Fetal head position and perineal distension associated with the use of the BD Odon Device™ in operative vaginal birth: a simulation study.

OBJECTIVE: To investigate (1) the placement of the BD Odon Device on the model fetal head and (2) perineal distention during simulated operative vaginal births conducted with the BD Odon Device. DESIGN: Observational simulation study. SETTING: North Bristol NHS Trust, UK. POPULATION OR SAMPLE: Four hundred and forty simulated operative vaginal births. METHODS: Three bespoke fetal mannequins were developed to represent (1) bi-parietal diameter of the 50th centile at term, (2) bi-parietal diameter at the 5th centile at term, and (3) 50th centile head with 2 cm of caput. Siting of the BD Odon Device on model heads was determined before and after 400 simulated operative vaginal births. Variables were analysed to determine their effect on device siting and movement during birth. The fetal mannequins were placed inside a maternal mannequin and the BD Odon Device was placed around the fetal head as per the instructions for use. The location of the air cuff was determined before and after the head was delivered. Perineal distension was determined by recording maximum perineal distention during a simulated operative vaginal birth using the same procedure, as well as scenarios employing an inappropriately non-deflated air cuff (for the BD Odon Device), the Kiwi ventouse and non-rotational forceps. MAIN OUTCOME MEASURES: Site and displacement during birth of the BD Odon Device on a model head. Maximal perineal distension during birth. RESULTS: The BD Odon Device was reliably sited in a standard over the fetal head position (approximately 40 mm above the fetal chin) for all stations, head sizes and positions with no significant displacement. In occipito-posterior births, compared with occipito-anterior or transverse, the BD Odon Device routinely sited further down the fetal head (toward the chin). The BD Odon Device was not associated with more perineal distension compared with forceps or Kiwi ventouse (respectively 21, 26 and 21 mm at posterior fourchette). CONCLUSIONS: The BD Odon Device reliably sited over a safe area of the fetal head in 400 simulated births representative of clinical practice. The BD Odon Device generates similar levels of perineal distension compared with Kiwi ventouse when used correctly. TWEETABLE ABSTRACT: Location of the BD Odon Device on a fetal head in simulation.

Pressure and traction on a model fetal head and neck associated with the use of forceps, Kiwi™ ventouse and the BD Odon Device™ in operative vaginal birth: a simulation study.

OBJECTIVE: To determine the pressure and traction forces exerted on a model fetal head by the BD Odon Device, forceps and Kiwi ventouse during simulated births. DESIGN: Simulation study. SETTING: Simulated operative vaginal birth. POPULATION OR SAMPLE: Eighty-four simulated operative vaginal births. METHODS: A bespoke fetal mannequin with pressure sensors around the head and strain gauge across the neck was used to investigate pressure applied over the head, and traction across the neck during 84 simulated births using the BD Odon Device, non-rotational forceps and Kiwi ventouse. MAIN OUTCOME MEASURES: Peak pressure on the fetal face and lateral aspects of the head during correct use of the BD Odon Device and forceps. Peak pressure on orbits and neck during misplacement of the BD Odon Device and forceps. Peak traction force generated until instrument failure using the BD Odon Device, forceps and Kiwi ventouse. RESULTS: When correctly sited and using 80 kPa inflation pressure on the cuff, the BD Odon Device generated a lower peak pressure on the fetal head than forceps (83 versus 146 kPa). When instruments were purposefully misplaced over the orbits, the BD Odon Device generated a lower peak pressure on the orbits compared with forceps (70 versus 123 kPa). When purposefully misplaced over the neck, the BD Odon Device, compared with forceps, generated a greater peak pressure on the anterio-lateral aspect of the neck (56 versus 17 kPa) and a lower peak pressure on the posterior aspect of the neck (76 versus 93 kPa) than forceps. In cases of true cephalic disproportion, the BD Odon Device 'popped-off' at a lower traction force than did forceps (208 versus 270 N). CONCLUSIONS: In simulated assisted vaginal birth with correctly placed instruments, the peak pressure exerted on the fetal head by a BD Odon Device is lower than the pressure exerted by non-rotational forceps. In cases in which delivery of the fetal head is not possible due to cephalo-pelvic disproportion, lower traction forces could be applied using the BD Odon Device than with forceps before the procedure was abandoned due to device failure. TWEETABLE ABSTRACT: BD Odon Device exerts less pressure on a model fetal head than forceps, but more than Kiwi ventouse.

