Umbilical cord management strategies at cesarean section.

AIM: To evaluate the effect of different strategies to improve placental transfusion in cesarean section (CS). METHODS: Retrospective analysis of all singleton term pregnancies that underwent CS over 6 months. Delayed umbilical cord clamping (dUCC) was defined as one done at least 60 s after birth. Umbilical cord milking (UCM) was an option when waiting 60 s was deemed unsafe. The two strategies were compared against early (<60 s) umbilical cord clamping (eUCC) without milking. Neonatal hematocrit (Hct) at 48 h was the main outcome variable. RESULTS: Of the 223 CS in the cohort, 100 were performed in labor and 123 were elective. dUCC was performed in 137, eUCC without milking in 53 and UCM in 33 cases. Neonatal Hct was higher in CS carried out in labor versus in elective CS (59.76% ± 6.17 vs 56.91% ± 5.95, P = 0.001). At multivariate analysis, CS performed in labor (coefficient [coeff.] 3.44, confidence interval [CI] 1.75-5.13, P < 0.001), UCM (coeff. 3.88, CI 1.61-6.14, P = 0.001) and birth weight (coeff. -0.003, CI -0.005 to -0.001, P = 0.001) were the only variables independently associated with neonatal Hct. In elective CS, UCM led to higher neonatal Hct (61.5% ± 5.5) compared to eUCC without milking (55.1% ± 5.5) and dUCC (56.4% ± 5.7, P = 0.001), while in CS performed in labor there were no significant differences among the placental transfusion strategies. CONCLUSION: In term CS, neonatal Hct is significantly higher when the CS is performed in labor or with UCM. In elective CS, UCM could be a valid option to favor placental transfusion.

Cesarean delivery rates and obstetric culture - an Italian register-based study.

INTRODUCTION: Cesarean delivery rates are rising due to multiple factors, including less use of operative vaginal delivery and vaginal birth after cesarean delivery, which often reflect local obstetric practices. Objectives of the study were to analyze the relations between cesarean delivery, these practices, and perinatal outcomes. MATERIAL AND METHODS: We included all deliveries in the 72 hospitals of Lombardia, a region in northern Italy, during the year 2013. The delivery certificate was used as data source. Pearson's correlation coefficient and logistic regression were used for statistical analysis. RESULTS: We included 87 896 deliveries. The number of deliveries per hospital ranged from 140 to 6123. The rate of cesarean delivery was 28.3% (range 9.9-86.4%), operative vaginal delivery 4.7% (range 0.2-10.0%), and vaginal birth after cesarean 17.3% (range 0-79.2%). We found a significant inverse correlation between rates of overall cesarean delivery and operative vaginal delivery (r = -0.25, p = 0.04). The correlation between rate of overall cesarean delivery and vaginal birth after cesarean was also inverse and significant (r = -0.57, p < 0.001). There was no association between overall cesarean delivery rate and the rates of Apgar score at 5 min <7 in term and late preterm neonates (r = -0.92, p = 0.46) and of perinatal mortality (r = -0.19, p = 0.13), respectively. The associations were independent of hospital volume of activity. CONCLUSIONS: An obstetric practice that encourages vaginal instrumental delivery in delayed second stage of labor or vaginal birth after previous cesarean delivery, could reduce the rising cesarean delivery rate. This will require a change in obstetric culture, continuing education of healthcare providers, and leadership.

Fetal hydronephrosis: natural history and risk factors for postnatal surgery.

BACKGROUND: The objective of this study was to assess the ability of prenatal ultrasound to predict an unfavorable outcome and the need for postnatal surgery in cases of fetal hydronephrosis (HY). METHODS: Antenatal HY was classified according to the renal pelvis anteroposterior (AP) diameter in the third trimester. Postnatal outcome was considered favorable in the presence of spontaneous resolution or postnatal diagnosis of HY <20 mm, and unfavorable in the presence of postnatal diagnosis of >20 mm HY or urinary tract pathologies. RESULTS: Prenatal diagnosis of HY was made in 120 fetuses (for a total of 161 abnormal renal units). The rates of postnatal urinary tract pathology were 14, 27 and 53% for antenatal HY of ≤7, 8-15 and >15 mm, respectively. An AP diameter ≥7 mm in the third trimester had a sensitivity of 100% and a specificity of 23% to predict unfavorable outcome. A formula inclusive of AP diameter and presence or absence of urinary tract anomalies can predict the need for postnatal surgery. CONCLUSIONS: The majority of infants with congenital HY have a favorable postnatal outcome. Risk of unfavorable outcome increases with the degree of dilatation of the renal pelvis and the presence of urinary tract anomalies. An AP diameter ≥7 mm in the third trimester warrants postnatal follow-up.

Effect of oxytocin during labor on neonatal acidemia.

OBJECTIVE: To assess the factors affecting neonatal acidemia, including occurrence of tachysystole/hypertonus in fetuses exposed to oxytocin during labour and with continuously-monitored fetal heart rate (FHR) tracings. METHODS: Prospective observational study of all women with term pregnancies who received oxytocin for induction/augmentation of labour. FHR tracings were prospectively classified using ACOG classification. Independent predictors of neonatal acidemia were identified using multivariate linear regression with p < 0.05 considered significant. RESULTS: We included 430 women, 236 of whom (54.9%) had spontaneous onset of labour. The duration of active phase of the second stage of labour and the presence of abnormal FHR tracing during labour were significantly associated with UA pH (p < 0.001) and BE (p < 0.001), while maximum dose of oxytocin (p < 0.17; p < 0.7) and tachysystole (p < 0.9; p < 0.8) were not. At logistic regression, the duration of active phase of the second stage of labour was independently predictive of neonatal acidemia (p < 0.009) while abnormal FHR tracing approached significance (p < 0.088). CONCLUSIONS: In women receiving oxytocin during labour, the duration of active phase of the second stage of labour correlates with neonatal acidemia, whereas maximum dose of oxytocin, duration of oxytocin administration and occurrence of tachysystole during labour do not.

