Predicting Postpartum Hemorrhage After Low-Risk Vaginal Birth by Labor Characteristics and Oxytocin Administration.

OBJECTIVE: To determine the odds of postpartum hemorrhage (PPH) in low-risk women who gave birth vaginally and were exposed to different durations and dosages of oxytocin across a range of labor durations during spontaneous or induced labor. DESIGN: A retrospective cross-sectional analysis of data from the Consortium for Safe Labor. SETTING: Data were gathered from 12 clinical institutions across the United States from 2002 to 2008. PARTICIPANTS: After exclusion of high-risk conditions associated with PPH, we examined data from 27,072 women who gave birth vaginally. METHODS: PPH was defined as estimated blood loss of greater than 500 ml at the time of birth and/or a diagnostic code for PPH before hospital discharge. We included covariates were if they were associated with oxytocin use and PPH and did not mediate oxytocin use. We used regression models to determine the likelihood of PPH overall and within the induced and spontaneous labor groups separately. We used subgroup analyses within specific durations of labor to clarify the findings. RESULTS: The overall rate of PPH was 3.9%. Women with induced labor experienced PPH more frequently than women who labored spontaneously. Labor augmentation was associated with greater adjusted odds for PPH when oxytocin was infused for more than 4 hours. Longer duration of spontaneous labor and the second stage of labor did not change this association. Oxytocin use during labor induction increased the odds for PPH when administered for more than 7 hours. The odds further increased when induction lasted longer than 12 hours and/or the second stage of labor was longer than 3 hours. CONCLUSION: Strategies for judicious oxytocin administration may help mitigate PPH in low-risk women having vaginal birth.

Severe maternal morbidity surveillance: Monitoring pregnant women at high risk for prolonged hospitalisation and death.

BACKGROUND: There is no international consensus on the definition and components of severe maternal morbidity (SMM). OBJECTIVES: To propose a comprehensive definition of SMM, to create an empirically justified list of SMM types and subtypes, and to use this to examine SMM in Canada. METHODS: Severe maternal morbidity was defined as a set of heterogeneous maternal conditions known to be associated with severe illness and with prolonged hospitalisation or high case fatality. Candidate SMM types/subtypes were evaluated using information on all hospital deliveries in Canada (excluding Quebec), 2006-2015. SMM rates for 2012-2016 were quantified as a composite and as SMM types/subtypes. Rate ratios and population attributable fractions (PAF) associated with overall and specific SMM types/subtypes were estimated in relation to length of hospital stay (LOS > 7 days) and case fatality. RESULTS: There were 22 799 cases of SMM subtypes (among 1 418 545 deliveries) that were associated with a prolonged LOS or high case fatality. Between 2012 and 2016, the composite SMM rate was 16.1 (95% confidence interval [CI] 15.9, 16.3) per 1000 deliveries. Severe pre-eclampsia and HELLP syndrome (514.6 per 100 000 deliveries), and severe postpartum haemorrhage (433.2 per 100 000 deliveries) were the most common SMM types, while case fatality rates among SMM subtypes were highest among women who had cardiac arrest and resuscitation (241.1 per 1000), hepatic failure (147.1 per 1000), dialysis (67.6 per 1000), and cerebrovascular accident/stroke (51.0 per 1000). The PAF for prolonged hospital stay related to SMM was 17.8% (95% CI 17.3, 18.3), while the PAF for maternal death associated with SMM was 88.0% (95% CI 74.6, 94.4). CONCLUSIONS: The proposed definition of SMM and associated list of SMM subtypes could be used for standardised SMM surveillance, with rate ratios and PAFs associated with specific SMM types/subtypes serving to inform clinical practice and public health policy.

Using Scorecard Feedback to Improve Quantitative Blood Loss Measurement at Birth.

OBJECTIVE: To increase the percentage of cases in which quantitative blood loss (QBL) was documented by labor and delivery nurses for women giving birth. DESIGN: Quality improvement project. SETTING/LOCAL PROBLEM: Labor and delivery unit of a community hospital in which a previous implementation of QBL measurement was not sustained. PARTICIPANTS: Labor and delivery nurses were the focus of the intervention, but the entire multidisciplinary team became involved. INTERVENTION/MEASUREMENTS: Based on literature supporting the use of scorecard feedback to stimulate performance improvement, weekly blinded individual scorecards showing the percentage of births attended by each labor and delivery nurse with QBL documented and a run chart showing the percentage of all births with QBL documented were posted on the unit and discussed during huddles for 12 weeks. Data on blood product administration were collected, and charts comparing QBL and estimated blood loss (EBL) volumes documented were shared with nurses and physicians. RESULTS: Over 12 weeks, the percentage of births with QBL documented increased from 22.7% to 80.0%. Consistent with previous reports comparing QBL and EBL volumes at birth, there was a significant difference between the mean QBL volume (mean = 482.20 ml, standard deviation = 358.03) and the mean EBL volume (mean = 313.15 ml, standard deviation = 211.91; p < .001) for total births. The mean QBL volume was also greater than the mean EBL volume for vaginal and cesarean births, but those differences were not statistically significant. There was no increase in blood product administration associated with the increase in QBL documentation. CONCLUSION: Discussing weekly scorecards and a run chart of QBL measurement was associated with an increase in documentation of QBL by labor and delivery nurses. Planning this project and discussing the results engaged the entire multidisciplinary team in more consistent measurement of QBL. The increased level of QBL documentation has been sustained for longer than 1 year.

