, giving an incidence of antenatal urinary retention of 0.92/1000 pregnancies. Questionnaire results were available for 25 women. One woman did not respond to one question, giving 99.9% complete data. The median (range) total pelvic floor score was 4.6 (0.2-10.7). Risk factors for antenatal urinary retention were identified in ten women. Most women denied any specific bladder symptoms, including difficulty in voiding and a feeling of incomplete emptying. CONCLUSIONS: Antenatal urinary retention is an uncommon form of pelvic floor dysfunction and occurs in 1-in-1000 pregnancies. Most women with antenatal urinary retention can be treated with an indwelling catheter for a short period, with only one in four women requiring intermittent self-catheterisation. Retention typically occurs in the late first and early second trimester, and while some risk factors have been identified, most women appear to have an uncomplicated pregnancy before developing acute urinary retention. Reassuringly, long-term pelvic floor dysfunction is minimal in women who experience antenatal urinary retention.

Optimization of protocols for human ovarian tissue cryopreservation with sucrose, 1,2-propanediol and human serum.

Chemotherapy and/or radiotherapy protocols have improved the long-term survival of cancer patients. Frequent consequences of antiblastic treatments, used to eradicate malignancies, are the partial loss of ovarian function, which in children and young women can result in permanent sterility. Ovarian tissue cryopreservation implemented before the beginning of treatment may potentially restore fertility. However, the physical effects of cryopreservation can damage oocyte survival and decrease follicular cell integrity and stromal preservation. The aim of this study was to examine the effects of different concentrations of 1,2-propanediol (PROH) and sucrose as cryoprotectants and human serum as protein support. Particular concentrations tested were 1.26, 1.5 and 1.08 mol/l PROH, 0.175, 0.2, 0.224 and 0.3 mol/l of sucrose and 20%, 30% and 40% human serum in the freezing solutions and normal or raised sucrose concentrations in the dilution solutions. Ovarian cortical slices from 13 patients, aged 5-38 years, were cryopreserved using slow freezing-rapid thawing. Tests were conducted using light and transmission electron microscopy. Cryo-damage occurred predominantly in the stromal and follicular cells. The best preservation of morphological characteristics was obtained using the freeze-thaw protocol in which concentrations of cryoprotectants were among the lowest (1.26 mol/l PROH+0.175 mol/l sucrose) with 30% human serum.

Epigenetic homogeneity in histone methylation underlies sperm programming for embryonic transcription.

Sperm contributes genetic and epigenetic information to the embryo to efficiently support development. However, the mechanism underlying such developmental competence remains elusive. Here, we investigated whether all sperm cells have a common epigenetic configuration that primes transcriptional program for embryonic development. Using calibrated ChIP-seq, we show that remodelling of histones during spermiogenesis results in the retention of methylated histone H3 at the same genomic location in most sperm cell. This homogeneously methylated fraction of histone H3 in the sperm genome is maintained during early embryonic replication. Such methylated histone fraction resisting post-fertilisation reprogramming marks developmental genes whose expression is perturbed upon experimental reduction of histone methylation. A similar homogeneously methylated histone H3 fraction is detected in human sperm. Altogether, we uncover a conserved mechanism of paternal epigenetic information transmission to the embryo through the homogeneous retention of methylated histone in a sperm cells population.

Exploring full cervical dilatation caesarean sections-A retrospective cohort study.