Maternal positioning to correct occiput posterior fetal position during the first stage of labour: a randomised controlled trial.

OBJECTIVE: To evaluate the efficacy of the hands and knees position during the first stage of labour to facilitate the rotation of the fetal head to the occiput anterior position. DESIGN: Randomised controlled trial. SETTING: Geneva University Hospitals, Switzerland. POPULATION: A total of 439 women with a fetus in the occiput posterior position during the first stage of labour. METHODS: The women in the intervention group were invited to take a hands and knees position for at least for 10 minutes. Women allocated to the control group received the usual care. For both groups, 15 minutes after randomisation, women completed a short questionnaire to report their perceived pain and the comfort of their position. MAIN OUTCOME MEASURES: The rotation of the fetal head in occiput anterior position confirmed by ultrasonography 1 hour after randomisation. RESULTS: One hour after the randomisation, 35 of 203 (17%) fetuses were diagnosed as being in the occiput anterior position in the intervention group compared with 24 of 209 (12%) in the control group. This difference was not statistically significant (relative risk 1.50; 95% CI 0.93-2.43; P = 0.13). The change in the evaluation of comfort between the randomisation and 15 minutes after showed an improvement in 70 and 39 women, no change in 82 and 78 women and a decrease in 56 and 86 women in the intervention and control groups, respectively (P = 0.02). CONCLUSIONS: This study could not demonstrate a benefit of the hands and knees position to correct the occiput posterior position of the fetus during the first stage of labour, but the women reported an increase in their comfort level. TWEETABLE ABSTRACT: Hands and knees position does not facilitate rotation into occiput anterior but increases the comfort level of women.

Elective induction of labour and maternal request: a national population-based study.

OBJECTIVE: To estimate the rate of elective inductions in France and the proportion of them that were maternally requested, and to study the factors associated with elective inductions that were or were not requested by women. DESIGN: Cross-sectional population-based study. SETTING: All maternity units in France. POPULATION: About 14 681 women from the 2010 French National Perinatal Survey of a representative sample of births. METHODS: Inductions were classified as elective based on their indications and maternal and fetal characteristics, collected from medical records. Elective inductions requested by women were identified from the mother's postpartum interviews. Polytomous logistic regression analysis was used to study the determinants of inductions that were or were not maternally requested. Women with spontaneous labour served as the comparison group. MAIN OUTCOME MEASURE: Rate of elective inductions. RESULTS: The induction rate was 22.6, 13.9% elective. Among elective inductions, 47.3% were requested by women. The characteristics of mothers, pregnancies, and maternity units were similar in both groups of elective inductions. The main associated factors were parity 2 or more [adjusted odds ratio (OR) 4.7, 95% confidence interval (CI) 3.1-7.2 for maternally requested inductions and aOR of 1.8 (95% CI1.2-2.7) for unrequested inductions, compared with parity 0] and private hospital status [aOR 4.5 95% (CI 3.3-6.0) for maternally requested inductions and aOR 3.7 (95% CI 2.8-4.9) for inductions not requested by the mother]. We found no association between maternal social characteristics and type of elective induction. CONCLUSION: Parity and organisational factors appear to influence the decision about elective inductions. It would be interesting to determine how obstetricians and women make this decision and for what reasons. TWEETABLE ABSTRACT: About 13.9% of inductions of labour were elective in France, 47.3% of these requested by women.

Fasting glycaemia to simplify screening for gestational diabetes.