What factors influence midwives to provide obstetric high dependency care on the delivery suite or request care be escalated away from the obstetric unit? Findings of a focus group study.

BACKGROUND: In the United Kingdom, midwives will engage in discussions with the multidisciplinary team as to whether they can provide Obstetric High Dependency Care (OHDC) on the Delivery Suite or whether a woman's care should be escalated to the critical care team. This study aimed to explore the question: What factors influence midwives to provide OHDC or request care be escalated away from the obstetric unit in hospitals remote from tertiary referral centres? METHODS: Focus groups were undertaken with midwives (n = 34) across three obstetric units in England, with annual birth rates ranging from 1500 to 5000 per annum, in District General Hospitals. Three scenarios in the form of video vignettes of handover were used as triggers for the focus groups. Scenario 1; severe pre-eclampsia, physiologically unstable 2; major postpartum haemorrhage requiring invasive monitoring 3; recent admission of woman with chest pain receiving facial oxygen and requiring continuous electrocardiogram (ECG) monitoring. Two focus groups were conducted in each of the obstetric units with experienced midwives. Data were analysed using a qualitative framework approach. RESULTS: Factors influencing midwives' care escalation decisions included the care environment, a woman's diagnosis and fetal or neonatal factors. The overall plan of care including the need for ECG and invasive monitoring were also influential factors. Midwives in the smallest obstetric unit did not have access to the facilities for OHDC provision. Midwives in the larger obstetric units provided OHDC but identified varying degrees of skill and sometimes used 'workarounds' to facilitate care provision. Midwifery staffing levels, skill mix and workload were also influential. Some differences of opinion were evident between midwives working in the same obstetric units as to whether OHDC could be provided and the support they would enlist to help them provide it. Reliance on clinical guidelines appeared variable. CONCLUSIONS: Findings indicate that there may be inequitable OHDC provision at a local level. Organisationally robust systems are required to promote safe, equitable OHDC care including skills development for midwives and precise escalation guidelines to minimise workarounds. Training for midwives must include strategies that prevent skills fade.

Análisis de las cesáreas en Uruguay por tipo de centro hospitalario / An analysis of caesarean sections in Uruguay by type of hospital

Objetivo: Analizar comparativamente la incidencia de las cesáreas en los subsistemas de salud de Uruguay y en relación con los estándares de la Organización Mundial de la Salud (OMS) considerando las características médico-obstétricas de los partos, en especial la clasificación de Robson. Método: Se emplean 190.847 nacimientos registrados en el Sistema Informático Perinatal de Uruguay entre 2009 y 2014 por tipo de subsector sanitario. Mediante modeloslogitse analiza la probabilidad de cesárea considerando la clasificación de Robson, otros factores de riesgo y las características de las madres. Se comparan las tasas de cesárea predichas por los distintos subsectores sanitarios para una población común. Asimismo, se contraponen las tasas de cesáreas observadas en cada subsistema con las que, hipotéticamente, se encontrarían si los hospitales siguiesen las pautas de la muestra de hospitales de referencia de la OMS. Resultados: El subsector privado, en términos generales, presenta una incidencia de cesáreas mucho más elevada que el público, incluso después de considerar las características médico-obstétricas de los nacimientos. Las tasas de cesáreas en Uruguay están más de un 75% por encima del valor que cabría esperar de acuerdo con el modelo de la OMS. Conclusiones: La incidencia de cesáreas en Uruguay es muy alta respecto a los estándares definidos por la OMS, en especial en el subsector privado. Este hecho no se explica por las características clínicas de los nacimientos

Objective: To analyse on a comparative basis the incidence of caesarean sections among the different health care systems in Uruguay and with respect to the World Health Organization's (WHO) standards, taking into account the medical-obstetric characteristics of the births, particularly, the Robson classification. Methods: We examine 190,847 births registered by the Perinatal Information System in Uruguay between 2009 and 2014 by type of health care system. Usinglogitmodels, we analyse the probability of caesarean section taking into account the Robson classification, other risk factors and the mothers’ characteristics. We compared the caesarean rates predicted by the different subsystems for a common population. Furthermore, we contrast the caesarean rates observed in each subsystem with the rates that resulted if the Uruguayan hospitals followed the guidelines of the sample of WHO reference hospitals. Results: Private health systems in Uruguay exhibit a much higher incidence of caesarean sections than public ones, even after considering the medical-obstetric characteristics of the births. Caesarean rates are more than 75% higher than those observed if the WHO standards are applied. Conclusions: Uruguay has a very high incidence of caesarean sections with respect to WHO standards, particularly, in the private sector. This fact is unrelated to the clinical characteristics of the births

Change in prevalence of gestational diabetes and obstetric complications when applying IADPSG screening criteria in a Belgian French speaking University Hospital. A retrospective cohort study.

