The use of continuous foetal monitoring technologies that enable mobility in labour for women with complex pregnancies: A survey of Australian and New Zealand hospitals.

OBJECTIVE: Freedom of movement and choice of positioning in labour and birth is known to enhance physiological processes and positive experiences for women during childbirth. Continuous foetal monitoring technologies that enable mobility in labour for women with complex pregnancies, such as wireless CTG, have been marketed for clinical use in most high resource settings since 2003 but there is a paucity of midwifery literature about its clinical use. The aim of this survey was to determine how often, and for whom, wireless and beltless technologies are being used in maternity settings across Australia and New Zealand and to identify any barriers to their uptake. DESIGN: A survey tool developed by Watson et al. (2018) for use in the United Kingdom was adapted for the Australian/New Zealand context. One Maternity Unit Manager or key midwifery clinician from each of 208 public and private hospitals across Australia and New Zealand was invited by email to participate in an online survey between October 2019 and January 2020. Descriptive statistics were used to describe the characteristics of the facilities and the frequency of availability of the monitors. Free text responses were thematically analysed. FINDINGS: The survey received a high (71%) response rate from a range of public and private hospitals in urban and rural settings. Women's freedom of movement and sense of choice and control in labour were seen by most respondents to be positively influenced by wireless monitoring technology. Most facilities reported having at least one wireless or beltless foetal monitor available, however, results suggest that many women consenting to continuous monitoring still do not have access to technology that enables freedom of movement. KEYCONCLUSIONS: Further research is required to explore the barriers and facilitators to enabling freedom of movement and positioning to all women in childbirth, including those women with complex pregnancies who may consent to continuous foetal monitoring.

Partograph Utilization and Associated Factors among Obstetric Care Providers Working in Public Health Facilities of Wolaita Zone, 2017.

BACKGROUND: Obstructed or prolonged labor is a major cause of maternal deaths. Prolonged and obstructed labor contributed to 13% of global maternal deaths which can be reduced by proper utilization of a partograph during labor. Obstetric caregivers' use of the partograph during labor has paramount importance in identifying any deviation during labor. Even though partograph use is influenced by different factors as obtained from the literatures, the magnitude of partograph utilization and the factors associated with its use are not well determined in the health facilities of Wolaita Zone. OBJECTIVE: To assess the magnitude of partograph utilization and factors that affect its utilization among obstetric caregivers in public health facilities of Wolaita Zone, Ethiopia, 2017. METHODS: An institution-based cross-sectional study was conducted on obstetric caregivers. A pretested and structured questionnaire was used to collect data. Data was entered to EpiData version 3.01 and exported to SPSS version 23.0 for further analysis. Logistic regression analyses were used to see the association of different variables. RESULT: A total of 269 obstetric caregivers participated in the study. Among those who were utilizing the partograph, 193 (71.7%) routinely used it for all laboring mothers and 76 (28.3%) of participants reported that they do not routinely utilize it. Greater number of service years (AOR = 4.93, 95% CI: 1.53-15.88), on-the-job training (AOR = 0.16, 95% CI: 0.06-0.43), good knowledge (AOR = 3.35, 95% CI: 1.61-6.97), and favorable attitude towards partograph utilization (AOR = 2.99, 95% CI: 1.28-7.03) were significantly associated with partograph utilization. Conclusion and Recommendation. Partograph utilization among obstetric caregivers in the public health facilities was good. Greater years of work experience, in-service training, having good knowledge, and favorable attitude towards partograph utilization among obstetric caregivers independently determined partograph utilization. Provision of on-the-job training to make obstetric caregivers improve knowledge and skill on partograph utilization, maintaining caregivers' retention to decrease turnover by providing different incentives to more experienced obstetric care providers, and establishing favorable attitude could improve the proper use of the tool.

Older age and higher parity are associated with nonuse of the partograph at Mbarara Regional Referral Hospital, Uganda.

