Caesarean delivery on maternal request: the perspective of the postpartum women.

BACKGROUND: Caesarean delivery on maternal request (CDMR) is an increasing delivery option among women. As such, we aimed to understand the reasons that led pregnant women to request a caesarean delivery. METHODS: A phenomenological study was conducted with semi-structured interviews, in a convenience sample, for women who had undergone a CDMR between March and June 2023, in a public reference university hospital in Campinas, Brazil. The interviews were recorded, transcribed and subjected to thematic analysis, supported by Nvivo®, and Reshape®. RESULTS: We interviewed eighteen women between 21 and 43 years of age. The reasons for C-section as their choice were: 1) fear of labour pain, 2) fear for safety due to maternal or fetal risks, 3) traumatic previous birth experiences of the patient, family or friends 4) sense of control, and 5) lack of knowledge about the risks and benefits of C-section. CONCLUSIONS: The perception of C-section as the painless and safest way to give birth, the movement of giving voice and respecting the autonomy of pregnant women, as well as the national regulation, contribute to the increased rates of surgical abdominal delivery under request. Cultural change concerning childbirth and better counseling could support a more adequate informed decision-making about delivery mode.

Delayed onset of neonatal compartment syndrome associated with compound fetal presentation.

Neonatal compartment syndrome, although rare, has a classic presentation with sentinel skin findings and development of swelling, erythema, and tenderness of the affected extremity. Neonatal compartment syndrome requires prompt surgical intervention to preserve the affected limb and ensure its normal growth and development. Our patient was born at term via vaginal delivery complicated by a compound presentation involving the left upper extremity. No physical exam abnormalities were noted at birth, but she developed signs of neonatal compartment syndrome by 15 h of life. She was surgically treated at 22 h of life and recovered well. At one year of age, she has normal growth and function of the affected extremity. Our case adds to the growing literature associating neonatal compartment syndrome with a compound fetal presentation.

Maternal outcomes of planned mode of delivery for term breech in nulliparous women.

OBJECTIVE: To estimate short- and long-term maternal complications in relation to planned mode of term breech delivery in first pregnancy. DESIGN: Register-based cohort study. SETTING: Denmark. POPULATION: Nulliparous women with singleton breech delivery at term between 1991 and 2018 (n = 30,778). METHODS: We used data from the Danish national health registries to identify nulliparous women with singleton breech presentation at term and their subsequent pregnancies. We performed logistic regression to compare the risks of maternal complications by planned mode of delivery. All data were proceeded and statistical analyses were performed in SAS 9.4 (SAS Institute Inc. Cary, NC, USA). MAIN OUTCOME MEASURES: Postpartum hemorrhage, operative complications, puerperal infections in first pregnancy and uterine rupture, placenta previa, post-partum hemorrhage, hysterectomy and stillbirth in the subsequent two pregnancies. RESULTS: We identified 19,187 with planned cesarean and 9,681 with planned vaginal breech delivery of which 2,970 (30.7%) delivered vaginally. Planned cesarean significantly reduced the risk of postoperative infections (2.4% vs 3.9% adjusted odds ratio (aOR): 0.54 95% confidence interval (CI) 0.44-0.66) and surgical organ lesions (0.06% vs 0.1%; (aOR): 0.29 95% CI 0.11-0.76) compared to planned vaginal breech delivery. Planned cesarean delivery in the first pregnancy was associated with a significantly higher risk of uterine rupture in the subsequent pregnancies but not with risk of postpartum hemorrhage, placenta previa, hysterectomy, or stillbirth. CONCLUSION: Compared to planned vaginal breech delivery at term, nulliparous women with planned cesarean breech delivery have a significantly reduced risk of postoperative complications but a higher risk of uterine rupture in their subsequent pregnancies.

Factors associated with perineal pain on the first postnatal day after vaginal delivery: a cross-sectional study of primiparous women.

