Impact of a virtual reality-based simulation training for shoulder dystocia on human and technical skills among caregivers: a randomized-controlled trial.

This study analyzed the adherence to the modified Advanced Life Support in Obstetrics (ALSO) algorithm (HELP-RER) for handling shoulder dystocia (SD) using a virtual reality (VR) training modality. Secondary outcomes were improvements in the post-training diagnosis-to-delivery time, human skills factors (HuFSHI), and perceived task-load index (TLX). Prospective, case-control, single-blind, 1:1 randomized crossover study. Participants were shown a 360° VR video of SD management. The control group was briefed theoretically. Both groups underwent HuFSHI and HELP-RER score assessments at baseline and after the manikin-based training. The TLX questionnaire was then administered. After a washout phase of 12 weeks, we performed a crossover, and groups were switched. There were similar outcomes between groups during the first training session. However, after crossover, the control group yielded significantly higher HELP-RER scores [7 vs. 6.5; (p = 0.01)], with lower diagnosis-to-delivery-time [85.5 vs. 99 s; (p = 0.02)], and TLX scores [57 vs. 68; (p = 0.04)]. In the multivariable linear regression analysis, VR training was independently associated with improved HELP-RER scores (p = 0.003). The HuFSHI scores were comparable between groups. Our data demonstrated the feasibility of a VR simulation training of SD management for caregivers. Considering the drawbacks of common high-fidelity trainings, VR-based simulations offer new perspectives.

A simulation study to assess the potential benefits of MRI-based fetal weight estimation as a second-line test for suspected macrosomia.

OBJECTIVE: To simulate the outcomes of Boulvain's trial by using magnetic resonance imaging (MRI) for estimated fetal weight (EFW) as a second-line confirmatory imaging. STUDY DESIGN: Data derived from the Boulvain's trial and the study PREMACRO (PREdict MACROsomia) were used to simulate a 1000-patient trial. Boulvain's trial compared induction of labor (IOL) to expectant management in suspected macrosomia, whereas PREMACRO study compared the performance of ultrasound-EFW (US-EFW) and MRI-EFW in the prediction of birthweight. The primary outcome was the incidence of significant shoulder dystocia (SD). Cesarean delivery (CD), hyperbilirubinemia (HB), and IOL at < 39 weeks of gestation (WG) were selected as secondary outcomes. A subgroup analysis of the Boulvain's trial was performed to estimate the incidence of the primary and secondary outcomes in the true positive and false positive groups for the two study arms. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) for the prediction of macrosomia by MRI-EFW at 36 WG were calculated, and a decision tree was constructed for each outcome. RESULTS: The PPV of US-EFW for the prediction of macrosomia in the PREMACRO trial was 56.3 %. MRI-EFW was superior to US-EFW as a predictive tool resulting in lower rates of induction for false-positive cases. Repeating Boulvain's trial using MRI-EFW as a second-line test would result in similar rates of SD (relative risk [RR]:0.36), CD (RR:0.84), and neonatal HB (RR:2.6), as in the original trial. Increasing the sensitivity and specificity of MRI-EFW resulted in a similar relative risk for SD as in Boulvain's trial, but with reduced rates of IOL < 39 WG, and improved the RR of CD in favor of IOL. We found an inverse relationship between IOL rate and incidence of SD for both US-EFW and MRI-EFW, although overall rates of IOL, CD, and neonatal HB would be lower with MRI-derived estimates of fetal weight. CONCLUSION: The superior accuracy of MRI-EFW over US-EFW for the diagnosis of macrosomia could result in lower rates of IOL without compromising the relative advantages of the intervention but fails to demonstrate a significant benefit to justify a replication of the original trial using MRI-EFW as a second-line test.

A rare case of adventitious placentation (diffuse semi-placenta) in a Jersey cow.