OBJECTIVE: To determine the frequency of partograph use, the proportion of mothers with partographs completed to standard, the completeness of recorded parameters, and factors associated with nonuse at Mbarara Regional Referral Hospital (MRRH), Uganda. METHODS: A retrospective review of medical records from mothers admitted to MRRH's postnatal ward between October 2016 and March 2017. Partograph use and whether it had been completed to standard were analyzed. RESULTS: Of 527 study participants, 409 (77.6%) records contained a partograph, of which only 17 (4.2%) had been completed to standard. Parameters most commonly completed to standard were monitoring of cervical dilatation (n=41, 10%), fetal heart rate (n=21, 5.1%), and uterine contractions (n=18, 4.4%). Age older than 30 years (prevalence ratio 1.73; 95% CI, 1.14-2.64) and parity greater than or equal to five (prevalence ratio 1.88; 95% CI, 1.19-2.98) were associated with nonuse of the partograph. Birth outcome was recorded in 98.8% (n=404) of partographs. CONCLUSION: Appropriate use of the partograph to monitor mothers in labor was extremely low; most common use was to record birth outcomes. Older mothers and those with higher parity were less likely to have their labor monitored using a partograph and should be targeted for partograph interventions.

Fetal movement frequency and the effect of associated perinatal factors: Multicenter study.

BACKGROUND: Decreased fetal movements are associated with adverse perinatal outcomes, including stillbirth. Delayed maternal visits to a health care provider after perceiving decreased fetal movements are frequently observed in stillbirths. Informing pregnant women of the normal range of fetal movement frequency is essential in their earlier visits in order to prevent stillbirth. AIM: To investigate the fetal movement frequency in late pregnancy and the effects of associated perinatal factors. METHODS: This prospective multicenter study was conducted in 20 obstetric facilities in our region of Japan. A total of 2337 pregnant women were asked to record the time it took to perceive 10 fetal movements by the modified 'count to 10' method every day from 34weeks of gestation until delivery. FINDINGS: The 90th percentile of the time for the maternal perception of 10 fetal movements was 18-29min, with a gradually increasing trend toward the end of pregnancy. The numbers of both pregnant women giving birth after 39weeks' gestation and infants with a birth weight exceeding 3000g were significantly higher in mothers who took ≥30min to count 10 fetal movements than in those who took <30min. CONCLUSION: The maternal perception time of fetal movements shows a gradually increasing trend within 30min for 10 fetal movements by the modified 'count to 10' method. Informing pregnant women of the normal range of the fetal movement count time will help improve the maternal recognition of decreased fetal movements, which might prevent fetal death in late pregnancy.

Interobserver agreement in analysis of cardiotocograms recorded during trial of labor after cesarean.

Introduction: To examine interobserver agreement in intrapartum cardiotocography (CTG) classification in women undergoing trial of labor after a cesarean section (TOLAC) at term with or without complete uterine rupture. Materials and methods: Nineteen blinded and independent Danish obstetricians assessed CTG tracings from 47 women (174 individual pages) with a complete uterine rupture during TOLAC and 37 women (133 individual pages) with no uterine rupture during TOLAC. Individual pages with CTG tracings lasting at least 20 min were evaluated by three different assessors and counted as an individual case. The tracings were analyzed according to the modified version of the Federation of Gynaecology and Obstetrics (FIGO) guidelines elaborated for the use of STAN (ST-analysis). Occurrence of defined abnormalities was recorded and the tracings were classified as normal, suspicious, pathological, or preterminal. The interobserver agreement was evaluated using Fleiss' kappa. Results: Agreement on classification of a preterminal CTG was almost perfect. The interobserver agreement on normal, suspicious or pathological CTG was moderate to substantial. Regarding the presence of severe variable decelerations, the agreement was moderate. No statistical difference was found in the interobserver agreement between classification of tracings from women undergoing TOLAC with and without complete uterine rupture. Conclusions: The interobserver agreement on classification of CTG tracings from high-risk deliveries during TOLAC is best for assessment of a preterminal CTG and the poorest for the identification of severe variable decelerations.

Assessment of partograph utilization and associated factors among obstetric care givers at public health institutions in central zone, Tigray, Ethiopia.