Many women report postpartum perineal pain due to perineal trauma after vaginal delivery. Perineal pain after giving birth declines over time; however, perineal trauma and pain negatively impact on the women's quality of life and their ability to care for their children. The degree of perineal trauma and instrument delivery with episiotomy are associated with perineal pain. Nevertheless, no studies have examined factors related to postpartum perineal pain, including weight changes during pregnancy as well as the course of delivery so far. We aimed to elucidate obstetric factors associated with perineal pain after vaginal delivery on the first postnatal day in Japanese primiparous women. A cross-sectional study conducted in five maternity hospitals in Japan included 142 primiparous women who vaginally delivered full-term and singleton infants. Perineal pain on the first postnatal day was evaluated using a visual analog scale. The final analysis included 92 participants with a mean age of 30.3 ± 4.6 years. The median visual analog scale score was 54.0 mm. Multiple linear regression analysis demonstrated that gestational weight gain above the recommended Japanese range was positively and significantly associated with perineal pain on the first postnatal day, independent of maternal age, episiotomy, painkiller use, and neonatal birth weight. This finding may provide additional evidence regarding gestational weight gain within the recommended range based on the pre-pregnancy body mass index to reduce perineal pain on the first postnatal day.

The REPAIR study: oral antibiotics to prevent infection and wound dehiscence after obstetric perineal tear-a double-blinded placebo controlled randomized trial.

BACKGROUND: Approximately 85% of women experience an obstetric tear at delivery and up to 25% subsequently experience wound dehiscence and/or infection. Previous publications suggest that intravenous antibiotics administrated during delivery reduces this risk. We do not know if oral antibiotics given after delivery can reduce the risk of wound dehiscence or infection. Our aim is to investigate whether three doses of oral antibiotics (amoxicillin 500 mg/clavulanic acid 125 mg) given after delivery can reduce the risk of wound dehiscence and infection in patients with a second-degree obstetric tear or episiotomy. METHODS: We will perform a randomized, controlled, double-blinded study including 221women in each arm with allocation 1:1 in relation to the randomization. The study is carried out at Department of Obstetrics & Gynecology, Herlev University Hospital, Copenhagen, Denmark. The women will be included after delivery if they have had a second-degree tear or episiotomy. After inclusion, the women will have a clinical follow-up visit after 1 week. The tear and healing will be evaluated regarding signs of infection and/or dehiscence. The women will again be invited for a 1-year clinical examination including ultrasound. Questionnaires exploring symptoms related to the obstetric tear and possible complications will be answered at both visits. Our primary outcome is wound dehiscence and/or wound infection, which will be calculated using χ2 tests to compare groups. Secondary outcomes are variables that relate to wound healing, as pain, use of painkillers and antibiotics, need for further follow-up, as well as outcomes that may be related to the birth or healing process, urinary or anal incontinence, symptoms of prolapse, female body image, and sexual problems. DISCUSSION: Reducing the risk of wound dehiscence and/or infection would decrease the number of control visits, prevent the need for longer antibiotic treatment, and possibly also decrease both short-term and long-term symptoms. This would be of great importance so the mother, her partner, and the baby could establish and optimize their initial family relation. TRIAL REGISTRATION: The conduction of this study is approved the 2/2-2023 with the EU-CT number: 2022-501930-49-00. CLINICALTRIALS: gov Identifier: NCT05830162.

Assisted reproductive technology-associated risk factors for placenta accreta spectrum after vaginal delivery.

This study aimed to investigate assisted reproductive technology (ART) factors associated with placenta accreta spectrum (PAS) after vaginal delivery. This was a registry-based retrospective cohort study using the Japanese national ART registry. Cases of live singleton infants born via vaginal delivery after single embryo transfer (ET) between 2007 and 2020 were included (n = 224,043). PAS was diagnosed in 1412 cases (0.63% of deliveries), including 1360 cases (96.3%) derived from frozen-thawed ET cycles and 52 (3.7%) following fresh ET. Among fresh ET cycles, assisted hatching (AH) (adjusted odds ratio [aOR], 2.5; 95% confidence interval [CI] 1.4-4.7) and blastocyst embryo transfer (aOR, 2.2; 95% CI 1.3-3.9) were associated with a significantly increased risk of PAS. For frozen-thawed ET cycles, hormone replacement cycles (HRCs) constituted the greatest risk factor (aOR, 11.4; 95% CI 8.7-15.0), with PAS occurring in 1.4% of all vaginal deliveries following HRC (1258/91,418 deliveries) compared with only 0.11% following natural cycles (55/47,936). AH was also associated with a significantly increased risk of PAS in frozen-thawed cycles (aOR, 1.2; 95% CI 1.02-1.3). Our findings indicate the need for additional care in the management of patients undergoing vaginal delivery following ART with HRC and AH.