BACKGROUND: In April 2012 our institution chose to switch from a two- step criteria for Gestational Diabetes Mellitus (GDM) screening, to the International Association of Diabetes in Pregnancy Study Group (IADSPG) criteria. This shift led to an increased prevalence of GDM in our pregnant population. We designed a study in order to estimate the magnitude of the increase in GDM prevalence before and after the switch in screening strategy. As a secondary objective we wanted to evaluate if there was a significant difference between the two periods in the percentage of maternal and neonatal complications such as gestational hypertensive disorders (GHD), primary cesarean section (pCS), preterm birth, large for gestational age (LGA) newborns, macrosomia, shoulder dystocia, 5' Apgar score less than to 7 at birth, neonatal intensive care unit (NICU) transfer and neonatal hypoglycemia. METHODS: We selected retrospectively 3496 patients who delivered between January 2009 and December 2011 who were screened with the two-step criteria (group A), and compared them to 2555 patients who delivered between January 2013 and December 2014 and who were screened with IADPSG criteria (Group B). We checked patients' electronic files to establish GDM status, baseline characteristics (age, body mass index, nationality, parity) and the presence of maternal and neonatal complications. RESULTS: GDM prevalence increased significantly from group A (3.4%; 95%CI 2.8-4.06%) to group B (16.28%; 95%CI 14.8 -17.7%). In group B there were significantly more non-Belgian and primiparous patients. There was no statistically significant difference in maternal and neonatal complications between the two groups, even after adjustment for nationality and parity. There was a non-significant reduction of the proportion of macrosomic and of LGA babies. CONCLUSIONS: In our population the introduction of IADPSG screening criteria has increased the prevalence of GDM without having a statistically significant impact on pregnancy outcomes.

Sequela of female genital mutilation on birth outcomes in Jijiga town, Ethiopian Somali region: a prospective cohort study.

BACKGROUND: In Ethiopia, female genital mutilation (FGM) remains a serious concern and has affected 23.8 million women and girls, with the highest prevalence in Somali regional state. Even though FGM is reported to be associated with a range of obstetric complications, little is known about its effects on childbirth in the region. Therefore, the objective of this study was to test the hypothesis that FGM is a contributing factor to the increased risk of complication during childbirth. METHODS: Facility based cohort study, involving 142 parturients with FGM and 139 parturients without FGM, was conducted in Jijiga town from October to December, 2014. The study participants were recruited by consecutive sampling technique. Data were collected using a structured interviewer administered questionnaire and observational checklists. Data were analyzed using SPSS version 16 and STATA version 11. RESULTS: The existence of FGM was significantly associated with perinealtear [RR = 2.52 (95% CI 1.26-5.02)], postpartum blood loss [RR = 3.14 (95% CI 1.27-7.78)], outlet obstruction [RR = 1.83 (95% CI 1.19-2.79)] and emergency caesarean section [RR = 1.52 (95% CI 1.04-2.22)]. FGM type I and FGM type II did not demonstrate any association with prolonged 2nd stage of labour, emergency caesarean section, postpartum blood loss, and APGAR score < 7. FGM type III however was significantly associated with prolonged 2nd stage of labour [RR = 2.47 (95% CI 1.06-5.76)], emergency caesarean section [RR = 3.60 (95% CI 1.65-7.86)], postpartum blood loss [RR = 6.37 (95% CI 2.11-19.20] and APGAR score < 7 [RR = 4.41 (95% CI, 1.84-10.60)]. FGM type II and type III were significantly associated with perinealtear [RR = 2.45(95% CI 1.03-5.83)], [RR = 4.91(95% CI 2.46-9.77)] and outlet obstruction [RR = 2.38(95% CI 1.39-4.08)], [RR = 2.94(95% CI 1.84-4.71)] respectively. CONCLUSION: Women with FGM are significantly more likely than those without FGM to have adverse obstetric outcomes. Risks seem to be greater with more extensive form of FGM. Adverse obstetric outcomes can therefore be added to the known harmful immediate and long-term effects of FGM.