BACKGROUND: The rate of caesarean sections at full cervical dilatation with their high risk of morbidity continues to rise mirroring the overall increase in caesarean section rates internationally. OBJECTIVES: The objectives of this study were to determine the rate of full dilatation caesarean section in a tertiary referral unit and evaluate key labour, maternal and fetal factors potentially linked to those deliveries. We also assessed maternal and fetal morbidity at full dilatation sections. Where possible, these were compared with successful operative vaginal deliveries carried out in theatre to determine key differences. STUDY DESIGN: Retrospective cohort study. We reviewed the rate of full dilatation caesarean section over a 10-year period. We analysed deliveries (caesarean sections or operative vaginal deliveries) in single cephalic pregnancies ≥34 weeks with contemporaneously collected data from our unit's electronic database for 2015. RESULTS: The rate of full dilatation caesarean section increased by over a third in the ten-year period (56/6947 (0.80%) vs 92/7378 (1.24%), p = 0.01). Of 84 full dilatation caesarean sections who met the inclusion criteria, 63 (75%) were nulliparous and the mean maternal age was 33 (±5) years. Oxytocin was used in the second stage in less than half of second stage caesarean sections (22 out of a recorded 57, 38.6%). There were more fetal head malposition (occipito-posterior, or occipito-transverse) at full dilatation caesarean section compared to successful operative vaginal deliveries (41/46 (89.1%) vs 2/21 (9.5), p < 0.001). The rate of significant postpartum haemorrhage (defined as estimated blood loss ≥1000 ml) was similar in both full dilatation caesarean section and operative vaginal deliveries. There was no difference in the mean birthweight at full dilatation caesarean sections compared to operative vaginal delivery (3.88 kg (2.80-5.33 kg) vs 3.48 kg (1.53-4.40 kg)). There was no difference in neonatal morbidity. CONCLUSION: Fetal head malposition is associated with a higher risk of full dilatation caesarean section. Interestingly, maternal and fetal morbidity were similar between full dilatation caesarean sections and anticipated difficult operative vaginal deliveries carried out in theatre. The management of labour in terms of the decision to use oxytocin judiciously in hope of correcting inefficient uterine contractions and continuous labour ward training, particularly the diagnosis of malposition and its correction may be beneficial in reducing the rate of full dilation caesarean sections.

Healthy early preantral follicle can be obtained in a culture of frozen-thawed human ovarian tissue of 32 weeks.

The objective of this study was to report morphological and functional evidence of a well-preserved preantral follicle recovered from human frozen-thawed ovarian tissue in a long-term culture. The tissue was originally obtained from a 26-year-old woman with breast cancer. The ovarian cortex was collected by laparoscopy and frozen/thawed and cultured for 32 weeks in minimum essential medium alpha-MEM, supplemented with insulin transferrine selenite (ITS), human serum (HS), antibiotics, follicle-stimulating hormone (FSH). and N-acetyl cysteine (NAC). Thawed tissue samples were examined by light microscopy (LM), transmission electron microscopy (TEM), and real-time RT-PCR. LM examination of cortical pieces after 32 weeks of culture showed a healthy early preantral follicle; TEM and real-time PCR confirmed its good state of preservation. The synergy in action of NAC and FSH plays an important role in follicle growth of ovarian tissue cultures. For the first time a well-preserved preantral follicle was found in a culture of frozen-thawed human ovarian tissue.

Emergency salpingectomy for ruptured ectopic pregnancy in patient with Melnick-Needles syndrome: a rare otopalatodigital syndrome.

Melnick-Needles syndrome (M-NS) is a rare genetic disorder which primarily affects skeletal developments. M-NS may also affect the cardiorespiratory and renal systems. A 35 kg patient presented complaining of abdominal pain. Following a positive pregnancy test and ultrasound examination, she was diagnosed with a ruptured ectopic pregnancy. She had a significant background history of M-NS, obstructive sleep apnoea (with narrow gauge tracheostomy in situ), obstructive lung disease and scoliosis. She received fluid resuscitation, and the case was managed using an open salpingectomy and clot evacuation under combined spinal/epidural anaesthesia. Anticipated difficulty in securing a definitive airway was pivotal to choosing a regional anaesthetic technique. The operation was successful and the patient recovered well. This was a unique surgical and anaesthetic challenge due to abnormal facial, spinal and abdominal morphology compounded by the time-critical emergency nature of the case. Individually tailored perioperative management is frequently required for patients with rare syndromes.