Placental abnormalities more frequently occur during pregnancy of somatic cell clones and may lead to pregnancy loss or dystocia. Adventitious placentation, or diffuse semi-placenta, is determined by the development of areas of accessory placentation between the cotyledons due to the abnormal growth of placentomes.After a full-term pregnancy, a 3-year-old Jersey heifer was referred for dystocia which resulted in the delivery of a dead calf. The cause of dystocia was found to be foetal malposition, while the placenta was physiologically expelled after dystocia resolution.Grossly, cotyledons appeared reduced in size and number in one placental horn, while the surface of the other horn was covered with microplacentomes. Numerous villous structures without trophoblastic coating were highlighted after histopathology. The dominant sign was an inflammatory reaction. The findings were consistent with inter-cotyledonal placentitis, which led to adventitial placentation.Diffuse semi-placenta compensates for the inadequate development of placentomes and may occur as a congenital or acquired defect. The outcome depends on its severity: in the worst scenario, pregnancy may not proceed beyond midterm and may be complicated by hydrallantois. In the case under examination, the dimensions of the cotyledons (from 2 to 10 cm) allowed for the natural course of pregnancy.

Parturition at term: induction, second and third stages of labor, and optimal management of life-threatening complications-hemorrhage, infection, and uterine rupture.

Childbirth is a defining moment in anyone's life, and it occurs 140 million times per year. Largely a physiologic process, parturition does come with risks; one mother dies every two minutes. These deaths occur mostly among healthy women, and many are considered preventable. For each death, 20 to 30 mothers experience complications that compromise their short- and long-term health. The risk of birth extends to the newborn, and, in 2020, 2.4 million neonates died, 25% in the first day of life. Hence, intrapartum care is an important priority for society. The American Journal of Obstetrics & Gynecology has devoted two special Supplements in 2023 and 2024 to the clinical aspects of labor at term. This article describes the content of the Supplements and highlights new developments in the induction of labor (a comparison of methods, definition of failed induction, new pharmacologic agents), management of the second stage, the value of intrapartum sonography, new concepts on soft tissue dystocia, optimal care during the third stage, and common complications that account for maternal death, such as infection, hemorrhage, and uterine rupture. All articles are available to subscribers and non-subscribers and have supporting video content to enhance dissemination and improve intrapartum care. Our hope is that no mother suffers because of lack of information.

Tafoxiparin, a novel drug candidate for cervical ripening and labor augmentation: results from 2 randomized, placebo-controlled studies.

BACKGROUND: Slow progression of labor is a common obstetrical problem with multiple associated complications. Tafoxiparin is a depolymerized form of heparin with a molecular structure that eliminates the anticoagulant effects of heparin. We report on 2 phase II clinical studies of tafoxiparin in primiparas. Study 1 was an exploratory, first-in-pregnant-women study and study 2 was a dose-finding study. OBJECTIVE: Study 1 was performed to explore the effects on labor time of subcutaneous administration of tafoxiparin before onset of labor. Study 2 was performed to test the hypothesis that intravenous treatment with tafoxiparin reduces the risk for prolonged labor after spontaneous labor onset in situations requiring oxytocin stimulation because of dystocia. STUDY DESIGN: Both studies were randomized, double-blind, and placebo-controlled. Participants were healthy, nulliparous females aged 18 to 45 years with a normal singleton pregnancy and gestational age confirmed by ultrasound. The primary endpoints were time from onset of established labor (cervical dilation of 4 cm) until delivery (study 1) and time from start of study treatment infusion until delivery (study 2). In study 1, patients at 38 to 40 weeks of gestation received 60 mg tafoxiparin or placebo daily as 0.4 mL subcutaneous injections until labor onset (maximum 28 days). In study 2, patients experiencing slow progression of labor, a prolonged latent phase, or labor arrest received a placebo or 1 of 3 short-term tafoxiparin regimens (initial bolus 7, 21, or 35 mg followed by continuous infusion at 5, 15, or 25 mg/hour until delivery; maximum duration, 36 hours) in conjunction with oxytocin. RESULTS: The number of participants randomized in study 1 was 263, and 361 were randomized in study 2. There were no statistically significant differences in the primary endpoints between those receiving tafoxiparin and those receiving the placebo in both studies. However, in study 1, the risk for having a labor time exceeding 12 hours was significantly reduced by tafoxiparin (tafoxiparin 6/114 [5%] vs placebo 18/101 [18%]; P=.0045). Post hoc analyses showed that women who underwent labor induction had a median (range) labor time of 4.44 (1.2-8.5) hours with tafoxiparin and 7.03 (1.5-14.3) hours with the placebo (P=.0041) and that co-administration of tafoxiparin potentiates the effect of oxytocin and facilitates a shorter labor time among women with a labor time exceeding 6 to 8 hours (P=.016). Among women induced into labor, tafoxiparin had a positive effect on cervical ripening in 11 of 13 cases (85%) compared with 3 of 13 participants (23%) who received the placebo (P=.004). For women requiring oxytocin because of slow progression of labor, the corresponding results were 34 of 51 participants (66%) vs 16 of 40 participants (40%) (P=.004). In study 2, tafoxiparin had no positive effects on the secondary endpoints when compared with the placebo. Except for injection-site reactions in study 1, adverse events were no more common for tafoxiparin than for the placebo among either mothers or infants. There were few serious or treatment-related adverse events. CONCLUSION: Subcutaneous treatment with tafoxiparin before labor onset (study 1) may be effective in reducing the labor time among women undergoing labor induction and among those requiring oxytocin for slow progression of labor. Moreover, tafoxiparin may have a positive effect on cervical ripening. Short-term, intravenous treatment with tafoxiparin as an adjunct to oxytocin in patients with labor arrest (study 2) did not affect labor time or other endpoints. Both studies suggest that tafoxiparin has a favorable safety profile in mothers and their infants.