OBJECTIVES: Partograph is one of the best effective obstetric tools used to monitoring labor and prevent prolonged or obstructed labor which accounts for about 22% of maternal deaths in Ethiopia. This study was aimed to assess partograph utilization and associated factors among obstetric care givers. Facility based cross sectional study was used in the randomly selected health facilities. Total 220 obstetric care givers were selected using simple random sampling technique. Data were entered and analyzed using SPSS version 22.0. Bivariate and multivariate logistic regression analysis was used to identify the associations of each explanatory variable with the outcome variable. Finally, odds ratio with its 95% confidence interval and p-value of 0.05 was used to identify significant variables. RESULT: Out of 198 obstetric care providers, 73.3% used partograph to monitor progress of labor. Those who were diploma holders (AOR = 3.8, CI = 2.2-6.2), receiving basic emergency obstetrics and new born care training (AOR = 5.6, CI 1.1-28.5), age between 20 and 29 years-old (AOR = 0.1, CI = 0.01-0.50), and male health care providers (AOR = 0.37, CI = 0.44-0.95) were factors significantly associated with partograph utilization. Partograph utilization in this study was below the WHO recommendation. Especial emphasizes and interventions should be given to increase partograph utilization.

Quality of care during childbirth in Tanzania: identification of areas that need improvement.

BACKGROUND: Making use of good, evidence based routines, for management of normal childbirth is essential to ensure quality of care and prevent, identify and manage complications if they occur. Two essential routine care interventions as defined by the World Health Organization are the use of the Partograph and Active Management of the Third Stage of Labour. Both interventions have been evaluated for their ability to assist health providers to detect and deal with complications. There is however little research about the quality of such interventions for routine care. Qualitative studies can help to understand how such complex interventions are implemented. This paper reports on findings from an observation study on maternity wards in Tanzania. METHODS: The study took place in the Lake Zone in Tanzania. Between 2014 and 2016 the first author observed and participated in the care for women on maternity wards in four rural and semi-urban health facilities. The data is a result of approximately 1300 hours of observations, systematically recorded primarily in observation notes and notes of informal conversations with health providers, women and their families. Detailed description of care processes were analysed using an ethnographic analysis approach focused on the sequential relationship of the 'stages of labour'. Themes were identified through identification of recurrent patterns. RESULTS: Three themes were identified: 1) Women's movement between rooms during birth, 2) health providers' assumptions and hope for a 'normal' birth, 3) fear of poor outcomes that stimulates intervention during birth. Women move between different rooms during childbirth which influences the care they receive. Few women were monitored during their first stage of labour. Routine birth monitoring appeared absent due to health providers 'assumptions and hope for good outcomes. This was rooted in a general belief that most women eventually give birth without problems and the partograph did not correspond with health providers' experience of the birth process. Contextual circumstances also limited health worker ability to act in case of complications. At the same time, fear for being held personally responsible for outcomes triggered active intervention in second stage of labour, even if there was no indication to intervene. CONCLUSIONS: Insufficient monitoring leads to poor preparedness of health providers both for normal birth and in case of complications. As a result both underuse and overuse of interventions contribute to poor quality of care. Risk and complication management have for many years been prioritized at the expense of routine care for all women. Complex evaluations are needed to understand the current implementation gaps and find ways for improving quality of care for all women.

Gaps in obstetric care processes - we can only improve what is being measured.

A multifaceted intervention at all six obstetric units in the Stockholm Health Region was performed in 2008-2011 in order to increase safety for the newborn infants. Case-controlled criterion-based reviews of care processes during labor and delivery have been used to assess factors associated with suboptimal care during labor and delivery. Categories of increased risk of adverse outcome during labor and delivery were defined. Cases with low Apgar scores and healthy controls were scrutinized and compared to data from a study with an identical design performed before the intervention. The risk of suboptimal care increased twice among controls and three times among cases when reviewing specific criteria after a multifaceted intervention. There are still gaps in care processes that need attention. Improving guidelines is important but not enough alone, and the management of fetal surveillance needs further improvement. The complexity of reviewing care processes using criterion-based research methodology is highlighted.

The perceptions of midwives regarding audit and feedback on the use of the partogram at Vhembe District of Limpopo Province, South Africa.