Effect of extra-amniotic Foley's catheter and vaginal misoprostol versus vaginal misoprostol alone on cervical ripening and induction of labor in Kenya, a randomized controlled trial.

BACKGROUND: The safest, most effective and fastest combined approaches to induction of labor is unknown. In an open-label randomized clinical trial we evaluated the efficacy of combination of extra-amniotic Foley's catheter and vaginal misoprostol compared to vaginal misoprostol alone for cervical ripening and induction of labor on the incidence of failed induction, induction-to-delivery interval and adverse maternal and perinatal outcomes. METHODS: Pregnant women at gestational age of 28 weeks or greater admitted at Kenyatta National Hospital, Kenya for induction of labor were enrolled then randomized to either a combination of extra-amniotic Foley's catheter inflated by 30 cm3 of normal saline and 25 micrograms of vaginal misoprostol or 25 micrograms of vaginal misoprostol alone. Women underwent 6 hourly reviews and additional misoprostol inserted if required. The primary outcome was incidence of failed induction. Secondary outcomes were induction-to-delivery interval and adverse maternal and perinatal outcomes. We conducted an intent-to-treat analysis and compared means or medians using t-test or Wilcoxon rank, proportions using Chi-square or Fishers test as appropriate. Induction-to-delivery interval were compared using the log-rank test. P-values of < 0.05 and 95% confidence intervals that excluded the null were considered statistically significant. RESULTS: Between February and May 2016, we enrolled 180 of 237 pregnant women admitted for induction of labor and randomized them to either a combination of extra-amniotic Foley's catheter and vaginal misoprostol (n = 90) or vaginal misoprostol alone (n = 90). The socio-demographic and obstetric characteristics were similar between the two groups. Failed induction rates were lower but not statistically significant following combined extra-amniotic Foley's catheter and vaginal misoprostol (8.9%) versus vaginal misoprostol alone (11.1%). The mean induction-to-delivery time was 4.8 h shorter in the combined extra-amniotic Foley's catheter and vaginal misoprostol (mean 18.9, standard deviation (SD) 7.2 h) compared to misoprostol only group (mean 14.1, SD 6.9 h) (log-rank test, p < 0.001). Maternal and perinatal complications were similar between the two groups. CONCLUSIONS: Extra-amniotic Foley's catheter and vaginal misoprostol for cervical ripening and induction of labor did not significantly lower the incidence of failed induction but safely shortened induction-to-delivery time compared to vaginal misoprostol only. TRIAL REGISTRATION: Trial was retrospectively registered on 14-03-2016 PACTR201604001535825.

Implementation of the Robson 10-Group Classification System at Hospital de Manises: Optimization of the cesarean delivery rate / Aplicación de los diez grupos de Robson en el hospital de Manises: racionalización de la tasa de Cesárea

Background: In view of the excessive increase in the incidence of cesarean delivery in recent decades, the World Health Organization proposes the 10-Group Classification System of Robson et al as a global standard for the classification of cesarean delivery in order to achieve optimal cesarean delivery rates of between 10% and 15%. Objective: To evaluate the implementation of the 10-Group Classification System in Hospital de Manises as an objective criterion for identifying groups of pregnant women at the highest risk of cesarean delivery and the clinical conditions that most affect the overall rate. Methods: A retrospective cohort study was performed of all deliveries attended at Hospital de Manises from January 1, 2015 to December 31, 2016. Results: There were 3171 deliveries with a total cesarean delivery rate of 16.08%. The highest rate of cesarean delivery (97.6%) was located in group 6 (all nulliparous breeches). The largest contribution to the total cesarean delivery rate was in group 2 (nulliparous, single cephalic, ≥37 weeks, induced or cesarean before labor), which accounted for 4.5% of the total. Conclusions: The 10-Group Classification System is easily implemented and enables identification of risk groups for cesarean delivery and of the clinical conditions that most impact this approach (AU)

Antecedentes: ante el incremento desmesurado en la incidencia de cesáreas durante las últimas décadas, la Organización Mundial de la Salud en el año 2014 propuso el sistema de clasificación de los diez grupos de Robson como estándar global para comparar la tasa de cesáreas. Objetivo: evaluar la implantación del modelo de clasificación de los diez grupos de Robson en el hospital de Manises como criterio objetivo para identificar los grupos de gestantes con mayor riesgo de cesárea y las condiciones clínicas más relevantes en la tasa global. Método: se realiza un estudio observacional de cohortes retrospectivo de todos los partos atendidos en el hospital de Manises desde el 1 de enero de 2015 al 31 de diciembre de 2016. Resultados: se han registrado 3.171 partos con una tasa total de cesárea de 16,08%. La mayor tasa de cesárea se localiza en el grupo 6 ("nulípara con un feto único en presentación podálica") con un total de 97,6%. La mayor contribución a la tasa total de cesárea la proporciona el grupo 2 ("nulíparas con un feto único en presentación cefálica, de 37 semanas o más de embarazo, que han sido sometidas a inducción o cesárea antes del inicio del parto") con un 4,5%. Conclusiones: la aplicación de la clasificación de los diez grupos de Robson es sencilla y permite identificar los grupos de riesgo de cesárea y las condiciones clínicas que más repercusión tienen en esta (AU)

[Evaluation of the Practice of Caesarean Section According to Robson's Classification in a Health District of Ouagadougou, Burkina Faso]. / Évaluation de la pratique de la césarienne selon la classification de Robson dans un district sanitaire de Ouagadougou, Burkina Faso.