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

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

Maternal postures for fetal malposition in late pregnancy for improving the health of mothers and their infants.

BACKGROUND: The optimal relationship of the fetus to the mother's birth canal is when the fetus is in the longitudinal lie, cephalic presentation with well-flexed head (vertex presentation), and in the occipito-anterior position. Fetal malposition is described as occipito-posterior (OP) when the back of the fetal head lies posteriorly in the mother's pelvis, and occipito-transverse (OT) when the back of the fetal head lies transversely in the mother's pelvis. The fetal head will often be deflexed and may extend further to a mento-anterior or mento-transverse position, where the chin is anterior or transverse to the maternal pelvis. Fetal malposition is associated with both maternal and fetal complications, including prolonged labour, fetal distress, maternal exhaustion, need for caesarean section, operative vaginal birth, and increased risk of perineal trauma and anal sphincter injuries. This review considered positional interventions in late pregnancy to correct fetal malposition. A separate Cochrane review addresses maternal postural position for fetal malposition during labour. OBJECTIVES: To assess the effects of maternal posture for fetal malposition in women in late pregnancy. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (24 October 2022), and reference lists of retrieved studies. SELECTION CRITERIA: Our selection criteria were randomised controlled trials and cluster-randomised controlled trials that included women in late pregnancy with a malposition of the fetus including OP and OT, mento-anterior and mento-transverse, or with uncertain fetal position, randomly allocated to use of specified maternal positioning in late pregnancy, compared with usual care. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed potential studies for inclusion in the review. We used standardised methodology for assessment of risk of bias and trustworthiness developed by the Cochrane Pregnancy and Childbirth Group. MAIN RESULTS: We reviewed three full-text reports; we excluded one due to lack of a comparison group and listed two as awaiting classification. We needed further information from the report authors for both potentially suitable studies to account for substantial imbalances between the numbers allocated to each group in one, or identical numbers for all groups in the other. The failure to resolve these issues may have been due to the long interval since publication of the studies (2004 and 1983). AUTHORS' CONCLUSIONS: We did not identify evidence for guiding practice with respect to positional interventions for fetal malposition in late pregnancy. More studies are needed to understand the effect of positional interventions in late pregnancy. Future research on positional interventions for fetal malposition in late pregnancy should include follow-up to determine whether short-term correction of fetal position translates to improved pregnancy outcomes. This might include interventions commenced in late pregnancy and repeated as needed until the onset of labour. The latter would be included in the review on maternal positions during labour.

Fertility policy changes, maternal and foetal characteristics and birth timing patterns at a tertiary referral centre in Beijing: a ten-year retrospective study.

OBJECTIVE: This study aimed to explore the impacts of the changing national fertility policy on maternal and fetal characteristics, and birth timing patterns and provide a basis for the management of the obstetric and midwifery workforce. DESIGN: Retrospective cohort study. SETTING: Data from medical register of a tertiary referral centre in Beijing, China. PARTICIPANTS: We included 20 334 births with a gestational age more than 28 weeks during January 2013-September 2023. MAIN OUTCOMES: The main outcomes included birth numbers, maternal age, parity, birth modes, premature rates, neonatal birth weight, and birth timings. RESULTS: The birth rates showed a general rising trend before 2016. Afterwards, the birth rates kept decreasing and reached the bottom level in 2022. The caesarean section rates showed a declining trend, while the assisted birth rates were progressively rising, especially among primiparous women. From 2013 to 2022, the proportions of multiparous women (increasing from 9.3% to 36.6%) and women with advanced maternal age (increasing from 11.4% to 34.5%) were on the rise, together with increasing rates of premature birth (increasing from 5.7% to 8.5%) and neonatal low birth weight (rising from 4.3% to 7.2%) in this population. This study found a significant peak of births between 14:00 and 15:00, which remained unchanged despite shifts in the fertility policy (p<0.001 and [Formula: see text] values close to 1, respectively). CONCLUSION: The 'three-child' policy did not boost the birth rate further 2 years later after its enactment, and the proportion of multiparous women and women with advanced maternal age were on the rise, accompanied by an increase in rates of premature birth and low birth weight. Targeted training should be offered to healthcare professionals to empower them to deal with possible negative pregnancy outcomes and childbirth complications. Prepregnancy and antepartum education should be parity specific. Adequate midwifery staffing during this 14:00-15:00 is vital to promote a safe birth.

