The association of inflammatory changes of the uterus and chorioamniotic membranes with different types of labor activity anomalies.

OBJECTIVE: Aim: To clarify the association between different types of uterine contractility dysfunction and the inflammation of the uterus and chorioamniotic membranes. PATIENTS AND METHODS: Materials and Methods: The association between the inflammation of the uterine layers, chorioamniotic membranes, umbilical cord, and different types of labor activity abnormalities was examined in 382 patients with singleton pregnancies at 28-42 weeks' gestation who underwent Caesarean section (CS) for abnormal uterine contractions and other complications. Statistical analyses included the Mann-Whitney U, Chi-squared test, and logistic regression. RESULTS: Results: In the control group, slight infiltration with polymorphonuclear leukocytes (PMNs) and macrophages of the myometrium and decidua of the lower uterine segment at term pregnancy was found in 59.7% and 73.6% of cases. The main clinical risk factors for placental and decidual membrane inflammation in patients with excessive uterine activity (EUA) were prematurity, multiparity, group B streptococcus (GBS) colonization, and duration of ruptured fetal membranes before the CS. Moderate or marked myometrial inflammation of both uterine segments in the EUA group was diagnosed only in patients with cervical dilation of >6 cm and duration of labor of >8h. In women with hypotonic uterine activity (HUA), decidual and myometrial inflammation was significantly associated with nulliparity and intrapartum factors, such as protracted active first stage of labor, advanced cervical dilation, and number of vaginal examinations. In all cases, inflammation of the myometrium was accompanied by deciduitis. CONCLUSION: Conclusions: Mild inflammation of the decidual membrane and myometrium of the lower segment at term pregnancy is a common physiological phenomenon contributing to labor initiation. Uterine hyperfunction comes as the response of the unaffected myometrium to the release of high concentrations of proinflammatory cytokines produced by the inflamed decidual and chorioamniotic membranes into the bloodstream. Marked myometrial inflammation that occurs in prolonged labor is an additional factor aggravating the hypotonic uterine activity.

Multilevel analysis of individual and community factors of awareness of obstetric fistula among women of childbearing age in Nepal: analysis of recent Nepal Demographic and Health Survey 2022 data.

BACKGROUND: According to the WHO, obstetric fistula (OBF) is an abnormal connection between the genital tract and the urinary tract that occurs as the result of obstetric trauma, typically from prolonged obstructed labour. In 2018, globally, 50 000 and 100 000 cases of OBF are reported each year. The core of activities focused on reducing fistulas depends on a review of the disorder's knowledge and the features of women at risk of having a lack of understanding. The effect of community-level factors on awareness of OBF was not yet known in Nepal. Therefore, we aimed to investigate the community-level and individual-level factors of awareness of OBF among childbearing-aged women in Nepal. METHODS: The 2022 Nepal Demographic and Health Survey data were used for this study. It included 14 845 childbearing-aged women. Because of the clustering effects of Demographic and Health Survey data and the binary nature of the outcome variable, a multilevel binary logistic regression model was applied. An adjusted OR (AOR) with a 95% CI was reported to declare the statistical significance. In addition, the model that had the lowest deviance was the one that best fit the data. RESULTS: The overall prevalence of awareness of OBF among childbearing women in Nepal was 35.9% (95% CI 35.1%, 36.7%). Educational status (women who attended secondary education (AOR=1.65; 95% CI 1.41, 3.03) and higher education (AOR=4.29; 95% CI 1.14, 36.70)), currently working status (AOR=1.85; 95% CI 1.04, 3.30), birth history (AOR=2.23; 95% CI 1.48, 4.10), media exposure (AOR=1.54; 95% CI 1.07, 3.09) and women's age from 30 to 39 (AOR=3.38; 95% CI 1.35, 8.93) and 40 to 49 years old (AOR=4.68; 95% CI 1.60, 13.67) at the individual level, as well as urban residence (AOR=1.53; 95% CI 1.99, 2.87) and high community-level media exposure (AOR=2.05; 95% CI 1.67, 2.64) at the community level were statistically significant factors with awareness of OBF. CONCLUSION: Our study revealed that awareness of OBF among childbearing-aged women in Nepal was low (35.9%). The findings of this study will assist policymakers and public health programmers in understanding the magnitude of OBF awareness and the contributory factors. In addition, it will be useful to increasing awareness of OBF in the communities and promoting primary prevention approaches through education and motivation efforts.

The burden of iatrogenic obstetric fistulas in Sub-Saharan Africa: Systematic review and meta-analysis protocol.