BACKGROUND: Audit and feedback is regarded as the cornerstone of clinical teaching to guarantee good practice and to correct poor performance. Feedback given to health professionals assists in narrowing the gap between the actual and the desired information. The findings of the research study on perceptions of midwives on audit and feedback highlighted aspects that needed improvement to address challenges on the use and documentation of the partogram. OBJECTIVES: The objectives of this article were to explore and describe the perceptions of midwives on auditing of the partogram by health professionals and to explore and describe the perceptions of midwives on the feedback that was given after audit was done. METHOD: A qualitative, exploratory and descriptive study was conducted to answer the two research objectives. Semi-structured face-to-face interviews were conducted with 17 midwives who were working in the labour wards of three hospitals. Eight steps of qualitative data analysis as indicated by Tesch were used to analyse the data. RESULTS: The findings revealed that auditing and feedback is sometimes done by midwives themselves, midwives' managers and district managers. Audit is done monthly or on a daily basis and sometimes inconsistently because of shortage of staff. Challenges indicated were lack of knowledge on the use of the partogram and lack of encouragement and praise when documentation was done correctly and that emphasis was mostly placed on negative aspects. CONCLUSION: The findings revealed that auditing and feedback and in-service education is done at the three hospitals, although challenges such as inconsistency in auditing because of shortage of staff, lack of knowledge on partogram use and on principles of giving feedback were highlighted.

Utilisation of the partogram among nurses and midwives in selected health facilities in the Eastern Province of Rwanda.

BACKGROUND: Maternal mortality continues to be a global burden, with more than 200 million women becoming pregnant each year and a large number dying as a result of complications of pregnancy or childbirth. The World Health Organisation has recommended use of the partogram to monitor labour and delivery in order to improve healthcare and reduce maternal and foetal mortality rates. OBJECTIVE: This study described factors affecting utilisation of the partogram among nurses and midwives in selected health facilities of Rwanda. METHOD: A descriptive quantitative and cross-sectional research design was used. The population comprised 131 nurses and midwives providing obstetric care in 15 health institutions (1 hospital and 14 health centres). Data collection was through a self-administered questionnaire, and a pre-test of the data collection instrument was carried out to enhance validity and reliability. The Statistical Package for Social Sciences (version 21) was used to capture and analyse data. Ethical clearance was obtained from the University of the Western Cape (Republic of South Africa) and from the Institutional Review Board of Kigali Health Institute (Rwanda). Patricia Benner's model of nursing practice was used to guide the study. RESULTS: It was found that 36.6% of nurses and midwives did not receive any in-service training on how to manage women in labour. Despite fair knowledge of the partogram among nurses and midwives in this study, only 41.22% reported having used the partogram properly, while 58.78% reported not having done so. CONCLUSION: Nurses' and midwives' years of professional experience and training in managing pregnant women in labour were found to be predictors of the likelihood of proper use of the partogram. In-service training of obstetric caregivers in the Eastern Province of Rwanda is recommended to improve use of the partogram while managing women in labour.

Inter-observer reliability of 4 fetal heart rate classifications.

OBJECTIVE: Different classification of fetal heart rate (FHR) pattern have been proposed: FHR classified as either "reassuring" or "non-reassuring", the National Institute of Child Health and Human Development (NICHD) published in 2008 a 3-tier system, the French College of Gynecology and Obstetrics (CNGOF) recommended in 2013 a 5-tier system and recently in 2015, the Federation International of Gynecology and Obstetrics (FIGO) proposed a new classification based on a 3-tier system. Our objective was to assess the inter-observer reliability of these 4 existing classifications. STUDY DESIGN: Four observers reviewed 100 FHR without clinical information. FHR were obtained from term singleton pregnancies. Fetal heart rate patterns were classified by one 2-tier ("reassuring vs. non-reassuring"), two 3-tier (NICHD 2008 and FIGO 2015), and one 5-tier (CNGOF 2013) fetal heart classifications. RESULTS: The global agreement between observers was moderate for each classification: 0.58 (0.40-0.74) for the 2-tier, 0.48 (0.37-0.58) for the NICHD 2008, 0.58 (0.53-0.63) for the CNGOF 2013 and 0.59 (0.49-0.67) for the FIGO 2015 classification. When FHR was classified as reassuring, it was classified as normal in 85.5% for the NICHD 2008 and in 94.5% for the FIGO 2015. For the CNGOF 2013, 65.0% were classified as normal and 32.5% as quasi normal. There was strong concordance between FIGO category I and "reassuring" FHR (kappa=0.95). CONCLUSION: Inter-observer agreement of FHR interpretation is moderate whatever the classification used. To evaluate the superior interest of one classification, it will be interesting to compare their impact on need of second line techniques and on neonatal outcome.