Assisted vaginal birth in 21st century: current practice and new innovations.

Assisted vaginal birth rates are falling globally with rising cesarean delivery rates. Cesarean delivery is not without consequence, particularly when carried out in the second stage of labor. Cesarean delivery in the second stage is not entirely protective against pelvic floor morbidity and can lead to serious complications in a subsequent pregnancy. It should be acknowledged that the likelihood of morbidity for mother and baby associated with cesarean delivery increases with advancing labor and is greater than spontaneous vaginal birth, irrespective of the method of operative birth in the second stage of labor. In this article, we argue that assisted vaginal birth is a skilled and safe option that should always be considered and be available as an option for women who need assistance in the second stage of labor. Selecting the most appropriate mode of birth at full dilatation requires accurate clinical assessment, supported decision-making, and personalized care with consideration for the woman's preferences. Achieving vaginal birth with the primary instrument is more likely with forceps than with vacuum extraction (risk ratio, 0.58; 95% confidence interval, 0.39-0.88). Midcavity forceps are associated with a greater incidence of obstetric anal sphincter injury (odds ratio, 1.83; 95% confidence interval, 1.32-2.55) but no difference in neonatal Apgar score or umbilical artery pH. The risk for adverse outcomes is minimized when the procedure is conducted by a skilled accoucheur who selects the most appropriate instrument likely to achieve vaginal birth with the primary instrument. Anticipation of potential complications and dynamic decision-making are just as important as the technique for safe instrument use. Good communication with the woman and the birthing partner is vital and there are various recommendations on how to achieve this. There have been recent developments (such as OdonAssist) in device innovation, training, and strategies for implementation at a scale that can provide opportunities for both improved outcomes and reinvigoration of an essential skill that can save mothers' and babies' lives across the world.

Soft-tissue dystocia due to paradoxical contraction of the levator ani as a cause of prolonged second stage: concept, diagnosis, and potential treatment.

Smaller pelvic floor dimensions seem to have been an evolutionary need to provide adequate support for the pelvic organs and the fetal head. Pelvic floor dimension and shape contributed to the complexity of human birth. Maternal pushing associated with pelvic floor muscle relaxation is key to vaginal birth. Using transperineal ultrasound, pelvic floor dimensions can be objectively measured in both static and dynamic conditions, such as pelvic floor muscle contraction and pushing. Several studies have evaluated the role of the pelvic floor in labor outcomes. Smaller levator hiatal dimensions seem to be associated with a longer duration of the second stage of labor and a higher risk of cesarean and operative deliveries. Furthermore, smaller levator hiatal dimensions are associated with a higher fetal head station at term of pregnancy, as assessed by transperineal ultrasound. With maternal pushing, most women can relax their pelvic floor, thus increasing their pelvic floor dimensions. Some women contract rather than relax their pelvic floor muscles under pushing, which is associated with a reduction in the anteroposterior diameter of the levator hiatus. This phenomenon is called levator ani muscle coactivation. Coactivation in nulliparous women at term of pregnancy before the onset of labor is associated with a higher fetal head station at term of pregnancy and a longer duration of the second stage of labor. In addition, levator ani muscle coactivation in nulliparous women undergoing induction of labor is associated with a longer duration of the active second stage of labor. Whether we can improve maternal pelvic floor relaxation with consequent improvement in labor outcomes remains a matter of debate. Maternal education, physiotherapy, and visual feedback are promising interventions. In particular, ultrasound visual feedback before the onset of labor can help women increase their levator hiatal dimensions and correct levator ani muscle coactivation in some cases. Ultrasound visual feedback in the second stage of labor was found to help women push more efficiently, thus obtaining a lower fetal head station at ultrasound and a shorter duration of the second stage of labor. The available evidence on the role of any intervention aimed to aid women to better relax their pelvic floor remains limited, and more studies are needed before considering its routine clinical application.