Short-term respiratory outcomes in late preterm infants.

OBJECTIVE: To evaluate short-term respiratory outcomes in late preterm infants (LPI) compared with those of term infants (TI). METHODS: A retrospective study conducted in a single third level Italian centre (2005-2009) to analyse the incidence and risk factors of composite respiratory morbidity (CRM), the need for adjunctive therapies (surfactant therapy, inhaled nitric oxide, pleural drainage), the highest level of respiratory support (mechanical ventilation - MV, nasal continuous positive airway pressure--N-CPAP, nasal oxygen) and the duration of pressure support (hours in N-CPAP and/or MV). RESULTS: During the study period 14,515 infants were delivered. There were 856 (5.9%) LPI and 12,948 (89.2%) TI. CRM affected 105 LPI (12.4%), and 121 TI (0.9%), with an overall rate of 1.6%. Eighty-four LPI (9.8%) and 73 TI (0.56%) received respiratory support, of which 13 LPI (1.5%) and 16 TI (0.12%) were ventilated. The adjusted OR for developing CRM significantly increased from 3.3 (95% CI 2.0-5.5) at 37 weeks to 40.8 (95% CI 19.7-84.9%) at 34 weeks. The adjusted OR for the need of MV significantly increased from 3.4 (95% CI 1.2-10) at 37 weeks to 34.4 (95% CI 6.7-180.6%) at 34 weeks. Median duration of pressure support was significantly higher at 37 weeks (66.6 h vs 40.5 h). Twin pregnancies were related to a higher risk of CRM (OR 4.3, 95% CI 2.6-7.3), but not independent of gestational age (GA). Cesarean section (CS) was associated with higher risk of CRM independently of GA, but the OR was lower in CS with labour (2.2, 95% CI 1.4-3.4 vs 3.0, 95% CI 2.1-4.2). CONCLUSIONS: In this single third level care study late preterm births, pulmonary diseases and supportive respiratory interventions were lower than previously documented. LPI are at a higher risk of developing pulmonary disease than TI. Infants born from elective cesarean sections, late preterm twins in particular and 37 weekers too might benefit from preventive intervention.

Comparative analysis of cesarean delivery rates over a 10-year period in a single Institution using 10-class classification.

OBJECTIVE: To evaluate the variables associated with changes in cesarean delivery (CD) rates in a University Hospital with standardized and unchanged protocols of care. METHODS: Retrospective analysis of consecutive deliveries between two triennia 10 years apart. The Robson classification of CD was used, and the analysis focused on factors affecting Robson's classes 1 and 2 combined (term singleton cephalic nulliparae) and class 5 (previous CD). RESULTS: A total of 8237 deliveries occurred in the 1st period, and 8420 in the 2nd. CD increased from 12.5 to 18% (p < 0.001). Robson's classes 1 and 2 combined contributed more than other classes to CD rates (32 vs 36%; p < 0.001). At multivariate analysis, BMI (Odds ratio [OR]: 1.08; 95% CI: 1.06-1.1) and maternal age (OR: 1.06; 95% CI: 1.05-1.08) were independently related to CD. In Robson class 5, the rate of CD increased from 34 to 46%, p < 0.001, mostly due to an increase in elective CD (39 vs 67.5%; p < 0.001). At multivariate analysis, BMI (OR: 1.06 95% CI: 1.02-1.1) and more than one previous CD (OR: 18.7; 95% CI: 9.6-36.4) were independently related to CD. CONCLUSIONS: BMI and maternal age are independent factors associated to the increasing rate of CD in nulliparae with spontaneous or induced labor at term. In women with previous CD, BMI and more than one previous CD are factors associated with the increasing rate of CD.

Gestational age at glucocorticoids administration after premature rupture of membranes and cerebral white matter damage.

OBJECTIVE: We investigated whether gestational age at glucocorticoids administration in very preterm premature rupture of membranes (PROM) affects the occurrence of neonatal cerebral white matter damage (WMD). METHODS: In a cohort of singleton neonates born at 24.0-33.6 weeks after PROM who underwent at least one full course of glucocorticoids (n = 130), we compared the gestational age at first and last course of glucocorticoids between those who developed WMD (n = 8) and those who did not (n = 122) after adjusting for gestational age at PROM using logistic regression with P < 0.05 considered significant. RESULTS: Gestational age at first course of glucocorticoids (P = 0.2), at last course of glucocorticoids (P = 0.2) and at delivery (P = 0.2), were not significantly different between those who developed WMD and those who did not. Although latency between PROM and first course of glucocorticoids was protective against WMD (P = 0.02), the significance was lost after controlling for gestational age at PROM, which was significantly lower in cases that developed WMD (P < 0.01). CONCLUSIONS: In very preterm PROM, the beneficial effect of glucocorticoids on occurrence of WMD is not related to gestational age at steroid administration.