Reference values for Lactate Pro 2™ in fetal blood sampling during labor: a cross-sectional study.

OBJECTIVE: Lactate Pro™ (LP1) is the only lactate meter evaluated for fetal scalp blood sampling (FBS) in intrapartum use. The reference values for this meter are: normal value <4.2 mmol/L, preacidemia 4.2-4.8 mmol/L, and acidemia >4.8 mmol/L. The production of this meter has been discontinued. An updated version, Lactate Pro 2TM (LP2), has been launched and is shown to be differently calibrated. The aims of the study were to retrieve a conversion equation to convert lactate values in FBS measured with LP2 to an estimated value if using LP1 and to define reference values for clinical management when using LP2. STUDY DESIGN: A cross-sectional study was conducted at a university hospital in Sweden. A total of 113 laboring women with fetal heart rate abnormalities on cardiotocography (CTG) had FBS carried out. Lactate concentration was measured bedside with both LP1 and LP2 from the same blood sample capillary. A linear regression model was constructed to retrieve a conversion equation to convert LP2 values to LP1 values. RESULTS: LP2 measured higher values than LP1 in all analyses. We found that 4.2 mmol/L with LP1 corresponded to 6.4 mmol/L with LP2. Likewise, 4.8 mmol/L with LP1 corresponded to 7.3 mmol/L with LP2. The correlation between the analyses was excellent (Spearman's rank correlation, r=0.97). CONCLUSION: We recommend the following guidelines when interpreting lactate concentration in FBS with LP2: <6.4 mmol/L to be interpreted as normal, 6.4-7.3 mmol/L as preacidemia indicating a follow-up FBS within 20-30 min, and >7.3 mmol/L as acidemia indicating intervention.

Integration of multivariate empirical mode decomposition and independent component analysis for fetal ECG separation from abdominal signals.

BACKGROUND: The fetal electrocardiogram (FECG) signals are essential to monitor the health condition of the baby. Fetal heart rate (FHR) is commonly used for diagnosing certain abnormalities in the formation of the heart. Usually, non-invasive abdominal electrocardiogram (AbECG) signals are obtained by placing surface electrodes in the abdomen region of the pregnant woman. AbECG signals are often not suitable for the direct analysis of fetal heart activity. Moreover, the strength and magnitude of the FECG signals are low compared to the maternal electrocardiogram (MECG) signals. The MECG signals are often superimposed with the FECG signals that make the monitoring of FECG signals a difficult task. OBJECTIVE: Primary goal of the paper is to separate the fetal electrocardiogram (FECG) signals from the unwanted maternal electrocardiogram (MECG) signals. METHOD: A multivariate signal processing procedure is proposed here that combines the Multivariate Empirical Mode Decomposition (MEMD) and Independent Component Analysis (ICA). RESULTS: The proposed method is evaluated with clinical abdominal signals taken from three pregnant women (N= 3) recorded during the 38-41 weeks of the gestation period. The number of fetal R-wave detected (NEFQRS), the number of unwanted maternal peaks (NMQRS), the number of undetected fetal R-wave (NUFQRS) and the FHR detection accuracy quantifies the performance of our method. Clinical investigation with three test subjects shows an overall detection accuracy of 92.8%. CONCLUSION: Comparative analysis with benchmark signal processing method such as ICA suggests the noteworthy performance of our method.