Dystocia frequency and causes in horses with pregnancy disorders or a history of dystocia: A prospective study.

Dystocia typically presents a life-threatening condition for both the mare and the foal. This prospective long-term study aimed to ascertain whether mares with prior pregnancy disorders or a history of dystocia were at a higher risk of experiencing subsequent dystocia in comparison to those without such medical antecedents. To achieve this goal, the authors analysed 207 parturitions and 164 mares over a 10-year period. Of these, 57 were associated with pregnancy disorders or prior dystocia (Group 1), while 150 parturitions followed uneventful pregnancies in mares that had not yet experienced dystocia (Group 2). Mares in Group 1 were significantly more likely to develop dystocia than those in Group 2 (p = .0180; odds ratio = 2.98). Foetal causes of dystocia were more prevalent than maternal causes (p < .0389). Maternal mortality stood at 0.5%, and neonatal mortality reached 1.9%. The results demonstrate that mares are at significantly higher risk of developing dystocia after experiencing pregnancy disorders or parturition complications during previous pregnancies, emphasizing the need for systematic birth monitoring.

Timing of induction of labor in suspected macrosomia: retrospective cohort study, systematic review and meta-analysis.

OBJECTIVE: Large-for-gestational-age (LGA) is associated with several adverse maternal and neonatal outcomes. Although many studies have found that early induction of labor (eIOL) in LGA reduces the incidence of shoulder dystocia (SD), no current guidelines recommend this particular strategy, due to concerns about increased rates of cesarean delivery (CD) and neonatal complications. The purpose of this study was to assess whether the timing of IOL in LGA fetuses affects maternal and neonatal outcomes in a single center; and to combine these results with the evidence reported in the literature. METHODS: This study comprised two parts. The first was a retrospective cohort study that included: consecutive patients with singleton pregnancy, an estimated fetal weight (EFW) ≥90th percentile on ultrasound (US) between 35+0 and 39+0 weeks of gestation (WG), who were eligible for normal vaginal delivery. The second part was a systematic review of literature and meta-analysis that included the results of the first part as well as all previously reported studies that have compared IOL to expectant management in patients with LGA. The perinatal outcomes were CD, operative vaginal delivery (OVD), SD, brachial plexus palsy, anal sphincter injury, postpartum hemorrhage (PPH), APGAR score, umbilical arterial pH, neonatal intensive care unit (NICU) admission, use of continuous positive airway pressure (CPAP), intracranial hemorrhage (ICH), phototherapy, and bone fracture. RESULTS: Retrospective cohort: of the 547 patients, 329 (60.1%) were induced and 218 (39.9%) entered spontaneous labor. Following covariate balancing, CD was significantly higher in the IOL group in comparison to the spontaneous labor group. This difference only became apparent beyond 40WG (hazard ratio: 1.9, p=0.030). The difference between both groups for shoulder dystocia was not statistically significant. Systematic review and metanalysis: 17 studies were included in addition to our own results giving a total sample size of 111,300 participants. When IOL was performed <40+0WG, the risk for SD was significantly lower in the IOL group (OR: 0.64, 95%CI: 0.42-0.98, I2 =19%). There was no significant difference in CD rate between IOL and expectant management after pooling the results of these 17 studies. However, when removing the studies in which IOL was done exclusively before 40+0WG, the risk for CD in the remaining studies (IOL not exclusively <40+0WG) was significantly higher in the IOL group (odds ratio [OR]: 1.46, 95% confidence interval [95%CI]: 1.02-2.09, I2 =56%). There were no statistically significant differences between IOL and expectant management for the remaining perinatal outcomes. Nulliparity, history of CD, and low Bishop score but not methods of induction were independent risk factors for intrapartum CD in patients who were induced for LGA. CONCLUSION: Timing of IOL in patients with suspected macrosomia significantly impacts perinatal adverse outcomes. IOL has no impact on rates of SD but does increase CD when considered irrespective of gestational age, but it may decrease the risk of SD without increasing the risk of other adverse maternal outcomes, in particular cesarean section when performed before 40+0 WG. (GRADE: Low/Very low). This article is protected by copyright. All rights reserved.