BACKGROUND: Obstetric fistulas are abnormal open connection(s) between the vagina and the urinary tract or the rectum resulting from tragic injuries sustained by mothers during childbirth that lead to urine and/or faecal incontinence. Due to the rapidly growing middle class in sub-Saharan Africa (SSA) and the corresponding quest for hospital delivery and caesarean section, surgery-related (iatrogenic) obstetric fistulas are on the rise. Worryingly, there is scanty data on surgery-related fistulas. This review aims to collate empirical evidence on the magnitude of iatrogenic obstetric fistulas in SSA, generate country-specific data and explore factors that influence obstetric surgery-related fistulas. METHODS: All relevant databases, PubMed, LILACS, CINAHL, SCOPUS and Google Scholar will be searched from 1st January 2000 to 31st March 2024 using search terms developed from the major concepts in the title without restrictions by language. The Cochrane Library, African Journals Online, Data Base of African Thesis and Dissertations Including Research (DATAD-R D Space) and preprint repositories will also be searched. Reference lists of relevant studies will be searched and experts in the field will be contacted for additional (unpublished) studies. The search output will be exported to Endnote where duplicate studies will be removed. The deduplicated studies will be exported to Rayyan where study screening and selection will be conducted. At least two authors will independently select studies, extract data and assess quality in the included studies using pretested tools. Disagreements between reviewers will be resolved through discussion. Data analysis will be performed with RevMan 5.4. Comparative binary outcomes will be reported as odds ratio (OR) or risk ratio (RR) and for continuous outcomes, mean difference and standard deviations (SDs) will be used. Non-comparative studies will be analysed as weighted proportions. Heterogeneity between studies will be assessed graphically and statistically, and where a significant level is detected, the random-effects model meta-analysis will be performed. All estimates will be reported with their 95% confidence intervals (CIs). Where data permit, we will conduct subgroup and sensitivity analyses to test the robustness of the estimates on key quality domains. The overall quality of the evidence will be assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation). EXPECTED STUDY OUTCOMES: This systematic review and meta-analysis uses rigorous methods and best practices to attempt to collate all empirical evidence and estimate country-specific proportions of iatrogenic (surgery-related) fistulas among obstetric fistula patients across countries in SSA. This review will explore context-specific variables, provide insights into their impact and relate them to the type and experience of personnel performing the obstetric procedures that lead to obstetric fistulas. The findings of the full review are expected to inform the development of national and regional Training Programs for Medical Officers, support the development of a consensus "minimum acceptable standard of care" and inform quality assurance standards for clinicians involved in the provision of surgical obstetric care.

Relative uteroplacental insufficiency of labor.

Relative uteroplacental insufficiency of labor (RUPI-L) is a clinical condition that refers to alterations in the fetal oxygen "demand-supply" equation caused by the onset of regular uterine activity. The term RUPI-L indicates a condition of "relative" uteroplacental insufficiency which is relative to a specific stressful circumstance, such as the onset of regular uterine activity. RUPI-L may be more prevalent in fetuses in which the ratio between the fetal oxygen supply and demand is already slightly reduced, such as in cases of subclinical placental insufficiency, post-term pregnancies, gestational diabetes, and other similar conditions. Prior to the onset of regular uterine activity, fetuses with a RUPI-L may present with normal features on the cardiotocography. However, with the onset of uterine contractions, these fetuses start to manifest abnormal fetal heart rate patterns which reflect the attempt to maintain adequate perfusion to essential central organs during episodes of transient reduction in oxygenation. If labor is allowed to continue without an appropriate intervention, progressively more frequent, and stronger uterine contractions may result in a rapid deterioration of the fetal oxygenation leading to hypoxia and acidosis. In this Commentary, we introduce the term relative uteroplacental insufficiency of labor and highlight the pathophysiology, as well as the common features observed in the fetal heart rate tracing and clinical implications.

Effect of an Intrapartum Pelvic Dilator Device on Levator Ani Muscle Avulsion During Primiparous Vaginal Delivery: A Pilot Randomized Controlled Trial.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the safety and effectiveness of an intrapartum electromechanical pelvic floor dilator designed to reduce the risk of levator ani muscle (LAM) avulsion during vaginal delivery. METHODS: A multicenter, randomized controlled trial enrolled nulliparous participants planning vaginal delivery. During the first stage of labor, participants were randomized to receive the intravaginal device or standard-of-care labor management. The primary effectiveness endpoint was the presence of full LAM avulsion on transperineal pelvic-floor ultrasound at 3 months. Three urogynecologists performed blinded interpretation of ultrasound images. The primary safety endpoint was adverse events (AEs) through 3 months. RESULTS: A total of 214 women were randomized to Device (n = 113) or Control (n = 101) arms. Of 113 Device assignees, 82 had a device placed, of whom 68 delivered vaginally. Of 101 Control participants, 85 delivered vaginally. At 3 months, 110 participants, 46 Device subjects who received full device treatment, and 64 Controls underwent ultrasound for the per-protocol analysis. No full LAM avulsions (0.0%) occurred in the Device group versus 7 out of 64 (10.9%) in the Control group (p = 0.040; two-tailed Fisher's test). A single maternal serious AE (laceration) was device related; no neonate serious AEs were device related. CONCLUSIONS: The pelvic floor dilator device significantly reduced the incidence of complete LAM avulsion in nulliparous individuals undergoing first vaginal childbirth. The dilator demonstrated an acceptable safety profile and was well received by recipients. Use of the intrapartum electromechanical pelvic floor dilator in laboring nulliparous individuals may reduce the rate of LAM avulsion, an injury associated with serious sequelae including pelvic organ prolapse.