The control of the caesarean rate is nowadays an important concern for the obstetric world, the priority being to make every effort to practice a caesarean in all the women who need it only instead of reaching a specific rate. The purpose of the present study was to apply the Robson classification to the evaluation of the practice of caesarean section at the maternity of the Bogodogo District Hospital. It turned to be an analytical cross-sectional study which was carried out from January 1st, 2013 till December 31st, 2015. The information sources used included the computer base of caesarean sections, the delivery records, the operating room records, the delivery hall and the monthly activity reports. The overall hospital frequency of caesarean section was 33.3%. The rate of caesarean section expected during the same period according to the C-Model was 9.7%. Patients in groups 5 (with a scar uterus) and 6 (nulliparous with siege presentation) of the Robson classification had all a caesarean section and contributed to the overall rate of caesarean for 30 and 8.6% respectively. Low-risk women (groups 1, 2, 3 and 4) had a relative contribution of 31.3% to the overall rate of caesarean section. Improvement of the antenatal assessment of the prognosis of childbirth, particularly in the case of uterine scar or siege presentation, improvement of the quality of the supervision of the delivery work and the fight against prematurity will help to control the rate of caesarean section at the Bogodogo District Hospital.

Le contrôle du taux de césariennes est, de nos jours, une préoccupation importante pour le monde obstétrical, la priorité étant de tout mettre en œuvre pour pratiquer une césarienne chez toutes les femmes qui en ont besoin plutôt que d'atteindre un taux spécifique. La présente étude a pour objectif d'appliquer la classification de Robson à l'évaluation de la pratique de la césarienne à la maternité de l'hôpital de district de Bogodogo. Il s'agit d'une étude transversale descriptive sur une période de trois ans, du 1er janvier 2013 au 31 décembre 2015. La base informatique des dossiers de césarienne, les dossiers d'accouchement, les registres du bloc opératoire, de la salle d'accouchement et les rapports mensuels d'activités étaient les sources d'information utilisées. La fréquence hospitalière globale de césarienne était de 33,3 %. Le taux de césarienne attendu durant la même période selon le C-Model était de 9,7 %. Les patientes des groupes 5 (avec un utérus cicatriciel) et 6 (nullipares avec présentation de siège) de la classification de Robson ont toutes bénéficié d'une césarienne et ont contribué au taux global de césarienne pour respectivement 30 % et 8,6 %. La contribution relative cumulée au taux global de césarienne des groupes 1, 2, 3 et 4 (femmes à bas risque de césarienne) était de 31,3 %. L'amélioration de l'évaluation anténatale du pronostic de l'accouchement, notamment en cas de cicatrice utérine ou de présentation de siège, l'amélioration de la qualité de la surveillance du travail d'accouchement et la lutte contre la prématurité contribueront à maitriser le taux de césarienne à l'hôpital de district de Bogodogo.

Risk factors for obstetric anal sphincter injuries (OASI) at a tertiary centre in south India.

INTRODUCTION AND HYPOTHESIS: Despite several studies that have reported risk factors for obstetric anal sphincter injuries (OASI), data from the Indian subcontinent are scarce. The purpose of this study was to identify risk factors for these sphincter injuries in an Indian population. METHODS: This was a case-control study within a retrospective cohort of vaginal deliveries at a tertiary care facility. All vaginal births beyond 24 completed weeks of gestation and birth weight ≥500 g from January 2008 to December 2012 were identified from the hospital electronic database. Cases were women with OASI sustained during vaginal delivery; the rest constituted controls. Potential risk factors for occurrence and severity of OASI were assessed initially using bivariate analysis and then a logistic regression model. RESULTS: The incidence of sphincter injury was 2.1% of vaginal births and 1.1% of all deliveries, and major-degree (3c and 4th-degree) tears constituted 20.9% of tears. After adjusted analysis, significant predictors for injury included primiparity, delivery at or beyond 41 weeks of gestation, epidural analgesia, instrumental delivery, shoulder dystocia, birth weight ≥4000 g, and head circumference ≥35 cm. Episiotomy protected against sphincter injuries, particularly in forceps and ventouse deliveries. Shoulder dystocia was significantly associated with major-degree tears, while episiotomy appeared to be protective. CONCLUSION: Risk factors are similar to those in other population groups; however, primiparity appears to be associated with lesser risk and forceps delivery with greater risk of sphincter trauma than previously reported.