OBJECTIVE: Recommendations in Switzerland on screening for gestational diabetes endorse the International Association of Diabetes in Pregnancy Study Group consensus. As universal testing is time consuming and glucose loading is unpleasant, the recommendations include a simplification, not performing the glucose loading in women with fasting glycaemia <4.4 mmol/l. Our objective was to evaluate the diagnostic performance of this simplified strategy, compared with the complete test, in our population with a low prevalence of gestational diabetes. DESIGN: We collected 2298 complete 75-g glucose tolerance tests. We simulated stopping the test, so avoiding the glucose loading and further glycaemia, if fasting glycaemia was <4.4 or ≥5.1 mmol/l. SETTING AND POPULATION: Unselected pregnant women from Geneva and Basel, at 24-28 weeks of gestation. METHODS: We calculated the sensitivity, and the percentage of women who would avoid the complete test with the strategy based on fasting glycaemia. RESULTS: The prevalence of gestational diabetes was 10.9% in our population. Among 251 women with gestational diabetes, fasting glycaemia was ≥5.1 mmol/l in 119 women (47.4%), between 4.4 and <5.1 mmol/l in 78 women (31.1%) and <4.4 mmol/l in 54 women (21.5%). Proceeding with the complete test only in women with fasting glycaemia between 4.4 and <5.1 mmol/l will result in a sensitivity of 78.5%. This strategy would avoid glucose loading in 63.8% of women. CONCLUSIONS: Screening with fasting glycaemia is an attractive alternative to universal screening with the complete 75-g glucose tolerance test. This strategy is, however, slightly less sensitive than previously reported in higher-risk populations. TWEETABLE ABSTRACT: Fasting glycaemia can be considered as an alternative to the complete test for gestational diabetes screening.

Prevention of preterm delivery with vaginal progesterone in women with preterm labour (4P): randomised double-blind placebo-controlled trial.

OBJECTIVE: To evaluate the effectiveness of 200 mg of daily vaginal natural progesterone to prevent preterm birth in women with preterm labour. DESIGN: Multicentre, randomised, double-blind, placebo-controlled trial. SETTING: Twenty-nine centres in Switzerland and Argentina. POPULATION: A total of 385 women with preterm labour (24(0/7) to 33(6/7) weeks of gestation) treated with acute tocolysis. METHODS: Participants were randomly allocated to either 200 mg daily of self-administered vaginal progesterone or placebo within 48 hours of starting acute tocolysis. MAIN OUTCOME MEASURES: Primary outcome was delivery before 37 weeks of gestation. Secondary outcomes were delivery before 32 and 34 weeks, adverse effects, duration of tocolysis, re-admissions for preterm labour, length of hospital stay, and neonatal morbidity and mortality. The study was ended prematurely based on results of the intermediate analysis. RESULTS: Preterm birth occurred in 42.5% of women in the progesterone group versus 35.5% in the placebo group (relative risk [RR] 1.2; 95% confidence interval [95% CI] 0.93-1.5). Delivery at <32 and <34 weeks did not differ between the two groups (12.9 versus 9.7%; [RR 1.3; 95% CI 0.7-2.5] and 19.7 versus 12.9% [RR 1.5; 95% CI 0.9-2.4], respectively). The duration of tocolysis, hospitalisation, and recurrence of preterm labour were comparable between groups. Neonatal morbidity occurred in 44 (22.8%) cases on progesterone versus 35 (18.8%) cases on placebo (RR: 1.2; 95% CI 0.82-1.8), whereas there were 4 (2%) neonatal deaths in each study group. CONCLUSION: There is no evidence that the daily administration of 200 mg vaginal progesterone decreases preterm birth or improves neonatal outcome in women with preterm labour.

[Induction of labour: benefits and risks]. / Déclenchement de l'accouchement: le pour et le contre.

A large proportion of pregnant women have induction of labour at or near term. Few randomized trials have evaluated the various indications to induce labour. In some cases, induction is highly recommended to avoid a life-threatening complication for the fetus or the mother. In other cases, the indication is controversial. We review the evidence for a benefit in case of post-term, premature rupture of membranes, maternal hypertensive disorders and suspicion of fetal macrosomia. In case of maternal diabetes or intrauterine growth impairment the need for induction of labour must probably be discussed according to the clinical features. In the above mentioned indications, it does not seem that the risk of caesarean section is increased.

[Atypical presentation of preeclampsia]. / Les présentations cliniques atypiques de la prééclampsie.