Adverse obstetric outcomes in cases of meconium-stained amniotic fluid complicated with intrapartum fever.

PURPOSE: Meconium-stained amniotic fluid (MSAF) often signifies colonization of the amniotic sac by microorganisms. This study investigated additional adverse obstetric outcomes associated with MSAF in deliveries complicated by maternal intrapartum fever (IF). METHODS: This retrospective study included all singleton pregnancies from 2014 to 2020, with intrapartum maternal fever ≥ 38 °C during a trial of labor. In accordance with departmental protocol, all patients received intravenous antibiotic therapy consisting of ampicillin and gentamicin in the absence of allergies to these medications. Subsequent antibiotic therapy was adjusted based on the culture results. Antibiotic treatment was discontinued postpartum after 48 h without fever. Swab cultures were obtained immediately postpartum from both the maternal and fetal sides of the placenta. Maternal and fetal outcomes, along with positive placental cultures, were compared between participants with MSAF&IF and those with clear amniotic fluid &IF (control group). RESULTS: In comparison to the control group (n = 1089), the MSAF&IF group (n = 264) exhibited significantly higher rates of cesarean delivery (CD) (p = 0.001), CD due to non-reassuring fetal heart rate (p = 0.001), and cord pH ≤ 7.1 (p = 0.004). Positive swab cultures from the placental maternal and fetal sides were more prevalent among the MSAF&IF group (23.1% vs. 17.6%, p = 0.041 and 29.2% vs. 22.9%, p = 0.032, respectively). Placental cultures yielding gastrointestinal pathogens and extended spectrum beta-lactamase were notably more common in the MSAF&IF group compared to controls (p = 0.023). However, there was no significant difference between groups regarding the rate of group B streptococcus positive placental cultures. CONCLUSIONS: Women experiencing IF and MSAF during labor face an elevated risk of CD compared to those with IF alone. The presence of MSAF heightens the risk of positive placental cultures, particularly with gastrointestinal and extended spectrum beta-lactamase pathogens.

Health seeking behaviour associated with obstetric fistula care in Guinea: An analysis of the 2018 Demographic and Health survey.

This study aimed to analyze factors associated with obstetric fistula care-seeking behavior in Guinea, based on data from the 2018 Demographic and Health Survey. Women aged 15-49 years who reported having obstetric fistula constituted the study population, statistical analysis was using Stata 16.0 software. Multivariate logistic regression was used to identify the factors associated with fistula care-seeking behavior. Among women with obstetric fistula, 78.9% sought care; 21.1% of those who sought care underwent repair. Factors associated with care-seeking behavior were being divorced (AOR =8.08; 95% CI:1.56-41.84), having a job (AOR =3.23; 95% CI: 1.11-9.44), being a member of a poor household (AOR =6.49; 95% CI:1.21-34.82) and whose fistula had appeared 6 days or more after the occurrence of the causal circumstance (AOR =3.63 95% CI: 1.28-10.28). This study suggests that the foundations on which fistula prevention and treatment programs are built should be reviewed, taking into account the factors highlighted by this study.

Cette étude visait à analyser les facteurs associés aux comportements de recherche de soins pour la fistule obstétricale en Guinée, partant des données de l'enquête démographique et de santé de 2018. Les femmes âgées de 15 à 49 ans ayant déclaré avoir une fistule obstétricale ont constitué la population d'étude, l'analyse statistique a été réalisée à l'aide du logiciel Stata 16.0. La régression logistique multivariée a été utilisée pour identifier les facteurs associés aux comportements de recherche de soins pour la fistule. Parmi les femmes atteintes de fistule obstétricale, 78,9 % ont eu recours à des soins ; 21,1 % de celles qui ont recouru ont subi une réparation. Les facteurs associés aux comportements de recherche de soins étaient le fait d'être divorcée (ORA=8.08 ; 95% IC :1.56-41.84), d'avoir un travail (ORA =3.23 ; 95% IC : 1.11-9.44), d'être membre d'un ménage pauvre (ORA =6.49 ; 95% IC :1.21-34.82) et dont la fistule était apparue 6 jours ou plus après la survenue de la circonstance causale (ORA =3.63 95% IC : 1.28-10.28). Cette étude suggère de revoir les bases sur lesquelles les programmes de prévention et de traitement de la fistule sont construits, tout en prenant en compte les facteurs mis en évidence par cette étude.