Resource setting impacts neonatal but not maternal survival in bitches treated for dystocia: 243 cases (2015-2020).

OBJECTIVE: To compare maternal and fetal outcomes of dystocia managed surgically and nonsurgically at referral hospitals (RHs) versus community medicine clinics (CMCs), determine the rate of C-section, and evaluate the incidence of hypoglycemia and hypocalcemia in bitches presented with dystocia. ANIMALS: Bitches presented with dystocia at 2 RHs and 2 CMCs. METHODS: Information on signalment, presence of hypoglycemia and/or hypocalcemia, diagnostic imaging performed, nonsurgical and surgical interventions performed, maternal and fetal outcomes, and total cost of care was obtained from the electronic medical records of bitches presenting for dystocia between October 2015 and October 2020. Descriptive statistics were performed and outcome compared between RHs and CMCs using a Fisher exact test, with a P < .05 considered significant. RESULTS: 230 bitches were evaluated with 243 separate episodes of dystocia, with 183 (75%) episodes treated at an RH and 60 (25%) at a CMC. There was a low incidence of hypoglycemia (5% [9/178]) and ionized hypocalcemia (1% [2/164]). Seventy-three percent (177/243) of bitches underwent surgical intervention, 25% (61/243) received nonsurgical management, and 2% (5/243) transferred to their primary veterinarian. There was no difference in survival for bitches operated at an RH compared with a CMC. However, bitches operated at an RH were more likely (P = .04) to be discharged with at least 1 live neonate. CLINICAL RELEVANCE: In bitches diagnosed with dystocia, hypoglycemia and hypocalcemia were rare. The majority of bitches underwent a C-section. The setting where the C-section was performed did not impact maternal survival.

Retrospective analysis of factors associated with umbilical diseases in foals.

In neonatal foals, umbilical remnants can be affected by infectious and non-infectious diseases. This study aimed to retrospectively evaluate historical, management and clinical factors that may be related to the occurrence of umbilical remnant diseases. Clinical reports of foals born or hospitalized within 24 h of life during the 2017-2021 foaling seasons were reviewed. Forty/183 foals (21.9 %) developed umbilical remnant diseases (URD group), while 143/183 foals (78.1 %) had normal umbilical remnants (NUR group). In the URD group, 24/40 (60 %) had a patent urachus, 16/40 (40 %) omphalo-arteritis, 4/40 (10 %) omphalo-phlebitis, 10/40 (25 %) urachitis, 9/40 (22.5 %) abscess, 3/40 (7.5 %) periumbilical hematoma and 12/40 (30 %) more than one condition. URD frequency was higher in foals hospitalized after birth than in those born at the hospital (17/46 vs 23/137; P = 0.0068), lower in those that had access to the paddock before three days of life (p = 0.0426) and higher in recumbent foals (P = 0.0001). URD occurred more frequently after dystocia (P = 0.0068), prolonged stage II parturition (19±20.51 min vs 13±6.41 in NUR group; P = 0.0279), traction at parturition (P = 0.0005), and in foals with lower APGAR scores (8±1.72 vs 9±0.86 in NUR; P = 0.0063). Sepsis (P = 0.0245), neonatal encephalopathy (P = 0.0014), meconium retention (P = 0.0241) and congenital flexural limb deformities (P = 0.0049) were the most common associated diseases. Umbilical cord (UC) coiling, abnormal UC rupture, umbilical hemorrhage and increased umbilical stump volume occurred more frequently in URD than in NUR group (P = 0.0329, P = 0.0191, P = 0.0007 and P < 0.00001, respectively). Recognition of the identified predisposing historical, management and clinical factors should prompt careful umbilical remnant monitoring in neonatal foals.