Preeclampsia is a pregnancy-related syndrome, which still represents one of the major causes of maternal-fetal mortality and morbidity. Diagnosis can be made difficult due to the complexity of the disorder and its wide spectrum of clinical manifestations. In order to provide an efficient diagnostic tool to the clinician, medical societies regularly rethink the definition criteria. However, there are still clinical presentations of preeclampsia that escape the frame of the definition. The present review will address atypical forms of preeclampsia, such as preeclampsia without proteinuria, normotensive preeclampsia, preeclampsia before 20 weeks of gestation and post-partum preeclampsia.

[What's new in gynecology and obstetrics]. / Gynécotogie et obstétrique.

Because of the lack of screening methods, ovarian cancer remains one of the major causes of mortality in gynecological oncology. Prevention by salpingectomy, based on a concept about the origin of serous carcinoma, may be proven effective in the future. Regarding cervical cancer, screening methods are improving and the benefit of HPV-HR testing has been recently demonstrated. Metabolic requirements and exercise are modified during pregnancy. Present recommendations are for pregnant women to practice regular moderate exercise, as in a non-pregnant population. This guideline, despite being reasonable, is not based on strong evidence. A randomised trial is ongoing in our Department to evaluate the effects of exercise in women with gestational diabetes.

[Management of gestational diabetes: current knowledge and future perspectives]. / Prise en charge du diabète gestationnel: nouvelles connaissances et perspectives futures.

Gestational diabetes (GDM) is one of the most common complications of pregnancy and its prevalence is increasing continuously. Diagnosis, screening of GDM and therapeutic interventions are topics of ongoing controversies and uncertainty that have contributed to make the management of GDM complex and different from one country to another. Recent studies, such as ACHOIS and HAPO, have contributed to better define screening criteria and international recommendations and have demonstrated that management of GDM, including glucose monitoring, diet and insulin if needed, is worthwhile. This article summarizes the current status of screening, management of GDM and postpartum follow-up.

[Psychosocial risk factors and preterm delivery]. / Facteurs de risque psychosociaux et accouchement avant terme.

Delivery before term (at less than 37 weeks of gestation) represents 5 to 10% of the deliveries and is an important cause of perinatal mortality and morbidity. Few improvements in prevention have been made. Difficulties include the multiplicity of medical risk factors, the absence of reliable diagnostic tests and the limited effectiveness of medical treatment. Several studies have shown that psychosocial risk factors are associated with preterm labour. The identification and management of these risk factors and of unfavorable social environment may potentially reduce the risk of preterm delivery. We describe and discuss the studies evaluating psychosocial interventions aiming at reducing the risk of prematurity.

[Vaginal birth after cesarean delivery: update 2010]. / Accouchement vaginal après césarienne en 2010.

Uterine rupture is a rare, but potentially catastrophic complication of a trial of vaginal birth after cesarean (VBAC). In part because of concerns about this complication, the rate of cesarean deliveries continue to raise in developed countries. However, multiple repeat cesarean deliveries are associated with a greater risk of complications during surgery and of abnormal placentation in a subsequent pregnancy. VBAC should be proposed to women with good prognosis of VBAC success and low risk of uterine rupture. We aimed to review antepartum and intrapartum factors that are required for a safe VBAC.

Clinical application of fetal urine production rate in unexplained polyhydramnios.

OBJECTIVE: To evaluate the clinical use of hourly fetal urine production rate (HFUPR) in polyhydramnios. METHODS: This was a retrospective review of 33 singleton pregnancies with polyhydramnios, 30 of them unexplained and three due to gastrointestinal atresia. HFUPR was estimated using three-dimensional ultrasound and was compared with recently established nomograms. Abnormal midterm outcome, defined as diagnosis or persistence of pathology after the neonatal period until the age of 2 years, was analyzed according to prenatal HFUPR measurements and other polyhydramnios characteristics. RESULTS: Seventeen of the 30 fetuses with unexplained polyhydramnios had an HFUPR above the 95(th) centile, and five (29.4%) of them developed midterm disorders. None of the 13 with normal HFUPR developed midterm disorders. The HFUPR was 1.9 (SD, 0.7) multiples of the median (MoM) in fetuses with an adverse childhood outcome and 1.4 (SD, 1.2) in fetuses with normal childhood outcome (P = 0.34). In the three fetuses with gastrointestinal atresia, the HFUPR was significantly lower than in those with unexplained polyhydramnios (P = 0.003). CONCLUSION: HFUPR was associated with the mechanism of polyhydramnios but failed to help in the prognosis of unexplained polyhydramnios because of lack of power. Children with prenatal unexplained polyhydramnios and HFUPR above the 95(th) centile should nevertheless receive detailed pediatric follow-up.