Midterm complications after primary obstetrical anal sphincter injury repair in France.

BACKGROUND: Incidence of complications following obstetrical anal sphincter injury (OASI) during vaginal delivery are poorly defined. They are only studied in high level maternities, small cohorts, all stages of perineal tear or in low-income countries. The aim of our study was to describe complications after primary OASI repair following a vaginal delivery in all French maternity wards at short and midterm and to assess factors associated with complication occurrence. METHODS: We conducted a historical cohort study using the French nationwide claim database (PMSI) from January 2013 to December 2021. All women who sustained an OASI repair following a vaginal delivery were included and virtually followed-up for 2 years. Then, we searched for OASIS complications. Finally, we evaluated factors associated with OASIS complication repaired or not and OASIS complication repairs. RESULTS: Among the 61,833 included women, 2015 (2.8%) had an OASI complication and 842 (1.16%) underwent an OASI complication repair. Women were mainly primiparous (71.6%) and 44.3% underwent an instrumental delivery. During a follow-up of 2 years, 0.6% (n = 463), 0.3% (n = 240), 0.2% (n = 176), 0.1% (n = 84), 0.06% (n = 43) and 0.01% (n = 5) of patients underwent second surgery for a perineal repair, a fistula repair, a sphincteroplasty, a perineal infection, a colostomy and a sacral nervous anal stimulation, respectively. Only one case of artificial anal sphincter was noticed. Instrumental deliveries (OR = 1.56 CI95%[1.29;1.9]), private for-profit hospitals (OR = 1.42 [1.11;1.82], reference group "public hospital"), obesity (OR = 1.36 [1;1.84]), stage IV OASIS (OR = 2.98 [2.4;3.72]), perineal wound breakdown (OR = 2.8 [1.4;5.48]), ages between 25 and 29 years old (OR = 1.59 [1.17;2.18], refence group "age between 13 and 24 years old") and 30 and 34 years old (OR = 1.57 [1.14; 2.16], refence group "age between 13 and 24 years old") were factors associated with OASIS complication repairs. CONCLUSIONS: Maternal age, stage IV OASIS, obesity, instrumental deliveries and private for-profit hospitals seemed to predict OASIS complications. Understanding factors associated with OASIS complications could be beneficial for the patient to inform them and to influence the patient's follow-up in order to prevent complications, repairs and maternal distress.

Husband responses towards birth preparedness, complications readiness, and associated factors in southern Ethiopia: the case of Kena District.

BACKGROUND: Birth preparedness and complication readiness is a holistic approach that empowers mothers and families with the knowledge, attitude, and resources to alleviate potential challenges during childbirth. Despite its benefits, husbands' participation in maternal care differs significantly between countries and regions. There is a lack of previous studies that look at husbands' responses to birth preparedness and complication readiness in the research area. Thus, the primary goal of this study is to find out how husbands who have wives with infants under 12 months old feel about birth preparation, readiness for problems, and its associated factors. METHODS: A community-based cross-sectional study design was conducted from May 30 to July 29, 2022. Simple random sampling was employed to select 499 husbands. An interviewer-administered, structured, and pretested questionnaire was used to collect the data. Data entry and analysis were performed using Epi Data version 4.6 and SPSS version 25, respectively. We used multivariable logistic regression to find statistically significant factors. P-values less than 0.05, 95% confidence intervals, and adjusted odds ratios are used to declare statistical significance. The findings were shown in figures, tables, and text. RESULTS: The study found that 55.9% (95% CI: 51.4 to 61.4%) of husbands responded to birth preparedness and complication readiness. This response was significantly associated with being employed (AOR = 3.7, 95% CI: 2.27-5.95), engaging in self-business (AOR = 5.3, 95% CI: 2.34-12.01), having wives who delivered in health facilities (AOR = 7.1, 95% CI: 3.92-12.86), accompanying wives for antenatal care (AOR = 2.2, 95% CI: 1.39-3.56), possessing good knowledge of danger signs during labor (AOR = 2.0, 95% CI: 1.08-3.74) and the postnatal period (AOR = 7.1, 95% CI: 3.14-16.01). Interestingly, residents living near a health facility (AOR = 0.6, 95% CI: 0.39-0.97) were less likely to respond. CONCLUSION: The present study found that nearly 6 out of 10 husbands actively responded in terms of birth preparedness and complication readiness. While husbands in this study showed some involvement in birth preparedness and complications, it is good when compared to studies carried out nationally. To improve this, educating husbands by focusing on the danger signs and their role in childbirth is recommended.