Effects of Elective Caesarean Sections in Healthy Near-Term Ewes on Subsequent Reproductive Performance.

Post-surgical reproductive performance following ovine caesarean section has not been well studied. To assess any direct effects of surgical delivery in the absence of confounders such as dystocia or underlying diseases, we studied elective surgery performed in healthy animals for teaching purposes. Four hundred and eleven paired breeding records following vaginal delivery (n = 233), elective caesarean section (n = 122), and subsequent further vaginal deliveries in animals with a history of one prior elective caesarean operation (n = 56) were evaluated retrospectively. The overall subsequent pregnancy rate was 95%. Multivariable statistical analyses did not reveal any significant influence of planned caesarean surgery on subsequent conception, stillbirth, perinatal lamb mortality, lamb birth weights, or the incidence of premature foetal death (mummification and abortion). A significantly higher number of mating attempts was, however, necessary. Also, a significant reduction in litter size was seen in the first pregnancy immediately following a surgical delivery in comparison to animals which had previously only delivered vaginally (p = 0.001), but litter size returned to pre-caesarean levels in further follow-up pregnancies in animals with a history of one elective caesarean section (p = 0.436). Subsequent long-term reproductive performance of sheep following elective caesarean section is thus excellent, and the results encourage retention for breeding.

Genetic correlation estimates between calving ease in primiparous cows and economically important traits in Nellore cattle.

This study aimed to estimate (co)variance components and genetic parameters for calving ease (CE) and their genetic correlations with growth, reproductive, carcass, and feed efficiency traits in Nellore cattle. Phenotypes for CE are scored in two categories: normal calving and assisted calving. The traits considered were probability of precocious calving, age at first calving, stayability, adjusted scrotal circumference at 365 days of age, accumulated cow productivity, age at puberty of males, gestation length, birth weight, adjusted weights at 210 and 450 days of age, adult cow weight, frame score, hip height, rib eye area, subcutaneous backfat thickness, rump fat thickness, intramuscular fat percentage, residual feed intake and dry matter intake. The estimation of genetic parameters was performed using a two-trait threshold-linear animal model, except for CE, stayability, and probability of precocious calving, which were evaluated through a two-trait threshold animal model. The direct (0.27) and maternal (0.19) heritability estimates for CE in heifers primiparous Nellore indicated that selecting for this trait is feasible. The selection to improve the female sexual precocity should consider CE during the selection and mating decisions to reduce calving problems. Genetic correlation estimates between CE and BW suggest that selecting low birth weight to reduce calving problems is not an appropriate strategy to improve calving ease in heifers Nellore. Therefore, adopting a multi-trait selection model with CE and BW in the Nellore breed would reduce calving difficulties, particularly in sexually precocious heifers, without impairing the growth, reproductive, feed efficiency conversion, and carcass indicator traits.

The improvement and retention of skills in shoulder dystocia management with the use of high-fidelity simulation: The SAFE (SimulAtion high-FidElity) study.

BACKGROUND: Shoulder dystocia is a relatively uncommon but serious childbirth-related emergency. AIM: To explore the improvement and retention of skills in shoulder dystocia management through high-fidelity simulation training. METHODS: The SAFE (SimulAtion high-FidElity) study was a prospective cohort study that utilised a high-fidelity birth simulator. Registered midwives and final year midwifery students were invited to participate in a one-day workshop at 6-monthly intervals. There was a 30-minute initial assessment, a 30-minute theoretical and hands-on training, and a 30-minute post-training assessment on shoulder dystocia management. Pre-training and post-training values for the predetermined outcomes were compared. In each workshop we assessed the proportion of successful simulated births, the performance of manoeuvres to manage shoulder dystocia, the head-to-body birth time, the fetal head traction force, the quality of communication, the perception of time-to-birth, and the self-reported confidence levels. FINDINGS: The baseline workshop recruited 101 participants that demonstrated a significant increase in the proportion of successful simulated births (8.9% vs 93.1%), and a two-fold to three-fold increase in the score of manoeuvres, communication, and confidence after training. Those with low pre-training levels of competency and confidence improved the most post-training at baseline. There was a retention of manoeuvres, communication skills and confidence at 6 months. There was no reduction in fetal head traction force over time. Those being proficient before initial training retained and performed best at the 6-month follow-up. CONCLUSION: The SAFE study found a significant improvement in skills and confidence after the initial high-fidelity simulation training that were retained after 6 months.