Singleton vaginal breech delivery at term: still a safe option.

OBJECTIVE: To examine the obstetric and perinatal outcome of pregnancies with singleton breech presentation at term when selection for vaginal delivery was based on clear prelabor and intrapartum criteria. METHODS: The outcomes of all pregnancies with a breech presentation after 37 weeks of gestation were retrospectively reviewed from January 1997 to June 2000. Criteria for prelabor cesarean or trial of vaginal breech delivery included type of breech, estimated fetal weight (more than 3,800 g), maternal preference, and gestation more than 41 weeks. An intrapartum protocol excluded induction and oxytocin augmentation of labor, combined with a low threshold for cesarean delivery for dystocic labor; an experienced obstetrician was in attendance during labor and delivery. RESULTS: Of 641 women, 343 (54%) underwent prelabor cesarean, and 298 (46%) had a trial of vaginal delivery, of whom 146 (49%) delivered vaginally. Significantly fewer nulliparas (58 of 158, 37%) than multiparas (88 of 140, 63%; P <.001) achieved vaginal delivery after trial of labor. Significantly more infants weighing more than 3,800 g were selected for prelabor (87 of 343, 25%) and intrapartum (31 of 152, 20%) cesarean than delivered vaginally (15 of 146, 10%). Two neonates (0.7%) had Apgar scores of less than 7 at 5 minutes; both were neurologically normal at 6 weeks. There were no nonanomalous perinatal deaths and no cases of significant trauma or neurological dysfunction; 3 infants delivered vaginally died due to lethal anomalies. CONCLUSION: Safe vaginal breech delivery at term can be achieved with strict selection criteria, adherence to a careful intrapartum protocol, and with an experienced obstetrician in attendance. Our protocol effectively selects larger infants for cesarean delivery. LEVEL OF EVIDENCE: II-2

Is the monitoring of anti-Xa activity necessary in pregnant women undergoing thromboprophylaxis?

Thromboprophylaxis is increasingly advocated in pregnancy for certain clinical conditions. Low molecular weight heparins offer potential benefit over unfractionated heparins with increased bioavailability and a longer half-life, thus allowing for once daily administration. This study aims to determine if monitoring of anti-Xa activity is necessary in pregnant women undergoing thromboprophylaxis. Twenty-five pregnancies were prospectively followed where either tinzaparin or enoxparin was employed for thromboprophylaxis. Once the anti-Xa levels were in the thromboprophylactic range (0.03-0.5 U/ml) no patient required a change of dose. Frequent monitoring of Anti-Xa levels, once in the thromboprophylactic range, may not be required.

Brominated and fluorinated organic pollutants in the breast milk of first-time Irish mothers: is there a relationship to levels in food?