The impact of a novel transendometrial approach for caesarean myomectomy on obstetric outcomes of subsequent pregnancy: a longitudinal panel study.

OBJECTIVE: To evaluate the obstetric and surgical outcomes of a novel transendometrial approach for myomectomy during caesarean section in subsequent pregnancies. DESIGN: Longitudinal panel study. SETTING: Chang Gung Memorial Hospital, Taiwan, with approximately 5000 births per annum. POPULATION: Pregnant women complicated with uterine myoma. METHOD: Sixty-three pregnant women who received transendometrial myomectomy during the first caesarean delivery reported a subsequent live pregnancy and planned an elective repeat caesarean delivery. MAIN OUTCOME MEASURES: Obstetric outcomes consisted of gestational age at birth, newborn weight, Apgar score, birthweight adequacy, uterine rupture, placental abruption, placenta praevia, placenta accreta, spontaneous preterm birth and preterm premature rupture of membranes. Surgical outcomes consisted of surgical time, blood loss, blood transfusion, postoperative fever, length of hospital stay and mean adhesion score. RESULT: The mean gestational age at birth and newborn weight at the subsequent caesarean section were superior to those at the first caesarean delivery. Spontaneous preterm birth, small-for-gestational-age infants and preterm premature rupture of membranes occurred more often in the first pregnancy than in the subsequent pregnancy. The mean surgical time was shorter for the subsequent caesarean delivery than for the first caesarean delivery combined with myomectomy. The other surgical composite outcomes of blood loss, blood transfusion, postoperative fever, length of hospital stay and mean adhesion score were similar across the two stages of caesarean deliveries. CONCLUSION: The novel transendometrial approach for caesarean myomectomy may improve the obstetric outcomes of subsequent pregnancy without causing any additional immediate and long-term adverse surgical outcomes. TWEETABLE ABSTRACT: Transendometrial caesarean myomectomy may improve future obstetric outcomes.

No episiotomy versus selective lateral/mediolateral episiotomy (EPITRIAL): an interim analysis.

INTRODUCTION AND HYPOTHESIS: The objective of this trial was to evaluate whether avoiding episiotomy can decrease the risk of advanced perineal tears. MATERIAL AND METHODS: In this randomized (1:1) parallel-group superiority trial, primiparous women underwent randomization into standard care (155 cases) vs. no episiotomy (154 cases) groups. The primary endpoint was the incidence of advanced (3rd- and 4th-degree) perineal tears. Secondary outcomes included perineal integrity, suturing characteristics, second-stage duration, incidence of postpartum hemorrhage, neonatal variables, and various postpartum symptoms 2 days and 2 months after delivery. RESULTS: At prespecified 1-year interim analysis, the groups did not differ in terms of baseline demographic and obstetric characteristics. Six advanced perineal tears (3.9%) were diagnosed in the standard care group vs. two in no episiotomy group (1.3%), yielding a calculated odds ratio (OR) of 0.33 [95% confidence interval (CI) 0.06-1.65). Unexpectedly, rates of episiotomy performance also did not significantly vary between groups: 26.5% (41 cases) vs. 21.4% (33 cases), respectively, p = 0.35. No significant differences were noted in any secondary outcomes. CONCLUSIONS: No difference in the rates of advanced perineal tears was found between groups; however, the main limitation of our study was unexpectedly high rates of episiotomy in the nonepisiotomy group. Thus, the main conclusion is that investigator monitoring and education should be continuously practiced throughout the trial duration, stressing the importance of adherence to the protocol.

Profile of Caesarean Section at Kathmandu Medical College.

BACKGROUND: There is a world-wide rise in caesarean section rateduring the last three decades and has been a cause of alarm and needs an in-depth study. The objective of this study was to determine the rate and clinical indications of Caesarean Section. METHODS: A hospital based study was carried out from 15th June 2015 to 15th January 2016 in Department of Obstetrics and Gynecology at Kathmandu Medical College, Sinamangal, Nepal. Patients who delivered by caesarean section were included in the study. Basic demographic data and clinical indications were noted. Results: A total of 1172 deliveries were carried out during the study period. Total number of caesarean section was 537 accounting to 45.81%. Most of the patients were of the age group of 25-29 years (42.8%). Most of the patients were primigravida (n=274; 51%). Emergency caesarean section was 411 (76.5%) and elective caesarean section was 126 (23.4%). Multigravida (71%) underwent more elective procedure than primigravida (25. 39%).The most frequent indication was fetal distress19.55% (n=105), failed induction 19.73%(n=106), and previous caesarean section 21.3% (n=115). CONCLUSIONS: The rate of cesarean section is quite high than that recommended by WHO which is (10-15%). Most of the caesarean sections were emergency caesarean section with previous caesarean being the leading cause.