Incidence of shoulder dystocia and risk factors for recurrence in the subsequent pregnancy-A historical register-based cohort study.

INTRODUCTION: Shoulder dystocia is a rare obstetric complication, and the risk of recurrence is important for planning future deliveries. MATERIAL AND METHODS: The objectives of our study were to estimate the incidence and risk factors for recurrence of shoulder dystocia and to identify women at high risk of recurrence in a subsequent vaginal delivery. The study design was a nationwide register-based study including data from the Danish Medical Birth Registry and National Patient Register in the period 2007-2017. Nulliparous women with a singleton fetus in cephalic presentation were included for analysis of risk factors in index and subsequent delivery. RESULTS: During the study period, 6002 cases of shoulder dystocia were reported with an overall incidence among women with vaginal delivery of 1.2%. Among 222 225 nulliparous women with vaginal births, shoulder dystocia complicated 2209 (1.0%) deliveries. A subsequent birth was registered in 1106 (50.1%) of the women with shoulder dystocia in index delivery of which 837 (77.8%) delivered vaginally. Recurrence of shoulder dystocia was reported in 60 (7.2%) with a six-fold increased risk compared with women without a prior history of shoulder dystocia (risk ratio [RR] 5.70, 95% confidence interval [CI]: 4.41 to 7.38; adjusted RR 3.06, 95% CI: 2.03 to 4.68). Low maternal height was a significant risk factor for recurrence of shoulder dystocia. In the subsequent delivery, significant risk factors for recurrence were birthweight >4000 g, positive fetal weight difference exceeding 250 g from index to subsequent delivery, stimulation with oxytocin and operative vaginal delivery. In the subsequent pregnancy following shoulder dystocia, women who underwent a planned cesarean (n = 176) were characterized by more advanced age and a higher prevalence of diabetes in the subsequent pregnancy. Furthermore, they had more often experienced operative vaginal delivery, severe perineal lacerations, and severe neonatal complications at the index delivery. CONCLUSIONS: The incidence of shoulder dystocia among nulliparous women with vaginal delivery was 1.0% with a 7.2% risk of recurrence in a population where about 50% had a subsequent birth and of these 78% had subsequent vaginal delivery. Important risk factors for recurrence were low maternal height, increase of birthweight ≥250 g from index to subsequent delivery and operative vaginal delivery.

New labor curves of dilation and station to improve the accuracy of predicting labor progress.