[Is preeclampsia a new cardiovascular and end-stage renal diseases risk marker?]. / La prééclampsie: un nouvea facteur de risque de maladies cardiovasculaire et rénale?

Is preeclampsia a new cardiovascular and end-stage renal diseases risk marker? Preeclampsia is a major obstetrical problem leading to high maternal and perinatal morbidity and mortality worldwide. It is characterized by hypertension and proteinuria occurring after 20 weeks of gestation. Increasing evidence indicates that preeclampsia is not just a pregnancy disease that resolves at the time of delivery, but represent a risk marker of cardiovascular and end-stage renal diseases later in life. The underlying link between preeclampsia and cardiovascular disease is unclear. Women with early onset/severe preeclampsia, recurrent preeclampsia, or preeclampsia with onset as a multipara appear to be at highest risk of cardiovascular disease later in life, including during the premenopausal period.

Intracervical prostaglandins for induction of labour.

BACKGROUND: Prostaglandins have been used for cervical ripening and induction of labour since the 1970s. The goal of the administration of prostaglandins in the process of induction of labour is to achieve cervical ripening before the onset of contractions. One of the routes of administration that was proposed is intracervical. Using this route, prostaglandins are less easy to administer and the need for exposing the cervix may cause discomfort to the woman. OBJECTIVES: To determine the effects of intracervical prostaglandins for third trimester cervical ripening or induction of labour compared with placebo/no treatment and with vaginal prostaglandins (except misoprostol). SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (August 2007) and bibliographies of relevant papers. SELECTION CRITERIA: Clinical trials comparing intracervical prostaglandins used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods (vaginal prostaglandins, except misoprostol). DATA COLLECTION AND ANALYSIS: A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. MAIN RESULTS: Fifty-six trials (7738 women) are included. INTRACERVICAL PGE2 WITH PLACEBO/NO TREATMENT: 28 TRIALS, 3764 WOMEN: Four studies reported the number of women who did not achieve vaginal delivery within 24 hours, showing a decreased risk with PGE2 (relative risk (RR) 0.61; 95% confidence interval (CI) 0.47 to 0.79). There was a small, and statistically non-significant, reduction of the risk of caesarean section when PGE2 was used (RR 0.88; 95% CI 0.77 to 1.00). The finding was statistically significant in a subgroup of women with intact membranes and unfavourable cervix only (RR 0.82; 95% CI 0.68 to 0.98). The risk of hyperstimulation with fetal heart rate (FHR) changes was not significantly increased (RR 1.21; 95% CI 0.72 to 2.05). However, the risk of hyperstimulation without FHR changes was significantly increased (RR 1.59; 95% CI 1.09 to 2.33. INTRACERVICAL PGE2 WITH INTRAVAGINAL PGE2: 29 TRIALS, 3881 WOMEN: The risk of not achieving vaginal delivery within 24 hours was increased with intracervical PGE2 (RR 1.26; 95% CI 1.12 to 1.41). There was no change in the risk of caesarean section (RR 1.07; 95% CI 0.93 to 1.22). The risks of hyperstimulation with FHR changes (RR 0.76; 95% CI 0.39 to 1.49) and without FHR changes (RR 0.80; 95% CI 0.56 to 1.15) were non-significantly different with the two methods of PGE2 administration. Only one trial with small sample size reported on women's views, with no difference between groups. INTRACERVICAL PGE2 LOW DOSE WITH INTRACERVICAL PGE2 HIGH DOSE: TWO TRIALS, 102 WOMEN: The trials are too small to provide any useful information. AUTHORS' CONCLUSIONS: Intracervical prostaglandins are effective compared to placebo, but appear inferior when compared to intravaginal prostaglandins.