Caesarean Section During Second Stage of Labor in a Tertiary Centre.

BACKGROUND: There is an alarming rise in caesarean section leading to increased adverse outcomes for both the mother and fetus when compared with vaginal delivery. Within this increasing caesarean section rate, there is a concerning increase in the rate of second stage caesarean section. This study highlight the feto-maternal outcome of caesarean section in second stage of labour. METHODS: This was a retrospective cohort review of all women with a singleton, cephalic fetus at term delivered by caesarean section in the second stage of labor between April 1, 2013 and March 30, 2017 at Patan Academy of Health Sciences. The main outcome measures were second stage caesarean section, indications and its maternal and fetal morbidity. RESULTS: During the study period, there were 40,860 deliveries. A total of 18,011 (44%) babies were born by caesarean section, 10484 emergency and 7527 elective. Out of the emergency caesarean section, 200 (1.9 %) were performed in second stage of labor. In this study, the most common indication was cephalopelvic disproportion. (92.4%) were delivered without a trial of instrumental delivery. In terms of maternal complications, atonic post partum haemorrhage uterine incision extension 18 (12.5%), postoperative fever 27(18.8%), wound infection 7 (4.8%) were observed. In perinatal complications, meconium stained amniotic fluid 49(34.2%), neonatal hyperbilirubinemia 14(9.7%) and increased nursery admission 2(15.3%) and 2(1.3%) perinatal mortality were seen. CONCLUSIONS: Cesarean sections done in second stage of labor are associated with several intra-operative maternal complications and neonatal morbidity.

Systematic approaches to adverse events in obstetrics, Part I: Event identification and classification.

Despite our best intentions to improve health when a patient presents for care, adverse events are ubiquitous in medical practice today. Known complications related to the course of a patient's illness or condition or to the characteristics of the treatment have been an openly stated part of taking care of patients for centuries. However, it is only in the past decade that preventable adverse events, instances of harm related to error and deviations in accepted practice have become a primary part of these conversations. Human and system errors are an innate part of working in a complex environment like health care and we are now well aware of this burden in medicine. Now, we are building ways to react to adverse events from error in systematic ways. A systematic approach to identifying and classifying events is a critical part of any safety program, let alone an obstetric safety program. This article reviews the various systems that are used to identify adverse events, in particular sentinel events, state reportable events, and the significant local adverse "trigger" events in obstetrics. These events typically become identified through robust reporting systems where staff can report adverse, near-miss events, or precursor safety events. After events are reported, a system for classifying events, including a structured tracking and reporting system with built in accountability, is necessary. The concept of the "serious safety event," and how these differ from known complications or unpreventable events, and how this is classified are also reviewed.

Assessment of an urgency classification for assisted vaginal delivery.

We performed a prospective observational audit to evaluate the application of the Lucas caesarean section urgency classification to assisted vaginal delivery in the operating theatre. We collected data from 400 women having category 1-3 delivery in the operating theatre. Twenty percent of the caesarean sections and 4% of the vaginal deliveries were category 1. The median (IQR) decision-delivery interval was 25 (19.5-37) min for category 1 caesarean section and 19.5 (15-29) min for category 1 vaginal delivery, and 43.5 (36-57) min and 45 (32-57) for category 2 caesarean section and vaginal delivery, respectively. Sixty-three percent of category 1 caesarean section and 75% of category 1 vaginal delivery were performed in ≤30 min. Antenatal or intrapartum risk factors were present before the decision for delivery in 82% of caesarean sections and 80% of vaginal deliveries. The application of the Lucas urgency classification to assisted vaginal delivery merits further evaluation.

Parity as a predictor of obstetric fistula classification.

INTRODUCTION AND HYPOTHESIS: Obstetric fistulas are injuries to the genital tract in women without emergency obstetric services. Parity may predict the characteristics of fistulas that affect closure success and residual incontinence. Circumferential fistulas may predispose patients to postoperative incontinence. We hypothesized that primiparous women have more distal fistulas than multiparous women, leading to more scarring and circumferential fistulas. METHODS: A retrospective observational study was conducted on 1,856 women with obstetric fistula evaluated at three sites by three providers. Fistulas were classified using the Goh classification system. Women aged 10 to 55 years were classified as primiparas or multiparas. Analysis by parity of fistula type and size, degree of scarring, and presence of circumferential defect used the Chi squared or Fisher's exact test, and binary logistic regression. RESULTS: Of the 1,841 (99.2 %) women included, 878 (47.7 %) were primiparas and 963 (52.3 %) were multiparas. Primiparas were more likely to have distal fistulas, type 4 being most common (31.5 %), whereas multiparas were more likely to have proximal fistulas, most commonly type 1 (48.1 %). Primiparas were more likely to have moderate to severe scarring (11.7 % vs 5.6 %; p < 0.001), and category III (57.1 % vs 39.2 %; p < 0.001), but not to develop circumferential fistulas (5.6 % vs 4.0 %; p = 0.127), be present for repeat surgery (7.1 % vs 7.6 %; p = 0.721), or have ureteric involvement (1.5 % vs 2.2 %; p = 0.301). Multivariate analyses confirmed increased risk with primiparity for distal fistula and scarring. CONCLUSIONS: As hypothesized, primiparas were more likely to have distal fistulas and more scarring, but were not more likely to have circumferential fistulas. Surgeons should plan accordingly.

