Assisted vaginal delivery in the obese patient.

Appropriate use of ventouse or obstetric forceps as options in the management of the second-stage of labor is good medical practice. The instruments are not inherently dangerous, however, the manner in which they are used may be. In addition to a working knowledge of the instruments, the operator must have the willingness to abandon an unsuccessful procedure. Awareness that failure of assisted vaginal delivery is more likely in women with BMI >30, hence, gives pause to consider trial in theatre with early recourse to cesarean delivery if unsuccessful Awareness that obesity is associated with increased risk of intrapartum complications, such as the need for second-stage assistance to achieve delivery, shoulder dystocia and postnatal complications, such as obstetric anal sphincter injury and febrile morbidity.

Developing the Parent-Coaching Assessment, Individualization, and Response to Stressors (PAIRS) Tool for Behavior Analysts.

Parent engagement in early behavioral intervention is essential to achieving meaningful intervention outcomes. However, parents may experience multiple barriers to engagement. The Parent-coaching Assessment, Individualization, and Response to Stressors (PAIRS) was developed to help practitioners assess families' barriers and facilitators, individualize their intervention, and respond to stressors using a contextual, functional approach. An expert panel of Board Certified Behavior Analysts ® (BCBAs) evaluated the content validity of the PAIRS. Average scale values (S-CVI/Ave) were 0.92 for relevance, 0.85 for effectiveness, and 0.91 for appropriateness. The PAIRS was revised, and a follow-up evaluation was conducted to rate the tool's utility. This led to the final version of the PAIRS. Clinical implications and future directions are discussed.

Adjustment of therapeutic LMWH to achieve specific target anti-FXa activity does not affect outcomes in pregnant patients with venous thromboembolism.

Venous thromboembolism (VTE) remains a leading cause of maternal morbidity and mortality in the developed world. Low molecular weight heparins (LMWH) are routinely used to provide therapeutic anticoagulation during pregnancy for women with VTE, with measurement of plasma anti-FXa activity used to guide dosing in certain patient groups. There is limited evidence to support the use of anti-FXa monitoring in pregnant patients. This study seeks to ascertain whether anti-FXa monitoring of pregnant patients with VTE influences patient outcomes. We performed a single-centre case series including two consecutive groups of pregnant patients treated with LMWH for VTE sustained in the index pregnancy with and without monitoring of anti-FXa levels. 35,394 patients delivered during the study period in a large urban stand-alone maternity hospital, with 26 cases of VTE eligible for inclusion. There was no significant difference between the two groups in any clinical outcome; including maternal blood loss at delivery, recurrent thromboembolic events or rates of planned delivery. These data provide clinical evidence to support current international guideline recommendations that measurement of plasma anti-FXa activity in the majority of patients receiving therapeutic-intensity antenatal LMWH is not warranted.

Improved Perinatal Mortality in Twins--Changing Practice and Technologies.

OBJECTIVE: We set out to examine rates of perinatal mortality in twin pregnancies over a 17-year study period. Changes in mode of delivery were also examined as well as causes of death in twin mortalities. STUDY DESIGN: This retrospective cohort study was performed at three large tertiary referral centers from 1996 to 2012. It included all normally formed twin infants with a birth weight more than 500 g. All cases of perinatal mortality in twin pregnancies (infants more than 500 g who suffered an intrauterine or early neonatal (≤ 7 days of age) death were recorded. The changing rate of cesarean delivery as well as varying causes of death in twins over the course of the study were also examined. RESULTS: During the study period, there were 395,830 pregnancies across the three institutions, this included 6,727 twin gestations. The perinatal mortality rate was 21.5/1,000 twin infants. The perinatal mortality rate in twins decreased over the study period (p = 0.0006; R (2) = 0.55; slope = -1.2). Rates of cesarean delivery in twin gestations were found to have increased over the course of the study (p < 0.0001; R (2) = 0.84; slope = 1.7). There were 288 intrauterine and early neonatal deaths in twin infants, 50% (147/288) occurred in twins born extremely premature (< 26 weeks). Prematurity was the leading cause of mortality in twins, followed by twin-to-twin transfusion syndrome (TTTS). TTTS was found to have a decreasing contribution to perinatal mortality during the study (p = 0.008; R (2) = 0.38; slope = -1.5). CONCLUSION: The perinatal mortality rate in twins improved during the study. The rate of cesarean delivery increased by 1.7% for each year of the study, culminating in a cesarean delivery rate of 62% in 2012. TTTS made a decreasing contribution to the mortality rate in twins during the study.