Maternal excessive weight gain as a potential risk factor for prolonged labor in Japanese pregnant women: The Japan Environment and Children's Study.

AIM: This study aimed to determine whether excessive maternal weight gain during pregnancy was associated with a higher risk of prolonged labor. METHODS: We analyzed the data regarding maternal weight gain during pregnancy for the participants of Japan Environment and Children's Study (JECS), which is an ongoing nationwide prospective birth cohort study in Japan. After excluding participants with multiple pregnancies, with deliveries before 37 or beyond 42 weeks of gestation, or who had undergone cesarean section, 71,154 (nulliparous, n = 28,442) Japanese women were included. Prolonged labor was defined by a cutoff ranking at the 95th percentile and consequently defined as labor duration exceeding 12.7 h in multiparous women and exceeding 23.2 h in nulliparous women. These classifications were made according to labor curves established by the Japanese Society of Obstetrics and Gynecology Perinatal Committee developed in June 2021. Considering that no studies have conducted an investigation based on this new guideline, we analyzed the association between excessive maternal weight gain during pregnancy and prolonged labor by parity. RESULTS: The overall incidence of prolonged labor was 10.2% (2,907/28,442) in nulliparous women and 6.1% (2,597/42,712) in multiparous women. Multivariable analysis indicated that excessive maternal weight gain was significantly associated with prolonged labor in nulliparous (adjusted odds ratio, 1.21; 95% confidence interval, 1.10-1.32) and multiparous women (adjusted odds ratio, 1.15; 95% confidence interval, 1.05-1.27). Kaplan-Meier survival analysis showed that as labor progressed, the percentage of women who had not yet delivered was higher among those with excessive maternal weight gain than among those with normal maternal weight gain in both the nulliparous (median labor duration 12.9 h vs 12.2 h, p<0.001) and multiparous (median labor duration 6.2 h vs 5.8 h, p<0.001) groups. CONCLUSION: Excessive maternal weight gain was significantly associated with prolonged labor in Japanese women.

Comparative assessment of birth preparedness and complication readiness among couples in rural and urban communities of Ekiti State, Southwestern Nigeria.

Objectives: To assess and compare the level of Birth Preparedness and Complications Readiness (BPCR) and determine the predicting effect of socio-demographic factors on it among couples in rural and urban communities of Ekiti State. Design: A community-based comparative cross-sectional study. Setting: The study was conducted in twelve rural and twelve urban communities in Ekiti State. Participants: Couples from rural and urban communities. Female partners were women of reproductive age group (15-49 years) who gave birth within twelve months before the survey. Main outcome measures: Proportion of couples that were well prepared for birth and obstetric emergencies, and its socio-demographic determinants. Results: The proportion of couples that were well prepared for birth and its complications was significantly higher in urban (60.5%) than rural (48.4%) communities. The study also revealed that living above poverty line (95% CI=1.01-3.79), parity and spousal age difference less than five years (95% CI=1.09 - 2.40) were positive predictors of BPCR among respondents. Conclusions: Urban residents were better prepared than their rural counterparts. Living above poverty line, parity, and spousal age difference less than five years were positive predictors of BPCR. There is a need to emphasize on educating couples on the importance of identifying blood donors as a vital component of BPCR. Funding: None declared.

Trauma-informed support after a complicated childbirth - An early intervention to reduce symptoms of post-traumatic stress, fear of childbirth and mental illness.

OBJECTIVE: Women who experience obstetric interventions and complications during childbirth have an increased risk of developing postnatal post-traumatic stress and mental illness. This study aimed to test the effect of a trauma-informed support programme based on psychological first aid (PFA) to reduce the mothers' symptoms of stress, fear of childbirth (FOC), anxiety and depression after a complicated childbirth. METHODS: The study population consisted of women ≥ 18 years old who had undergone a complicated childbirth (i.e. acute or emergency caesarean section, vacuum extraction, child in need of neonatal care, manual placenta removal, obstetric anal sphincter injury, shoulder dystocia or major haemorrhage (>1000 ml)). A total of 101 women participated in the study, of whom 43 received the intervention. Demographic questions and three self-assessment instruments measuring stress symptoms, FOC, anxiety and depression were answered one to three months after birth. RESULTS: The women in the intervention group scored significantly lower on the stress symptom scale, with a halved median score compared to the control group. There was no significant difference between the groups regarding FOC, depression and anxiety. CONCLUSION: Our results indicate that this PFA-based support programme might reduce post-traumatic stress symptoms in women who have gone through a complicated childbirth. With further studies in a larger population, this support programme has the potential to contribute to improved maternal care optimizing postnatal mental health.

"I became a person again": Social inclusion and participation experiences of Ethiopian women post-obstetric fistula surgical repair.