[What's new in gynecology and obstetrics?]. / Gynécologie.

Among the improvements in gynecology reported in 2007, we highlight those in the field of cervical cancer. A randomized trial showed that HPV testing has higher sensitivity compared to the screening based on Papanicolaou smears. The recent availability of a HPV vaccine is also an important event. In obstetrics, the results of several trials evaluating the administration of progesterone to prevent preterm birth were published. The benefit of the administration of progesterone is still controversial. Prevention of early onset groupe B Streptococcus sepsis might be improved by rapid PCR testing during labor.

[Occiput posterior presentation at delivery: Materno-foetal outcomes and predictive factors of rotation]. / Accouchement en variété occipito-postérieure : issues materno-fœtales et facteurs prédictifs de la rotation.

OBJECTIVES: To describe the maternal and foetal outcomes of an occiput posterior foetal position at delivery; to evaluate predictive factors of anterior rotation during labour. METHODS: Descriptive retrospective analysis of a cohort of 439 women with foetuses in occiput posterior position during labour. Logistic regression analysis to quantify the effect of factors that may favour anterior rotation. RESULTS: Most of foetuses (64%) do an anterior rotation during labour and 13% during the expulsive phase. The consequences of a persistent foetal occiput posterior position during delivery are a significantly increased average time of second stage labour compared to others positions (65.19minutes vs. 43.29, P=0.001, respectively); a higher percentage of caesarean sections (72.0% versus 4.7%, P<0.001) and instrumental delivery (among low-birth deliveries, 60.7% versus 25.2%, P<0.001); more frequent third-degree perineal tears (14.3% vs. 0.6%, P<0.001) and more abundant blood loss (560mL versus 344mL, P<0.001). In a multi-variable model including nulliparity, station of the presenting part and degree of flexion of the foetal head at complete dilatation, the only predictive factor independent of rotation at delivery is a good flexion of the foetal head at complete dilatation, which multiplies the anterior rotation probability by six. CONCLUSION: A good flexion of the foetal head is significantly associated with anterior rotation. Other studies exploring ways to increase anterior rotation during labour are needed to reduce the very high risk of caesarean section and instrumentation associated with the foetal occiput posterior position.

The diagnostic accuracy of external pelvimetry and maternal height to predict dystocia in nulliparous women: a study in Cameroon.

OBJECTIVE: In many developing countries, most women deliver at home or in facilities without operative capability. Identification before labour of women at risk of dystocia and timely referral to a district hospital for delivery is one strategy to reduce maternal and perinatal mortality and morbidity. Our objective was to assess the prediction of dystocia by the combination of maternal height with external pelvimetry, and with foot length and symphysis-fundus height. DESIGN: A prospective cohort study. SETTING: Three maternity units in Yaoundé, Cameroon. POPULATION: A total of 807 consecutive nulliparous women at term who completed a trial of labour and delivered a single fetus in vertex presentation. METHODS: Anthropometric measurements were recorded at the antenatal visit by a researcher and concealed from the staff managing labour. After delivery, the accuracy of individual and combined measurements in the prediction of dystocia was analysed. MAIN OUTCOME MEASURES: Dystocia, defined as caesarean section for dystocia; vacuum or forceps delivery after a prolonged labour (>12 hours); or spontaneous delivery after a prolonged labour associated with intrapartum death. RESULTS: Ninety-eight women (12.1%) had dystocia. The combination of a maternal height less than or equal to the 5th percentile or a transverse diagonal of the Michaelis sacral rhomboid area less than or equal to the 10th percentile resulted in a sensitivity of 53.1% (95% CI 42.7-63.2), a specificity of 92.0% (95% CI 89.7-93.9), a positive predictive value of 47.7% (95% CI 38.0-57.5) and a positive likelihood ratio of 6.6 (95% CI 4.8-9.0), with 13.5% of all women presumed to be at risk. Other combinations resulted in inferior prediction. CONCLUSION: The combination of the maternal height with the transverse diagonal of the Michaelis sacral rhomboid area could identify, before labour, more than half of the cases of dystocia in nulliparous women.