Brominated flame retardants - polybrominated diphenyl ethers (PBDEs), polybrominated biphenyls (PBBs), hexabromocyclododecane (HBCD) and others - have been measured in 11 pooled breast milk samples from 109 first-time mothers in Ireland. Additionally, the study has measured levels of polybrominated dibenzo-p-dioxins and furans (PBDD/Fs), mixed halogenated dioxins (PXCC/Fs) and biphenyls (PXBs), polychlorinated naphthalenes (PCNs) and perfluoroalkylated substances (PFAS) in these samples. The mean sum of 19 PBDEs including BDE-209 was 4.85 ng g(-1) fat, which is comparable with that found in other European countries. BDE-47, BDE-153, BDE-209, BDE-99 and BDE-100 were found at the highest concentrations. The only PBBs detected consistently were BB-77, BB-126 and BB-153, with highest concentrations being found for BB-153 (mean = 0.13 ng g(-1) fat). The mean sum of HBCD enantiomers was 3.52 ng g(-1) fat, with α-HBCD representing over 70% of the total. Of the other brominated flame retardants - tetrabromobisphenol-A (TBBP-A), hexabromobenzene (HBB), decabromodiphenylethane (DBDPE) and bis(2,4,6-tribromophenoxyethane) (BTBPE) - examined, only TBBP-A was detected above the limit of detection (LOD), in two of the 11 pools analysed. All measured PBDF congeners were observed (at 0.02-0.91 pg g(-1) fat), but 2,3,7,8-tetrabromo-dibenzodioxin (TeBDD) was the only PBDD detected, with a mean concentration of 0.09 pg g(-1) fat. The occurrence of the mixed chlorinated/brominated dibenzodioxins, dibenzofurans and biphenyls, 2-B-3,7,8-CDD, 2,3-B-7,8-CDF, 4-B-2,3,7,8-CDF, PXB 105, PXB 118, PXB 126 and PCB 156 in breast milk in the current study may indicate that levels of these contaminants are increasing in the environment. Polychlorinated naphthalenes were detected in all samples, but not perfluorooctane sulfonate (PFOS) and other PFAS. The pattern of occurrence of these brominated and fluorinated persistent organic pollutants (POPs) in Irish breast milk shows a general relationship to their occurrence in food, as reported in a number of surveillance studies carried out by the Food Safety Authority of Ireland.

Early and late preterm delivery rates - a comparison of differing tocolytic policies in a single urban population.

OBJECTIVE: Preterm delivery results in neonatal morbidity and mortality. We set out to estimate the difference in rates of preterm delivery in two institutions, serving a single population, with differing policies regarding use of tocolytic drugs for the prevention of preterm delivery. STUDY DESIGN: A retrospective study comparing preterm delivery rates between 2002 and 2007 in two large tertiary hospitals serving a single urban population with similar risk factor profile located less than 2 miles from each other. During the study period Hospital A routinely used tocolytic therapy, Hospital B operates a policy of never using any tocolytic drugs. Rates of delivery prior to 26, 30, 34 and 37 weeks were compared for each hospital. RESULTS: During the study period there were 90,843 deliveries between the two hospitals. The overall rates of preterm delivery at less than 37 weeks gestation were comparable with 6.62% (2794/42,232) in Hospital A and 6.15% (2989/48,611) in Hospital B (p = 0.99). There was no significant difference in the numbers delivering at less than 34 weeks, 995/42,232 (2.36%) versus 1134/48,611 (2.33%), p = 0.59, less than 30 weeks, 403/42,232 (0.95%) versus 429/48,611 (0.88%), p = 0.87 or prior to 26 weeks, 126/42,232 (0.29%) versus 121/48,611 (0.25%), p= 0.08. CONCLUSION: In this large population routine use of tocolytic drugs in the treatment of threatened preterm labor does not alter rates of early or late preterm delivery. While this study is limited by its retrospective nature, it calls into question the practice of tocolysis.

Polychlorinated dibenzo-p-dioxins (PCDDs), polychlorinated dibenzofurans (PCDFs) and polychlorinated biphenyls (PCBs) in breast milk of first-time Irish mothers: impact of the 2008 dioxin incident in Ireland.

The 2008 dioxin incident in Ireland resulted in elevated concentrations of polychlorinated dibenzo-p-dioxins (PCDDs), dibenzofurans (PCDFs) and polychlorinated biphenyls (PCBs) in Irish pork and pork products, due to the consumption of contaminated animal feed by pigs. In order to investigate any resulting impact on the Irish population, these contaminants were measured in pooled breast milk samples from 109 first-time mothers, collected in 2010. A comparison of the results with similar data from 2002 revealed generally lower concentrations of PCDD/Fs and dioxin-like PCBs in the 2010 samples, confirming the declining trend reported by many authors. Contaminant concentration levels for both 2002 and 2010 were generally slightly lower than those reported internationally, with a mean combined PCDD/F and PCB WHO-TEQ of 9.66pgg(-1)fat, for an overall pooled sample of milk from 2010. An apparent slight increase in PCDFs was observed between 2002 and 2010 (from 2.73pg WHO-TEQ g(-1)fat to 3.21pg WHO-TEQ g(-1)fat), with the main contributory congener being 2,3,4,7,8-PentaCDF. While it cannot be totally discounted that the slight increase in 2,3,4,7,8-PentaCDF and in the overall PCDF WHO-TEQ in breast milk could be attributable to consumption of Irish pork during the 2008 incident, we consider that it is more likely that this was due to other factors, including the predominantly urban/industrial sampling locations for the 2010 samples, compared to 2002.