Birth Outcomes, Intervention Frequency, and the Disappearing Midwife-Potential Hazards of Central Fetal Monitoring: A Single Center Review.

INTRODUCTION: Many birth units use central fetal monitoring (CFM) under the assumption that greater surveillance improves perinatal outcomes. The unexpected loss of the CFM system at a tertiary unit provided a unique opportunity to evaluate outcomes and staff attitudes toward CFM. METHODS: This retrospective cohort study compared patient data from 2,855 electronically monitored women delivering over a 12-month period, where CFM was available for the first 6 months but unavailable for the following 6 months. Primary outcomes relating to neonatal morbidity and secondary outcomes relating to intrapartum interventions were examined. Additionally, birth unit staff members were surveyed about aspects of care related to CFM. RESULTS: There were no significant differences in perinatal outcomes between the cohorts. While unadjusted analysis suggested a lower spontaneous vaginal birth rate (55.4% vs 60.3%) and a higher cesarean delivery rate (25.1% vs 22.0%, p = 0.026), together with higher epidural (53.0% vs 49.2%, p = 0.04) and fetal blood sampling (11.8% vs 9.4%, p = 0.03) rates in the presence of CFM, these differences were lost when adjusted for prostaglandin ripening. Over half of the staff (56.0% of midwives, 54.0% of obstetricians) reported spending more time with the laboring woman in the period without CFM. CONCLUSIONS: This single institution's experience indicates that in birth units staffed for one-to-one care in labor, central fetal monitoring does not appear to be associated with either a benefit on perinatal outcomes or an increase in cesarean delivery and other interventions. However, it is associated with a reduction in the time a midwife spends with the laboring woman.

Antepartum nonobstetrical surgery at ≥23 weeks' gestation and risk for preterm delivery.

OBJECTIVE: We sought to describe the influence of antepartum nonobstetrical surgical procedures performed at viable fetal gestational ages (GAs) on incidence of preterm delivery. STUDY DESIGN: This was a retrospective case series of patients requiring nonobstetrical surgery at ≥23 weeks' gestation at the Mayo Clinic during the interval 1992 through 2014. Data were abstracted for maternal demographic variables, operative procedure, anesthetic type, whether intraoperative fetal monitoring was employed, and both GA and method of delivery. RESULTS: In all, 111 patients underwent 121 operative procedures at a mean GA of 29.2 weeks (range, 23-37 weeks). The majority of procedures were completed under general anesthesia (88/121, 73%), with intraoperative fetal monitoring performed in 14 cases (14/121, 12%); fetal loss occurred during a single unmonitored procedure. Outcome data were available for the majority of patients (86/111, 78%) with preterm delivery occurring in 41% (35/86) at a mean GA of 36.9 weeks (range, 25-41 weeks). Mean interval from procedure to delivery was 7.7 weeks, with 9 patients (9/86, 10%) delivering within 1 week of surgery. Neither procedures requiring entry into the abdominal cavity (P = .65) nor GA at time of procedure (P = 1.0) statistically influenced the risk of preterm delivery. CONCLUSION: Nonobstetrical surgical procedures performed at or beyond fetal viability increased the incidence of preterm delivery regardless of surgical site or timing of procedure, however the risk of intraoperative or immediate postoperative obstetrical complications was relatively low.

Fetal head-symphysis distance and mode of delivery in the second stage of labor.