BACKGROUND: The diagnosis of failure to progress, the most common indication for intrapartum cesarean delivery, is based on the assessment of cervical dilation and station over time. Labor curves serve as references of expected changes in dilation and fetal descent. The labor curves of Friedman, Zhang et al and others are based on time alone and derived from mothers with spontaneous labor onset. However, labor induction is now common, and clinicians also consider other factors when assessing labor progress. Labor curves that consider the use of induction and other factors that influence labor progress have the potential to be more accurate and closer to clinical decision-making. OBJECTIVE: To compare the prediction errors of labor curves based on a single factor (time) or multiple clinically relevant factors using 2 modeling methods: mixed-effects regression, a standard statistical method, and Gaussian processes, a machine learning method. STUDY DESIGN: This was a longitudinal cohort study of changes in dilation and station based on data from 8022 births in nulliparous women with a live, singleton, vertex presenting fetus at ≥35 weeks of gestation with a vaginal delivery. New labor curves of dilation and station were generated with 10-fold cross-validation. External validation was performed using a geographically independent group. Model variables included time from the first exam in the 20 hours before delivery; dilation, effacement and station recorded at the previous examination; cumulative contraction counts; and use of epidural anesthesia and labor induction. To assess model accuracy, we calculated the differences between each model's predicted value and its corresponding observed value. These prediction errors were summarized using mean absolute error and root mean squared error statistics. RESULTS: (1) Dilation curves based on multiple parameters were more accurate than those derived from time alone. (2) The mean absolute error with the multifactor methods were better (lower) than those from the single-factor methods [0.826 cm (95% CI, 0.820-0.832) for the multifactor machine learning and 0.893 cm (95% CI, 0.885-0.901) for the multifactor mixed-effects method and 2.122 cm (95% CI, 2.108-2.136) for the single-factor methods; P<0.0001 for both comparisons]. (3) The root mean squared errors with the multifactor methods were also better (lower) than those from the single-factor methods [1.126 cm (95% CI, 1.118-1.133) P<0.0001 for the machine learning and 1.172cm (95% CI, 1.164-1.181) for the mixed-effects method and 2.504 cm (95% CI, 2.487-2.521) for the single-factor; P<0.0001 for both comparisons]. (4) The multifactor machine learning dilation models showed small but statistically significant improvements in accuracy compared to the mixed-effects regression models (P<0.0001). (5) The multifactor machine learning method produced a curve of descent with a mean absolute error of 0.512 cm (95% CI, 0.509-0.515) and a root mean squared error of 0.660 cm (95% CI, 0.655-0.666). (6) External validation using independent data produced similar findings. CONCLUSIONS: (1) Cervical dilation models based on multiple clinically relevant parameters showed improved (lower) prediction errors compared to models based on time alone; (2) the mean prediction errors were reduced by more than 50%; and (3) a more accurate assessment of departure from expected dilation and station may help clinicians optimize intrapartum management.

Toxigenic Endophyte-Infected Tall Fescue and Ergot Alkaloids.

"Fescue toxicosis" and reproductive ergotism present identical toxidromes in late-gestational mares and, likely, other equids. Both toxic syndromes are caused by ergopeptine alkaloids (EPAs) of fungal origin, and they are collectively referred to as equine ergopeptine alkaloid toxicosis (EEPAT). EPAs are produced by either a toxigenic endophyte (Epichloë coenophiala) in tall fescue and/or a nonendophytic fungus (Claviceps purpurea), infecting small grains and grasses. EEPAT can cause hypoprolactinemia-induced agalactia/dysgalactia, prolonged gestation, dystocia, and other reproductive abnormalities in mares, as well as failure of passive transfer in their frequently dysmature/overmature/postmature foals. Prevention relies on eliminating exposures and/or reversing hypoprolactinemia.

Multiple independent de novo mutations are associated with the development of schistosoma reflexum, a lethal syndrome in cattle.

Schistosoma reflexum (SR) is a lethal congenital syndrome characterized by U-shaped dorsal retroflexion of the spine and exposure of abdominal viscera. SR is usually associated with severe dystocia. The syndrome is thought to be inherited as a Mendelian trait. We collected a series of 23 SR-affected calves from four breeds (20 Holstein, one Red Danish, one Limousin, one Romagnola) and performed whole-genome sequencing (WGS). WGS was performed on 51 cattle, including 14 cases with parents (trio-based; Group 1) and nine single cases (solo-based; Group 2). Sequencing-based genome-wide association studies with 20 Holstein cases and 154 controls showed no association (above Bonferroni threshold; P-value<3 ×10-09). Assuming a monogenic recessive inheritance, no region of shared homozygosity was observed, suggesting heterogeneity. Alternatively, the presence of possible dominant acting de novo mutations were assessed. In Group 1, heterozygous private variants, absent in both parents, were found in seven cases. These involved the ACTL6A, FLNA, GLG1, IQSEC2, MAST3, MBTPS2, and MLLT1 genes. In addition, heterozygous private variants affecting the genes DYNC1LI1, PPP2R2B, SCAF8, SUGP1, and UBP1 were identified in five cases from Group 2. The detected frameshift and missense variants are predicted to cause haploinsufficiency. Each of these 12 affected genes belong to the class of haploinsufficient loss-of-function genes or are involved in embryonic and pre-weaning lethality or are known to be associated with severe malformation syndromes in humans and/or mice. This study presents for the first time a detailed genomic evaluation of bovine SR, suggesting that independent de novo mutations may explain the sporadic occurrence of SR in cattle.