Levator ani injury in primiparous women with forceps delivery for fetal distress, forceps for second stage arrest, and spontaneous delivery.

OBJECTIVE: To compare levator ani muscle injury rates in primiparous women who had a forceps delivery owing to fetal distress with women delivered by forceps for second stage arrest; and to compare these injury rates with a historical control group of women who delivered spontaneously. METHODS: Primiparous women who delivered by forceps were recruited retrospectively into 2 groups: forceps for fetal distress with short second stage (25±11 minutes; n=19); and forceps delivery for second stage arrest (137±26 minutes; n=19). MR images of the levator ani muscles were compared with a historical control group of women from a previous study who had delivered spontaneously (n=129). RESULTS: Major defect rates were: 42% for forceps and short second stage; 63% for forceps and second stage arrest; and 6% for spontaneous delivery. The odds ratios for major injury were: 11.0 for forceps and short second stage compared with spontaneous delivery; 25.9 for forceps and second stage arrest compared with spontaneous delivery; and 2.3 for forceps and second stage arrest compared with short second stage (P=0.07). CONCLUSION: Women delivered by forceps have a higher rate of levator ani injury compared with spontaneous delivery controls; the difference between the forceps groups did not reach significance.

Culture of cryopreserved ovarian tissue: state of the art in 2008.

This paper reviews the most relevant literature from the past 10 years on different techniques for the culture of fresh and cryopreserved ovarian tissue from animals and humans. Information on strategies for culturing whole ovarian tissue and isolated follicles are provided as well as an updated and comprehensive view of the role that growth factors have in mediating and regulating in vitro folliculogenesis.

Term neonatal asphyxial seizures and peripartum deaths: lack of correlation with a rising cesarean delivery rate.

OBJECTIVE: The purpose of this analysis was to study the relationship between an increasing cesarean delivery rate and term neonatal seizures and peripartum deaths. STUDY DESIGN: This was a retrospective analysis of annually collated institutional data on cesarean delivery and perinatal outcome. RESULTS: Of 77,350 women who delivered at 37 weeks' gestation or more through 12 years (1989 to 2000), the cesarean rate increased from 6.9% to 15.1%; perinatal mortality at term, average 3.1/1000, was unchanged. The cesarean rate for nulliparas doubled from 8.3% to 17.5%. The overall neonatal term seizure rate (overall 1.3/1000; and for nulliparas 2.5/1000) did not change. The overall peripartum death rate (0.8/1000) was unchanged, although the rate for nulliparas (1.5/1000) showed a significant decline. Overall seizure rate in nulliparas was 5-fold higher than in multiparas; presumed intrapartum asphyxia was associated with 84% of both seizures and neonatal deaths in nulliparas. Among 2547 prelabor cesarean deliveries, there were no peripartum deaths and one neonatal seizure, an incidence comparable with that in multiparas who labored. CONCLUSION: Despite a greater than 2-fold rise in cesarean section rate, the seizure rate and overall peripartum death rate at term did not alter significantly. Neonatal seizures occurred 5 times more often following first deliveries.

Does fetal head position at the term plus 12 scan influence induction, labor and delivery outcome?