The postnatal effects of perineal trauma on maternal psychological and emotional wellbeing: A longitudinal study.

OBJECTIVE: To examine the postnatal psychological health and parenting adjustment of primiparous women experiencing perineal trauma. STUDY DESIGN: Longitudinal cohort study assessing body image, perceptions of traumatic birth, psychological distress, perineal pain, impact upon parental tasks and mother-infant bonding at 6-12 weeks (n = 103) and 6-10 months postnatally (n = 91). Primiparous women were recruited following vaginal birth and perineal suturing in a UK-based maternity hospital. al. Comparisons made according to the objective classification of perineal trauma experienced; 1st/2nd degree tear, episiotomy, and Obstetric Anal Sphincter Injuries (OASI). RESULTS: At 6-12 weeks women with an episiotomy reported a more negative perception of their body image than those with OASI. Women with OASI or an episiotomy were more likely to have experienced birth as traumatic, and those with OASI reported more avoidance symptoms of post-traumatic stress and a greater negative impact on parenting tasks. At 6-10 months significantly more avoidance symptoms continued to be reported by those with OASI, whereas those with an episiotomy reported more anxiety related symptoms in general than those with OASI. CONCLUSIONS: OASI, whilst associated with traumatic birth and some early parenting impacts, may not be linked to general negative psychological outcomes when specialist routine follow-up care is provided. Psychological impacts for women with episiotomy may merit further input than currently provided. Consideration should be given with regards to widening the access to postnatal perineal care by extending the criteria for specialist follow up beyond those sustaining OASI.

The clinical significance of cervical tears' anatomical location - A retrospective study.

OBJECTIVE: Up to 4.8% of all vaginal deliveries are complicated by significant cervical tears related to maternal compromise, yet the location of the cervical tear and its impact on the attributed risk have not been studied to date. This study aimed to determine the associations between the location and characteristics of cervical tears with short-term maternal complications and outcomes. METHODS: This is a retrospective cohort study. Included were all patients that delivered vaginally at our institute between the years 2009-2020 and were diagnosed with a cervical tear. Maternal complications were compared between cases with posterior cervical tears and cases with anterior or lateral cervical tears. Exclusion criteria included patients who delivered by cesarean delivery and preterm labor below 37.0 weeks of gestation. RESULTS: Overall, 96 patients were diagnosed with posterior cervical tears, while 117 patients were diagnosed with anterior or lateral tears. Maternal demographics and pregnancy characteristics were similar between the groups. There were also no differences in delivery outcomes between the groups. Patients with posterior cervical tears had a higher rate of disseminated intravascular coagulation (DIC) (6.25 % vs. 0.9 %, p = 0.04) and prolonged hospitalization (35.4 % vs. 23.1 %, p = 0.05), as compared to patients with anterior or lateral tears. There were no differences in other maternal complications. CONCLUSIONS: Cases of posterior cervical tears are at higher risk for maternal adverse outcomes (DIC and prolonged hospitalization), as compared to cases of anterior or lateral tears.

Epidemiological, anatomoclinical, and therapeutic profile of obstetric fistula in the Democratic Republic of the Congo: About 1267 patients.