BACKGROUND: Childbirth-related mortality and morbidity affect many women globally, especially in low-income countries like Ethiopia. Obstetric fistula-a preventable condition mainly caused by prolonged and obstructed labor-can lead to physical, psychological, and social challenges, affecting women's social participation and inclusion. OBJECTIVE: This study aims to understand women's social participation and inclusion experiences post-obstetric fistula surgery. METHODS: This study is part of a larger research project investigating the social inclusion process of women who have had obstetric fistula surgery in Ethiopia. For this study, we conducted a qualitative exploration of women's experiences, guided by a constructivist grounded theory approach. Twenty-one women discharged from fistula treatment facilities following obstetric fistula surgery were interviewed using a semi-structured interview guide. Data was analyzed using Charmaz's inductive analysis approach, which involves an initial line-by-line coding followed by focused coding to identify the most significant codes. Subsequently, sub-themes and themes were developed from the focused codes. RESULT: The data analysis revealed four themes reflecting the women's experiences of social participation and inclusion. These are the experience of recovery and the journey toward social participation, participating in expected and meaningful activities, the continued challenge with a romantic relationship, and formal and informal support. Overall, the women who received fistula surgery reported positive life changes, especially regarding their physical well-being. However, they continued to face social challenges such as financial hardship, reproductive health problems, and issues with marriage and family life, which negatively impacted their social participation and inclusion experiences. CONCLUSION: While more research is needed, the findings of this study suggest that the social aspects of obstetric fistula are crucial for healthcare professionals to consider. Providing appropriate care and support to address unmet social relationship, employment, and childcare needs could enable women to lead fulfilling lives.

A denigration curve to delineate the spread of communication about obstetric staff errors in Italy and its practical application.

Background: Mistrust of doctors and the desire for compensation are driving a rise in malpractice litigation worldwide. Aim: To estimate the extent to which Italians view birth complications as malpractice in obstetric care, and how widespread this perception is. Method: WhatsApp® and Facebook® contacts of one of the authors were invited to respond to an online questionnaire. The answers of 265 Italian respondents were used to estimate how common the perception of obstetric staff errors is and how this perception spreads over time: the denigration curve. To test if the denigration curve is reliable, the curve has been plotted along with the trend of the rate of litigation in Italy. Results: Almost a 50% of respondents deemed that birth complications are due to obstetric staff errors. The likelihood of the percep-tion that one has experienced a birth complication was 64.5%. The communication of obstetric staff error seemed low overall among the respondents. The denigration curve shape is almost coincident with the curve of claim rates in Italy, proving that it would be reliable. Conclusion: The respondents provided an estimate of the rate of birth complications that was higher than the real occurrence rate, and attributed these complications to obstetric staff errors. The denigration curve could predict whether and when there might be litigation related to any birth complications (both error related and non-error related).

Obstetric Characteristics and Functional Outcomes in Women with Obstetric Anal Sphincter Injury.

BACKGROUND: Obstetric anal sphincter injury is a complication of vaginal delivery, if left untreated, causes significant maternal morbidities; urinary problems and fecal/ flatus incontinence. The aim of this study was to determine the incidence and describe the obstetric characteristics and functional outcomes of women who had vaginal delivery at Paropakar Maternity and Women's Hospital Nepal and sustained Obstetric anal sphincter injury. METHODS: This retrospective descriptive study included women who had vaginal delivery, irrespective of parity, in the labor room or birthing unit of Paropakar Maternity and Women's Hospital from April 2018 to September 2020, and sustained Grade III or IV Obstetric anal sphincter injury after 28 weeks period of gestation. Maternal characteristics, obstetric details and perineal status after vaginal delivery were noted after review of hospital records. The patients were further inquired via telephone for their current status of fecal and/or urinary incontinence. RESULTS: The incidence of OASI was 106 (0.33%) among 31, 786 Nepalese women with vaginal birth over a 2-year period. The mean age women with Obstetric anal sphincter injury was 24.6 ± 4.3 years and 45(52.9%) cases belonged to Janajati ethnicity. Fifty two (61.2 %) were primipara and 77 (90.6%) had spontaneous vaginal deliveries. Episiotomy was not performed on most of the patients (63, 74.1%). Problems with flatus holding, stool holding and urine holding was reported by 28.3%, 13.2% and 22.6% women respectively. CONCLUSIONS: The incidence of Obstetric anal sphincter injury among Nepalese women with vaginal birth over a 2-year period was 0.33%, which was lower than other South Asian studies. Grade III Obstetric anal sphincter injury was the frequent most type. The injuries were more common in women with Janajati ethnicity, primipara and women who did not have episiotomy. Problems with flatus holding and urine holding were present in almost one-fourth of the women with Obstetric anal sphincter injury at follow up.

