Variability and associated factors in the management of cord clamping and the milking practice among Spanish obstetric professionals.

Clinical practice guides recommend delayed clamping of the umbilical cord. If this is not possible, some authors suggest milking as an alternative. The objective of this study was to determine the variability in professional practice in the management of umbilical cord clamping and milking and to identify factors or circumstances associated with the different methods. An observational cross-sectional study done on 1,045 obstetrics professionals in Spain in 2018. A self-designed questionnaire was administered online. The main variables studied were type of clamping and use of milking. Crude odds ratios (OR) and adjusted odds ratios (ORa) were estimated using binary logistic regression. 92.2% (964) performed delayed clamping. 69.3% (724) clamped the cord when it stopped beating. 83.8% (876) had heard of milking, and 55.9% (584) had never performed it. Professionals over 50 were less likely to perform delayed clamping, with an ORa of 0.24 (95% CI: 0.11-0.52), while midwives were more likely to perform delayed clamping than obstetricians, with an ORa of 14.05 (95% CI: 8.41-23.49). There is clinical variability in the management of umbilical cord clamping and the use of milking in normal births. Part of this variability can be attributed to professional and work environment factors.

Evaluation of the results of end-of-pregnancy protocols in diabetic pregnant women / Evaluación de los resultados de dos protocolos de finalización de la gestación en gestantes diabéticas

Objective: The objective of our study was to compare perinatal outcomes in 2 cohorts; one from before and one from after the implementation of a new protocol for the care of pregnant diabetic woman. Material and methods: We performed a retrospective study on 262 pregnant women diagnosed with pregestational or gestational diabetes in whom labor was induced. Results: Diabetes went from being the second reason for induction to the third reason, with a statistically sig-nificant increase in the duration of gestation in favor of the second cohort. The percentage of premature births was lower, as was that of low-birth-weight newborns. Conclusions: There are no quality studies in the literature that indicate guidelines to be followed for the monito-ring and treatment of diabetic pregnant women. In our hospital, induction rates improved after implementation of the protocol

Objetivo: el objetivo de nuestro estudio fue comparar los resultados perinatales en dos cohortes; antes y después de la implantación de un nuevo protocolo de asistencia a la gestante diabética. Material y métodos: se llevó a cabo un estudio sobre dos cohortes retrospectivas formadas por un total de 262 gestantes con diagnóstico de diabetes pregestacional o gestacional a las que se les indujo el parto .Resultados: las inducciones por diabetes pasaron de constituir el segundo motivo de inducción al tercer motivo con un aumento estadísticamente significativo de duración de la gestación a favor de la cohorte del protocolo 2. Se observó con un menor porcentaje de partos prematuros; así como un menor porcentaje de recién nacidos de bajo peso Conclusiones: en la literatura no aparecen estudios de buena calidad que marquen las directrices a realizar en el seguimiento y tratamiento de la gestante diabética. En nuestro hospital se han mejorado las tasas de inducción con el nuevo protocolo establecido

Variabilidad en la tasa de episiotomías y su relación con desgarros perineales graves y morbilidad neonatal / Variability in the rate of episiotomies and its relation to severe perineal tears and neonatal morbility

Objetivo Determinar la variabilidad en la práctica de episiotomías entre matronas y su relación con la aparición de desgarros perineales tipo III-IV, así como sus repercusiones sobre la morbilidad neonatal. Método Cohortes históricas sobre 2.366 partos eutócicos con feto vivo único, mayor o igual a 37 semanas de gestación y 18 matronas del Hospital la Mancha-Centro de Alcázar de San Juan durante los años 2009, 2010 y 2011. Las variables principales fueron la incidencia de episiotomías, desgarros perineales y morbilidad neonatal. Resultados La variabilidad en la práctica de la episiotomía osciló entre el 19,5 y el 50,1% entre las 18 matronas a estudio, con una tasa promedio del 34,9% (824). Al agrupar por intervalo, el 22,1% (524) presentaba una tasa ≤ 25%, el 26,1% (621) entre el 26-35%, el 38% (898) entre el 36-44% y el 13,7% (323) una tasa ≥ 45%, observándose homogeneidad entre los grupos para todos los factores de confusión. No se observó asociación estadística entre mayores tasas de episiotomías y pH de arteria umbilical < 7,10, puntuaciones de apgar a los 5 min < 7 y grado de reanimación neonatal tipo III y IV. Tampoco encontramos asociación entre tasa de episiotomías con integridad perineal y desgarros tipo III-IV. ConclusiónLa variabilidad en la tasa de episiotomías es alta y no se relaciona con la mayor presencia de desgarros tipo III y IV, ni mayor morbilidad neonatal. No se justifican tasas mayores del 25% de episiotomías para prevenir el trauma perineal ni la pérdida de bienestar fetal (AU)