OBJECTIVE: Our aim is to describe the epidemiological, anatomoclinical and therapeutic profile of obstetric fistula (OF) in the Democratic Republic of the Congo (DRC). METHODOLOGY: This was a descriptive retrospective study that collected 1416 obstetric fistulas in 1267 patients in seven provinces of the DRC, treated between January 2017 and December 2022. The variables studied were epidemiological, anatomoclinical and therapeutic. RESULTS: The mean age of patients at the time of surgical repair was 33.2 years (range: 15 and 77 years) and 32.8% of patients were aged between 20 and 29 years. The mean age of the fistula at repair was 10 years (range: 3.5 months and 56 years). At the time of fistula, 61.7% of patients had delivered vaginally and 28.7% by caesarean section and 8.2% of patients had a haemostasis hysterectomy. Labour lasted at least 3 days in 47.3% of these patients for the fistula birth. Deliveries took place either at home (27.4%) or in a health facility (72.6%); 83.6% of newborns resulting from these births had died. Taken as a whole, urogenital fistulas are more common than genito-digestive fistulas. Urethro-vaginal (26.2%) and vesico-uterine (24.7%) anatomoclinical entities were predominant among urogenital fistulas. A total of 1416 fistulas were surgically repaired in 1267 patients. These repairs were successful for 1226 (86.6%) fistulas. The main surgical route used was transvaginal (68.8%). CONCLUSION: In the DRC, obstetric fistula is common in young adult women. It often results from vaginal delivery, after prolonged labour. Fistula births often result in the death of newborns. Uro-genital obstetric fistulas are the most frequent with predominance of urethro-vaginal and vesico-uterine anatomoclinical entities. Fistulas remain untreated for a long time. Mostly done transvaginally, surgical repair gives a good result.

Pelvic floor injury during vaginal birth is life-altering and preventable: what can we do about it?

Pelvic floor disorders after childbirth have distressing lifelong consequences for women, requiring more than 300,000 women to have surgery annually. This represents approximately 10% of the 3 million women who give birth vaginally each year. Vaginal birth is the largest modifiable risk factor for prolapse, the pelvic floor disorder most strongly associated with birth, and is an important contributor to stress incontinence. These disorders require 10 times as many operations as anal sphincter injuries. Imaging shows that injuries of the levator ani muscle, perineal body, and membrane occur in up to 19% of primiparous women. During birth, the levator muscle and birth canal tissues must stretch to more than 3 times their original length; it is this overstretching that is responsible for the muscle tear visible on imaging rather than compression or neuropathy. The injury is present in 55% of women with prolapse later in life, with an odds ratio of 7.3, compared with women with normal support. In addition, levator damage can affect other aspects of hiatal closure, such as the perineal body and membrane. These injuries are associated with an enlarged urogenital hiatus, now known as antedate prolapse, and with prolapse surgery failure. Risk factors for levator injury are multifactorial and include forceps delivery, occiput posterior birth, older maternal age, long second stage of labor, and birthweight of >4000 g. Delivery with a vacuum device is associated with reduced levator damage. Other steps that might logically reduce injuries include manual rotation from occiput posterior to occiput anterior, slow gradual delivery, perineal massage or compresses, and early induction of labor, but these require study to document protection. In addition, teaching women to avoid pushing against a contracted levator muscle would likely decrease injury risk by decreasing tension on the vulnerable muscle origin. Providing care for women who have experienced difficult deliveries can be enhanced with early recognition, physical therapy, and attention to recovery. It is only right that women be made aware of these risks during pregnancy. Educating women on the long-term pelvic floor sequelae of childbirth should be performed antenatally so that they can be empowered to make informed decisions about management decisions during labor.

[Evolution of the rate of episiotomies and obstetric anal sphincter injuries since the last recommendations of 2018]. / Évolution du taux d'épisiotomies et des lésions obstétricales du sphincter de l'anus depuis les recommandations de 2018.