The global burden, risk and inequality of maternal obstructed labor and uterine rupture from 1990 to 2019.

BACKGROUND: Obstructed labor (OL) and uterine rupture (UR) are common obstetric complications. This study explored the burden, risk factors, decomposition, and health inequalities associated with OL and UR to improve global maternal health. METHODS: This was a cross-sectional analysis study including data on OL and UR from the Global Burden of Diseases, and Risk Factors Study (GBD) 2019. The main outcome measures included the number and age-standardized rate (ASR) of incidence, disability-adjusted life years (DALYs), prevalence, and deaths. RESULTS: The global burden of OL and UR has declined, with a decrease in incidence (number in 2019: 9,410,500.87, 95%UI 11,730,030.94 to 7,564,568.91; ASR in 2019: 119.64 per 100,000, 95%UI 149.15 to 96.21; estimated annual percentage change [EAPC] from 1990 to 2019: -1.34, 95% CI -1.41 to -1.27) and prevalence over time. However, DALYs (number in 2019: 999,540.67, 95%UI 1,209,749.35 to 817,352.49; ASR in 2019: 12.92, 95%UI 15.63 to 10.56; EAPC from 1990 to 2019: -0.91, 95% CI -1.26 to -0.57) and deaths remain significant. ASR of DALYs increased for the 10-14 year-old age group (2.01, 95% CI 1.53 to 2.5), the 15-19 year-old age group (0.07, 95% CI -0.47 to 0.61), Andean Latin America (3.47, 95% CI 3.05 to 3.89), and Caribbean (4.16, 95% CI 6 to 4.76). Iron deficiency was identified as a risk factor for OL and UR, and its impact varied across different socio-demographic indices (SDIs). Decomposition analysis showed that population growth primarily contributed to the burden, especially in low SDI regions. Health inequalities were evident, the slope and intercept for DALYs were - 47.95 (95% CI -52.87 to -43.02) and - 29.29 (95% CI -32.95 to -25.63) in 1990, 39.37 (95%CI 36.29 to 42.45) and 24.87 (95%CI 22.56 to 27.18) in 2019. Concentration indices of ASR-DALYs were - 0.2908 in 1990 and - 0.2922 in 2019. CONCLUSION: This study highlights the significant burden of OL and UR and emphasizes the need for continuous efforts to reduce maternal mortality and morbidity. Understanding risk factors and addressing health inequalities are crucial for the development of effective interventions and policies to improve maternal health outcomes globally.

Associations between fetal position at delivery and duration of active phase of labor: A historical cohort study.

INTRODUCTION: In clinical experience, occiput posterior (OP) position is associated with longer labor duration than occiput anterior (OA) position, but few studies have investigated the association between labor duration and fetal position. We aimed to compare duration of the active phase of labor in OP deliveries with OA deliveries in a contemporary population using survival methods. Secondary aims were to compare the frequencies of operative interventions, obstetric anal sphincter injuries (OASIS), postpartum hemorrhage, and newborn outcomes in OP with OA deliveries. MATERIAL AND METHODS: We did a historical cohort study in three university hospitals in Norway from 2012 to 2022. Women with a single fetus in cephalic presentation, no previous cesarean section and gestational age ≥37 weeks were eligible and stratified into the first four groups of the Robson ten-group classification system (TGCS). We estimated the mean duration and calculated the hazard ratio (HR) for delivery using survival analyses. Cesarean sections and instrumental vaginal deliveries were censored. RESULTS: The study population comprised 112 019 women, 105 571 (94.2%) were delivered in OA and 6448 (5.8%) in OP position. The estimated mean duration of the active phase of labor was longer in women with the fetus in OP position in all four TGCS groups. The estimated duration was longer in the OP groups in analyses stratified with respect to epidural analgesia and oxytocin augmentation. The graphical abstract illustrates the probability of delivery in OP compared with OA position in merged TGCS groups 1 and 2a, as a function of time. The unadjusted HR was 0.33 (95% CI 0.31-0.36) for fetuses delivered in OP position compared with OA position in TGCS group 1, 0.25 (95% CI 0.21-0.27) in group 2a, 0.70 (95% CI 0.67-0.73) in group 3, and 0.61 (95% CI 0.55-0.67) in group 4a, respectively. Neither maternal age, gestational age, BMI nor birthweight had confounding effect. Operative delivery rates and OASIS rates were higher in OP position in all four groups. CONCLUSIONS: We found longer duration of the active phase of labor in women with the fetus delivered in OP position in all four TGCS groups.

Clinical algorithms for the monitoring and management of spontaneous, uncomplicated labour and childbirth.