Objective: To determine the variability in the use of episiotomy among midwives and its relation to third and fourth-degree tears, and the impact on neonatal morbidity. Method: A study was conducted on historical groups from a total of 2,366 eutocic births with a single live fetus greater than or equal to 37 weeks gestation and 18 midwives over a three year period (2009, 2010 and 2011) in «Mancha-Centro» Hospital (Alcázar de San Juan).The outcomes variables for this analysis were the incidence of episiotomy, perineal lacerations, and neonatal morbidity. Results: The variability in the use of episiotomy ranged from 19.5% to 50.1% among the 18midwives in the study, with an average rate of 34.9% (824). Grouped at intervals, 22.1% (524)had a rate of ≤ 25%, 26.1% (621) between 26-35%, 38% (898) between 36-44%, and 13.7% (323)a rate of ≥ 45%, with homogeneity between the groups for all the confounding factors. There was no statistical association between higher rates of episotomy and pH of umbilical artery <7.10, Apgar score after 5 min <7, and the level of neonatal resuscitation type iii and iv. There was also no relationship between the rate of episiotomy with perineal integrity and third and fourth-degree tears. Discussion: The variability in the rate of episiotomy is high, and it is not related to the increased presence of third and fourth-degree tears or increased neonatal morbidity. Episiotomy rates should not be greater than 25%, in order to prevent perineal trauma or loss of fetal well-being (AU)

Relation between induced labour indications and neonatal morbidity.

PURPOSE: To assess the main neonatal morbidity results in relation to induced labour indications. METHODS: Historical groups from a total of 3,817 deliveries over a three year period (2009, 2010 and 2011) in "Mancha-Centro" Hospital (Alcázar de San Juan) formed the study group. All programmed and non-avoidable caesarean sections and pregnancies under 35 weeks were excluded. The main variable result was a neonatal morbidity variable made up of the Apgar score after 5 min, pH of umbilical artery <7.10 and the neonatal need for resuscitation type III-V. Multivariate analysis was used to control confounding variables. RESULTS: The incidence of induced labour was 22.6 % (862). The highest indication was premature rupture of membranes for more than 12 h 22.8 % (190), poorly controlled diabetes 22.6 % (189) and oligoamnios 16.2 % (135). The rate of pH lower than 7.10 was 2.8 % (22), the rate of the Apgar score lower than 7 after 5 min was 0.2 % (2) and the neonatal need for resuscitation type III-IV was 5.7 % (48) for induced labour. The relation between induced labour and neonatal morbidity indicators were not statistically significant. 10.1 % (4) of induced labour for suspected intrauterine growth restriction and 8.6 % (10) of postterm pregnancies required neonatal resuscitation type III-IV. DISCUSSION: No relation was found between induced labour and the neonatal morbidity indicators. The highest neonatal risk indicator is when a intrauterine growth restriction, hypertensión/preeclampsia or a postterm pregnancy is suspected.

[Differences in cesarean sections between spontaneous and induced labour]. / Diferencias en el número de cesáreas en los partos que comienzan espontáneamente y en los inducidos.

BACKGROUND: The induction of labour (IOL) may be associated with complications for pregnant women. The aim was to assess the differences in the number of caesarean sections between spontaneous or induced labour. METHODS: Historical groups from 841 women with induced labour and 2,534 women with an spontaneous onset of labour over a three- year period (from 2009 to 2011). They were carried out in "Mancha Centro" Hospital (Alcázar de San Juan). It was used a multivariate analysis through binary logistic regression to control confounding variables. RESULTS: The prevalence of IOL was 22,9%. The most frequent indications were: Premature Rupture of Membranes (22,7%), bad- controlled Diabetes (22,5%). It was reported a relation between induced labour and cesarean section risk due to parity (nulliparous OR= 2.68, IC 95%: 2.15- 3.34 and multiparous OR= 2.10, IC 95%: 1.72- 2.57). Postterm pregnancy (37,1%), pathological monitor (35.3%) and hypertensive diseases of pregnancy (34%) reported the highest risks of cesarean section. The IOL was related to other factors: a long- time length first -stage of labour (OR= 6.00; IC 95%: 4.02- 8.95), use of epidural analgesia (OR= 3.10; IC 95%: 2.24- 4.29) and blood transfusion needs (OR= 3.33; IC 95%: 1.70- 9.67). CONCLUSION: Independently of parity, The IOL increases the risk to: have a longer duration first- stage, use epidural analgesia, need a blood transfusion and have a cesarean section. This relation is stronger when induction is due to postterm pregnancy, pathological monitor or hypertensive diseases. No relation was found among induced labour and second- stage duration, episiotomy, perineal tears, excessive blood loss or uterine rupture.