[Collective memories of women who have experienced maternal near miss: health needs and human rights]. / Memórias coletivas de mulheres que vivenciaram o near miss materno: necessidades de saúde e direitos humanos.

The collective memories of women that have experienced maternal near miss can help elucidate serious obstetric events, like maternal death. Their experience is authentic and representative, with the construction of a common identity. This identity lends quality to a group's memory, and such memory is thus a social phenomenon. The study analyzed the experience of twelve women who nearly died during the gestational and postpartum cycle. The thematic oral history method was used, from the perspective of health needs and human rights. Six collective memories comprised the discourses: unmet health needs; healthcare deficiencies; denial of contact with the newborn child; violation of rights; absence of demand for rights; and compensation for unmet rights and needs. To understand these women's health needs is to acknowledge the women as bearers of rights and to individualize care, respecting their autonomy, guaranteeing access to technologies, and establishing an effective bond with health professionals.

Memórias coletivas de mulheres que vivenciaram o near miss materno: necessidades de saúde e direitos humanos / Collective memories of women who have experienced maternal near miss: health needs and human rights / Memorias colectivas de mujeres que experimentaron el near miss materno: necesidades de salud y derechos humanos

Resumo: Mulheres que vivenciaram o near miss materno podem, por meio de suas memórias coletivas, ajudar na compreensão dos eventos obstétricos graves, como a morte materna. A experiência das pessoas é autêntica e representativa do todo com a construção de uma identidade comum. É a identidade que dá qualidade à memória de um grupo. Assim, cada memória é um fenômeno social. Analisou-se a experiência de 12 mulheres que quase morreram em função do estado gravídico-puerperal. O método da história oral temática foi utilizado, na perspectiva das necessidades de saúde e direitos humanos. Seis memórias coletivas compuseram os discursos: necessidades de saúde não atendidas; deficiências assistenciais; privação do contato com o filho; violação de direitos; ausência de reivindicação dos direitos; e compensações dos direitos e necessidades não atendidos. Compreender as necessidades de saúde dessas mulheres é reconhecê-las como sujeitos de direitos; é individualizar a assistência, respeitando sua autonomia, garantindo o acesso às tecnologias e estabelecendo vínculo (a)efetivo com o profissional de saúde.

Abstract: The collective memories of women that have experienced maternal near miss can help elucidate serious obstetric events, like maternal death. Their experience is authentic and representative, with the construction of a common identity. This identity lends quality to a group's memory, and such memory is thus a social phenomenon. The study analyzed the experience of twelve women who nearly died during the gestational and postpartum cycle. The thematic oral history method was used, from the perspective of health needs and human rights. Six collective memories comprised the discourses: unmet health needs; healthcare deficiencies; denial of contact with the newborn child; violation of rights; absence of demand for rights; and compensation for unmet rights and needs. To understand these women's health needs is to acknowledge the women as bearers of rights and to individualize care, respecting their autonomy, guaranteeing access to technologies, and establishing an effective bond with health professionals.

Resumen: Las mujeres que experimentaron un near miss materno pueden, mediante sus memorias colectivas, ayudar a la comprensión de eventos obstétricos graves como la muerte materna. La experiencia de las personas es auténtica y representativa del todo con la construcción de una identidad común. Es la identidad la que da calidad a la memoria de un grupo. Así, cada memoria es un fenómeno social. Se analizó la experiencia de 12 mujeres que casi murieron en función del estado de embarazo-puerperio. Se utilizó el método de la historia oral temática, desde la perspectiva de las necesidades de salud y derechos humanos. Seis memorias colectivas compusieron los discursos: necesidades de salud no atendidas; deficiencias asistenciales; privación del contacto con el hijo; violación de derechos; ausencia de reivindicación de los derechos; y compensaciones de los derechos y necesidades no atendidas. Comprender las necesidades de salud de esas mujeres es reconocerlas como sujetos de derechos; es individualizar la asistencia, respetando su autonomía, garantizando el acceso a las tecnologías y estableciendo vínculo (a)efectivo con el profesional de salud.