AIMS: To assess the influence that fetal head position has on induction, labor and delivery outcome for both mother and baby. METHODS: During a one month period, in November 1999, all women attending for a post-dates scan were enrolled as the study population. In total, 91 women formed our study population for analysis of data. The sonographic, induction and labor details of all women were recorded on a dedicated data sheet. As well as documenting the maternal age, parity, liquor volume (mm) and BPS, the position of the fetal head was noted by the sonographer as occipitoanterior, occipitotransverse or occipitoposterior. All women had gestation confirmed by ultrasound early during the course of their pregnancy. Maternal, ultrasonographic, induction and labor variables were correlated with fetal head presentation at scan. RESULTS: There was no positive correlation found between fetal head position at the term plus 12 scan and associated induction, labor or delivery complications in the 91 women studied. CONCLUSIONS: Our study shows no positive correlation between fetal head position and induction, labor or delivery complications.

The continuing effectiveness of active management of first labor, despite a doubling in overall nulliparous cesarean delivery.

OBJECTIVE: The purpose of this study was to determine the continuing effectiveness of active management of labor, a protocol that involves early detection and correction of dystocia with oxytocin in spontaneous cephalic nulliparous labor, by analysis of the contribution of this cohort to a doubled overall nulliparous cesarean delivery rate. STUDY DESIGN: This was a retrospective analysis of annually collated institutional data on cesarean delivery and perinatal outcome. RESULTS: From 1989 to 2000, 81,855 women were delivered at the National Maternity Hospital, of whom 34,201 women (42%) were nulliparous; the annual proportion of nulliparous women in spontaneous labor decreased progressively from 83% to 60%; the overall nulliparous cesarean rate increased from 8.1% to 16.6%. Cesarean birth rate among nulliparous women in spontaneous labor, although showing a significant upward trend between 1989 and 2000 (2.4%-4.8%; P = .001), was stable, averaging 5% for the last 8 years (P = .705); the peripartum death rate in this group fell significantly (P = .024). Comparing results for 1989 with results for 2000, nulliparous women in spontaneous labor accounted for 14% of the overall increase in cesarean deliveries (dystocia, 5%), compared with 51% for nulliparous women with induced labor. The perinatal mortality rate in term infants was unchanged. CONCLUSION: Active management of spontaneous first labors remains an effective protocol for the promotion of vaginal delivery with low peripartum mortality rates; factors other than dystocia in spontaneous labor account for the progressive increase in the nulliparous cesarean delivery rate.

Neonatal brachial plexus palsy: an unpredictable injury.

OBJECTIVE: Brachial plexus paralysis is a serious form of neonatal morbidity. We determined its incidence and persistence of disability and evaluated whether its occurrence could be predicted by maternal characteristics or partographic analysis in a large cohort of recent cases. STUDY DESIGN: During the years 1994 through 1998, all infants with neonatal evidence of obstetric brachial plexus injury were identified and followed 14;>or=1 year. Obstetric details in these maternal-infant pairs were compared with 108 control pairs, matched for maternal and gestational age, parity, and birth weight. Partographs of cases and control subjects were reviewed, in a blinded manner, by 3 obstetricians who were asked to identify likely cases of nerve injury. A risk score comprising eight recognized associated clinical features was assigned. RESULTS: Fifty-four of 35,796 infants (1.5/1000) had evidence of brachial plexus injury; in 10 cases (19%), neurologic deficit persisted to 1 year. Although the risk factor profile was relatively higher in cases compared with control subjects, the highest score was 5 of 8 in six cases (2 cases, 4 control subjects). Obstetricians' partographic assessment identified "likely brachial plexus injury" in 13 of 54 cases (24%) and 16 of 108 control subjects (15%), and in only 3 cases (6%) did the assessors concur (positive predictive value, 7%-17%; negative predictive value, 5%-12%; sensitivity, 24%-50%; specificity, 66%-68%). Risk scores were similar among persistently and transiently injured cases. CONCLUSION: Our results indicate that brachial plexus injury is not predictable before delivery, either by risk factor scoring or by partographic analysis.