AIM: To develop evidence-based clinical algorithms for the assessment and management of spontaneous, uncomplicated labour and vaginal birth. POPULATION: Pregnant women at any stage of labour, with singleton, term pregnancies considered to be at low risk of developing complications. SETTING: Health facilities in low- and middle-income countries. SEARCH STRATEGY: We searched for relevant published algorithms, guidelines, systematic reviews and primary research studies on Cochrane Library, PubMed, and Google on terms related to spontaneous, uncomplicated labour and childbirth up to 01 June 2023. CASE SCENARIOS: Three case scenarios were developed to cover assessments and management for spontaneous, uncomplicated first, second and third stage of labour. The algorithms provide pathways for definition, assessments, diagnosis, and links to other algorithms in this series for management of complications. CONCLUSIONS: We have developed three clinical algorithms to support evidence-based decision making during spontaneous, uncomplicated labour and vaginal birth. These algorithms may help guide health care staff to institute respectful care, appropriate interventions where needed, and potentially reduce the unnecessary use of interventions during labour and childbirth.

Prevalence and associated factors of maternal birth trauma following vaginal delivery at University of Gondar Comprehensive Specialized Hospital, North-West Ethiopia, 2022.

BACKGROUND: Maternal injury with any form of perineal trauma following vaginal delivery is very common which ranges globally from 16.2 to 90.4%. The frequency of Obstetric anal sphincter Injuries and the incidence of cervical laceration increases rapidly. However, in Ethiopia, there is limited evidence on the prevalence of maternal birth trauma and its determinant factors after vaginal delivery. OBJECTIVE: To assess the magnitude and associated factors of Maternal Birth Trauma after vaginal delivery at University of Gondar Comprehensive Specialized Hospital, Gondar, North-West Ethiopia, 2022. METHODS: An Institution based cross-sectional study was conducted among mothers with singleton vaginal delivery at University of Gondar Comprehensive Specialized Hospital from 9th May to 9th August 2022 among 424 study participants. Pre-tested semi-structured questioner was utilized. Epi-Data version 4.6 was used for data entry and exported to SPSS version 25 for data management and analysis. To identify the determinant factors, binary logistic regression model was fitted and variables with p-value < 0.2 were considered for the multivariable binary logistic regression analysis. In the multivariable binary logistic regression analysis, Variables with P-value < 0.05 were considered to have statistical significant association with the outcome variable. The Adjusted Odds Ratio (AOR) with 95% CI was reported to declare the statistical significance and strength of association between Maternal Birth Trauma and independent variables. RESULTS: A total of 424 mothers who delivered vaginally were included. The mean age of participants was 26.83 years (± 5.220 years). The proportion of birth trauma among mothers after vaginal delivery was47.4% (95%CI: 43.1, 51.7). Of different forms of perineal trauma, First degree tear in 42.8%, OASIs in 1.5% and Cervical laceration in 2.5% study participants. In the multivariable binary logistic regression analysis being primiparous (AOR = 3.00; 95%CI: 1.68, 5.38), Gestational age ≥ 39 weeks at delivery (AOR = 2.96; 95%CI: 1.57, 5.57), heavier birth weight (AOR = 12.3; 95%CI: 7.21, 40.1), bigger head circumference (AOR = 5.45; 95%CI: 2.62, 11.31), operative vaginal delivery (AOR = 6.59; 95%CI: 1.44, 30.03) and delivery without perineum and/or fetal head support (AOR = 6.30; 95%CI: 2.21, 17.94) were significantly associated with the presence of maternal birth trauma. CONCLUSION AND RECOMMENDATION: Maternal birth trauma following vaginal delivery was relatively high in this study. Prim parity, gestational age beyond 39 weeks at delivery, heavier birth weight, bigger head circumference, operative vaginal delivery and delivery without perineum and/or fetal head supported were factors affecting perineal outcome. The Ministry of Health of Ethiopia should provide regular interventional training as to reduce maternal birth trauma.

Improving management of first and second stages of labour in low- and middle-income countries.

Labour care must balance aspirations of parents with vigilance for unanticipated calamities. The 'on-site midwife-led primary care birth unit' facilitates this. The World Health Organization have replaced the traditional partograph with the 'Labour Care Guide'. An implementation project in Botswana included the mnemonic COPE: Companion, Oral fluids, Pain relief and Eliminate the supine position. The Parto-Ma project in Tanzania used guidelines, training and support to improve childbirth outcomes. We list labour practices supported by recent evidence, and highlight new developments. Foetal macrosomia increases risk but mistaken diagnosis increases caesarean births. Obstructed labour is a complex clinical diagnosis, and is difficult to predict. For shoulder dystocia prioritise delivery of the posterior shoulder, facilitated if needed by posterior axilla sling traction. 'Extended balloon labour induction' with two or three Foley catheters side by side, may reduce risks associated with uterine stimulants. Bedside ultrasound may facilitate the diagnosis of cephalic malpositions and malpresentations.