OBJECTIVES: There is a progressive reduction in the rate of episiotomies since the recommendations of the French college of gynaecologists. Our objective was to study the evolution of the rate of episiotomies and Obstetric Anus Sphincter Injury (OASI) since the restriction of episiotomies in our department. METHODS: Observational monocentric retrospective study performed at the Rouen University Hospital. The inclusion criteria were monofetal pregnancies, delivery at a term greater than or equal to 37 weeks of amenorrhea of a living, viable child and by cephalic presentation. We compared two periods corresponding to before and after the 2018 recommendations. We used logistic regression modelling to identify factors associated with the risk of episiotomies and of obstetrical anal injuries, overall and in case of instrumental delivery. RESULTS: We included 3329 patients for the 1st period and 3492 for the 2nd period, and the rate of instrumental deliveries were respectively of 16.4% (n=547) and 17.9% (n=626). Multivariate analysis showed a significant decrease in the rate of episiotomies in the 2nd period (OR 0.14, CI 95% [0.12; 0.16], P<0.0001). Main factors associated with the risk of OASI were primiparity (OR 6.21, CI 95% [3.19; 12.11]) and the use of forceps (OR 4.23, CI 95% [2.17; 8.27]) overall; and instrumental delivery using forceps (OR 3.25, CI 95% [1.69; 6.22]) and delivery during the 2nd period (OR 1.98, CI 95% [1.01; 3.88]) in case of instrumental delivery. CONCLUSIONS: Our study confirms that the voluntary reduction in the episiotomy rate does not seem to be associated with an increased risk of OASI, overall and in case of instrumental delivery. However, we show an increase in the rate of OASI in case of instrumental delivery since the latest recommendations.

Irritable bowel syndrome worsens faecal incontinence after primary repair of major obstetric anal sphincter injuries.

AIM: Obstetric anal sphincter injuries (OASIS) occur in approximately 3%-6% of vaginal deliveries and are the leading risk factor for late-onset faecal incontinence, which is an underdiagnosed pathology. The aim of this work was to use a validated scoring system to quantify the effect of irritable bowel syndrome (IBS) on the severity of faecal incontinence symptoms after primary repair of major OASIS (Grade IIIb-IV). METHOD: A prospective cohort study was performed on all women who underwent primary repair of major OASIS over a 6-year period. They were assessed with ultrasonography within 12 weeks. Two control groups (who did not have OASIS) were women who underwent elective caesarean section and primigravid women. Questionnaires were sent at least 12 months after delivery, or at first consultation for primigravids, which generated the main outcome measures: Cleveland Clinic faecal incontinence severity scores and the presence of IBS based on Rome III criteria. RESULTS: There was a total of 211 patients included in the three groups and the mean follow-up time was 26 months after sphincter repair. Ultrasonographic sphincter defects were detected in 37% but did not affect the faecal incontinence score (p = 0.47), except in patients with IBS. Within each group, patients with IBS had significantly worse faecal incontinence than those without. Women with both OASIS and IBS had the most severe faecal incontinence scores. CONCLUSION: OASIS has a limited negative effect on faecal incontinence, independent of whether residual ultrasonographic sphincter defects are present. However, the presence of IBS has a significant compounding effect on faecal incontinence in OASIS patients. The effect of IBS on faecal incontinence is also notable in caesarean section patients and primigravids, suggesting that IBS is an independent risk-factor that should have its place in predelivery assessment and counselling.

Morphological examination of pelvic floor muscles in a rat model of vaginal delivery.

OBJECTIVE: This study investigated morphological changes in the composition of the pelvic floor muscles, degree of atrophy, and urethral function in a rat of simulated birth trauma induced by vaginal distension (VD) model. METHODS: Female Sprague-Dawley rats were classified into four groups: a sham group, and 1, 2, and 4 weeks post-VD (1 W, 2 W, and 4 W, respectively) groups. We measured the amplitude of urethral response to electrical stimulation (A-URE) to evaluate urethral function. After measuring the muscle wet weight of the pubococcygeus (Pcm) and iliococcygeus (Icm) muscles, histochemical staining was used to classify muscle fibers into Types I, IIa, and IIb, and the occupancy and cross-sectional area of each muscle fiber were determined. RESULTS: There were 24 Sprague-Dawley rats used. A-URE was significantly lower in the 1 W group versus the other groups. Muscle wet weight was significantly lower in the VD groups versus the sham group for Pcm. The cross-sectional area of Type I Pcm and Icm was significantly lower in the VD groups versus the sham group. Type I muscle fiber composition in Pcm was significantly lower in the VD groups versus the sham groupand lowest in the 2 W group. Type I muscle fiber composition in Icm was significantly lower in the 2 and 4 W groups versus the sham group. CONCLUSION: Muscle atrophy and changes in muscle composition in the pelvic floor muscles were observed even after improvements in urethral function. These results may provide insight into the pathogenesis of stress urinary incontinence after VD.