Diferencias en el número de cesáreas en los partos que comienzan espontáneamente y en los inducidos / Differences in cesarean sections between spontaneous and induced labour

Fundamentos: La inducción del parto (IDP) puede estar asociada a mayores complicaciones para la mujer gestante. El objetivo de este trabajo fue determinar las diferencias en el número de cesáreas entre partos espontáneos y partos inducidos. Métodos: Cohortes históricas sobre un total de 841 inducciones y 2.534 partos espontáneos realizados entre 2009 y 2011 en el Hospital "Mancha-Centro" de Alcázar de San Juan. Se empleó análisis multivariante por medio de regresión logística binaria para control de la confusión. Resultados: La prevalencia de IDP fue del 22,9%, presentándose como indicaciones más frecuentes la rotura prematura de membranas (RPM) de más de 12 horas (22,7%) y diabetes mellitus mal controlada con un 22,5%. Se observó relación entre inducción y riesgo de cesárea tanto en mujeres nulíparas (OR= 2,68; Intervalo de confianza [IC] 95%: 2,15-3,34) como en multíparas (OR=2,10; [IC] 95%:1,72-2,57). La indicación con mayor riesgo de cesárea fue la gestación cronológicamente prolongada (GCP) (37,1%) seguida del registro cardiotográfico (RCTG) patológico (35,3%) y estados hipertensivos del embarazo (EHE) (4,0%). La IDP también se relacionó con la mayor duración de la dilatación (OR=6,00; IC 95%:4,02-8,95), empleo de epidural (OR=3,10;IC95%: 2,24-4,29) y necesidades de transfusión sanguínea (OR=3,33; IC %:1,70-5,67). Conclusiones: La IDP es un factor de riesgo para una mayor duración de la dilatación, empleo de analgesia epidural, necesidad de transfusión sanguínea y de cesárea tanto en mujeres nulíparas como en multíparas, especialmente en las indicaciones de gestación cronológicamente prolongada, registro cardiotocográfico patológico y estados hipertensivos del embarazo. No se encontró relación con la duración del período expulsivo, la práctica de episiotomía, desgarros, sangrado excesivo y rotura uterina (AU)

Background: The induction of labour (IOL) may be associated with complications for pregnant women. The aim was to assess the differences in the number of caesarean sections between spontaneous or induced labour. Methods: Historical groups from 841 women with induced labour and 2,534 women with an spontaneous onset of labour over a three- year period (from 2009 to 2011). They were carried out in "Mancha Centro" Hospital (Alcázar de San Juan). It was used a multivariate analysis through binary logistic regression to control confounding variables. Results: The prevalence of IOL was 22,9%. The most frequent indi- cations were: Premature Rupture of Membranes (22,7%), bad- controlled Diabetes (22,5%). It was reported a relation between induced labour and cesarean section risk due to parity (nulliparous OR= 2.68, IC 95%: 2.15- 3.34 and multiparous OR= 2.10, IC 95%: 1.72- 2.57). Postterm pregnancy (37,1%), pathological monitor (35.3%) and hypertensive diseases of preg- nancy (34%) reported the highest risks of cesarean section. The IOL was related to other factors: a long- time length first -stage of labour (OR= 6.00; IC 95%: 4.02- 8.95), use of epidural analgesia (OR= 3.10; IC 95%: 2.24- 4.29) and blood transfusion needs (OR= 3.33; IC 95%: 1.70- 9.67). Conclusion: Independently of parity, The IOL increases the risk to: have a longer duration first- stage, use epidural analgesia, need a blood transfusion and have a cesarean section. This relation is stronger when induction is due to postterm pregnancy, pathological monitor or hyperten- sive diseases. No relation was found among induced labour and second- duration, episiotomy, perineal tears, excessive blood loss or uterine rupture (AU)

[Variability in the rate of episiotomies and its relation to severe perineal tears and neonatal morbility]. / Variabilidad en la tasa de episiotomías y su relación con desgarros perineales graves y morbilidad neonatal.

OBJECTIVE: To determine the variability in the use of episiotomy among midwives and its relation to third and fourth-degree tears, and the impact on neonatal morbidity. METHOD: A study was conducted on historical groups from a total of 2,366 eutocic births with a single live fetus greater than or equal to 37 weeks gestation and 18 midwives over a three year period (2009, 2010 and 2011) in "Mancha-Centro" Hospital (Alcázar de San Juan).The outcomes variables for this analysis were the incidence of episiotomy, perineal lacerations, and neonatal morbidity. RESULTS: The variability in the use of episiotomy ranged from 19.5% to 50.1% among the 18 midwives in the study, with an average rate of 34.9% (824). Grouped at intervals, 22.1% (524) had a rate of ≤25%, 26.1% (621) between 26-35%, 38% (898) between 36-44%, and 13.7% (323) a rate of ≥45%, with homogeneity between the groups for all the confounding factors. There was no statistical association between higher rates of episotomy and pH of umbilical artery<7.10, Apgar score after 5 min<7, and the level of neonatal resuscitation type iii and iv. There was also no relationship between the rate of episiotomy with perineal integrity and third and fourth-degree tears. DISCUSSION: The variability in the rate of episiotomy is high, and it is not related to the increased presence of third and fourth-degree tears or increased neonatal morbidity. Episiotomy rates should not be greater than 25%, in order to prevent perineal trauma or loss of fetal well-being.