OBJECTIVE: To evaluate whether the fetal head-symphysis distance measured by three-dimensional transperineal ultrasound during the active second stage predicts operative delivery. DESIGN: Prospective observational study. SETTING: University hospital, Bologna, Italy. POPULATION: Seventy-one nulliparous women at term in active second stage of labor. METHODS: We acquired a series of sonographic volumes at the beginning of the active second stage (T1) and every 20 min thereafter (T2, T3, T4, T5, T6) until delivery. All volumes were retrospectively analyzed and head-symphysis distance was measured for each acquisition. We compared head-symphysis distance between women with spontaneous vaginal delivery and those with operative delivery. Receiver operator characteristic curves were constructed to estimate the accuracy of head-symphysis distance in the prediction of operative delivery. Logistic regression was used to identify independent variables associated with operative delivery. MAIN OUTCOME MEASURES: Operative delivery (vacuum or cesarean). RESULTS: Of the women included, 81.7% had a spontaneous vaginal delivery and 18.3% underwent operative delivery. Women with spontaneous vaginal delivery had shorter head-symphysis distance than women in the operative delivery group at T1 (p < 0.001), T2 (p < 0.001) and T3 (p = 0.025), whereas no significant differences were recorded thereafter. Receiver operator characteristic curves revealed accuracy values of 81.0%, 87.9% and 77.6% in the prediction of operative delivery at T1, T2 and T3, respectively. At multivariate logistic regression head-symphysis distance and epidural analgesia were the only independent predictors of operative delivery among ultrasonographic, maternal and intrapartum variables. CONCLUSIONS: Ultrasonographic measurement of head-symphysis distance in the second stage of labor can be used to predict operative delivery.

Is there an association between sonographically determined occipito-transverse position in the second stage of labor and operative delivery?

OBJECTIVE: To evaluate if ultrasound-determined occipito-transverse position early in the second stage of labor is associated with operative delivery. DESIGN: Retrospective review of two prospective cohort studies. SETTING: An Australian tertiary referral hospital. POPULATION: Women with term, cephalic singleton pregnancies. METHODS: Retrospective analysis of data from two prospective studies. Logistic regression was undertaken to assess the independent contribution of the occipito-transverse position to operative delivery. MAIN OUTCOME MEASURE: Operative delivery (cesarean section, forceps or vacuum extraction). RESULTS: Among 422 women included, the occipito-transverse position was present in 80, occipito-anterior in 303 and the occipito-posterior in 39. Compared with occipito-anterior, the adjusted odds ratio for operative delivery was 2.1 (95% confidence interval 1.2-3.8, p = 0.02) for the occipito-transverse position, and 7.4 (95% confidence interval 3.2-17) for the occipito-posterior position. Factors that independently predicted operative delivery were nulliparity, abnormal second stage cardiotocography, maternal place of birth and epidural analgesia. The length of second stage of labor was longer for the occipito-transverse group than for the occipito-anterior group (median 2 h 7 min vs. 1 h 36 min, p = 0.003). CONCLUSION: The occipito-transverse position early in the second stage of labor was associated with an increased operative delivery rate.

Interrelations between four antepartum obstetric interventions and cesarean delivery in women at low risk: a systematic review and modeling of the cascade of interventions.

OBJECTIVES: To critically appraise the literature on the relations between four intrapartum obstetric interventions-electronic fetal monitoring (EFM), epidural analgesia, labor induction, and labor acceleration; and two types of delivery-instrumental (forceps and vacuum) and cesarean section. METHODS: This review included meta-analyses published between January 2000 and April 2012 including at least one randomized clinical trial published after 1995 and presenting results on low-risk pregnancies between 37 and 42 weeks of gestation, searched in the databases Medline, Cochrane Library, and EMBASE with no language restriction. RESULTS: Of 306 documents identified, 8 fulfilled the inclusion criteria and presented results on women at low risk. EFM at admission (vs intermittent auscultation) was associated with cesarean delivery (odds ratio [OR] = 1.20, 95% confidence interval [CI] 1.00-1.44) and epidural analgesia (OR = 1.25, 95% CI 1.09-1.43). Epidural on request was associated with cesarean delivery (OR = 1.60, 95% CI 1.18-2.18), instrumental delivery (OR = 1.21, 95% CI 1.03-1.44), and oxytocin use (OR = 1.20, 95% CI 1.01-1.43) when compared with epidural on request plus nonpharmacological labor pain control methods such as one-to-one support, breathing techniques, and relaxation. Induction and acceleration of labor showed heterogeneous patterns of associations with cesarean delivery and instrumental delivery. CONCLUSIONS: Complex patterns of associations between obstetric interventions and modes of delivery were illustrated in an empirical model. Intermittent auscultation and nonpharmacological labor pain control interventions, such as one-to-one support during labor, have the potential for substantially reducing cesarean deliveries.