Is water delivery a good idea to prevent obstetric anal sphincter injuries in low risk primiparae? An exploratory study in a Swiss public teaching hospital.

OBJECTIVE: Obstetric anal sphincter injuries are feared perineal injuries that are associated with increased pelvic floor disorders. The knowledge of influencing factors as the mode of delivery is therefore important. The aim of this study is to compare the rate of obstetric anal sphincter injuries in primiparae after water and bed deliveries. STUDY DESIGN: In this retrospective cohort study 3907 primiparae gave birth in water or on a bed in a Swiss teaching hospital. The diagnosis of obstetric anal sphincter injuries was confirmed by a consultant of obstetrics and gynecology and treated by them. The rates of these injuries after water and bed births were compared. Subgroup analysis was performed to detect possible associative factors, such as birth weight, episiotomy, use of oxytocin in first and second stage of labor. RESULTS: 1844 (47.2 %) of the primiparae had a water delivery and 2063 (52.8 %) a bed delivery. 193 (4.94 %) were diagnosed with obstetric anal sphincter injuries, of which 68 (3.7 %) had a water delivery and 125 (6.1 %) a bed delivery, p < 0.001. Subgroup analysis revealed that, in the first and second stage of labor, the rate of obstetric anal sphincter injuries with oxytocin was significantly lower in water than in bed deliveries; p = 0.025, p < 0.017, respectively. The rate of obstetric anal sphincter injuries in the birth weight or episiotomy subgroups did not reach significance. CONCLUSIONS: In a teaching hospital setting with standardized labor management, primiparae with a water delivery have the lowest risk for obstetric anal sphincter injuries.

Pitfalls in the diagnostics of shoulder dystocia: an analysis based on the scrutiny of 2274 deliveries.

PURPOSE: Shoulder dystocia is an obstetric emergency with severe complications. Our objective was to evaluate the major pitfalls in the diagnostics of shoulder dystocia, diagnostic descriptions documented in medical records, use of obstetric maneuvers, and their correlations to Erb's and Klumpke's palsy and the use of ICD-10 code 066.0. METHODS: A retrospective, register-based case-control study included all deliveries (n = 181 352) in Hospital District of Helsinki and Uusimaa (HUS) area in 2006-2015. Potential shoulder dystocia cases (n = 1708) were identified from the Finnish Medical Birth Register and the Hospital Discharge Register using ICD-10 codes O66.0, P13.4, P14.0, and P14.1. After thorough assessment of all medical records, 537 shoulder dystocia cases were confirmed. Control group consisted of 566 women without any of these ICD-10 codes. RESULTS: The pitfalls in the diagnostic included suboptimal following of guidelines for making the diagnosis of shoulder dystocia, subjective interpretation of diagnostic criteria, and inexact or inadequate documentation in medical records. The diagnostic descriptions in medical record were highly inconsistent. The use of obstetric maneuvers was suboptimal among shoulder dystocia cases (57.5%). Overall, the use of obstetric maneuvers increased during the study period (from 25.7 to 97.0%, p < 0.001), which was associated with decreasing rate of Erb's palsy and increasing use of ICD-10 code O66.0. CONCLUSION: There are diagnostic pitfalls, which could be addressed by education regarding shoulder dystocia guidelines, by improved use obstetric maneuvers, and more precise documentation. The increased use of obstetric maneuvers was associated with lower rates of Erb's palsy and improved coding of shoulder dystocia.